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Companion FOR MINNESOTA’S VETERINARY COMMUNITY FROM BLUEPEARL VETERINARY PARTNERS Once Bitten, Twice Shy DOG AND CAT BITES are the most common risk we face in our practices because we handle painful and frightened animals every day. Despite our best efforts at being vigilant, it is nearly impossible to avoid this risk. The compassion we feel for our patients is a hindrance in this respect. In a veterinary hospital, most bites occur to the hands and, less commonly, to the arms. Bites to the face also occur due to our proximity to the patient’s mouth when we lift, carry or reach for the pet. What’s the risk? Because of their smooth teeth and strong jaws, dogs inflict injury primarily by crushing and tearing tissues below the skin, such as muscle, tendons and nerves. By contrast, cats have sharp canine teeth that produce punctures into deeper tissue, introducing bacteria into these tissues and the blood stream. Because cat bites create only small skin punctures, it is difficult for these deeper wounds to drain. Secondary infections are a common complication of bite injuries. A mix of anaerobic and aerobic bacteria from the animal’s oral cavity is frequently identified. Pasteurella multocida is one of the most common bacteria isolated from both dog and cat bites. Less common, but of serious concern, would be the presence of methicillin-resistant Stapylococcus aureus, Bartonella henselae (the cause of cat scratch fever), and rabies virus. Do Not Take Chances! All dogs and cats bite. Despite giving the impression that you may lack compassion, use a muzzle or other means to protect yourself from all trauma presentations and patients with uncertain dispositions. You should constantly be reading the patient’s appearance for signs that he or she may bite. Don’t be afraid to ask for help with restraint of a patient even if you are not certain it is needed. And don’t be afraid to inform the clinician on duty that sedation may be needed to perform an exam or treatment. I’ve been bitten. Now what? Should you be bitten by a dog or cat, you should wash the wound as soon as possible with soap and water. Inform the individual in charge. In most cases you should seek prompt medical attention from a human physician. Secondary infections from cat bites are very common, and can develop very quickly (within hours) into severe infections. Broad-spectrum antibiotics such as amoxicillin-clavulanate are most commonly prescribed. True or False: The mouth of a dog or cat is cleaner than that of a human. The answer is false. The microbial population in the mouth of dogs and cats includes the resident population as well as transient micro-organisms introduced from what the cat or dog most recently ate or licked. Realizing that animals, especially dogs, will lick and chew most anything (dead animals, feces, etc.), it makes you second guess accepting their kisses. For the record, dog breath is caused by the gases given off by microbials in their mouths. b lu ep ea rlve t.co m FALL 2015 How Is Cancer Treated? THE FIELD OF VETERINARY ONCOLOGY is changing rapidly. Effective therapies, longer remission times, and improved quality of life are now available for cancers that were once considered untreatable. These include surgery, radiation therapy and chemotherapy. Surgery Surgery is the surest way to cure a tumor, but only if it can be removed entirely. This may not be possible without significantly harming the tissues surrounding the mass. Many tumors are invasive with microscopic “roots” that invade surrounding tissues. For this reason, a buffer zone of normal appearing tissue around the tumor should also be removed during the surgery. The larger this “margin,” the more likely the tumor can be completely excised. If metastatic lesions are present, then surgery is typically not the best option. Surgery can also be performed to “debulk” a tumor. That is, the goal of the surgery is to remove as much of the tumor as possible, although the surgeon knows a portion will remain. This would be performed to improve the patient’s quality of life, even though it would not cure the patient of the cancer. Radiation therapy or chemotherapy may be used after surgery to kill the remaining tumor cells or slow the tumor’s continued growth, especially if it has already spread. Radiation Therapy The high energy waves used in radiation therapy kill cancer cells. Damage to the cancer cell results from the direct disruption of electrons within the DNA molecules and indirectly from damage caused by free radicals formed when the radiation reacts with water molecules within the cancer cells. The damaged DNA causes the cancer cells to die as they attempt to divide. Both normal cells and cancer cells are affected by radiation therapy. Cancer cells are preferentially killed because they divide more rapidly than normal cells and don’t repair themselves of the DNA damage as well as normal cells do. An advantage to radiation therapy is the ability to focus the energy waves directly at the tumor and surrounding tissues where microscopic disease may exist. Radiation therapy can be used as adjunctive treatment after the surgical debulking of a tumor or as a stand-alone