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276 Cards in this Set

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How can you tell if a patient w/ signs of HAC does not just have DM
There should be glucosuria w/ DM
What are 3 other dzs that can cause adrenal fxn testing abnormalities, besides HAC
Uncontrolled DM
Liver dz
Renal failure
What is the most Sp test for HAC
ACTH Stim
What is the most Se test for HAC
LDDST
T/F: ACTH is a good test for IDing iatrogenic HAC
True
It can also be used to monitor therapy
What does a high resting cortisol level mean in an ACTH stim test
?
What is considered a + result for ACTH stim
Post-ACTH cortisol value > reference range
T/F: A drawback to the LDDST is the # of false -s you can have
False
The problem is it is not very Sp, and there are many false +s
What is considered a positive result for LDDST
Cortisol > 1ug/dL (or the RI) at any point in the test (3hrs, or 8hrs)
What is meant by "rebound" LDDST results
Cortisol suppresses to <50% of baseline at 3hrs, but jumps back up at 8hrs
Consistent w/ PDH
T/F: A patient w/ a positive LDDST has HAC
False
You must look at the big picture; + LDDST alone is not definitive!
What does it mean if the Cortisol is high before ACTH, but w/in post-ACTH RI after giving ACTH
? Inconclusive; do LDDST
If, after therapy for HAC the Cortisol values normalize, but there is no clinical response, what does that mean
Likely not HAC to blame for the signs
Do other diagnostics to find out reason for signs
How is the Se for Urine Cortisol:Creat
Very good
But, unacceptable Sp
Requires 2nd confirmatory test
What are 4 ways to tell b/t PDH and ADH HAC
HDDST
Endogenous ACTH
Abd U/S
LDDST (if rebounds)
How often does Cortisol suppress in HDDST testing of PDH cases
75-85% cases
T/F: There is no suppression of cortisol in HDDST testing if a case of ADH
True
What can you conclude about the source of the HAC problem if there is no cortisol suppression in a HDDST
Nothing
There is 50:50 chance of ADH or PDH
"Failure to suppress is ambiguous"
What is, reportedly, the most reliable test for differentiation of ADH from PDH
How is it interpreted
Endogenous ACTH
<10 pg/mL = ADH
>45 pg/mL= PDH
In b/t those values, ?
What is a + HDDST
Post-dexamethasone Cortisol <50% of baseline at any time during the test
Do NOT use RIs for this test, use the patient's baseline
What is the caveat for the use of U/S to tell b/t ADH and PDH
Both adrenal glands must be visualized
What is atypical HAC
Dog has signs of HAC, but normal or low cortisol [ ]s
What causes atypical HAC
Adrenal tumors making a hormone other than cortisol
OR
PDH w/ excessive production of 2 or more cortical Hs other than cortisol
How do you dx atypical HAC
ACTH Stim, but measure progesterone, 17-OH progesterone, +/- estradiol
(in addition to cortisol)
How do you tx atypical HAC
Like any other case of HAC
What are the two protocols for use of Mitotane (Lysodren) in tx of HAC
"Old Standby"- selective destruction of cortex; must monitor erll

Alternative- wipe out cortex via high dose for 25d, with H replacement starting at day 3; may be cheaper and have fewer complications
Why might the "alternative" Lysodren protocol end up actually costing more than the "traditional" protocol
Supplemental tx may add up!
What determines which method you should use when txing HAC w/ Mitotane
The owner, and their ability to "regulate" via clinical signs, etc.
How does Ketoconazole work for HAC? SEs?
Enzyme inhibition blocks production of Cortisol
Works in 75% PDH cases
Can be hepatotoxic
What does L-deprenyl work on for tx of HAC
Only the region of pituitary under influence of DA (pars intermedia)
SO, reduces cortisol in only 15-20% cases (i.e. if have pars distalis tumor, will not decrease cortisol)
But, does improve signs in 83% of cases!
What is Trilostane, and what are the benefits of it vs. Mitotane
Enzyme inhibitor
If wrong dx, can stop drug w/ "no harm, no foul"
89% have good response

Rarely can cause permanent HYPOadreno and death, but considered as safe as Mitotane
How should tx of HAC w/ Trilostane be started
Start once daily and adjust based on signs and [cortisol]

But, some need BID, and it may be best to start them that way b/c safer
What are potential SEs of Trilostane
Lethargy
Decrease appetite
Can die, rarely
How soon after starting Trilostane should you do an ACTH
10-14, 30, and 90 days after start tx (do 4-6hrs after dose)

