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Companion FOR THE SUNSHINE STATE’S VETERINARY COMMUNITY FROM BLUEPEARL VETERINARY PARTNERS FALL 2015 When is Feline Hyperthyroidism and Kidney Failure a Concern? IT IS WELL DOCUMENTED that increases in renal blood flow and glomerular filtration rate secondary to hyperthyroidism can mask renal insufficiency. Inversely, correction of the hyperthyroid condition thereby normalizing the hypermetabolic state may allow a concurrent kidney insufficiency to become apparent. Even though the hyperthyroid treatment is not the cause, azotemia may become evident. The good news is that, despite the development of posttreatment azotemia, most cats will do fine. In one study, the median survival time in cats treated for hyperthyroidism that developed azotemia was similar to treated cats that did not develop azotemia (>500 days). It is the correction of the Technetium scans hyperthyroid state and not the type confirming increased of treatment that unmasks the radioactive uptake by the azotemia. Therefore, it is possible to thyroid glands get a preview of the cat’s true kidney function, prior to curing the condition with radioactive iodine, by performing what has been termed a methimazole trial. To perform a trial, administer methimazole with the goal of dropping thyroid hormone levels into the normal range. Once thyroid levels have normalized, then blood tests performed two to four weeks later would be expected to demonstrate the BUN and creatinine values that you would see after radioactive iodine therapy. Join us for our half-day seminar and family event on September 26, 2015 When should a methimazole trial be performed? There is no straightforward answer to this question. Most cats with hyperthyroidism don’t need a methimazole trial. After all, you still have to treat the hyperthyroid condition. Nevertheless, we will consider performing a methimazole trial in cats greater than 15 years of age and in those cats with any suspicion for concurrent kidney disease based on the patient’s history, exam findings, and lab test results (significantly elevated BUN value and isosthenuria). Sheraton Sand Key Resort 1160 Gulf Blvd Clearwater Beach FL 33767 What is the best treatment for hyperthyroidism? Overwhelming opinion is that radioactive iodine therapy is the best treatment. Curing the condition by this method does not risk damage to the parathyroid glands, which may occur during surgical removal of the thyroid glands. On the other hand, poor client compliance and inadequate methimazole dosing can allow the hyperthyroid condition to slowly damage the heart and even the kidneys when medical management is pursued. The risk for side effects from the methimazole and the additive expense of the medication and subsequent thyroid monitoring are additional reasons to consider curing the condition with a single dose of radioactive iodine. In a recent JAVMA study, hyperthyroid cats treated with radioactive iodine were shown to live longer than those treated with methimazole despite the iodine-treated population actually being older in age. bl uepearl vet. com We request a $25 donation to attend, which is given to the Pinellas Animal Foundation. Please register at bluepearlvet.com/florida under the For Veterinarians tab, then Continuing Education. Brought to you by our sponsors: Antech Diagnostics, Boehringer Ingelheim, Elanco, Hill’s Pet Nutrition, Honor Thy Pet, Nutramax Laboratories, Patterson Veterinary, Sound-Eklin, Stokes Pharmacy, Trupanion Tampa 3000 Busch Lake Blvd Tampa FL 33614 813.933.8944 Brandon 607 Lumsden Professional Ct Brandon FL 33511 813.571.3303 ClearwaterSarasota 4525 Ulmerton Rd 7414 South Tamiami Trail Clearwater FL 33762 Sarasota FL 34231 727.572.0132877.838.5909 WHEN THEY CAN’T EAT ANOTHER BITE Do You Hate Stormy Mondays? YOU WOULD NEVER RECOGNIZE it by its name, astraphobia, which is derived from the EVERY HOLIDAY I OVEREAT. My belly gets a little distended, and I feel over full. I recognize my mistake and swear not to eat as much next year. But what if the food you ate at the holiday meal kept on increasing in volume as it sat in your stomach? That could be a problem. So it is with dogs who get into a bag of dry food. Every dog will eat until they are full; that’s not the problem. It has been reported that the normal canine stomach can accommodate 7-8% of the dog’s body weight in food. The problem starts when the dry food starts to absorb fluid from the stomach, or the dog drinks. The dry food