Radiographic and Scintigraphic Evidence of Focal Pulmonary Neoplasia in Three Cats With Hyperthyroidism: Diagnostic and Therapeutic Considerations

Three cats were diagnosed as hyperthyroid based on clinical signs, historical findings, laboratory abnormalities, and basal serum thyroxine (T₄) concentrations, and/or nuclear thyroid scans. Additionally, a presumptive diagnosis of thyroid carcinoma with pulmonary metastasis was made in each cat based on radiographic or scintigraphic evaluation. All three cats had solitary pulmonary nodules 1.5 to 2 cm in diameter on survey thoracic radiographs; one cat also had chylous pleural effusion and pulmonary lobar consolidation. Focal pulmonary accumulation of sodium pertechnetate (^99mTcO₄ -) and/or radioiodine (¹³¹I) corresponding to radiographic lesions were seen in all cats. Two cats were treated with single ablative doses (1111 to 1480 MBq) of¹³¹I; the remaining cat was euthanatized.
One of the treated cats died 8 days later; the other cat was euthanatized 22 weeks following treatment. Histopathologic examination of tissue obtained at necropsy confirmed metastatic thyroid carcinoma in one cat and bronchogenic adenocarcinoma in two cats. Our findings indicate that increased radionuclide uptake in focal pulmonary lesions and cytologic evaluation of tissue obtained by fine-needle aspiration are not specific for thyroid tissue. (Journal of Veterinary Internal Medicine 1993; 7:303–308. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Hypophosphatemia Associated With Enteral Alimentation in Cats

Hypophosphatemia is uncommon in cats, but it has been reported in association with diabetes mellitus and hepatic lipidosis, where it can cause hemolysis, rhabdomyopathy, depression, seizures, and coma. The purpose of this article is to describe 9 cats that developed low serum phosphorus concentrations (<2.5 mg/dL) subsequent to enteral alimentation. Serum biochemical analyses from more than 6,000 cats were reviewed. The medical records of all cats with hypophosphatemia were examined for history of enteral alimentation; diabetic cats were excluded from the study. Nine cats, ranging in age from 3 to 17 years, were identified. All cats had normal serum phosphorus concentrations before tube feeding began. Onset of hypophosphatemia occurred 12 to 72 hours after initiation of enteral alimentation, and the nadir for phosphorus concentrations ranged from 0.4 to 2.4 mg/dL. Hemolysis occurred in 6 of the 9 cats. Hypophosphatemia secondary to enteral alimentation is an uncommon clinical finding in cats. Cats with high alanine aminotransferase activity, hyperbilirubinemia, and weight loss should be closely monitored for hypophosphatemia during the first 72 hours of enteral alimentation.     

Thrombocytopenia in Cats: A Retrospective Study of 41 Cases

The prevalence of feline thrombocytopenia (<200,000 platelets/L) at North Carolina State University, College of Veterinary Medicine Teaching Hospital, from January 1985 to March 1990, was 1.2% (41/3300). Cats were divided into six categories based on clinical diagnoses: 29% (12/41) had infectious disease, 20% (8/41) had neoplasia, 7% (3/41) had cardiac disease, 2% (1/41) had primary immune-mediated disease, 22% (9/41) had multiple diseases, and 20% (8/41) had disorders of unknown etiology. The mean platelet count for all thrombocytopenic cats was 52,000/μL ± 46,000/μL (1 SD) with a range of 1000–190,000/μL. No significant differences were found between groups with respect to platelet count, packed cell volume, or white blood cell count, though anemia and leukopenia were common among the cats as a whole. Bleeding disorders (hemorrhage or thrombosis) were observed in 29% (12/41) of thrombocytopenic cats and were more likely to be associated with neoplasia, cardiac disease, and platelet counts less than or equal to 30,000/μL. Disseminated intravascular coagulopathy was diagnosed in 12% (5/41) of the cats. Infections and/or neoplasia affecting the bone marrow were the most common diseases associated with thrombocytopenia. Feline leukemia virus and myeloproliferative neoplasia accounted for approximately 44% (18/41) of the specific diagnoses in thrombocytopenic cats. (Journal of Veterinary Internal Medicine 1993; 7:261–265. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Hemolytic Uremic Syndrome in Dogs

