Ultrasound-guided noninvasive pancreas ablation using histotripsy: feasibility study in an in vivo porcine model.

Pancreatic cancer is a malignant disease associated with poor survival and nearly 80% present with unresectable tumors. Treatments such as chemotherapy and radiation therapy have shown overall improved survival benefits, albeit limited. Histotripsy is a noninvasive, non-ionizing, and non-thermal focused ultrasound ablation modality that has shown efficacy in treating hepatic tumors and other malignancies. In this novel study, we investigate histotripsy for noninvasive pancreas ablation in a pig model. In two studies, histotripsy was applied to the healthy pancreas in 11 pigs using a custom 32-element, 500 kHz histotripsy transducer attached to a clinical histotripsy system, with treatments guided by real-time ultrasound imaging. A pilot study was conducted in 3 fasted pigs with histotripsy applied at a pulse repetition frequency (PRF) of 500 Hz. Results showed no pancreas visualization on coaxial ultrasound imaging due to overlying intestinal gas, resulting in off-target injury and no pancreas damage. To minimize gas, a second group of pigs (n = 8) were fed a custard diet containing simethicone and bisacodyl. Pigs were euthanized immediately (n = 4) or survived for 1 week (n = 4) post-treatment. Damage to the pancreas and surrounding tissue was characterized using gross morphology, histological analysis, and CT imaging. Results showed histotripsy bubble clouds were generated inside pancreases that were visually maintained on coaxial ultrasound (n = 4), with 2 pigs exhibiting off-target damage. For chronic animals, results showed the treatments were well-tolerated with no complication signs or changes in blood markers. This study provides initial evidence suggesting histotripsy's potential for noninvasive pancreas ablation and warrants further evaluation in more comprehensive studies.

Evaluation of gallbladder motility assessed by ultrasonography in dogs with hyperlipidemia.

BACKGROUND: The pathogenesis of gallbladder (GB) mucoceles in dogs is unknown. It has been proposed that hyperlipidemia could impair GB motility and contribute to GB mucocele formation. HYPOTHESIS/OBJECTIVES: The objective of this study was to compare GB motility in dogs with hyperlipidemia to control dogs using ultrasonography. We hypothesized that hyperlipidemic dogs will have decreased GB motility compared with controls. ANIMALS: Twenty-six hyperlipidemic and 28 healthy, age-matched control dogs were prospectively enrolled. METHODS: Cholesterol and triglyceride concentrations were measured in all dogs. Hyperlipidemia was defined as hypercholesterolemia (>332 mg/dL) and/or hypertriglyceridemia (>143 mg/dL) using a biochemical analyzer. Ultrasound was performed before feeding, and 60 and 120 minutes after ingestion of a high fat diet. Gallbladder volumes (GBV) and ejection fractions (EF) were calculated. RESULTS: Hyperlipidemic dogs had significantly larger GBVs (ml/kg) before feeding and 60 minutes after feeding of 1.2 (0.4-7.5; P = .008) and 0.6 (0.1-7.2; P = .04) compared with controls 0.6 (0.2-2.6) and 0.4 (0.1-1.9), respectively. Severely hyperlipidemic dogs had significantly larger GBV at baseline, 60 minutes, and 120 minutes of 1.7 (0.6-7.5; P = .03), 1.3 (0.4-7.2; P = .02), and 1.3 (0.2-8.2; P = .04), respectively compared with mildly hyperlipidemic dogs. EFs at 60 and 120 minutes between controls, hyperlipidemic, and severely hyperlipidemic were all 0.3 at 60 minutes and 0.5, 0.3, and 0.3 at 120 minutes, respectively which were not statistically different. CONCLUSIONS AND CLINICAL IMPORTANCE: Hyperlipidemia leads to GB distention in dogs which could lead to retention of bile and gallbladder disease.

Prevalence of gallbladder sludge and associated abnormalities in cats undergoing abdominal ultrasound.