treatment for those cancer types that have been shown to be easily killed by radiation. Surgically removing a splenic tumor from a cat. Radiation therapy can be very effective for treating nasal lymphoma in cats. Chemotherapy Precautions are taken to protect the staff Chemotherapy, in which medications are used to treat cancer cells, when administering chemotherapy. typically targets all rapidly dividing cells. Chemotherapy acts by interfering with the ability of cancer cells to divide, damaging their DNA, and/or limiting their access to required nutrients. Cancer cells, unlike normal body cells, have less capacity for repairing themselves after being injured and therefore are more susceptible to the actions of the anticancer medications. However, chemotherapy will also affect normal rapidly dividing cells in the body. The side effects associated with chemotherapy are a result of damage to the normal cells lining the GI tract (vomiting, diarrhea, appetite loss), within the hair follicles (thinning hair coat), as well as white blood cells in the bone marrow (an increased susceptibility to infections). Side effects can be minimized by controlling the dosages of the medications administered and by administering a regimen of multiple medications having non-additive side effects to kill the cancer cells. An advantage to chemotherapy is its ability to travel throughout the body killing cancer cells that have metastasized to multiple locations. If you have any questions about the cancer treatments available at BluePearl, please call the hospital and speak with Dr. Joanna Schmidt from our oncology service. She would be happy to discuss your cancer cases with you. Eden Prairie Blaine 7717 Flying Cloud Drive 11850 Aberdeen Street NE Eden Prairie MN 55344 Blaine MN 55449 952.942.8272763.754.5000 Indications for Arthroscopy SNIFF… Meet Dr. Kathryn Kaufman Surgery Service “My father was a paramedic, and he would tell us of stories from work. From listening to him I fell in love with medicine and learned that the healing capabilities of a body could be amazing. As a kid I was always intrigued with animals as well, their kind nature, honesty and love. I wanted to help those that helped me get through some tough times, and this is the best way to do so!” Dr Kaufman earned her doctor of veterinary medicine from Iowa State University and completed three internships prior to finishing a residency in animal surgery at Texas A & M University. Away from surgery she enjoys spending time with her husband and their two dogs Isabella, a 3-year-old pit bull/ boxer mix, who loves to sleep under the covers, and Keela, an 8-year-old German shorthaired pointer, who loves, loves, loves to hunt! When she’s not spending time with her family she enjoys antiques and has a soft spot for Starbucks. As a Midwest native she is happy to be closer to friends and family and doesn’t mind Minnesota’s snowy winters. We are excited to have Dr. Kaufman join us at BluePearl. We asked her a couple of questions about what keeps her interested day after day and her thoughts about surgery, so you could get to know her better. What interests you most about surgery? I enjoy veterinary surgery in all areas of orthopedics and soft tissue, but one area that I am especially interested in is arthroscopy. It is a very helpful tool not only diagnosing problems but treating them as well. I was trained extensively in the use of arthroscopy at Texas A&M during my residency and find it most beneficial in diseases of the stifle, elbow and shoulder. I feel the magnification and light offered with arthroscopy helps me better diagnose and treat the joint problem. I also feel that my patients are much more comfortable with after-surgery and recover more quickly. Many think that size of the patient may be limited with the use of arthroscopy; however, with the tools we have available at BluePearl we can use arthroscopy for patients ranging in size from a Yorkie to a great Dane. The most common diseases that we evaluate and treat include cranial cruciate disease and meniscal damage of the stifle, elbow dysplasia, biceps tenosynovitis of the shoulder and OCD of multiple joints. How do you collaborate with the primary care veterinarian? I strongly believe in keeping the primary care veterinarian updated. Asking if they have questions or concerns is important to building strong relationships. I have been told I have a good listening ear, am dedicated, innovative, and a good person to bounce ideas off of, and it is with those qualities that I want to encourage the referring community to reach out to me for questions about cases or other areas of interest. I’m excited to be a BluePearl doctor and supporting my team! Medical Director: Jenifer Myers DVM Hospital Administrator: Mary Lecy CRITICAL CARE Tracy Julius DVM, DACVECC Katherine Peterson DVM, DACVECC Mallory Salcedo DVM DENTISTRY & ORAL SURGERY Emily Edstrom DVM Donnell Hansen DVM, DAVDC DIAGNOSTIC IMAGING Megan MacLellan DVM VETERINARY ARTHROSCOPY HAS GAINED popularity and enhanced our ability to diagnose and treat many orthopedic diseases, including pathology of the shoulder, elbow, carpus, stifle and hock. Arthroscopy offers several advantages over traditional surgery, including •• better visualization of structures within the joint by magnification, •• minimal invasiveness and decreased pain, and •• more rapid recovery. Shoulder osteochondritis dissecans (OCD) Shoulder arthroscopy is commonly used to diagnose and treat OCD, which often presents as a unilateral lameness in young, large-breed dogs. However, the contralateral limb is also affected in a large percentage of dogs. Following bilateral radiographic screening, arthroscopy is ideal for confirming the diagnosis and definitive treatment of OCD. After arthroscopic removal of the cartilage fragments, curettage is performed within the articular cartilage defect to stimulate fibrocartilage healing. Patients recover rapidly after this procedure. Prognosis for OCD of the shoulder is good to excellent. Bicipital tenosynovitis This condition often presents as a unilateral lameness that may be chronic and progressive in a middle-aged or older medium to large breed dog. Arthroscopy may identify a partial or completely torn biceps tendon and/or fibrous proliferation and osteophyte formation within the bicipital groove. Treatment includes biceps tendon release. Patients treated for biceps tenosynovitis have a good to excellent prognosis if pathology within the shoulder joint is limited. Shoulder instability Capsular or ligamentous injury leads to a chronic unilateral lameness, which is often worse after exercise. This condition occurs in middle-aged dogs of any breed and size. Diagnosis can be challenging and often requires heavy sedation and palpation for laxity. Radiography identifies non-specific findings. Arthroscopy is recommended to rule out other joint pathology and to confirm joint capsule and ligamentous tears. Gross instability requires surgical stabilization with ligament reconstruction, now commonly performed using bone anchors and non-absorbable suture material. The prognosis for treatment of instability by arthroscopy and surgery is good if mild to moderate disease exists but may be only fair with advanced disease. Elbow dysplasia Elbow dysplasia is commonly characterized using arthroscopy following identification on radiographs. Components of elbow dysplasia often diagnosed by arthroscopy include fragmented medial coronoid process (FCP), OCD, ununited anconeal process (UAP) and elbow incongruity. Since FCP is poorly recognized on radiographic examination, it often goes undiagnosed, which leads to progressive osteoarthritis. Early diagnosis, prior to advancement of osteoarthritis and subsequent treatment by medial joint assessment and removal of the fragment along with medial coronoidectomy, usually improves limb function. Secondary humeral condylar osteochondrosis, known as a kissing lesion, cannot be seen on radiographs and is often assessed and treated by articular cartilage curettage. INTERNAL MEDICINE Alexis Cottingham DVM Alyssa Mourning DVM, DACVIM Jenifer Myers DVM Sean Teichner DVM Fragmented medial coronoid process (FCP) Large fragmented medial coronoid process. Note pathology of full thickness articular cartilage defects of the humeral condyle (kissing lesion). NEUROLOGY Christina Wolf DVM, DACVIM ONCOLOGY Joanna Schmit DVM OPHTHALMOLOGY Nicole Trumble DVM, DACVO Vaccines or Titers? VACCINE PRODUCTS HAVE BEEN USED in companion animal medicine for ARTHROSCOPY CAN BE USED TO ASSIST IN ASSESSMENT FOR OTHER JOINT PATHOLOGY AND PARTICULARLY IDENTIFIES A UAP LESION AS A LINE OF FIBROUS TISSUE AND IRREGULAR CARTILAGE BETWEEN THE ANCONEUS AND THE ULNA. OCD of the medial humeral condyle is often identified on radiographs but is best further characterized by arthroscopy. Once identified, the OCD flap can be removed from its articular bed by graspers, followed by curettage of the subchondral bone defect. Again, most patients have improved limb function following flap removal, but this varies based on prior degenerative joint disease (DJD) presence. UAP is usually recognized using radiography and treated either by anconeal fragment removal or lag screw fixation. Arthroscopy can be used to assist in assessment for other joint pathology and particularly identifies a UAP lesion as a line of fibrous tissue and irregular cartilage between the anconeus and the ulna. Lastly, elbow incongruity is a disease with controversy surrounding the ideal diagnostics. It may be assessed by alignment of the radial head and ulnar trochlear notch for step defects. Since this condition is often thought to contribute to FCP, UAP and secondary humeral condylar osteochondrosis, medial corinoidectomy may be considered to alter the joint biomechanics, particularly unloading the medial joint. The outcome is often based on prior DJD advancement and may be fair to excellent. Stifle joint Arthroscopy is most commonly used for identification of cruciate ligament and meniscal pathology in the stifle. In cases of suspected cranial cruciate ligament disease that are lacking signs of instability, assessment of the ligament for partial or complete tearing is easily done arthroscopically. Additionally, medial meniscal disease may occur before or after stifle joint surgical stabilization. Arthroscopic assessment and treatment of meniscal disease by debridement can be done with limited morbidity. Other