Recurrence rate, clinical outcome, and cellular proliferation indices as prognostic indicators after incomplete surgical excision of cutaneous grade II mast cell tumors: 28 dogs (1994-2002)

The objectives of this study were to determine local recurrence rate, clinical outcome, and prognostic value of the number of argyrophylic nucleolar organizer regions (AgNORs), presence of proliferating cell nuclear antigen (PCNA), and number of Ki-67-positive nuclei after incomplete surgical excision of canine cutaneous grade II mast cell tumors (MCTs). This retrospective study included 30 MCTs in 28 dogs. Medical records were examined and follow-up information was obtained from owners and referring veterinarians. Only cases in which excision was incomplete and no anvcillary therapy (other than prednisone) for MCT was given were included. Paraffin-embedded tumor tissues were retrieved for AgNORs, PCNA, and Ki-67 staining. Median follow-up time was 811.5 days. Seven (23.3%) tumors recurred locally. Median time to local recurrence was not reached with a mean of 1,713 days. The estimated proportions of tumors that recurred locally at 1, 2, and 5 years were 17.3, 22.1, and 33.3%, respectively. Eleven (39.3%) dogs developed MCTs at other cutaneous locations. Median progression-free survival was 1,044 days. Median overall survival was 1,426 days. The combination of Ki-67 and PCNA scores was prognostic for local recurrence (P = .03) and development of local recurrence was prognostic for decreased overall survival (P = .04). Results suggest that a minority of incompletely excised MCTs recur. Therefore, ancillary local therapies may not always be necessary. However, local recurrence can negatively affect survival of the affected dogs. Cellular proliferation indices may indicate the likelihood of MCT recurrence after incomplete excision.     

Recurrence rates and clinical outcome for dogs with grade II mast cell tumours with a low AgNOR count and Ki67 index treated with surgery alone

Grade II mast cell tumours (MCT) are tumours with variable biologic behaviour. Multiple factors have been associated with outcome, including proliferation markers. The purpose of this study was to determine if extent of surgical excision affects recurrence rate in dogs with grade II MCT with low proliferation activity, determined by Ki67 and argyrophilic nucleolar organising regions (AgNOR). Eighty‐six dogs with cutaneous MCT were evaluated. All dogs had surgical excision of their MCT with a low Ki67 index and combined AgNORxKi67 (Ag67) values. Twenty‐three (27%) dogs developed local or distant recurrence during the median follow‐up time. Of these dogs, six (7%) had local recurrence, one had complete and five had incomplete histologic margins. This difference in recurrence rates between dogs with complete and incomplete histologic margins was not significant. On the basis of this study, ancillary therapy may not be necessary for patients with incompletely excised grade II MCT with low proliferation activity.     

Mast cell tumor destruction by deionized water

In a controlled study, malignant murine P815 mastocytoma cells exposed in vitro to distilled and deionized water died as a result of progressive swelling, degranulation, and membrane rupture. A 90% mean cell death occurred when cells obtained directly from culture were exposed to deionized water for 2 minutes. Of 6 cryopreserved malignant murine cell lines, which included Cloudman S91 melanoma, CMT-93 rectum carcinoma, MMT-06052 mammary carcinoma, and S-180 Sarcoma, only P815 mastocytoma and YAC-1 lymphoma were significantly (P less than 0.05) affected by hypotonic shock; Cloudman S91 melanoma cells were the most resistant. Mastocytoma cells were selectively killed by hypotonic solution, and lymphoma cells were also killed by isotonic saline solution. Local mast cell tumor (MCT) recurrence and percentage survival were evaluated in 12 cats (21 MCT) and 54 dogs (85 MCT) subjected to surgery alone or local infiltration of deionized water as an adjunct to surgery. Of all 16 incompletely excised MCT in cats, there was no local recurrence following injection. Four mast cell tumors (2 cats) regressed after being injected in situ. In dogs with clinical stage-I MCT, local recurrence was detected in 50% (5/10), but with injection after incomplete excision, local MCT recurrence was significantly (P less than 0.05) less (6.6%, 1/15). Percentage recurrence was significantly (P less than 0.05) less and survival significantly greater when incompletely excised grade-II MCT were injected. Mean follow-up period after surgery in cats and dogs was 35 and 23.4 months, respectively.     