swells as it absorbs the fluid overdistending the stomach. This condition is known as food bloat. Signs of food bloat are usually acute in onset. Patients frequently present similar to those with GDV. Dogs demonstrate abdominal discomfort and anxiety. Attempts at vomiting are frequently non-productive, and pressure on the diaphragm from the gastric distention can cause increased respiratory effort. Occasionally, the stomach is distended enough to interfere Food bloat is diagnosed with radiographs. The food-filled stomach, unlike a GDV, is normally with blood return by the vena cava positioned. causing signs of poor cardiac output. Treatment recommendations for patients with food bloat vary: 1. Some clinicians attempt to induce vomiting; however, this is frequently ineffective. Overdistention of the stomach interferes with its ability to contract and expel its contents. GDV We don’t recommended emesis. 2. The administration of IV fluids is recommended. Dogs risk dehydration as the dry stomach contents draw in fluid. Furthermore, the stomach contents need to be moist enough to be broken down and passed through the pyloris. Those dogs demonstrating compromise in perfusion from dehydration, or reduced cardiac return from the excessive gastric dilation, could also benefit from fluid therapy. 3. Providing frequent walks has been suggested as it appears to help stimulate gastric emptying. 4. Administering pro-motility medications such as metoclopramide may also be helpful. 5. Analgesics are indicated in painful dogs. It has been suggested that NSAIDs be avoided so as not to further irritate the stomach. 6. Finally, the resolution of food bloat takes time. Most dogs improve within 12 hours of presentation. 7. Surgery is not recommended to treat food bloat unless the stomach is torsed. How about lavaging the food out of the stomach? Lavage is typically not necessary and would likely prove difficult to perform because of the density and dryness of the stomach contents. The risk of inducing aspiration pneumonia in many cases outweighs any potential benefit you might gain. Lavage might be considered if the stomach is distended to the point where perfusion is compromised. NOTE: The occurrence of food bloat has not been associated with an increased risk of developing GDV. Greek word for lightning. However, if your dog has this fear, it will drive you crazy. Technically, it is the fear of thunder and lightning, but to those of us who deal with these patients, we recognize it as the fear of thunderstorms. Astraphobia is more common than you think, affecting up to 30% of dogs. For some dogs it’s the loud noise that frightens them. These dogs would be expected to demonstrate similar signs after hearing gunshots and fireworks. Other dogs appear to start demonstrating signs even before the rain starts falling possibly due to a drop in barometric pressure. It is suspected that the pressure drop is sensed by the inner ear. Other triggers for astraphobia remain less apparent but could include increased static electricity in the air or even the smell of ozone resulting from the lightning. Affected dogs demonstrate mild to severe signs of anxiety and fear. Panting, pacing, trembling, drooling, whining, hiding, or climbing onto the owner are most commonly described. Occasionally dogs will become destructive as they try to escape from the storm. Cortisol levels have been documented to rise in affected pets due to the stress. So what’s an owner to do? It is important for pet owners not to show anxiety or behavior changes, which the pet may key in on. It is also important that owners not overly coddle their pet during these periods to the point of reinforcing or rewarding the behavior. Determining the most effective treatment for each particular pet requires trial and error. 1.Owners can try to create a more comforting environment during storms by identifying a safe place for the pet to hide or even turning on white noise to mask the storm sounds. They might also try to distract the pet by playing a game. 2.Garments that snuggly fit around the trunk of dogs have been used to calm anxious pets. Few studies exist supporting the effectiveness of these garments; however, many pet owners swear by them. How these garments calm the dogs remains undetermined. 