A disease syndrome similar to the hemolytic uremic syndrome of people is described in three dogs with acute renal failure. In each dog, hemorrhagic gastroenteritis preceded the onset of anuric acute renal failure. Evidence of microangiopathic hemolytic anemia (schizocytes, thrombocytopenia, and increased concentrations of fibrin split products) was present in the three dogs. Serum chemistry results showed increased concentrations of blood urea nitrogen, creatinine, and phosphorus. Ultrasound examination performed in one dog revealed increased echogenicity of the renal cortices. Treatment for anuric acute renal failure using a continuous dopamine and furosemide infusion established urine production in one of three dogs. Microscopic examination of tissue from the two dogs that underwent necropsy showed occlusion of the renal vasculature by fibrin thrombi consistent with microangiopathic arteriolar thrombosis. The pathophysiology and current knowledge of human hemolytic uremic syndrome is compared with hemolytic uremic syndrome in these dogs. (Journal of Veterinary Internal Medicine 1993; 7:220–227. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Systemic Toxicity Associated With Doxorubicin Administration in Cats

The systemic toxicity of doxorubicin, 30 mg/m² body surface area (BSA) every 21 days to a cumulative dose of 300 mg/m², was evaluated in six cats. Appetite, body weight, and the presence of vomiting and/or diarrhea were monitored throughout the study. Renal function was monitored by measuring serum blood urea nitrogen (BUN) and creatinine concentrations, urine specific gravity, and creatinine clearance before each treatment. Electrocardiograms and echocardiograms were also done before each treatment. The cats were killed 3 weeks after the last treatment, and complete necropsies were performed. Partial or complete anorexia occurred in all cats with significant weight loss occurring after a cumulative doxorubicin dose of 150 mg/m² BSA. Mild vomiting and diarrhea that required no treatment also occurred sporadically in all cats. Echocardiographic changes consistent with doxorubicin-induced cardiomyopa-thy occurred in four cats after cumulative doses of 170 to 240 mg/m² BSA. Clinical heart disease and electrocardiographic changes were not observed. Subsequent histological examination revealed myocyte vacuolization and myocytolysis in all six hearts. Renal dysfunction, characterized by increasing azotemia with progressively more dilute urine, was detected in two cats. Mean creatinine clearance values also decreased significantly throughout the study. At necropsy, all cats had histological evidence of renal disease. (Journal of Veterinary Internal Medicine 1993; 7:309–317. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Tidal Breathing Flow-Volume Loops in Healthy and Bronchitic Cats

Tidal breathing flow-volume loops (TBFVL) were obtained from 19 healthy cats and 7 cats with chronic bronchial disease. Peak inspiratory flow (PIF) occurred late in the inspiratory cycle and was preceded by a gradual but more linear increase in the flow rate. Peak expiratory flow (PEF) occurred early during expiration and was followed by a curvilinear decrease in flow to a point near the end of expiration where flow ceased. The loops obtained were generally reproducible. The mean coefficient of variation (CV) for TBFVL indices of healthy cats ranged from 5.6% to 21.9%. Loop indices from cats with chronic bronchial disease had a mean CV between 6.6% and 28.4%. Significant differences were noted in the bronchitic cats' TBFVLs, including an increased ratio of expiratory time to inspiratory time, lower expiratory flow rates, decreased area under total and peak expiratory flow curves, and decreased tidal breathing expiratory volumes (TBEV) at 0.1 and 0.5 seconds. Selected TBFVL indices were also significantly reduced. TBFVL evaluation in the cat is easy to perform, is reproducible, and has allowed for the detection of changes during tidal breathing in cats with histories and physical findings of chronic lower airway disease. (Journal of Veterinary Internal Medicine 1993; 7:388–393. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Acute Pancreatitis in Cats With Hepatic Lipidosis

