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magenta cyan yellow black vetm0112_cvtp1.pgs 01.09.2012 16:26 ADVANSTAR_PDF/X-1a magenta cyan yellow black vetm0112_cvtp2.pgs 12.27.2011 12:48 ADVANSTAR_PDF/X-1a VETERINARY MEDICINE January 2012, Vol. 107, No. 1 ❖ PEER-REVIEWED ❖ Medical recommendations Essential medicine for exemplary patient care J a nu a r y 2 012 ❖ Vo l .107, N o.1 ❖ Pe e r- r ev i ewe d ❖ d v m 3 6 0 .c o m Lead the Way How to get clients to follow your medical recommendations PLUS Three parasites of increasing concern in the United States Illustrated guides to four key oral nerve blocks Nurturing safe surgeries: New anesthetic guidelines When clients decline immunotherapy for atopy Feeling a bit yellow and need extra support? ThOse are what I take to keep feeling great. Now they’re chewable too! LIVER SUPPOR T STATION Max, the hard-working liver, knows dogs and cats often need extra support when their liver function is compromised. Veterinary recommended Denamarin®, Marin® and Denosyl® can provide needed support to help livers feel great! To learn more about our new Chewable Denamarin and Denosyl for dogs or any of our Liver Support products go to Maxknowslivers.com or call 1-888-886-6442. Research is looking into dog aging and associated decreases in levels of S-Adenosylmethionine (SAMe) in cerebrospinal fluid. Age related brain issues include confusion, inappropriate urination/defecation or personality changes often expressed through being less social. Denamarin and Denosyl provide SAMe in a stabilized form to help with brain health and act as a neuroprotector. Denamarin®, Marin® and Denosyl® are available for cats & dogs of all sizes. Departments 10 Editors’ Guest There isn’t much of a market for buggy whips –Michael A. Paul, DVM 12 Leading Off Be aware of the new anesthesia guidelines for dogs and cats –Richard Bednarski, MS, DVM, DACVA 15 Letters Questioning the great outdoors 16 Just Ask the Expert When clients decline immunotherapy for atopy –Ian B. Spiegel, VMD, MHS, DACVD 18 Toxicology Brief Vol. 107, No. 1 • January 2012 Veterinary Medicine ® dvm360.com 36 Lead the way: 7 STEPS to boost acceptance of your medical recommendations Michael A. Paul, DVM Clients are not being intentionally defiant when they forgo preventives or do not comply with your treatment protocol. Instead, it is usually a sign of a communication breakdown. Phenylpropanolamine toxicosis in dogs and cats –Judy K. Holding, DVM, RN 20 Community Blog TSH as a marker for the development of hyperthyroidism in geriatric cats 24 Idea Exchange Warm up cold patients with cozy water beds, and more tips 26 Image Quiz • The case of the crying rat • A panting Great Dane with red eyes –Enry Garcia, DVM, MS 50 Mind Over Miller 30 skills laboratory How to perform four oral regional nerve blocks in dogs and cats Brett Beckman, DVM, FAVD, DAVDC, DAAPM These quick and easy pain management techniques decrease the amount of inhalant anesthetic needed during oral surgery and enhance postoperative patient comfort. 40 The expanding universe of three parasites Lora R. Ballweber, DVM, MS Three parasites that primarily affect dogs are becoming an increasing concern in the United States. Are these three emerging parasites on your radar? Practical jokes, Tucson style –Robert M. Miller, DVM Reader Resources 35 Author Guidelines 48 Showcase and Marketplace ❖PEER- R E V I E WED Peer-reviewed articles have been reviewed by at least two board-certified specialists or recognized experts to ensure accuracy, thoroughness, and suitability. dvm360.com Veterinary Medicine January 2012 3 toxin L ab It’s the tasty ingredient that makes her chocolate cake so rich. When an anxious client calls because her dog has eaten chocolate, knowledge is your lifeline. What kind of chocolate? How much did the dog eat? What’s the dog’s weight? These factors can determine if it’s a minor problem or a serious emergency. That’s why we developed the Dogs and Chocolate Risk Wheel to guide your first critical steps. For over 30 years, the ASPCA Animal Poison Control Center has been the only center in North America dedicated solely to animals. Our team of board-certified veterinary toxicologists* utilize our exclusive AnTox database to provide you with lifesaving information 24/7/365. No one else offers you all these essential ingredients. ® ™ Be prepared. Email [email protected] to order your FREE Dogs and Chocolate Risk Wheel. Add 888-426-4435 to your contacts list and speed dial. For information on our online Toxicology CE courses, visit www.aspca.org/apcc. No animals were harmed during the production of this ad. *American Board of Veterinary Toxicology www.abvt.org American Board of Toxicology, Inc. www.abtox.org A consultation fee may apply. Veterinary Medicine Go to dvm360.com and click on the Medicine tab to find these multimedia extras and to read this issue online. Achieving canine-feline harmony Veterinary behaviorist Dr. Jacqueline Neilson has a few tips to stop dogs from chasing cats living in the same household. Have You Heard? Considering the canine IQ What you mustn’t miss at every patient visit Chaser, a female border collie that can distinguish among more than 1,000 objects, is helping to show that dogs learn in much the same way as humans do. Visit dvm360.com/HYH to hear all about it. Veterinary behaviorist Dr. Gary Landsberg explains exactly why asking owners about any behavior changes in their pets each time they come in for an appointment is paramount to patient health and well-being. Find these videos at dvm360 .com/medicinevideos. Got questions? Get expert answers! Submit your questions at dvm360.com/myquestion Internal Medicine Dentistry Endocrinology Imaging Oncology Laura J. Smallwood, Daniel T. Carmichael, David S. Bruyette, Tasha M. Axam, Timothy M. Fan, Ian Spiegel, DVM, DACVIM DVM, DAVDC DVM, DACVIM DVM, DACVR DVM, DACVIM VMD, MHS, DACVD DVM, DACVECC, DACVIM Surgery Soft Tissue Surgery Ophthalmology Behavior Dermatology Clinical Pathology Internal Medicine Jenifer Newton, Steven F. Swaim, Juliet R. Gionfriddo, Valarie V. Tynes, Paul Bloom, Jennifer L. Garcia, DVM, MS DVM, MS, DACVO DVM, DACVB DVM, DACVD, DABVP Joyce S. Knoll, DVM, MS, DACVS DVM, PhD, DACVP DVM, DACVIM Veterinary Medicine (iSSn 8750-7943 print; iSSn 1939-1919 online) is published monthly by advanstar communications inc., 131 West First St., duluth, Mn 55802-2065. One year subscription rates: $60 in the United States & Possessions; $72 in canada and Mexico; $97 all other countries. Single issue orders $17 a copy in the United States, $23 in all other countries. Periodicals postage paid at duluth, Mn 55806 and additional mailing offices. POStMaSter: Please send address changes to Veterinary Medicine, P.O. Box 6087, duluth, Mn 55806-6087. canadian GSt number: r-124213133rt001. Publications Mail agreement number: 40612608. return undeliverable canadian addresses to: Pitney Bowes, P.O. Box 25542, London, On n6c 6B2, canada. 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Veterinary Medicine does not verify any claims or other information appearing in any of the advertisements contained in the publication, and cannot take responsibility for any losses or other damages incurred by readers in reliance on such content. Publisher assumes no responsibility for unsolicited manuscripts, photographs, art, and other material. Unsolicited material will not be returned. address correspondence to Veterinary Medicine, 8033 Flint, Lenexa, KS 66214; (913) 871-3800; e-mail [email protected]. to subscribe, call toll-free 877-527-7008. Outside the U.S. call 218-740-6477. PRINTED IN THE U.S.A. dvm360.com Veterinary Medicine January 2012 5 ® BIG. SMALL. HAVE IT ALL. CVC WASHINGTON, D.C. APRIL 25 – 29, 2012 BIG-CONVENTION CE. Take advantage of leadingedge veterinary learning, rich with the real-world skills and strategies needed to provide the level of care today’s clients expect. COMMUNITY SETTING. Benefit from personal attention, best-in-class customer service, and the comfort of a close-knit setting. SUIT-YOURSELF CITY FUN. Experience spring in a big city with small-city charm — via a waterfront vacation packed with outdoor recreation. REGISTRATION IS OPEN! Use promo code DC12VM REGISTER BY MARCH 14 & SAVE UP TO $75 Three shows put CVC everywhere you want to be: CVC WASHINGTON, D.C. — April 25 – 29, 2012 CVC KANSAS CITY — August 22 – 28, 2012 CVC SAN DIEGO — December 5 – 9, 2012 REGISTER NOW! Call 800.255.6864, ext. 6 or visit TheCVC.com. • follow us: VETERINARY MEDICINE dvm360.com E ditori al Advisor y B o ard Leading specialists who direct our content and ensure our editorial quality and integrity Joseph W. Bartges, DVM, PhD, DACVIM, DACVN Department of Small Animal Clinical Sciences College of Veterinary Medicine The University of Tennessee Knoxville, Tennessee John Ciribassi, DVM, DACVB Chicagoland Veterinary Behavior Consultants Carol Stream, Illinois Karen A. Moriello, DVM, DACVD Department of Medical Sciences School of Veterinary Medicine University of Wisconsin Madison, Wisconsin David S. Bruyette, DVM, DACVIM VCA West Los Angeles Animal Hospital West Los Angeles, California Timothy M. Fan, DVM, DACVIM Department of Veterinary Clinical Medicine College of Veterinary Medicine University of Illinois Urbana, Illinois Barrak M. Pressler, DVM, PhD, DACVIM Department of Veterinary Clinical Sciences College of Veterinary Medicine The Ohio State University Columbus, Ohio Juliet R. Gionfriddo, DVM, MS, DACVO Department of Clinical Sciences College of Veterinary Medicine and Biomedical Sciences Colorado State University Fort Collins, Colorado Walter Renberg, DVM, MS, DACVS Department of Clinical Sciences College of Veterinary Medicine Kansas State University Manhattan, Kansas See Dr. Bruyette‘s and Dr. Jennifer Garcia’s blog on TSH as a marker for feline hyperthyroidism, page 20. Barret Bulmer, DVM, MS, DACVIM (cardiology) Department of Clinical Sciences Cummings School of Veterinary Medicine Tufts University North Grafton, Massachusetts Pra c t it ioner Advisor y B o ard Progressive practitioners who keep our content practical, timely, and relevant Mili Bass, DVM, DABVP Bass Vet Consulting/ Animal Acupuncture & Pain Management Farragut, Tennessee Jennifer McDermott, DVM Banfield, The Pet Hospital Overland Park, Kansas R. Wayne Randolph, VMD, DABVP Countryside Veterinary Hospital Flemington, New Jersey Robin Downing, DVM Windsor Veterinary Clinic PC Windsor, Colorado Melissa M. Mckendry, DVM, DABVP Pet Care Veterinary Hospital Virginia Beach, Virginia Michael H. Riegger, DVM, DABVP Northwest Animal Clinic, Hospital and Specialty Practice Albuquerque, New Mexico Corey Entriken, DVM Kansas City Veterinary Care Kansas City, Missouri Fred L. 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APRIL 25–29, 2012 KANSAS CITY, MO AUGUST 22–28, 2012 SAN DIEGO, CA DECEMBER 5–9, 2012 Phone: 800.255.6864, ext. 6 • [email protected] • thecvc.com • Fax: 913.871.3908 CVC, brought to you by the brands you trust for cutting-edge news and real-world content. VETERINARY MEDICINE Serving the veterinary profession since 1905 ® Mission Statement Veterinary Medicine is a peer-reviewed journal dedicated to providing concise, credible, and essential information on the most common and crucial clinical problems seen in companion-animal practice. Editorial We’d like to welcome two new Editorial Advisory Board members, Drs. Barret Bulmer and Walter Renberg. Editor Margaret Rampey, [email protected] Medical Director Theresa Entriken, DVM Senior Editor Mindy Valcarcel Medical Editor Heather Lewellen, DVM Managing Editor Brendan Howard Associate Editor Ashley Barforoush Technical Editor Jennifer Vossman, RVT Consulting Technical Editor Avi Blake, DVM Design Director Greg Kindred Senior Art Director Alison Fulton Art Directors Josh Fultz; Melissa Galitz; Ryan Kramer Multimedia Contributor Troy Van Horn And we wish to thank two members retiring from the board—Drs. Joseph Harari and Robert Prosek—for their valuable contributions over the years. Advanstar Communications Veterinary Group Executive Vice President Daniel M. 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Hewins Vice President, Human Resources Nancy Nugent Chief Information Officer J. Vaughn Editorial and Sales Office 8033 Flint, Lenexa, KS 66214; (800) 255-6864; (913) 871-3800; fax: (913) 273-9876; e-mail: [email protected] Article Reprints For article reprint packets, call (800) 290-5460, ext. 100; e-mail [email protected]; or visit www.industrymatter.com; international customers call (717) 505-9701, ext. 100. For bulk orders, call Sandy Sailes-Colbert at (800) 255-4569, or e-mail scolbert@advanstar. com. Subscriber Customer Service Visit dvm360.com to request or change a subscription or call our Customer Service Department toll free at (888) 527-7008 or at (218) 740-6395. Permissions/International Licensing Call Maureen Cannon at (440) 891-2742. List Account Executive Call Renée Schuster at (440) 891-2613. Printed in the U.S.A. dvm360.com VETERINARY MEDICINE January 2012 9 Editors’ Guest There isn’t much of a market for buggy whips Michael A. Paul, DVM A bout 100 years ago, veterinarians were playing a death knell for the profession as they knew it. Veterinary medicine’s foundation rested on equine practice, and internal combustion engine development signaled an end to horse-drawn vehicles. With no horses to care for, what would veterinarians do for a living? Fortunately for us, our predecessors reinvented the profession to focus on production and companion animals. But in the following years, several farming and production changes have all but eliminated the family farm as a viable industry. Swine, poultry, and beef and dairy cattle production have largely become the purview of consolidated farming and reduced the number of veterinarians in production medicine. Increasingly, these veterinarians have shifted their services from treating individual animals to providing herd health services and consultation. Those who have failed to adapt have struggled and become less relevant. During this time, companion-animal medicine prospered. The strengthening human-animal bond and change Michael A. Paul, DVM, is the former executive director of the Companion Animal Parasite Council and a former president of the American Animal Hospital Association. He is currently the principal of MAGPIE Veterinary Consulting. He is retired from practice and lives in Anguilla, British West Indies. Follow him at Twitter.com/magpievet. in the role of dogs and cats in society led to greater educational emphasis on companion-animal care. The understanding and treatment of diseases, Draft horses Monty and Prince make a delivery from the brewery—a once commonplace service. 