CONNECTED. The Neurological Examination. Methicillin-Resistant Staphylococcus: Frequently Asked Questions Clinical Trials Upcoming Events

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1 CONNECTED Yo u r L i n k to V e t e r i n a r y S P E C I A LT Y H O S P I TA L A P R M AY The Neurological Examination IN THIS ISSUE: Methicillin-Resistant Staphylococcus: Frequently Asked Questions Clinical Trials Upcoming Events SAN DIEGO Sorrento Valley Rd San Diego, CA NORTH COUNTY 2055 Montiel Rd San Marcos, CA

2 richter scale Hi Colleagues: This is the most boring time of the year no football or baseball! All I have to think about is VSH (scary thought, I know). I am very proud of our staff, and the new emphasis on client experience is paying off. We are getting great feedback from our client surveys, though we also welcome any feedback from you. Feel free to call me any time. We want you to use us as a resource and make your partnership with VSH the way you want it! Dr. Jackson s traveling surgery is being very well received by the community. We have had many of you tell us how nice it is to have VSH come to me for certain types of cases. Josh welcomes you to call him directly on his cell at I want to congratulate all of our interns who have been placed into residency programs. VSH has one of the highest placement rates in the country (if not THE highest). This is a testament to the quality of our program and the interns they are truly the cream of the crop! I am ashamed to report that I will be out of town at a meeting on April 12th. What is the significance of that? It is Opening Day! I haven t missed Opening Day since well, never!! There must be something I can take to get over this. Once we start piling up the wins and we reach the World Series, it will be a distant memory. And yes, I m a realist. Just remember, Life begins on Opening Day. Until next time Keith Richter, DVM Diplomate ACVIM

3 The Neurological Ex amination by Robin Levitski-Osgood,, DVM, DACVIM (Neurology) The neurological examination, in combination with the patient s signalment and history, is used to document neurological disease and to localize the lesion. Perfoming the exam in the same order each time helps to ensure certain tests are not forgotten and minor deficits are not missed. At the end of the exam, the abnormal findings are used to localize the lesion. Once the lesion has been localized, a list of differential diagnoses can be constructed and the appropriate diagnostic procedures can be recommended. The mentation of the patient can be evaluated while taking the history. There are many different degrees of awareness: normal, obtunded (dull), stuporous (responds to moderate stimulation), semi-comatose (patient can be aroused with vigorous stimulation), and comatose (non-rousable). Some patients may act demented, hyper-excitable, hyper-aggressive, stand with their head pressed into the corner, or pace compulsively. Posture can also be evaluated at the same time. Evaluate the head (head tilt, head turn, head bobbing/tremors, wide excursions of the head), tail (low tail carriage, flaccid) and limb (knuckling on paw, holding limb up, wide based vs. narrow based, crouched) position. If the patient is recumbent, are they exhibiting Schiff-Sherrington (normal mentation, paraplegia, extensor rigidity thoracic limbs), decerebellate (normal mentation, dorsoflexion of the neck, extensor rigidity thoracic limbs, flexion pelvic limbs), or decerebrate (comatose, dorsoflexion of the neck, extensor rigidity all limbs) posture? All three of these postures can look similar when the patient is in lateral recumbency. Watching the patient ambulate on a non-slippery surface, turn to the left and right, and navigate a few steps or a curb is a very important part of the exam. The gait is examined for both strength and coordination. Watching the patient walk in a small exam room is not enough to fully evaluate the gait. Weakness is termed paresis. The patient may be monoparetic (one leg), paraparetic (pelvic limbs), hemiparetic (thoracic and pelvic on one side), or tetraparetic (all four legs). Absence of voluntary motion is paralysis/plegia. Again, the patient may have a mono, para, hemi or tetraplegia. A withdrawal of the leg when the toes are pinched is not considered voluntary motion. Lameness, ataxia, dysmetria, hypermetria, scuffing of the toe nails, and circling are other signs that may be observed during the gait evaluation. Cranial nerves are examined in order from CN I to CN XII. These tests evaluate the function of the cranial peripheral nerve and the specific area of the brain stem from which the nerve arises. Common cranial nerve tests include visual tracking, menace, pupillary light reflex, comparing pupil size, presence of normal physiologic nystagmus, strabismus, size of muscles of mastication, sensation to the face, corneal reflex, palpebral, vibrissae and auricular reflex, head tilt, head turn, resting or spontaneous nystagmus, gag reflex, presence of stridor, and unilateral atrophy of the tongue. When testing conscious proprioception the patient must be supported properly when lifting and turning the paw over, and then observed to see if they correct the abnormal position. Wheelbarrowing, hopping, extensor postural thrust with the pelvic limbs, visual placing and tactile placing can be performed to evaluate postural reactions in the cat and small to medium sized dogs. The common spinal reflexes that are tested include the bicep, tricep, patellar, gastrocnemius, withdrawal reflexes. The limbs should be relaxed when testing. The reflex is either absent, decreased, or present/brisk. The patellar reflex is the most useful and easy to grade monosynaptic reflex, while the tricep reflex is the least useful. The withdrawal reflex is tested by lightly pinching or wiggling your fingers in the interdigital tissue and observing flexion of the limb. The opposite limb is observed for an exaggerated crossed extensor reflex which indicates upper motor neuron damage. The withdrawal reflex is a spinal reflex only, and does not evaluate voluntary motion or the presence or absence of deep pain. The cutaneous trunci (CT) or panniculus reflex is twitching of the skin in response to pinching. It can be tested from the L4 region up to T2 along both sides of the spine. The area where the CT response changes from being absent to being intact is an indicator of where the spinal cord white matter is damaged. The CT can be helpful in localizing T3-L3 lesions. The perineal reflex can be evaluated when the patient s temperature is taken. The spine is palpated for areas of increased sensitivity or pain. Support under the thorax and abdomen when palpating the thoracolumbar spine. Cervical range of motion can be evaluated by having the patient follow a treat to both sides and then up and down. Muscle size, tone and symmetry is also evaluated. Somatosensory function is typically tested by applying a painful stimulus and watching for a behavioral response such as turning the head, crying, trying to bite, pupillary dilation, or cessation of panting. This is usually tested at the end of the exam. Pinch the skin to check for superficial pain and pinch the bone of the digit for deep pain. If a patient has voluntary motion, you do not need to test for superficial or deep pain sensation.

