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Treating IBD and lymphoma without a biopsy

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Megan McClosky, DVM, DACVIM (SAIM), explains how irritable bowel disease is linked to small cell lymphosarcoma, and what happens if a client refuses a biopsy

Megan McClosky, DVM, DACVIM (SAIM), an internist and assistant professor at the University of Pennsylvania School of Veterinary Medicine, shared her insight and knowledge on irritable bowel disease (IBD) and its link to small cell lymphosarcoma (SCLSA), during the 2022 American Association of Feline Practitioners annual conference in Pittsburgh, Pennsylvania.1 “IBD, small cell lymphoma–and likely large cell lymphoma–represent a spectrum of disease,” she explained to attendees.

McClosky compared these diseases to moving targets that require veterinarians to alter therapies as cats progress. This relative unpredictability makes ruling out certain, and sometimes more serious, gastrointestinal (GI) differentials more important than getting a biopsy in some instances, she added.

What is IBD?

IBD is a clinical definition that requires the presence of clinical signs and the demonstration of inflammation on intestinal biopsies. Before biopsy, McClosky explained the inflammation shown is chronic enteropathy, which is further characterized by its response to therapy as diet-responsive, antibiotic-responsive, steroid-responsive, and fiber-responsive.

“Ultimately, the underlying etiology of IBD is unknown for cats, but the disease may share some similarities to human IBD. We think that it comes from a breakdown of tolerance within the GI immune systems to antigens in the diet, antigens in bacteria, and, potentially, self-antigen,” she explained.

Biopsies from cats with IBD–or chronic enteropathy–most commonly reveal lymphoplasmacytic enteritis as the most common type of inflammation regardless of the cause, according to McClosky. However, lymphoplasmacytic enteritis is not limited to cats with IBD, McClosky clarified. It is also present in cats with hyperthyroidism, parasitic infections, or asymptomatic felines. Less common types of inflammation can also occur, including eosinophilic, neutrophilic, granulomatous, or pyogranulomatous inflammation.

What is SCLSA?

SCLSA is cancer that specifically affects the lymphocytes in the GI tract. Although less aggressive than large or intermediate cell lymphoma, SCLSA shares many clinical similarities with feline IBD. “The clinical signs may actually be identical,” she clarified.

Upon hearing the term lymphoma, clients–especially those with loved ones with cancer–are instinctively scared. “I like to talk to them about the differences between small versus large cell,” she said. McClosky noted that small cell lymphoma will be less aggressive and will cause diffused small intestinal thickening on ultrasound. Large cell lymphoma is more likely to cause mass-like lesions in the stomach, small intestine, and colon.

“The median survival time for small cell lymphoma, if it is reached in studies, is usually 2 to 3 years. If we are talking about cats diagnosed later in life, they may go on to die from something other than their cancer. Large cell lymphoma has a pretty poor prognosis, even with treatment. The median survival time is only about 6 to 8 months,” she said.

Diagnostic workup

“The signs of GI disease are pretty vague,” McClosky said. These signs include vomiting, diarrhea, weight loss, and changes in appetite. She told attendees that she makes a point to remind her students that cats with significant intestinal disease do not always present with vomiting and diarrhea. Weight loss in the face of a typical or increased appetite may be the only indication that something is awry in the GI tract.

“Similar to working up pancreatitis, the baseline blood work is to rule out other causes of GI signs,” she explained. Feline patients with chronic enteropathy may have mild anemia or mild leukocytosis on a complete blood count (CBC), but it could be normal. Hypocholesterolemia is common on the chemistry panel, whereas panhypoproteinemia is possible but less common than in dogs.

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Another important part of the workup is fecal testing to rule out intestinal parasites, nematodes, and Giardia, especially in cats with weight loss and diarrhea. “Even if the fecal is normal–because the sensitivity of fecal floats is pretty poor if cats are not having active diarrhea–empiric deworming should also be performed,” McClosky advised.

A 2010 study published in the Journal of Veterinary Internal Medicine2 established a feline chronic enteropathy activity index (FCEAI) to evaluate the severity of disease and response to therapy. The FCEAI scoring system includes scores for attitude/activity, appetite, vomiting, stool consistency, stool frequency, and unintended weight loss.

Monitoring of this value may be helpful as an objective way to assess response to therapy, McClosky said. However, one of the faults of the index, she pointed out, is that it does include endoscopic biopsy scores, which would not be available when treating a patient without a biopsy diagnosis.

