1 - Veterinary Medicine

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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
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 VLPP@aspca.org 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
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VETERINARY
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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
University of Illinois
Urbana, Illinois
Barrak M. Pressler, DVM, PhD, DACVIM
Department of Veterinary
Clinical Sciences
The Ohio State University
Columbus, Ohio
Juliet R. Gionfriddo, DVM, MS, DACVO
Department of Clinical Sciences
and Biomedical Sciences
Colorado State University
Fort Collins, Colorado
Walter Renberg, DVM, MS, DACVS
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)
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. Metzger Jr., DVM, DABVP
Metzger Animal Hospital
State College, Pennsylvania
David Robbins, DVM
VCA West Bernardo Animal
Hospital
San Diego, California
Wayne L. Hunthausen, DVM
Animal Behavior Consultations
Westwood Animal Hospital
Westwood, Kansas
Robert M. Miller, DVM
Thousand Oaks, California
Philip VanVranken, DVM
Dickman Road Veterinary Clinic
Battle Creek, Michigan
Thomas McCoy, DVM
Harvard Avenue Veterinary Clinic
Tulsa, Oklahoma
Gary D. Norsworthy, DVM, DABVP
Alamo Feline Health Center
San Antonio, Texas
Laura L. Wade, DVM, DABVP
Broadway Veterinary Clinic
Lancaster, New York
dvm360.com VETERINARY MEDICINE January 2012
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Editorial
We’d like to welcome
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Drs. Barret Bulmer and
Walter Renberg.
Editor Margaret Rampey, mrampey@advanstar.com
Medical Director Theresa Entriken, DVM
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Art Directors Josh Fultz; Melissa Galitz; Ryan Kramer
Multimedia Contributor Troy Van Horn
And we wish to thank two
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Advanstar Communications Veterinary Group
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9
Editors’ Guest
There isn’t much of a
market for buggy whips
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
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adverse reactions reported in decreasing order of frequency are: depression/
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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
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For product labels, including complete safety
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Gfk Kynetec, 2010 Comfortis is recommended more
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©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
(¿ÈÅŰÂ·È¿·¿ÃÃ¿Ê¿ÉƻƔÁ¿ÂÂÉŲ»·É·Äº¿É¿Äº¿¹·Ê»º¼ÅÈÊ¾»
ÆÈ»Ì»ÄÊ¿ÅÄ·ÄºÊÈ»·ÊÃ»ÄÊÅ¼Ų»·¿Ä¼»ÉÊ·Ê¿ÅÄÉƺÊ»ÄÅ¹»Æ¾·Â¿º»É
¼»Â¿É), and the treatment and control of adult hookworm
(Ä¹ÏÂÅÉÊÅÃ·¹·Ä¿ÄËÃ), adult roundworm (ÅÎÅ¹·È·¹·Ä¿É
and ÅÎ·É¹·È¿ÉÂ»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¿ÃÃ¿Ê¿É.
¾¿Â»Ê¾»ÄËÃ¸»ÈÅ¼¹¿È¹ËÂ·Ê¿Ä½Ã¿¹ÈÅŰÂ·È¿·»Ã·Ïº»¹È»·É»
¼ÅÂÂÅÍ¿Ä½ÊÈ»·ÊÃ»ÄÊƑ¿ÉÄÅÊ¿Äº¿¹·Ê»º¼ÅÈÃ¿¹ÈÅŰÂ·È¿·»
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¿½¾ÄËÃ¸»ÈÅ¼¹¿È¹ËÂ·Ê¿Ä½Ã¿¹ÈÅŰÂ·È¿·»Ɣ¾»É»È»·¹Ê¿ÅÄÉ·È»
presumably caused by release of protein from dead or dying
Ã¿¹ÈÅŰÂ·È¿·»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»ÂÂƖ¹ÅÄÊÈÅÂÂ»ºŰ»ÂºÉÊËºÏƑÍ¾¿¹¾¿Ä¹ÂËº»º·ÊÅÊ·ÂÅ¼
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
ÄÊ¾»Ű»ÂºÉÊËºÏƑÅÄ»ºÅ½·ºÃ¿Ä¿ÉÊ»È»º»ÎÆ»È¿»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: ÊÈ»Ã¸Â¿Ä½ƭÊÍ¿Ê¹¾¿Ä½ƑÉ·Â¿Ì·Ê¿ÅÄƭºÈÅÅÂ¿Ä½Ƒ
É»¿ÐËÈ»ÉƑ·Ê·Î¿·ƑÃÏºÈ¿·É¿ÉƑ¸Â¿ÄºÄ»ÉÉ·Äºº¿ÉÅÈ¿»ÄÊ·Ê¿ÅÄ. Spinosad
alone has been shown to be safe when administered concurrently
with heartworm preventatives at label directions.
Ä·ÄºËÈÅÆ»·ÄŰ»ÂºÉÊËº¿»ÉƑÄÅºÅ½É»ÎÆ»È¿»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»¹ÅÄººÅÉ»Å¼ÉÆ¿ÄÅÉ·ºƑ¸ËÊÄÅÉ»¿ÐËÈ»É¼ÅÂÂÅÍ¿Ä½Ê¾»ŰÈÉÊ·Äº
Ê¾¿ÈººÅÉ»ÉƔ¾»¹·ËÉ»Å¼Ê¾»É»¿ÐËÈ»ÉÅ¸É»ÈÌ»º¿ÄÊ¾»Ű»ÂºÉÊËº¿»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
»·ÈÊÍÅÈÃÈ»Ì»ÄÊ¿ÅÄƓ
In a well-controlled laboratory study, TRIFEXIS was 100%
