Today veterinary magazine march 2013

Presorted Standard

U.S. Postage Paid

Lebanon Junction, KY

Permit No. 794

March/April 2013 Volume 3, Issue 2March/April 2013 Volume 3, Issue 2

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GI InterventIonThe Vomiting PatientGI InterventIonThe Vomiting Patient

neuroloGIc

examInatIon

Abnormal Findings

veterInary

DermatoloGy

Five Common Mistakes

conSIDer

tHIS caSe

Estrus in a Spayed Cat

ImaGInG

eSSentIalS

Cervical Spine

Dental

DIaGnoSIS

Canine Tooth Fracture

top ten

Toxicoses in Dogs & Cats

vItal vaccInatIon

Rabies Virus

neuroloGIc

examInatIon

Abnormal Findings

veterInary

DermatoloGy

Five Common Mistakes

conSIDer

tHIS caSe

Estrus in a Spayed Cat

ImaGInG

eSSentIalS

Cervical Spine

Dental

DIaGnoSIS

Canine Tooth Fracture

top ten

Toxicoses in Dogs & Cats

vItal vaccInatIon

Rabies Virus

A Peer-Reviewed Journal

http://tvpjournal.com/subscribe

Nobivac® Lyme knocks out OspA, then knocks out

OspC, providing patients with two-fsted protection.

The Borrelia that cause Lyme disease are pretty tricky villains to conquer. Just when you think you have outer surface protein A (OspA) under control, it down-regulates and OspC kicks in. That’s why it takes a dual-acting vaccine like Nobivac Lyme—with proven borreliacidal activity against both OspA and OspC—to be successful in the fght against Lyme disease.1

Without protection against OspC, a Lyme vaccine just isn’t in the heavyweight class. So get tough on Lyme and protect your patients with the vaccine that’s a known champion.

Reference: 1. LaFleur RL, Dant JC, Wasmoen TL, et al. Bacterin that induces anti-OspA and anti-OspC borreliacidal antibodies provides a high level of protection against canine Lyme disease. Clin Vaccine Immunol. 2009;16(2):253–259.

Copyright © 2012 Intervet Inc., a subsidiary of Merck & Co., Inc. All rights reserved. Intervet Inc. d/b/a Merck Animal Health, Summit, NJ 07901. MAH-VC-638a

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March/April 2013 Today’s Veterinary Practice 1

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rights reserved. no part of this publication may be reproduced in any form without written permission from the publisher. entire contents ©2012 Vetmed Communications, inc.

PUBLisHerNick [email protected]

eDitoriaL DireCtorKelly Soldavin

267-228-1640ksoldavin@todays

veterinarypractice.com

art DireCtorDiane Paolodpaolo@todays veterinarypractice.com

saLes & marKetinG DireCtor

Renee Luttrell610-558-1819

rluttrell@todays veterinarypractice.com

assistant editor: Amanda Wright

Graphic Designer: Courtney Ballauer

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eDitoriaL Peer reVieW BoarD

Kenneth abrams, DVM, Diplomate ACVO

Clarke atkins, DVM, Diplomate ACVIM

Brett Beckman, DVM, FAVD, Diplomate AVDC

& AAPM

Paul Bloom, DVM, Diplomate ACVD & ABVP

(Feline & Canine Practice)

Dwight D. Bowman, MS, PhD

regina J. Brotherton, DVM, CCRP, PhD

Camilo Bulla, DVM, MS, PhD

terry marie Curtis, DVM, MS, Diplomate

ACVB

michael J. Dark, DVM, PhD

Craig Datz, DVM, Diplomate ABVP (Canine &

Feline Practice) & ACVN

mark epstein, DVM, Diplomate ABVP (Canine

& Feline Practice) & AAPM

Derek Fox, DVM, PhD, Diplomate ACVS

Laura Garrett, DVM, Diplomate ACVIM

(Oncology)

Frederic P. Gaschen, DrMedVet, Diplomate

ACVIM (Small Animal Internal Medicine) &

ECVIM (Companion Animal)

Gregory F. Grauer, DVM, MS, Diplomate

ACVIM (Small Animal Internal Medicine)