indications for stifle arthroscopy include diagnosis and treatment of OCD of the lateral and medial femoral condyles, treatment of septic osteomyelitis and Cranial cruciate ligament tear (partial) placement of transarticular pins. Since the institution of arthroscopy for assessment of canine and feline joint pathology, disease recognition and treatment outcomes have been enhanced. Shoulder, elbow and stifle joints have numerous pathologies, which benefit greatly from the reduced morbidity, recovery time and cost associated with arthroscopy. Early identification of joint pathology and referral for further diagnostics and treatment will undoubtedly benefit patients preventing progression of joint disease. At BluePearl Veterinary Partners, our team is excited to offer arthroscopy to your patients. If you have a case that you feel may benefit from arthroscopy and would like to discuss the options, please do not hesitate to call a member of our surgery team. more than 40 years. They could arguably be considered one of the most important scientific advancements that have helped us improve quality and longevity of the life of our cat and dog patients. In the last decade, a significant change in our thinking about vaccination protocols has been seen due to several different factors. Our understanding of the science of vaccination-induced immunity has evolved suggesting more prolonged infectious disease protection with specific core vaccines (canine distemper, parvovirus, adenovirus; feline panleukopenia virus). Major veterinary associations (AAHA and AVMA) with the support of vaccine amanufacturers now recommend reassessment of annual vaccination protocols, especially for the core vaccines. Vaccination every three years has become accepted practice by many veterinary practices. Vaccine manufacturers have introduced new products with more extended duration of immunity and fewer antigenic components. Our society has become more concerned about possible vaccine reactions in children, and this has also created concern over side effects in pets. Side effects are fortunately infrequent in dogs and cats, but there has been association between vaccination and the development of vaccine sarcomas in cats and immune-mediated disease in dogs. With the concern from pet owners about “over vaccination” and the possibility of serious vaccine side effects, clients may now be requesting vaccine titers instead of vaccines. How reliable are these vaccine titers? Vaccine titers have been the cornerstone of the change in our knowledge about vaccine protection. They measure the presence of serum antibody able to neutralize the virus and prevent infection. IgG is the antibody class measured by vaccine titer assays. Studies have shown that for specific viral diseases in dogs (parvovirus, distemper, adenovirus) and cats (panleukopenia virus) protection after initial appropriate vaccination can last for 4 to 10 years based on serologic titer results and challenge studies. The “gold standard” assays for these virus titers are the viral neutralizing titer (VIN) and hemagglutination inhibition (HI). Most state diagnostic labs utilize the gold standard methodologies. Most, if not all, commercial veterinary laboratories have qualified and standardized alternative methodologies including enzyme immunoassays (ELISA) and immunofluorescence assays (IFA) to provide similar titer information compared to the gold standard VIN and HI assays. Due to variations in lab assay methodologies, different reference ranges, and potential change in titers from the pet over time, titers should not be compared between different laboratories. In-clinic titer test kits for canine distemper, parvovirus, and adenovirus and feline panleukopenia virus are now available. TiterCHEK® (Zoetis) and VacciCheck® are the names of two commercially available in-clinic titer kits. Both test kit systems have been validated independently and correlated with the gold standard titer assays. Rabies virus titers can also be assayed by the fluorescent antibody virus neutralizing titer, but the assay is available only through a limited number of certified laboratories. How are these titers interpreted? Depending on the individual lab and test methodology used, vaccine titer results may be reported as “protective” or “positive” (high antibody titer), “not protective” or “negative” (low antibody titer), or “borderline.” Some assays will provide an actual titer level from the laboratory to use in interpretation. The in-clinic titer test kits provide either a protected or not-protected result (TiterCHEK) or a semi-quantitative score for serum antibodies (VacciCheck). Protective, positive or high titers indicate that there is a high antibody titer to that virus either from vaccination or previous natural exposure or disease. For pets with a not protective, negative or low titer, lack of virus protection is of concern and booster vaccinations are recommended. The best correlation between antibody and protective immunity are for the viruses previously discussed (canine parvovirus, distemper, adenovirus, feline panleukopenia, rabies). It is important to remember that other factors may affect titer interpretation and risk for the pet. The immune system