The purpose of this study was to characterize the incidence, clinical features, and prognosis of acute pancreatitis in cats with hepatic lipidosis. Of 13 cats histologically diagnosed with hepatic lipidosis between July 1988, and November 1989,5 (38%) were also histologically diagnosed with acute pancreatitis. In cats with hepatic lipidosis alone, the signalment, history, physical examination, and clinicopatho-logic findings were generally indistinguishable from those of cats with concurrent acute pancreatitis except that cats with acute pancreatitis were more likely to be cachectic and to have coagulation abnormalities. Hepatomegaly was seen on abdominal radiographs in both groups. Of the 5 cats with concurrent acute pancreatitis, abdominal ultrasonography detected 1 cat with a hypoechoic pancreas and 5 with peritoneal effusion; those abnormalities were not seen in cats without concurrent acute pancreatitis. Cats with concurrent acute pancreatitis had only a 20% recovery rate, compared with a 50% recovery rate in cats with hepatic lipidosis alone. We conclude that cats with hepatic lipidosis should be rigorously evaluated for concurrent acute pancreatitis because of 1) the rate of disease coincidence, 2) the inability of signalment, history, physical examination, and clinicopathologic findings to adequately distinguish between hepatic lipidosis and acute pancreatitis, 3) the worse prognosis associated with concurrent acute pancreatitis, and 4) the opposing nutritional strategies for hepatic lipidosis and acute pancreatitis. (Journal of Veterinary Internal Medicine 1993; 7:205–209. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Evidence for Genetic Involvement in Feline Dilated Cardiomyopathy

Quantitative genetic evaluation of clinical dilated cardiomyopathy (DCM) was conducted in a large cattery with known history. Data showed that clinically affected cats were significantly more interrelated than randomly chosen case-control populations from the same colony. The results of this study suggest that quantitative inheritance, either interactive with or independent of nutrition or presently unknown factors, is involved in feline dilated cardiomyopathy. (Journal of Veterinary Internal Medicine 1993; 7:383–387. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Urinary Indices of Horses After Intravenous Administration of Crystalloid Solutions

Saline or glucose solution was infused for approximately 4 hours into six healthy mares in two separate experiments to determine the effect of infusion of crystalloid solutions on fractional excretion (FE) of sodium (Na), chloride (Cl), potassium (K), and phosphorus (P), ratio of urinary creatinine to serum creatinine (U_Cr/S_Cr), and ratio of urinary osmolality to serum osmolality (U_osm/S_osm). After intravenous infusion of either saline or glucose solution, FE_Na, FE_Cl and FE_P were significantly increased, whereas U_Cr/S_Cr and U_osm/S_osm were significantly decreased. In addition, FE_K was significantly increased after infusion of glucose solution. It was concluded that urinary indices were altered by intravenous infusion of crystalloid solutions in healthy mares and that fluid therapy may interfere with the use of these indices for diagnostic purposes. (Journal of Veterinary Internal Medicine 1993; 7:241–246. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Use of continuous renal replacement therapy for treatment of dogs and cats with acute or acute-on-chronic renal failure: 33 cases (2002–2006)

Objective: To describe the indications, clinical features, outcomes and complications associated with use of continuous renal replacement therapy (CRRT) in 17 client-owned dogs and 16 client-owned cats with acute or acute-on-chronic renal failure refractory to aggressive medical management.
Series summary: Twenty-nine percent of dogs and 44% of cats had evidence of pre-existing chronic kidney disease (CKD). Median duration of CRRT was 16.3 hours (range 0.3–83.0 hours) in dogs and 11.5 hours (range 1.0–35.5 hours) in cats. Median canine blood urea nitrogen (BUN) improved from 41.0 mmol/L (115.0 mg/dL) to 11.8 mmol/L (33.0 mg/dL) and creatinine from 636.5 mmol/L (7.2 mg/dL) to 274 mmol/L (3.1 mg/dL). Median feline BUN improved from 46.4 mmol/L (130 mg/dL) to 13.9 mmol/L (39.0 mg/dL) and creatinine from 1069.6 mmol/L (12.1 mg/dL) to 291.7 mmol/L (3.3 mg/dL). Metabolic acidosis resolved in 80% of affected dogs and 71% of affected cats. Hyperkalemia resolved in 100% of affected dogs and 88% of affected cats. Complications noted with CRRT included iatrogenic hypokalemia, iatrogenic metabolic alkalosis, clinical hypocalcemia, total hypercalcemia, filter clotting, anemia, hypothermia, and neurologic complications. Forty-one percent of dogs and 44% of cats survived to discharge. No dogs and only 1 cat developed newly diagnosed CKD.
New or unique information provided: CRRT can be a viable option for the management of acute or acute-on-chronic renal failure in dogs and cats that are refractory to aggressive medical management. The frequency of complications associated with CRRT in this study warrants further experience with this modality before its widespread use can be recommended.     