3.Various synthetic pheromone products on the market may help to calm the pet. 4.Occasionally, excessively anxious dogs will benefit from medications to reduce their anxiety. Alprazolam, clomipramine, fluoxetine, and diazepam have been prescribed for this purpose. Tranquilization with acepromazine is less commonly used due to its systemic side effects, such as inducing hypotension. Finally, dogs with severe thunderstorm phobia are best evaluated by an animal behaviorist who can work directly with the pet and owner to countercondition and desensitize the pet. Counterconditioning involves training the dog to associate storms with something enjoyable. Desensitization is the process of getting the pet used to the storm conditions typically by introducing mimicked storm sounds at low levels and increasing them over time. It’s not just dogs In people, astraphobia has been reported to be the third most common phobia in the U.S. Astraphobia has also been identified in cats though much less frequently. Can you prevent your pet from developing astraphobia? This is unknown. There may be a genetic basis to the response. Interestingly, studies suggest that dogs living with other dogs are less likely to demonstrate anxiety during thunderstorms. DOGS WITH SEVERE THUNDERSTORM PHOBIA ARE BEST EVALUATED BY AN ANIMAL BEHAVIORIST WHO CAN WORK DIRECTLY WITH THE PET AND OWNER Medical Director: Erick Mears DVM, DACVIM Editor: Amy Johnson CVT AVIAN/EXOTICS Peter Helmer DVM, DABVP-Avian CARDIOLOGY Alan Spier DVM, DACVIM CRITICAL CARE John Gicking DVM, DACVECC Lauren Harris DVM Brittany Jaeger DVM Danielle Pollio DVM Miryam Reems DVM, DACVECC DERMATOLOGY Robert Schick DVM, DACVD Nadine Znajda DVM DIAGNOSTIC IMAGING Wendy Gwin DVM, DACVR Valerie Sadler DVM, DACVR EMERGENCY MEDICINE Katherine Brammer DVM Lee Burstiner DVM, DABVP Dee Ann Dugger DVM Kelley Eckert DVM David Hoch DVM Kevin Kelley DVM Sonja Olson DVM Allison Shreve DVM Taylor Tungsten DVM Steven Tutela DVM Jessica Weeks DVM Marie Yakubik DVM Gastrointestinal Ulcers in Fido? GASTROINTESTINAL (GI) ULCERATIONS ARE DEFECTS in the mucosal barrier that Diagnosis extend into the deeper layers of the gastrointestinal tract. The gastric mucosal barrier is a complex defense mechanism protecting the normal mucosa from erosions and ulcers. GI ulcers may occur in the stomach and in the duodenum. They may be superficial or deep and range from simple epithelial erosion to full thickness bleeding or perforating lesions. The GI ulcer may occur independently or due to a disease process. There is no predilection for a particular age group or breed, and signs can be extremely variable from patient to patient. Some patients may have no clinical signs, while others may be in immediate need of intensive support and hospitalization, including blood transfusions. A presumptive diagnosis of GI ulceration can sometimes be made on the basis of history and clinical findings such as the previously mentioned aspirin administration or known foreign body ingestion. A full diagnostic workup is recommended, regardless of the cause. A complete blood cell count (CBC), biochemical profile and urinalysis should be performed in all cases. A CBC will evaluate for the presence of infections, inflammation and anemia, associated with gastrointestinal ulceration. A biochemical profile evaluates organ function, which is important to establish if there may be an underlying metabolic disorder. Screening abdominal radiographs are commonly normal; yet, they may support the diagnosis of an ulcer secondary to a tumor or foreign body. Abdominal radiographs will also help with diagnosis of a GI perforation. An abdominal ultrasound may note thickness in the GI wall; however, GI ulceration is commonly not evident with ultrasonography. The abdominal ultrasound evaluates the abdominal organs and helps determine if tumors are present that may be associated with ulcers. A contrast upper GI study with barium may identify ulcers. It is a safe test; results are not always conclusive. Gastrointestinal endoscopy is the gold standard in diagnosing GI issues. It may facilitate the removal of foreign bodies, evaluate for ulcers and sample tissue for the presence of inflammation or cancer, which may cause the ulcer. It does require general anesthesia in our veterinary patients; however, it is a fairly quick and safe procedure. Other tests may be recommended on a case-by-case basis. These may include a liver function test for certain liver disorders or an ACTH stimulation test to rule out hypoadrenocorticism (Addison’s disease). Causes There are many potential causes of GI ulceration ranging from medication to tumors. Some cases of ulceration are clear-cut. A prime example would be in a case of dog