Integrative veterinary medical education and consensus guidelines for an integrative veterinary medicine curriculum within veterinary colleges.

Integrative veterinary medicine (IVM) describes the combination of complementary and alternative therapies with conventional care and is guided by the best available evidence. Veterinarians frequently encounter questions about complementary and alternative veterinary medicine (CAVM) in practice, and the general public has demonstrated increased interest in these areas for both human and animal health. Consequently, veterinary students should receive adequate exposure to the principles, theories, and current knowledge supporting or refuting such techniques. A proposed curriculum guideline would broadly introduce students to the objective evaluation of new veterinary treatments while increasing their preparation for responding to questions about IVM in clinical practice. Such a course should be evidence-based, unbiased, and unaffiliated with any particular CAVM advocacy or training group. All IVM courses require routine updating as new information becomes available. Controversies regarding IVM and CAVM must be addressed within the course and throughout the entire curriculum. Instructional honesty regarding the uncertainties in this emerging field is critical. Increased training of future veterinary professionals in IVM may produce an openness to new ideas that characterizes the scientific method and a willingness to pursue and incorporate evidence-based medicine in clinical practice with all therapies, including those presently regarded as integrative, complementary, or alternative.

Preliminary evidence for biologic activity of toceranib phosphate (Palladia(®)) in solid tumours.

The purpose of this study was to provide an initial assessment of the potential biologic activity of toceranib phosphate (Palladia®, Pfizer Animal Health, Madison, NJ, USA) in select solid tumours in dogs. Cases in which toceranib was used to treat dogs with apocrine gland anal sac adenocarcinoma (AGASACA), metastatic osteosarcoma (OSA), thyroid carcinoma, head and neck carcinoma and nasal carcinoma were included. Clinical benefit (CB) was observed in 63/85 (74%) dogs including 28/32 AGASACA [8 partial response (PR), 20 stable disease (SD)], 11/23 OSAs (1 PR and 10 SD), 12/15 thyroid carcinomas (4 PR and 8 SD), 7/8 head and neck carcinomas [1 complete response (CR), 5 PR and 1 SD] and 5/7 (1 CR and 4 SD) nasal carcinomas. For dogs experiencing CB, the median dose of toceranib was 2.8 mg kg(-1) , 36/63 (58.7%) were dosed on a Monday/Wednesday/Friday basis and 47/63 (74.6%) were treated 4 months or longer. Although these data provide preliminary evidence that toceranib exhibits CB in dogs with certain solid tumours, future prospective studies are necessary to define its true activity.

Complex vertebral arteriovenous fistula and ruptured aneurysm in neurofibromatosis: a therapeutically challenging case.

The objective and importance of this study was to describe the challenges encountered with treating a high-flow vertebral arteriovenous fistula (AVF) and ruptured aneurysm in a patient with life-threatening hemorrhage. A 36-year-old female with Neurofibromatosis type 1 (NF1) presented 2 weeks after uneventful cesarean section with a rapidly expanding pulsatile neck mass. Angiography demonstrated a complex left vertebral AVF and multiple associated vertebral artery aneurysms. Emergent endovascular coil embolization was performed using a retrograde and antegrade approach to occlude the fistulas and trap the ruptured aneurysm, successfully treating the acute hemorrhage. Subsequent definitive therapy was accomplished utilizing a combined neurointerventional and neurosurgical strategy of direct-puncture acrylic embolization and ligation of the vertebral artery. Recent advances in neurointerventional technology allow novel approaches in the primary and/or preoperative treatment of complex vascular lesions such as those seen in NF1.

Inferior division third nerve paresis from an orbital dural arteriovenous malformation.

Isolated inferior division third nerve palsies are rare. The authors report a patient with an isolated, pupil-involving inferior division third cranial nerve palsy from an intraorbital dural arteriovenous malformation. Despite spontaneous thrombosis of the malformation, the third nerve palsy persisted. To the authors' knowledge, this is the first case report of an inferior division third nerve palsy caused by an orbital dural arteriovenous malformation.

Orbital infections.

Orbital infections account for the majority of primary intraorbital disease processes. Sinusitis is the most common etiology. Five stages of cellulitis secondary to sinusitis have been described. Systemic conditions which predispose to orbital infection include diabetes, septicemia, malignancy, and immunosuppresion. Clinical signs and symptoms include superficial inflammatory changes, as well as proptosis, limitation of extraocular motility, and visual loss. Causative agents are most commonly bacteria, with fungus, viruses, and parasites seen less frequently. Imaging is performed by CT and/or MRI which are complementary in certain cases. Differential diagnosis of imaging abnormalities includes inflammatory and granulomatous diseases, as well as neoplasm.

Use of ex vivo magnetic resonance imaging to detect onset of vigabatrin-induced intramyelinic edema in canine brain.

