VETgirl December 2023 Beat e-Magazine

The VETgirl Beat is a quarterly publication available to all subscribed members of VETgirl. The digital newsletter features highlighted webinars (small animal, large animal, veterinary technician, leadership), tech tips, provider spotlights, and recent happenings.

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ISSUE 19 | DECEMBER 2023

EMAGAZINE

TOP 10 EQUINE EMERGENCIES

mind massage recap

ART OF DELEGATION

VETGIRL U 2024

Better for You, Better for Your Team

TECH TIP SMS WEBINAR REMINDERS 32

WHAT’S ON THE CALENDAR FEATURED STORY FIC: ADDRESSING THE RISK FACTORS THAT MATTER MOST

A Clinically Relevant Review IMAGING THE BLOCKED CAT

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beat ISSUE 19 | DECEMBER 2023

BEAT EMAG Contents

• WEBINAR HIGHLIGHTS • FEATURED CONTENT • ARTICLES • TIPS •

4–5 The Founders’ Note 6 Holiday Treats Cookbook Recipes 8–10 FEATURED STORY:

24–26 WEBINAR HIGHLIGHTS: Top 10 Equine Emergencies 28–29 WEBINAR HIGHLIGHTS: The Art of Delegation: Better for You, Better for Your Team 30–31 Mind Massage 32 TECH TIPS: SMS Webinar Reminders 35 WHAT’S ON THE CALENDAR: Upcoming Webinars

FIC Addressing the Risk Factors That Matter Most 12–13 WEBINAR HIGHLIGHTS:

12 6

Canine and Feline Vestibular Disease 14–17

WEBINAR HIGHLIGHTS: The Sneezing Cat: Feline Upper Respiratory Disease 18–23 WEBINAR HIGHLIGHTS: Imaging the Blocked Cat: A Clinically Relevant Review

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THE FOUNDERS’ NOTE

Founder/CEO JUSTINE LEE

GARRET PACHTINGER

Founder/COO

HERE ARE SOME TIPS WE WANTED TO SHARE:

As 2023 comes to an end, we’re excited for what 2024 brings! It’s been an amazingly busy year for our VETgirl team and we’re really proud of what our team has accomplished! We’re closing out the 2023 year with 102.5 hours of LIVE webinars, 31.5 hours of sponsored LIVE webinars, and 12 FREE hours of Spanish CE (not including the 1,000 hours on-demand in our library)! Not only that, but we had an incredible, sold-out VETgirl U Conference at the bougie Fairmont Scottsdale Princess resort, which included over 1,000 veterinary professionals; our first ever successfully, sold-out dental lab; almost 70 exhibitors; and both a veterinarian and veterinary technician education track. Now we have to turn right around and plan VETgirl U 2024 in beautiful New Orleans. (Don’t forget to sign up to go before it sells out, because seriously, you’ll never go to another veterinary conference like this again!).

• Focus on one thing. • Schedule in breaks in your day.

• Only handle it once (OHIO). More on this in a future blog! • Have a shorter to-do list. (Lower your expectations while setting yourself up for success. Only have 3 things on your to- do list a day!) • Practice 3-minute meditation. • Reconnect with people outside of the veterinary world. • Don’t solve other people’s problems - that’s not your role. • Start a gratitude journal. • Focus on being refreshed and energized. • Be intentional. Pause. Reset. • Be hopeful. • Find your tribe, brag buddy, and accountability partner, as it’s lonely out there sometimes. • Know that there is always a community out there for you (especially with VETgirl!). Make sure to reach out and find it. • Be intentional and add it to your schedule to take care of yourself. (e.g., Block out time on your calendar to preserve it!) • Set boundaries on emails. Like no sending email outside of “normal” work hours (e.g., preschedule emails to go out the following morning so your staff doesn’t feel the pressure to check email all the time!). • You don’t have to solve every problem. • Slow down, fill your cup, and keep filling it with things that light your spark.

We know we’ll be prioritizing these things as we enter the New Year. We know the rest of our VETgirl team will be too. We wish you all the best 2024 and thank you for being such an amazing part of our VETgirl community.

WHAT ELSE WAS NEW WITH VETgirl IN 2023?

We changed our VETgirl ELITE content to provide weekly (from bi-weekly) educational videos, teamed up with some amazing education partners (such as Viticus Group and VetLead), and celebrated many job anniversaries within our amazing VETgirl team. We added three amazing downloadable e-books, including our Ultimate Guide to Toxicology book, our Put Your Mental Health First book, and our Top 10 Go-To-Guides for Vet Tech Life. I mean, how much educational content can we make?! As the New Year (2024, whoop!) approaches, we know that one of our New Year’s Resolutions is to continuously work on our own personal work-life balance. Because the struggle is REAL! And constant!

JUSTINE LEE

GARRET PACHTINGER

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Holiday Treats Cookbook Recipes apple crisp

ingredients

directions 1 Preheat oven to 350°F/177°C. 2 Place sliced apples in greased 9”x13” pan. In bowl, mix the rest of the ingredients until crumbly. 3 Bake for 30 minutes or until lightly browned and crisp. directions 1 In medium-sized bowl, combine milk and water. Add pudding mixture, mix well with a fork, and put into the refrigerator for 5 minutes. Pudding will set. 2 In a large mixing bowl, whip the cream until soft peaks form. Slowly fold in the pudding mixture and 1 tablespoon of orange juice, being careful to not over- mix and flatten the whipped cream. 3 Gently fold the raspberry preserves in with the seasonal berries, being careful not to smash the berries too much.

• 6 cups sliced apples • 1/2 cup flour • 3/4 cup brown sugar • 1/2 cup rolled oats • 2/3 cup margarine/butter, softened

Every vaccination counts

• 3/4 teaspoon cinnamon • 3/4 teaspoon nutmeg

Every extra year of FeLV protection matters

berry trifle Submitted by Hannah Duranleau

ingredients

4 Layer 1/2 of the cake into the bowl to fully cover the bottom, then sprinkle with 1/8 cup of orange juice. Layer 1/3 of the berries and top with 1/2 of the whipped cream mixture. Follow with layers using the remaining 1/2 of cake sprinkled with 1/8 cup of orange juice, 1/3 of berries, and remaining 1/2 of whipped cream. Use the last 1/3 of the berries for decor on top of the final cream layer. 5 Let sit in refrigerator for at least 2 hours, but ideally overnight, before serving.

• 1 can (14 oz.) of sweetened condensed milk • 1/2 cup of cold water • 1 package (4 serving size) instant vanilla pudding • 2 cups whipping cream • 1/4 cup of orange juice + 1 tablespoon divided • 2 cups of angel food cake, cubed • 1/4 cup red raspberry preserve (original recipe calls for 1/2 cup, but it’s too much), divided • 2 cups seasonal berries (I usually use raspberries, blueberries, and sliced strawberries)

Nobivac ® Feline 2-FeLV—the ONLY feline leukemia vaccine shown to be effective against viremia for 2 years after vaccination 1

With a 2-year duration of immunity, 1 and a 99% reaction-free safety profile, 2 Nobivac ® Feline 2-FeLV delivers unrivaled confidence and peace of mind.