Is diagnosis possible without a biopsy?

According to McClosky, GI biopsy remains the gold-standard diagnosis to differentiate between IBD and SCLSA. While some clinical features are more consistent in one disease than the other, there is too much overlap for these to be useful in individual patients.

McClosky encouraged attendees to advocate for biopsies for younger patients with refractory disease, patients that may be intolerant of oral medications, those with comorbidities that require dietary therapy, and patients that may respond poorly to steroids.

Still, forgoing a biopsy does not mean that treatment is impossible. To hit the moving target, special care and consideration must be taken.

Important differentials to rule out

“If a sick GI cat looks like a sick GI cat and we think that we are not going to be able to biopsy, are there other things to think about that may be made worse with therapy,” McClosky explained.

Infectious diseases that cause GI signs are most likely to present in younger patients or those with a compatible travel history. “Many infectious conditions can be made much worse by starting steroids, so ruling them out is important; and in some cases, more important than a GI biopsy,” she warned.

“If you know that you are not going to get a biopsy, some things to consider would be infectious disease testing, fungal testing, fecal polymerase chain reaction (PCR) panels, fecal cultures, and abdominal imaging,” she encouraged.

Infectious diseases to test for include Giardia, clostridial infections, infiltrative fungal disease, histoplasmosis, and salmonellosis. Further diagnostics should include a malabsorption/maldigestion panel, pancreatic lipase immunoreactivity, and trypsin-like immunoreactivity.

Lastly, abdominal imaging is recommended to rule out mass-like lesions in the GI tract or other organs and may even lead to a more positive discovery. For example, polyps confirmed via ultrasound may cause vomiting due to partial obstruction and changes in appetite but are often benign and can be removed.

Management

Pharmacologic interventions for IBD and SCLSA are nearly identical, especially if the IBD is refractory to dietary management, McClosky said. Patients that can maintain a good appetite, have no or minimal weight loss, and minimal vomiting or diarrhea should undergo empiric trials of a novel protein or hydrolyzed protein diet and/or an antibiotic trial with metronidazole or tylosin. Typically, it takes between 4 and 8 weeks to observe a response.

If a patient is inappetent, rapidly losing weight, or presents with severe clinical signs, a faster-acting therapy should be prescribed. Once GI differentials have been ruled out, a steroid trial can be initiated for chronic enteropathy. If there is a partial response to steroids, adding chlorambucil may achieve complete control of the disease.

The initial therapies for SCLSA are prednisolone and chlorambucil, so the treatment ends up being the same, she pointed out. The goal in either instance is to reduce the clinical signs of disease, but it is unlikely to eliminate them.

“These are diseases that are managed, not cured,” McClosky concluded.

References

  1. McClosky M. IBD to Lymphoma: How Do I Manage if the Client Won’t Biopsy? Presented at: 2022 American Association of Feline Practitioners Conference, Pittsburgh, Pennsylvania. October 27-30, 2022.
  2. Jergens AE, Crandell JM, Evans R, et al. A clinical index for disease activity in cats with chronic enteropathy. J Vet Intern Med, 2010;24(5):1027-1033.

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What’s the greatest holiday gift: lips, hair, skin? Give the gift of great skin this holiday season

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Give the gift of great skin this holiday season

Skinstitut Holiday Gift Kits take the stress out of gifting

Toronto, October 31, 2024 – Beauty gifts are at the top of holiday wish lists this year, and Laser Clinics Canada, a leader in advanced beauty treatments and skincare, is taking the pressure out of seasonal shopping. Today, Laser Clincs Canada announces the arrival of its 2024 Holiday Gift Kits, courtesy of Skinstitut, the exclusive skincare line of Laser Clinics Group.

In time for the busy shopping season, the limited-edition Holiday Gifts Kits are available in Laser Clinics locations in the GTA and Ottawa. Clinics are conveniently located in popular shopping centers, including Hillcrest Mall, Square One, CF Sherway Gardens, Scarborough Town Centre, Rideau Centre, Union Station and CF Markville. These limited-edition Kits are available on a first come, first served basis.

“These kits combine our best-selling products, bundled to address the most relevant skin concerns we’re seeing among our clients,” says Christina Ho, Senior Brand & LAM Manager at Laser Clinics Canada. “With several price points available, the kits offer excellent value and suit a variety of gift-giving needs, from those new to cosmeceuticals to those looking to level up their skincare routine. What’s more, these kits are priced with a savings of up to 33 per cent so gift givers can save during the holiday season.