Vigabatrin (VGB) causes intramyelinic edema (microvacuolation) in brain of dogs and rodent, which has encouraged development of noninvasive methods to monitor for this effect during clinical trials. We report the qualitative ex vivo magnetic resonance imaging (MRI) changes observed in a neuropathology study in dogs to detect time of onset and regression of VGB-induced intramyelinic edema. Beagles were randomly assigned to 18 groups of 6 dogs per group and administered vigabatrin orally (p.o.) at a dose of 300 mg/kg/day (2 males, 2 females) or placebo (1 male, 1 female). Animals were killed and examined at weekly intervals during the 12 weeks of treatment and at 1, 2, 4, 8, 12, and 16 weeks after discontinuation of drug treatment. Myelin microvacuolation in thalamus, hypothalamus, and fornix were noted histologically after 4-5 weeks of treatment. Increases in MRI T2 intensity were observed in hypothalamus after 4 weeks and in thalamus and columns of the fornix after 7 weeks. Both MRI T2 intensity and microvacuolation continued to increase during 12-week VGB treatment. When VGB treatment was discontinued after 12 weeks, both MRI T2 intensity and microvacuolation began to decrease. Sixteen weeks after VGB discontinuation, histopathology had returned to normal and MRI examination demonstrated a marked trend toward reversal of the increased T2 signal intensity. MRI thus has potential as a noninvasive surveillance technique in certain experimental and clinical conditions associated with intramyelinic edema.

Suprasellar masses: diagnosis and differential diagnosis.

Suprasellar masses are neoplastic, vascular, congenital, or infectious/inflammatory in origin. Magnetic resonance imaging (MRI) is the study of choice for evaluating suprasellar masses, although computed tomography (CT) may provide complementary information. Suprasellar masses present with a variety of neurologic or endocrine dysfunctions depending on their site of origin and mass effect on adjacent structures. Imaging characteristics of the most common suprasellar lesions are described with particular emphasis on MR findings.

An unusual angiographic picture in status migrainosus.

Arteriographic findings suggestive of inflammation are described in a 26-year-old woman presenting with headache and syncope. There were no clinical findings of angitis, and a diagnosis of status migrainosus was eventually made. We present her case, as well as a review of previous cases of arterial changes in patients with headache. Most previous cases report arterial narrowing, felt to reflect spasm, whereas our patient demonstrated segmental stenoses and dilatations, perhaps implicating inflammation. The inflammatory process has been postulated as the pathogenesis of migraine pain. As most migraineurs do not undergo arteriography, the incidence of arterial change in these patients is unknown. This finding has therapeutic implications for selecting the optimal anti-migraine agent.

Juvenile laryngeal carcinoma: correlation of computed tomography and magnetic resonance imaging with pathology.

The clinical, radiologic and pathologic features of invasive squamous cell carcinoma of the larynx are reported in a 16-year-old girl. In particular, computerized tomography (CT) and magnetic resonance imaging (MRI) are correlated with histopathological findings. It was found that the combined use of CT and MRI enabled an accurate identification of laryngeal tissue components and a precise delineation of extent of cancer spread. This diagnostic approach is emphasized as well as the need to suspect carcinoma of the larynx in any child unrelenting or recurring hoarseness.

Initial experience with SPECT imaging of the brain using I-123 p-iodoamphetamine in focal epilepsy.

Nineteen patients with complex partial seizures refractory to medical treatment were examined with routine electroencephalography (EEG), video EEG monitoring, computed tomography or magnetic resonance imaging, neuropsychological tests and interictal single photon emission computed tomography (SPECT) with I-123 iodoamphetamine (INT). In 18 patients, SPECT identified areas of focal reduction in tracer uptake that correlated with the epileptogenic focus identified on the EEG. In addition, SPECT disclosed other areas of neurologic dysfunction as elicited on neuropsychological tests. Thus, IMP SPECT is a useful tool for localizing epileptogenic foci and their associated dynamic deficits.

Intraocular tumors: evaluation with MR imaging.

Sixty-seven ocular tumors were studied with magnetic resonance (MR) imaging and computed tomography (CT). These tumors included primary uveal melanoma (n = 55), circumscribed choroidal hemangioma (n = 3), diffuse choroidal hemangioma (n = 1), retinal capillary hemangioma (n = 1), medulloepithelioma (n = 1), choroidal nevus (n = 1), retinoblastoma (n = 1), and choroidal metastases (n = 4). MR imaging demonstrated all these lesions, while CT demonstrated 88%. Associated retinal detachment was more easily distinguished from the neoplasms with MR imaging. Extrascleral extension of melanoma and hemorrhagic cystic necrosis within the melanoma were clearly demonstrated with MR imaging, but not with CT. Ninety-three percent of melanomas were markedly hyperintense, compared with the intensity of the vitreous body, on T1-weighted images and hypointense on T2-weighted images. All metastatic lesions were isointense on T1-weighted images and hypointense on T2-weighted images. The circumscribed choroidal hemangiomas were hyperintense on T1-weighted images and isointense on T2-weighted images. MR imaging is superior to CT in detection of intraocular tumors and may be more specific in diagnosis.