being treated with nonsteroidal anti-inflammatory drugs (NSAID) and a corticosteroid simultaneously. Others, and perhaps the majority, are more difficult to determine. Some of the more common causes of GI ulceration in our pets include • Ingestion of certain medications (NSAIDs and corticosteroid) • Systemic disorders such as renal failure, hepatic disease and hypoadrenocorticism (Addison’s disease) • Stress, pain and/or major medical illness/surgery • Dietary indiscretion or the ingestion of foreign objects • Pancreatitis (inflammation of the pancreas) • Microscopic disease of the GI tract including inflammatory bowel disease • Primary GI neoplasia (lymphoma, adenocarcinoma, leiomyoma, and leiomyosarcoma) • Mast cell tumors and gastrinomas Symptoms - What to Watch For There are a number of symptoms that patients with gastrointestinal ulceration may exhibit. The most common include any/all of the following: •• •• •• •• •• •• •• •• Vomiting (with or without digested blood) Hematemesis Melena Abdominal pain Decreased appetite Anemia Weakness Anorexia Treatment Management of gastrointestinal ulcers centers on treatment of the primary cause and blocking excessive stomach acid production. Rarely, in severe cases control of bleeding and blood transfusions may be indicated. Withholding food initially is recommended to avoid stimulation of gastric acid and pepsin secretion. Gradual reintroduction of small amounts of bland food should then be instituted, similar to treatment of pets with acute gastritis. Drugs may help decrease acid production by the stomach and expedite the resolution of GI ulcers. Examples include H2 blockers (famotidine, cimetidine) and proton pump inhibitors (omeprazole, pantoprazole). The proton pump inhibitors offer a more complete inhibition of gastric acid secretion. Cytoprotective agents include antacids and sucralfate which help protect the healthy denuded musosa and promote gastric mucosa epithelialization. Antiemetic drugs, fluid therapy and/or antibiotics are considered in treatment of some patients on a case-by-case basis. Pain medication should be considered in pets with ulcer disease. Ulcers can cause intense abdominal discomfort, and affected patients may benefit greatly. Endoscopy may be indicated to remove foreign objects, diagnose tumors causing ulcers, or biopsy associated tissue with the ulcer. Surgery is less commonly performed to treat gastric ulceration. You Are What You Eat DIET IS AN OFTEN OVERLOOKED component of treating dogs and cats with a variety of disorders. In our culture, pet owners are looking for the easy cure. And in our attempt to please our clients we get into the habit of prescribing the pill that will fix every illness. But is this really the best medicine? Maybe we should be taking a page from the human field where a significant number of illnesses are managed with recommendations for dietary changes, increased activity and stress reduction. Sure, it’s hard to get pet owners to change the way they are treating their pets. But it’s not enough to treat arthritis with just anti-inflammatory medications or a metabolic disease with anti-nausea medications. The appropriate dietary changes could reduce a pet’s need for medications. Hill’s Pet Nutrition, a BluePearl Partner in Education, continues to research the roles diet plays in treating our pets’ diseases. They have recently introduced a number of new diets to treat patients afflicted with multiple conditions such as arthritis in overweight dogs and urinary tract issues in overweight cats as well as to reduce canine GI inflammation that may be related to stress or food sensitivities. Give your Hill’s representative a call today to find out what diets you should be adding to your treatment arsenal. And make certain to ask about their free trial bag and sample program for those clients who are reluctant to switch a pet’s diet without trying the food first. INTERNAL MEDICINE Jennifer Goodman DVM Anthony Ishak DVM, DACVIM Melinda Larson DVM Brian Luria DVM, DACVIM Erick Mears DVM, DACVIM Cathy Meeks DVM, DACVIM Melanie Otte DVM, DACVIM Neil Shaw DVM, DACVIM NEUROLOGY Michael Kimura DVM, DACVIM ONCOLOGY Jen Coyle DVM, DACVIM Curtis Kane DVM OPHTHALMOLOGY T. Miller Michau DVM, DACVO Jessica Stine DVM Anja Welihozkiy DVM, DACVO Jennifer Welser DVM, DACVO One of Hill’s new metabolic diets REHABILITATION Jennifer Brown DVM, DACVS-LA, DACVSMR, CCRT SURGERY Helga Bleyaert DVM, DACVS Sylvia Lee DVM Nick Rappa DVM Michael Reems DVM, DACVS Nicole Salas