Influence of surgical margin completeness on risk of local tumour recurrence in canine cutaneous and subcutaneous soft tissue sarcoma: A systematic review and meta‐analysis

The present peer‐reviewed veterinary literature contains conflicting information regarding the impact of surgical margin completeness on risk of local tumour recurrence in canine soft tissue sarcoma (STS). This systematic review and meta‐analysis was designed to answer the clinical question: “Does obtaining microscopically tumour‐free surgical margins reduce risk for local tumour recurrence in canine cutaneous and subcutaneous STS?” A total of 486 citations were screened, 66 of which underwent full‐text evaluation, with 10 studies representing 278 STS excisions ultimately included. Cumulatively, 16/164 (9.8%) of completely excised and 38/114 (33.3%) of incompletely excised STS recurred. Overall relative risk of 0.396 (95% confidence interval = 0.248‐0.632) was calculated for local recurrence in STS excised with complete margins as compared to STS excised with incomplete margins. Risk of bias was judged to be low for all studies in terms of selection bias and detection bias but high for all studies in terms of performance bias and exclusion bias. The results of the present meta‐analysis, coupled with the results of individual previous studies, strongly suggest that microscopically complete surgical margins confer a significantly reduced risk for local tumour recurrence in canine STS. Future studies ideally should adhere to standardized conducting and reporting guidelines to reduce systematic bias.     

Histological and immunohistochemical features of cutaneous mast cell tumor in six captive four-toed hedgehogs (Atelerix albiventris)

This report described the histopathological and immunohistochemical features of cutaneous mast cell tumor (MCT) in six hedgehogs. The hedgehogs presented single cutaneous mass with ulcer and crusting. Histologically, the neoplastic lesions were characterized by the proliferation of well-differentiated mast cells (3 cases), and atypical mast cells (3 cases) with one atypical histiocytic morphology. Immunohistochemically, tumor cells were positive for KIT and mast cell tryptase, and were negative for Iba-1. In well-differentiated MCT, all patients were clinically improved and survived more than 365 days after surgical excision, whereas an atypical histiocytic MCT showed aggressive behavior with re-recurrence, and the animal died 115 days after surgery. These findings suggest that, compatible with other animals, well-differentiated MCT has a better prognosis in hedgehogs.     

The European College of Veterinary Surgeons 1991-2011: a 20-year success story

The first meeting leading to the formation of the European College of Veterinary Surgeons (ECVS) was held August 30/31, 1990 in Lenzburg, Switzerland. Specialists in small animal and large animal surgery from practice and academicians from many European countries were invited. The constitution was developed based on that of the American College of Veterinary Surgeons (ACVS). ECVS was founded during the ACVS European Surgical Forum in Nice in 1991. The provisional Board elected at this meeting stayed active during the initial 4 years to provide stability. For the 146 Charter Members to become a Diplomate, they had to pass an examination. Therefore, the ECVS is the only Specialty College that does not have a "Grand Father Clause." In 2000 ECVS, was the first College to acquire full recognition-status by the European Board of Specialization (EBVS), which underlines the leading role the surgeons play in the development of the European veterinary specialty colleges. Like its American Sister College, ECVS maintains high standards for surgical training programs for Residents and administers rigorous certifying examinations. It is appropriate to recall the facts that lead to foundation of ECVS on its 20-year anniversary.     