There are two kits to select from, each designed to address key skin concerns and each with a unique theme — Brightening Basics and Hydration Heroes.

Brightening Basics is a mix of everyday essentials for glowing skin for all skin types. The bundle comes in a sleek pink, reusable case and includes three full-sized products: 200ml gentle cleanser, 50ml Moisture Defence (normal skin) and 30ml1% Hyaluronic Complex Serum. The Brightening Basics kit is available at $129, a saving of 33 per cent.

Hydration Heroes is a mix of hydration essentials and active heroes that cater to a wide variety of clients. A perfect stocking stuffer, this bundle includes four deluxe products: Moisture 15 15 ml Defence for normal skin, 10 ml 1% Hyaluronic Complex Serum, 10 ml Retinol Serum and 50 ml Expert Squalane Cleansing Oil. The kit retails at $59.

In addition to the 2024 Holiday Gifts Kits, gift givers can easily add a Laser Clinic Canada gift card to the mix. Offering flexibility, recipients can choose from a wide range of treatments offered by Laser Clinics Canada, or they can expand their collection of exclusive Skinstitut products.

 

Brightening Basics 2024 Holiday Gift Kit by Skinstitut, available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

Hydration Heroes 2024 Holiday Gift Kit by Skinstitut – available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

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Here is how to prepare your online accounts for when you die

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LONDON (AP) — Most people have accumulated a pile of data — selfies, emails, videos and more — on their social media and digital accounts over their lifetimes. What happens to it when we die?

It’s wise to draft a will spelling out who inherits your physical assets after you’re gone, but don’t forget to take care of your digital estate too. Friends and family might treasure files and posts you’ve left behind, but they could get lost in digital purgatory after you pass away unless you take some simple steps.

Here’s how you can prepare your digital life for your survivors:

Apple

The iPhone maker lets you nominate a “ legacy contact ” who can access your Apple account’s data after you die. The company says it’s a secure way to give trusted people access to photos, files and messages. To set it up you’ll need an Apple device with a fairly recent operating system — iPhones and iPads need iOS or iPadOS 15.2 and MacBooks needs macOS Monterey 12.1.

For iPhones, go to settings, tap Sign-in & Security and then Legacy Contact. You can name one or more people, and they don’t need an Apple ID or device.

You’ll have to share an access key with your contact. It can be a digital version sent electronically, or you can print a copy or save it as a screenshot or PDF.

Take note that there are some types of files you won’t be able to pass on — including digital rights-protected music, movies and passwords stored in Apple’s password manager. Legacy contacts can only access a deceased user’s account for three years before Apple deletes the account.

Google

Google takes a different approach with its Inactive Account Manager, which allows you to share your data with someone if it notices that you’ve stopped using your account.

When setting it up, you need to decide how long Google should wait — from three to 18 months — before considering your account inactive. Once that time is up, Google can notify up to 10 people.

You can write a message informing them you’ve stopped using the account, and, optionally, include a link to download your data. You can choose what types of data they can access — including emails, photos, calendar entries and YouTube videos.

There’s also an option to automatically delete your account after three months of inactivity, so your contacts will have to download any data before that deadline.

Facebook and Instagram

Some social media platforms can preserve accounts for people who have died so that friends and family can honor their memories.

When users of Facebook or Instagram die, parent company Meta says it can memorialize the account if it gets a “valid request” from a friend or family member. Requests can be submitted through an online form.

The social media company strongly recommends Facebook users add a legacy contact to look after their memorial accounts. Legacy contacts can do things like respond to new friend requests and update pinned posts, but they can’t read private messages or remove or alter previous posts. You can only choose one person, who also has to have a Facebook account.

You can also ask Facebook or Instagram to delete a deceased user’s account if you’re a close family member or an executor. You’ll need to send in documents like a death certificate.

TikTok

The video-sharing platform says that if a user has died, people can submit a request to memorialize the account through the settings menu. Go to the Report a Problem section, then Account and profile, then Manage account, where you can report a deceased user.

Once an account has been memorialized, it will be labeled “Remembering.” No one will be able to log into the account, which prevents anyone from editing the profile or using the account to post new content or send messages.

