Fluorine-18-fluoro-2-deoxy-d-glucose PET-CT aids in detection of soft-tissue injuries for dogs with thoracic or pelvic limb lameness.

Fluorine-18-fluoro-2-deoxy-d-glucose positron emission tomography (FDG PET) provides physiologic images of tissues based on their glucose metabolism. The combination of FDG PET and CT (FDG PET-CT) has been utilized in human musculoskeletal imaging to localize soft tissue lesions, however, this modality has not been thoroughly investigated for the diagnosis of canine lameness. This prospective, descriptive study evaluated FDG PET-CT findings in 25 client-owned dogs with inconclusive origin of thoracic or pelvic limb lameness (thoracic limb n = 15/25, 60%; pelvic limb n = 6/25, 24%; and combination of both limbs n = 4/25, 16%). We hypothesized that FDG PET-CT would aid the detection of soft tissue lesions not visible with other imaging modalities. Combined FDG PET-CT detected soft tissue lesions in 40% (n = 10/25) and osteoarthritis in 64% (n = 16/25) of the patients. FDG PET detected more soft tissue lesions than contrast-enhanced CT (n = 15/15, 100% and n = 12/15, 80%, respectively), while CT identified more osteoarthritis lesions than FDG PET (n = 26/26, 100% and n = 18/26, 69%, respectively). The three imaging-diagnoses based on the FDG PET component included the following: flexor carpi ulnaris muscle tear, psoas major myopathy, and tarsal desmopathy. No diagnosis for the lameness was obtained in three dogs. Findings supported FDG PET-CT as a useful adjunct imaging modality for detection of certain soft tissue injuries of the musculoskeletal system. Combined FDG PET-CT should be considered for cases where the cause of lameness is thought to be of soft tissue origin and cannot be diagnosed by conventional means.

Trauma Management of Military Working Dogs.

There are about 2,500 war and military service dogs in service, with about 700 serving at any given time overseas. Military Working Dogs (MWDs) are critical assets for military police, special operations units, and others operating in today's combat environment. The expectation, given the significant combat multiplier impact of these dogs and the intense bond between the handler and dog, is that injured working dogs will receive the same level of care as any injured U.S. military personnel. Veterinary care is available at multiple locations throughout theater, and the veterinary healthcare team is the MWD's primary provider. Yet, human healthcare providers (HCPs) may be the only medical personnel available to MWDs that are gravely ill or injured. As most HCPs are unfamiliar with medical care of dogs, the Joint Trauma System published a Clinical Practice Guideline (CPG), a set of detailed clinical guidelines for managing life-threatening problems of MWDs encountered in combat operations. The CPG is available at the JTS website. This article is covers the most common urgent MWD care challenges HCPs may face.

Frequency and number of B-lines using a regionally based lung ultrasound examination in cats with radiographically normal lungs compared to cats with left-sided congestive heart failure.

OBJECTIVE: To establish a baseline lung ultrasound (LUS) artifact profile using a regionally based protocol in cats without clinical signs of respiratory disease and with radiographically normal lungs compared to a cohort of cats with left-sided congestive heart failure (CHF). DESIGN: Prospective case series. ANIMALS: Forty-nine cats without clinical signs of respiratory disease and with radiographically normal lungs and 7 cats with radiographic evidence of left-sided CHF. INTERVENTIONS: Application of a previously published LUS protocol. Frequency of B-lines was compared based on signalment, body condition score, investigator, and reasons for radiography and between 49 cats with radiographically normal lungs to 7 cats with radiographic evidence of left-sided CHF. RESULTS: Overall frequency of B-lines was 12% (95% confidence interval, 5-24%) in cats without respiratory disease versus 100% (95% confidence interval, 65-100%) in those with left-sided CHF. Six cats (6/49) had B-lines with 5/6 having B-lines at a single site; and 4/5 having a single B-line at 1 site, 1/5 having 2 B-lines at 1 site; and the sixth cat having 2 positive sites with a single B-line at each. In the cohort of cats with left-sided CHF, all cats (7/7) had >3 B-lines detected at every site. CONCLUSIONS: The lack of B-lines in cats without respiratory disease (with radiographically normal lungs) and the predominance of B-lines in cats with left-sided CHF suggest that a regionally based LUS protocol may be clinically useful for the identification and evaluation of feline respiratory conditions.

18F-FDG Positron Emission Tomography - An Innovative Technique for the Diagnosis of a Canine Lameness.