Diagnosis and treatment of pyogranulomatous panniculitis due to Mycobacterium smegmatis in cats

Four cats with extensive pyogranulomatous panniculitis and dermatitis due to Mycobacterium smegmatis were evaluated over an eight-month period. All were treated initially with doxycycline (50 mg per cat every eight to 12 hours) for several weeks, then subjected to radical surgical excision of infected tissues. Reconstructive surgery utilising advancement flaps was required to close wounds without undue tension. Postoperatively, the cats received parenteral gentamicin (2 mg/kg every eight hours) for three to five days, followed by orally administered ciprofloxacin (62.5 mg per cat every eight hours or 125 mg per cat every 12 hours) for three to six months. Infection was eradicated in all the cats, with no signs of recurrence 15 to 23 months after surgery.     

Changes in thermal threshold response in eight cats after administration of buprenorphine, butorphanol and morphine

Thermal thresholds were measured in eight cats after the intramuscular administration of morphine (0.2 mg/kg), buprenorphine (0.01 mg/kg) or butorphanol (0.2 mg/kg), doses commonly used in clinical practice; 0.9 per cent saline (0.3 ml) was injected as a control. Groups of six cats were used and each cat participated in at least two treatments, according to a randomised design. The investigator was blinded to the treatments. The thermal thresholds were measured with a testing device developed specifically for cats, and measurements were made before and five, 30, 45 and 60 minutes and two, four, six, 12 and 24 hours after the injections. There was no significant change in thermal threshold after the injection of saline. With butorphanol, the threshold was increased only at five minutes after the injection and was decreased two hours after the injection; with morphine it was increased from between four and six hours after the injection, and with buprenorphine it was increased from between four and 12 hours after the injection.     

Hemolytic anemia and red blood cell metabolic disorder attributable to low phosphorus intake in cows

Hypophosphatemia was induced in 2 cows by reducing phosphorus content in their feed after parturition. Serum inorganic phosphorus (Pi) values decreased to 1 mg/dl within 10 days after parturition; and RBC adenosine 5'-triphosphate (ATP) and reduced glutathione values decreased to 50 and 70% of baseline values, respectively. Methemoglobin concentration was moderately higher than normal. These changes preceded the onset of hemolysis, and anemia progressed with decreases in PCV, hemoglobin concentration, and RBC counts. Serum Pi resumed its normal value when anemia was most severe. This RBC disorder was confirmed to be characteristic of hemolytic anemia in cows resulting from hypophosphatemia. The RBC glycolytic intermediates, total triose phosphate (combined glyceraldehyde-3-phosphate and dihydroxyacetone phosphate content) and fructose-1,6-diphosphate, greatly increased in vivo and in vitro with decreases in serum or plasma Pi and RBC ATP. From our results, we concluded that inadequate Pi in the plasma impairs the function and viability of RBC by hindering the production of ATP via disturbance of reactions at the glyceraldehyde-3-phosphate dehydrogenase step.     

Spontaneous Adult-Onset Hypothyroidism in a Cat

Spontaneous adult-onset hypothyroidism, confirmed by a thyroid-stimulating hormone stimulation test, thyroid biopsy, and response to replacement therapy, is described in a female cat. Clinical signs consisted of profound apathy, hypothermia, poor hair growth, severe seborrhea sicca, and a puffy face. Cutaneous histological changes consisted of epidermal and follicular hyperkeratosis, teloginization of hairs, and dermal mucin deposition. There was no adnexal atrophy. Lymphocytic thyroiditis, equivalent to Hashimoto's thyroiditis, was shown by thyroid biopsy. Clinical signs rapidly responded to thyroxine replacement therapy. Glucose intolerance was coexistent with the hypothyroidism, but was not dramatically influenced by thyroxine therapy and probably was an independently occurring endocrinopathy. (Journal of Veterinary Internal Medicine 1993; 7:272–276. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Evaluation of the low-dose dexamethasone suppression test and ultrasonographic measurements of the adrenal glands in cats with diabetes mellitus