Deborah Gross saunders, DPT, MSPT, OCS,

CCRP, Diplomate ABPTS

Debra F. Horwitz, DVM, Diplomate ACVB

sandra Koch, DVM, MS, Diplomate ACVD

angela Lennox, DVM, Diplomate ABVP (Avian)

steve martinez, DVM, MS, Diplomate ACVS

Kathryn michel, DVM, MS, Diplomate ACVN

mark oyama, DVM, Diplomate ACVIM

(Cardiology)

mark Papich, DVM, MS, Diplomate ACVCP

r. michael Peak, DVM, Diplomate AVDC

Lysa P. Posner, DVM, Diplomate ACVA

Jody D. ray, DVM, MS

ernest rogers, DVM, PhD

margaret root Kustritz, DVM, PhD,

Diplomate ACT

rose raskin, DVM, PhD, Diplomate ACVP

elizabeth rozanski, DVM, Diplomate ACVIM &

ACVECC

margie scherk, DVM, Diplomate ABVP (Feline

Practice)

J. Catharine scott-moncrieff, VetMB, MS,

MA, Diplomate ACVIM & ECVIM

Claire sharp, BSc, BVMS (Hons), MS, CMAVA,

Diplomate ACVECC

Jörg steiner, MedVet, DrMedVet, PhD,

Diplomate ACVIM & ECVIM (Companion

Animal)

Charles H. Vite, DVM, PhD, Diplomate ACVIM

(Neurology)

Jennifer L. Wardlaw, DVM, MS, Diplomate

ACVS

tina Wismer, DVM, Diplomate ABVT & ABT

James Young, DVM

eDitor in CHieF

Lesley G. King, MVB,

Diplomate ACVECC, ACVIM

(Small Animal Internal Medicine),

& ECVIM (Companion Animal)

University of Pennsylvania

College of Veterinary Medicine

editorinchief@todays


ContriBUtinG meDiCaL

eDitor

travis meredith, DVM, MBA,

Diplomate ACT

tmeredith@todays


eDitoriaL aDVisorY BoarD

P. Jane armstrong, DVM,

MS, MBA, Diplomate ACVIM

(Small Animal Internal Medicine)

University of Minnesota


mark Cofone, VMD,

Diplomate ACVS

Veterinary Specialty Center

Wilmington, Delaware

sheila Grosdidier, RVT, PHR

Veterinary Management

Consultation

Evergreen, Colorado

rosemary Lombardi, CVT,

VTS (ECC)

University of Pennsylvania

Ryan Veterinary Hospital

Garret Pachtinger, VMD,

Diplomate ACVECC

Veterinary Specialty &

Emergency Center

Levittown, Pennsylvania

michael schaer, DVM,

Diplomate ACVIM & ACVECC

University of Florida


mailto:[email protected]





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Today’s Veterinary Practice March/April 20132

Today’s Veterinary Practice (ISSN 2162-3872 print and ISSN 2162-3929 online) does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products

and claims contained therein. The publisher, VetMed Communications, Inc (VMC), disclaims any liability for any damages resulting from the use of any product advertised herein and sug-

gests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective authors and do not necessarily represent

the opinions of VMC nor its Editorial Advisory Board. VMC does not guarantee nor make any other representation that the material contained in articles herein is valid, reliable, or accurate;

nor does VMC assume any responsibility for injury or death arising from any use, or misuse, of same. There is no implication that the material published herein represents the best or only

procedure for a particular condition. It is the responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly

available. Today’s Veterinary Practice is published Jan/Feb, Mar/Apr, May/June, Jul/Aug, Sept/Oct, Nov/Dec (6x per year) by VetMed Communications, Inc, PO Box 390, Glen Mills, PA. 19342.

Cover Story

18 GI INTERVENTION: APPROACH TO DIAGNOSIS & THERAPY OF

THE VOMITING PATIENT

P. Jane Armstrong, DVM, MS, MBA, Diplomate ACVIM

Vomiting is a common clinical complaint in both dogs and cats and a clinical

sign common to diseases of many body systems. Management includes

controlling vomiting, addressing underlying causes, and correcting fluid and

electrolyte abnormalities.

