Presumptive phenobarbital-induced systemic lupus erythematosus in a domestic dog.

CASE DESCRIPTION: We describe a case of presumptive acquired systemic lupus erythematosus secondary to phenobarbital administration in a dog, which resolved with withdrawal of the drug. CLINICAL FINDINGS: A 3.5 year-old poodle presented to a veterinary teaching hospital for Tier 1 idiopathic epilepsy and was treated with phenobarbital. The dog experienced fever, multiple cytopenias, and proteinuria in conjunction with a positive antinuclear antibody (ANA) titer. DIAGNOSTICS: Serial CBCs, urine protein : creatinine ratios, and sternal bone marrow aspirates were performed to evaluate improvement. TREATMENT AND OUTCOME: Phenobarbital was withdrawn and levetiracetam initiated. All abnormalities resolved with supportive care, without initiation of immunosuppressive drugs. All cytopenias and proteinuria resolved and ANA test results became negative within 3 months. The patient recovered and did well clinically. CLINICAL RELEVANCE: Systemic lupus erythematosus is a disease of multiple autoimmune syndromes occurring concurrently or sequentially in conjunction with the presence of circulating ANA. It has been well described in dogs as an idiopathic condition, but in human medicine may occur secondary to drug reactions (drug-associated lupus) including as a reaction to phenobarbital. The findings in our case are consistent with the criteria for drug-induced lupus in humans and we suggest it as the first report of phenobarbital-induced lupus in a dog.

Point-of-care platelet function testing results in a dog with Bernard-Soulier syndrome.

Bernard-Soulier syndrome (BSS), also known as hemorrhagiparous thrombocytic dystrophy (OMIA 002207-9615), is a rare defect in platelet function recognized in both dogs and humans. It is caused by a deficiency in glycoprotein 1b-IX-V, the platelet surface protein which acts as a receptor for the von Willebrand factor. The characteristic features of BSS in humans and dogs include macrothrombocytes and mild-to-moderate thrombocytopenia with a bleeding tendency. This condition has previously been reported in European Cocker Spaniel dogs; however, the results of platelet function tests in these animals have not been reported. This case report describes a European Cocker Spaniel dog with spontaneously occurring Bernard-Soulier syndrome and the results of point-of-care platelet function tests, including a prolonged buccal mucosal bleeding time (>8 min), prolongation (>300 s) of PFA-200 COL/ADP, COL/EPI, and P2Y closure times, and reduced aggregation (15%-48%) with Plateletworks ADP, but with normal aggregation (92%) with Plateletworks AA. This is the first description of the results of platelet function tests in canine Bernard-Soulier syndrome.

Abnormal bone mineralization in a puppy fed an imbalanced raw meat homemade diet diagnosed and monitored using dual-energy X-ray absorptiometry.

A 4-month-old male Old English Sheepdog was presented for evaluation of a raw meat-based homemade diet after a 1-month history of progressive lameness. Marked dietary deficiencies were detected, which included calcium, phosphorus and vitamin D. Hypovitaminosis D and hypocalcaemia were diagnosed by serum analysis. Evidence of severe diffuse osteopenia was noted on survey radiographs. Dual-energy X-ray absorptiometry (DEXA) was used to quantify bone mineral content and density and compare to published reference ranges. The puppy's initial bone mineralization was markedly subnormal, with bone mineral density 66% lower than expected, and bone mineral content 40% lower than expected. Subsequent DEXA scans were performed at intervals during the puppy's recovery to document the rate of bone re-mineralization and guide therapeutic recommendations. Marked improvement was achieved within 4 months through exercise control and feeding of a diet appropriately formulated for large breed puppy growth and development. This report reinforces the necessity of thorough dietary history and highlights the potential for malnutrition in pets fed homemade and raw meat-based diets. Use of DEXA has rarely been reported in clinical cases, yet can be a valuable tool for diagnosing and monitoring cases with abnormal bone mineralization. Further studies using DEXA to track bone mineralization in healthy puppies are encouraged to develop a more robust reference range of bone mineralization in growing dogs of varying sizes, weights and ages.

Novel Association Between Intrathecal Drug Administration and Arachnoiditis Ossificans.

BACKGROUND: We present a case of delayed progression of adhesive arachnoiditis to arachnoiditis ossificans (AO) in a patient being treated with a high-dose polypharmaceutical intrathecal regimen. CASE DESCRIPTION: The patient is a 39-year-old Caucasian male who was implanted with an intrathecal pump in 2006 to control severe low back pain and administered intrathecal pain medication for a period of 10 years. In 2016, he developed new-onset radicular pain and worsened sensation in his lower extremities. Computed tomography scan of the lumbar spine at that time demonstrated profound calcification of the arachnoid consistent with a diagnosis of AO. It was presumed that prolonged high-dose intrathecal medication precipitated this condition, and his intrathecal medications were titrated down with removal of the pump. CONCLUSIONS: It is unlikely that his condition occurred as a result of prior surgery, with the more likely cause being hyperplasia of the spinal arachnoid, leading to scarring and calcification, due to the high-dose intrathecal regimen. This case highlights the delayed progression from stable arachnoiditis to AO concurring with a regimen of high-dose intrathecal medications. Clinicians should closely monitor patients undergoing intrathecal drug administration, particularly at elevated doses, for indications of damage to the spinal arachnoid mater.

