At Your Service: Internal Medicine/Diabetes Care

Foster Hospitals team of internal medicine specialists treats medical issues affecting major body systems, from endocrine, kidney, urinary, gastrointestinal, liver, pancreas, and respiratory system as well as infectious diseases. Although many of our internal medicine specialists have developed sub-specialties each is equipped to diagnose and manage a wide variety of complex medical issues, interpret laboratory and imaging tests and perform advanced diagnostic procedures.

Meet our internal medicine veterinary specialists:

Lilian Cornejo, DVM, DACVIM
Clinical Interest: Gastroenterology

Mary Labato, DVM, DACVIM
Clinical Interest: Renal and Urinary Tract

Orla Mahony, MVB, DACVIM, DECVIM
Clinical Interest: Endocrine

Linda Ross, DVM, MS, DACVIM
Clinical Interest: Renal and Urinary Tract

Mike Stone, DVM, DACVIM
Clinical Interest: Infectious Diseases

Cyndie Webster, DVM, DACVIM
Clinical Interest: Gastroenterology and Hepatology (Liver)

Virginia Rentko, VMD, DACVIM
Clinical Interest: Hematology

Some of the special procedures that can be performed include, but are not limited to:

  • dialysis for acute kidney injury
  • laser lithotripsy for bladder and urethral stones
  • laser therapy for transitional cell carcinoma of the bladder
  • coil placement for liver shunts
  • endoscopy, rhinoscopy and cystoscopy
  • dietary consultation and obesity management
  • bronchoscopy and pulmonary function testing
  • interventional procedures such as stent placement for collapsing trachea, ureteral stones, urethral obstruction
  • consults on hepatic histopathology with our pathologists
  • evaluation of blood coagulation with thromboelastography to aid in predicting bleeding and clotting risk
  • Interstitial glucose monitoring

Spotlight on Orla Mahoney: MVB, DACVIM

Experience, clinical expertise and compassion treating hormone-related and endocrine conditions are just some of what Orla Mahony, MVB, DACVIM, DECVIM, brings to her patients and owners each and every day. “Given my specialty interest, I see and treat a number of diseases that affect the hormonal systems of dogs and cats, including diabetes melllitus, thyroid diseases, Cushing’s disease, adrenal tumors, and Addison’s disease. Dr. Mahony continues, “Our 24-hour critical care and emergency staff will stabilize the case, but I will often get involved after the pet’s been stabilized for ongoing, regulation and monitoring,” referring to Fido, the ketoacidotic dog.

In some circumstances, you may be familiar with the expertise of one of the Foster Hospital internists and make a special request that your client see this doctor. When a pet is referred for an urgent appointment, however, it may not always be possible to honor that request. Dr. Mahony explains, “Even though I may not see a ketoacidotic diabetic pet initially, I am almost always available for an onsite consultation with one of our internal medicine specialists. The access to the combined brain power of many specialists is one of the incredible benefits of sending your patients to Foster Hospital.

Teamwork Integral to Care Approach

Foster Hospital for Small Animals offers access to state of the art diagnostic and therapeutic technologies that enable us to diagnose and treat many advanced diseases and uncommon problems. Our internists will get a detailed history, take note of the current clinical signs, review all the testing and medical notes from the referring veterinarian, order additional testing and special procedures, and then put it all together to paint a complete picture of the pet’s condition. An appropriate clinical plan will then be developed in conjunction with the referring veterinarian, if relevant. One area in which we take great pride is with the interactions between the internists and radiologists and pathologists. Our board certified radiologists have years of imaging experience, and can instantaneously interpret findings along with the internists, which offers a team approach of care.. Also, being able to sit down with our pathologists and look at cytology and histopathology slides speeds up the diagnostic process and gets the animals the treatment they need.

Supporting our team of internists are trained technicians, interns, residents, students and an expert team of other veterinary specialists within a state-of-the-art facility. The size and breadth of our clinical faculty allows a unique opportunity for consultation with other clinical services, such as radiology, pathology, surgery, dermatology, ophthalmology, and cardiology, providing your client and its owner with an extensive resource of specialists all under one roof.

Combine our staff’s love for animals with the more than the century of experience our internal medicine specialists bring to your pet, plus the cooperation with our broad array of specialists, and we are able to offer the most comprehensive and most compassionate care available to the patients that you entrust in our care.