Want post-ACTH results w/in normal PRE-ACTH range
How should you adjust Trilostane based on ACTh results
If post-ACTh cortisol <0.7, stop pill for 2days, and then re-start at lower dose (w/ another ACTh in 10-14days)

If post-ACTH >4.3, increase dose by 25-50%

If b/t 0.7 and 4.3, and clinical control seems adequate, leave alone
What is mean survival of HAC dogs on Trilostane
661 days
What txs can be used for ADH
Sx
Mitotane
Ketoconazole (helps 80%)
Trilostane
What should you do before doing sx for ADH HAC
Tx medically to stop the HAC before do sx (then replace steroids post-op)
What is the px for PDH HAC tx'd w/ Mito or Trilo
1yr- 70% still alive*
2yr- 50% still alive*
4yr- 20% still alive*

* may have died from other causes *
What is the breakdown of tumor type in ADH HAC
40% adenomas
60% AC (1/2 of are inoperable)
T/F: It is recommended that you refer for adrenalectomy in ADH
True
There can be many complications
Why do IV fluids and Abx result in temporary improvement in cases of HypoAC
Rebalances electrolytes temporarily
T/F: Addison's is often a waxing/waning dz
True
What are the 2 most impt DDx for HypoAC, and which is the hardest to tell it apart from
Acute oliguric/anuric RF***
Post-renal uremia

***= hardest to tell from
What should be your diagnostic plan for HypoAC
CBC/Chem/UA
ECG (look for bradycardia w/ sinoventricular rhythm)
Basal cortisol
ACTH stim
How does a Basal Cortisol test aid in dx of HypoAC
If result >2, can R/O
If <1, likely has HypoAC
Gray area in b/t
What is unqique about the leukogram of a patient in hospital w/ HypoAC
There is no stress leukogram, despite being chronically ill, and hospitalized
What biochem markers make HypoAC hard to tell from renal failure
Azotemia
Increased Ca
Increased K
What does it mean if the post-ACTH cortisol is higher than the baseline RI, but not w/in the post-ACTH RI
Likely HypoAC
Use signs to help guide dx
T/F: In a crisis situation, being therapy for HypoAC before you have test results
True
Best to wait to administer gluco/mineralo corticoids until have results, too, but cna use Dex if you have to
Why must you keep hypoAC patients NPO for 24hrs
It takes 24hrs for GI motility to normalize again (after the v+ they likely presented w/)
What is the fluid therapy of choice for HypoAC
0.9% NaCl
Add 2.5-5% glucose if needed
(may be hypoglycemic since no glucocorticoids)
What rate should you give fluids to for a hypoAC patient
If shocky, 90 mL/kg/hr
If not, rpelace deficit over 12-24hrs
Remember to include losses in calculation if still v+
How often must hyperkalemia be treated (besides fluids) in HypoAC
Rarely
Saline rehydration often improves electrolytes alone
T/F: If giving glucose to a Addison's pt, you should also give insulin
False
Unless diabetic, does not need
What should you use for initial gluco/mineralo replacement in hospital for HypoAC cases
Hydrocortisone
CRI preferred, but can give IV q6hrs, too
When should you switch fromn parenteral to oral mineralo/gluco replacement in a HypoAC patient
When they are eating
What happens if you change the sodium concentration too quickly in an Addison's pt
Nervous system abnormalities
What are the electrolytes like in an Addion's pt
Increased K+ and Ca2+
Decreased Na+ and Cl-

Usually Na:K <27:1
How do you use Fludorcortisone as mineralo replacement
qd or BID
Check Na+ and K+ qd for 2-3 days; adjust dose to keep wnl
PU/PD may occur
What should you use as oral glucocorticoid replacement, and how
Prednisolone
Give qd for 1-2wks, and then taper over 1-2wks
May be able to withdraw completely (50% cases) if on fludrocortisone b/c has some gluco activity
How and how often should Addison's pts be monitored post-crisis
Weekly for 2-3wks:
Na+, K+, BUN

Then, q 3-4mths for a year
Then, q 3-6mths after that
What is DOCP
Injectable mineralocorticoid replacement
Inject q 25-30d IM or SC
Less likely to cause PU/PD

BUT:
1. Can't change dose quickly
2. Most still need gluco, too
3. Just as $ as fludrocortisone
When should salt supplementation be considered in hypoAC
When Na+ low despite normal K+

Add to diet, and recheck serum Na+
What is the px for Addison's
Excellent for normal lifespan