4 Methicillin-Resista nt Staphylococcus: Frequently Asked Questions by Laura Stokking, PhD, DVM, DACVD How common is methicillin-resistant Staphylococcus in dogs and cats? Historically, methicillin-resistant staphylococcal (MRS) infections have not been common in pets. However, the numbers of pets infected with MRS infections has increased along with the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in humans. A 1-yr study at The Ohio State University reported that nearly 7% of patients admitted were MRSA-positive; several were asymptomatic carriers. The prevalence of methicillin resistance varies geographically. The percentage of MRSA infections tend to be higher in communities with a large number of hospitals and other human health-care facilities. No difference in outcome was determined between patients with MRSA vs. MSSA. Survival rates for both types of infection are high. What is Staphylococcus pseudintermedius? In 2005, Staphylococcus intermedius was subdivided into three separate species based on 16S rdna sequencing; Staphylococcus pseudintermedius is the pathogen present on dogs. When if I suspect methicillin-resistant Staphylococcus? Culture and sensitivity testing should be done whenever a patient fails empirical therapy. The choice of systemic antibiotic should be based on those results, with a duration of 4 weeks or 2 weeks beyond resolution of clinical signs. Topical therapy is essential; 2% chlorhexidine solution remains effective against MRS. What should I tell my clients about methicillin-resistant staphylococci? Information designed for clients is available at the University of Minnesota website: Family members should practice careful hand hygiene. The home should be cleaned carefully to prevent transmission to other individuals and to prevent recontamination of the infected patient. The pet s bedding should be washed regularly. Beds that cannot be washed should be discarded. Leather collars, leashes, and harnesses cannot be disinfected, so should be replaced with washable items. Control of the underlying cause is critical to prevent recurrence. Pathogenicity and zoonotic potential differ between MRSA and MRSPI, as associated genes associated with virulence and resistance are more frequent in MRSA in humans than MRSA in dogs. Thus, MRSA is not as virulent in companion animals as it is in humans. Staphylococcus aureus appears to be host-adapted to humans, whereas Staphylococcus pseudintermedius is adapted to canines. The risk of transmission of MRSA from dogs to humans is greater than that of methicillin-resistant Staphylococcus pseudintermedius (MRSPI) from dogs to humans. Cases of MRSPI in humans are extremely rare and are usually associated with bite wounds. Conversely, dogs have a greater chance of passing MRSPI to another dog than they do of transmitting MRSA. In all species, transmission requires disruption of epidermal integrity or immune compromise.