Surgery and Doxorubicin in Dogs With Hemangiosarcoma

Forty-six dogs with histologically confirmed hemangiosarcoma of various locations other than skin were used in a prospective study to determine the efficacy of adjuvant doxorubicin (30 mg/m² IV q 3 weeks for 5 treatments) 10 to 14 days after the tumor was partially or completely excised. Analysis of the data included information on variables that were hypothesized to influence response to therapy, disease-free interval (DFI), or survival time (ST). Other information collected included age, gender, breed, weight, prior therapy, type of surgery, location of the primary tumor, presence of metastases, number of doses of doxorubicin, response to doxorubicin therapy (complete or partial response!, and the following histological criteria: overall differentiation, nuclear pleomorphism, percent necrosis, mitotic score, total histological score, and grade. Surgery outcome (complete versus incomplete surgical excision) markedly influenced survival times (P < .001). Twenty percent of the dogs rendered free of disease were alive at 1 year, whereas none of the dogs that had residual tumor after surgery were alive at 1 year. Most of the histological criteria (nuclear pleomorphism, mitotic score, grade, overall differentiation) had marked (P < .05), or close to marked, independent associations with ST for dogs that had complete tumor removal. Results from analysis of DFI were generally similar to those of ST in dogs with complete excision of the tumor. Twenty-seven of the 46 dogs (58.7%) had all clinical evidence of tumor successfully removed. Logistic regression analysis of surgical outcome (ability to remove all visible tumor) suggested that age of the subject was the only factor markedly influencing surgical outcome (P= .017). As age increased, the probability of success increased. Those dogs that had previous treatment for their hemangiosarcoma tended (P= .08) to have a shorter DFI and ST. Therefore, complete removal of all evidence of tumor followed by 5 doses of doxorubicin may be an effective treatment for dogs with hemangiosarcoma. Dogs that had all tumor successfully removed had a mean and median ST of 267 and 172 days, respectively. Dogs with incomplete tumor removal had a mean and median ST of 172 and 60 days, respectively. Similarly, prognostic variables such as the ability to completely excise all evidence of tumor, histological criteria, and age of the patient are potentially important prognostic variables for predicting outcome.     

Long-term postsurgical outcomes of mast cell tumors resected with a margin proportional to the tumor diameter in 23 dogs

We evaluated the postsurgical outcomes of cutaneous or subcutaneous mast cell tumors (MCTs, n=25) in 23 dogs, resected with lateral surgical margins proportional to the widest tumor diameter, including at least one facial plane. The tumor diameter range was 0.3–2.6 cm (median: 0.9 cm), and all were histologically diagnosed as Kiupel’s low-grade MCT. Resection was histologically complete in 20, close (deep margin) in three, and incomplete (deep margin) in two. No dogs developed local recurrence at the site of initial surgery during follow-up of 161–2,219 days (median: 976 days). These results suggest that resection of low-grade, relatively small MCTs with surgical margins proportional to the tumor diameter is a practical procedure with high success rates.     

PREOPERATIVE RADIOTHERAPY FOR VACCINE ASSOCIATED SARCOMA IN 92 CATS

Medical records for 92 cats with a vaccine associated sarcoma receiving preoperative irradiation, with or without chemotherapy, between December 1985 and September 1998 were reviewed. The purposes were to quantify response to treatment and to attempt identification of factors associated with favorable response. Variables evaluated for a relationship to outcome included signalment, tumor location, presence of gross vs. microscopic tumor, radiation field size, irradiation technique, type of surgical procedure, completeness of excision, and chemotherapy (none, carboplatin alone, and others). Time to first event was calculated for the first day of treatment until local tumor recurrence or metastasis, or the date of euthanasia or death. Median time to first event for all 92 cats was 584 days. Only completeness of surgical excision was related to the time to first event. Median time to first event in cats having complete surgical excision was 986 days compared to 292 days for cats with incomplete excision (P = 0.004). Cats requiring bone removal to effect tumor removal had earlier failure than cats having other types of surgery. There was not a significant relationship between administration of chemotherapy or chemotherapy type and time to first event although outcome in cats receiving carboplatin was better than all other treatment groups. Carboplatin addition to preoperative irradiation appears worthy of further study. Preoperative irradiation is an effective treatment for cats with vaccine associated sarcoma, especially if complete excision can be accomplished following irradiation.     

Association of Ki67 index with prognosis for intermediate‐grade canine cutaneous mast cell tumours*

Intermediate‐grade mast cell tumours (MCT) represent a heterogeneous population of tumours. The prognosis for the majority of dogs is excellent following surgical excision, but a minority die because of their disease. A previous study identified Ki67 expression as a predictor of prognosis in all three grades of MCT. The purpose of this study was to validate those results in a new group of dogs, with intermediate‐grade MCT only. Ki67 immunohistochemistry was performed on intermediate‐grade MCT from 163 dogs with known outcome. Digital microscopy images were taken from each tumour, and an index calculated of Ki67‐positive cells. Ki67 index as a binary variable with a cut‐off value of 1.8% was confirmed to be associated with prognosis (hazard ratio = 19.1, P < 0.0001) for this cohort of dogs. The 1‐year, 2‐year and 3‐year survival probabilities (with standard errors) of 127 dogs with a Ki67 index ≤1.8% were [0.95 (0.024), similar for all] and for 36 dogs with a Ki67 index >1.8% were 0.54 (0.100), 0.45 (0.101) and 0.33 (0.104), respectively.     