March/April 2013 • Vol 3, No 2Contents

26 IN-CLINIC TABLE

MEDICATIONS FOR ACUTE VOMITING: DOGS & CATS

P. Jane Armstrong, DVM, MS, MBA, Diplomate ACVIM

This comprehensive table outlines drugs commonly used to manage acute vomiting

in dogs and cats, including antiemetic, gastroprotectant and cytoprotective, and

prokinetic agents, organized by classifaction, use, and dose.

34 HOW TO AVOID THE FIVE MOST COMMON MISTAKES IN VETERINARY DERMATOLOGY

Lori A. Thompson, DVM, Diplomate ACVD

Discover the five pitfalls most commonly encountered by practitioners when

diagnosing and treating dermatologic conditions in dogs and cats, while learning

how to fine tune your approach to history taking, biopsies, skin scrapings, and

antibiotic selection.

40 THE NEUROLOGIC EXAMINATION IN COMPANION ANIMALS

PART 2: INTERPRETING ABNORMAL FINDINGS

Helena Rylander, DVM, Diplomate ACVIM (Neurology)

Once a neurologic examination has been completed in a patient, the practitioner

can use the abnormalities, or lack thereof, to help localize the lesion to the brain,

spinal cord, peripheral nervous system, or cauda equine, which provides critical

information on the patient’s condition.

46 IN-CLINIC TABLE

LESION LOCATION ORGANIZED BY NEUROLOGIC ASSESSMENT & FINDINGS


This chart organizes neurologic findings by the seven assessment tests discussed

in The Neurologic Examination in Companion Animals—Part 1: Performing the

Examination; then provides potential anatomic locations of neurologic disease

indicated by the findings.


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17 PRODUCT PROFILE Common Heartworm Preventive &

Intestinal Parasite Medications for

Dogs & CatsThis table is the third in our

Product Profile series on parasite

preventives, which provide products’

manufacturers, ingredients, species

specifications, and indications.

28 PRACTICE TO PRACTICEPromoting Parasite Prevention

in PracticeKelly Soldavin

Today’s Veterinary Practice interviewed

Madeleine Womble, the Hospital

Manager at Central Veterinary Hospital

in Knoxville, to learn about how this

busy veterinary practice implements

effective parasites prevention

strategies for their patients.

48 HEARTWORM HOTLINEThe American Heartworm Society

& YouWallace Graham, DVM

April is National Heartworm Awareness

Month and Dr. Graham, President of

the American Heartworm Society,

tells readers about the ways the AHS

provides information about prevention

and treatment of heartworm disease.

50 IMAGING ESSENTIALSSmall Animal Spinal Radiography

Series: Cervical Spine

RadiographyDanielle Mauragis, CVT, and Clifford R.

Berry, DVM, Diplomate ACVR

Proper technique for routine lateral

and dorsoventral projections as well

as flexed, extended, and oblique

views, is described for cervical and

cervicothoracic radiography.

57 VITAL VACCINATION SERIESWhat You Need to Know About Rabies Richard B. Ford, DVM, MS, Diplomate

ACVIM & ACVPM (Hon)

Dr. Ford presents nine key questions that

address rabies immunization. The answers

address which agencies handle rabies law,

the definitions of exposure and vaccinated,

appropriate diagnostic testing, and more.

61 CONSIDER THIS CASEEstrus in a Spayed Cat Erin O. Dresner, DVM, MS, and Gary D.

Norsworthy, DVM, Diplomate ABVP (Feline)

An aging spayed female cat is presented

with signs typical of estrus. A history, physical

examination, and extensive diagnostics are

performed. Can you determine the diagnosis?

65 NEW DENTAL DIAGNOSISCanine Tooth FractureBrook A. Niemiec, DVM, FAVD,

Diplomate AVDC

A picture is worth 1000 words, and the

challenge is to determine what type of tooth

fracture is shown in this article as well as the

appropriate therapeutic action.

67 TOP TEN

Toxicoses in Dogs & CatsTina Wismer, DVM, Diplomate ABVT & ABT

In honor of Poison Prevention Week, Dr.