The significance of gallbladder sludge in cats remains largely unknown and has been speculated to be a pathologic finding in cats. The objectives of this retrospective, observational study were to determine the prevalence of gallbladder sludge in the population of cats presenting for abdominal ultrasound; to describe clinical signs, laboratory findings and certain abdominal ultrasound abnormalities; and to compare these findings to cats without gallbladder sludge. One hundred and ninety-two cats were included. Medical records were searched for cats with an abdominal ultrasound performed between October 2014-2015. Signalment, clinical signs, complete blood count, biochemical findings, presence or absence of gallbladder sludge, and hepatobiliary and pancreatic ultrasound findings were recorded. Gallbladder sludge was present in 44% of cats that underwent an abdominal ultrasound. There was no significant difference in age, sex, presenting clinical signs or clinicopathologic variables between the two groups. Gallbladder wall thickening significantly increased the odds of detecting gallbladder sludge (OR-3.7 95% CI 1.4 - 10.0). Gallbladder sludge was not associated with other ultrasonographic abnormalities of the liver, gallbladder, bile duct or pancreas. Gallbladder sludge is common in cats undergoing abdominal ultrasound and appears to be a non-specific finding. The clinical significance of concurrent gallbladder sludge and gallbladder wall thickening present on ultrasound in cats remains to be determined.

Comparison of linear and volumetric criteria for the determination of therapeutic response in dogs with intracranial gliomas.

BACKGROUND: Brain tumor therapeutic responses can be quantified from magnetic resonance images (MRI) using 1- (1D) and 2-dimensional (2D) linear and volumetric methods, but few studies in dogs compare these techniques. HYPOTHESES: Linear methods will be obtained faster, but have less agreement than volumetric measurements. Therapeutic response agreement will be highest with the total T2W tumor volumetric (TTV) method. Therapeutic response at 6-weeks will correlate with overall survival (OS). ANIMALS: Forty-six dogs with intracranial gliomas. METHODS: Prospective study. Three raters measured tumors using 1D and 2D linear, TTV, and contrast-enhancing volumetric (CEV) techniques on 143 brain MRI to determine agreement between methods, define therapeutic responses, and assess relations with OS. RESULTS: Raters performed 1D the fastest (2.9 ± 0.57 minutes) and CEV slowest (17.8 ± 6.2 minutes). Inter- and intraobserver agreements were excellent (intraclass correlations ≥.91) across methods. Correlations between linear (1D vs 2D; ρ > .91) and volumetric (TTV vs CEV; ρ > .73) methods were stronger than linear to volumetric comparisons (ρ range, .26-.59). Incorporating clinical and imaging data resulted in fewer discordant therapeutic responses across methods. Dogs having partial tumor responses at 6 weeks had a lower death hazard than dogs with stable or progressive disease when assessed using 2D, CEV, and TTV (hazard ration 2.1; 95% confidence interval, 1.22-3.63; P = .008). CONCLUSIONS AND CLINICAL IMPORTANCE: One-dimensional, 2D, CEV, and TTV are comparable for determining therapeutic response. Given the simplicity, universal applicability, and superior performance of the TTV, we recommend its use to standardize glioma therapeutic response criteria.

Histotripsy Ablation in Preclinical Animal Models of Cancer and Spontaneous Tumors in Veterinary Patients: A Review.

New therapeutic strategies are direly needed in the fight against cancer. Over the last decade, several tumor ablation strategies have emerged as stand-alone or combination therapies. Histotripsy is the first completely noninvasive, nonthermal, and nonionizing tumor ablation method. Histotripsy can produce consistent and rapid ablations, even near critical structures. Additional benefits include real-time image guidance, high precision, and the ability to treat tumors of any predetermined size and shape. Unfortunately, the lack of clinically and physiologically relevant preclinical cancer models is often a significant limitation with all focal tumor ablation strategies. The majority of studies testing histotripsy for cancer treatment have focused on small animal models, which have been critical in moving this field forward and will continue to be essential for providing mechanistic insight. While these small animal models have notable translational value, there are significant limitations in terms of scale and anatomical relevance. To address these limitations, a diverse range of large animal models and spontaneous tumor studies in veterinary patients have emerged to complement existing rodent models. These models and veterinary patients are excellent at providing realistic avenues for developing and testing histotripsy devices and techniques designed for future use in human patients. Here, we provide a review of animal models used in preclinical histotripsy studies and compare histotripsy ablation in these models using a series of original case reports across a broad spectrum of preclinical animal models and spontaneous tumors in veterinary patients.

Bile duct obstruction associated with pancreatitis in 46 dogs.