Can decomp if miss meds
Can be $ for large dogs
T/F: Most cases of feline HAC are d/t ADH
False
Most cats have PDH
What percentage of HAC cats also have DM
90-100%!!!
When should you sample for ACTH testing in cats
0, 30, and 60 minutes
(some cats peak at 30, some at 60)
What is the most effective tx for feline PDH
Bilateral adrenalectomy
T/F: Trilostane can be used in cats
True
Why might you be more likely to question your dx of HypoAC in a cat when treating
It takes cats 3-5 days to respond to tx (slower than dogs)
Also, very rare in cats anyways
If a dog has iatrogenic HAC, what should the ACTH show (assuming patient had meds D/C for 24-48hrs prior to test, as it should)
Should have normal results
What if:
Signs of HAC
ACTH stim:
Pre- wnl
Post- increased from base,
but still low
1. Iatrogenic HAC causing adrenal gland atrophy
OR
2. Atypical HAC- check other Hs
At what age would you be able to detect congenital pituitary dwarfism
3-4mths old
Normal until then
How do you dx congenital pituitary dwarfism
R/O other DDx

GH assay (stim w/ GHRH or xylazine)

Somatomedin-C (IGF-1)

Endogenous ACTH
ACTH Stim ** do together**

T4 and TSH (if both low, may mean 2' hypothyroidism)
T/F: In cases of congenital pituitary dwarfism, you may see signs of 2' hypoAC and/or hypothy
True
What are 2 txs for congenital pituitary dwarfism
Human GH- hard to get

Progesterone (stimulates GH production from mammary tissue)
What causes feline acromegaly, and who does it affect
GH-producing pituitary tumor
Males 8-14 years
Why do cats w/ feline acromeglay often not lose wt despite their concurrent insulin-resistant DM
GH may actually make them get bigger!
How can you tx feline acromegaly
Palliate: insulin, diuretics (of goes into heart failure)

Radiation to shrink mass
What clinical signs might patients w/ feline acromegaly present w/
PU/PD
Cardiomegaly, Murmur
Enlarged head
Signs of DM
What causes CDI
Partial or complete ADH deficiency

Renal tubules and CDs are impermeable to H2O
True/False: CDI patients have a 1' PU w/ a 2' PD
True
What is the most common cause(s) of CDI

What are some other causes
Historically, idiopathic
Currently, neoplasia 66%

Head trauma
Pituitary malformation
Inflammation
Congenital (familial)
What are the signs of CDI
PU/PD
Perceived incontinence
Wt loss
V+ water
Dehydration if water-restricted
Dementia/Stupor/Ataxia/
Blindness/Seizures- if pituitary tumor
What is the USG like in CDI
Usually <1.008
Often 1.001-1.002
What is the CBC/Chem like in CDI
CBC-wnl
Chem:
Decreased BUN

If water-deprived, pre-renal
azotemia and increased Na+
When should you do CT/MRI in cases of CDI
Esp. older patients
MRI preferred
Only do if owner wants to tx tumor
How do you do Modified Water Deprivation test
R/O all but CDI, NDI, PP 1st
Water deprive until lose 5% BW (should be maximally making ADH at that point)
Give ADH
Check urine osmolality (+= 50-600% increase after ADH); can use USG, but osmolality more accurate
Who is Modified Water Deprivation testing C/I in
Azotemic patients
Those you have not R'd/O everything but PP, CDI, NDI
Which test for CDI gives the most info
MWD test
But, not always easy to do, and can be dangerous
How do you perform ADH response test
Measure drinking for 2-3days
Give DDAVP
Measure drinking for 5-7days
Check USG qd while getting DDAVP
CDI=marked decrease in urine volume and H2O consumption
Monitor Na+ for 2-4wks
Why do you monitor the plasma Na+ for 2-4 wks after doing ADH response test
If remains normal, likely CDI
If it drops, consider PP, etc.
How do you tx CDI
DDAVP (synthetic ADH)
- in conjunctival sac or oral
- give BID and monitor (or can wait for PU/PD before redose)

Consider radiation if pituitary mass
What is the px for CDI
Excellend if idiopathic or congenital (b/c can replace ADH)

Worse if pituitary mass (neuro signs w/in 2wks-5mths)

$ of tx is limiting factor
Who does PP mostly occur in
Hyperactive, lg breed dogs
What is often the hx of a patient w/ Psychogenic PD
Restriction of exercise or human contact (often, reviously v. active)
How do you test for PP
Modified Water Deprivation test
Should have little or no response to ADH since already making as much as they can
How do you interpret MWD test for PP if USG not >1.030, but dx highly suspected
Reinstitute medullay solute via parital water restriction and salt supplementation