Put confidence into practice with Nobivac ® Feline 2-FeLV.

To learn more, contact your Merck Animal Health sales representative or your distributor representative. Customer Service: 1-800-521-5767 Technical Services: 1-800-224-5318 (Monday–Friday, 9:00AM–6:00PM EST) (Monday–Friday, 9:00AM–7:00PM EST)

Protection unites us.

References: 1. Jirjis FF, Davis T, Lane J, et al. Protection against feline leukemia virus challenge for at least 2 years after vaccination with an inactivated feline leukemia virus vaccine. Vet Ther . 2010;11:E1–E6. 2. Data on file. Merck Animal Health.

Submitted by Olga Vinogradova

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Featured

Box 3: Five Pillars of a Healthy Feline Environment

Story

Provide a safe place

Provide multiple and seperate resources for food, water, toileting, scratching, resting/sleeping

FIC: ADDRESSING THE RISK FACTORS THAT MATTER MOST Kelly A. St. Denis, MSc, DVM, DABVP (Feline Practice)

Provide opportunity for play and predatory behavior

*Please note the opinions of this article are the expressed opinion of the author and not directly endorsed by VETgirl.

Provide positive, consistent & predictable human-cat social interactions

The AAFP and ISFM Feline Environmental Needs Guidelines describe the 5 pillars of a healthy feline environment (Box 3). 12 These are not to be confused with environmental enrichment, but rather represent the bare essentials that cats require in order to experience good cognitive, physical, and emotional health. Cats need to feel a sense of safety in their environment, with places to hide or perch, and with minimal intruders that may pose a threat to the cat’s safety or to the stability of the cat’s resources. While there is often a focus on litterboxes as a resource when a cat is diagnosed with FLUTD, attention should also be given to other resources including food and feeding stations, water stations, sleeping spaces, hiding and perching locations, scratching posts and toys. Toys represent an outlet for a cat’s prey drive. Cats need to engage regularly in play and predatory activities to satisfy their need to hunt. Toys may include those that the cat can play with independently as well as those that are reserved for interactive play with the caregiver. Regular, interactive play with the caregiver is one element of providing positive, consistent, and predictable human-cat interactions. All members of the household should interact with the cat in a respectful manner, allowing the cat to choose when to initiate and terminate interactions and never subjecting the cat to punishment or rough handling. Finally, the home environment should be arranged to respect the cat’s sense of smell and other senses, minimizing overpowering odors, lighting, or sounds. These have the potential to obtund the cat’s ability to detect predators, predisposing the cat to protective emotions including fear-anxiety and frustration.

Feline lower urinary tract disease (FLUTD) describes conditions that affect the urinary bladder and urethra that present with a variety of clinical signs (Box 1). The most common cause of non-obstructive FLUTD is feline idiopathic cystitis (FIC), 1–5 a diagnosis that requires exclusion of all other causes of FLUTD. Cats with FIC experience waxing and waning, often recurrent episodes, with approximately 15% of patients presenting with urethral obstruction. FIC is a complex condition, occurring as a result of interactions between the nervous system, the adrenergic system, husbandry practices and the environment in which the cat lives. 6,7 Cats predisposed to FIC exhibit abnormal responses to day-to-day stressors, with an exaggerated sympathetic nervous system response including increased catecholamine release, as well as blunted endocrine and cortisol responses. 8,9 Unlike their healthy counterparts, these cats are poorly equipped to handle a stimulus or challenge, and have an increased likelihood of developing sickness behaviors. This can manifest as an FIC flareup, or in some cats may affect other body systems including the gastrointestinal, immune, dermatologic, or respiratory systems. 6,7,10,11

Provide an environment that respects the cat’s sense of smell & other senses

Whether in a single or multi-cat household, ensuring cats live in a healthy environment can be achieved through identification and correction of deficiencies in these five pillars. Multi-cat households present additional challenges. Cats are by nature an asocial species, living in a defined territory with specific, protected resources. 13 When it comes to sharing that territory with other cats, cats may experience increased fear-anxiety and frustration related to their asocial nature. 14 Cohabitating cats may develop affiliative (‘friend’) habits, but many caregivers mistake co-existence for friendliness, even missing cues associated with agonistic (‘foe’) relationships (Box 4). Veterinary teams will need to work with the caregiver to elaborate on inter- cat relationships. In cases where cats are exhibiting agonistic interactions, correction of deficiencies in the five pillars may improve management of individual cat territories within the home. Consultation with a certified behaviorist is recommended.

Obesity, diet, and water intake are risk factors which are manageable with appropriate nutritional guidance. Development of a weight loss plan for obese cats should include assessment of current caloric intake, evaluation of the cat’s specific diet, and calculation of the cat’s resting energy requirements. 15,16 Body weight, body condition score, and muscle condition score trends should be monitored. 16 Overweight FIC cats are likely to benefit from a dietary change. Royal Canin Multifunction Urinary SO + Satiety + Calm is a therapeutic diet designed to promote healthy weight loss while helping to manage FIC. If weight loss is not required, adult and mature FIC patients are likely to benefit from formulations such as Royal Canin Multifunction Urinary SO + Calm or Royal Canin Multifunction Urinary SO Aging 7+ + Calm. The addition of canned food formulations may assist in any needed weight loss through portion control and reduction of intake. 17 Canned food is additionally beneficial for FIC patients due to its ability to lower urine specific gravity, potentially minimizing FIC flareups. 18 In situations where canned food cannot be fed, or where additional water intake is recommended, addressing patient water preferences includes evaluating desired drinking water temperatures, the cat’s preference for still or circulating water, specific water vessel shape preferences, and preferred water vessel locations. As the most common form of FLUTD, FIC requires an increased focus when evaluating cats with lower urinary tract signs. The role of stress in FIC reinforces the need to guide caregivers on the ideal characteristics of a healthy feline environment. 19 Risk factors for FIC are best addressed as part of a preventive approach, however promoting the resolution of flexible risk factors in a therapeutic plan for FIC patients offers the best opportunity for successful disease management.