BACKGROUND: Pancreatitis is a common cause of extrahepatic bile duct obstruction (EHBDO) in dogs. Information describing the clinical course of dogs with pancreatitis associated bile duct obstruction (PABDO) is limited. OBJECTIVES: To describe the clinical course of PABDO in dogs and determine if presumed markers of disease severity are predictors of survival. ANIMALS: Forty-six client-owned dogs with PABDO. METHODS: A retrospective review of medical records from dogs diagnosed with PABDO was performed. Data, including clinical signs and biochemical changes, were collected 6 times throughout the course of disease. Outcome was defined as either survival (discharge from the hospital) or death. RESULTS: Thirty-three (79%) out of 42 dogs with PABDO survived. Thirty-one (94%) of the 33 dogs that survived received medical management alone. Time from onset of clinical signs to initial documented increase in serum bilirubin concentration, peak bilirubin elevation, and initial decline in serum bilirubin concentration were 7 (median), 8, and 15 days, respectively. The median number of days from onset of clinical signs to outcome date was 13. Clinical signs of fever, vomiting, and anorexia were decreased in frequency from the onset of clinical signs to the time of peak bilirubin. Median bile duct dilatation at the time of ultrasonographic diagnosis of PABDO and peak bilirubin were not different between survivors (7.6 mm, 11.7 mg/dL) and nonsurvivors (6 mm, 10.6 mg/dL, P = .12, P = .8). CONCLUSIONS: Dogs with PABDO often have a prolonged course of illness and improve clinically despite biochemical evidence of progression of EHBDO.

Diffusion weighted magnetic resonance imaging is a feasible method for characterizing regional lymph nodes in canine patients with head and neck disease.

In dogs diagnosed with solid tumors, regional lymph node involvement or evidence of distant metastasis can predict worse prognoses and significantly decreased survival. Lymph node size alone has been shown to be insufficient as a predictor for the accurate clinical staging of some canine neoplasia. However, certain regional lymph nodes (including those of the oral cavity) are difficult to access for routine tissue sampling. Diffusion weighted magnetic resonance imaging (MRI) has demonstrated the ability to differentiate metastatic from inflammatory/benign lymph nodes in clinical studies with human cancer patients through the calculation of quantitative values of diffusion termed apparent diffusion coefficients (ADC). The objective of this prospective, exploratory study was to evaluate diffusion-weighted MRI and ADC as potential methods for detecting metastatic lymph nodes in dogs with naturally occurring disease. We hypothesized that diffusion-weighted MRI would identify significantly different ADC values between benign and metastatic lymph nodes in a group of canine patients with head or neck disease. Our study population consisted of eight client-owned canine patients, with a total of 20 lymph nodes evaluated (six metastatic, 14 benign). Our results demonstrated that two of four observers identified a significant difference between the mean ADC values of the benign and metastatic lymph nodes. When data from all four observers were pooled, the difference between the mean apparent diffusion coefficients values of the benign and metastatic lymph nodes did not reach significance (P-value = 0.0566). Findings indicated that diffusion-weighted MRI is a feasible method for further characterizing enlarged lymph nodes in dogs with head and neck disease, however measured ADC values did not differ for benign vs. metastatic lymph nodes in this small sample of dogs.

Implementation of Lung Cancer Screening in the Veterans Health Administration.

Importance: The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years. There is little published experience regarding implementing this recommendation in clinical practice. Objectives: To describe organizational- and patient-level experiences with implementing an LCS program in selected Veterans Health Administration (VHA) hospitals and to estimate the number of VHA patients who may be candidates for LCS. Design, Setting, and Participants: This clinical demonstration project was conducted at 8 academic VHA hospitals among 93 033 primary care patients who were assessed on screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015. Interventions: Implementation Guide and support, full-time LCS coordinators, electronic tools, tracking database, patient education materials, and radiologic and nodule follow-up guidelines. Main Outcomes and Measures: Description of implementation processes; percentages of patients who agreed to undergo LCS, had positive findings on results of low-dose computed tomographic scans (nodules to be tracked or suspicious findings), were found to have lung cancer, or had incidental findings; and estimated number of VHA patients who met the criteria for LCS. Results: Of the 4246 patients who met the criteria for LCS, 2452 (57.7%) agreed to undergo screening and 2106 (2028 men and 78 women; mean [SD] age, 64.9 [5.1] years) underwent LCS. Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%). Conclusions and Relevance: It is estimated that nearly 900 000 of a population of 6.7 million VHA patients met the criteria for LCS. Implementation of LCS in the VHA will likely lead to large numbers of patients eligible for LCS and will require substantial clinical effort for both patients and staff.