5 In Our Community The Veterinary Hospital is proud to support the FACE Foundation (Funding Animal Care and Education). FACE provides funds for clients who cannot afford medical care for their critically ill pet. FACE has granted over $141,000 in 2009, and over $324,000 since A beautiful mural at our entry was recently completed and dedicated to FACE to raise funds for this most worthwhile cause. You can get more information about FACE by calling them directly at FACE (3223) or on their website at Take Note A nnouncements Dr. Steve Hill and Dr. Keith Richter presented abstracts at the Comparative Gastroenterology Society (CGS) Gutski conference in Winter Park, CO, held on February 28th through March 2nd. Dr. Steve Hill is also the featured preceptor/clinical assistant professor by Western University College of Veterinary Medicine in their winter edition of The Outlook. Current Clinica l Tria ls Dermatology Medication to Control Pruritus Dr. Laura Stokking is enrolling dogs for a new medication to control pruritus. Contact Christie Yamazaki at (858) Internal Medicine Canine IBD Study In conjunction with the Texas A&M GI Lab, VSH is enrolling dogs with chronic gastrointestinal disease in a study to evaluate the usefulness of several new markers of inflammatory diseases in serum, urine, and feces. Dogs with chronic small bowel diarrhea, vomiting or weight loss are eligible. Contact Dr. Hill at (858) x702 or Jen Fulbright at (858) x729. Surgery Micro Total Hip Replacement VSH is enrolling 25 small dogs in a clinical study to compare the results of micro THR to those of femoral head and neck excision. If you know of a candidate for this procedure or would like to learn more about the benefits of participating, contact any VSH surgeon at (858) Internal Medicine Spotted Fever Rickettsioses in Southern California Dogs Purpose: To determine if Spotted Fever Group Rickettsia infections are occurring in dogs with signs of tick-borne illness in Southern California. The study provides an extensive tick-borne disease screening panel with both serology and PCR. The owner is required to return 10 days to 3 weeks after the acute sample for convalescent sample. Cost to the owner is a one time fee of $ Case Selection: Dogs with a variety of clinical signs suggestive of or consistent with a tick-borne illness can be included. Samples need to be drawn prior to administration of doxycycline, enrofloxacin or chloramphenicol (will cause PCR to be negative). If you have a case where a tick-borne illness is suspected you can contact any of the internal medicine specialists at VSHSD or VSHNC at (858) for more information.

6 10435 Sorrento Valley Rd Suite 100 San Diego, CA We re Listening We know you are all very busy and cannot all make it to our quarterly CE events. We recently added a webinar option to allow you to attend our meetings from the comfort of your home or office. This is a free service we are providing, and just involves clicking on an link we send you. For any upcoming meeting, just contact Ann Ong, our events coordinator at ann.ong@vshsd.com or her direct line at (858) ), to get set up. It just takes a few minutes. Of course we d love you to come in person and socialize with your colleagues, get a wonderful free dinner, and even win a raffle prize! If you would like to receive invitations by , please Ann Ong at ann.ong@vshsd.com. save the date April Roundtable Discussion: Elbow Dysplasia April 15, 7:00 pm (San Diego Facility) Spring CE Dinner and Lecture (San Diego and North County Facilities, Webinar) April 29, 6:00 pm 9:15 pm Gastric Dilatation Volvulus: Past, Present & Future, Dr. Mauricio Dujowich Case Reviews of the Neurologic Exam, Dr. Robin Levitski Osgood Current Trends in Veterinary Orthopedics, Dr. Fred Pike Cerenia : New Information, Dr. Keith Richter Dermatology Rounds May 13, 8:00 am (San Diego Facility) Neurology Rounds: Case Presentations May 20, 7:00 pm (North County Facility) June Roundtable Discussion: Elbow Dysplasia June 10, 7:00 pm (North County Facility) June Roundtable Discussion: Oxygen Therapy & Monitoring June 17, 7:00 pm (San Diego Facility) For more information on Continuing Education events, please visit or contact Ann Ong at (858) or ann.ong@vshsd.com.