For more information or to arrange for a referral you may contact our Clinical Liaisons at 508-887-4988.

At Your Service

Oncology Service
Providing Families More Quality Time with their Companion Pets

Who We Are
The Harrington Oncology Program at the Tufts Foster Hospital for Small Animals at Cummings School of Veterinary Medicine provides state-of-the-art diagnostic, medical, radiation therapy and surgical techniques. Led by board-certified specialists in medical and radiation oncology, it is supported by a team of residents, dedicated technicians and staff.

Foster Hospital believes in a team approach to care and our oncologists work closely with a highly skilled surgery service with expertise in surgical oncology, as well as with the pathology, diagnostic imaging, interventional radiology and pain management services. Our collaboration allows us to offer treatment options that are customized based on the tumor type, the spread of the cancer, and the overall health of the pet. This could involve a single treatment modality or a combination of different therapies. In some cases, in accordance with the client’s wishes, a more conservative strategy may focus on palliative care. Through all of this we provide you and your client with detail on the type of cancer, treatment options, and expected outcomes, keeping quality of life as a top priority. The oncology service takes pride in ensuring that all of the client’s questions are answered and that the veterinarians, technicians and pet owners work as a team.

As an academic veterinary medical center, we are training the veterinarians of the future, and are also actively engaged in research into the causes, biology and treatment of cancer. As a member of the National Cancer Institute’s Comparative Oncology Trials Consortium, and through independent studies and collaboration with other veterinary and biomedical institutions, the oncology service is able to offer investigational therapies, in addition to conventional treatment. In addition, we participate in the Tufts Human Animal Cancer Collaborative with the Medical School at Tufts University, where treating cancer in companion animals helps inform how we treat humans.

Technology and Services Available
The Harrington Oncology Program is recognized nationally in the field, boasting some of the most advanced technology available in veterinary medical establishments. With medical staff and technicians well-versed and experienced in chemotherapy administration, radiation therapy and anesthesia, specific features of our service include:

  • Intravenous, intralesional an intracavitary chemotherapy administration, including long continuous-rate infusions
  • Melanoma vaccine administration
  • Siemens Primus linear accelerator with 6MV photon and 6-21 MeV electron capabilities and a 56-leaf collimator that allows for intensity modulated radiation therapy
  • Three-dimensional computerized radiation therapy planning
  • Strontium plesiotherapy
  • Various biospy techniques, including manual incision, punch, needle-core biopsies as well as image-guided (ultrasound or computed tomography) and open surgical procedures
  • Interventional radiologic procedures, such as chemoembolization and intra-arterial chemotherapy administration
  • Access to investigational clinical protocols

Referring a Patient
The Harrington Oncology Program typically sees new patients who have a confirmed cancer diagnosis. This often allows us to provide clients with a full array of staging and treatment options during the initial visit. We understand, however, that circumstances arise in which an oncology consult is valuable before a diagnosis is made. You should feel free to call us about these cases to facilitate a referral. We welcome the opportunity to even provide you with a telephone consult (free of charge) regarding general information on cancer management or to discuss a possible referral.

In situations when pet owners are uncertain whether they wish to pursue treatment for their pets with a cancer diagnosis, we encourage referrals to address their questions regarding anticipated course of the disease, treatment options and palliative care. You may contact Kelly Reed, our clinical liaison, at 508-887-4682, and she will facilitate all care for pets you refer.

Meet the Team

Radiation Oncology Faculty

Michele Keyerleber, DVM, DACVR, a board-certified veterinary radiation oncologist and faculty member, is a 2008 graduate of Cornell University’s College of Veterinary Medicine. She later completed a small animal internship at The Ohio State University, before returning to Cornell for a residency in radiation oncology. Dr. Keyerleber joined the faculty of Cummings School of Veterinary Medicine at Tufts University in 2011. Her research interests include radiation therapy planning for neoplasia in dogs and cats, brain tumors, and palliative radiation therapy. Dr. Keyerleber also has a strong interest in pain and side effect management for radiation therapy patients.

