Effect of duration of packed red blood cell storage on morbidity and mortality in dogs after transfusion: 3,095 cases (2001-2010).

BACKGROUND: Accumulating evidence suggests that transfusion of packed red blood cells (PRBCs) stored for >14 days is associated with increased rates of sepsis, multiple organ dysfunction, and mortality in human patients. OBJECTIVE: To determine if duration of PRBC storage has an effect on morbidity and mortality in dogs after transfusion. ANIMALS: Dogs admitted to the Matthew J Ryan Veterinary Hospital of the University of Pennsylvania. METHODS: A retrospective case review of dogs identified through blood bank logbooks that received PRBC transfusions (minimum, 5 mL/kg) between 2001 and 2010. Dogs were categorized according to major cause of anemia (eg, hemorrhage, hemolysis, ineffective erythropoiesis) for analysis. RESULTS: A total of 3,095 dogs received 5,412 PRBC units. Longer duration of PRBC storage was associated with development of new or progressive coagulation failure (P = .001) and thromboembolic disease (P = .005). There was no association between duration of PRBC storage and survival for all dogs overall. However, a logistic regression model indicated that for dogs with hemolysis, 90% of which had immune-mediated hemolytic anemia, longer duration of PRBC storage was a negative risk factor for survival. For every 7 day increase in storage, there was a 0.79 lesser odds of 30 day survival (95% CI, 0.64-0.97; P = .024). CONCLUSIONS AND CLINICAL IMPORTANCE: Duration of PRBC storage does not appear to be a major contributing factor to mortality in the overall canine population. However, longer duration of PRBC storage may negatively impact outcome in dogs with immune-mediated hemolytic anemia, thus warranting further investigation with prospective studies.

Prediction of long-term outcome by measurement of serum concentration of cardiac troponins in critically ill dogs with systemic inflammation.

BACKGROUND: Myocardial injury, detected by cardiac troponin I and T (cTnI and cTnT), has been associated with long-term death in the noncardiac human intensive care unit (ICU). HYPOTHESIS: Presence of myocardial injury predicts 1-year case fatality in critically ill dogs with systemic inflammation. ANIMALS: Thirty-eight dogs with evidence of systemic inflammation and no primary cardiac disease. METHODS: Prospective cohort study. In dogs admitted to the ICU with evidence of systemic inflammation, blood samples were obtained at ICU admission for measurement of cTnI and cTnT, and cTnI was measured once daily during ICU hospitalization. Receiver operating characteristic (ROC) curves were used to examine prognostic capacity of admission cTnI, admission cTnT, and peak cTnI concentrations. RESULTS: One-year case fatality rate was 47% (18/38 dogs). Admission cTnI concentrations were (median [range]) 0.48 [0.004-141.50] ng/mL, and peak cTnI concentrations were 1.21 [0.021-141.50] ng/mL. Admission cTnT concentrations were 15 [<13-3744] ng/L. For each marker, non-survivors had significantly higher concentrations than survivors (P = .0082-.038). ROC analyses revealed areas under curves [95% CI] of 0.707 [0.537-0.843] for peak cTnI and 0.739 [0.571-0.867] for admission cTnT, respectively. At the optimal cut-off, concentrations were 1.17 ng/mL (peak cTnI) and 23 ng/L (admission cTnT), sensitivities were 72% and 72%, and specificities were 70% and 80%, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE: While peak cTnI and admission cTnT are significantly related to 1-year case fatality in critically ill dogs with systemic inflammation, low sensitivities and specificities prevent their prediction of long-term outcome in individual patients. Troponins might play a role in identification of dogs at long-term risk of death.

Prognostic importance of myocardial injury in critically ill dogs with systemic inflammation.