MRI of central nervous system: early clinical results.

In patients with central nervous system problems, a comparison of the results obtained with high-field MRI (1.5 T) to those achieved with more conventional imaging studies, primarily CT, reveals significant improvement in the demonstration of various abnormalities by MRI (56.5%), with increased specificity in some (29.5%). High-field MRI provides advantages over CT by providing both multiplanar images and superior contrast resolution. The diagnostic specificity of MRI is increased when acute, subacute, and chronic hematomas are visualized and when flowing blood within vessels is demonstrated in addition to the location and extent of the disease process. In this series, MRI produced a more accurate diagnosis in 8.7% of cases, revealed clinically unexpected abnormalities in 3.9% of cases, and was less invasive or avoided the risk of complications in 17.4% of cases. Despite the success of MRI, CT continues to play an important role in demonstrating calcification and contrast enhancement, and in evaluating patients in whom MRI is contraindicated or impossible because of an unsuitable clinical state.

Magnetic resonance imaging of the child's brain.

The most significant difference between magnetic resonance imaging (MRI) and computed tomography (CT) is that the former graphic representation of the cerebrospinal axis and its structures does not use ionizing radiation or the injection of contrast material. The physical principles of MRI and the very characteristic appearances of some pathological processes common in children require special study. Low-proton density areas are generally dark; the short T1 value is responsible for white matter appearing clear; inversion recovery sequences permit study of the progression of myelination.

Pediatric brain computed tomography.

Computed tomography today provides good anatomic depiction of the brain and its gross disease processes that have as a manifestation alteration of brain density, disturbance in blood-brain barrier, or mass effect. As such, computed tomography often provides valuable diagnostic information in the appropriate clinical setting. This article reviews many of the more common pediatric central nervous system disease states that have been demonstrated more easily as a result of computed tomography.

Topical acyclovir treatment of herpes zoster in immunocompromised patients.

Topical acyclovir favorably influences the healing of localized herpes zoster in immunocompromised patients. This therapy, or placebo, was applied to forty-three patients in a random access, double-blind trial, four times daily for 10 days, beginning within 72 hours after the onset of skin lesions. The mean time to pustulation is decreased from 12.4 to 6.7 days and the mean time to crusting is decreased from 16.0 to 11.4 days (p = 0.038 and 0.086, respectively) by topical treatment. The mean time to 50% healing is decreased from 24.5 to 15.2 days and the mean time to 100% healing is decreased from 34.9 to 25.8 days (p = 0.023 and 0.033, respectively). Favorable effects in treated patients are not associated with a more rapid decline in lesion virus titer, but do accrue without any toxicity.

Use of trimethoprim-sulfamethoxazole to prevent bacterial infections in children with acute lymphoblastic leukemia.

We assessed the efficacy of prophylactic antibiotics in children receiving intensive chemotherapy for acute lymphoblastic leukemia. The patients were randomized to receive either trimethoprim-sulfamethoxazole (TMP-SMX) or placebo in a double-blind trial. Thirty patients were evaluated in each group. Children receiving TMP-SMX had fewer episodes of bacteremia (0 vs. 5) and otitis media (3 vs. 18). The geometric mean of the neutrophil nadir was 172 in the TMP-SMX group and 287 in controls. However, no increased delay or dose reduction of chemotherapy was observed in the TMP-SMX treated patients. Five patients who received TMP-SMX developed Gram-negative rods resistant to TMP-SMX on surveillance stool cultures. We conclude that TMP-SMX prophylaxis decreased certain bacterial infections in children with acute lymphoblastic leukemia without causing clinically significant toxicity. The emergence of Gram-negative rods resistant to TMP-SMX in treated patients suggests that TMP-SMX prophylaxis should be restricted to patients who are at high risk for developing a bacterial infection or Pneumocystis carinii pneumonia.

Infections caused by herpes simplex virus in the immunocompromised host: natural history and topical acyclovir therapy.

Sixty-three immunocompromised patients with infections caused by herpes simplex virus were evaluated in a double-blind, placebo-controlled study of topical acyclovir therapy; 33 patients received acyclovir and 30 received the placebo. The two populations of patients were balanced in terms of age, race, sex, underlying disease, preceding chemotherapy, and site, size, and duration of lesions. Acyclovir recipients experienced an acceleration in the clearance of virus (P = .0006), the resolution of pain (P = .004), and the total healing of lesions (P = .038); median temporal differences between populations averaged six days for each of these three parameters. The surface area of herpetic lesions continued to enlarge in placebo recipients after entry into the trial; in contrast, lesion surface area decreased progressively during therapy in drug recipients. The speed of healing was influenced by lesion size. Patients with lesions of greater than or equal to 50 mm2 benefited most from therapy, particularly in terms of pain resolution and time to total healing (median differences between groups, eight days). Irrespective of underlying disease, sex, preceding chemotherapy, or age, acyclovir therapy was of clinical benefit. No adverse clinical or laboratory reactions were encountered.