X

It’s not possible to nominate a legacy contact on Elon Musk’s social media site. But family members or an authorized person can submit a request to deactivate a deceased user’s account.

Passwords

Besides the major online services, you’ll probably have dozens if not hundreds of other digital accounts that your survivors might need to access. You could just write all your login credentials down in a notebook and put it somewhere safe. But making a physical copy presents its own vulnerabilities. What if you lose track of it? What if someone finds it?

Instead, consider a password manager that has an emergency access feature. Password managers are digital vaults that you can use to store all your credentials. Some, like Keeper,Bitwarden and NordPass, allow users to nominate one or more trusted contacts who can access their keys in case of an emergency such as a death.

But there are a few catches: Those contacts also need to use the same password manager and you might have to pay for the service.

___

Is there a tech challenge you need help figuring out? Write to us at onetechtip@ap.org with your questions.

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Pediatric group says doctors should regularly screen kids for reading difficulties

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The Canadian Paediatric Society says doctors should regularly screen children for reading difficulties and dyslexia, calling low literacy a “serious public health concern” that can increase the risk of other problems including anxiety, low self-esteem and behavioural issues, with lifelong consequences.

New guidance issued Wednesday says family doctors, nurses, pediatricians and other medical professionals who care for school-aged kids are in a unique position to help struggling readers access educational and specialty supports, noting that identifying problems early couldhelp kids sooner — when it’s more effective — as well as reveal other possible learning or developmental issues.

The 10 recommendations include regular screening for kids aged four to seven, especially if they belong to groups at higher risk of low literacy, including newcomers to Canada, racialized Canadians and Indigenous Peoples. The society says this can be done in a two-to-three-minute office-based assessment.

Other tips encourage doctors to look for conditions often seen among poor readers such as attention-deficit hyperactivity disorder; to advocate for early literacy training for pediatric and family medicine residents; to liaise with schools on behalf of families seeking help; and to push provincial and territorial education ministries to integrate evidence-based phonics instruction into curriculums, starting in kindergarten.

Dr. Scott McLeod, one of the authors and chair of the society’s mental health and developmental disabilities committee, said a key goal is to catch kids who may be falling through the cracks and to better connect families to resources, including quicker targeted help from schools.

“Collaboration in this area is so key because we need to move away from the silos of: everything educational must exist within the educational portfolio,” McLeod said in an interview from Calgary, where he is a developmental pediatrician at Alberta Children’s Hospital.

“Reading, yes, it’s education, but it’s also health because we know that literacy impacts health. So I think that a statement like this opens the window to say: Yes, parents can come to their health-care provider to get advice, get recommendations, hopefully start a collaboration with school teachers.”

McLeod noted that pediatricians already look for signs of low literacy in young children by way of a commonly used tool known as the Rourke Baby Record, which offers a checklist of key topics, such as nutrition and developmental benchmarks, to cover in a well-child appointment.

But he said questions about reading could be “a standing item” in checkups and he hoped the society’s statement to medical professionals who care for children “enhances their confidence in being a strong advocate for the child” while spurring partnerships with others involved in a child’s life such as teachers and psychologists.

The guidance said pediatricians also play a key role in detecting and monitoring conditions that often coexist with difficulty reading such as attention-deficit hyperactivity disorder, but McLeod noted that getting such specific diagnoses typically involves a referral to a specialist, during which time a child continues to struggle.

He also acknowledged that some schools can be slow to act without a specific diagnosis from a specialist, and even then a child may end up on a wait list for school interventions.

“Evidence-based reading instruction shouldn’t have to wait for some of that access to specialized assessments to occur,” he said.

“My hope is that (by) having an existing statement or document written by the Canadian Paediatric Society … we’re able to skip a few steps or have some of the early interventions present,” he said.

McLeod added that obtaining specific assessments from medical specialists is “definitely beneficial and advantageous” to know where a child is at, “but having that sort of clear, thorough assessment shouldn’t be a barrier to intervention starting.”

McLeod said the society was partly spurred to act by 2022’s “Right to Read Inquiry Report” from the Ontario Human Rights Commission, which made 157 recommendations to address inequities related to reading instruction in that province.

He called the new guidelines “a big reminder” to pediatric providers, family doctors, school teachers and psychologists of the importance of literacy.

“Early identification of reading difficulty can truly change the trajectory of a child’s life.”

This report by The Canadian Press was first published Oct. 23, 2024.

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