DVM, DACVS-SA Andrea Smith DVM, DACVS-SA Elbow Dysplasia The problem Elbow dysplasia includes the following conditions: fragmented medial coronoid process (FCP), osteochondritis dissecans (OCD), elbow incongruity, ununited anconeal process (UAP) and ununited medial epicondyle. FCP is a small piece of bone on the inner side of the joint, which has broken off the ulna. This fragment of bone irritates the lining of the joint and grinds off the cartilage of the adjacent humerus (similar to a pebble in your shoe that is irritating your foot). UAP is a condition in which the anconeal process fails to fuse with the main ulna bone during the growth phase. Normally this bony process fuses to the ulna bone by 20 weeks of age. OCD is a condition in which a piece of cartilage becomes partially or fully detached from the surface of the humerus bone. Elbow incongruity is a poorly fitting joint, which results in excessive wear of the cartilage within the joint. The ununited medial epicondyle is a piece of bone, which has separated from the medial side of the humerus bone. This is the site where a group of forelimb muscles attaches. If this region fails to develop into bone within the normal timing of development, the muscles may pull this part off the humerus, resulting in a loose piece of bone that rubs on the inner side of the elbow and on the ulnar nerve. Fig. 1 Clinical signs Clinical signs include acute or chronic forelimb lameness that worsens after exercise. Large and giant breed dogs are commonly affected, with both elbows involved in 35% of affected dogs. Signs often become apparent at 5-12 months of age. Fig. 2 Diagnostics Physical examination findings may reveal varying degrees of lameness and pain with manipulation of the elbow joint, (specifically with medial palpation, flexion and supination). Craniocaudal, 90° lateral and flexed lateral radiographs of the elbow joint are recommended to evaluate UAP, ununited medial epicondyle and sometimes OCD, as well as to document changes consistent with arthritis. CT scan and arthroscopic surgery of the elbow joint are usually the best diagnostic tools used to diagnose FCP, OCD and incongruity of the elbow joint. Fig. 3 CONTINUED BELOW Companion 3000 Busch Lake Blvd Tampa FL 33614 To go green and receive only an electronic version of the COMPANION, or to add your email to our address list, please send an email to Amy Johnson, [email protected]. Elbow Dysplasia CONTINUED FROM ABOVE Treatment Arthroscopic surgery is the recommended treatment for elbow conditions. The joint is examined with a very thin telescope to confirm the diagnosis. If an OCD cartilage flap is present, it is removed from the joint. The OCD bed is trimmed at the edges, and small holes are made in the OCD bed so that healing will occur faster. The area of the medial coronoid is examined with the arthroscope. If fragmented, it is removed with a combination of an arthroscopic shaver and small instruments. If an UAP is present, the bony fragment is removed via a 2 cm incision made on the side of the joint. If an ununited medial epicondyle is determined to be the problem, the joint is examined with the arthroscope, as some of epicondyle will be removed through a separate 3 cm incision. Elbow incongruity is not treated surgically if it is mild. If this problem is significant, the ulna bone is cut just below the elbow joint to improve congruity. Prognosis Arthroscopic elbow surgery is currently one of the best methods available to both diagnose and treat elbow conditions. Although all dogs that have elbow dysplasia develop arthritis, surgical intervention with arthroscopy can help decrease pain within the joint. Stem cell therapy may also be of benefit and can be coordinated with our surgery service. Continued medical management including weight control, fatty acid supplementation, nutraceuticals, intermittent use of NSAIDs and physical rehabilitation may be indicated to manage arthritis long term. BluePearl Veterinary Partners is a leader in minimally invasive procedures. A member of the surgery team is on-call 24/7 to provide consultations to our emergency doctors and to perform emergency surgeries when on call. Our specialists are available for questions and consultations on surgical conditions Monday through Saturday. BluePearl’s newsletters are produced for the veterinary community with support from your Partners in Education: Antech Diagnostics, Elanco, Hill’s Pet Nutrition, Stokes Pharmacy, Trupanion, Zoetis © 2015 BluePearl Veterinary Partners