10 January 2012 Veterinary MeDicine dvm360.com Photo courtesy of Dr. Paul increased development of vaccines, advances in parasite control, and advent of professional specialization have resulted in a healthier and better-cared-for pet population. today’s intErnal combustion EnGinE Veterinarians primarily provide diagnostic services, therapeutic care, pharmaceutical and nutritional products, and information. With the advent of alternative electronic sources for these services, veterinary medicine is again faced with our own version of the internal combustion engine—the Internet and a fragmented profession. In the past, that clients can eliminate their interactions with primary care veterinarians and go directly to specialists. morE obstaclEs in thE road takinG back thE rEins In addition, wellness services such as surgical sterilization and vaccination are readily available at animal shelters and mobile clinics. And with early spay and neuter and increased adoptions of older pets, surgical sterilization is frequently performed even before a pet is obtained. The result is that fewer dogs and cats are being sterilized in private practices. Parasite control products are widely available at retail markets and from Veterinarians can’t be beaten on relationships and communication. pet owners sought advice, information, care, and products primarily from their veterinarians. The veterinarian was a resource and a friend. Unfortunately, that relationship has been eroded in no small part because of the rising complexity and cost of veterinary care. With the universality of the Internet, pet owners can now obtain information about problems that once took them to their veterinarians for answers. From the Internet, pet owners learn that many minor illnesses will resolve without treatment, and many more can be managed with modest intervention such as antidiarrheals, antihistamines, and dietary control. The result is a lack of client-veterinarian interaction along with a demonstration that the pet seemingly didn’t need the veterinarian. In many cases, veterinarians see only significant problems, and those patients are then frequently referred to a specialist for care. This leads to a mistaken perception economy, but in many cases veterinary care has become a commodity, and even veterinary-client relationships are increasingly susceptible to the clouds of cost. Internet pharmacies—often at prices private veterinary practices have decided not to compete with. Furthermore, discount pharmacies and super stores are now providing veterinary prescription services at deep discounts compared with clinic pharmacies. Many states require that veterinary clients be given the option of having prescriptions filled at local pharmacies. After the AVMA, AAHA, and AAVMC commissioned the KPMG study “The Current and Future Market for Veterinarians and Veterinary Medical Services” in the United States just over 10 years ago, it was said that the demand for veterinary care was rather inelastic (rising prices for goods and services would not result in decreased demand for these services) and that price sensitivity was not a major force when pet owners selected a service provider. But recent surveys and studies have indicated that inelasticity has faded.1 Blame declining visits if you will on the How will the veterinary profession respond? We can’t keep selling buggy whips and compete on a commodity basis. We must reinvent, repurpose, and refocus on the things veterinarians can’t be beaten on—relationships and communication. While we all agree that new medical and surgical technology, diagnostic advances, and the achievement of successfully treating severely injured or ill animals are tremendously exciting, we must remember that the training and education we’ve put into those things is hugely disproportionate to the energy we put into advocating for veterinary healthcare compliance and communicating with each client every day. It is time for veterinarians to put those buggy whips away and focus on appropriately pricing medical services, competitively pricing products, and communicating the value—rather than the price—of veterinary care. ❖ REFERENCE 1. Bayer Veterinary care Usage Study: the decline of veterinary visits and how to reverse the trend. Bayer Healthcare, 2011. available at http://www.bayer-ah.com/nr/45/pdf. For more on how to communicate the value of veterinary medicine, see Dr. Paul’s article “Lead the way: 7 steps to boost acceptance of your medical recommendations” on page 36. dvm360.com Veterinary MeDicine January 2012 11 Leading Off Be aware of the new anesthesia guidelines for dogs and cats Richard Bednarski, MS, DVM, DACVA P rompted by the variety of anesthetic and analgesic drugs, patient monitoring equipment, and local and regional differences in anesthesia practice, the American Animal Hospital Association (AAHA) convened a task in January 2011 to develop anesthesia guidelines for dogs and cats. The guidelines were published in the November 2011 Journal of the American Animal Hospital Association (download a PDF at aahanet.org/ library/Anesthesia_Guidelines.aspx). As stated in the guidelines, “In recognition of differences among practices, these guidelines are not meant to establish a universal anesthetic plan or legal standard.” Rather, they are intended to provide a framework for the delivery of safe and effective anesthesia and perianesthetic pain management. analgesia, muscle relaxation, and amnesia—are best met by choosing drugs from several pharmacologic categories: sedatives and tranquilizers, hypnotics, opioids, inhalants, and local anesthetics can be used in combination. Analgesic adjuncts including local anesthetic nerve blocks, epidural analgesia, and analgesic infusions should be considered where appropriate. THE MONITORING PLAN for anesthesia and analgesia, and the animal’s temperament. Physical status is determined from a comprehensive preanesthetic physical examination and review of pertinent laboratory data. No one anesthetic plan is suitable for all dogs and cats. A good plan The most important aspect of safe anesthesia is patient monitoring. The American College of Veterinary Anesthesiologists (ACVA) developed a set of monitoring guidelines that emphasize its importance, which can be found at acva.org. A comprehensive monitoring plan includes determining at regular intervals adequate circulation, ventilation, oxygenation, and body temperature. A THE ANESTHETIC PLAN Today it is not sufficient to define “good” anesthesia simply as that which does not result in patient morbidity and mortality. Providing appropriate patient comfort, sedation, and analgesia and minimizing the stress response associated with surgery and anesthesia define modern anesthesia. The emphasis should be on developing a comprehensive anesthetic plan for each individual based on that patient’s physical status and signalment, the reason Dr. Richard Bednarski, Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, was the chair of the anesthesia guidelines task force. 12 Today it is not sufficient to define “good” anesthesia simply as that which does not result in patient morbidity and mortality. includes appropriate drug selection, the need for the amount and type of perioperative fluids, an approach to patient monitoring, and support of patient homeostasis. Currently, a multidrug approach is preferred for general anesthesia. The key components of general anesthesia—unconsciousness, January 2012 VeTerInary MeDIcIne dvm360.com trained observant and focused individual who understands the clinical pharmacology and the patient adaptation to anesthetic drugs should be present with the patient. This person must be able to determine normal vs. abnormal response to surgery and anesthesia. Untoward reaction to anesthetic Diane Diederich/Getty Images A AR S E PR E OT CT IT IO N P Powerful choices to fight parasites When it comes to parasites, Elanco has the innovative choices your clients are looking for. Comfortis, the #1 veterinarian-recommended prescription flea medication,1 provides month-long flea protection. Three-in-one Trifexis kills fleas, prevents heartworm disease and controls hookworm, roundworm and whipworm. Our effective, chewable parasite products offer you a choice to help protect your clients’ dogs inside and out, all year long. For more information, visit us online or call your Elanco or distributor representative today. elancovet.com • 888.545.5973 Important Safety Information Comfortis: The most common adverse reaction reported is vomiting. Other adverse reactions reported in decreasing order of frequency are: depression/ lethargy, decreased appetite, incoordination, diarrhea, itching, trembling, excessive salivation and seizures. Following concomitant extra-label use of ivermectin with Comfortis, some dogs have experienced the following clinical signs: trembling/twitching, salivation/drooling, seizures, ataxia, mydriasis, blindness and disorientation. Post-approval experience continues to support the safety of Comfortis when used concurrently with heartworm preventatives according to label directions. Trifexis: Serious adverse reactions have been reported following concomitant extra-label use of ivermectin with spinosad alone, one of the components of Trifexis chewable tablets. Treatment with fewer than three monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention. Prior to administration of Trifexis, dogs should be tested for existing heartworm infection. The most common adverse reactions recorded in clinical trials were vomiting, pruritus, lethargy and diarrhea. If vomiting occurs within an hour after administration, redose with another full dose. Puppies less than 14 weeks of age may experience a higher rate of vomiting. For product labels, including complete safety information, see page 14 1 Gfk Kynetec, 2010 Comfortis is recommended more than any other veterinary prescription flea control product. ©2012 Elanco CAH689 Leading Off TRIFEXIS™ (spinosad + milbemycin oxime) Chewable Tablets Before using TRIFEXIS chewable tablets, please consult the product insert, a summary of which follows: Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Indications: TRIFEXIS is indicated for the prevention of heartworm disease (¿ÈÅŰ·ȿ·¿ÃÿʿÉƻƔÁ¿ÂÂÉŲ»·É·Äº¿É¿Äº¿¹·Ê»º¼ÅÈʾ» ÆȻ̻ÄÊ¿ÅķĺÊÈ»·ÊûÄÊżŲ»·¿Ä¼»ÉÊ·Ê¿ÅÄÉƺÊ»ÄŹ»Æ¾·Â¿º»É ¼»Â¿É), and the treatment and control of adult hookworm (ĹÏÂÅÉÊÅ÷¹·Ä¿ÄËÃ), adult roundworm (ÅÎŹ·È·¹·Ä¿É and Åηɹ·È¿É»ÅÄ¿Ä·) and adult whipworm (È¿¹¾ËÈ¿ÉÌËÂÆ¿É) infections in dogs and puppies 8 weeks of age or older and 5 pounds of body weight or greater. Contraindications: There are no known contraindications to the use of TRIFEXIS Chewable Tablets. Warnings: Not for human use. Keep this and all drugs out of the reach of children. Serious adverse reactions have been reported following concomitant extra-label use of ivermectin with spinosad alone, one of the components of TRIFEXIS Chewable Tablets (see ADVERSE REACTIONS). Precautions: Treatment with fewer than 3 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention (see EFFECTIVENESS). Prior to administration of TRIFEXIS, dogs should be tested for existing heartworm infection. At the discretion of the veterinarian, infected dogs should be treated with an adulticide to remove adult ¾»·ÈÊÍÅÈÃÉƔ¿ÉÄÅÊ»Ů»¹Ê¿Ì»·½·¿ÄÉÊ·ºËÂÊƔ¿ÃÿʿÉ. ¾¿Â»Ê¾»ÄËø»Èż¹¿È¹Ë·ʿĽÿ¹ÈÅŰ·ȿ·»Ã·Ïº»¹È»·É» ¼ÅÂÂÅͿĽÊÈ»·ÊûÄÊƑ¿ÉÄÅʿĺ¿¹·Ê»º¼ÅÈÿ¹ÈÅŰ·ȿ·» clearance. Mild, transient hypersensitivity reactions manifested as labored respiration, vomiting, salivation and lethargy, have been noted in some dogs treated with milbemycin oxime carrying ·¾¿½¾ÄËø»Èż¹¿È¹Ë·ʿĽÿ¹ÈÅŰ·ȿ·»Ɣ¾»É»È»·¹Ê¿ÅÄÉ·È» presumably caused by release of protein from dead or dying ÿ¹ÈÅŰ·ȿ·»Ɣ Use with caution in breeding females. The safe use of TRIFEXIS in breeding males has not been evaluated. Use with caution in dogs with pre-existing epilepsy. Puppies less than 14 weeks of age may experience a higher rate of vomiting. Adverse Reactions: Ä·Í»ÂÂƖ¹ÅÄÊÈÅ»ºŰ»ÂºÉÊ˺ÏƑ;¿¹¾¿Ä¹Â˺»º·ÊÅÊ·Âż 352 dogs (176 treated with TRIFEXIS chewable tablets and 176 treated with an active control), no serious adverse reactions were attributed to administration of TRIFEXIS chewable tablets. All reactions were regarded as mild. Reactions that occurred at an incidence >2% (average monthly rate) within any of the 6 months of observation are presented in the following table: Average Monthly Rate (%) of Dogs With Adverse Reactions Adverse Reaction Vomiting Pruritus Lethargy Diarrhea TRIFEXIS Chewable Tabletsa 6.13 4.00 2.63 2.25 a Active Control Tabletsa 3.08 4.91 1.54 1.54 n=176 dogs Äʾ»Ű»ÂºÉÊ˺ÏƑÅÄ»ºÅ½·ºÃ¿Ä¿ÉʻȻº»Îƻȿ»Ä¹»º a single mild seizure 2½ hours after receiving the second monthly dose. The dog remained enrolled and received four additional monthly doses after the event and completed the study without further incident. Following concomitant extra-label use of ivermectin with spinosad alone, a component of TRIFEXIS, some dogs have experienced the following clinical signs: ÊȻø¿ĽƭÊͿʹ¾¿Ä½Ƒɷ¿̷ʿÅÄƭºÈÅÅ¿ĽƑ É»¿ÐËÈ»ÉƑ·Ê·Î¿·ƑÃϺȿ·É¿ÉƑ¸Â¿ÄºÄ»Éɷĺº¿ÉÅÈ¿»ÄÊ·Ê¿ÅÄ. Spinosad alone has been shown to be safe when administered concurrently with heartworm preventatives at label directions. ķĺËÈÅÆ»·ÄŰ»ÂºÉÊ˺¿»ÉƑÄźŽɻÎƻȿ»Ä¹»ºÉ»¿ÐËÈ»É when dosed with spinosad alone at the therapeutic dose range of 13.5-27.3 mg/lb (30-60 mg/kg), including 4 dogs with pre-existing epilepsy. Four epileptic dogs that received higher than the maximum recommended dose of 27.3 mg/lb (60 mg/kg) experienced at least one seizure within the week following the É»¹ÅĺºÅɻżÉÆ¿ÄÅÉ·ºƑ¸ËÊÄÅÉ»¿ÐËȻɼÅÂÂÅͿĽʾ»ŰÈÉʷĺ ʾ¿ÈººÅÉ»ÉƔ¾»¹·Ëɻżʾ»É»¿ÐËȻɟɻÈÌ»º¿Äʾ»Ű»ÂºÉÊ˺¿»É could not be determined. For technical assistance or to report an adverse drug reaction, call 1-888-545-5973. Additional information can be found at www.TRIFEXIS.com. Ů»¹Ê¿Ì»Ä»ÉÉƓ »·ÈÊÍÅÈÃȻ̻ÄÊ¿ÅÄƓ In a well-controlled laboratory study, TRIFEXIS was 100% »Ů»¹Ê¿Ì»·½·¿ÄÉʿĺ˹»º¾»·ÈÊÍÅÈÿļ»¹Ê¿ÅÄÉ;»Ä·ºÃ¿Ä¿ÉʻȻº for 3 consecutive monthly doses. Two consecutive monthly doses º¿ºÄÅÊÆÈÅÌ¿º»ʸʷʷ̈»Ů»¹Ê¿Ì»Ä»ÉÉ·½·¿ÄÉʾ»·ÈÊÍÅÈÿļ»¹Ê¿ÅÄƔ In another well-controlled laboratory study, a single dose of Í·Éʸʷʷ̈»Ů»¹Ê¿Ì»·½·¿ÄÉʿĺ˹»º¾»·ÈÊÍÅÈà ¿Ä¼»¹Ê¿ÅÄÉƔÄ·Í»ÂÂƖ¹ÅÄÊÈÅ»ºÉ¿ÎƖÃÅÄÊ¾Ű»ÂºÉÊ˺ϹÅĺ˹ʻº with TRIFEXIS, no dogs were positive for heartworm infection as determined by heartworm antigen testing performed at the end of the study and again three months later. »·È»·ÊûÄʷĺȻ̻ÄÊ¿ÅÄƓ In a well-controlled laboratory study, TRIFEXIS demonstrated ʸʷʷ̈»Ů»¹Ê¿Ì»Ä»ÉÉÅÄʾ»ŰÈÉʺ·Ï¼ÅÂÂÅͿĽÊÈ»·ÊûÄʷĺ ʸʷʷ̈»Ů»¹Ê¿Ì»Ä»ÉÉÅÄ·ÏʺʷƔÄ·Í»ÂÂƖ¹ÅÄÊÈÅ»ºÂ·¸ÅÈ·ÊÅÈÏ ÉÊ˺ÏƑÉÆ¿ÄÅÉ·ºƑ·¹ÅÃÆÅÄ»ÄÊżƑ¸»½·ÄÊÅÁ¿ÂÂŲ»·É 30 minutes after administration and demonstrated 100% »Ů»¹Ê¿Ì»Ä»ÉÉͿʾ¿Äʻ¾ÅËÈÉƔÄŰ»ÂºÉÊ˺¿»É¹Åĺ˹ʻº¿Ä ¾ÅËÉ»¾ÅºÉͿʾ»Î¿ÉʿĽŲ»·¿Ä¼»ÉÊ·Ê¿ÅÄÉż̷ÈϿĽɻ̻ȿÊÏƑŲ»· reductions of 98.0% to 99.8% were observed over the course of ʺÃÅÄʾÂÏÊÈ»·ÊûÄÊÉͿʾÉÆ¿ÄÅÉ·º·ÂÅÄ»ƔŽÉͿʾɿ½ÄÉżŲ»· allergy dermatitis showed improvement in erythema, papules, scaling, alopecia, dermatitis/pyodermatitis and pruritus as a direct È»ÉËÂÊż»Â¿Ã¿Ä·Ê¿Ä½Ê¾»Ų»·ÉƔ È»·ÊûÄʷĺÅÄÊÈÅÂżÄÊ»Éʿķ»÷Êź»Ä¼»¹Ê¿ÅÄÉƓ ÄÍ»ÂÂƖ¹ÅÄÊÈÅ»ºÂ·¸ÅÈ·ÊÅÈÏÉÊ˺¿»ÉƑÍ·É̟ˀʷ̈ »Ů»¹Ê¿Ì»¿ÄÈ»ÃÅ̿ĽķÊËÈ·ÂÂϷĺ»ÎƻȿûÄÊ·ÂÂϿĺ˹»º·ºËÂÊ roundworm, whipworm and hookworm infections. NADA #141-321, Approved by the FDA Manufactured for Elanco Animal Health A Division of Eli Lilly & Co. Lilly Corporate Center, Indianapolis, IN 46285 Trifexis™ is a trademark of Eli Lilly and Company PA9945DEAMX (V01-12-2010) drugs, blood loss, cardiac rhythm disturbances, inappropriate anesthetic depth, and inadequate analgesia need to be recognized early because recognition and rapid intervention are the keys to preventing irreversible changes. Regular palpation of a peripheral pulse, observation of mucous membrane color, and observation of patient ventilation are the minimum monitoring requirements. Consideration should be given to obtaining and learning how to use modern anesthetic monitoring devices. These devices greatly enhance the ability to discern the unexpected. Modern anesthetic monitors can be configured for capnometry, electrocardiography, blood pressure, pulse oximetry, and body temperature to optimize the monitoring of cardiovascular and respiratory function. Monitoring should continue well into the recovery period at regular intervals until the patient is awake, warm, and comfortable. CONTINUING YOUR EDUCATION The measures outlined in the AAHA Anesthesia Guidelines for Dogs and Cats are a good step toward safe anesthetic procedures in all pets. For further guidance, numerous continuing education opportunities in anesthesia are available at local, regional, and national meetings. Anytime a question arises regarding any aspect of anesthesia, you should contact an ACVA diplomate. Contact the anesthesiologist at your alma mater, or refer to acva.org for a list of ACVA consultants. ❖ 14 January 2012 VeTerInary MeDIcIne Letters Questioning the great outdoors Thank you for publishing the article titled “Treat or euthanize? Helping owners make critical decisions regarding pets with behavior problems” (November 2011). It is heartening to hear a dialogue about this difficult issue. However, I take exception to publishing the suggestion that we encourage clients to make cats outdoor pets in lieu of euthanasia (“When housesoiling is the problem” by Dr. Gary Norsworthy in “Advising clients on treating or euthanizing pets with behavior problems,” p. 571). My objections to this suggestion are threefold. First, domestic cats have a devastating effect on the environment when allowed to roam free. They can decimate