BACKGROUND: In noncardiac critical disease in humans, myocardial injury as detected by cardiac troponin I and T (cTnI and cTnT) has been linked to high intensive care unit (ICU) death independent of prognostic composite scoring. HYPOTHESIS: Presence of myocardial injury predicts short-term death in critically ill dogs with systemic inflammation and provides additional prognostic information when combined with established canine prognostic composite scores. ANIMALS: Forty-two dogs admitted to the ICU with evidence of systemic inflammation and no primary cardiac disease. METHODS: Prospective cohort study. Blood samples were obtained at ICU admission for the measurement of cTnI and cTnT, C-reactive protein, and several cytokines. The acute patient physiologic and laboratory evaluation (APPLE) score and the survival prediction index were calculated within the first 24 hours of admission. Receiver operating characteristic (ROC) curves were used to examine the prognostic capacity of each biomarker and severity score. Multiple logistic regression analysis was performed to evaluate whether cardiac markers significantly contributed to severity scores. RESULTS: Twenty-eight day case fatality rate was 26% (11/42 dogs). cTnI concentrations were (median [range]) 0.416 [0.004-141.5] ng/mL and cTnT concentrations were 13.5 [<13-3,744] ng/L. cTnI, cTnT, and the APPLE score were all significant prognosticators with areas under the ROC curves [95% CI] of 0.801 [0.649; 0.907], 0.790 [0.637; 0.900], and 0.776 [0.621; 0.889], respectively. cTnI significantly contributed to the APPLE score in providing additional prognostic specificity (P = .025). CONCLUSIONS AND CLINICAL IMPORTANCE: Markers of myocardial injury predict short-term death in dogs with systemic inflammation and cTnI significantly contributes to the APPLE score.

Ventilatory failure, ventilator management, and outcome in dogs with cervical spinal disorders: 14 cases (1991-1999).

OBJECTIVE: To determine the incidence of and risk factors for ventilatory failure in dogs undergoing surgery for treatment of cervical spinal disorders and to document ventilator management, clinical course, and long-term outcome of dogs that experienced ventilatory failure in association with cervical spinal disorders or their management. DESIGN: Retrospective study. ANIMALS: 14 dogs. PROCEDURE: Dogs with cervical spinal disorders that required positive-pressure ventilation (PPV) were identified, and signalment, concurrent diseases, neurologic status at initial examination, clinical course, pulmonary function before, during, and after PPV, management techniques, complications, and outcome were recorded. Dogs that underwent surgery and required PPV were compared with dogs that underwent cervical spinal surgery during the same period that did not require PPV. RESULTS: 14 dogs with cervical spinal disorders required PPV to treat hypoventilation, including 13 of 263 (4.9%) dogs that underwent surgery for cervical spinal disorders. Lesions between the second and fourth cervical vertebrae and treatment by means of a dorsal decompressive laminectomy were associated with a significantly increased risk of perioperative hypoventilation. Pulmonary gas exchange function was normal or nearly normal throughout the course of PPV in dogs that survived. Ten dogs survived, and 9 of the 10 regained neurologic function. All 9 dogs that regained neurologic function had deep pain perception on initial examination at the veterinary teaching hospital. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that a small percentage of dogs with cervical spinal disorders may require perioperative ventilatory support. With prolonged PPV and aggressive management, a good outcome may be achieved in dogs similar to those described in the present study.

Evaluation of the survival prediction index as a model of risk stratification for clinical research in dogs admitted to intensive care units at four locations.

OBJECTIVE: To prospectively evaluate a survival prediction index (SPI) in dogs admitted to intensive care units (ICU) and to generate and test an improved SPI (ie, SPI2). SAMPLE POPULATION: Medical records of 624 critically ill dogs admitted to an ICU. PROCEDURE: Data were collected from dogs within 24 hours after admission to an ICU. Variables recorded reflected function of vital organ systems, severity of underlying physiologic derangement, and extent of physiologic reserve; outcome was defined as dogs that survived or did not survive until 30 days after admission to the ICU. Probabilities of survival were calculated, using an established model (SPI). We then performed another logistic regression analysis, thereby reestimating the variables to create the new SPI2. Cross-validation of the models obtained was performed by randomly assigning the total sample of 624 dogs into an estimation group of 499 dogs and validation group of 125 dogs. RESULTS: Testing of SPI resulted in an area under the curve (AUC) of 0.723. Testing of SPI2 revealed an AUC of 0.773. A backwards-elimination procedure was used to create a model containing fewer variables, and variables were sequentially eliminated. The AUC for the reduced model of SPI2 was 0.76, indicating little loss in predictive accuracy. CONCLUSIONS AND CLINICAL RELEVANCE: The new SPI2 objectively stratified clinical patients into groups according to severity of disease. This index could provide an important tool for clinical research.