INTRODUCTION: Positron emission tomography (PET) imaging with fluorine-18-fluorodeoxyglucose (18F-FDG) is widely known for its use in the diagnosis and tracking of primary and metastatic tumors via uptake and retention of the radiopharmaceutical by hypermetabolic cells. 18F-FDG is also used to study the normal physiology of glucose uptake, metabolism, and muscle activity during and after exercise. BACKGROUND: A pilot study adding PET imaging to the diagnostic evaluation of canine patients undergoing computed tomography (CT) for mild or intermittent thoracic and pelvic limb lameness is ongoing. Dogs with an observable (grade 1-2/5) lameness that have undergone routine radiography and complete physical examination by board-certified veterinary surgeons and sports medicine and rehabilitation specialists are enrolled. Each patient undergoes leash walking for 15 min prior to premedication and induction of general anesthesia for the PET-CT examination. 18F-FDG is injected intravenously, and a whole-body PET examination is conducted after 1 h of radiopharmaceutical uptake time. Standard algorithm, whole-body pre- and post-contrast CT examinations, and focused, standard, and bone algorithm CT scans of the thoracic or pelvic limb areas of interest are obtained concurrently. Abnormal PET-CT findings are further investigated with additional diagnostic imaging or at surgery (e.g., ultrasound, MRI, and arthroscopy). DISCUSSION: This case report uses a canine patient referred for thoracic limb lameness to illustrate the role of advanced imaging in a diagnostic plan and to discuss a recommended PET-CT procedure for lameness evaluation. The PET-CT imaging protocol recommended in this report was designed to significantly enhance a routine thoracic limb CT examination and to identify areas of muscle, tendon, or ligament overuse, inflammation, or injury for further diagnostic procedures or definitive treatment. CONCLUDING REMARKS: 18F-FDG PET-CT adds valuable physiologic and anatomic information to the diagnostic evaluation of patients presenting with indistinct or intermittent clinical signs of musculoskeletal inflammation or injury. In addition, tailoring the PET acquisition and radiopharmaceutical parameters allows for detailed information gathering to more closely assess normal and abnormal physiology, unlocking a new frontier in the study of canine athletic injury and optimal performance.

Kitona 2013: A Medical Readiness Training Exercise in the Democratic Republic of the Congo Leading to Lion Rouge.

BACKGROUND: Health initiatives support regional stability and are a priority for US and African partners. We present data and experience from the Democratic Republic of Congo (DRC), a strategically and epidemiologically ideal location for collaborative medical engagement (CME). Our objectives included relationship building, exposure of US military medical personnel to uncommon tropical diseases, bolstering a referral hospital, and updating Congolese physicians on new treatment or preventive standards of care. METHODS: We conducted a CME-styled medical readiness training exercise (MEDRETE) at the Military Referral Hospital of Kitona in June 2013. US and Congolese healthcare providers presented 20 lectures and evaluated 158 patients collaboratively; 132 for infections. RESULTS: The CME led to Lion Rouge, the first joint military, multidisciplinary engagement between the respective militaries. Equally noteworthy is that some of the same participants returned to the same location for the follow-on exercise, providing continuity. CONCLUSION: These outcomes suggest the MEDRETE and CME approaches were successful.

Validation of 64Cu-ATSM damaging DNA via high-LET Auger electron emission.

Radioactive copper (II) (diacetyl-bis N4-methylthiosemicarbazone) (Cu-ATSM) isotopes were originally developed for the imaging of hypoxia in tumors. Because the decay of a (64)Cu atom is emitting not only positrons but also Auger electrons, this radionuclide has great potential as a theranostic agent. However, the success of (64)Cu-ATSM internal radiation therapy would depend on the contribution of Auger electrons to tumor cell killing. Therefore, we designed a cell culture system to define the contributions to cell death from Auger electrons to support or refute our hypothesis that the majority of cell death from (64)Cu-ATSM is a result of high-LET Auger electrons and not positrons or other low-LET radiation. Chinese hamster ovary (CHO) wild type and DNA repair-deficient xrs5 cells were exposed to (64)Cu-ATSM during hypoxic conditions. Surviving fractions were compared with those surviving gamma-radiation, low-LET hadron radiation, and high-LET heavy ion exposure. The ratio of the D(10) values (doses required to achieve 10% cell survival) between CHO wild type and xrs5 cells suggested that (64)Cu-ATSM toxicity is similar to that of high-LET Carbon ion radiation (70 keV/µm). γH2AX foci assays confirmed DNA double-strand breaks and cluster damage by high-LET Auger electrons from (64)Cu decay, and complex types of chromosomal aberrations typical of high-LET radiation were observed after (64)Cu-ATSM exposure. The majority of cell death was caused by high-LET radiation. This work provides strong evidence that (64)Cu-ATSM damages DNA via high-LET Auger electrons, supporting further study and consideration of (64)Cu-ATSM as a cancer treatment modality for hypoxic tumors.

Collaborative medical engagement and needs assessment in the Democratic Republic of the Congo: a preliminary report from Muanda.

The Democratic Republic of the Congo is the second largest and fourth most populous country in Africa. More than two decades of ongoing conflicts have degraded its healthcare system. A broad range of tropical diseases, along with opportunities for collaborative medical engagements (CMEs), are prevalent. However, reports from such events in this country are sparse. In June 2013, a CME was conducted in the western town of Muanda. Twenty-two hours of didactic sessions were collaboratively presented, and 158 patients were collaboratively evaluated. Durable dental and respiratory equipment, infrastructure improvements, and training opportunities were the top needs identified by the providers. Whether the regional referral hospital received sustainable benefit remains under investigation. However, the approach and needs assessment described herein provide a framework for future engagements or assistance. This CME established a precedence of medical partnership in the region because it led to the largest multidisciplinary joint collaboration in the history of the Democratic Republic of the Congo.