Then, test again
(likely had medullary washout)
How do you tx PP
Gradual water restriction
Increase exercise
Get another dog?
Increase human contact
Of what age are most patients w/ 1' HyperPTism
Older
Dog- avg 11
Cat- avg 13
In which species are females predisposed to 1' hyperPTism
Cats
What is the most common cause of 1' HyperPTism
Adenoma

But, realize there is a fine line b/t adenoma and hyperplasia
What are Ca2+ and P like in 1' HyperPTism
Ca2+ high (including iCa2+)
P normal or low
What are the 2 main R/Os for high Ca2+/low P
Cancer (LSA)
OR
HyperPTism
What 4 body systems does hyperCa2+emia affect cell membrane activity and permeability in
Neuromuscular
CV
Renal (dysfxn)
GI (reduced fxn)
When does ST mineralization occur
When Ca2+ x P >60-70
Often, we do not see w/ 1' hyperPTism b/c P gets low
How is hyperPTism most commonly noted
Serendipitously on chemistry
What are the most common signs of 1' HyperPTism in dogs
LUT signs d/t calculi
(hemat, pollak, stranguria)
PU/PD
Weak/Lethargy
Poor appetite
Wt Loss/Muscle Wasting

These are the same signs as in cats, but anorexia and lethargy are most common in cats
How common is rubber jaw in cases of 1' hyperPTism
It is an uncommon sign, and occurs when bone is demineralized
How do you make a dx of 1' HyperPTism
Typical chem changes
(CBC usually wnl)
R/O cancers
Rectal palp
Thoracic/Abd rads or U/S
LN aspirates

THEN
Simultaneous plasma PTH, PTH-rp, and iCa2+

Surgical exploration/bx
What dz, besides cancer, is it impt to tell apart from 1' hyperPTism
1' Renal Failure
(iCa2+ is usually wnl iin renal failure, but is often high in 1' hyperPTism)
What is the typical USG of a patient w/ 1' hyperPTism
<1.028
(dogs usually <1.015)
What is PTH normally like in a 1' hyperPTism patient
Most are high or in the upper 1/2 of the RI

This is INAPPROPRIATE b/c high PTH should only be seen w/ low Ca2+ (in an effort to increase it)
What is the iCa2+ usually like in a 1' hyperPTism case
High
(vs. wnl for renal failure)
How do you tx 1' hyperPTism
Sx to remove abnorm tissue
Monitor Ca2+ and P after
What are 5 reasons for implementing aggressive medical therapy for hyperCa2+emia
1. Azotemia
2. Dehydration
3. Signs of hyperCa2+emia
4. Ca x P >70
5. Ca >16 mg/dL
What constitutes aggressive medical therapy for hyperCa2+emia
IV 0.9% NaCl
Furosemide- NO THIAZIDES
Corticosteroids
Calcitonin
Pamidronate disodium IV
What three things constitute maintenance therapy for hyperCa2+emia
Oral:
Corticosteroids and Furosemide

Inj:
Calcitonin
What is the px for 1' hyperPTism
Good w/ sx for adenoma or hyperplasia (35% have low Ca2+ after sx)

RF worsens px
What is the most common cause of hyperCa2+emia in cats
Idiopathic Feline HyperCa2+emia (IFH)
What is the avg age of a cat w/ idiopathic hyperCa2+emia
~10yrs
T/F: Almost 1/2 of cats w/ idipathic hyperCa2+emia have no clinical signs
True
46%
What is confusing about the cause of IFH if CRF is present
Which came first?
What is iCa2+ and PTH like in cases of IFH
PTH in lower 1/2 of RI
High iCa2+

This is APPROPRIATE
T/F: Cats w/ IFH that have no, or only mild signs, may not need to be treated
True
What txs can you employ for a cat w/ IFH
Diets to decrease Ca2+, i.e.:
High fiber
Diets for RF
Diets for preventing CaOx's

Corticosteroids (Prednisolone)- 1/2 respond to

Bisphosphonates helps some (be careful to not cause esophageal erosion)
What are the two major categories of 1' hypoPTism
Iatrogenic
Thyroidectomy in cats
PT adenoma removal in dogs
Naturally Occurring
D: immune destruction and
atrophy
C: idiopathic atrophy
What is the most common cause of 1' hypoPTism
Thyroidectomy in cats
What clinical manifestations can be expected w/ hypoCa2+emia
SIgns relating to NM dysfxn(since Ca2+ needed for NT release, and for STABILIZATION OF NERVE CELL MEMBRANES)
What are some of the signs of 1' hypoPTism
Nervousness/Seizures
Muscle fasciculations/tremors
Ataxia/Stiff gait/Weakness
Muscle cramp/pain
Hyperthermia
Lethargy/Anorexia
Facial pruritus
Aggression-dogs
Ptyalism/Dysphagia- cats
+/- PU/PD
Tachyarrhythmias- dogs
Bradycardia (dogs or cats)
What is one feature that can be used to tell 1' hypoPTism from RF
Lack of azotemia