Lung lobe torsion in dogs: 22 cases (1981-1999).

OBJECTIVE: To identify breed disposition, postoperative complications, and outcome in dogs with lung lobe torsion. DESIGN: Retrospective study. ANIMALS: 22 client-owned dogs. PROCEDURE: Information on signalment; history; clinical findings; results of clinicopathologic testing, diagnostic imaging, and pleural fluid analysis; surgical treatment; intra- and postoperative complications; histologic findings; and outcome were obtained from medical records. RESULTS: All 22 dogs had pleural effusion; dyspnea was the most common reason for examination. Fifteen dogs were large deep-chested breeds; 5 were toy breeds. Afghan Hounds were overrepresented, compared with the hospital population. One dog was euthanatized without treatment; the remaining dogs underwent exploratory thoracotomy and lung lobectomy. Eleven dogs recovered from surgery without complications, but 3 of these later died of thoracic disease. Four dogs survived to discharge but had clinically important complications within 2 months, including chylothorax, mediastinal mesothelioma, gastric dilatation, and a second lung lobe torsion. Six dogs died or were euthanatized within 2 weeks after surgery because of acute respiratory distress syndrome, pneumonia, septic shock, pneumothorax, or chylothorax. Chylothorax was diagnosed in 8 of the 22 dogs, including 4 Afghan Hounds. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that lung lobe torsion is rare in dogs and develops most frequently in large deep-chested dogs, particularly Afghan Hounds. Other predisposing causes were not identified, but an association with chylothorax was evident, especially in Afghan Hounds. Prognosis for dogs with lung lobe torsion was fair to guarded.

Severe sepsis in cats: 29 cases (1986-1998).

OBJECTIVE: To document the clinical, clinicopathologic, and pathologic findings in cats with severe sepsis, identify abnormalities unique to this species, and identify criteria that could be used antemortem to diagnose the systemic inflammatory response syndrome in cats. DESIGN: Retrospective study. ANIMALS: 29 cats confirmed to have severe sepsis at necropsy. PROCEDURE: Pertinent history, physical examination findings, and results of hematologic and biochemical testing were extracted from medical records. RESULTS: Clinical diagnoses included pyothorax, septic peritonitis, bacteremia secondary to gastrointestinal tract disease, pneumonia, endocarditis, pyelonephritis, osteomyelitis, pyometra, and bite wounds. Physical examination findings included lethargy, pale mucous membranes, poor pulse quality, tachypnea, hypo- or hyperthermia, signs of diffuse pain on abdominal palpation, bradycardia, and icterus. Clinicopathologic abnormalities included anemia, thrombocytopenia, band neutrophilia, hypoalbuminemia, low serum alkaline phosphatase activity, and hyperbilirubinemia. Necropsy findings included multi-organ necrosis or inflammation with intralesional bacteria. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that severe sepsis in cats is characterized by lethargy, pale mucous membranes, signs of diffuse abdominal pain, tachypnea, bradycardia, weak pulses, anemia, hypoalbuminemia, hypothermia, and icterus. Recognition of this combination of clinical findings should facilitate the diagnosis of severe sepsis in cats.

Postoperative management of the emergency surgery small animal patient.

Hypovolemia, hypothermia, and hypotension are common postoperative findings that predispose the critically ill patient to secondary complications. This patient population is especially vulnerable to sepsis, hypoxia, and immune dysfunction. Careful monitoring is essential for early recognition of potentially life-threatening physiologic derangements. Early and aggressive intervention may help minimize systemic insult before it progresses to acute respiratory distress syndrome, acute renal failure, disseminated intravascular coagulation, or multiple organ failure.

Pulmonary function, ventilator management, and outcome of dogs with thoracic trauma and pulmonary contusions: 10 cases (1994-1998).