songbird populations and attract wildlife into urban areas. Second, they are a significant nuisance to neighbors (imagine my chagrin when I find the feces of my neighbor’s outdoor cat in the planter bed where I grow food). Most important, we must consider the hazards to the cat. The world is a harsh place where outdoor cats can encounter untold suffering and stress, especially one that has lived its life inside. As a veterinarian and animal lover, I would rather counsel a guardian on euthanasia than suggest subjecting a pet to the vagaries of the great outdoors (and vice versa). Melissa Simpson DVM Marshfield, Wisconsin Dr. Norsworthy replies: Thank you for reading the article regarding euthanasia and behavior problems in cats. Although I listed banning the cat to the outdoors, I certainly do not advocate such. I agree completely with your objections to this practice and do not consider it a viable alternative. However, the reality is that clients have and will do that for this situation. Thus, to make the discussion complete I listed it as an option that has been exercised. Gary D. Norsworthy, DVM, DABVP Alamo Feline Health Center San Antonio, Texas ❖ For more expert opinions, watch the Specialist in the Spotlight video “Does allowing cats outdoors help treat inappropriate elimination?” at dvm360 .com/OutdoorElimination. Not All Kittens are Born Cuddly. Feral kitten socialization information availible at alleycat.org/kittens. Do you have something to say? E-mail your questions, comments, and suggestions to [email protected]; write us at Veterinary Medicine, 8033 Flint, Lenexa, KS 66214; or fax us at (913) 273-9876. W W W. A L L E Y C AT. O R G dvm360.com VETERINARY MEDICINE January 2012 15 Education Advocacy Action Just Ask the Expert When clients decline immunotherapy for atopy What is your treatment of choice for atopy if clients won’t perform allergy testing to identify an immunotherapy formulation? A. Serologic or intradermal testing is indicated when a client is interested in immunotherapy to manage atopic dermatitis and is performed to determine which allergens should be incorporated into the immunotherapy formulation. One could argue that allergy testing is indicated for avoidance, but this is difficult in many cases. However, management for environmental allergies does not always need to involve immunotherapy. In fact, for many cases, it may not be the best option. Management of atopic dermatitis often involves a multimodal approach. clients are better served by performing an elimination diet trial with a novel protein or hydrolyzed diet. CYCLOSPORINE Cyclosporine is an excellent option for managing atopic dermatitis with or without immunotherapy. However, when allergy testing is not elected by the owner because of reluctance to followup with the required hyposensitization injections, cyclosporine is the treatment of choice. Atopica (Novartis Animal Health) is the first oral nonsteroidal treatment approved for treating canine atopic Management for environmental allergies does not always need to involve immunotherapy. Ian B. Spiegel, VMD, MHS, DACVD Veterinary Specialty and Emergency Center (VSEC) 24 hr Emergency and Referral Hospital 301 Veterans Hwy, Levittown, PA 19056 Animerge 24/7 Animal Emergency and Specialty Care 21 U.S. Hwy. 206 Raritan, NJ 08869 Jersey Shore Veterinary Emergency Service (JSVES) Dermatology and Allergy Service 1000 Route 70 East Lakewood, NJ 08701 It is imperative that infections and parasites be well-controlled and treated before treatment with cyclosporine. Also, using the correct dose (5 mg/kg/day for dogs and 7 mg/kg/day for cats given orally) is important. Ideally, the modified formulation (e.g. Atopica) is a better choice, as the bioavailability is better understood, and less medication is used to achieve the desired effect. ANTIHISTAMINES Treating secondary bacterial and yeast (Malassezia species) infections is the key to successful management. Preventing flea infestations and ruling out sarcoptic mange, demodicosis, and cheyletiellosis are also necessary. Addressing a potential cutaneous adverse food reaction is important as well, since a patient may be food allergic as well as environmentally allergic. Tests for food allergies are available too. However, in my experience, 16 dermatitis and, just recently, feline allergic dermatitis. Atopica is a fat-soluble, cyclic polypeptide fungal metabolite with immunomodulating activity and is a calcineurin inhibitor. Cyclosporine targets specific cells (T cells) in the immune system that lead to an allergic reaction. This is well-tolerated and highly effective when used properly. This medication lacks major adverse effects often associated with corticosteroids. January 2012 Veterinary Medicine dvm360.com Antihistamines may be considered, and you have several options. Some of the older-generation antihistamines such as hydroxyzine and diphenhydramine are sedating, which may prove beneficial. Other newer-generation options such as cetirizine, loratadine, and fexofenadine may be indicated. Sometimes I recommend a nonsedating antihistamine in the morning and a sedating antihistamine in the evening. While in my experience antihistamines are about 10% to 30% effective, they are still often indicated as an adjunctive treatment. ESSENTIAL FATTY ACIDS Essential fatty acids supplemented daily can be helpful as well. Omega-3 essential fatty acids such as eicosapentaenoic acid and docosahexaenoic acid, as well as the omega-6 essential fatty acid dihomo-gamma-linolenic acid, can decrease skin inflammation via competition with arachidonic acid for metabolic enzymes. Essential fatty acids can also modulate leukotriene and prostaglandin synthesis. Eicosanoids are anti-inflammatory. The goal is a decrease in the highly inflammatory (arachidonic acid-derived) eicosanoids (inflammatory mediators) and, thus, an increase in the less inflammatory mediators. Also, essential fatty acids help restore normal composition of lipids to skin (barrier function) and modulate lymphocyte functions. CORTICOSTEROIDS Corticosteroids are usually indicated at some point during the management of allergies. Ideally, corticosteroids are used only when necessary and as infrequently as possible. Oral administration is, in my opinion, a better option. It allows for methodical dosage adjustments. Longacting injection options are less ideal, in my opinion. I usually use oral prednisolone, methylprednisolone, dexamethasone, or triamcinolone. Trimeprazine with prednisolone (Temaril-P—Pfizer Animal Health) is also an option. cell tumors in dogs, have been considered as an option for managing allergies in dogs. Treatment with tyrosine kinase inhibitors is in the early stages, and more time will be necessary to determine how effective and safe these medications are in allergic patients. CONCLUSION TOPICAL THERAPY In addition to the aforementioned oral medication options and injectable immunotherapy, topical treatments are helpful. Some topical antimicrobials target the secondary infections. More recently, products are available that help maintain better barrier function (e.g. Allerderm Spot-On Skin Lipid Complex—Virbac Animal Health; DOUXO—Sogeval), which is often compromised in allergic patients. There are also numerous topical anti-inflammatory and antipruritic options (e.g. corticosteroid sprays or analgesic sprays containing pramoxine). Topical treatments often compliment the other options mentioned above. In some cases, topical treatments are all that is indicated. TYROSINE KINASE INHIBITORS More recently, tyrosine kinase inhibitors such as masitinib (Kinavet-CA1—AB Science), which are used to treat mast Many management options are available for atopic patients that are not receiving allergen-specific immunotherapy. Every patient is different, and every client situation is unique. This is where the art of managing the allergic patient, and trying different options, comes into play. And new options for treating atopic dermatitis are on the horizon. Researchers are currently investigating oral immunotherapy (sublingual) as well as regionally specific immunotherapy (formulating immunotherapy based on the most common allergens in a specific region rather than based on allergy test results). ❖ SUGGESTED READING numerous other options are beyond the scope of this overview, but i strongly recommend reading Olivry t, deBoer dJ, Favrot c, et al. treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the international task Force on canine atopic dermatitis. Vet Dermatol 2010;21(3):233-248. Have a question for one of our experts? Submit it at dvm360.com/MyQuestion. And find out the answers to more questions at dvm360.com/JustAsk, including: • How do you manage canine chin acne? • What frequency of immunotherapy works for your patients? • How should I treat a dog that is allergic to only house dust mites? dvm360.com Veterinary Medicine January 2012 17 Toxicology Brief managing common poisonings in companion animals ❖ PeeR-ReVIeweD Phenylpropanolamine toxicosis in dogs and cats Judy K. Holding, DVM, RN P henylpropanolamine (PPA) is a sympathomimetic drug used in dogs and cats primarily to treat urinary incontinence secondary to urethral sphincter hypotonia. It is labeled for use in dogs and is available as a solution in 25- and 50-mg/ml concentrations (Proin Drops—PRN Pharmacal); in chewable 25-, 50-, and 75-mg tablets (Proin—PRN Pharmacal, Propalin— Vétoquinol, Uricon—Neogen Corporation, Uriflex-PT—Butler Schein Animal Health); and as a 75-mg timed-release prescription use in the United States in 2000 because of data that suggested PPA increases the risk of hemorrhagic stroke in people.2 It has since also been removed from the market in Canada. PHARMACOKINETICS AND MECHANISM OF ACTION PPA is readily absorbed orally, with an oral bioavailability of approximately 98% in dogs.3 In people, the onset of action is The most common clinical finding of PPA toxicosis is hypertension secondary to peripheral vasoconstriction. capsule (Cystolamine—Veterinary Product Laboratories).1 PPA is classified as a list 1 chemical (can be used to manufacture methamphetamine) in the United States. Restrictions regarding its sale may vary among states, and in some states it may be a controlled substance.1 Historically in people, PPA was used as a decongestant and anorectic. It was removed from both over-the-counter and “Toxicology Brief” was contributed by Dr. Judy K. Holding, ASPCA Animal Poison Control Center, 1717 S. Philo Road, Suite 36, Urbana IL 61802. The department editor is Petra Volmer, DVM, MS, DABVT, DABT. 18 rapid, occurring within 15 to 30 minutes. It is widely distributed into multiple tissues and fluids, including the central nervous system (CNS). Approximately 80% to 90% of the drug is excreted unchanged in the urine within 24 hours of dosing.1 The serum half-life in dogs is approximately three to four hours.3 Clinical effects may persist well beyond what is expected based on the half-life.4 The recommended dosage for the immediate-release forms in dogs is 1 to 2 mg/kg given orally b.i.d.5 The dose using the time-release 75-mg capsules is one-half capsule given orally once a day for dogs weighing < 40 lb (18.2 kg), 1 capsule given orally once a day for dogs January 2012 VeTerInAry MedIcIne dvm360.com weighing 40 to 100 lb (18.2 to 45.5 kg), and 1.5 capsules given orally once a day for dogs weighing >100 lb (45.5 kg).6 The exact mechanism of PPA’s action has not been determined. It is thought that it directly stimulates alphaadrenergic receptors and indirectly stimulates both alpha-adrenergic and beta-adrenergic receptors by causing the release of norepinephrine.1 It acts primarily on peripheral alpha receptors, with a weak effect on beta receptors.7 Other pharmacologic effects of PPA include vasoconstriction, mild CNS stimulation, decreased nasal congestion, and decreased appetite. It also increases urethral sphincter tone.1 TOXICITY Adverse effects can potentially be seen at therapeutic doses and include restlessness, urine retention, anorexia, tachycardia, and hypertension. Stroke-like clinical signs have been reported rarely in dogs at therapeutic doses of PPA.1 The most common clinical finding of PPA toxicosis is hypertension secondary to peripheral vasoconstriction. A reflex bradycardia can be seen.4 Other clinical manifestations of toxicosis may include piloerection, vomiting, tachypnea, anxiety or agitation, hyperthermia, tachycardia, tremors, and potential seizures.1 In one case report, a 5-year-old dog Getty Images DECONTAMINATION developed tachypnea, tachycardia, and ataxia after ingesting about 48 mg/kg of PPA.8 Diagnostic test results (electrocardiography, echocardiography, creatine kinase activity, and cardiac troponin concentration) revealed areas of focal myocardial necrosis and multiform ventricular tachycardia consistent with myocardial damage from infarction or direct catecholamine-induced myocardial toxicity. During hospitalization, the dog developed ventricular tachycardia that was successfully treated with lidocaine. Enalapril and atenolol were also administered and continued after discharge. The owners were instructed on discharge to restrict the dog’s activity. All abnormalities resolved within six months.8 Because of the rapid onset of action, emesis, using 3% hydrogen peroxide (2 ml/kg orally with a maximum of 50 ml) or apomorphine (0.03 mg/kg intravenously; or, in the conjunctival sac, 0.25 mg/kg after dissolving the tablet in saline solution), may be attempted within the first 10 to 15 minutes of exposure in animals not exhibiting clinical signs.1 After, or in lieu of, emesis, activated charcoal (1 to 2 g/kg orally) with a cathartic such as sorbitol may be given.9 The decision to give charcoal should be based on the dose of PPA ingested, weighing the benefit of activated charcoal with the potential risks for aspiration and the development of hypernatremia. ASPCA APCC DATA MONITORING AND TREATMENT From 2003 to 2011, the ASPCA Animal Poison Control Center (APCC) database contains 823 cases of PPA exposures; 97% of the cases involved dogs, 3% cats, and < 1% birds.4 Only single-exposure cases were included. One cat receiving 2.8 mg/kg of PPA developed no signs.4 Another cat that ingested 9.1 mg/kg presented with vomiting and mild hypertension, and a third cat that ingested 13.8 mg/kg developed moderate hypertension and tachypnea.4 In dogs, doses of 2.8 and 6.8 mg/kg resulted in mild hypertension and bradycardia.4 Ingestion of > 15 mg/kg often resulted in significant cardiovascular signs.4 At 16.6 mg/kg, a dog developed agitation, moderate hypertension, and ventricular tachycardia.4 Ingestion of a similar dose at 16.7 mg/kg resulted in severe hypertension that responded to administration of acepromazine.4 After ingestion of 43 mg/kg, one dog developed anxiety, severe hypertension, and bradycardia.4 Both acepromazine and nitroprusside were administered to control the hypertension. Final outcomes were not obtained in these cases. Observe for CNS signs such as agitation or restlessness. Heart rate and rhythm, blood pressure, and body temperature should be monitored carefully. If marked hyperthermia is present, monitor for the development of disseminated intravascular coagulation. When hyperthermia is marked, cooling techniques should be instituted. If ventricular arrhythmias are detected, an echocardiographic examination should be considered. Nitroprusside can be used to treat hypertension (1 to 2 µg/kg/min; increase the dose incrementally every three to five minutes, if necessary, until desirable blood pressure is achieved).1 If nitroprusside is unavailable, a low dosage of acepromazine may be given (0.02 mg/kg intravenously) and increased in small amounts to the desired effect.10 Phenothiazines are also effective for the anxiety or agitation that can be seen. Bradycardia is usually a reflex mechanism that does not require specific intervention and is expected to resolve with correction of hypertension. If marked supraventricular tachycardia is present, a beta-1-specific beta-blocker can be used, such as esmolol at 0.2 to 0.5 mg/kg given intravenously over one to two minutes or 25 to 200 µg/kg/min as a constant-rate infusion.1 Propranolol, a nonspecific beta-blocker, should be avoided since blockade of beta-2 receptors may worsen any hypertension that is present. Ventricular arrhythmias may be treated with lidocaine or other appropriate antiarrhythmics. Intravenous fluids should be administered to maintain hydration, provide venous access, and promote adequate renal function. Fluids should be administered judiciously when hypertension is present. Other supportive measures should be instituted as needed. Depending on the dose, clinical signs may persist up to 48 hours. Ideally, patients should be monitored in the hospital until they are not exhibiting any clinical abnormalities and are not receiving any medications for CNS or cardiovascular signs for six to eight hours. If a patient has experienced marked ventricular arrhythmias, follow-up echocardiographic and electrocardiographic examinations may be indicated. With appropriate symptomatic treatment, a full recovery is expected. ❖ REFERENCES 1. Plumb dc. Plumb’s veterinary drug handbook. 