Box 1: Clinical Signs of FLUTD

Box 4: Affiliative and Agonistic Interactions

• Hematuria • Stranguria • Vocalization • Pollakiuria • Dysuria

• Obstruction • Periuria • PAIN • Abdominal Barbering

Affiliative ‘Friend’ Interactions Facial rubbing or body rubbing between cats Tail wrapping Nose touching Resting or sleeping in physical contact or close proximity

Agonistic ‘Foe’ Interactions

Box 2: Risk Factors Associated with FIC

•

• Live in separate areas of house • Hissing/growling • Confrontational stares • Time-share resources • Resource-blocking • Monopolizing resources

Fixed

Flexible

• Genetics & Epigenetics • Sex • Neuter Status • Early Life Events • Age • Indoor Status

• Environment • Husbandry • Stress in a Multi-cat Household • Obesity • Diet • Water Intake

• • •

In order to prevent chronic, recurrent, or persistent disease, a multimodal approach to care should include analgesia for acute flareups, as well as therapies directed at any additional presenting problems or comorbidities. Targeting risk factors that are amenable to change offers a successful approach to long-term care. Many risk factors associated with FIC have been identified (Box 2). Some of these cannot be altered, while others can be successfully managed.

• Allogrooming • Playing together

Continued on Page 10

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References

CLICK TO DOWNLOAD NOW

1. Kruger JM, Osborne CA, Goyal SM, et al. Clinical evaluation of cats with lower urinary tract disease. JAVMA 1991; 199: 211–216. 2. Buffington CA, Chew DJ, Kendall MS, et al. Clinical evaluation of cats with nonobstructive urinary tract diseases. JAVMA 1997; 210: 46–50. 3. Lekcharoensuk C, Osborne CA, Lulich JP. Epidemiologic study of risk factors for lower urinary tract diseases in cats. J Am Vet Med Assoc 2001; 218: 1429–1435. 4. Sævik BK, Trangerud C, Ottesen N, et al. Causes of lower urinary tract disease in Norwegian cats. J Feline Med Surg 2010; 13: 410–417. 5. Gerber B, Boretti FS, Kley S, et al. Evaluation of clinical signs and causes of lower urinary tract disease in European cats. J Small Anim Pr 2005; 46: 571–577. 6. Buffington CAT, Westropp JL, Chew DJ. From FUS to Pandora syndrome Where are we, how did we get here, and where to now? J Feline Med Surg 2014; 16: 385–394. 7. Buffington CAT. Idiopathic cystitis in domestic cats--beyond the lower urinary tract. Journal of Veterinary Internal Medicine 2011; 25: 784–796. 8. Forrester SD, Towell TL. Feline idiopathic cystitis. The Veterinary clinics of North America Small animal practice 2015; 45: 783–806. 9. Westropp JL, WELK KA, Buffington CT. Small adrenal glands in cats with feline interstitial cystitis. The Journal of urology 2003; 170: 2494–2497. 10. Buffington CAT. Comorbidity of interstitial cystitis with other unexplained clinical conditions. The Journal of urology 2004; 172: 1242–1248.

11. Stella JL, Lord LK, Buffington CAT. Sickness behaviors in response to unusual external events in healthy cats and cats with feline interstitial cystitis. Journal of the American Veterinary Medical Association 2011; 238: 67–73. 12. Ellis SLH, Rodan I, Carney HC, et al. AAFP and ISFM feline environmental needs guidelines. Journal of Feline Medicine & Surgery 2013; 15: 219–230. 13. Bradshaw JWS. Sociality in cats: A comparative review. J Vet Behav Clin Appl Res 2016; 11: 113–124. 14. Heath S. Understanding feline emotions: … and their role in problem behaviours. J Feline Med Surg 2018; 20: 437–444. 15. Cline MG, Burns KM, Coe JB, et al. 2021 AAHA Nutrition and Weight Management Guidelines for Dogs and Cats. J Am Anim Hosp Assoc 2021; 57: 153–178. 16. Freeman L, Becvarova I, Cave N, et al. WSAVA Nutritional Assessment Guidelines. J Feline Med Surg 2011; 13: 516–525. 17. Wei A, Fascetti AJ, Villaverde C, et al. Effect of water content in a canned food on voluntary food intake and body weight in cats. Am J Vet Res 2011; 72: 918–923. 18. Markwell PJ, Buffington CA, Chew DJ, et al. Clinical evaluation of commercially available urinary acidification diets in the management of idiopathic cystitis in cats. Journal of the American Veterinary Medical Association 1999; 214: 361–365. 19. Buffington CAT, Westropp JL, Chew DJ, et al. Clinical evaluation of multimodal environmental modification (MEMO) in the management of cats with idiopathic cystitis. Journal of Feline Medicine & Surgery 2006; 8: 261–268

From handy downloads to helpful guides, this crash guide has got your back. EBOOK FREE

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TABLE 1: Localization

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PARADOXICAL (Subset of Central)

PERIPHERAL

CENTRAL

VESTIBULAR DISEASE Canine & Feline CENTRAL, PERIPHERAL, I DON’T NEURO?

Alert, but can be disoriented/ confused based on severity

Normal or abnormal (depressed, stuporous, comatose)

MENTATION

HEAD TILT

Ipsilateral

Contralateral

H/R>>V Doesn’t change with position Fast phase AWAY

H/R/V Can change with head position Fast phase any direction

H/R/V Can change with head position Fast phase TOWARDS the lesion

NYSTAGMUS

MISSY CARPENTIER , DVM, DACVIM (Neurology)

Vestibular ataxia +/- cerebellar ataxia Paresis possible

Vestibular ataxia GOOD STRENGTH

GAIT

SMALL ANIMAL WEBINAR

Know the difference between peripheral vs central vestibular? Learn the difference in this webinar! If you missed Dr. Missy Carpentier-Anderson’s webinar on October 24, 2023 entitled Canine and Feline Vestibular Disease, read the highlights below! Want to learn more about vestibular disease? Tune in to learn how to differentiate peripheral from central vestibular disease and, based on the neurolocalization, the most common differential diagnoses and treatments!

FACIAL NERVE

+/-

HORNER’S

+/-

+/-but is rare

OTHER CN DEFICITS SPECIFICALLY V-XII)

+/-

CP DEFICITS

YES (lesion side)

WATCH FULL WEBINAR

TABLE 2: Differential Diagnosis Based on Localization

Vestibular disease is a frequent presenting complaint for our patients. The question you should always be asking yourself once you evaluate your vestibular patient is, is it peripheral or central? Below you will find a brief description of vestibular disease, followed by two charts that will: 1) Help you determine if your neurologic findings point towards a peripheral or central localization (Table 1) AND 2) Provide differentials for a peripheral vs central localization (Table 2) The vestibular system refers to all parts of the body that set up balance and orientation. When we discuss the vestibular system, we divide it into peripheral (with the ear) and central (within the brain). With peripheral vestibular disease, we have a problem within the petrous temporal bone and our focus involves the middle and/ or inner ear. With central vestibular disease, we are focused on the brainstem or the cerebellum. Using your neurologic examination, you should be able to tell if your patient (more confidently with dogs than cats), neurolocalizes peripheral or central. When I look at a vestibular patient, they are all peripheral until proven otherwise. You don’t want your patient to have a central vestibular disturbance, so you use your evaluation to know if there is anything that tells you that you need to be more focused on the brainstem or cerebellum in that patient. THEN THERE ARE CATS… Every part of your exam can point to a peripheral vestibular problem in a cat, and they are central. Unless I have a very obvious middle ear infection or a severe upper respiratory infection with a cat, I would never bet that a cat is peripheral (and trust me early on I made this mistake many times, lesson learned!). They always have the potential to be central, simply because they are a cat.