Elizabeth McNiel, DVM, PhD, DACVIM, DACVR is board-certified in radiation and medical oncology. She is a 1992 graduate of Texas A&M University and completed a small animal rotating internship at Angell Memorial Animal Hospital in Boston. Dr. McNiel completed a medical oncology residency program followed by a combined radiation oncology residency and PhD program at Colorado State University. Prior to coming to Cummings School of Veterinary Medicine at Tufts University in 2012, she served on the faculty of the University of Minnesota and Michigan State University. An active researcher, Dr. McNiel studies the molecular biology of canine and feline tumors in her laboratory at the Molecular Oncology Research Institute at the Tufts Medical Center. Her goal is to translate basic discoveries in the laboratory into clinical advances for animals through clinical trials.

Medical Oncology Faculty

Lisa Barber, DVM, DACVIM, is a 1992 graduate of Ohio State University. She completed a small animal internship and residency in veterinary oncology at the University of Pennsylvania School of Veterinary Medicine where she subsequently served as a staff oncologist prior to joining the faculty at Cummings School of Veterinary Medicine at Tufts University. She specializes in treating dogs and cats with a variety of cancers, and consults on large animals as well as exotic animals. Her research interests include epidemiologic studies to identify risk factors for various cancers as well as investigation of novel treatments for cancer.

Kristine Burgess, DVM, DACVIM, is a board-certified veterinary oncologist at the Tufts Foster Hospital for Small Animals at Cummings School of Veterinary Medicine. After receiving her undergraduate degree from UMass, and completing a masters degree from work at Dana-Farber Cancer Institute, Kristine went on to earn her DVM from the Cummings School in 1997. She subsequently completed her residency training at the University of Wisconsin. She collaborates with several other institutions to run clinical trials for new and advanced cancer treatments for dogs and cats, which may lead to better treatment options for both pets and humans.

Oncology Residents

Kelly Kezer, DVM, a first-year medical oncology resident, received her veterinary degree from Massey University in New Zealand. After graduation, she completed a small animal rotating internship at BluePearl Veterinary Partners in Tampa, Florida, a high-volume practice, where she solidified her interest in oncology. Dr. Kezer enjoys all aspects of veterinary oncology, but has particular interest in novel therapies and international veterinary medicine.

Felicia Lew, DVM, a second-year medical oncology resident, is originally from Seattle, Washington. A 2012 graduate of Washington State University College of Veterinary Medicine, she completed a small animal rotating internship at a private specialty hospital in San Diego, California. Dr. Lew has an interest in basic science research, specifically in cancer biology and carcinogenesis.

Bobbi McQuown, DVM, a third year oncology resident, is originally from the Midwest. Prior to veterinary school, she spent 5 years in the Army as a communications officer. In 2011, she graduated from the North Carolina State University College of Veterinary Medicine, subsequently completing a small animal rotating internship at VCA VREC/Shoreline in Connecticut. Her ongoing research includes assessment of palliative radiation therapy and anal sac tumors, IGF-1 levels in dogs with lymphoma, and the use of Palladia in dogs with heart base tumors.

Oncology Technicians
Amy Bengtson
Tiffany DeNitti
Jenn Ford
Pam Shaw

Clinical Trials Coordinator
Diane Welsh

Oncology Liaison
Kelly Reed

Clinical Case Challenge

Oscar, a 10-year-old male castrated Yorkshire terrier, presented to the Tufts Foster Hospital for Small Animals at Cummings School Radiation Oncology Service for a several month history of nasal signs. Oscar’s owners initially noted increased sneezing and increased respiratory noise/congestion approximately six months prior that was non-responsive to treatment with steroids and antibiotics. Intermittent unilateral epistaxis was then noted approximately three months prior. This progressed to a mild but noticeable facial deformity approximately three weeks prior to presentation.

On presentation to Foster Hospital for Small Animals, physical examination revealed a mild facial deformity over the dorsal maxilla. There was no evidence of nasal, ocular, or aural discharge but no airflow was present from the left nare. Nuclear sclerosis was present bilaterally and retropulsion of both eyes was normal. Mild dental calculus was present. The mandibular lymph nodes were mildly enlarged but soft and symmetrical. Thoracic auscultation and abdominal palpitation were unremarkable.

Based on examination findings, what are your primary differential diagnoses? What further diagnostics would you consider, and what treatment options would you recommend?