6th ed. Ames, Iowa: Blackwell Publishing, 2008;68,359,660,726-727. 2. FdA Talk Paper: FdA issues public health warning on phenylpropanolamine; nov. 6, 2000. Available at http:// www.fda.gov/drugs/drugSafety/Informationbydrugclass/ ucm150763.htm/ 3. Hussain M, Aungst B, Lam G, et al. Phenylpropanolamine pharmacokinetics in dogs after intravenous, oral, and oral controlled-released doses. Biopharm Drug Dispos 1987;8(5):497-505. 4. AnTox database. Urbana, Ill: ASPcA Animal Poison control center, 2003-2011. 5. Prn Pharmacal: Proin product label. Pensacola, Fla. 6. Veterinary Product Laboratories: cystolamine product label. Phoenix, Ariz. 7. Phenylpropanolamine. In: POISIndeX System [intranet database]. Version 5.1. Greenwood Village, colo: Thomson reuters (Healthcare) Inc. 8. crandell JM, Ware WA. cardiac toxicity from phenylpropanolamine overdose in a dog. J Am Anim Hosp Assoc 2005;41(6):413-420. 9. Poppenga r. Treatment. In: Plumlee KH, ed. Clinical veterinary toxicology. Mosby, St. Louis, Mo: Mosby, 2004;15. 10. Tranquilli WJ. college of Veterinary Medicine, University of Illinois, champaign, Ill: Personal communication with dr. Judy Holding, 2003. dvm360.com VeTerInAry MedIcIne January 2012 19 dvm360 Community Blog TSH as a marker for the development of hyperthyroidism in geriatric cats Veterinary Diagnostic Investigation and Consultation S ubnormal concentrations of thyroid stimulating hormone (TSH) along with an elevation in free thyroxine concentration is the primary method of diagnosing hyperthyroidism in people. The role of TSH in the diagnosis of cats with this disease, however, is still an area of active research in veterinary medicine. Previous studies have demonstrated that cats with a low TSH concentration may indeed have a form of subclinical hyperthyroidism that can ultimately become overt disease. Researchers at the Royal Veterinary College in London A single TSH concentration below 0.03 ng/ml is a strong predictor for the development of hyperthyroidism. 20 January 2012 VeTerInary MedIcIne dvm360.com conducted a prospective, cohort study evaluating whether low TSH concentrations in a population of geriatric cats would eventually lead to a diagnosis of hyperthyroidism and what, if any, clinical signs developed. Results of this study were published in a recent issue of the Journal of Veterinary Internal Medicine. The population consisted of cats over 9 years of age that were presented for routine evaluation and with no apparent clinical problems or history of chronic illness or medications. Cats were excluded if a diagnosis of hyperthyroidism was made at the time of the initial visit or within 3 months of enrollment. The diagnosis of hyperthyroidism was based on a serum total T4 > 55 nmol/L (range 19-55 nmol/L), a serum total T4 > 40 nmol/L and free T4 > 40 pmol/L (range 19-40 pmol/L) in a cat with concurrent illness and supportive signs of hyperthyroidism, or by T3 suppression test. A complete physical examination, systolic blood pressure measurement (by Doppler), thyroid/TSH concentrations, PCV, urinalysis, and baseline serum Veterinary Diagnostic Investigation and Consultation (VDIC)— David S. Bruyette, DVM, DACVIM, and Jennifer L. Garcia, DVM, DACVIM—has over 40 years of experience in internal medicine and endocrinology. Todd Gipstein/Getty Images ,(:6;0* Otic suspension (hydrocortisone aceponate, miconazole nitrate, gentamicin sulfate) Anti-inflammatory, antifungal, and antibacterial For Otic Use in Dogs Only *(<;065 Federal law restricts this drug to use by or on the order of a licensed veterinarian. )90,- :<44(9@! Please consult package insert for complete product information. 05+0*(;065: EASOTIC® suspension is indicated for the treatment of otitis externa in dogs associated with susceptible strains of yeast (Malassezia pachydermatis) and bacteria (Staphylococcus pseudintermedius). *65;9(05+0*(;065: Do not use in dogs with known tympanic membrane perforation. EASOTIC® suspension is contraindicated in dogs with known or suspected hypersensitivity to corticosteroids, imidazole antifungals, or aminoglycoside antibiotics. >(9505.: Human Warnings: Not for use in humans. Keep this and all drugs out of reach of children. Humans with known or suspected hypersensitivity to hydrocortisone, aminoglycoside antibiotics, or azole antifungals should not handle this product. Animal Warnings: As a class, aminoglycoside antibiotics are associated with ototoxicity, vestibular dysfunction and renal toxicity. The use of EASOTIC® suspension in a dog with a damaged tympanic membrane can result in damage to the structures of the ear associated with hearing and balance or in transmission of the infection to the middle or inner ear. Immediately discontinue use of EASOTIC® suspension if hearing loss or signs of vestibular dysfunction are observed during treatment (see ADVERSE REACTIONS). 79,*(<;065: Do not administer orally. Concurrent administration of potentially ototoxic drugs should be avoided. Use with caution in dogs with impaired hepatic or renal function (see ANIMAL SAFETY). Long-term use of topical otic corticosteroids has been associated with adrenocortical suppression and iatrogenic hyperadrenocorticism in dogs (see ANIMAL SAFETY). The safe use of EASOTIC® suspension in dogs used for breeding purposes, during pregnancy, or in lactating bitches, has not been evaluated. ADVERSE REACTIONS In a field study conducted in the United States, there were no adverse reactions reported in 145 dogs administered EASOTIC® suspension. In foreign market experience, reports of hearing loss and application site erythema have been received. In most reported cases, the hearing loss and erythema were transient and resolved with discontinuation of EASOTIC® suspension. To report suspected adverse drug events, or for technical assistance contact Virbac at 800-338-3659 . (504(3:(-,;@ Aural administration of EASOTIC® suspension to 12 week old Beagle dogs at 1, 3, and 5 times the recommended dose (1 mL/ear/day) for 15 days (three times the treatment length) was associated with alterations of the hypothalamic-pituitary-adrenal axis as evidenced by the ACTH stimulation results. Other findings considered to be related to treatment include the development of aural hyperemia; the presence of renal tubular crystals and possibly renal tubular basophilia and atrophy; elevated liver weights; the development of otitis externa and media; and elevations in alanine aminotransferase, alkaline phosphatase, total protein, albumin, and cholesterol levels. :;69(.,05-694(;065! Store at temperatures between 20º C-25º C (68º F-77º F), with excursions permitted between 15º C-30º C (59º F-86º F). /6> :<7730,+! EASOTIC® suspension is supplied in a polyethylene canister, with a soft applicator canula. Distributed by: Virbac AH, Inc. Fort Worth, TX 76137 USA NADA 141-330, Approved by FDA. dvm360 Community Blog chemistry testing were obtained at the initial visit. Cats with no underlying health problems at the initial visit were re-evaluated every 6 months. Those with evidence of azotemia, urinary tract infections, or hypertension were monitored as clinically necessary. All cats were followed for a minimum of 2.5 years and up to 4.5 years. A total of 104 cats were enrolled. Thyroid status, TSH concentrations, and baseline variables were reevaluated between 9 and 14 months of enrollment (short-term follow-up endpoint)and again between 2.5 to 4.5 years post-enrollment (long-term follow-up endpoint). Age, breed, sex, history of weight loss, vomiting, diarrhea, polyphagia, polydipsia, skin disease, behavioral changes, presence of a goiter, blood pressure, heart rate, and presence of a murmur were evaluated for a possible association with the development of hyperthyroidism. At the time of the short-term follow-up, 85 cats remained in the study and, of these, 11 were diagnosed with hyperthyroidism. While baseline free T4 concentrations were similar between the hyperthyroid and nonhyperthyroid groups, the baseline TSH concentrations were significantly lower (<0.03 ng/ml) for those in the hyperthyroid group. Cats in this group were also more likely to have a goiter, a heart murmur, a history of vomiting, and a higher alkaline phosphatase; however, only a subnormal TSH concentration was determined to be predictive of the development of hyperthyroidism within 14 months. Of the cats with a subnormal TSH concentration at enrollment, 40% went on the develop hyperthyroidism. Only 1 cat with a detectable TSH concentration at the time of enrollment was diagnosed with hyperthyroidism at the short-term follow-up visit. Internal medicine insight Visit dvm360.com/VDIC to read more blogs by Veterinary Diagnostic Investigation and Consultation (VDIC). Long-term follow-up evaluation took place between 2.5 and 4.5 years following enrollment. An additional 6 cats were diagnosed with hyperthyroidism during this phase of the study for a total of 17 hyperthyroid cats. All of these cats also developed signs associated with hyperthyroidism (weight loss, tachycardia, vomiting, diarrhea, polyphagia). Thirteen of the 17 cats had undetectable TSH concentrations (< 0.03 ng/ml) at the baseline visit. For the 4 with detectable TSH concentrations at enrollment, all went on to demonstrate a decline in their TSH to < 0.03 ng/ml within 12 months with a subsequent diagnosis of hyperthyroidism within 6 to 28 months. One of the limitations of using TSH concentrations in the evaluation of thyroid status in cats is the insensitivity of the assay at very low TSH concentrations. Almost one-third of recruited cats had a TSH concentration < 0.03 ng/ml at baseline and yet only 13 of 25 were diagnosed with hyperthyroidism during the study period. While development of a more sensitive assay will help determine the prognostic value of a single TSH concentration, results of this study still demonstrate that a single TSH concentration below 0.03 ng/ml is a strong predictor for the development of hyperthyroidism. Furthermore, results suggest that a TSH concentration above 0.03 ng/ml may serve as a marker to rule out hyperthyroidism in a geriatric cat. ❖ Wakeling J, elliott J, Syme H. evaluation of predictors for the diagnosis of hyperthyroidism in cats. J Vet Intern Med 2011;25(5):1057-1065. © 2011 Virbac AH, Inc. All Rights Reserved. Rev 8/2011 22 January 2012 VeTerInary MedIcIne dvm360.com Healing Touch Download the new dvm360 app for iPad — FREE! Introducing for iPad Improve patient care with rich, interactive media at your fingertips Obtain industry news and best practice updates Learn from integrated audio bites and interviews while surfing each issue Test your knowledge with interactive quizzes Flip through engaging photo galleries Explore dynamic charts, tools, and references www.dvm360.com/iPadApp Idea Exchange tips from the trenches Create your own warming waterbeds Keep spare glasses on hand for hurried pet owners Many of our surgery patients are dropped off first thing in the morning as their owners are rushing to work. We found that many of our clients were having difficulty reading the consent forms because they forgot their reading glasses. We now keep several pairs at the reception desk for clients to borrow. Dr. Jennifer Walters Columbia, Md. 24 We warm up our cold patients in a cozy waterbed that we create with a litter box (big or small, depending on the size of the patient) and a heavy-duty trash bag. We place the litter box into the bag, add about 2 in of warm water to the litter box, and tie a knot in the trash bag. Then we lay a thin blanket, such as a receiving blanket, over the trash bag. This bed is great for young puppies and kittens as well as small patients recovering from anesthesia. Cheryl Camou, veterinary assistant South Pasadena, Calif. A less painful way to remove torn nails To decrease the discomfort of removing a torn nail, we place a drop of ophthalmic proparacaine on the torn nail five minutes before removal. Dr. Keena Van Horn Port Orchard, Wash. Send us your great idea, and we’ll send you $50! E-mail us at [email protected], send a fax to (913) 273-9876, or write to Idea Exchange Editor at 8033 Flint, Lenexa, KS 66214. January 2012 Veterinary Medicine dvm360.com We want to hear your ideas! We know you love to read Veterinary Medicine’s “Idea Exchange.” And we’ll bet your practice has developed many clinical and management tips or useful forms to help you save time and better serve your patients and clients. This is your chance to share your practice tips with your colleagues and make a little money on the side! Please take a moment E-mail: [email protected] Mail: Idea Exchange Editor 8033 Flint, Lenexa, KS 66214 Fax: (913) 273-9876 to jot down your idea and send it to us. We pay $50 for every idea we publish. This is my practice tip for “Idea Exchange” (explain each tip in a few words, and feel free to include a sketch, a photo, or your favorite form if appropriate): NaME POSITION (e.g. DVM, LVT, CVT, RVT, veterinary assistant, practice manager) addrESS □ Practice □ Home CITy PhONE STaTE/ZIP Fax E-MaIl dvm360.com Veterinary Medicine January 2012 25 Image Quiz scan the photos, spot the answers Enry Garcia, DVM, MS Quiz 1 The case of the crying rat T his 2-year-old female intact pet rat has an acute history of ocular discomfort in its right eye. It has suddenly started to show signs of blepharospasm and excessive lacrimation. The rat keeps its eye closed most of the day and is starting to rub the eye more often. 