Wismer of the ASPCA’s Poison Control

Center reviews information gathered from

over 180,000 cases to name the “top ten”

types of poisonings in 2012.

72 TODAY’S TECHNICIANAssisting the Surgeon: Practical Strategies

for Preventing Nosocomial Infections Noah Jones, RVT

Postoperative patients are among those

at highest risk for nosocomial infection.

Strategies for disinfecting personnel,

equipment, and the surgical suite are

meticulously outlined.

80 THE BACK PAGEThe Future of Veterinary Medicine

Makes HeadlinesA Response From Our Editorial Team

March/April 2013 • Vol 3, No 2Contents

ColuMNs


67

50

28

72

61

todaysveterinarypractice.com • facebook.com/todaysveterinarypractice

6 Editor’s Note

7 Advertiser Index

8 Letters to the Editor

10 Today’s Veterinary News

77 Journal Club: Focus on Endocrinology


http://facebook.com/todaysveterinarypractice


Uniting Medical Professionals

That’s one of the reasons why I am very interested in the

“One Health” initiative—a worldwide effort to “promote,

improve, and defend the health and well-being of all species

by enhancing cooperation and collaboration between physi-

cians, veterinarians, and other scientific health and environ-

mental professionals.” This exciting international movement

complements the efforts of individual veterinary profession-

als to communicate with and educate those outside the pro-

fession, especially fellow medical colleagues.

The primary goals of this initiative are to:

• Advance biomedical research

• Enhance public health with regard to zoonotic and

infectious disease.

It is hoped that if we can open doors of communica-

tion between all health-related professions, we can facili-

tate the discovery–development–delivery paradigm and,

therefore, accelerate progress in clinical care and medical

education within all disciplines.

Health Care Leadership

Veterinarians have a long track record of using diagnos-

tic tests and therapies that have first been developed and

applied in people. And, of course, research in animals

is routinely used to study human illness and treatment.

But, consider how exciting it would be for veterinarians

to lead health care by developing and testing therapies

in pet animals with naturally occurring diseases that can

then be extrapolated to humans with the same diagnosis.

If the goals of the One Health initiative are achieved, we

can look forward to a future in which the medical commu-

nity works closely together, with a better understanding

about the similarities between animal and human disease

and the challenges each present.

I’m sure those questions about pet health that follow the

disclosure that I’m a veterinarian will never go away, but

wouldn’t it be wonderful if the questioner wasn’t surprised

to find out that dogs can get chronic bronchitis?

—Lesley King, Editor in Chief

How many of us have

been asked questions

about pet health as

soon as someone finds out

that we are veterinarians?

I was sitting in my doctor’s office recently, listening to a

nurse tell me about her beloved Yorkie and its worsening

cough. When I commented that her veterinarian might be

able to evaluate the dog for common conditions, such as

collapsing trachea or chronic bronchitis, she looked at me

in surprise and said, “Dogs can get chronic bronchitis?”

I’m sure that many others have had similar experiences,

when both “human” medical professionals and the lay

public are astonished to find out that animals can suffer

from the same disease conditions as people.

The Knowledge Gap

It is frustrating to confront this misconception. To me, it

suggests that these individuals have not given a great deal

of thought to the similarity of body systems between spe-

cies. If the pet has a trachea and bronchi, why wouldn’t chronic bronchitis be a possibility, just as it is in that other

animal, the human being?

The sad truth is that many members of the public, includ-

ing educated medical professionals, don’t recognize that

their much loved pets can be afflicted by diseases that also

affect humans. Further, they don’t realize that many of these

conditions can be treated, thereby improving the quality

and duration of life of their pets.

This lack of understanding can also manifest as a lack of

respect for veterinary professionals, especially in compari-

son to the esteem ascribed to human medical professionals.

Promoting the Profession

This combined lack of knowledge and respect regard-

ing veterinary medicine and its professionals highlights

the need for more successful marketing of the profession,

including ourselves. Lately, this has been a “hot” topic on

some online veterinary list servers (emails that facilitate

discussions among members of a group).

It seems that we, as a profession, might be able to seize

an opportunity: if we can make a special effort to commu-

nicate, educate, and collaborate with our human medicine

counterparts, we could advance their understanding of

animal illness and health and the role veterinarians play in

diagnosis and treatment, thereby enhancing our visibility

and status within the community.