Previously unreported complications associated with integrated cage screws following anterior lumbar interbody fusion: report of 2 cases.

Anterior lumbar interbody fusion (ALIF) is a widely performed surgical treatment for various lumbar spine pathologies. The authors present the first reports of virtually identical cases of complications with integrated screws in stand-alone interbody cages. Two patients presented with the onset of S-1 radiculopathy due to screw misplacements following an ALIF procedure. In both cases, an integrated screw from the cage penetrated the dorsal aspect of the S-1 cortical margin of the vertebra, extended into the neural foramen, and injured the traversing left S-1 nerve roots. Advanced neuroimaging findings indicated nerve root impingement by the protruding screw tip. After substantial delays, radiculopathic symptoms were treated with removal of the offending instrumentation, aggressive posterior decompression of the bony and ligamentous structures, and posterolateral fusion surgery with pedicle screw fixation. Postoperative radiographic findings demonstrated decompression of the symptomatic nerve roots via removal of the extruded screw tips from the neural foramina.

Mapping of pain curricula across health professions programs at the University of Toronto.

BACKGROUND: There is a growing societal need for health professional competency in pain care. The University of Toronto Centre for the Study of Pain-Interfaculty Pain Curriculum (UTCSP-IPC) has been offered since 2002. Content and process have been updated annually. In addition, participating health professions programs have advanced their pain teaching. A curricular scan was needed to creatively and constructively advance the UTCSP-IPC. AIM: The aim of this study was to map curricular pain content in participating health professions programs onto the UTCSP-IPC content as a first step to further curriculum design. METHODS: UTCSP-IPC committee members and faculty representatives from six health profession programs completed a 27-item online survey in this collaborative action study. Descriptive statistics were completed in Microsoft Excel. RESULTS: The UTCSP-IPC provided an average of 43.3% (range 32%-62%) of total pain content teaching hours to participating health professions students and a range of 8% to 100% of total opioid-related teaching hours. Curricular overlaps and gaps in pain content were identified and will be used to update and inform the iterative design of the UTCSP-IPC. Ninety-three percent of participating health professions faculty indicated that the interprofessional focus on pain care in the UTCSP-IPC was important. CONCLUSION: This study highlighted the value of the UTCSP and areas of curricular refinement to ensure continued relevance in relationship to pain content within the six participating health professions programs. Mapping a coordinated approach between uniprofessional and interprofessional teaching will both meet the demands of professional competence and create greater applicability to future practice settings.

Contexte : Il est de plus en plus nécessaire que les professionnels de la santé aient les compétences nécessaires pour la prise en charge de la douleur au sein de la société. Le Programme interfacultaire sur la douleur du Centre pour l'étude de la douleur de l'Université de Toronto (UTCSP-IPC) est offert depuis 2002. Son contenu et son processus ont été mis à jour chaque année. Les programmes des professions du domaine de la santé participantes ont eux aussi perfectionné leur enseignement sur la douleur. Une radiographie du programme était donc nécessaire afin d'améliorer l'UTCSP-IPC de manière créative et constructive.Objectif : Recenser le contenu sur la douleur dans les programmes des professions du domaine de la santé participantes afin de l'inclure dans l'UTCSP-IPC en tant que première étape pour améliorer la conception du programme.Méthodes : Des membres du comité de l'UTCSP-IPC et des représentants des facultés de six programmes de professions du domaine de la santé ont répondu à un sondage en ligne comprenant 27 énoncés dans le cadre de cette étude collaborative. Des statistiques descriptives ont ensuite été compilées dans Microsoft Excel™.Résultats : Au total, l'UTCSP-IPC a donné en moyenne 43,4 % (entre 32 et 62 %) d'heures d'enseignement sur la douleur aux étudiants des professions du domaine de la santé participantes, et de huit à 100 % d'heures d'enseignement liées aux opioïdes. Les lacunes et les chevauchements dans le contenu portant sur la douleur ont été répertoriés. Cette information sera utilisée pour la mise à jour et la conception itérative de l'UTCSP-IPC. Quatre-vingt-treize pour cent des facultés des professions du domaine de la santé participantes ont souligné l'importance de continuer à mettre l'accent sur l'aspect interprofessionnel de la prise en charge de la douleur dans l'UTCSP-IPC.Conclusion : Cette étude a mis en évidence l'importance de l'UTCSP ainsi que les aspects du programme qui doivent être peaufinés pour maintenir sa pertinence en ce qui concerne le contenu sur la douleur au sein des six programmes des professions du domaine de la santé participantes. L'élaboration d'une approche coordonnée entre l'enseignement uniprofessionnel et l'enseignement interprofessionnel permettra à la fois de répondre aux exigences en matière de compétences professionelles et d'améliorer l'applicabilité dans les futurs milieux de pratique.