26 January 2012 Veterinary Medicine dvm360.com What’s your diagnosis? a) Distichiasis b) Complete hyphema c) Central corneal dystrophy causing an ulcer d) Trauma causing a corneal ulcer and hyphema Quiz 2 T A panting Great Dane with red eyes his 8-year-old male Great Dane was presented for evaluation of worsening episodes of respiratory discomfort and panting. When the dog was hospitalized, increased redness was noted in both eyes. In what location is the most important lesion shown in the left eye? a) Eyelids (diamond eye) b) Third eyelid (chemosis and hyperemia) c) Anterior segment (large pigmented spot on dorsomedial iris) d) Posterior segment (mass in the vitreous) See the answers on page 28 dvm360.com Veterinary Medicine January 2012 27 Image Quiz AnsWers Quiz 1: The correct answer is a) Distichiasis. This pet rat has several distichia lining the right lower eyelid margin (arrows) and rubbing against the cornea. Distichia are abnormal eyelashes that, just like normal eyelashes, grow out of the meibomian gland ducts. However, they are smaller and often grow backward, rubbing against the cornea. In dogs, distichia are not always pathologic, but, as in this case, they can cause a lot of discomfort. No ulcer was present in this case yet, thanks to the prompt referral. The treatment for distichia is the same across species and can vary according to the location and number of abnormal eyelashes—the most common being cryoepilation. The white spot in the center of the cornea is a flash artifact. This case highlights the importance of a systematic ocular examination regardless of the species in question. Quizzes contributed by Enry Garcia, DVM, MS, Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colo. 28 January 2012 Veterinary Medicine dvm360.com Quiz 2: The correct answer is d) Posterior segment (mass in the vitreous). This dog does have all the listed signs. The diamond eye is an eyelid problem often seen in large-breed dogs. It is related to the exceeding laxity of the eyelid skin in which the upper eyelid has a shape of an upside down “V,” sometimes with consequent entropion, whereas the lower eyelid acquires the shape of a right side up “V,” with ectropion. This usually leads to conjunctivitis from continuous exposure, as demonstrated by the third eyelid chemosis and hyperemia. The iris lesion, with the different colors in the same iris, is normal (heterochromia iridis). This dog had a tumor growing out of the ciliary body and touching the posterior aspect of the lens ventrally, hence the reason it could be seen with a naked eye (because of its proximity to the lens). This case highlights the importance of a complete eye examination regardless of the presenting complaint. This animal had congestive heart failure, and the eye lesions were unrelated. Thomas P. Lewis II, DVM, DACVD Dr. Lewis discusses the concerns about the possible effects of this drug combination on the liver. How to make a rotation skin flap Surgery Do you use ketoconazole in conjunction with cyclosporine? Steven F. Swaim, DVM, MS Pain management Dermatology Clinical advice straight from the experts Options for relieving pain In this six-part series, learn to perform this reconstruction technique, which will help you close triangular skin defects in which skin for closure is available on only one side of a defect. Imaging Gary Landsberg, DVM, DACVB, DECVB-CA Dr. Landsberg addresses the short-term vs. long-term solutions for clients whose dogs exhibit this form of noise reactivity. Does allowing cats outdoors help treat inappropriate elimination? Susan Little, DVM, DABVP (feline practice) Featured Specialist in the Spotlight Dr. Susan Little and host Dr. Philip Van Vranken sort out possible solutions for cats experiencing this inconvenient problem. Interventional radiology: Overview and indications Reproduction Feline medicine Behavior How to treat storm phobias James Gaynor, DVM, MS, DACVA, DAAPM Featured Specialist in the Spotlight Dr. James Gaynor and host Dr. Philip VanVranken discuss CRIs, intrapleural analgesia, oral tramadol, and other methods to treat pain associated with various conditions. Your common canine reproduction questions answered Autumn Davidson, DVM, MS, DACVIM Does supplementing thyroid hormone improve fertility? Are vaginal culture results helpful in prebreeding examinations? How should apparent failure to lactate be treated? Allyson Berent, DVM, DACVIM Dr. Berent of New York’s Animal Medical Center provides a practical perspective on using interventional radiology in veterinary patients. Treating tracheal, urethral, or ureteral obstructions and closing portosystemic shunts are some of the procedures that can be performed less invasively by using fluoroscopy and endoscopy. Watch these and many more practical clinical videos at dvm360.com/medicinevideos dvm360.com VETERINARY MEDICINE January 2012 29 ❖ Peer-reviewed SkillS laboratory How to perform four oral regional nerve blocks in dogs and cats Brett Beckman, DVM, FAVD, DAVDC, DAAPM N erve blocks are an essential component of a high-quality dentistry service in smallanimal practice. nerve blocks not only provide excellent postoperative analgesia but also contribute extensively to maximizing the safety of the anesthetic event. this is accomplished by the resulting sodium channel neuronal blockade, which minimizes the required concentration of the inhalant anesthetic. Lower inhalant concentrations allow cardiac output, respiration rate, blood pressure, tissue oxygenation, and tissue perfusion to remain optimal.1 Veterinary dentistry commonly involves small patients and long procedures, so maintaining normothermia with optimal perfusion is also essential and is enhanced by using lower inhalant anesthetic concentrations. EQUIPMENT Most practices likely have everything available to deliver regional nerve blocks to their patients undergoing oral surgery. a tuberculin syringe with a 5/8 -in 25-ga needle is used for patients up to 8.8 lb (4 kg). For patients over 8.8 lb, 3- or 6-ml syringes with 3/4 -in 22- to 25-ga needles are used, depending on the infusion volume needed. Smaller-gauge needles minimize the feel of the needle in the tissue and make correct placement confirmation difficult. AGENTS Brett Beckman, dvM, FAvd, dAvdC, dAAPM Affiliated veterinary Specialists, Orlando, Fla. Animal emergency Center of Sandy Springs, Atlanta, Ga. Florida veterinary dentistry and Oral Surgery, Punta Gorda, Fla. dallas veterinary dentistry & Oral Surgery, Southlake, Texas 30 Lidocaine (2%) and bupivacaine (0.5%) can be used in the same syringe. the quick onset of lidocaine and the long duration of bupivacaine provide obvious dual benefit.2 the maximum recommended total dose for these agents is 1 mg/kg of each in the mixture. the proper dose can be drawn by using 0.2 ml of 2% lidocaine and 0.8 ml of 0.5% bupivacaine per 10 lb body weight. VOLUME PER SITE the maximum recommended volume of the lidocaine-bupivacaine mixture to January 2012 Veterinary Medicine dvm360.com These quick and easy pain management techniques decrease the amount of inhalant anesthetic needed during oral surgery and enhance postoperative patient comfort. be injected per site is based on the size of the patient as follows3: • Cat or small dog (< 13.2 lb [6 kg]) = 0.1 to 0.3 ml • Medium-sized dog (13.2 to 55 lb [6 to 25 kg]) = 0.3 to 0.6 ml • Large dog (55.1 to 88 lb [25.1 to 40 kg]) = 0.8 to 1.2 ml • Extra-large dog (> 88 lb [40 kg]) = 1.4 to 1.6 ml COMMON BLOCKS Four nerve blocks are commonly used to provide regional analgesia to the different regions of the oral cavity of mesocephalic and dolicocephalic dogs— the infraorbital and maxillary and the middle mental and inferior alveolar. Only three of these nerve blocks are performed in cats and brachycephalic dogs because the extremely short infraorbital foramen in these patients allows the infraorbital approach to affect the entire maxilla on the corresponding side. therefore, this precludes the need for a separate maxillary nerve block in these patients. For each of these blocks, once the correct dose of the desired local anesthetic agent is drawn and the needle is advanced to the desired location, the agent is placed after aspiration to ensure that the needle is not in a vessel. avoid advancing or retracting the needle while injecting to avoid inadvertent vessel entry. (See references on page 34.) rostral maxillary (infraorbital) regional block this block affects the infraorbital nerve and the rostral maxillary alveolar nerve. it provides analgesia to the incisors, canine, and first three premolar teeth of the corresponding side. the adjacent maxillary bone and surrounding soft tissue are also affected. 1 Use a skull to identify the infraorbital foramen just mesial to the mesiobuccal root of the maxillary fourth premolar. The needle is shown passing through the foramen and into the infraorbital canal. 2B Also, palpate the infraorbital neurovascular bundle as it exits the infraorbital canal and courses rostrodorsally. The circle represents the infraorbital foramen, and the arrow demonstrates the course and direction of the corresponding neurovascular bundle. 2A To perform the infraorbital nerve block, retract the upper lip dorsally, and palpate the infraorbital foramen. 3 with the lip and the bundle retracted dorsally with one hand, use the opposite hand to advance the needle close to the maxillary bone ventral to the retracted bundle in a caudal direction to a point just inside the canal. The needle should pass into the canal without hitting bone. if bone is encountered, withdraw the needle slightly, and redirect it to pass easily into the canal. To view a video of this technique, visit dvm360.com/OralNerveBlocks. dvm360.com Veterinary Medicine January 2012 31 Skills Laboratory ❖ Peer-reviewed Caudal maxillary (maxillary) regional block this block affects the branches of the maxillary nerve—the infraorbital nerve, the pterygopalatine nerve, and the major and minor palatine nerves.4 Structures that are blocked include the bones, teeth, and soft tissues of the upper jaw, including the bones of the hard palate and the soft and hard palatal mucosa on the corresponding side. 1 Use a skull to visualize the needle placement caudal to the maxillary second molar. 2 To perform the maxillary block, open the patient’s mouth, and retract the lip commissure caudally. 3 Advance the needle in a dorsal direction perpendicular to the plane of the palate, penetrating the mucosa directly behind the palatal and distobuccal roots of the maxillary second molar tooth. The needle does not need to be advanced more than 3 to 5 mm beyond the mucosa, depending on the patient’s size. To view a video of this technique, visit dvm360.com/OralNerveBlocks. 32 January 2012 Veterinary Medicine dvm360.com rostral mandibular (middle mental) regional block this block affects the incisors and canine tooth of the corresponding side along with the adjacent bone and soft tissues. 1 Use a skull to familiarize yourself with the middle mental foramen. The needle is shown passing through the middle mental foramen into the mandibular canal. 2 To perform the middle mental nerve block, retract the mandibular labial frenulum ventrally with one hand. 3 3. with the other hand, guide the needle in a caudal and slightly ventral direction, passing into the middle mental foramen that exists one-third of the distance from the ventral border of the mandible. in dogs, this foramen is at the level of the mesial root of the second premolar. in cats, it lies halfway between the canine tooth and the third premolar. To view a video of this technique, visit dvm360.com/OralNerveBlocks. dvm360.com Veterinary Medicine January 2012 33 Skills Laboratory ❖ Peer-reviewed Caudal mandibular (inferior alveolar) regional block this block affects all mandibular teeth, mandibular bone, and soft tissue on the corresponding side rostral to the injection site. 1 Use a skull to identify the inferior alveolar nerve (short white arrow), the angular process of the mandible (yellow arrow), and the location of the intended needle placement (long white arrow). The inferior alveolar nerve is blocked before its entry into the mandibular canal. 2 The inferior alveolar block is performed extraorally by first palpating the indentation on the ventral border of the caudal mandible just rostral to the angular process. This indentation should be at the same rostral-to-caudal plane as the lateral canthus of the eye. So if the indentation is difficult to palpate, the lateral canthus of the eye can be used as a landmark. 3 Pass the needle into the skin on the lingual aspect of the caudal extent of the indentation. with the needle parallel to the lingual aspect of the mandible, advance it along the bone until it reaches one-third of the distance from the ventral to the dorsal mandibular body. The needle will now be in the vicinity of the mandibular foramen where the inferior alveolar nerve enters the mandibular canal. To view a video of this technique, visit dvm360.com/OralNerveBlocks. REFERENCES 1. Holmstrom Se, Frost P, eisner er. regional and local anesthesia. in: Veterinary dental techniques. 2nd ed. Philadelphia, Pa: WB Saunders, 2007;626. 2. Mama Kr. Local anesthetics. in: Gaynor JS, Muir WW, eds. Handbook of veterinary pain management. St. Louis, Mo: Mosby, 2002;232. 34 January 2012 Veterinary Medicine dvm360.com 3. Beckman BW. Pathophysiology and management of surgical and chronic oral pain in dogs and cats. J Vet Dent 2006;23(1):50-60. 4. Beckman BW, Legendre L. regional nerve blocks for oral surgery in companion animals. Compend Contin Ed Pract Vet 2002;24:439-444. Author Guidelines Veterinary Medicine’s goal is to provide concise, essential information on the most common and emerging diagnostic and therapeutic problems seen in companion-animal practice. Articles submitted should be immediately useful to busy practitioners and presented in a clear and readable format. Manuscripts are accepted for consideration with the understanding that the material has neither been published elsewhere nor is currently under consideration by another publication. When the manuscript is submitted, the authors must disclose any financial arrangement they may have with any company whose product is mentioned in the article or with any company making a competitive product. 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(Examples of reference format can be found in past issues of Veterinary Medicine.) Illustrative materials Digital photos should have a minimum resolution of 300 dpi at 3 inches wide in TIF, JPEG, or EPS format. When sending hard copies of illustrative materials, authors should retain one copy of all illustrative materials submitted and send three copies. Figures and tables should be numbered sequentially and cited at the appropriate places in the text. Legends for figures and illustrations should be concise and typed on a separate sheet of paper. Avoid long, complicated graphs, tables, and charts. Drawings (e.g. algorithms and special or surgical anatomy) are encouraged. Pay careful attention to radiographic technique—we cannot enhance a poor-quality radiograph. Photos and radiographs should not be trimmed (crop marks can be indicated on borders), and the top and right and left sides of the illustration must be clearly marked. Arrows and letters on photographs should be clear and must be explained in accompanying captions. Publication and reprints The time between acceptance of manuscripts and publication varies from four to 12 months. The senior author will receive the edited copy for final approval a few weeks before the scheduled publication date. After publication, the senior author receives an honorarium. Direct manuscripts and questions about manuscripts to: Margaret Rampey, Editor, Veterinary Medicine, 8033 Flint, Lenexa, KS 66214; [email protected]. dvm360.com Veterinary Medicine January 2012 35 Lead the way 7 steps to boost acceptance of your medical recommendations Clients are not being intentionally defiant when they forgo preventives or do not comply with your treatment protocol. Instead, it is usually a sign of a communication breakdown. Michael A. Paul, DVM S urveys have repeatedly revealed that what pet owners want from their veterinarians is respect, clear and consistent information and recommendations, and relationships built on trust—the very things that increase acceptance of your medical recommendations. yet, the thought of discussing ability to comply with veterinary recommendations stirs defensive responses in veterinarians and pet owners alike. Veterinarians are convinced that clients ignore their recommendations because of issues of convenience or expense. Pet owners often feel that the recommendations are not clear or the reasons for them are uncertain. Michael A. Paul, DVM, is the former executive director of the Companion Animal Parasite Council and a former president of the American Animal Hospital Association. He is currently the principal of MAGPIE Veterinary Consulting. He is retired from practice and lives in Anguilla, British West Indies. Follow him at Twitter.com/magpievet. 