Ultrasound Imaging of the Hepatobiliary System and Pancreas.

Ultrasound is an extremely valuable diagnostic modality for the diagnosis of hepatobiliary and pancreatic disease. Normal appearance and normal variations are important to understand to avoid misinterpretation. Although ultrasound can identify a lesion, cytology and histopathology are usually needed for a final diagnosis.

Histopathological and immunohistochemical findings of primary and metastatic medullary thyroid carcinoma in a young dog.

This report describes the gross, histological, and immunohistochemical features of medullary thyroid carcinoma (MTC) with pulmonary metastases in a young dog. Sheets of pleomorphic cells supported by fibrous stroma characterized the primary mass, while metastatic nodules had a neuroendocrine pattern. Despite differing histologic features, all masses showed marked immunoreactivity against calcitonin and multiple neuroendocrine markers consistent with MTC. Although MTC is a well-recognized entity, it may be difficult to distinguish this mass from other thyroid neoplasms, necessitating immunohistochemical characterization.

Vorinostat and bortezomib as third-line therapy in patients with advanced non-small cell lung cancer: a Wisconsin Oncology Network Phase II study.

INTRODUCTION: The primary objective of this phase II trial was to evaluate the efficacy and tolerability of vorinostat and bortezomib as third-line therapy in advanced non-small cell lung cancer (NSCLC) patients. METHODS: Eligibility criteria included recurrent/metastatic NSCLC, having received 2 prior systemic regimens, and performance status 0-2. Patients took vorinostat 400 mg PO daily days 1-14 and bortezomib 1.3 mg/m2 IV day 1, 4, 8 and 11 in a 21-day cycle. Primary endpoint was 3-month progression free survival (3m-PFS), with a goal of at least 40 % of patients being free of progression at that time point. This study followed a two-stage minimax design. RESULTS: Eighteen patients were enrolled in the first stage. All patients had two prior lines of treatment. Patients received a median of two treatment cycles (range: 1-6) on study. There were no anti-tumor responses; stable disease was observed in 5 patients (27.8 %). Median PFS was 1.5 months, 3m-PFS rate 11.1 %, and median overall survival 4.7 months. The most common grade 3/4 toxicities were thrombocytopenia and fatigue. Two patients who had baseline taxane-related grade 1 peripheral neuropathy developed grade 3 neuropathy. The study was closed at its first interim analysis for lack of efficacy. CONCLUSIONS: Bortezomib and vorinostat displayed minimal anti-tumor activity as third-line therapy in NSCLC. We do not recommend this regimen for further investigation in unselected patients.

Feasibility and accuracy of ultrasound-guided sacroiliac joint injection in dogs.

Frozen cadaver specimens from three dogs were used to create a sectional anatomic atlas of the sacroiliac region. Frozen/thawed cadaver specimens from 12 dogs were used to develop an ultrasound-guided sacroiliac joint injection technique. Accuracy of the technique was tested in 15 additional canine cadaver specimens, using injectate containing blue dye and iodinated contrast medium. Sonoanatomic landmarks for consistently identifying a caudodorsal window into the canine sacroiliac joint space included the L7-S1 articular process joints, ilial wing, sacral wing, sacral lamina, and median sacral crest. Accuracy of ultrasound-guided sacroiliac joint injection was not significantly affected by operator, but was affected by the tissue location targeted and the reference standard used for calculations. Accuracy of the technique was good for placing injectate into either the synchondrosis component, dorsal sacroiliac ligament or ventral sacroiliac ligament; fair to poor for placing injectate into the synovial component; and poor for placing injectate into all four sacroiliac soft tissue structures. Concurrent placement of injectate into extraarticular tissues occurred frequently. We conclude that ultrasound-guided sacroiliac joint injection is feasible for evaluation as a treatment method for lumbosacral region pain in dogs, but is not sufficiently accurate for localizing pain to the sacroiliac joint alone.