The objectives of the study were to evaluate the low-dose dexamethasone suppression (LDDS) test and the size of the adrenal glands via ultrasonography in cats with diabetes mellitus. Twenty-two cats were enrolled in the study. In 19 cats, suppression of cortisol concentrations below 5.5 nmol/litre occurred four and eight hours after intravenous administration of dexamethasone (0.1 mg/kg). In one other cat, the cortisol concentration was also below 5.5 nmol/litre at eight hours but was 11.0 nmol/litre at four hours. The results were in agreement with those of healthy cats in a previous study. The cortisol concentrations four and eight hours after administration of dexamethasone did not differ between cats with good glycemic control (n = 8) and those with moderate to poor control (n = 12). The adrenal glands of the diabetic cats were not enlarged compared with those of healthy cats. In two diabetic cats, the LDDS test results were abnormal. One cat had a pituitary adenoma and adrenal glands of normal size as determined by ultrasonography. The size of the adrenal glands of the other cat clearly differed; histological examination of the larger adrenal gland revealed an adrenocortical adenoma. Based on our findings, the results of the LDDS test using 0.1 mg/kg of dexamethasone are normal in cats with diabetes mellitus independent of the quality of glycemic control. In addition, diabetes mellitus does not lead to a measurable increase in the size of the adrenal glands in cats. Further studies are needed to evaluate if the dexamethasone dosage used in this study is useful to diagnose mild form of hypercortisolism.     

Endoscopic Diagnosis of Chronic Hypertrophic Pyloric Gastropathy in Dogs

The endoscopic appearance of chronic hypertrophic pyloric gastropathy (CHPG) in five dogs is described. Several patterns of enlarged mucosal folds that surrounded and obstructed the pyloric canal were observed. Initially, endoscopically obtained biopsy samples of mucosa were judged to be histologi-cally normal. Diagnosis of CHPG was confirmed and relief of pyloric obstruction accomplished at exploratory laparotomy (in four dogs). Retrospective evaluation of pyloric tissue samples, obtained during endoscopy, identified subtle histological characteristics of CHPG. Gastric and duodenal neopla-sia or antral polyps can mimic the endoscopic appearance of CHPG but can be differentiated based on their endoscopic and histological appearance. These cases show that endoscopic examination is a valuable procedure for the diagnosis of CHPG in dogs that chronically vomit. (Journal of Veterinary Internal Medicine 1993; 7:335–341. Copyright © 1993 by the American College of Veterinary Internal Medicine.)     

Hypothermic Storage of Feline Kidneys for Transplantation: Successful Ex Vivo Storage Up to 7 Hours

Objective—To describe the effect of hypothermic storage on transplanted feline kidneys.
Study Design—Kidneys were stored in University of Wisconsin (UW) sodium gluconate (n = 3) or phosphate-buffered sucrose (n = 5) solutions before transplantation.
Animal Population—Eight cats with renal failure and seven normal cats as kidney donors.
Methods—Kidneys were perfused through the renal artery with cold (10°C) storage solution and immersed in the solution on ice until transplantation.
Results—Mean ex vivo storage time was 4.8 ± 0.36 hours (range, 3.5 to 7 hours). Seven recipient cats survived surgery. Five of the cats had decreased serum creatinine concentrations from a mean of 8.2 mg/dL (range, 4.0 to 15.8 mg/dL) preoperatively to 1.7 mg/dL (range, 1.3 to 2.2 mg/dL) within 4 days of surgery. In one cat, serum creatinine concentration dropped from 15.1 to 3.7 mg/dL in 3 days, but the cat developed a ureteral stricture that required revision. One graft did not function, and the cat died on day 19. The mean postoperative survival time of cats that were discharged from the hospital (n = 6) was 254 days (range, 49 to 717 days) at the time of this report. Long-term renal function (>60 days postoperatively; n = 5) was excellent with mean serum creatinine concentrations of 1.6 ± 0.15 mg/dL.
Conclusions—Hypothermic storage is feasible for short-term preservation of feline kidneys.
The maximal length of feasible storage remains unknown.
Clinical Relevance—Hypothermia protects against ischemia-induced nephron loss during ex vivo manipulation of the allograft and allows longer safe vascular anastomosis times. Short-term hypothermic storage also provides time to accommodate modifications in scheduling or anesthetic management of the recipient operation.     