Just like every neurologic patient, you are going to start with the signalment, history, and your physical evaluation. Then, you will move onto your hands off and on neurologic evaluation. The nice thing about vestibular disease is it is pretty easy to know that that is what you are dealing with if a head tilt is present. Is there a head tilt? Yes, well there you go your patient has vestibular disease. Now we need to figure out if it is peripheral or central with our examination. Below is a chart for determining peripheral vs central disease. You will also notice that there is a category for paradoxical. Paradoxical is a form of central vestibular disease due to a disturbance involving either the flocculonudular lobe of the cerebellum or the caudal cerebellar peduncle. Another category of peripheral vestibular disease that is not in the chart is bilateral peripheral – these patients will NOT have a head tilt, no pathologic or physiologic nystagmus, they do have side to side head excursions, and are found with a crouching posture due to decreased extensor tone. The most common presenting complaint for these animals (most commonly cats), is that they are anorexic or are vomiting due to the disequilibrium. The most common diagnosis is a bilateral otitis media (hopefully without intra-cranial extension, but again cats…). Webinar Highlights

PERIPHERAL

CENTRAL

DEGENERATIVE

Lysosomal storage diseases

Arachnoid cyst COMS (Caudal occipital malformation syndrome) Hydrocephalus

Congenital vestibular disease Idiopathic vestibular disease

ANOMOLOUS

METABOLIC

Hypothyroidism

Aural neoplasia Malignant nerve sheath tumor

NEOPLASTIC

Intracranial neoplasia (primary vs metastatic)

NUTRITIONAL

Thiamine deficiency

Otitis media/interna with intracranial extension MUO (meningoencephalitis of unknown origin) Infectious inflammatory (FIP)

Otitis media/interna nasopharyngeal polyps PSOM (Primary secretory otitis media)

INFLAMMATORY

Ototoxic (aminoglycosides, iodophors, diuretics, cisplatin, chlorhexidine)

TOXIC

+/-but is rare

TRAUMATIC

Inner ear trauma

Head trauma

VASCULAR

Cerebrovascular accident (paradoxical)

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FELINE UPPER RESPIRATORY DISEASE The Sneezing Cat: SNEEZING, ULCER, INFECTION?…OH MY!

be reactivated due to stress, illness, or immunosuppression and can result in intermittent reactivation and shedding of the virus, which can also occur in the absence of clinical signs in cases of chronic, latent FHV infection. Both FCV and FHV-1 are mainly transmitted from cat to cat but can also be transmitted in the environment and on fomites. FHV-1 is susceptible to common disinfectants, but FCV can persist in the environment for about a month and is resistant to many common disinfectants; bleach is the preferred agent for killing the virus. Cats with URT signs should be isolated and strict hygiene practices should be followed. FCV and FHV-1 can best be detected by polymerase chain reaction (PCR) in conjunctival and oropharyngeal swabs. Caution should be taken when interpreting any FCV RT-PCR- positive result because of the poor correlation between the presence of viral RNA and clinical signs; a negative result does not rule out FCV infection and healthy cats can test positive. All cats should be vaccinated against FCV and FHV-1 (core vaccine). Vaccination usually protects from disease but not from infection. Considering the high genetic variability of FCV, changing to different vaccine strain(s) may be of benefit if significant disease occurs or recurs in fully vaccinated cats. Vaccination protocols for cats in multi-cat environments should adopt yearly schedules as per the AAFP vaccination guidelines. Infection-induced immunity is not life-long and does not protect against all strains, therefore vaccination of cats that have recovered from caliciviral disease is also recommended.

BACTERIAL INFECTIONS The main bacterial pathogens in cats causing URT include Chlamydia psittaci, Mycoplasma felis, and Bordetella bronchiseptica. Although these can be primary pathogens, they are more commonly secondary to and concurrent with viral infection. Viral agents damage the respiratory epithelium, making cats (especially young cats) more susceptible to opportunistic pathogens, such as staphylococci, streptococci, and other bacterial pathogens. Most cats with mucopurulent nasal discharge maintain normal appetite and attitude and experience spontaneous resolution of illness within 10 days without antimicrobial treatment. The ISCAID Working Group recommends that antimicrobial treatment be considered within the 10-day observation period only if fever, lethargy, or anorexia is present concurrently with mucopurulent nasal discharge. A more extensive diagnostic workup should be considered for cats with URTD of >10 days of duration, particularly in the face of therapeutic failure after treatment of suspected acute bacterial URI.

DR. PETRA CERNA , MRCVS, AFHEA, AdvCertFB

Colorado State University

Sneezing, ulcer, infection?...Oh my! MVDr. Petra Cerna, PhD, MRCVS, CertAVP, AFHEA, AdvCertFB reviews what you need to know when it comes to different feline upper respiratory diseases. Learn how to approach these feline cases and what to consider for your diagnostic workup for upper respiratory tract signs in cats. If you missed MVDr. Petra Cerna on November 28, 2023 entitled Case-Based Approach to the Sneezing Cat, read the highlights below!

SMALL ANIMAL WEBINAR

WATCH FULL WEBINAR

TABLE 1: First-line antimicrobial options for bacterial respiratory infections in the dog and cat.

Upper respiratory tract (URT) diseases are a commonly encountered in cats and can be both acute and chronic in presentation and challenging and frustrating to treat in cats. There are several differential diagnoses for URT in cats. Most commonly, especially in younger cats, infectious agents are the main cause of URT. The pathogens that most commonly cause URT infections in cats are viral, such as feline herpes virus (FHV- 1) and feline calicivirus (FCV), or bacterial, including (Bordetella bronchiseptica, Mycoplasma spp., and Chlamydophila felis). Fungal organisms such as cryptococcus, aspergillosis can also cause URT signs in cats, especially in endemic areas. Chronic idiopathic rhinitis is commonly seen in cats and is typically considered a diagnosis of exclusion. Other diseases such as nasopharyngeal polyps, nasopharyngeal stenosis, and foreign bodies can cause URT in cats. Neoplasia such as lymphoma or adenocarcinoma can be seen, especially in older cats, and less commonly tooth root abscesses, fistulas, and laryngeal disease can be seen in cats with URT. In some cats, more than one cause of URT disease can be seen and it is therefore important to identify the underlying causes as well as most of these diseases are treatable in cats and have a good prognosis. Clinical signs that can be seen in cats with URT are sneezing and nasal congestion, ocular or nasal discharge, oral ulceration (mainly with feline calicivirus), stertor or stridor. In patients with systemic signs fever, lethargy, and inappetence/anorexia can occur. In some cases, mainly with fungal infections and neoplasia, facial asymmetry can be present, and these patients