»Ů»¹Ê¿Ì»·½·¿ÄÉÊ¿ÄºË¹»º¾»·ÈÊÍÅÈÃ¿Ä¼»¹Ê¿ÅÄÉÍ¾»Ä·ºÃ¿Ä¿ÉÊ»È»º
for 3 consecutive monthly doses. Two consecutive monthly doses
º¿ºÄÅÊÆÈÅÌ¿º»ʸʷʷ̈»Ů»¹Ê¿Ì»Ä»ÉÉ·½·¿ÄÉÊ¾»·ÈÊÍÅÈÃ¿Ä¼»¹Ê¿ÅÄƔ
In another well-controlled laboratory study, a single dose of
Í·Éʸʷʷ̈»Ů»¹Ê¿Ì»·½·¿ÄÉÊ¿ÄºË¹»º¾»·ÈÊÍÅÈÃ
¿Ä¼»¹Ê¿ÅÄÉƔÄ·Í»ÂÂƖ¹ÅÄÊÈÅÂÂ»ºÉ¿ÎƖÃÅÄÊ¾Ű»ÂºÉÊËºÏ¹ÅÄºË¹Ê»º
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.
Â»·È»·ÊÃ»ÄÊ·ÄºÈ»Ì»ÄÊ¿ÅÄƓ
In a well-controlled laboratory study, TRIFEXIS demonstrated
ʸʷʷ̈»Ů»¹Ê¿Ì»Ä»ÉÉÅÄÊ¾»ŰÈÉÊº·Ï¼ÅÂÂÅÍ¿Ä½ÊÈ»·ÊÃ»ÄÊ·Äº
ʸʷʷ̈»Ů»¹Ê¿Ì»Ä»ÉÉÅÄ·ÏʺʷƔÄ·Í»ÂÂƖ¹ÅÄÊÈÅÂÂ»ºÂ·¸ÅÈ·ÊÅÈÏ
ÉÊËºÏƑÉÆ¿ÄÅÉ·ºƑ·¹ÅÃÆÅÄ»ÄÊÅ¼Ƒ¸»½·ÄÊÅÁ¿ÂÂŲ»·É
30 minutes after administration and demonstrated 100%
»Ů»¹Ê¿Ì»Ä»ÉÉÍ¿Ê¾¿Äʻ¾ÅËÈÉƔÄŰ»ÂºÉÊËº¿»É¹ÅÄºË¹Ê»º¿Ä
¾ÅËÉ»¾ÅÂºÉÍ¿Ê¾»Î¿ÉÊ¿Ä½Ų»·¿Ä¼»ÉÊ·Ê¿ÅÄÉÅ¼Ì·ÈÏ¿Ä½É»Ì»È¿ÊÏƑŲ»·
reductions of 98.0% to 99.8% were observed over the course of
ʺÃÅÄÊ¾ÂÏÊÈ»·ÊÃ»ÄÊÉÍ¿Ê¾ÉÆ¿ÄÅÉ·º·ÂÅÄ»ƔÅ½ÉÍ¿Ê¾É¿½ÄÉÅ¼Ų»·
allergy dermatitis showed improvement in erythema, papules,
scaling, alopecia, dermatitis/pyodermatitis and pruritus as a direct
È»ÉËÂÊÅ¼»Â¿Ã¿Ä·Ê¿Ä½Ê¾»Ų»·ÉƔ
È»·ÊÃ»ÄÊ·ÄºÅÄÊÈÅÂÅ¼ÄÊ»ÉÊ¿Ä·Â»Ã·ÊÅº»Ä¼»¹Ê¿ÅÄÉƓ
ÄÍ»ÂÂƖ¹ÅÄÊÈÅÂÂ»ºÂ·¸ÅÈ·ÊÅÈÏÉÊËº¿»ÉƑÍ·É̟ˀʷ̈
»Ů»¹Ê¿Ì»¿ÄÈ»ÃÅÌ¿Ä½Ä·ÊËÈ·ÂÂÏ·Äº»ÎÆ»È¿Ã»ÄÊ·ÂÂÏ¿ÄºË¹»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
vm@advanstar.com; 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
15
Education
Advocacy
Action
Just Ask the Expert
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?
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
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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 vm@advanstar.com, send a fax to (913) 273-9876,
or write to Idea Exchange Editor at 8033 Flint, Lenexa, KS 66214.
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: vm@advanstar.com
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
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
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
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
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
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
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.
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.
32
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.
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.
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
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.
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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.
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-
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?
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
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identify ways to communicate for better pet healthcare. For more information,
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38
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.
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
(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.
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
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
43
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
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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
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.
45
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
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.
47
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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
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48
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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.”
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.
%
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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.
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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

1 - Veterinary Medicine

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