OBJECTIVE: To document pulmonary function, ventilator management, and outcome of dogs with thoracic trauma that required mechanical ventilation because of severe pulmonary contusions. DESIGN: Retrospective study. ANIMALS: 10 dogs that required mechanical ventilation because of severe pulmonary contusions caused by blunt thoracic trauma. PROCEDURE: Signalment, historical data, arterial blood gas values, oxygen tension-based indices, ventilator settings, peak inspiratory pressure, positive end-expiratory pressure, tidal volume, and minute ventilation values were retrieved from medical records. RESULTS: All 10 dogs required positive-pressure ventilation because of dyspnea following trauma and had severely abnormal pulmonary function. Survival rate to discharge was 30%. Dogs were categorized into 2 groups; group A included 5 dogs in which pulmonary function improved during ventilation, whereas group B included 5 dogs that were euthanatized because of progressive lung dysfunction (n = 4) or cardiac arrest (1). Mean +/- SD body weight of group-A dogs (30.9 +/- 15.9 kg [68 +/- 35 lb]) was significantly greater than that of group-B dogs (7.6 +/- 1.8 kg [16.7 +/- 4 lb]). Dogs with improved lung function had peak inspiratory pressure that decreased progressively, whereas lung compliance deteriorated in dogs in group B. CONCLUSIONS AND CLINICAL RELEVANCE: Dyspneic dogs with severe pulmonary contusions may require and benefit from positive-pressure ventilation Prognosis is better for dogs that weigh > 25 kg (55 lb).

The gramicidin-based biosensor: a functioning nano-machine.

Biosensors combine a biological recognition mechanism with a physical transduction technique. In nature, the transduction mechanism for high sensitivity molecular detection is the modulation of the cell membrane ionic conductivity through specific ligand-receptor binding-induced switching of ion channels. This effects an inherent signal amplification of six to eight orders of magnitude, corresponding to the total ion flow arising from the single channel gating event. Here we describe the first reduction of this principle to a practical sensing device, which is a planar impedance element composed of a macroscopically supported synthetic bilayer membrane incorporating gramicidin ion channels. The membrane and an ionic reservoir are covalently attached to an evaporated gold surface. The channels have specific receptor groups attached (usually antibodies) that permit switching of gramicidin channels by analyte binding to the receptors. The device may then be made specific for the detection of a wide range of analytes, including proteins, drugs, hormones, antibodies, DNA, etc., currently in the 10(-7)-10(-13) M range. It also lends itself readily to microelectronic fabrication and signal transduction. By adjusting the surface density of the receptors/channel components during fabrication, the optimum sensitivity range of the device may be tuned over several orders of magnitude.

Clinical manifestations and associated disease syndromes in dogs with cranial vena cava thrombosis: 17 cases (1989-1996).

OBJECTIVE: To characterize cranial vena cava thrombosis in dogs with regard to signalment, clinical manifestation, potential inciting causes, treatment, and outcome. DESIGN: Retrospective study. ANIMALS: 17 dogs with a cranial vena cava thrombus. PROCEDURE: Medical and necropsy records were reviewed for signalment, potential causes of thrombus formation, diagnosis, clinicopathologic findings, treatment, and outcome. RESULTS: A signalment predisposition was not found. Ten dogs had cranial vena cava syndrome, and 10 had a pleural effusion. Ten dogs were dyspneic, and 5 had palpable jugular thrombi. Predisposing conditions identified were presumed immune-mediated hematologic disease and corticosteroid administration (6 dogs), sepsis (6), protein-losing nephropathy (2), neoplasia (2), and cardiac disease (1). Central venous catheterization was implicated as a contributing cause. Thrombocytopenia was the most consistent clinicopathologic finding, and ultrasonography was helpful in confirming the diagnosis. Treatment varied, but 15 of the 17 dogs died or were euthanatized within 20 days of clinical manifestation of the thrombus. At necropsy, thrombi were found in other organs, mainly the right atrium, jugular veins, and pulmonary arteries. CLINICAL IMPLICATIONS: Prognosis is poor for dogs with cranial vena cava thrombosis associated with clinical signs. Use of central venous catheters should be avoided in dogs with predisposing diseases such as immune-mediated disease, sepsis, protein-losing nephropathy, neoplasia, and cardiac disease.

Fluid therapy in shock.

The goal of treatment for all types of shock is the improvement of tissue perfusion and oxygenation. The mainstay of therapy for hypovolemic and septic shock is the expansion of the intravascular volume by fluid administration, including crystalloids, colloids, and blood products. Frequent physical examinations and monitoring enable the clinician to determine the adequacy of tissue oxygenation and thus the success of the fluid therapy.