US veterinary support to standardization of food and water safety and animal care and use within NATO.

NATO requires all standardization agreements and Al-lied Medical Publications to be reviewed at least once every 3 years to ensure they reflect current technologies and national military policies and procedures. This is particularly applicable with regard to veterinary medi-cine and food and water safety where advances in scientific knowledge and practices may result in documents quickly becoming obsolete. Such is the case with the 8 standardization agreements for which the FWSVS has responsibility; all are currently undergoing major revisions. With each revision, national representatives, including US veterinary and preventive medicine personnel, must review the documents to ensure there are no significant issues which would prevent ratification and implementation. This improves standardization and enhances interoperability between NATO partners to minimize duplication. This is accomplished by leveraging other national military capabilities, while maintaining confidence that the food, water, and veterinary support provided to their Warriors, support personnel, and animals in the field is safe and high in quality. Adherence to such standards is a major factor in maintaining the operational readiness of all alliance armed forces.

Managing diabetes with integrated teams: maximizing your efforts with limited time.

The importance of glycemic control has been well established. In response, the American Diabetes Association has established goals for glycemic control and other cardiovascular parameters, including blood pressure and low-density and high-density lipoprotein cholesterol. However, the National Health and Nutrition Examination Survey has shown that only about half (57%) of patients with diabetes meet a glycated hemoglobin A(1c) (HbA(1c)) goal of < 7%, approximately 45% meet blood pressure and total cholesterol goals, and only 12% achieve all 3 treatment goals. While treating hyperglycemia remains the primary treatment goal, careful selection of pharmacotherapies that do not adversely affect cardiovascular risk factors or long-term glycemic control is an important consideration for patients with type 2 diabetes mellitus. During the past 5 years, the number of treatment options and the complexity of treatment guidelines for diabetes have increased markedly, which makes treatment decisions more complicated and time-consuming, and greatly impacts the workload of the primary care physicians who deliver care to the majority of this population. To provide optimal diabetes care when time and resources are limited, primary care physicians may want to enlist the support of other providers, such as nurse practitioners, physician assistants, diabetes educators, dietitians, and social and case workers. The use of team care, coupled with appropriately chosen pharmacologic therapy and patient education that fosters the development of critical thinking skills and the ability to make self-management decisions, have been shown to improve glycemic control and cardiovascular outcomes.

Evaluation of an abdominal fluid scoring system determined using abdominal focused assessment with sonography for trauma in 101 dogs with motor vehicle trauma.

OBJECTIVE: Evaluate an abdominal fluid scoring (AFS) system using an abdominal focused assessment with sonography for trauma (AFAST) protocol. DESIGN: Prospective study. SETTING: Private veterinary emergency center. ANIMALS: One hundred and one client-owned dogs with motor vehicle trauma. Interventions- AFAST performed on admission and 4 hours post-admission. MEASUREMENTS AND MAIN RESULTS: An AFS was assigned to each dog based on the number of AFAST fluid-positive quadrants identified using a 4-point scale: AFS 0 (negative for fluid in all quadrants) to AFS 4 (positive for fluid in all quadrants). Free abdominal fluid was identified in 27 of 101 dogs (27%). Dogs with AFS scores of 3 or 4 (14/27 [52%] AFS-positive dogs) experienced more marked decreases in packed cell volume and total plasma protein, increases in alanine aminotransferase, and needed more blood transfusions than dogs with lower AFS scores and AFS-negative dogs. Serial AFAST was performed in 71% of dogs (71/101); 17% (12/71) of these cases changed AFS score, and 75% (9/12) of the changes were higher (worsened) AFS, correlating with increasing amounts of free abdominal fluid. Ninety-eight percent of the study population was a primary presentation. Overall, median time from trauma to initial AFAST was 60 minutes, and median AFAST examination time was 3 minutes. CONCLUSIONS: Initial and serial AFAST with applied AFS allowed rapid, semiquantitative measure of free abdominal fluid in traumatized patients, was clinically associated with severity of injury, and reliably guided clinical management. Where possible, AFAST and AFS should be applied to the management of blunt trauma cases.

Effect of modem transmission of blood glucose data on telephone consultation time, clinic work flow, and patient satisfaction for patients with gestational diabetes mellitus.

PURPOSE: To determine if modem transmission of blood glucose data by patients with gestational diabetes could provide faster communication of results, increased clinic work-flow efficiency, and equivalent accuracy. Participant and health care provider satisfaction with the technique was also assessed. DATA SOURCES: Participants were randomized to the modem group, which used the Acculink Modem to report blood glucose data, or to the control group, which used the telephone to report the data. Telephone consultation time, clinic visit time, and accuracy of data were measured. Participants and health care providers completed satisfaction questionnaires. CONCLUSIONS: No significant differences in telephone consultation time, clinic work-flow efficiency, or accuracy were found between the groups. However, both the modem group and clinic staff were highly satisfied with telemedicine transmission of blood glucose data. IMPLICATIONS FOR PRACTICE: Telemedicine is a convenient method for monitoring patients with gestational diabetes mellitus. As a result of this study, modem transmission was instituted in our clinic for insulin pump patients interested in using modem technology.