can also present with submandibular lymphadenopathy. On the other hand, patients with nasopharyngeal polyps can present with stertorous breathing and/or otitis. While nasopharyngeal foreign bodies usually present as acute onset of sneezing and reverse sneezing, gagging, and difficulty swallowing. INFECTIOUS DISEASES FELINE HERPESVIRUS & CALICIVIRUS The pathogens that most commonly cause URT infections in cats are viral. Feline herpes virus (FHV-1) and feline calicivirus (FCV) account for approximately 90% of all feline URT disease. Viral URT disease is especially common in kittens and stressed or immunocompromised adults. Some adult cats with idiopathic chronic rhinitis are thought to have had viral (FHV or FCV) URT infections in early life as well. FCV commonly causes oral ulceration, which affects the tongue and the soft palate. These ulcers contribute to ptyalism and oral pain and result in inappetence. Cats with FHV-1 have more marked ocular signs, including blepharospasm, conjunctivitis, keratitis, chemosis, and superficial ulceration (dendritic ulcers; Figure 1). These viral pathogens enter through the oral and nasal conjunctiva; FHV-1 and FCV replicate in the nasal mucosa, nasopharynx, and tonsils. Viral shedding occurs throughout the duration of clinical signs, but many cats also continue shedding after resolution of clinical signs. In most cases, clinical signs resolve within two weeks, but shedding can continue for another few weeks or even lifelong in some cats. Cats with FHV-1 can also often be latently infected in the trigeminal ganglion and the virus can

First-Line Drug Options

Infection Type

Acute bacterial upper respiratory infection (URI) in cats.

Doxycycline or amoxicillin per os (PO)

Doxycycline or amoxicillin PO Base the choice on C & S if available

Chronic bacterial URI in cats

Table 1: Taken from Lappin et al. Antimicrobial use Guidelines for Treatment of Respiratory Tract Disease in Dogs and Cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases. J Vet Intern Med. 2017 Mar;31(2):279-294.

Figure 1: Fluorescein stain in a cat with corneal ulcer secondary to FHV-1 infection. Photo courtesy of Dr. Petra Cerna, PhD, MRCVS, CertAVP, AFHEA, AdvCertFB.

Continued on Page 16

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TREATMENT Treatment of feline URT disease depends on the underlying cause, whether signs of disease are acute or chronic, and the extent and severity of systemic illness. Chronic URT disease can be frustrating to treat, and often for cats with chronic idiopathic rhinitis there is no cure. Please see recommendations for bacterial infections in cats with URT above (Table 1). Cats infected with FHV-1 can be treated with famciclovir 90 mg/kg TID for 21 days or with cidofovir topically if only ocular signs are present. For cats with chronic rhinitis, the treatment is not always successful and individual cats might respond to different therapy. Anti-inflammatory doses of systemic corticosteroids may help in cases of lymphoplasmacytic inflammation. Some cats may respond to antihistamines but further research with new immune modulatory drugs in this field is needed. Nasopharyngeal polyps can be removed by simple traction and is considered first-line treatment, but a ventral bulla osteotomy can be considered if clinical signs recur, however there is a risk of development of Horner’s syndrome after removal, which is mainly transient but may be permanent in some cats. Nasopharyngeal stenosis can be treated with balloon dilation and stent placement. Anti-inflammatory medications such as corticosteroids can also be considered in cats with nasopharyngeal polyps or stenosis. Foreign bodies might require endoscopic removal or nasal flushing (post visualization with endoscopy). PROGNOSIS The prognosis for cats with URT signs depends on the nature of the underlying disease. Feline URT infections are generally associated with high morbidity (especially in at-risk populations) but low mortality. Most infections are typically self-limiting in young adult immunocompetent cats. Poorer prognosis is seen in kittens and cats with systemic clinical signs, such as viral pneumonia, and concurrent infectious disease, such as panleukopenia. Cats with chronic rhinitis will likely always have some clinical signs.

References

oral ulcers etc.) but additional diagnostic tests might be needed, especially for cats with chronic URT signs. All cats should be tested for FIV/FeLV as URT disease can be associated with immunosuppression. Complete blood cell count and serum biochemistry are indicated in cats that are systemically unwell or have chronic clinical signs. Please see the above discussion on PCR testing for infectious agents. Diagnostics for cats with chronic URT signs and/or localizing signs should be more thorough given the broad range of differential diagnoses. Oral examination under sedation or anesthesia should be performed to fully assess the extent of dental disease and its potential contribution to URT signs. Diagnostic imaging should be performed in cats with chronic respiratory signs or in cats that are not responding to treatment. Computed tomography (CT) is now used instead of traditional skull radiographs to assess nasal passages and bullae for potential masses, lytic lesions, or polyps. Rhinoscopy is used to assess the nasal cavity and nasopharynx for possible masses, foreign bodies, and stenosis. Antegrade rhinoscopy is challenging and can be performed with narrow rigid scopes (Figure 2). Retroflex rhinoscopy is commonly performed to assess the nasopharynx (Figure 3). A biopsy is indicated in cases of a mass in the nasal passages and can be done blind or guided during rhinoscopy.

OTHER CAUSES Nasopharyngeal polyps and nasal tumors can cause chronic URT signs in cats. These polyps originate in the Eustachian tube or middle ear and are a source of upper airway obstruction. The exact etiology of these polyps is not known but are benign masses. Polyps are generally found in young cats, while nasopharyngeal masses of neoplastic origin (e.g., lymphoma or adenocarcinoma) are seen in older cats. Nasal tumors are a less common cause of URT signs. These tumors tend to be locally invasive without distant metastases. Nasal/nasopharyngeal foreign bodies are less common in cats than in dogs, and most of them are plant material. Nasopharyngeal stenosis is not common in cats but can be seen in young cats as a congenital disease or be acquired secondary to chronic infection/ inflammation. Dental disease can be the cause of URT signs in cats; tooth root abscesses and fistulas should be considered a differential diagnosis for cats with URT signs, particularly unilateral discharge with other evidence of dental disease. DIAGNOSTICS The diagnosis of feline URT infection often is based on history and physical examination (ocular and nasal discharge, ocular/