(Just high P and low Ca2+)
What is PTH like in 1' hypoPTism
Low or low normal

INAPPROPRIATE w/ low Ca2+
How do you treat hypoCa2+emic tetany
IV Ca gluconate to effect
Then CRI or SC q6-8hrs
What is the maintenance tx for 1' hypoPTism
Oral vit D (calcitriol)
Oral Ca2+
Low P diets
Non-Ca2+ P-binders

Check Ca and P qd, q wk, q 1-3mths
Monitor for PU/PD
Where would we like to keep Ca2+ when monitoring for tx of 1' hypoPTism
Ca2+ 8-10 mg/dL
Ca2+ x P <70
What is the px for 1' hypoPTism
Excellent

(only a small % die during initial crisis)
What are 3 reasons you might see increased Na+ in a case of DKA
PU/PD
V+
Hyperglycemia
What is the recommended fluid therapy for DKA if glucose >250
0.9% NaCl while glucose >250
(not LRS since lactate metabolized by same mechanism as ketones)

If shocky, 90 mL/kg/hr
If not, replace deficit over 12hrs for dogs, and 24hrs for cats
When should you add dextrose to fluid therapy for DKA, and how much
BG 150-250, add 2.5% dextrose

BG <150, add 5% dextrose
Why should you replace the DKA fluid deficit more slowly in cats
If replace too quickly, you can cause cerebral edema
When is using "twice maintenance" an appropriate course of action for DKA
Never
Calculate it out
What is the maximum allowable K+ supplementation rate
0.5 mEq K+/kg/hr
Don't exceed this!
T/F: Despite bloodwork results, DKA patients likely have a total body K+ deficit
True
T/F: P decreases w/ insulin and fluid therapy
True
Monitor it, along w/ K+, q 12-24hrs
T/F: In cases of DKA low P often causes hemolysis, seizures, and cardiomyopathy
False
It must be lower than 1.2 to cause these signs, and rarely gets that low
If it does, give 1/4 of the K+ supplementation as K-PO4
What are the three steps of correcting acid/base imbalance in DKA
Stop ketone formation (insulin)
Correct hypovolemia- fluids
Bicarb if pH<7.1 or CO2<12
T/F: You can delay administration of insulin to a DKA cat for a few hours
True
It might be good to do so since so hyperosmolar initially
Which spp. has been shown to have low Mg in DKA
Cats
Can give MgSO4
T/F: It is best to place a urinary catheter to measure urine output in DKA
False
Use repeated palpation or metabolism cage, instead, since I/C
Monitor well b/c at risk for ARF
What are the two indications for placement of urinary catheter in DKA
Oliguria
Comatose
What are the 3 fxns of insulin
1. Decrease glucose
2. Stop ketogenesis
3. Decrease glucagon
T/F: Overcorrecting metabolic acidosis can cause more problems than you had initially in DKA
True
What type of insulin, and by which route, should DKA patients get
Short-acting (i.e. Regular)
IV or IM
Delay for 2-6hrs in cats until rehydrated somewhat
Explain CRI insulin for DKA
Uses pump
2.2 U/kg dogs; 1.1 U/kg cats
Put in 250mL 0.9% NaCl
Use double-lumen or 2 catheters
Adjust rate depending on BG (monitor BG q 2hrs)
What is the therapeutic endpoint for CRI of insulin in DKA
No urine ketones
Patient eats
How long does it take DKA patients to decrease their BG to <250
dogs- 10 hours avg
cats- 16 hours avg
After BG drops below 250 when using CRI of insulin for DKA, then what
Regular insulin SC until nexty morning