Phase I study of sunitinib and erlotinib in advanced nonsquamous non-small cell lung cancer.

INTRODUCTION: Erlotinib has prolonged survival in unselected patients with advanced non-small cell lung cancer, whereas sunitinib has yielded promising rates of disease control in previously treated patients. We conducted a dose escalation study of this combination to determine the maximum tolerated dose of sunitinib in combination with a fixed dose of erlotinib and to evaluate the toxicities of this combination. METHODS: Patients with advanced nonsquamous non-small cell lung cancer were treated at two dose levels: sunitinib at either 25 mg or 37.5 mg, with erlotinib 150 mg. Both drugs were given once daily, continuously. RESULTS: Eleven patients enrolled from November 2007 to October 2009. No dose-limiting toxicities occurred. Grade 3/4 adverse events at least possibly related to treatment were seen in seven patients (64%). Six patients (54%) required dose modifications, and three (27%) discontinued study treatment due to toxicity. Rates of grade 3 diarrhea and mucositis exceeded those seen with single-agent erlotinib or sunitinib. One patient (9%) attained a partial response lasting 16.3 months. CONCLUSIONS: Although no dose-limiting toxicities occurred, it is difficult to recommend erlotinib 150 mg and sunitinib 37.5 mg daily as the phase II dose for this combination due to the high rate of adverse events. Because of the overlapping toxicity profile of each agent, this combination was poorly tolerated in our population.

Quantitative pertechnetate thyroid scintigraphy and the ultrasonographic appearance of the thyroid gland in clinically normal horses.

We characterized the scintigraphic and sonographic appearance of the thyroid gland in clinically normal horses to establish the value of these modalities for assessment of the thyroid gland in this species. Horses were divided into two age groups. One group consisted of eight horses between 3 and 10 years of age and the other of seven horses between 11 and 20 years of age. Total T4 concentrations were within the laboratory reference interval in all horses. Thyroid to salivary (T/S) ratio, percent dose uptake of pertechnetate (Na99mTcO4) and thyroid lobe volume were calculated. The echogenicity of thyroid lobes and presence of nodules was documented. The two groups were compared using appropriate parametric and nonparametric statistics. Mean total T4 concentration was lower in older horses. Sixty minute mean +/- standard deviation (SD) T/S ratios for old vs. young horses were 5.8 +/- 3.0 and 5.3 +/- 2.2, respectively. Sixty-minute median and interquartile ranges for percent dose uptake of pertechnetate for old vs. young horses were 3.64% (1.5-3.98%) and 2.55% (2.33-2.90%), respectively. Mean +/- SD thyroid lobe volume for old vs. young horses were 18.93 +/- 5.16 cm 3 and 13.55 +/- 3.56 cm3, respectively. Differences between groups were not significant. Most thyroid lobes were hyper or isoechoic to the sternocephalicus muscle. Prevalence of thyroid nodules did not differ between groups. Further study is needed to determine if thyroidal percent dose uptake is significantly different in horses with thyroid dysfunction and if it is clinically useful.

Modeling of the spread of infection in the interdigital spaces of the manus in limbs from clinically normal dogs.

OBJECTIVE: To determine whether the pattern of extension of modeled infection from the interdigital web spaces in dogs is predictable and whether the distribution differs among initial injury sites. SAMPLE POPULATION: Thawed frozen forelimbs from 23 cadavers of previously healthy adult medium- to large-breed dogs. PROCEDURES: The manus of each forelimb was evaluated by use of computed tomography (CT) before and after injection of radiopaque blue-staining contrast medium into the interdigital web spaces. Two veterinary radiologists reviewed the CT images and recorded the extent of contrast medium from each site. Each manus was dissected or sectioned transversely after imaging, and the extent of contrast medium accumulation was recorded and compared with locations of CT contrast enhancement. The Fisher exact test was performed to determine whether the pattern of contrast medium extension differed by injection site. RESULTS: Injections made in the interdigital web spaces of the canine manus led to unique and predictable patterns of extension into the surrounding soft tissues. That pattern of extension primarily involved the soft tissues of the digits. CONCLUSIONS AND CLINICAL RELEVANCE: In humans, knowledge of common extension patterns from infected soft tissue spaces is used to predict the spread of disease within the hand and develop surgical plans that will minimize patient illness. Identification of the common sites of disease spread from the interdigital web spaces in dogs may help improve surgical planning and treatment for infection in the manus.