1. Bannasch MJ, Foley JE (2005). Epidemiologic evaluation of multiple respiratory pathogens in cats in animal shelters. J Feline Med Surg, 7: 109-19. 2. Coyne KP, Dawson S, Radford AD, Cripps PJ, Porter CJ, McCracken CM, Gaskell RM (2006). Long term analysis of FCV prevalence and viral shedding patterns in naturally infected colonies of domestic cats. Vet Microbiol, in press. 3. Radford AD, Addie D, Belak S, et al. Feline calicivirus infection. ABCD guidelines on prevention and management. J Feline Med Surg2009; 11:556-564. 4. Schorr-Evans EM, Poland A, Pedersen NC (2003). An epizootic of highly virulent feline calicivirus disease in a hospital setting in New England. J Fel Med Surg, 5: 217-226. 5. Hurley KF, Sykes JE (2003): Update on feline calicivirus: new trends. Vet Clin North Am Small Anim Pract 33(4), 759-772. 6. Ruch-Gallie RA, Veir JK, Hawley JR, Lappin MR (2011): Results of molecular diagnostic assays targeting feline herpesvirus-1 and feline calicivirus in adult cats administered modified live vaccines. J Feline Med Surg 13(8), 541-545. 7. Sykes JE, Studdert VP, Browning GF (1998): Detection and strain differentiation of feline calicivirus in conjunctival swabs by RT-PCR of the hypervariable region of the capsid protein gene. Archives of Virology 143(7), 1321-1334. 8. Quimby J, Lappin MR. Update on feline upper respiratory diseases: Introduction and diagnostics. Compend Cont Ed Pract Vet2009; 31:554-564. 9. Scherk M. Snots and snuffles: Rational approach to chronic feline upper respiratory syndromes. J Feline Med Surg2010; 12:548-557. 10. Burns RE, Wagner DC, Leutenegger CM, et al. Histologic and molecular correlation in shelter cats with acute upper respiratory infection. J Clin Microbiol 2011; 49:2454-2460. 11. Helps CR, Lait P, Damhuis A, et al. Factors associated with upper respiratory tract disease caused by feline herpesvirus, feline calicivirus, Chlamydophila felis, and Bordetella bronchiseptica in cats: Experience from 218 European catteries. Vet Rec2005; 156:669-673. 12. Thiry E, Addie D, Belak S, et al. Feline herpesvirus infection. ABCD guidelines on prevention and management. J Feline Med Surg 2009; 11:547-555.

Figure 3: Visualization of normal nasopharynx with flexible endoscopy in a cat. Photo courtesy of Dr. Petra Cerna, PhD, MRCVS, CertAVP, AFHEA, AdvCertFB.

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Figure 2: Normal nasal turbinates in a cat during rigid rhinoscopy. Photo courtesy of Dr. Petra Cerna, PhD, MRCVS, CertAVP, AFHEA, AdvCertFB.

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A CLINICALLY RELEVANT REVIEW Imaging the Blocked Cat: BLOCKED CAT, STAT!

uroliths are seen. 3 Small stones or mineralized urinary bladder debris are not always visible on radiographs, especially when the urinary bladder size is small. Other radiographic findings are variable and are dependent on the severity of various sequelae. Renal size, shape, and margination are usually normal. Small and irregularly shaped kidneys may indicate chronic kidney disease, renal cortical infarction, atrophy secondary to prior obstruction, or, more uncommonly, renal hypoplasia/ dysplasia. Renomegaly inconsistently occurs as a consequence of ascending pressure from the urethral obstruction itself, but can also indicate acute kidney injury, pyelonephritis, hydronephrosis from uroliths, feline infectious peritonitis, perinephric pseudocyst, or renal neoplasia such as lymphoma. Discussed further in the ultrasound section, retroperitoneal and peritoneal effusion/steatitis is common and manifests as soft tissue opaque wisps superimposed over the surrounding fat. Effusion can make it harder to visualize the kidneys, ureters, and urinary bladder due to border effacement. The urinary bladder is often large in cats with UO. However, a normal or small bladder size does not rule out the presence of obstruction. In the absence of peritoneal effusion, not visualizing the urinary bladder prior to urethral catheterization should raise concern for urinary bladder rupture, a finding that should be further interrogated with ultrasonography. RETROGRADE CYSTOGRAPHY AND URETHROGRAPHY Positive contrast radiographic studies have fallen out of favor in veterinary medicine due to more advanced imaging such as ultrasonography and computed tomography. However, these studies still hold immense value for evaluating the urinary tract for rupture and evaluating the urethra for stones. Urethral rupture presents a particular diagnostic challenge as tears are not easily identified with ultrasound and resulting urine leakage can occur into the surrounding soft tissues in addition to or instead of the peritoneal space. Clinically, urethral tears are suspected during difficult or unsuccessful catheterization and can result from mural inflammation and/or improper unblocking technique. A urethral tear should also be considered in any animal with persistent or worsening azotemia following unblocking.

retroperitoneal and peritoneal fat stores, especially when they are overweight. Excessive fat stores can displace the kidneys ventrally and medially. Additionally, the ureters are sometimes visible dorsally and laterally as thin and wispy soft tissue opaque tubes coursing between the kidneys and urinary bladder that should not be confused with retroperitoneal effusion. Increased fat stores also increase conspicuity of the deep circumflex iliac arteries and veins that lie dorsal to the L6 vertebral body. On lateral radiographs, the summation effect of these vessels viewed end on can be confused with faint calculi. Some cats have increased fat in the renal hilus which will appear as a focal region of lucency. Finally, cat kidneys are smaller as compared to those of the dog, with a renal length measuring approximately 2-3 times the length of the body of the L2 (L2L) vertebral body. The kidneys of younger and intact cats (up to 3.2x L2L) are usually larger as compared to their older and neutered counterparts (~1.9-2.6x L2L). Finally, over one-third of cats have a mineral opaque os penis visible on radiographs that should not be confused with a mineralized plug or urethrolith. 1 The os penis is more easily seen in older cats suggesting mineralization or size may increase with age, and its presence is not correlated to increased risk for feline urinary tract disease or UO. 1 ABDOMINAL RADIOGRAPHIC FINDINGS Abdominal radiographs are most useful for screening cats for radiopaque urinary calculi within the kidneys, ureters, urinary bladder, or urethra. Cranial and caudal landmarks of properly collimated abdominal radiographs are typically the diaphragm and femoral heads, respectively. However, including or obtaining a separate radiograph centered on the perineal soft tissues helps evaluate for stones or mineralized plugs in the urethra. Timing of radiography before or after urethral unblocking carries advantages and disadvantages either way. A recent study 2 demonstrated that preprocedural radiographs improve visualization of mineralized plugs or stones in the urethra that may be dislodged during unblocking. However, post-procedural radiographs are usually more comfortable for the patient due to decreased pain and increased compliance following unblocking and sedation/analgesic drug administration. Post-procedural radiographs also help evaluate the terminal location of the indwelling urinary catheter. The majority of cystoliths and urethroliths are composed of either struvite or calcium oxalate, both of which are radiopaque. Struvite is the predominate composition of urethral plugs whereas calcium oxalate is the predominate composition of nephroliths and urethroliths. While differences have been reported, the shape and margination (smooth vs rough) of stones cannot be reliably used to determine a stone’s composition. Less common uroliths such as urate and cystine have historically been considered radiolucent and hence not seen on plain film radiographs. However, recent evidence suggests urate and cystine calculi are detected with digital radiography and hence should not be excluded as a differential if mineral opaque

MARC SEITZ , DVM, DACVR, DABVP, BCSCP (Canine and Feline Practice)

Assistant Clinical Professor of Diagnostic Imaging Mississippi State University, Mississippi State, MS

SMALL ANIMAL WEBINAR

Ever imagined what it would be like to visualize a feline urethral obstruction during a diagnostic imaging procedure? Dr. Marc Seitz, DACVR, DABVP (Canine and Feline Practice) reviews what you need to know when it comes to imaging the feline urethral obstruction – from abdominal radiographs to POCUS. If you missed Dr. Marc Seitz on November 8, 2023 entitled Imaging the Blocked Cat: A Clinically Relevant Review, read the highlights below!