Intermediate-acting insulin starting the next morning
Explain Low Dose IM insulin therapy for DKA
Give hourly IM injections and monitor BG hourly
0.2 U/kg initially
Ten, 0.1 U/kg/hr
What might be the most practical way to give insulin for a DKA patient
IM low dose
What is the therapeutic endpoint for IM low dose insulin therapy in cases of DKA
Glucose < 250
How long does it take most dogs to decrease glucose to <250 when using low dose IM insulin therapy for DKA
4hrs avg
(faster than for CRI, so be careful)
When should SC insulin be started in cases of low dose IM insulin therapy for DKA
When glucose b/t 150 and 250
If BG drops too low, and there are still ketones present, what should you do
Add glucose to the fluids
You have to give insulin to get rid of ketones, regardless of whether or not BG has resolved
What is the px for DKA
25-30% die
BUT:
<5% die from the DKA; most die from the inciting cause
What are some potential complications of DKA
Cerebral edema
Hypokalemia
Hypoglycemia
Hypophosphatemia
What is Hyperosmolar Nonketotic DM (HNDM)
Severe elevation of BG w/ DM w/o significant ketosis
Made possible via enough insulin-producing capacity remaining despite underlying/2' dz causing abnormal insulin:glucose
What are the signs of HNDM
Like DKA
Concurrent renal failure common
How is fluid therapy different for HNDM than for DKA
Replace 1/2 of the deficit and maintenance in 1st 12 hrs, then next half over next 24hrs
(since often have RF, too)
As long as urine output is okay, how should K+ be supplemented in cases of HNDM
20 mEq/L
T/F: Insulin therapy should be held off for 4-6hrs in cases of HNDM
True
This prevents too rapid of a decrease in glucose and osmolality
How is insulin therapy different in cases of HNDM than for DKA
Use only 1/2 of the insulin dose you would use for DKA
What is the px for HNDM
Poor-Grave
What is Whipple's Triad
Qualifications for dx of Insulinoma:
1. Typical signs
2. Hypoglycemia
3. Correction of signs once hypoglycemia is corrected
What are insulinomas tumors of
Insulin-secreting islet cells of the pancreas
What test helps make dx of insulinoma
Simultaneous BG and insulin levels

Measure when hypoglycemic

If insulin is in upper 1/2 of RI, or higher, w/ simultaneous BG <60 mg/dL, likely insulinoma (if also has signs)
How quickly do most insulinoma patients become hypoglycemic in hospital
w/in 10-12hrs
Use overnight fast (normal at home) to kick it off, and then measure BG every hour until low BG, and then do insulin level
What percentage of insulinoma cases have normal insulin
25-35%
What is AIGR?
Adjusted Insulin:Glucose Ratio

Useful if normal insulin, but suspect insulinoma

AIGR=
Insulin x 100/ (glucose-30)
Values >30 "positive"
Not Sp for insulinoma, though
T/F: Most cases of insulinoma are treated w/ combo of sx and medical tx
True
What % of insulinoma cases have LN or liver mets at time of sx
Almost 1/2
(45%)
What are some common insulinoma post-op complications
Pancreatitis- 1/3 cases
Continued low BG- 1/4-1/3
Hyperglycemia- 10-15%
What is medical mgmt of insulinoma
Multiple small meals
Oral Prednisolone
Diazoxide- hard to get
(Streptozotocin experimental)

May need CRI of dextrose or glucagon while waiting for sx to prevent clinical signs
What is the px for insulinoma
Nearly all met despite histological appearance

Avg survival 10-14mths w/ combo sx & medical mgmt

6 1/2 mths if medical alone
How does Diazoxide affect insulinoma px
60-65% improve
Avg duration of improvement 6 mths
Who is VUH appropriate for
Dogs-
<4mm for females >10#
<3mm for males >15#

Cats-
</= 2mm for females
Who is VUH C/I in
Male cats
Urethral obstruction
(even partial)
Giant breed dogs b/c size
Uncontrolled infection
Uro sx w/in 2wks
T/F: Patients need to be heavily sedated or anesthetized for VUH
True
Need abd to be loose and for sphincter tone to be abolished
What are some possible complications of VUH
Hematuria WILL occur (for a few days)
UTI- can put on ABx for few days after procedure
Bladder rupture
Urethral obstruction
What is the other name for Brushite stones
Ca-H-P Dihydrate
What is the other name for Hydroxyapatite stones
Ca-P Apatite
What is the other name for Carbonate Apatite stones
Ca-P Carbonate
Which stones occur secondary to excessive urinary Ca2+ loss
Brushite and Hydroxyapatite
What are some causes of excessive urinary Ca2+ loss
Distal renal tubular acidosis

Hypercalcemia (d/t hypetPT)

Decreased crystallization inhibitors

HAC

Normocalcemic Hypercalciuria (idiopathic)
What is the association b/t calcium phosphate stones and urine pH
Acidic- Brushite