Computed tomographic and cross-sectional anatomic characterization of myofascial compartments and soft tissue spaces in the manus in cadavers of dogs without forelimb disease.

OBJECTIVE: To characterize the computed tomographic (CT) and cross-sectional anatomic features of myofascial compartments and soft tissue spaces in the manus of cadavers of dogs without forelimb disease. ANIMALS: 33 cadavers of adult medium- to large-breed dogs without forelimb disease. PROCEDURES: Forelimbs were removed from the cadavers within 4 hours after euthanasia or within 6 hours after thawing from initial freezing. Specimens were then frozen for variable periods and thawed for approximately 16 hours before use. Each manus of 60 forelimbs underwent CT before and after injection of a radiopaque, blue-staining contrast medium into locations where soft tissue spaces and myofascial compartments were predicted (on the basis of pilot study data [6 forelimbs]). Two veterinary radiologists reviewed CT images and recorded the presence or absence of a discrete space or compartment at each injection site. Each manus was subsequently dissected or sectioned transversely. Locations of blue-staining contrast medium accumulation were compared with locations of contrast enhancement in CT images. Anatomic structures within each soft tissue space or myofascial compartment were described. RESULTS: 13 soft tissue spaces and 5 myofascial compartments were identified in the manus. Three myofascial structures that were examined were determined not to be compartments. CONCLUSIONS AND CLINICAL RELEVANCE: Knowledge of soft tissue spaces and myofascial compartments are used to map the likely spread of disease in the hands and feet of humans. Thus, understanding the locations and extent of similar structures in the canine manus may improve the effectiveness of surgical interventions in dogs with injury or inflammation of this region of the forelimb.

Ultrasound of the thorax (noncardiac).

Ultrasound examination of the thorax is an extremely valuable adjunct imaging modality in chest wall, pleural, mediastinal, and pulmonary disease. While air-filled lungs will obscure some deeper pulmonary lesions, ultrasound can evaluate peripheral pulmonary disease, mediastinal masses, and the extent and character of pleural effusions. Ultrasound guidance of needle biopsies and thoracocentesis provides safe and accurate lesion sampling.

Ultrasound of the gastrointestinal tract.

Sonographic scanning techniques of the gastrointestinal tract are presented. Normal anatomy and ultrasound appearance of the stomach, small intestine, and large intestine are discussed, followed by the ultrasound appearance of gastrointestinal inflammation, neoplastic disease, and obstruction.

Diffuse osteopenia and myelopathy in a puppy fed a diet composed of an organic premix and raw ground beef.

CASE DESCRIPTION: An 8-month-old Shetland Sheepdog was evaluated because of the sudden onset of signs of neck pain, collapse, and inability to rise. A cursory diet history indicated that the dog had been fed a raw meat-based diet. CLINICAL FINDINGS: Initial evaluation of the dog revealed small physical stature, thin body condition, and signs of cranial cervical myelopathy. Radiographically, diffuse osteopenia of all skeletal regions was identified; polyostotic deformities associated with fracture remodeling were observed in weight-bearing bones, along with an apparent floating dental arcade. Hypocalcemia and hypophosphatemia were detected via serum biochemical analyses. The dog's diet was imbalanced in macronutrients and macrominerals. TREATMENT AND OUTCOME: The dog received supportive care and treatment of medical complications; neurologic abnormalities improved rapidly without intervention. Dietary changes were implemented during hospitalization, and a long-term feeding regimen was established. Following discharge from the hospital, exercise restriction was continued at home. Serial follow-up evaluations, including quantitative bone density measurements, revealed that dietary changes were effective. After 7 months, the dog was clinically normal. CLINICAL RELEVANCE: In the dog of this report, vitamin D-dependent rickets type I and suspected nutritional secondary hyperparathyroidism developed following intake of a nutritionally incomplete and unbalanced diet. The raw meat-based, home-prepared diet fed to the dog was not feed-trial tested for any life stage by the Association of American Feed Control Officials, and its gross nutrient imbalance induced severe metabolic, orthopedic, and neurologic abnormalities. Inadvertent malnutrition can be avoided through proper diet assessment and by matching nutrient profiles with patients' nutritional needs.