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I NTRODUCTION Feline urethral obstruction (UO) is a common complication of feline lower urinary tract disease (FLUTD) in male cats. Common causes include mucous or crystalline urethral plugs, mural inflammation or spasms, and urethroliths. In many cases, a definitive structural cause of the UO is not identified and termed “idiopathic.” Etiologies contributing to obstruction include feline idiopathic cystitis, crystalluria, calculi, urinary infections (more common in cats older than 10 years of age), and neoplasia. Much of what is considered standard of care remains unchanged. Goals of therapy include patient stabilization, restoration of urethral patency, a diagnostic work-up to identify the underlying cause and etiology, supportive care, and long-term management of the underlying disease. These proceedings will review the role of diagnostic imaging in feline patients with UOs, including abdominal radiography, iodinated contrast studies, and abdominal point-of-care ultrasound (POCUS). EMERGENCY STABILIZATION Feline UO has the potential to cause severe morbidity and even mortality due to the resultant hyperkalemia, metabolic acidosis, cardiovascular compromise, arrhythmias, uremia, and acute kidney injury. Once obstruction occurs, these metabolic derangements occur within 24 hours and, if left untreated, death ensues within 3-6 days. Despite this, evidence and clinical experience demonstrate

that only a small percentage (~12%) of patients present severely metabolically affected. Still, most patients do benefit from some form of stabilization. As a result, patient stabilization should take priority over any diagnostic imaging procedures as feline UO is easily diagnosed during the physical examination. Fluid therapy in the form of a balanced isotonic crystalloids is the cornerstone of stabilization. Patients also benefit from pain medication and/or anxiolytic drugs. In cases of moderate to severe hyperkalemia, therapies that augment fluid therapy in the lowering of serum potassium include insulin, dextrose, and/or albuterol. Additionally, calcium gluconate can improve the resting membrane potential of cardiomyocytes until hyperkalemia improves. Once stabilized, diagnostic imaging procedures such as radiography, contrast radiography, and abdominal POCUS may be more safely performed. Still, it is reasonable and often more ideal to restore urethral patency prior to imaging.

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RADIOGRAPHIC APPEARANCE OF THE NORMAL FELINE URINARY TRACT

Abdominal radiographs are an essential part of the blocked cat work- up. When evaluating radiographs, a systematic approach should be used to ensure all peritoneal, retroperitoneal, and extra-abdominal structures are evaluated. However, the genitourinary tract and surrounding soft tissues should be closely scrutinized. While there are numerous radiographic species differences as compared to the dog, the most important involves fat. Cats typically have increased

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IS THERE PERITONEAL OR RETROPERITONEAL EFFUSION? • Peritoneal effusion is very common in cats with UO, with an incidence ranging between 33% and 93% across four studies 5,7,8,9 . Retroperitoneal effusion is reported in up to 36% of patients 5 . Improving ultrasound technology combined with increasing clinician skill level with POCUS have likely in part contributed to increasing rates of detection. Numerous fluid types are possible including modified transudate, exudate, urine, and hemorrhage. The presence of urine does not always indicate urinary rupture as transmural leakage is postulated to occur in animals as it does in humans. Peritoneal effusion can also occur and/or mildly progress immediately following cystocentesis. Since ultrasound is incapable of differentiating fluid types based on their appearance alone, abdominocentesis may be performed for fluid analysis and cytology. However, this may not be necessary all the time since many cases of peritoneal effusion are self- limiting with supportive care. IS THERE EVIDENCE OF URINARY BLADDER RUPTURE? • The accurate diagnosis of urinary bladder rupture with ultrasound is challenging. An accurate diagnosis requires visualization of a defect in or thinning of the bladder wall in the presence of confirmed uroperitoneum. A false negative exam is possible as urinary wall thickening (whether pathologic or secondary to insufficient urine volume) can hide defects in the wall. On the contrary, a false positive may occur if the edge shadowing artifact is misinterpreted as a rent in the apex of the urinary bladder wall. It is also important to remember that uroperitoneum can occur with rupture of the proximal urethra and uroretroperitoneum can occur with rupture of the ureters. While radiograph or CT contrast studies are still the gold standard for diagnosing rupture anywhere throughout the urinary tract, ultrasonographic contrast cystography using agitated saline is quite helpful at confirming urinary bladder or proximal urethral rupture 10 . Agitated saline is created by rapidly injecting saline (32 mL) admixed with room air (3 mL) back and forth between two 35mL syringes via a three-way stopcock. The author finds smaller syringes easier to work with.

ULTRASONOGRAPHIC APPEARANCE THE NORMAL FELINE URINARY TRACT

of information gleaned from these rapid exams has expanded. The purpose of this session is to review the role of POCUS in feline patients presenting with UO. Although experienced clinicians can glean a lot of information from focused ultrasound exams, they should never be relied on for a definitive diagnosis or to rule out a condition. The primary purpose of POCUS is to identify potential “game changers” and confirm them through other more definitive diagnostics. Clinicians can expect to find a lot of ultrasonographic abnormalities in blocked cats, even when the underlying cause is idiopathic cystitis. Abnormalities are the result of ascending pressure throughout the genitourinary tract and the inflammatory nature of most underlying etiologies. A retrospective study 5 described the following common findings among 87 cats with naturally occurring UO (and without cystocentesis): echogenic urinary sediment, bladder wall thickening, pericystic effusion, hyperechoic percystic fat, and increased urinary echoes. Specific to the kidneys, mild renal pelvic dilation, renomegaly, perirenal effusion, hyperechoic perirenal fat, and ureteral dilation were commonly observed. Importantly, the authors found no association among any findings and the risk for short-term recurrent UO. Some of these findings overlap with more insidious etiologies such as pyelonephritis, hydronephrosis, and urinary bladder rupture. Furthermore, therapies such as sedation and aggressive fluid therapy can induce abnormal findings such as renal pelvic dilation and peritoneal effusion. This is partly why POCUS cannot be relied on for a definitive diagnosis. Fortunately, most of these findings are transient and resolve with supportive care. Previously reported point-of-care ultrasound exam techniques 2,6 may be used to evaluate blocked cats. Transducer pressure should be minimized since excessive amounts can displace peritoneal effusion outside of the field-of-view, increasing the potential for a false negative, especially when the patient is standing 3 . Excessive transducer pressure can also distort or displace soft tissue structures located in the near field. If not already part of a clinician’s routine POCUS exam, both kidneys should be evaluated. When evaluating POCUS locations containing the urinary bladder and kidneys, more time can be spent fanning or sweeping through these target organs in both longitudinal and transverse planes. Evaluation of the ureters and the majority of the viewable urethra are beyond the intended purpose of a standard POCUS exam. If the urinary bladder is small or not identified and a urethral catheter is in place, 10-20 mL of sterile saline can be instilled to improve visualization of the wall and intraluminal contents. When evaluating the urinary tract, the following clinical questions can guide the clinician’s POCUS of the typical blocked cat. WHAT CLINICAL QUESTIONS CAN BE ASKED AND ANSWERED WITH ABDOMINAL POCUS