Acute fulminating myasthenia gravis in five dogs.

Acute fulminating myasthenia gravis (MG) was diagnosed in 5 dogs. Acute fulminating generalized MG in dogs is characterized by sudden onset of megaesophagus and frequent regurgitation of large volumes of fluid. Generalized muscle weakness can worsen and lead to recumbency within days. Despite appropriate supportive care, weakness is not alleviated by rest. Respiratory failure caused by aspiration pneumonia and loss of strength in muscles involved with respiration is a common cause of death. In dogs with acute onset of regurgitation, MG should be considered as a differential diagnosis. Clinicians should be aware of the risk of rapid progression to quadriparesis if aspiration pneumonia develops.

Kinetics of the competitive response of receptors immobilised to ion-channels which have been incorporated into a tethered bilayer.

A competitive ion channel switch (ICS) biosensor has been modelled yielding ligand mediated monomer-dimer reaction kinetics of gramicidin (gA) ion-channels within a tethered bilayer lipid membrane. Through employing gramicidin A, functionalized with the water-soluble hapten digoxigenin, it is possible to cross-link gramicidin to antibody fragments tethered at the membrane/aqueous interface. The change in ionic conductivity of the channel dimers may then be used to measure the binding kinetics of hapten-protein interactions at the membrane surface. The approach involves measuring the time dependence of the increase in impedance following the addition of a biotinylated antibody fragment (b-Fab'), which cross-links the functionalized gramicidin monomers in the outer layer of the lipid bilayer to tethered membrane spanning lipid. The subsequent addition of the small molecule digoxin, (M(r) 781 Da), competes with and reverses this interaction. The model provides a quantitative description of the response to both the cross-linking following the addition of the b-Fab' and the competitive displacement of the hapten by a water-soluble small analyte. Good agreement is obtained with independent measures of the cross-linking reaction rates of the gramicidin monomer-dimer and the b-Fab: hapten complex. The rate and amplitude of the competitive response is dependent on concentration and provides a fast and sensitive detection technique. Estimates are made of the concentration of gramicidin monomers in both the inner and outer monolayer leaflets of the membrane. This is used in the calculation of the gramicidin monomer/dimer equilibrium constant, K2D3. Other considerations include the membrane impedance limit set by the membrane leakage which is also a function of the concentration of the gA monomer concentration, and the two-dimensional kinetic association constant k2D2, of the hapten: b-Fab' complex. The gA dimer concentration is dependent on both the concentration of gA-dig and of the tethered streptavidin: b-Fab' complexes. The model shows that the 2D dissociation constant k2D3(-1), must be at least 10 times faster than the 3D dissociation constant k3D2(-1) for digoxin to completely reverse the cross-linked hapten-receptor interaction at the membrane interface.

A biosensor that uses ion-channel switches.

Biosensors are molecular sensors that combine a biological recognition mechanism with a physical transduction technique. They provide a new class of inexpensive, portable instrument that permit sophisticated analytical measurements to be undertaken rapidly at decentralized locations. However, the adoption of biosensors for practical applications other than the measurement of blood glucose is currently limited by the expense, insensitivity and inflexibility of the available transduction methods. Here we describe the development of a biosensing technique in which the conductance of a population of molecular ion channels is switched by the recognition event. The approach mimics biological sensory functions and can be used with most types of receptor, including antibodies and nucleotides. The technique is very flexible and even in its simplest form it is sensitive to picomolar concentrations of proteins. The sensor is essentially an impedance element whose dimensions can readily be reduced to become an integral component of a microelectronic circuit. It may be used in a wide range of applications and in complex media, including blood. These uses might include cell typing, the detection of large proteins, viruses, antibodies, DNA, electrolytes, drugs, pesticides and other low-molecular-weight compounds.

Measurement of urinary urea nitrogen content as an estimate of the amount of total urinary nitrogen loss in dogs in intensive care units.