Alkaline- Hydroxyapatite and Carbonate Apatite
Which stone type are Ca-H-P Dihydrate stones often seen w/
CaOx (acidic urine)
Which stone type are Ca-P Apatite stones often seen w/
Struvite (alkaline)
What type of stone is Ca-P Carbonate typically seen w/
Can see w/ CaOx or MAP
Which calcium phosphate stone is NEVER 100% pure
Carbonate Apatite
Which calcium phosphate stones can be seen in environments w/ urease producing bacteria
Ca-P Apatite
Ca-P Carbonate
What is the typical signalment of calcium phosphate stones
Middle-aged
Breeds predisposed to other stones
When should you work calcium phosphate stone patients up for hypercalcemic disorders
If they have Ca Apatite or Brushite stones
T/F: Calcium phophate stones can be a reason for incomplete dissolutionof struvites
True
How do you treat calcium phosphate stones if they are assoc'd w/ struvites and urease-producing bacteria
Treat for the bacteria and struvites
What type of diuretic is indicated in tx of calcium phosphate stones
Thiazides to decrease Ca2+ in urine
Of what pH is urine typically if it has cystine stones
Usually acidic
What are some of the Newfie exceptions w/ Cystine stones
Non-sense mutation in gene
Autosomal recessive (carriers not affected)
Females often affected
Nephroliths common
What is the typical opacity of cystine stones
Variable, but more likely opaque if big
Aside from Newfies, what is the typical signalment of dogs w/ cystine stones
Middle-aged
Almost only males
How long does it take to dissolve cystine stones usually
3-4mths
How do you dissolve cystine stones
Increase H2O intake
U/D to alkalinize urine and decrease protein/AAs
2MPG or Penicillamine to bind cysteine so can't make cystine
How long should you treat for cystine stones
1 mth past resolution
What is responsible for silica stones
Diets high in plant matter
Pica
What normally happens to any silica ingested/absorbed
It is readily filtered through the kidney
What stone type may be seen w/ silicates (d/t epitaxial growth)
CaOx
Which gender are silica stones usually seen in
Males
T/F: Silica stones are not seen on UA
True
What do the silica stones look like (if they are pure)
Jackstone shape
What is the radiographic density of silica stones
Opaque (if pure)
How can you treat/prevent silica stones
Feed low plant matter diet
Increase H2O intake
Treat for CaOx if present
What is the common denominator, usually, in dogs w/ xanthine stones
On Allopurinol for recurrent urates
What pH of urine do you see xanthine stones in
Acidic
What stone type are xanthines usually compounded w/
Urates
T/F: Xanthines are usually found unexpectedly when analyzing stone of another suspected type
True
What is the radiographc density of xanthine stones
Radiolucent to only moderately opaque
How can you be sure that an animal w/ xanthines (or urates) is actually eating a low protein diet (to prevent them)
Low-Low normal BUN
Low norm Alb
USG <1.020
Neutral urine pH
If animal is eating low protein diet for urates/xanthines, but pH is not neutral, what can you do
Add K Citrate to alkalinize back to neutral
What are sulfadiazine stones usually d/t
Chronic, high dose therapy w/ Sulfadiazine-Trimethoprim
(not done much anymore, anyway, b/c of concern for KCS)
What stone type has crystals that resemble wheat bunches
Sulfadiazene
What are the only three stone types formed in alkaline urine
Struvites/MAP

Ca-P Carbonate
(Carbonate Apatite)

Ca-P Apatite
(Hydroxyapatite)
What are 4 types of non-erosive, non-infectious inflammatory jt dz
Idiopathic Immune-Mediated Polyarthritis

Chronic Inflammatory-Induced Polyarthritis

Plasmacytic-Lymphocytic Synovitis

SLE
What are 4 types of erosive, non-infectious inflammatory jt dz
RA

Feline Chronic Progressive Polyarthritis

Erosive Polyarthritis of Greyhounds

Periosteal Proliferative Arthropathy
What is the hallmark of inflammatory arthritis
Cyclic, Non-Abx responsive fever
What is a 1' immune-mediated polyarthritis
Abs directed against the jts
What is reactive polyarthritis
Deposition of immune complexes into joints (d/t chronic long-term infection, for example)
What is the most commonly diagnosed immune-mediated inflammatory jt dz
Idiopathic Polyarthritis
What is the #1 erosive jt dz er see assoc'd w/ polyarthritis
RA
How commonly is bacteria the cause of inflammatory arthritis
Rare, except for 2' to trauma or multiple sx procedures

Although, a foci/abscess/endocarditis can cause reactive polyarthritis
Which viruses are thought to have a role in inflamm arthritis
Calici
FeLV
FIV
Which mycoses are most commonly seen w/ inflamm arthritis
Blasto
Coccidio