36 Part of that defensiveness stems from the unspoken and unpleasant connotations that veterinarians associate with pet owners and the word compliance: “i told you what to do. you chose to ignore me, and now look where we are. i guess you don’t care what’s best for your pet.” in their book Skills for Communicating with Patients, the authors, Jonathan Silverman, Suzanne Kurtz, and Juliet draper, present alternatives to the unfriendly terms compliance and noncompliance and introduce instead the terms concordance, implying understanding and agreement, and adherence, implying consistent follow-through. i suggest that veterinarians adopt these terms in their thinking and professional dialogues about their recommendations to clients and their clients’ abilities to follow through. nevertheless, whether we call it compliance or concordance and adherence, all of us, veterinarians and pet owners, need to realize that we have a virtually identical concern: doing what is best for pets to the best of our ability. and we must do this in a time of economic difficulty and fragmentation wherein veterinary care, services, and products are available from a number of competing sources such as low-cost, not-for-profit, mobile, and emergency care clinics; human or online pharmacies; and pet stores and big-box and online retailers. to veterinarians, it often seems as if we are giving recommendations or pre- January 2012 Veterinary Medicine dvm360.com scribing treatments that would benefit pets—but “the clients just don’t listen.” Unfortunately, pet owners often feel as if they are given confusing and sometimes conflicting recommendations and are left asking themselves, “What am i supposed to do?” the vital step veterinarians often skip is communication, which is different from simply talking Main illustration by art Glaser/Getty images; additional animals and children by Steve Pica clearly convey the reasons behind your recommendations. or giving pedantic directions. i have often caught myself saying, “i care about your pet as much as you do,” because i believe that most pet owners who seek veterinary services care deeply. However, pet owners often do not understand the issues at hand, and frequently their ability to provide care is affectd by concerns veterinarians are not aware of. i have come to realize i should have been saying, “i care as much as i think you care.” Veterinarians frequently make judgments about clients’ commitments without knowing what factors may be behind their decisions. at the same time, we may not always convey the reasoning behind our recommendations. Most failure by pet owners to follow veterinary recommendations is not willful defiance or even indifference. Failure occurs as a result of a lack of clarity from veterinarians, a lack of understanding by clients, and a lack of joint commitment to achieving the best healthcare outcome. So what is the solution? dvm360.com Veterinary Medicine January 2012 37 Improving client acceptance 1. FORM A CONSENSUS RECOMMENDATION the first step toward concordance is forming a consensus recommendation and having all doctors and staff members repeat that recommendation regularly. Frequently, the doctors in a practice have not agreed on wellness care recommendations, and the technicians may ultimately deliver discordant messages about pet healthcare. the greatest barrier to client acceptance of a recommendation is the confusion brought about by inconsistent recommendations. We cannot expect clients to understand and accept inconsistent recommendations. Some practices i have visited routinely stock all available parasite preventives, all available nonsteroidal anti-inflammatory products, and three or four virtually identical antibiotics. Why? Because stocking inventory is easier than reaching a consensus recommendation. if a client requests a particular parasite control product, it is either because he or she been guided by an advertisement or because we introduced a new product that we believe is superior but we did not take the time to convert the client. Pet owners generally won’t recognize that chemical compositions are often very similar or even identical. the product they request may very well be identical to the one we dispense. We just need to explain it to them. tell your clients why you support certain products. Brand recognition is important, but not as important as professional advocacy. the positive influence of professional advocacy on consumer purchasing decisions is why advertisements make statements such as “this product is preferred by nine out of 10 dentists.” 2. BE SIMPLE AND DIRECT, AND MAKE YOUR BEST RECOMMENDATION in their book Made to Stick: Why Some Ideas Survive and Others Die, the authors, chip A don’t-miss CVC exclusive At the CVC Washington, D.C., April 25-29, Veterinary Medicine and Veterinary Economics will present “Current Trends in Medicine and Management.” In these workshopstyle sessions led by Drs. Michael Paul and Amanda Donnelly, you’ll learn how medical protocols improve quality of patient care, why clients don’t do what you tell them to do, and how to identify ways to communicate for better pet healthcare. For more information, visit thecvc.com. 38 January 2012 Veterinary Medicine dvm360.com and dan Heath, stress that using technical jargon is a barrier to communication with people not in the know. clients may not say, “i don’t understand that term,” but if you listen with your eyes, you may see their posture change or their brows furrow when you say, “polycythemia rubra vera,” or “thoracolumbar.” these terms are appropriate when talking to colleagues or writing medical records, but when communicating with clients, saying “too many red blood cells” or “middle of the back”is clearer. even when numerous preventive measures or diagnostic or treatment options are available, there is still generally one agreed upon best option—and that is what you should recommend. While clients want to be involved in medical decisions, they are rarely prepared to appreciate differences among the options presented. So if veterinarians offer multiple options, we must make it clear that the options are not interchangeable. a fractured pelvis might best be resolved by using plate fixation. Perhaps, an external fixation device would also be appropriate. But you need to explain to clients the benefits and disadvantages of each option. all options might be presented but not on equal footing. the preferred option should be presented as clearly superior. then comes the hard part—be quiet and let the client speak. there may be a long and awkward silence, but stick it out. either clients will accept your recommendation and you will have achieved concordance, or they will ask for another option and you start over again. So make your best recommendation and give the client a chance to say, “yes.” 3. MAKE IT PERSONAL avoid statements such as, “Studies have shown that this situation responds best to this recommendation 53% of the time.” instead, personalize the recommendation and say, “While no one can predict what will happen in any case, i am comfortable that this recommendation gives Scout the best chance for a full recovery.” Broad recommendations are great, but Mrs. Jones is concerned about one thing: What is the best thing you can offer to keep her pet healthy, happy, and comfortable? So personalize your recommendations to make it clear you think they are in her pet’s best interest. 4. SAY IT YOURSELF “i will have the technician discuss parasite prevention with you” may be more than what many veterinarians are doing, but it sends a signal to clients that the discussion is not worth your time. if a recommendation is worth making, it is worth the time to make it, explain it, and advocate for it. certainly, team members play a key role in clarifying the recommendation and in helping facilitate adherence to the recommendation through reminders and inquiries. Most important, team members can facilitate client adherence to your recommendations by walking the talk and honestly reporting that they follow your recommendations. consider statements such as “Mrs. Jones, i know how important Scout is to you, and i want to be sure we do all we can to protect her from serious diseases that can shorten her life and some that can potentially cause diseases in your children. Heartworm preventives are effective and have the added advantage of preventing internal worms that can cause disease in people. i strongly recommend that we start Scout on a monthly product that will help you and me keep her healthy. do you have any questions i can answer? can i count on you to stick to this plan with our help?” this one-time discussion explains what you advocate and why you feel so strongly about it. you are acknowledging possible concerns and offering your support. 5. COMMUNICATE WITH CLIENTS REGULARLY One thing veterinarians have over internet pharmacies and web-based resources is a relationship with clients, so it is important that we foster these relationships by communicating with clients regularly. in today’s practices, it “can i count on you to stick to this plan with our help?” is not uncommon to have 25% to 30% of office visits unscheduled. Why not use those lulls to call clients and just say, “Howdy.” Seek other opportunities to reach out, such as surprising clients with a chat in the waiting room. an offer of a cup of coffee or juice or a cookie is always welcome. Websites are great, but when did you last update yours? clients are likely to be linked into social media, such as Facebook, Foursquare, and twitter. chances are you have someone on your staff who would be great at handling social media contacts and tweets to keep your message in front of your clients. 6. BE VALUABLE all of us are consumers and are influenced by our own circumstances—busy schedules, conflicting responsibilities, finances. We all look for convenience and value and shop based on price. i bet you shop at big-box stores. We all seek convenience and price, but not at the expense of value. to compete with internet pharmacies and web-based resources, veterinarians must emphasize value and relationships and provide better service experiences. Look at online review sites to see what people are saying about your clinic. clients are increasingly making decisions based on consumer review sites. consumer publications are advising pet owners to look beyond the veterinary hospital for products and services in order to save money. consider hosting a focus group to learn what your clients think and where they are shopping for your services when they look elsewhere. We must stop treating our professional services and knowledge as a commodity. Surveys have shown that while clients are concerned about price, they want to know they are receiving value. Veterinarians must compete on price with relationships, knowledge, and value. 7. RESPECT THE CLIENT’S DECISION it has been said that medical decisions should be made by addressing three concerns: What is best for the outcome of the disease or injury? What is best for the patient’s quality of life? and what is best for the pet owners and their family? We do not know the details of clients’ circumstances. all we can do is provide clear and direct information and treatment options and then give clients permission to decide. We then must respect their decisions. CONCLUSION We veterinarians need to take the leadership role when it comes to achieving concordance with and adherence to our guidelines. We need to build consensus in our practice teams, but we also need to be the primary communicators of clear, direct, and personalized recommendations with adequate follow-up. then we can feel confident that our clients will be able to make wellinformed decisions. ❖ For information on a new wellness tool now available to practitioners, visit dvm360.com/WellnessTool. dvm360.com Veterinary Medicine January 2012 39 CE ❖ Peer-reviewed The expanding universe of three parasites Three parasites that primarily affect dogs are becoming an increasing concern in the United States. Are these three emerging parasites on your radar? Lora R. Ballweber, DVM, MS Y ou have undoubtedly heard it before, but transporting our pets around the world is one of the most significant factors in the emergence of diseases in new geographic areas. this article discusses three primar- ily canine parasites: Angiostron- gylus vasorum, Heterobilharzia americana, and Trypanosoma 1. A histologic section of canine lung with adult Angiostrongylus vasorum present cruzi. two of these parasites (arrow) (hematoxyllin and eosin stain; 10X). (Photo courtesy of Dr. Gary Conboy, University of Prince Edward Island.) are already spreading within ANGIOSTRONGYLUS VASORUM the United States, while the third is not yet present but is knocking at the door. Lora r. Ballweber, dvM, MS department of Microbiology, immunology, and Pathology College of veterinary Medicine and Biomedical Sciences Colorado State University Fort Collins, CO 80523 40 canine pulmonary angiostrongylosis is caused by the nematode A. vasorum.1-3 the first anecdotal reports of canine pulmonary angiostrongylosis were in France in 1813 and 1833. Subsequent research on this nematode in France, coupled with endemic foci identified in southwestern France, led to this parasite’s common name—the French heartworm. no longer limited to France, the distribution of this parasite is worldwide. recent reports of canine pulmonary angiostrongylosis in newfoundland and canada,4,5 as well as in Scotland6 and elsewhere indicate this parasite continues to spread (see the sidebar titled “angiostrongylus vasorum: Spreading in North America”). Life cycle compared with Dirofilaria immitis, which are 120 to 310 mm, A. vasorum adults are small (14 to 20.5 mm).1 Like that of D. immitis, the life cycle of A. vasorum is indirect, but snails and slugs are the intermediate hosts rather than mosquitoes.1-3 Both male and female A. vasorum live in the right side of the canine heart and pulmonary arteries (Figure 1), although with aberrant migration, they can end up in other areas January 2012 Veterinary Medicine dvm360.com (eyes, kidneys, brain, pancreas, femoral artery).1-3 the females lay eggs that lodge in smaller capillaries where they develop and hatch (Figure 2). the hatched firststage larvae (L1) penetrate capillaries and alveoli and migrate into larger airways where they are eventually coughed up, swallowed, and passed in the feces. they then infect a suitable gastropod intermediate host where development to the infective third-stage larvae (L3) occurs in as little as 16 to 18 days. More than 25 species of slugs and terrestrial and aquatic snails have been shown to be suitable intermediate hosts. dogs become infected by ingesting the infected gastropod intermediate hosts. Spontaneous expulsion of viable L3 from 2. A histologic section of canine lung showing numerous eggs (several indicated by arrows) and L1 of Angiostrongylus vasorum (hematoxyllin and eosin stain; 10X). (Photo courtesy of Dr. Gary Conboy, University of Prince Edward Island.) Angiostrongylus vasorum: Spreading in North America Although Angiostrongylus vasorum has been found around the world, its distribution is patchy. It was not endemic in North America—only diagnosed in dogs that had become infected during travel and had brought the parasite back with them. However, the first report in a red fox in Newfoundland occurred in 1973, with subsequent reports in dogs that had not traveled. This new focus in Newfoundland appears to have originated from Europe.1 How far and how fast it may spread in North America is not known. However, predictions, based on a simple climate matching model, suggest the spread and establishment of A. vasorum to continental North America is quite possible.2 Continued expansion of the range of A. vasorum seems likely given that1,2 • There are no travel restrictions between Newfoundland and mainland Canada. • There are no animal testing or quarantine requirements for travel between Canada and the United States, which would prevent entry of an infected dog. • Infected dogs shedding larvae are usually asymptomatic in the early phase of infection, allowing for prolonged shedding of L1. • If A. vasorum becomes established in mainland Canada, no regulatory restrictions would prevent wild red fox populations, the primary reservoir host, from crossing into the United States. • Suitable hosts are present in the proper climatic regions. Thus, it is not a matter of if it will occur but when. REFERENCES 1. conboy Ga. canine angiostrongylosis: the French heartworm: an emerging threat in north america. Vet Parasitol 2011;176:382-389. 