Applications and Outcome of Hemodialysis in Cats: A Review of 29 Cases

Hemodialysis (HO) has been used in the management of renal failure in dogs, but its feasibility has not been reported for uremic cats. Therefore, we investigated the technical possibility, efficacy, and complications of intermittent HD in cats with severe uremia. A total of 160 HD treatments were performed on 29 cats with acute renal failure (ARF) (n = 15), chronic renal failure (CRF) (n = 6), or acute on CRF (n =8) between November 1993 and June 1996. Hemodialysis treatments were performed with transcutaneous dialysis catheters using a bicarbonate-based delivery system, sodium modeling, and volumetric-controlled ultrafiltration. Presenting serum chemistries (mean ± SD) for all cats were creatinine, 16.4 ± 7.5 mg/dL; blood urea nitrogen (BUN), 229 ± 87 mg/dL; phosphate, 15.4 ± 5.4 mg/dL; potassium, 6.0 ±1.6 mEq/L; and HCO^-₃, 16.0 ± 4.4 mEq/L. For intensive HD treatments, pre-HD versus post-HD creatinine changed from 10.3 ± 4.4 to 1.6 ± 0.9 mg/dL and BUN from 105 ± 33 to 8 ±10 mg/dL. One or more adverse events occurred during 111 (69%) treatments. Dialysis-related events included hypotension, dialysis dysequilibrium, clotting, and bleeding. Nine of 15 (60%) cats with ARF and 1 cat with CRF recovered sufficiently to survive without ongoing need for HD. For the remaining cats, the proximate causes of death were dialysis related in 9 cats, uremia related in 6 cats, and iatrogenic or unknown in 4 cats. Hemodialysis is technically feasible and effectively controls the biochemical disturbances of uremic cats. It is especially valuable for the management of severe ARF, permitting recovery in a large number of cats refractory to conventional therapy. Technical complications and chronic debility, however, may limit its usefulness for cats with advanced CRF.     

Hypophosphatemia

Severe hypophosphatemia (i.e., serum phosphorus concentration below 1 mg/dl) occurs infrequently in veterinary patients. It is most often associated with diabetic ketoacidosis in small animals. Phosphate is necessary for the production of 2,3 diphosphoglycerate (2,3-DPG) and adenosine triphosphate (ATP); both are important for normal cellular metabolism. Consequences of severe hypophosphatemia may include hemolytic anemia, seizures, altered mentation, cardiomyopathy, and skeletal muscle weakness. Parenteral phosphate therapy is necessary in most cases of severe hypophosphatemia.     

Plasma Endotoxin Concentrations in Clinically Normal and Potentially Septic Equine Neonates

Plasma endotoxin concentrations were measured at 1 to 2 and 5 to 6 days of age in clinically normal foals and in potentially septic neonatal foals admitted to North Carolina State University's Veterinary Teaching Hospital for a variety of conditions. In 1 to 2 and 5 to 6 day old normal foals, median plasma endotoxin concentrations were 2.17 (range, 1.61–2.54; n = 6) and 2.89 (range, 2.61–3.50; n = 7) endotoxin units/mL (EU/mL), respectively. Median plasma endotoxin concentration in potentially septic foals with negative blood cultures or gram positive isolates (n = 8) was 2.73 (range, 0.59–4.04) EU/mL. In hospitalized foals with gram negative isolates (n = 6), median plasma endotoxin concentration was 78.06 (range, 0.76–2,696.41) EU/mL, but individual endotoxin values were only increased in foals that were extremely sick and died within hours of sampling. Plasma endotoxin concentrations were significantly greater in foals with sepsis scores ≥ 11 compared with foals with sepsis scores ≤ 10. Increased plasma endotoxin concentrations appear to predict an unfavorable outcome in septic foals, but normal endotoxin concentrations do not appear to have any predictive value. (Journal of Veterinary Internal Medicine 1993; 7:296–302. Copyright © 1993 by the American College of Veterinary Internal Medicine.)