is complex. Antibodies target the foreign invaders for destruction, but other immune system cells actually destroy the invader. An insufficiency in the cellmediated immune system (immunosuppression) may leave a pet at risk for disease even if protective titers are present. Even if a titer is considered low, exposure to the same antigen may result in a rapid immune response with new antibodies produced within hours to days. CONTINUED ON PAGE 4 SURGERY Judith Feldsien BVMS, MVSc, DACVS-SA Heather Hadley DVM, DACVS-SA Andrew Jackson DVM, DACVS Katie Kaufman DVM Jeff Yu DVM, DACVS-SA Vaccines or Titers? CONTINUED FROM PAGE 3 These animals may be susceptible to infection but may be fully protected due to immune-cell memory and cell-mediated immunity. By law, rabies vaccine titers cannot be used in place of re-vaccination. When a rabies vaccination is not current, a pet that bites someone must be considered unvaccinated and quarantined. Antibody titers to vaccines other than the core viruses have limited or no value as “protective titers.” Antibodies may persist for a short time, and there is no correlation between serum antibody testing and protection. This includes antibody testing for leptospirosis, feline herpes virus, feline calici virus, Lyme disease, and Bordetella. With other diseases, feline immunodeficiency virus for example, titer levels equate only to exposure to the pathogen or active infection. What is the appropriate clinical application of these titers for the veterinary patient? Protective titer levels may be appropriate clinically for specific patients. The most common application of vaccine titers is to help determine the need for vaccination in an adult pet. The reason for the request for titer assessment is often because of previous history of suspected or severe vaccine reactions in the pet, concurrent medical illness or just the owner’s concern about the need for vaccination. Evaluation of vaccine titers may be helpful to determine the need for core vaccines in other clinical scenarios: •• Evaluation of vaccine response in a young pet to help identify non-responders that may not be able to produce a protective antibody response •• Identification of possibly unprotected pets with recent exposure to a contagious viral disease •• Determination of antibody level in pet with unknown vaccination status •• Management of infection risks and infectious disease outbreaks in shelters Vaccine titers may be helpful in determining the need for specific vaccines in the individual pet, but it is important that the owner understand the factors other than titer results that may affect the decision to vaccinate. Each veterinarian must determine the appropriate vaccination schedule for a patient based on risk of exposure, age of the pet and current medical status of the pet. Vaccine titers should not be considered a substitute for an appropriate core vaccine protocol for most clinically healthy pets. The recent outbreak of measles in children exposed to the virus at a national amusement park was suspected to be correlated with a decline in vaccination for this virus. This is a warning to us all and a reminder of the importance of consistent vaccination for “herd health.” All puppies and kittens should complete the recommended core vaccination protocols recommended with the last vaccine being at or beyond 16 weeks of age. An evaluation of pathogen exposure risk, lifestyle, age of the pet and concurrent medical problems along with vaccine titer status are all factors that should affect the decision to vaccinate the individual adult pet. We thank our colleague, Susan Yohn, DVM, MS, DAVBP Canine/Feline, DACVIM, from BluePearl in Illinois for allowing us to se this article for Companion. Companion 7717 Flying Cloud Drive Eden Prairie MN 55344 To go green and receive only an electronic version of the COMPANION, or to add your email to our address list, please send an email to Jackie Todd, [email protected]. CONTINUING EDUCATION BluePearl is strongly committed to the veterinary community. One of the ways we demonstrate this commitment is through our continuing education program, which is subsidized in part by our Partners in Education. All BluePearl CE lectures are free and open to all area veterinary professionals. Registration is required, please; space is limited. Dinner will be provided. To register, please email Jackie Todd at [email protected]. For the most current information about BluePearl CE, please click the For Veterinarians tab on our homepage: bluepearlvet.com/minnesota. Date Time Type Topic/Speaker Oct 24 8AM Dr/Office Manager Crown Plaza Raking in CE for Veterinarians and Practice Managers Plymouth Multiple Speakers Minnetonka Community Center Nov 4 7PM Dr/Tech Interesting Imaging Jen Myers, DVM Nov 12 7PM Dr/Tech Interesting Imaging Jen Myers, DVM Location Blaine Broadway Pizza CE 4 hr 1 hr 1 hr BluePearl’s newsletters are produced for the veterinary community with support from Partners in Education: If you would like to receive an electronic version of Companion, please send an email to your Georgia Flood at [email protected]. Antech Diagnostics, Elanco, Hill’s Pet Nutrition, Stokes Pharmacy, Trupanion, Zoetis © 2015 BluePearl Veterinary Partners