2. Morgan er, Jefferies r, Krajewski M, et al. canine pulmonary angiostrongylosis: the infiuence of climate on parasite distribution. Parasitol Int 2009;58:406-410. dvm360.com Veterinary Medicine January 2012 41 Three emerging parasites ❖ Peer-reviewed gastropods also occurs, indicating dogs may become infected by direct ingestion of the L3. experimentally, nile rats can develop patent infections, and frogs have been shown to be both intermediate and paratenic hosts. However, their relative importance to the maintenance of the life cycle is unclear. Once ingested by the dog, the L3 penetrate the gastrointestinal tract wall, migrate to visceral lymph nodes, and develop into immature adult nematodes. they then migrate to the right ventricle and pulmonary arteries via the portal circulation. the prepatent period is around 38 to 57 days, although longer prepatent periods may also occur. the adult nematodes are long-lived (at least five years), and the dog may remain infected for life. reservoir hosts for A. vasorum include other canids, such as red foxes, wolves, coyotes, and jackals. this parasite has also been reported in lynx, eurasian badgers, and red pandas.1-3,7 Signalment in europe, there does not appear to be any sex or breed disposition, although one study did show cavalier King charles spaniels and Staffordshire bull terriers were overrepresented among dogs with canine pulmonary angiostrongylosis compared with the control group.3,8 in contrast, most dogs with canine pulmonary angiostrongylosis in newfoundland are beagles used for rabbit hunting.1 canine pulmonary angiostrongylosis has been reported in dogs as young as 3 months old and as old as 14 years; however, more than half the european cases have been reported in dogs ≤ 1 year, whereas the median age in newfoundland cases is 4.25 years.1,2 Clinical findings clinically, infected dogs may be asymptomatic or minimally affected or have severe disease. classic canine pulmonary angiostrongylosis usually presents with respiratory signs, including dyspnea and coughing.1,2,4,6,8 crackles may be present in severe cases. dogs with chronic infections can have pulmonary hypertension, cor pulmonale, and subsequent systolic heart murmur. Other signs may include depression, exercise intolerance, anorexia, weight loss, vomiting, or diarrhea. Severe coagulation disorders have also been identified in chronically infected dogs.1,2,9 Petechial and ecchymotic hemorrhages, hematomas (both traumatic and surgically induced), epistaxis, hemoptysis, intracranial hemorrhages, hematuria, and gastrointestinal bleeding have all been reported.1,2,9 thrombocytopenia, prolonged activated partial thromboplastin and prothrombin times, the presence of fibrin degradation products, hyperglobulinemia, anemia, or Factor V deficiency are associated with these cases.1,2,9 thus, a consumptive coagulopathy is indicated, but the mechanisms involved are not defined. Diagnosis Because the clinical spectrum of canine pulmonary angiostrongylosis is not unique, many differential diagnoses are usually considered, including viral respiratory disease, immune-mediated thrombocytopenia, and other cardiopulmonary parasites. thus, an initial work-up, based on the severity of signs, has been described.2 Parasitologic diagnosis depends on finding L1 (Figure 3) in the feces by using the Baermann techinque.1,2 Because of the sporadic shedding of larvae in the feces, it is recommended that samples be collected on three consecutive days to enhance detection. the L1 can also be found in direct fecal smears, particularly if clinical signs are moderate 3. First-stage larva of Angiostrongylus vasorum, stained with Lugol’s iodine. Note the kinked-tail at the to severe or recovered by posterior end with the short, dorsal spine (arrow). This characteristic will differentiate first-stage larvae of A. vasorum from those of Crenosoma vulpis and Strongyloides stercoralis (40X). (Photo courtesy of tracheal wash or bronchoalveolar lavage. Angiostrongylus Dr. Gary Conboy, University of Prince Edward Island.) 42 January 2012 Veterinary Medicine dvm360.com vasorum L1 are 310 to 399 µm in length with an anterior cephalic button and an S-shaped tail (severe kink) with a dorsal spine. these features distinguish A. vasorum L1 from those of other canine parasites, such as Crenosoma vulpis or Strongyloides stercoralis. by which dogs become infected and how off-leash walking of dogs contributes to their risk is advised.2 Finally, monitoring by using Baermann tests should be incorporated into the yearly wellness examination to help identify infected but asymptomatic animals. Treatment HETEROBILHARZIA AMERICANA Several anthelmintics and therapeutic regimens have been used to treat canine pulmonary angiostrongylosis. recommendations include milbemycin oxime (0.5 mg/kg once a week for four weeks), topical moxidectin (2.5 mg/ kg; imidacloprid-moxidectin spot-on combination product applied once), or fenbendazole (20 to 50 mg/kg daily for five to 21 days).1 not every treatment is 100% efficacious; thus, follow-up fecal examinations should be conducted three to seven days after completion of the treatment regimen. an additional three-day Baermann test should be conducted again at three months and then twice a year. if no larvae are found, then further testing is performed if suspicious clinical signs recur.2 resolution of clinical disease but not infection can occur; in these cases, retreatment is necessary. Post-treatment complications may occur, such as severe dyspnea or ascites. Strict cage rest for the initial two or three days of treatment is recommended. the use of additional supportive therapy, such as antibiotics, immunosuppressive doses of corticosteroids, and bronchodilators, will depend on the clinical presentation.2 Prevention in endemic and hyperendemic areas, monthly anthelmintic prophylaxis may be considered. although adult nematodes were not found after topical moxidectin was administered at four days or 32 days postinfection,1 protocols for its, or any other anthelmintic’s use, have not been established or verified. removing feces will be a tremendous help, as it will break the life cycle and reduce environmental contamination. Owner education regarding the means canine schistosomiasis is not an exotic disease. rather, it is caused by the digenetic trematode H. americana. its geographic distribution in the United States originally included the southern atlantic coast and the Gulf coast but has now been documented as far north as Kansas. thus, the distribution of the tion. cercariae penetrate the intact skin of the definitive host and migrate through the lungs to the liver. the trematodes grow and mature in about 40 days and then migrate to the mesenteric veins. the prepatent period is about 68 days. there are numerous reservoir hosts for H. americana, but raccoons and nutria appear to be the primary ones. dogs are the most important domestic definitive host, but red wolves and coyotes may be important wild canid reservoirs. experimental or natural infections with H. americana have been demonstrated in two species of aquatic snails; however, little information is known about whether additional species can be competent intermediate hosts. Passage of the eggs through the tissues provokes a severe granulomatous reaction that is responsible for most of the clinical signs. parasite appears to be the central and southeastern United States.10,11 Life cycle Unlike most trematodes, H. americana has separate sexes. the mature trematodes live in the mesenteric veins, where they mate and the female produces eggs. eggs in the terminal mesenteric veins penetrate through the vessel, entering the intestinal wall. after traversing the wall, they are released into the lumen and are passed with feces. the miracidium is fully developed by the time the egg enters the external environment. if the egg contacts water, the miracidium hatches and enters a freshwater snail. asexual reproduction occurs, producing cercariae. these emerge from the snail beginning as early as 25 days after infec- Clinical findings Passage of the eggs through the tissues provokes a severe granulomatous reaction that is responsible for most of the clinical signs.11,12 a wide spectrum of disease and presentations occurs in dogs, ranging from subclinical to granulomatous intestinal disease, granulomatous liver disease, or renal failure induced by the hypercalcemia that can result from granulomatous disease. the most common clinical findings include lethargy, weight loss, anorexia, hyporexia, vomiting, hypercalcemia, diarrhea, and polyuria and polydipsia.12 in severe infections, hepatic disease may also be present. complete blood count and serum chemistry profile results are often normal, although hypercalcemia with decreased serum parathyroid hormone or increased dvm360.com Veterinary Medicine January 2012 43 Three emerging parasites ❖ Peer-reviewed With the increased movement of people from endemic areas, tourism, and pet travel, chagas disease has become an important public health issue in the United States. serum parathyroid hormone-related protein concentrations may be present. the hypercalcemia in these cases may be misdiagnosed as neoplasia and hypercalcemia of malignancy. thus, canine schistosomiasis should be included on the differential diagnosis list, particularly in endemic areas, for dogs presenting with unexplained glomerulonephritis or weight loss, gastrointestinal or liver disease, or hypercalcemia.13-15 Diagnosis clinical diagnosis generally comes from the demonstration of the eggs in feces or in intestinal or hepatic biopsy samples. routine fecal fiotations will not detect eggs since they do not readily fioat. also, if placed in water, the eggs will hatch within minutes. thus, fecal sedimentation with 0.85% saline solution is the diagnostic technique of choice for demonstrating these eggs. the examination of direct saline smears may also reveal the presence of eggs. as with other parasites, eggs are Apply for CE credit Fill out the answer form on page 47, or visit dvm360.com/vetmedce to earn two hours’ continuing education credit from Kansas State University for this article. The test will be accepted for grading until Feb. 1, 2013. 44 passed intermittently in feces, so multiple fecal examinations may be required. the identity of suspect eggs can be conflrmed by resuspending eggs in deionized water, which allows them to hatch, or through a polymerase chain reaction assay. an antigen-capture eLiSa is an additional diagnostic choice.11 Treatment Both praziquantel (25 mg/kg two or three times a day for two or three days) and fenbendazole (40 to 50 mg/kg once a day for 10 days) have been used to treat this infection with variable results.11 in at least one study, hypercalcemia did not resolve unless the animals had been treated with praziquantel.12 the prognosis is good even in the presence of hypercalcemic-induced renal failure or ascites.12 TRYPANOSOMA CRUZI Trypanosoma cruzi is a protozoan parasite that causes chagas disease, or american trypanosomiasis. the parasite is endemic throughout Mexico and central and South america, and an estimated 7.7 million people are infected, with 3 to 3.3 million symptomatic cases and an additional 108.6 million people at risk.16 However, with the increased movement of people from endemic areas, tourism, and pet travel, chagas disease has become an important public health issue in the United States. even though human prevalence within the United States is low, the blood supply is now routinely tested for evidence of January 2012 Veterinary Medicine dvm360.com chagas infection because the parasite can be transmitted through blood transfusion and organ transplantation.17,18 Life cycle chagas disease is primarily a vectorborne disease, although transmission routes, in addition to those mentioned previously, also include vertical transmission (mother to fetus) and ingestion.16 indirect transmission involves mammalian deflnitive hosts and triatomine bug intermediate hosts, such as assassin bugs. Mammalian hosts within the United States include opossums, wood rats, raccoons, armadillos, and coyotes.17,19 an infected triatomine bug will defecate as it feeds and pass organisms in the feces. Trypanosoma cruzi can then invade various cells at the bite wound site, form into amastigotes, and undergo asexual reproduction. they then transform in a nonreproducing stage in which they leave the cell and either invade new tissues or are ingested by a different triatomine bug as it takes a blood meal. if not ingested by an intermediate host, they transform again into intracellular amastigotes, reproducing in reticuloendothelial, neural, and glial cells and cardiac and smooth muscle cells. Within the newly infected intermediate host, the parasite multiplies and undergoes metamorphosis into a new form in the hindgut. When the bug feeds again on a different animal, it will defecate as it feeds, and the parasite is transmitted in the feces. it then enters the body by penetrating the oral, nasal, or conjunctival mucosa or by rubbing the infectious bug feces into abrasions, such as when the bug bite site is scratched. ingestion of an infected bug will also result in transmission of the organism.20 Signalment the age range of clinical cases in dogs has been reported to be 6 weeks to 13 years, with about half the cases in animals < 1 year old. no sex predilection has been reported. cases have been reported in 48 breeds of dogs, with most in the sporting group, likely as a result of lifestyle factors. cases have also been reported in dogs from both urban and rural areas.19 Clinical findings acute disease in dogs is characterized by lymphadenopathy and clinical signs associated with acute myocarditis, such as pale mucous membranes, lethargy, ascites, and tachyarrhythmia.19,20 dogs surviving the acute phase enter the indeterminate phase characterized by the lack of clinical signs. circulating parasites can only be demonstrated by blood culture or xenodiagnosis, which is when uninfected intermediate hosts are purposefully fed on presumed infected animals and subsequently examined for the presence of the organism. an electrocardiogram is usually normal at this stage, although ventricular-based arrhythmias can be induced with exercise.20 Some dogs may then progress to chronic disease with clinical signs related to congestive myocardial failure.19,20 in a recent report characterizing chagas disease in dogs, about half of dogs < 1 year of age presented with acute death.19 in nonacute death cases, the duration of apparent illness ranged from one day to six weeks and depended on when the client sought veterinary attention. cardiac dysfunction, represented by cardiac enlargement and myocarditis, was the primary problem reported in both puppies and adults. conduction disturbances, including premature ventricular contractions and atrial fibrillation, were reported in about one-fifth of the animals. Diagnosis and treatment diagnosing chagas disease is difficult. the first step is to suspect the infection. chagas disease should be included on the differential diagnosis list for dogs presenting with signs of myocarditis or cardiomyopathy, particularly in endemic areas or if a dog has lived at any time—even years before presentation—in an endemic area.20 diagnosis has traditionally depended on demonstration of parasites in peripheral blood or amasti- gotes in tissue biopsy samples. Several serologic and molecular methods are also available, which may be particularly useful during the indeterminate and chronic phases.20-23 immunochromatographic assays for the detection of antibodies in dogs in-clinic have been described and appear useful as screening tools.21-23 the primary problem with most serologic methods is the cross-reaction with Leishmania infantum, another protozoan parasite endemic to the same areas of the United States.20,23 recommendations are to confirm screening tests with another diagnostic method available through specialized laboratories. Because most cases are diagnosed during the chronic stage, treatment is unrewarding. Supportive cardiac therapy becomes the mainstay of treatment.20 Prevention recommendations aimed at preventing infections include limiting contact with vectors and wild reservoir hosts. although the parasite is usually transmitted in the feces of the vector, it is thought that most infections in dogs in the United States are acquired through the ingestion, which releases the organisms into the mouth of the dog. Use of integrated pest management methods, such as changing outside lighting, housing dogs indoors at night, and optimizing pesticide regimens, should be used to reduce contact with vectors.19,20 additionally, dogs should not be fed fresh meat from reservoir hosts.19,20 removing T. cruzi antibody-positive females from the breeding stock may reduce vertical transmission. dogs used as blood donors should also be screened to determine their status. dogs are more competent definitive hosts than either cats or people are and are considered important reservoir hosts in central and South america.19 However, the risk of acquiring infection from an infected dog is thought to be extremely low in the United States at this time.20 nevertheless, because infections can be passed through blood, veterinarians and their staffs need to be especially careful when handling blood from an infected dog, and any accidental needle sticks should be reported to the centers for disease control and Prevention immediately.20 ❖ REFERENCES 1. conboy Ga. canine angiostrongylosis: the French heartworm: an emerging threat in north america. Vet Parasitol 2011;176:382-389. 