Severe holocord syrinx in a child with megalencephaly-capillary malformation syndrome.

The authors present the case of a child with megalencephaly-capillary malformation syndrome who developed a rapidly progressive holocord syringomyelia that was treated surgically. A 3-year-old boy with megalencephaly-capillary malformation-polymicrogyria (MCAP) syndrome presented with several months of right leg weakness, worsening scoliosis, and increased seizures. An MRI study of the brain demonstrated a Chiari I malformation and massively dilated syringomyelia extending from C-2 to the conus medullaris. The patient underwent an urgent suboccipital craniectomy with C1-3 laminectomies to relieve the CSF outflow obstruction with significant clinical improvement. Surgery was complicated by bleeding from intracranial vascular malformations. This report describes a very rapidly developing, massive holocord syringomyelia related to CSF obstruction due to an unusual congenital brain malformation and associated vascular overgrowth at the site. Serial, premorbid MRI studies demonstrated the very rapid progression from no Chiari malformation, to progressively greater cerebellar tonsillar herniation, to holocord syrinx. This complication has never been reported in MCAP syndrome and should be considered in any affected MCAP patient with a progressive neurological decline, even if previous spine imaging findings were normal. Surgical complications due to hemorrhage also need to be considered in this vascular brain malformation.

Progressive multifocal leukoencephalopathy: a rare cause of cerebellar edema and atypical mass effect. A case report.

Progressive multifocal leukoencephalopathy (PML) is an opportunistic demyelinating disease of the CNS caused by the JC papovavirus (JCV). Demyelination due to oligodendrocyte death leads to multifocal, asymmetric lesions. MRI is a valuable tool for detecting and differentiating PML from other neuropathies. Radiographically, PML classically presents as bilateral, subcortical white matter lesions with a lack of brain atrophy. As the disease progresses, lesions become larger and coalesce to become confluent. Minor edema and mass effect are infrequently described and the presence of significant mass effect suggests an alternative diagnosis. In our case, a patient demonstrated atypical marked infratentorial mass effect. Bilaterally, cerebellar lesions with associated mass effect were observed, as well as effacement of cerebellar folia and partial effacement of the fourth ventricle. The diagnosis of PML was confirmed with a biopsy of the right cerebellar lesion showing classic PML histology, with JCV DNA detection by polymerase chain reaction in the biopsy material.

Metastatic renal cell carcinoma, with a radiographically occult primary tumor, presenting in the operative site of a thoracic meningioma: long-term follow-up: Case report.

Lesions metastatic to the site of a meningioma resection from a different primary tumor are rare. Metastasis of a tumor without a known primary tumor is also rare. Metastasis of a renal cell carcinoma, without an identifiable primary tumor, to the bed of a meningioma resection has not been previously reported. The authors describe the case of a 54-year-old man who presented with decreased sensory and motor function in the lower extremities. He underwent T3-5 laminectomies and gross-total removal of an intradural, extramedullary meningioma. The postoperative course was uneventful, and the patient regained full neurological function. After a 3-year period, he developed progressive upper thoracic pain and lower-extremity paresthesias. Imaging studies showed an epidural mass at the T2-4 levels and what appeared to be blastic involvement of the T2-4 vertebrae. A metastatic workup was negative. Emergency revision laminectomies yielded a fibrous, nonvascular mass. Neuropathology was consistent with metastatic renal cell carcinoma. After 6 months, the patient's symptoms of pain and paresthesias recurred. Repeat excision, with decompression of the spinal cord, revealed tumor cells morphologically and immunophenotypically similar to those obtained from the prior surgery. Cytogenetic analysis confirmed the presence of metastatic renal cell carcinoma. A novel case of an epidural metastatic renal cell carcinoma, of unknown primary origin, in the same operative bed of a previously resected intradural, extramedullary meningioma of the thoracic spine is reported.

Carpal intra-articular blastomycosis in a Labrador retriever.

A 6-month-old male castrated Labrador retriever was presented for coughing and forelimb lameness. Blastomyces dermatitidis was identified in cytology of sputum and synovial fluid. Repeat arthrocentesis 7 months later revealed resolution of septic arthritis. Fungal septic arthritis should be considered for cases of monoarthritis and may respond to oral itraconazole treatment.