Evaluation of prognostic indicators in dogs with multiple,simultaneously occurring cutaneous mast cell tumours: 63 cases

Sixty‐three dogs with multiple contemporaneous cutaneous mast cell tumours (MCTs) were identified. The aim of this study was to determine the significance of breed, concurrent dermatological condition; number of cutaneous MCTs, size, location, histological grade and mitotic index; completeness of excision (complete, close or incomplete); local recurrence, metastasis and adjuvant therapy for the prognostic evaluation of dogs with a unique disease presentation of multiple, simultaneously occurring cutaneous MCTs. On the basis of multivariable survival analysis, dogs with one recorded grade 3 MCT had shorter progression‐free survival (PFS) times (18.7 versus 2.2 months) and median survival times (MSTs) (24 versus 3 months). Dogs treated with adjuvant vinblastine/lomustine had a 16 times increased risk of dying. MSTs were found to be significantly longer in dogs with one recorded MCT on an extremity. For all dogs, the PFS (range 14–1835 days) and MSTs (range 28–1835 days) were not reached.     

Prognostic significance of surgical margin, Ki-67 and cyclin D1 protein expression in grade II canine cutaneous mast cell tumor

The prognosis for canine cutaneous mast cell tumor (CCMT) is thought to be correlated with histopathological grading. However, the wide variety of histopathologic types of grade II is one of the most troublesome and difficult points for prognosis. The objective of this study is to determine the prognostic value of surgical margin, ki-67 and cyclin D1 protein expression in grade II tumor. Surgically resected specimens of solitary grade II CCMT from 48 dogs with follow-up periods over 360 days (median was 1080 days) were used in this study. The expression of cyclin D1 and ki-67 proteins was determined by morphometrically using slides stained immunocytochemically, and the correlations among the results, survival rate, and recurrence and/or metastasis rate of each dog were analyzed statistically. The recurrence and/or metastasis and mortality rate in the incomplete surgical excision group within 30 months postoperatively were higher than that of the complete surgical excision group. In the incomplete surgical excision group, dogs with low positive staining of ki-67 had a significantly better survival, but the recurrence and metastasis rate and ki-67 positivity failed to show a significant correlation. Only a small number of cases showed cyclin D1-positive tumor cells, but most of them had a poor outcome with a high recurrence rate. In grade II CCMT, incomplete excision induced a relatively high metastasis rate and poor prognosis. Ki-67 positivity is a marker for the estimation of overall survival in incomplete surgical excision cases. Cyclin D1 positivity was low and may not have a prognostic role.     

The effect of prednisone on histologic and gross characteristics in canine mast cell tumors

The objective of the study was to determine whether neoadjuvant prednisone therapy affects histological features of cutaneous and subcutaneous mast cell tumors. Twenty-eight dogs with a treatment naïve > 1-cm diameter mast cell tumor (MCT) were randomly assigned (Random number generator; Random.org, Dublin, Ireland) in a blinded fashion to receive either prednisone or placebo (Quality Food Center Pharmacy, Kirkland, Washington, USA). Volumes of mast cell tumors were calculated before incisional and excisional biopsies. Following incisional biopsy, patients received either prednisone (1 mg/kg body weight) daily or a placebo for 7 to 14 days leading up to excisional biopsy. Tumor grade for cutaneous MCT, and mitotic count and atypia for all tumors were reported. Perioperative treatment with prednisone had no significant effect on tumor grade, atypia, or mitotic count. Tumor volume was significantly decreased with prednisone treatment. The use of neoadjuvant prednisone to decrease MCT volume in order to facilitate tumor excision, can be considered without significant concern for change of tumor histologic features in the common population of low- to intermediate-grade MCT.     

The American College of Veterinary Surgeons The First Twenty-Five Years

The American College of Veterinary Surgeons (ACVS), founded in 1965 and recognized by the AVMA in 1970, maintains high standards for surgical training programs and administers rigorous certifying examinations. It provides educational outreach to the veterinary medical profession by presenting scientific programs at ACVS annual meetings, sponsoring the Veterinary Surgical Forum in the USA and Europe, and publishing a refereed journal, Veterinary Surgery. The ACVS offers research grants and other awards to surgical residents, and encourages its members to pursue original investigations and contribute to the veterinary literature. In its silver anniversary year, it is appropriate to recall the aspirations and accomplishments of this forward-looking specialty organization.     