Can also see Crypto, Histo
How does RMSF typically present
Acutely in the spring
Patient often systemically ill
What is the most common sign of SLE
Polyarthritis
Many signs are present, and not all of them occurring at the same time
Which types of immunological injury are implemented in SLE
II- cytotoxic
III- immune complex
IV- CMI
What are the major signs of SLE
Polyarthritis
Glomerulonephritis (proteinuria)
Bullous dermatitis
Polymyositis
Hemo- pancytopenia
What are the minor signs of SLE
FUO
Pleuritis
Pericarditis
Oral ulcerations
Neuro signs
Lymphadenopathy
Why might you see inflammatory urine sediment in SLE w/ sterile urine
Vasculitis can cause leakage of RBC and WBC
What is the biggest complicating factor for dx/tx of SLE
Renal dz
How are the Sp and Se for ANA testing
Very Se
But, not very Sp
(treatments can affect, too)
How Sp is LE Prep for SLE (if use jt fluid for test)
Very Specific
T/F: Previous tx can affect results of LE Prep
True
What is the tx/px for SLE
Tx:
Immunosuppression w/ Pred; Cyclophosphamide and/or Azathioprine if Pred alone does not work; Life-long
Address renal dz!


Px-poor
How do the ages for Idiopathic Polyarthritis and Chronic Reactive Polyarthritis compare
Idiopathic usually younger
Which breeds are known to have breed-specific polyarthropathies
Akitas
boxers
Y-Mars
Bernese
GSD
Beagle
Shar-Pei
Which diagnostics should always be done in cases of suspected idiopathic polyarthritis
CBC/Chem/UA
Cytology of jt fluid
Serology- 4DX, ANA, RA, FeLV/FIV
Urine culture
How many joints should be tapped when trying to dx idiopathic polyarthritis
At least 3, even if no evidence of effusion or pain
(as long as multiple joints known to be affected)
If get jt fluid, which order should tests be done on it
1. Slide/Cytology
2, Purple top (EDTA)- cell ct
3. Red top- Mucin clot
4. Culture (1:9 w/ broth)
Why is the mucin clot reduced in cases of idiopathic polyarthritis
Inflammation decreases hyaluronate, which decreases mucin clot
What is the cell makeup for purulent inflammation
>75% neutros
What is the cell makeup for chronic active inflammation
Lymphos and Macrophages
But, also neutros
What is the normal cell count in joint fluid
<3000/uL
What cell count can you expect for degenerative/traumatic jt fluid
3,000-5,000/uL
What cell count is suggestive of immune-mediated jt dz
10,000/uL+

The higher it is, though, the more you should suspect infectious component
What are the clinical signs of idiopathic polyarthritis
Intermittent shifting leg lameness
Smaller, distal jts more affected (i.e. tarsus)
Spinal pain in some
CS wax and wane
Explain the Latex Agglutination RA test
IgG against IgM Abs
Test joint fluid or serum for RA factor
T/F: Rads can be used to help dx RA
True
RA is erosive
What radiographic changes might you see in a case of RA
Radiolucent lesions in subchondral bone

Irregular erosions

Narrowed jt spaces

Fibrous ankylosis
T/F: In cases of RA, you may need to give Abx and steroids concurrently
True
If there is an infectious underlying cause, you may need Abx to resolve infection, but also steroids to decrease immune response
How should you recheck patients w/ RA after starting on tx of Abx and steroids (for infectious underlying cause)
Re-tap the joints you originally tapped 2-4 wks after starting therapy

Do not wean meds until cell count <2000/uL
What immunosuppressive drugs can be used as tx for RA
Prednisolone
Cyclophosphamide
Azathioprine- for dogs only
Methotrexate
Gold salts
Leflunomide
What dz is Levamisole used for
SLE only

It is an immune stimulant at low doses
What are some complications of RA
Renal dz
Cytopenias (check CBCs, esp. w/ drugs aside from Pred)
Infxn- skin and UTI most common
Cushing's
2' Hypertension
T/F: Culture urine in all cases of RA on immunosuppressives, regardless of clinical signs
True
You are inhibiting the ability of the patient to show any signs by suppressing the IR
Explain the pathogenesis of RA
Rheumatoid factors are produced against IgG and form complexes that cause:
Joint inflammation
Synovial membrane thickening
Proteolytic enzyme erosion of articular cartilage and subchondral bone
T/F: Hyperproteinemia and Proteinuria are common in RA
True
What is the most prominent sign of reactive polyarthritis
Often, is a sign of the underlying dz process

Arthritis is NOT usually the most prominent sign
T/F: Tx for reactive arthritis is often of long duration
False
Usually only need short-term tx b/c not usually any flare-ups like with other dzs (if you tx the underlying problem, too)