2. Koch J, Willesen JL. canine pulmonary angiostrongylosis: an update. Vet J 2009;179:348-359. 3. Morgan er, Shaw Se, Brennan SF, et al. Angiostrongylus vasorum: a real heartbreaker. Trends Parasitol 2005;21:49-51. 4. Bourque ac, conboy G, Miller LM, et al. Angiostrongylus vasorum infection in 2 dogs from newfoundland. Can Vet J 2002;43:876-879. 5. conboy G. natural infections of Crenosoma vulpis and Angiostrongylus vasorum in dogs in atlantic canada and their treatment with milbemycin oxime. Vet Rec 2004;155:16-18. 6. Helm J, Gilleard JS, Jackson M, et al. a case of canine Angiostrongylus vasorum in Scotland confirmed by Pcr and sequence analysis. J Small Animal Pract 2009;50:255-259. 7. Patterson-Kane Jc, Gibbons LM, Jefferies r, et al. Pneumonia from Angiostrongylus vasorum infection in a red panda (Ailurus fulgens fulgens). J Vet Diagn Invest 2009;21:270-273. 8. chapman PS, Boag ad, Guitian J, et al. Angiostrongylus vasorum infection in 23 dogs (1999-2002). J Small Animal Pract 2004;45:435-440. 9. Sasanelli M, Paradies P, Otranto d, et al. Haemothorax associated with Angiostrongylus vasorum infection in a dog. J Small Animal Pract 2008;49:417-420. 10. McKown rd, Veatch JK, Fox LB. new locality record for Heterobilharzia americana. J Wildl Dis 1991;27:156-160. 11. Johnson eM. canine schistosomiasis in north america: an underdiagnosed disease with an expanding distribution. Compend Contin Ed Pract Vet 2010;March:e1-e4. 12. Fabrick c, Bugbee a, Fosgate G. clinical features and outcome of Heterobilharzia americana infection in dogs. J Vet Intern Med 2010;24:140-144. 13. rohrer cr, Phillips La, Ford SL, et al. Hypercalcemia in a dog: a challenging case. J Am Anim Hosp Assoc 2000;36:20-25. 14. Fradkin JM, Braniecki aM, craig tM, et al. elevated parathyroid hormone-related protein and hypercalcemia in two dogs with schistosomiasis. J Am Anim Hosp Assoc 2001;37:349-355. 15. ruth J. Heterobilharzia americana infection and glomerulonephritis in a dog. J Am Anim Hosp Assoc 2010;46:203-208. 16. reisenman ce, Lawrence G, Guerenstein PG, et al. infection of kissing bugs with Trypanosoma cruzi, tucson, arizona, USa. Emerg Infect Dis 2010;16:400-405. 17. dorn PL, Perniciaro L, yabsley MJ, et al. autochthonous transmission of Trypanosoma cruzi, Louisiana. Emerg Infect Dis 2007;13:605-607. 18. Leiby da, Herron rM Jr, Garratty G, et al. Trypanosoma cruzi parasitemia in US blood donors with serologic evidence of infection. J Infect Dis 2008;198:609-613. 19. Kjos Sa, Snowden KF, craig tM, et al. distribution and characterization of canine chagas disease in texas. Vet Parasitol 2008;152:249-256. 20. Barr Sc. canine chagas’ disease (american trypanosomiasis) in north america. Vet Clin North Am Small Anim Pract 2009;39:1055-1064. 21. cardinal MV, reithinger r, Gürtler re. Use of an immunochromatographic dipstick test for rapid detection of Trypanosoma cruzi in sera from animal reservoir hosts. J Clin Microbiol 2006;44:3005-3007. 22. nieto Pd, Boughton r, dorn PL, et al. comparison of two immunochromatographic assays and the indirect immunofluorescence antibody test for diagnosis of Trypanosoma cruzi in dogs in south central Louisiana. Vet Parasitol 2009;165:214-247. 23. rosypal ac, Hill r, Lewis S, et al. evaluation of a rapid immunochromatographic dipstick test for detection of antibodies to Trypanosoma cruzi in dogs experimentally infected with isolates obtained from opossums (Didelphis virginiana), armadillos (Dasypus novemcinctus), and dogs (Canis familiaris) from the United States. J Parasitol 2011;97:140-143. dvm360.com Veterinary Medicine January 2012 45 Three emerging parasites ❖ Peer-reviewed CE You can earn two hours of Continuing Education credit from Kansas State University by answering the following questions on three emerging parasites. Circle only the best answer for each question, and transfer your answers to the form on page 47 or take the test online at https://outreach.ksu.edu/ce/. This test expires Feb. 1, 2013. 1. The primary intermediate hosts of Angiostrongylus 6. The primary reservoir hosts for Heterobilharzia ameri- vasorum are: cana are: a. Mosquitoes a. Wood rats and field mice b. Gastropods b. Armadillos and opossums c. Ticks c. Fox squirrels and striped skunks d. Ants d. Nutria and raccoons e. Mites e. Beavers and muskrats 2. In Newfoundland, the dog breed often reported with 7. Canine schistosomiasis should be included on the dif- canine pulmonary angiostrongylosis is: ferential diagnosis list, particularly in endemic areas, for a. Staffordshire bull terrier dogs presenting with: b. Cavalier King Charles spaniel a. Unexplained hypercalcemia c. Beagle b. Coagulopathy d. Labrador retriever c. Systolic heart murmur e. Newfoundland d. Pulmonary hypertension e. Tachyarrhythmia 3. Classic canine pulmonary angiostrongylosis primarily presents as a: a. Respiratory disease 8. The fecal parasitological diagnostic technique of choice for Heterobilharzia americana is a: b. Neurologic disease a. Flotation with zinc sulfate solution at 1.18 specific gravity c. Renal disease b. Sedimentation with 0.85% saline solution d. Gastrointestinal disease c. Flotation with Sheather’s sugar solution at 1.27 specific e. Cardiac disease gravity d. Sedimentation with distilled water 4. The fecal parasitological diagnostic technique of choice for Angiostrongylus vasorum is a: 9. Canine Chagas disease (T. cruzi) is primarily a: a. Flotation a. Respiratory disease b. Sedimentation b. Neurologic disease c. Baermann c. Renal disease d. Direct smear d. Gastrointestinal disease e. Cardiac disease 5. The spread of Angiostrongylus vasorum from Newfoundland to other areas of North America is: 10. Although Trypanosoma cruzi is usually transmitted in a. Supported by a climate-matching model the feces of the vector, it is thought that most infections b. Prevented by animal testing requirements that would in dogs in the United States are acquired through: detect an infected dog c. Unlikely, given that there are no suitable wildlife definitive hosts present d. Not possible given the prophylactic programs in place 46 January 2012 Veterinary Medicine dvm360.com a. Eating the triatomine vector b. Vertical transmission from dam to offspring c. Blood transfusions d. Organ transplantation (e.g. myocardial valve replacements) CE The expanding universe of three parasites To apply for CE credit: ❖ Return the completed test with $20 per article to Division of Continuing Education, Kansas State University, 141 College Court Building, Manhattan, KS 66506-6015. Please make checks payable to Kansas State University, or ❖ Fax the completed test with your credit-card information to (785) 532-2422, Attention: Noncredit registration staff, or ❖ Take the test online: https://outreach.ksu.edu/ce/. This month’s article, which is worth two contact hours, will be accepted for grading until Feb. 1, 2013. Note: Credit for CE activities varies from state to state. It is your responsibility to check with your accrediting agency to verify that these CE hours are accepted. (Please print or type) NAMe LAST FIRST PrACTiCe/iNSTiTUTiON AddreSS □ PRACTICE □ HOME CiTY STATe ZiP e-MAiL PHONe □ PRACTICE □ HOME FAX □ MASTerCArd □ viSA □ AMeriCAN eXPreSS □ diSCOver CArd # eXP. NAMe AS IT APPEARS ON CARD SiGNATUre If you have questions regarding this test, call Kansas State University’s Continuing Education Department at (785) 532-5569. Answers choose only one answer for each question. Fill in your choice completely. to qualify for two hours of credit per article, a passing grade of 70% (7 of 10) is required. The expanding universe of three parasites 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. dvm360.com Veterinary Medicine January 2012 47 Products & Ser vices Showcase DENTAL PRODUCTS The Power of MERCY nspired by the heartache of losing her beloved dog Mercy after a routine dental procedure in 1992, Lise Guerin was determined to find another way to maintain the dental health of dogs and cats. After numerous consultations and rigorous testing with medical professionals on different continents, Leba III was created from a combination of safe and effective herbs, including mint (Larniaceae) and Rose (Rosaceae) stabilized in 25% ethyl alcohol (human, food grade) and distilled water. The herbs are the active ingredients, changing the chemistry in the mouth, stimulating the enzymes and causing the tartar to soften and fall off. “It works with the saliva by stimulating the good flora,” Lise explains. “You hear a lot about probiotics now, because we know that to maintain health in a live system, you fight bad bacteria with good bacteria.” When you use a product with an antiseptic, it kills both the good and bad bacteria and puts the chemistry in the mouth even more off balance. Leba III has a different action.” By 1994, veterinarians all across Canada were buying Leba III to use in their practices. Soon, the product was available in the U.S. through veterinarians, pet stores and sold directly to customers. Now with the demand interna- 48 January 2012 VETERINARY MEDICINE dvm360.com Lise and Mercy, pro mi ses to keep. tionally, we know that pets all over the world are using Leba III. Helping other animals and protecting them from what happened to Mercy means the world to Lise. “We received an email recently from a customer in New York whose dog had terrible teeth and breath. She wrote, ‘It has been life changing as we now allow her to sit with us for hours instead of minutes! Thank you for making such an easy to use and effective product.’” Testimonial won’t bring Mercy back, but they celebrate her memory. For more information on Leba III visit www.lebalab.com or call 1-866-532-2522 M arketplace ANESTHESIA EQUIPMENT MEDICAL EQUIPMENT dvm360.com VETERINARY MEDICINE January 2012 49 Mind Over Miller musings from Dr. Robert M. Miller Practical jokes, Tucson style M y veterinary schoolmate Walter Cole pulled a nasty practical joke on me nearly three decades ago. I received a scrawled letter. It read: Dear Doctor Miller, I am sure you remember Pal. You first saw him to vaccinate him when he was just a puppy. Well, Pal is old now, like me. He is 14, and the local vet says he has chronic kidney disease and nothing can be done for him except a special diet. We have been feeding it, but he gets worse, and the vet says he is youremic and can’t be helped. I know you can save him, so I am sending him to you. Tucson Dr. Cole lived in Tucson and I suspected that this was one of his pranks. A week later, I was notified by the railroad station in Oxnard that a cage with a dog in it had been shipped to me. Rather exasperated, I drove 25 miles to Oxnard to find a cage with a toy dog in it and a note that said “Gotcha!” Long afterward, I drove to Tucson with my family to see my parents. As we drove, I said, “I have to get even with Walter. I have to pull something on him while I’m in Tucson.” Laurel, my 13-year-old daughter, piped up, “He doesn’t know me. Why don’t I make an appointment for him to see Molly. I’ll tell him that I want a puppy vaccinated and that I have no money.” Molly was our aging Australian shepherd. “Brilliant,” I said. A veterinarian’s daughter knows exactly what it means 50 when a child brings a pet in without the presence of an adult. Accordingly, when we arrived in Tucson, I telephoned to find out if Walter would be seeing patients the next morning, which was Saturday. I explained to the receptionist that I was planning a practical joke to get even with him. “Oh, good!” she said, and arranged a 9 a.m. appointment. The next morning, my daughter, sloppily dressed, brought old Molly into the office. Laurel, who was chewing bubble gum, said, “A man gave me this puppy, and she needs shots.” The cooperative receptionist showed them into an exam room, and after Walter entered, she signaled to me and my wife, who were hiding outside. We entered and stood on each side of the exam room door and listened to the conversation within. What my daughter said was entirely her own idea. Walter: “Well, young lady, what have we here?” Laurel: “New puppy. A guy gave him to us, and she needs shots and whatever. My dad gave me 10 bucks to cover the cost.” Walter: “Well, first of all, this isn’t a pup. This is an older dog.” Laurel: “Na-ah! The man said!” Walter: (Laughs) “No, I’m afraid I’m right. See these yellow teeth. That shows she is an older dog.” January 2012 Veterinary Medicine dvm360.com Robert M. Miller, DVM, is an author and a cartoonist, speaker, and Veterinary Medicine Practitioner Advisory Board member from Thousand Oaks, Calif. His thoughts in “Mind Over Miller” are drawn from 32 years as a mixed-animal practitioner. Visit his website at robertmmiller.com. Laurel: “Yeah? OK! My dad has teeth like that so maybe you are right.” At this point, Debby and I are choking with laughter, trying to be quiet. Walter: “Where is your dad? Can he come in?” Laurel: “Nah! He’s across the street having a beer. Once he starts, you can’t get him to leave.” My wife and I are now strangling. Walter: “How about your mom. Is she available?” Laurel: “Nah! She ran off with my schoolteacher.” Debby and I are now in tears, struggling to be silent. Walter: “Aah! I need to talk to my receptionist. I’ll be right back.” At this point, the exam room door opened, and Walter stepped out. Seeing us, he cried, “Hey! Hi! What are you guys doing here?” Then, as realization set in, he ignored the crowded waiting room and bellowed, “You got me, you son of a b**ch!” Walter is retired now and still living in Tucson. I genuinely fear what will happen after he reads this column. ❖ The views expressed in “Mind Over Miller” do not necessarily reflect those of the editorial and practitioner advisory boards or the editorial staff. % When you can satisfy this many veterinarians, you’re gold. After 25 years, 98% of veterinarians said they are Extremely or Very Satisfied with SOLOXINE (Levothyroxine Sodium) Tablets for canine thyroid replacement therapy.* And it still costs just pennies a day to prescribe the most trusted choice. ® Ask for the brown bottle, get the gold standard. Contact your Virbac Animal Health sales representative or distributor, and learn more about hypothyroidism at virbacuniversity.com/soloxine. *Perceptions of SOLOXINE Tablets Survey, July 2010. Virbac AH, Inc., 3200 Meacham Blvd., Fort Worth, TX 76137 800-338-3659 Soloxine is a registered trademark of Virbac AH, Inc. ©2011 Virbac AH, Inc. All Rights Reserved. Passionate About Animal Health