Cellular proliferation in canine cutaneous mast cell tumors: associations with c-KIT and its role in prognostication

Canine cutaneous mast cell tumor (MCT) is a common neoplastic disease in dogs. Due to the prevalence of canine MCTs and the variable biologic behavior of this disease, accurate prognostication and a thorough understanding of MCT biology are critical for the treatment of this disease. The goals of this study were to evaluate and compare the utility of the proliferation markers Ki67, proliferating cell nuclear antigen (PCNA), and argyrophilic nucleolar organizing region (AgNOR) as independent prognostic markers for canine MCTs and to evaluate the use of these markers in combination, as each marker assesses different aspects of cellular proliferation. An additional goal of this study was to evaluate the associations between cellular proliferation and c-KIT mutations and between cellular proliferation and aberrant KIT protein localization in canine MCTs. Fifty-six MCTs treated with surgical excision alone were included in this study. Each MCT was evaluated for Ki67 expression, PCNA expression, and KIT protein localization using immunohistochemistry; for AgNOR counts using histochemical staining; and for the presence of internal tandem duplication c-KIT mutations using polymerase chain reaction amplification. In this study, increased Ki67 and AgNOR counts were both associated with significantly decreased survival. On the basis of these results, we recommend that the evaluation of cellular proliferation, including evaluations of both Ki67 expression and AgNORs, should be routinely used in the prognostication of canine MCTs. Additionally, the results of this study show that MCTs with aberrant KIT protein localization or internal tandem duplication c-KIT mutations are associated with increased cellular proliferation, further suggesting a role for c-KIT in the progression of canine MCTs.     

Surgical Excision of Soft Tissue Fibrosarcomas in Cats

Objective — The purpose of this study was to determine the tumor-free interval and survival times of cats who had one (group 1) or more (group 2) surgeries, or surgery and radiation therapy (RTH) (group 3) for treatment of soft tissue fibrosarcomas (FSA).
Study Design — Retrospective study.
Animals or Sample Population — 45 client-owned cats.
Methods — Medical records of cats with soft tissue FSA were examined. Vaccination and feline leukemia virus (FeLV) status, age, sex, breed, tumor location, number of surgeries, completeness of excision, and histopathological grade were evaluated to correlate with tumor-free interval and survival periods.
Results — Overall median tumor-free interval and survival times were 10 and 11.5 (range, 1 to 40) months. Median tumor-free interval and survival times were more than 16 months each in group 1, more than 5 and 13 months in group 2, and 4.5 and 9 months in group 3. Age, sex, breed, vaccination or FeLV status, tumor location, or histopathological grade did not affect median tumor-free interval or survival times ( P <.05). Cats with complete excisions had significantly longer median tumor-free interval (>16 versus 4 months) and survival time (>16 versus 9 months) than those with incomplete excisions ( P =.008). Radiation therapy did not seem to extend tumor-free interval and survival times ( P =.013). However, most group 3 cats had incomplete surgical excisions, resulting in recurrent or progressive disease.
Conclusions — Complete surgical excision of FSA in cats is possible and can be curative.
Clinical Relevance — Aggressive surgical excision with wide margins appears to contribute to extended tumor-free interval and survival times in cats with soft tissue FSA. Controlled prospective studies are needed to determine the efficacy of RTH in treatment.     

Periocular cutaneous mast cell tumors in cats: evaluation of surgical excision (33 cases)

Objective  To describe feline periocular cutaneous mast cell tumor (CMCT) clinical features, rates of local tumor recurrence and metastases, and cat survival time following surgical excision.
Animals studied  Thirty-three cats with periocular CMCTs.
Procedures  Medical records of cats diagnosed with periocular CMCTs were reviewed; cats were included if CMCTs were surgically excised and the diagnosis confirmed by histopathology. The appearance, size, location and histopathology findings of CMCTs were recorded. Rates of local recurrence, metastasis, and survival time following surgical excision were collected when available.
Results  All periocular CMCTs were restricted to the eyelids. In addition to surgical excision, three cats were treated with adjunctive therapy (strontium-90 irradiation or cryotherapy) intraoperatively. Local tumor control was achieved in 22/23 cats with a minimum follow-up of 30 days (median follow-up time of 711 days); one cat developed disseminated CMCTs but no local recurrence. Cats with periocular CMCTs had a median survival time of 945 days. Metastatic disease involving peripheral lymph nodes or abdominal viscera was not detected in any cat at any time during the study. All periocular CMCTs were classified as low-grade based on histopathology, and complete excision was achieved in approximately 50% of cases.
Conclusions  Surgical excision of periocular CMCTs in cats is an effective treatment option with rare local recurrence and metastases, even following incomplete surgical excision.     