The procedure is technically simple considering most patients already have an indwelling urinary catheter in place. Most water-soluble iodinated contrast agents can be used. The author prefers non-ionic monomers due to their lower osmolality and reasonable viscosity. Examples include iohexol and ioversol with a concentration ranging between 240-350 mg/ mL. Diluting the contrast 1:1 or 1:2 with sterile saline is less irritating and improves visualization of the urethral wall. If both cystography and urethrography are to be performed, cystography is typically performed first. The patient should be heavily sedated or placed under general anesthesia. If not already done so, a urinary catheter should be placed in a sterile fashion such that the tip terminates just inside the urinary bladder neck. Preprocedural radiographs are obtained to confirm proper catheter placement and to establish a baseline. The urinary bladder should be drained and then refilled with dilute iodinated contrast until it is moderately distended based on palpation and radiographic appearance. The typical cystogram dose for most cats ranges between 2-5ml/kg. The author typically starts with 2ml/kg and then obtains radiographs. Subsequent doses of 1-2ml/kg are administered with repeat radiographs performed after each dose. Retrograde filling of the ureters can occur with overfilling of the urinary bladder. Leakage of iodinated contrast into the peritoneal space confirms rupture, as evidenced by discrete streaks of contrast and/or a diffuse increase in opacity throughout the entire peritoneal space. Once the cystogram is complete, the urethrogram may be performed by repositioning the urinary catheter into the distalmost aspect of the penile urethra. The urinary catheter should be left distended as the pressure helps dilate and fill the urethra with contrast. In fact, if the urinary catheter diameter is considerably smaller than the urethral luminal diameter, inadvertent filling of the urethra with contrast can occur during the cystogram. Once the catheter is properly placed, 5 mL of the same diluted contrast is injected into the urethra. Radiographs should ideally be obtained during injection after the final 1-2 mL to ensure adequate filling and distention of the urethra. This may require gentle clamping of the tip of the prepuce to ensure the catheter does not move retrograde during injection. Obviously, hands should be kept out of the primary X-ray beam and protected from scatter radiation with the use of lead gloves and/or shields. The normal feline penile urethra is smaller in diameter than the other sections and should not be confused with a stricture. Similar to that above, a urethral tear is confirmed if there is extravasation of contrast into the surrounding soft tissues or peritoneal space. Calculi are seen as persistent radiolucent filling defects in the contrast column that do not clear with repeat boluses of contrast. While air bubbles appear as similar filling defects, they are easily cleared with repeat injections of contrast. As mentioned above, iodinated contrast is irritating to the mucosal layer of the urinary tract. Therefore, all contrast should be removed upon completion of the study. If no tear is identified, the author additionally flushes the urethra (following a urethrogram) or lavages the urinary bladder (following a cystogram) with a small amount of sterile saline to dilute any residual contrast.

The ultrasonographic appearance of the feline urinary tract differs from dogs in many ways. While more superficially located, excessive transducer pressure can make finding feline kidneys harder due to their mobile nature as compared to the dog. Cat kidneys are more oval in shape with a consistent size across breeds, ranging between 3.0-4.5 cm in length. Renal size may be slightly larger in cats that are intact, male, and/or Maine Coon. Additionally, the right kidney may be slightly longer than the left in some cats. Fat deposition in the renal cortex and sinus and excretion into the urine changes the expected ultrasonographic appearance of the urinary tract as compared to the dog. Fat is hyperechoic and hence increases the echogenicity of any parenchyma in which it is contained. Increased renal hilar fat results in hyperechoic tissue in and adjacent to the renal sinus, which attenuates the beam and sometimes causes faint distal acoustic shadowing, mimicking mineralization. The echogenicity of the renal cortex is highly variable and often hyperechoic to the liver and/ or spleen, especially in older neutered male cats. As a result, increased renal cortical echogenicity cannot always be presumed to be pathologic as is seen with pyelonephritis, tubulointerstitial or glomerular nephritis, feline infectious peritonitis, or renal lymphoma. The outer portion of the renal medullae in some cats contains a well-demarcated hyperechoic band, termed a “medullary rim.” While a medullary rim is reported with numerous pathologies, it should not be over-interpreted in an otherwise normal cat. The renal pelvis is inconsistently seen within the renal sinus, and normally measures less than 1-2 mm in thickness. However, mild renal pelvic dilation up to 3.2 mm in one or both kidneys may be normal in some feline patients, especially when receiving fluid diuresis. The normal ureters are uncommonly seen in cats as they measure < 0.4 mm in diameter. Similar to the dog, the feline urinary bladder wall measures 1-2 mm in thickness. An elongated urinary bladder neck is common in the cat. Finally, normal cats without lower urinary tract disease can have a mild to moderate amount of hyperechoic urinary bladder debris from lipiduria 4 . Curiously, the degree of lipiduria is independent of body condition score. Unfortunately, fat is hard to distinguish from cellular/proteinaceous debris, sediment, and hemorrhage. Although lipid debris does not typically settle out with gravity or cause distal acoustic shadowing, the author relies heavily on the presence or absence of lower urinary signs as well as urinalysis results to interpret urinary bladder debris in the cat. ABDOMINAL POCUS In general practice and emergency medicine, point-of-care ultrasound (POCUS) exams have gained popularity as a valuable adjunct triage tool. Unlike full diagnostic ultrasound exams, POCUS techniques are designed to answer specific clinical questions in a yes or no format to help guide the initial diagnostic and therapeutic plan. For example, abdominal POCUS was originally designed to identify abnormal free fluid most likely to be hemorrhage in human trauma patients (i.e., Focused Assessment with Sonography for Trauma, or FAST). Soon after, clinicians realized POCUS also aided in the bedside evaluation of non-traumatized patients. As POCUS has gained popularity in both human and veterinary medicine, the amount

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