OBJECTIVE: To investigate whether urinary urea nitrogen (UUN) content can be used to accurately estimate total urinary nitrogen content in hospitalized dogs. DESIGN: Prospective, cohort study. ANIMALS: 24 client-owned dogs admitted to an intensive care unit of a veterinary teaching hospital. PROCEDURE: Indwelling urinary catheters and closed collection systems were placed for the purpose of monitoring urine output. Urine was collected during a 24-hour period from each dog. For each collection, the total volume was measured. Urine was analyzed for urea nitrogen content at an in-house laboratory, using standard methods for determination of BUN content. Total urinary nitrogen content was determined by another laboratory, using Kjeldahl's method. Correlation between UUN content and total urinary nitrogen content was evaluated by use of linear regression analysis. RESULTS: Total urinary nitrogen content adjusted for metabolic body weight ranged from 0.21 to 2.21 g/ kg0.75/d (mean +/- SD, 0.81 +/- 0.46 g/kg0.75/d). Adjusted UUN content ranged from 0.05 to 1.50 g/kg0.75/d (0.54 +/- 0.38 g/kg0.75/d). Total urinary nitrogen content was highly correlated with UUN content (R2, 0.88; P < 0.001). CLINICAL IMPLICATIONS: Measurement of UUN content can be used to estimate total urinary nitrogen content in a clinical setting. Furthermore, critical illness in dogs is associated with substantial catabolism of endogenous proteins.

Identification and minimization of nonideal binding effects in BIAcore analysis: ferritin/anti-ferritin Fab' interaction as a model system.

The interaction of human spleen ferritin with a monoclonal antibody Fab' fragment has been studied as a model system for BIAcore analysis. In particular, the influence of nonideal binding effects has been examined both experimentally and by the theoretical simulation of sensorgram curves. Mass transfer effects were found to have a small but significant influence on the observed binding kinetics of the ferritin/antiferritin Fab' interaction; however, this nonideal behavior could be overcome by systematic manipulation of experimental conditions such as the flow rate and the surface density of the immobilized antigen. Because of the multivalent nature of ferritin with 12 antiferritin Fab' binding sites per molecule, immobilization of the antigen by amine coupling had little effect on the majority of free binding sites on the molecule. Consequently, the binding data for both ferritin and apoferritin correlated well with an ideal binding model which assumes binding homogeneity. On the other hand, when ferritin was dissociated to its subunit dimer form (containing one Fab' binding site) prior to surface immobilization significant deviation from this model was observed. This nonideal behavior was probably due to heterogeneity of the immobilized ferritin subunit dimer on the sensor surface, resulting from the nonspecific amine coupling procedure.

Glucocorticoid deficient hypoadrenocorticism in dogs: 18 cases (1986-1995).

OBJECTIVE: To characterize naturally developing glucocorticoid deficiency in dogs. DESIGN: Retrospective case series. ANIMALS: 18 dogs with glucocorticoid deficiency defined by an inadequate response to stimulation with adrenocorticotropic hormone (ACTH), a normal Na:K ratio (> 27), and no history of receiving corticosteroids for at least 6 weeks. PROCEDURE: Information including signalment, body weight, clinical signs on admission, historical findings, physical examination findings, results of CBC and serum biochemical analyses, results of ACTH stimulation tests and other ancillary endocrine tests, diagnostic imaging findings, findings from other procedures such as endoscopy and surgery, and information on concurrent diseases, management, and outcome were retrieved from the medical records of dogs with glucocorticoid deficiency treated between 1986 and 1995 at the University of Pennsylvania's School of Veterinary Medicine and 2 dogs from private practices. RESULTS: Most dogs were young (< 7 years) and represented larger breeds (> 20 kg). Clinical signs were nonspecific: lethargy, weight loss, and gastrointestinal disturbances including regurgitation with radiographic evidence of megaesophagus. Hypocholesterolemia, hypoalbuminemia, hypoglycemia, and a mild, nonregenerative anemia were common. Ten of the 18 dogs responded well to glucocorticoid supplementation alone, with only 2 dogs developing electrolyte abnormalities. Four (22%) of the dogs died, with death usually occurring as a result of secondary disease processes rather than hypoadrenocorticism. CLINICAL IMPLICATIONS: An ACTH stimulation test should be considered as part of the diagnostic plan in dogs with signs of weight loss, inappetence, and intermittent vomiting and diarrhea. Glucocorticoid-deficient dogs may not require supplemental mineralocorticoids.