Dietary stimulation of the endogenous somatotropic axis in weaner and growerfinisher pigs using medium chain triglycerides and cysteamine hydrochloride

Background: Three experiments were conducted to examine the overall hypothesis that addition of medium chain triglycerides(MCT) and cysteamine hydrochloride(CSH) into the diets of young and growing pigs would stimulate the endogenous somatotropic axis to improve growth and performance.Results: In Experiment 1, weaner pigs were given either a 5 d dietary supplement of 5 % MCT(n = 8) or a control diet(n = 8). MCT increased the plasma concentration of growth hormone(GH; P 0.05) and the GH secretagogue,ghrelin(P 0.05). Additionally, the MCT treatment reduced scouring(P 0.05), maintained villous height in the small intestine(P 0.05) and stabilised daily weight gain(P 0.05), compared to the controls. Experiment 2compared the effects of 4 levels(0, 1, 3 and 6 % v/v) of MCT supplementation in grower-finisher male pigs, of approximately 35 kg live weight(n = 15 per treatment). Blood samples taken after 7 wk of treatment showed that the MCT supplementation increased circulating ghrelin(P 0.001), GH(P 0.01) and insulin(P 0.05)concentrations in a dose-dependent manner. Daily weight gain, feed intake and feed conversion ratio were not affected by the MCT diets. In Experiment 3, 64 female pigs of approximately 60 kg live weight were allocated to one of three dietary treatments: control(n = 20); 6 % MCT(n = 21); and 70 mg/kg CSH(n = 21). After 3 wk of supplementation, the MCT treated pigs had a higher plasma concentration of ghrelin compared to the control and CSH pigs(P 0.05). Plasma concentrations of GH and weight were not affected by any of the dietary treatments.Conclusions: Evidence is provided in Experiment 1 to support the use of dietary MCT supplements, perhaps acting via stimulation of somatotropic endocrine pathways, to minimise weaning-associated disorders such as slowing of growth and diarrhoea. In Experiments 2 and 3, although there was no effect on weight gain or feed conversion ratio in either experiment, MCT and CSH increased endocrine components of the somatotropic axis.     

Estimate of the annual economic impact of treatment of cranial cruciate ligament injury in dogs in the United States

OBJECTIVE: To estimate the economic impact to veterinary clients for the medical and surgical treatment of rupture of the cranial cruciate ligament (RCCL) in dogs for the year 2003. DESIGN: Economic impact survey. SAMPLE POPULATION: 501 diplomates of the American College of Veterinary Surgeons (ACVS) indicating that their area of surgical emphasis was small animal orthopedic surgery or small animal general and orthopedic surgery and 4,000 veterinarians indicating to the AVMA that their professional area was small animal practice exclusive or mixed animal practice (at least 80% small animal). PROCEDURE: Veterinarians were surveyed concerning the cost for medical and surgical treatment of RCCL for 2003. The economic impact was calculated by multiplying the number of RCCL surgeries performed by the mean cost of surgery. This was added to the number of RCCL cases managed medically multiplied by the mean cost of medical management. This estimate for survey responders was extrapolated to the total number of veterinarians in the study population for the ACVS or AVMA. RESULTS: Estimates for the total cost of surgery were $171,730,134.72 and $1,020,167,907 for veterinarians in the ACVS and AVMA populations, respectively. The cost of medical management was $2,885,687.86 and $126,558,155.16 for veterinarians in the ACVS and AVMA populations, respectively. After combining the ACVS and AVMA populations, we estimated that owners spent $1.32 billion for the treatment of RCCL in the United States in 2003. CONCLUSIONS AND CLINICAL RELEVANCE: RCCL is a prevalent, costly injury. Results may motivate veterinary and consumer agencies to prioritize funding for a better understanding of the injury.