Diagnosis
Based on the clinical history of epistaxis and presence of facial deformity, neoplasia is the primary differential diagnosis. Adenocarcinoma is the most common nasal tumor in dogs. Additional neoplastic considerations include undifferentiated carcinomas, squamous cell carcinoma, fibrosarcoma, chondrosarcoma, osteosarcoma, and lymphoma. Non-neoplastic differentials are considered less likely, but include fungal infection (aspergillosis most common), other infectious rhinitis, or foreign body.

Figure 1. Contrast-enhanced, soft-tissue window CT image of the initial CT scan, displaying a large, destructive heterogeneously contrast-enhancing, left-sided nasal mass, extending into the right nasal cavity invading into the right size with destruction of the left nasal and maxillary bones.

Figure 1. Contrast-enhanced, soft-tissue window CT image of the initial CT scan, displaying a large, destructive heterogeneously contrast-enhancing, left-sided nasal mass, extending into the right nasal cavity invading into the right size with destruction of the left nasal and maxillary bones.

A diagnostic workup for nasal tumors includes obtaining a sample of cells, usually through a biopsy to establish a definitive diagnosis. Options for biopsy include transnostril core sampling, blind or rhinoscopy-guided pinch biopsy, nasal flushing or punch biopsy of facial deformities. The latter option was performed on Oscar and histopathology revealed nasal adenocarcinoma. Staging tests then helped to determine the extent of disease through the body as well as a dog’s general health. These tests included blood work with a complete blood count and serum chemistry profile, urinalysis, chest x-rays, abdominal ultrasound and aspirates of the regional lymph nodes (if enlarged). This information is used to develop the best treatment plan for an individual patient. Oscar’s blood work and urinalysis were unremarkable. An abdominal ultrasound revealed hepatic and splenic nodules. Ultrasound-guided fine needle aspiration of the hepatic nodules revealed moderate hepatocyte vacuolization, a suggestion of glycogen deposition, and fine needle aspiration of the spleen revealed reactive lymphoid tissue. The mandibular lymph nodes were aspirated and found to be reactive. Oscar subsequently underwent a CT scan of his head for radiation therapy planning and a thoracic CT scan to complete staging. The CT scan revealed a large (1.7 x 2.7 x 3.1 cm), destructive, heterogeneously contrast-enhancing, left-sided nasal mass, extending into the right nasal cavity invading into the right size (Figure 1). The mass was causing destruction of the left nasal and maxillary bones, the right and left aspect of the cribriform plate and the left palatine and frontal bones with extension into the left retrobulbar space. The left mandibular lymph node was mildly enlarged. There was no evidence of pulmonary metastasis.

Treatment
Nasal carcinomas are the most common type of nasal tumor in dogs, accounting for ≥50-75% of all nasal tumors in dogs. Nasal tumors are relatively common in older dogs and long-nosed dog breeds seem to be predisposed. Nasal cancer is a progressive disease, that mostly affects dogs through space occupation, local destruction, and invasion of nearby tissues and can lead to clinical signs such as nasal discharge, nose bleeds, facial deformity, and occasionally neurologic deficits (such as seizures). Metastatic potential to other areas of the body is low with nasal carcinomas (<30% metastatic rate), but it can happen, and usually occurs in the lymph nodes and lungs, often later in the disease course.

Surgery is not typically recommended for nasal tumors in dogs due to the location of the tumor and inability to remove the entire tumor.

Definitive radiation therapy allows for the best control over future tumor growth with the average survival time being 1 to 1.5 years for most nasal tumors. This treatment plan typically involves 16-19 daily treatments (M-F) under a light plane of general anesthesia. There are some short- and long-term side effects associated with definitive radiation therapy. Short-term side effects typically arise midway through the treatment cycle and peak around the end or 1 week following completion of radiation therapy before healing. Short-term effects include: dry eye and/or conjunctivitis; erythema, hair loss, and dry or moist desquamation of the skin; and inflammation to the oral cavity and throat. We typically manage these short term side effects with oral antibiotics (if indicated), anti-inflammatory medications, pain medications, and topical eye medications. There is also a small risk of long-term effects from radiation therapy, which may develop several months to years after treatment has finished. These effects include: chronic nasal discharge/sneezing, dry eye, cataracts (typically begin to develop around 9-12 months post radiation), bone or soft tissue damage/cell death, and rarely (<3-5% incidence at 3-5 years post radiation) secondary tumor induction.