Blastomycose carpienne intra-articulaire chez un Labrador retriever. Un Labrador retriever mâle castré âgé de 6 mois a été présenté pour une toux et une boiterie du membre antérieur. Blastomyces dermatitidis a été identifié lors d'une cytologie de l'expectoration et du liquide synovial. Une nouvelle arthrocentèse 7 mois plus tard a révélé la résolution de l'arthrite septique. L'arthrite septique fongique devrait être considérée pour les cas de mono-arthrite et elle peut réagir au traitement à l'itraconazole oral.(Traduit par Isabelle Vallières).

The role of collaborative interactivity in the observational practice of clinical skills.

CONTEXT: Video-based observational practice can extend simulation-based learning outside the training space. This study explores the value of collaborative feedback provided during observational practice to the acquisition of clinical skills. METHODS: Nursing students viewed a video demonstrating the proper ventrogluteal injection technique before performing a videotaped pre-test trial on a simulator. They were then assigned randomly to one of three observational practice groups: a group that observed the expert demonstration (EO group); a group that viewed the expert demonstration, self-assessed their individual pre-test and contrasted their self-assessments with expert feedback (ESO group), and a group that observed the expert demonstration, self-assessed and contrasted their assessments with those of an expert, and formed a community that engaged in peer-to-peer feedback (ESPO group). The observation of all videos, the provision of assessments and all networking occurred via an Internet-mediated network. After 2 weeks, participants returned for post-tests and transfer tests. RESULTS: The pre-test-post-test analyses revealed significant interactions (global rating scale: F((2,22)) =4.00 [p =0.033]; checklist: F((2,22)) =4.31 [p =0.026]), which indicated that post-test performance in the ESPO group was significantly better than pre-test performance. The transfer analyses revealed main effects for both the global rating scale (F((2,23)) =6.73; p =0.005) and validated checklist (F((2,23)) =7.04; p =0.004) measures. Participants in the ESPO group performed better on the transfer test than those in the EO group. CONCLUSIONS: The results suggest that video-based observational practice can be effective in extending simulation-based learning, but its effectiveness is mediated by the amount of time the learner spends engaged in the practice and the type of learning activities the learner performs in the observational practice environment. We speculate that increasing collaborative interactivity supports observational learning by increasing the extent to which the educational environment can accommodate learners' specific needs.

Transtumoral plating as a novel method for palliative limb spare and thromboembolism in a dog with a distal radial primary bone tumor.

A 7-year-old, spayed, female great Pyrenees with a primary tumor of the distal radius was treated with placement of a bone plate that spanned the tumor. The goals were palliation and prevention of pathologic fracture. This is an option for select patients with osteosarcoma.

Women as radiologists: are there barriers to entry and advancement?

PURPOSE: In consideration of the fact that women constitute only 25% of radiology residents, even though they constitute 45% of medical students, this study was conducted to determine if the trend of women choosing radiology as a career differs from that for other medical specialties and if there are differences on the basis of the gender of program directors or geographic location. The authors also wished to determine if constraints exist that prevent women from advancing into positions of leadership in radiology. METHOD: The percentage of women in each of the 186 radiology residency programs was compiled to determine the mean and standard deviation of women represented and from those data to examine if there were patterns of exclusion related to program size, location, or the gender of program directors. The membership and committee lists of the ACR and the Radiological Society of North America (RSNA) were examined to gauge the participation of women as leaders in these 2 organizations, as were the mastheads of Radiology and the American Journal of Roentgenology. The number of female chairs of academic departments was also examined. RESULTS: Over the past decade, the percentage of women in diagnostic radiology residencies has remained remarkably constant at or slightly above 25%. There was no discernable prejudice against women applicants by program size, location, or program director gender. In both the ACR and the RSNA, women are represented in positions of leadership approximately in proportion to their percentage in the general membership. Journal mastheads have fewer women than might be expected given the participation of women in academic radiology. There are a small but increasing number of women chairing academic radiology departments. CONCLUSION: The relatively low percentage of women in diagnostic radiology residencies is not a reflection of the gender of program directors. Women are represented in positions of influence and authority in major organizations in American radiology in proportion to the overall number of women in the organization. However, women continue to be underrepresented in radiology chair positions. Explanations must be sought for the relative unattractiveness of radiology to prospective women residents and barriers to the advancement of women in academic radiology.

Disseminated Mycobacterium avium infection in a cat.

A domestic shorthair cat was presented for lethargy and ataxia. Clinical findings included an abdominal mass, lumbosacral pain, ataxia. Aspirates from the liver and lymph nodes revealed intracellular, negative-staining rods. Treatment for presumptive mycobacterium infection was unsuccessful and the cat was euthanized. Disseminated Mycobacterium avium was confirmed on culture.