A less aggressive course of radiation, termed palliative radiation therapy, may also be considered. This treatment protocol typically involves either 6 once weekly treatments or 10 daily radiation treatments (M-F), but other protocols are also available. Palliative radiation generally decreases the number and severity of the potential short-term side effects mentioned above to a very mild level, if at all. This treatment plan is associated with a median survival time of approximately 6-10 months for nasal tumors.

Figure 2. Graphical representation of Oscar’s 3-D conformal radiation therapy plan. The target volume is represented by the red shaded region. The concentric colored lines represent the dose level as a percentage of prescription dose.

Figure 2. Graphical representation of Oscar’s 3-D conformal radiation therapy plan. The target volume is represented by the red shaded region. The concentric colored lines represent the dose level as a percentage of prescription dose.

Although radiation therapy is considered the gold standard for treatment of nasal tumors, chemotherapy can also be considered. There are two different chemotherapy options: conventional and non-conventional chemotherapy. Conventional chemotherapy for treatment of nasal tumors is typically intravenous therapy with a platinum agent, such as cisplatin or carboplatin. Reported response rates are low at approximately 30%. Non-conventional chemotherapy for treatment of nasal carcinomas includes use of the small molecule inhibitor, Palladia. There is little clinical research regarding response rates with Palladia treatment in nasal carcinomas but anecdotally it seems to have some efficacy.

Figure 3. Contrast-enhanced, soft-tissue window CT image of recheck scan at 7 months post radiation  therapy, displaying resolution of the previously described contrast enhancing soft tissue mass associated  with the nasal cavities but persistent loss of the left nasal and maxillary bones.

Figure 3. Contrast-enhanced, soft-tissue window CT image of recheck scan at 7 months post radiation therapy, displaying resolution of the previously described contrast enhancing soft tissue mass associated with the nasal cavities but persistent loss of the left nasal and maxillary bones.

In the case presented herein, after discussion with the owners, definitive radiation therapy was performed. Oscar underwent 16 daily radiation therapy treatments (Figure 2). Halfway through the radiotherapy course, the facial deformity was nearly completely resolved. Epistaxis also resolved. He experienced moderate inflammation to his skin and oral cavity secondary to the radiation therapy, which resolved by 2 weeks post radiation therapy. Oscar was subsequently monitored every 3 months via physical exam and thoracic radiographs. Repeat CT scan at 7 months post radiation therapy revealed complete resolution of the previously described contrast enhancing soft tissue mass associated with the nasal cavities (Figure 3). There was persistent right displacement of the nasal septum and loss of the majority of the left nasal turbinates, as well as persistent loss of the left nasal and maxillary bones, left palatine bone, and right and left cribriform plate.

Clinical Case Challenge: Animal Behavior Clinic

Digital StillCameraCase Description

A 2.5-year-old miniature dachshund named Otto, presented to the Animal Behavior Clinic at Cummings School of Veterinary Medicine at Tufts University for the sudden onset of aggression to his owners. The aggression consisted of growling, lunging, snapping and biting. Lifting him, attaching a leash and approaching him while resting triggered an aggressive response. He used aggression to guard valued resources, such as his food bowl, long-lasting treats and objects he had taken that did not belong to him. He growled or snapped when petted. He was more likely to attack when he was on an elevated level, such as a sofa or lap. The aggression was intermittent, giving the impression of unpredictability to the owners.

Otto’s referring veterinarian conducted a thorough physical examination. A CBC, chemistry and total T4 were within normal limits. Medical causes of behavioral changes secondary to hypothyroidism, hepatic insufficiency, painful conditions, such as IVDD or orthopedic issues were ruled out.

What is your diagnosis and what treatment would you recommend?

Diagnosis

The correct diagnosis is conflict aggression, which is characterized by aggressive behavior directed toward owners in response to a perceived provocation. Triggers can be separated into three categories: resource guarding (e.g., resting places), postural interventions (e.g., lifting, petting, nail trims) and when owner takes on a leadership role (e.g., grabbing the collar, removing from furniture, reprimands, physical punishment). A dog with this problem may behave differently to different individuals in the family. The behavior may also appear unpredictable to owners because it is intermittent. For example, a dog may tolerate being picked up one day and not the next. However, close questioning reveals that there is generally a predictable set of triggers that at least sometimes, will lead to an aggressive response.

This diagnosis used to be called Dominance Aggression. However, our current understanding is that this form of owner-directed aggression is rooted in anxiety, not confidence. Conflict-aggressive dogs are temperamentally bold. However, their anxiety renders them impulsive and reactive toward members of their social group. Studies have shown that conflict-aggressive dogs have lower levels of the transmitter serotonin. (Çakiroǧlu 2007). This condition can be inherited genetically, as seen by its increased frequency in certain breeds, such as dachshunds, chihuahuas, Australian cattle dogs, and others (Serpell 2008). Insufficient early socialization can also predispose dogs to conflict aggression. While the seeds of conflict aggression are planted early in life, it usually manifests at social maturity (9 -24 months of age.)

Important differentials are Irritable Aggression, Fear Aggression and Rage Syndrome (partial complex seizures). Irritable aggression occurs when a dog has a painful medical condition that lowers his or her aggression threshold. Fear aggression is commonly directed at people outside of the dog’s inner circle of family and friends. Rage syndrome occurs in response to a trivial trigger or no trigger at all. It is prolonged and often accompanied by a pre- and postictal behavior change. Dogs may have multiple diagnoses.

Treatment

Treatment consists of behavioral modification in which triggers of aggression are strictly avoided and steps are taken to improve the owner’s benign leadership position in the eyes of the dog. Changes in diet and exercise are also part of the treatment regimen.

Exercise and Diet:

The owners were instructed to provide Otto with an hour a day of aerobic exercise. They were also told to feed a diet low in protein and free of colorings and preservatives. Exercise and diets lower in protein may help to stabilize serotonin in the brain.

Neutering:

Neutering was recommended as it has been associated with a decrease in aggression. (Tsu 2010)

Avoidance of Conflict and Triggers of Aggression:

The list of triggers was discussed in depth with the owners, and strategies were developed to avoid them. It was explained to the owners that avoidance is therapeutic in that it prevents Otto’s continued sensitization to interactions that he does not like, thereby building trust. The owners were told to no longer permit Otto on laps or furniture and to leave him alone when he rested in his own bed. He should not be lifted up the stairs or into the car. He should not be given any chews or toys he would guard. If he had a stolen object, the owners were instructed to let him have it if it were not dangerous for him or valuable to them. If it were necessary to take it away from him, they were instructed to use a distraction technique such as ringing the doorbell or asking him to go for a walk, then picking it up when he left the room. They were instructed to decrease the frequency and duration of petting sessions. The owner developed a very clever leash and collar combination that could be slipped over his head and fixed onto him from a standing position.

Leadership:

The owners were instructed to strengthen their leadership position by having Otto obey a command before both of his twice daily meals and all food treats. Once his food was prepared, Otto was told one time to sit. If he obeyed, the food was put down instantly and the owner was to walk away. Otto was given 15 minutes to eat. All uneaten food was picked up to prevent guarding. If he did not obey the command to sit, his food was put away and he was not to be fed again until the next meal. If he anticipated the command by sitting before he was told, he was given a different command, such as down. The owners were also instructed to ignore demanding and attention-seeking behaviors.

Medication:

Fluoxetine (Prozac) was prescribed at 1 mg/kg once daily. Fluoxetine is a selective serotonin reuptake inhibitor that stabilizes mood, increases confidence and decreases reactivity and impulsivity.

Follow-Up

Weekly follow-up phone calls were instituted to check in about the program. Each episode of aggression was discussed in detail and the behavioral modification plan was adjusted. The dose of fluoxetine was adjusted once. Otto was neutered.

Outcome

Three months after the consultation, aggression decreased from one episode per day to one per week. Six months after the consultation, aggression occurred less than once per month.

References

  1. Duffy D, Hsub Y, Serpell JA, Breed differences in canine aggression Applied Animal Behaviour Science, Volume 114, Issues 3–4, 1 December 2008, Pages 441–46
  2. Çakiroǧlu D, Meral Y, Sancak AA, Çifti G, Relationship between the serum concentrations of serotonin and lipids and aggression in dogs Veterinary Record 2007;161:59-61 doi:10.1136/vr.161.2.59
  3. Hsu Y, Liching Sun L, Factors associated with aggressive responses in pet dogs, Applied Animal Behaviour ScienceVolume 123, Issues 3–4, March 2010, Pages 108–123