Dogs Can Get Chronic Bronchitis? Lesley G. King, MVB, Diplomate ACVECC, ACVIM (Small Animal Internal

Medicine), & ECVIM (Companion Animal)

EdiTor’s NoTE

read more about the One Health Initiative at

onehealthinitiative.com. The One Health 4th Annual

Public Health Symposium takes place April 2, 2013, at

Colorado state University; learn more at publichealth.

colostate.edu/GPPH/2013Symposium.pdf.

http://onehealthinitiative.com

http://publichealth.colostate.edu/GPPH/2013Symposium.pdf

http://publichealth.colostate.edu/GPPH/2013Symposium.pdf


Advertiser Index

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AllPro Imaging, 53

scanx duo

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Bayer HealthCare Animal

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Bio-Response Solutions, 16

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Elanco, 56, 55

Trifexis Parasite Protection

888-545-5973 •

trifexis.com/vet

Hill’s Pet Nutrition, 5

Prescription diet Metabolic

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Hill’s Pet Nutrition, 7

Healthy Weight Protocol

diagnostic Tool

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IDEXX Laboratories, 60

snap 4dx Plus Test

idexx.com/snap4dxplus

Merck Animal Health, inside

front cover

nobivac Lyme Vaccine

merck-animal-health-usa.com/

lyme

Merck Animal Health, 25

Activyl (for dogs and cats)

us.activyl.com

Merck Animal Health, 27

Activyl TickPlus (for dogs only)us.activyl.com

Merial, 9

Previcoxprevicoxsweepstakes.com

Merial, 11

recombitek Lyme Vaccine merialconnect.com

Merial, 13

PureVax Feline rabies Vaccine merialconnect.com

Merial, 15

Frontline Tritak for dogs (select states) •

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Merial, back cover, inside back

Heartgard Plusheartgard.com

Midmark, 64

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Novartis, 45

Parastar PlusdogsneedAdventure.com

Putney, 39

Cefpodoxime Proxetil866-683-0660 •

putneyvet.com/howtobuy

Today’s Veterinary Practice, 71Website • tvpjournal.com

Virbac, 31, 32

iverhart Max800-338-3659 • virbacvet.com

Virbac, 33, 32

easOtic suspension800-338-3659 • virbacvet.com

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http://bioresponsesolutions.com

http://trifexis.com/vet

http://hillsvet.com/metabolic

http://hwp.hillsvet.com

http://idexx.com/snap4dxplus

http://us.activyl.com


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LeTTers To The ediTors

Dear Editor,

I wanted to send a quick note to say that I

thought Dr. Michael Schaer’s article, Internal

Medicine Practice Pearls (September/Octo-

ber 2012) was the most concise and valuable

piece of veterinary literature I have read in a

long, long time. As the newbies would say, “it

rocked!” I read every article and thought they

were all excellent. Great issue! Thanks and keep

it up!

—Krista Magnifico, DVM

Jarrettsville Veterinary Center

Jarrettsville, Maryland

When to Give Bordetella Boosters Dear Editor,

I read the article, Canine Vaccination Guidelines:

Key Points for Veterinary Practice (September/

October 2012) by Dr. Richard B. Ford and would

like to ask him a question:

Our veterinary clinic currently administers an ini-

tial intranasal or oral vaccine for Bordetella; only 1

initial vaccine is given. Subsequently, we administer

an injectable Bordetella vaccine on an annual basis,

with only 1 vaccine given annually.

Should we be administering a booster of the inject-

able Bordetella vaccine 2 to 3 weeks after the orig-

inal injectable vaccine is given? We have assumed

that the pet has an anamnestic response from the

initial nasal/oral vaccine; therefore, we do not

adminster a booster after the injectable is given.

—Jerry L. Pearson, DVM

Chillicothe Animal Clinic, Inc

Chillicothe, Ohio

Author Responds

The concept of vaccinating dogs against Bordetella

bronchiseptica infection using an initial intranasal (IN)

dose, followed by annual boosters using the parenter-

al (monovalent) Bordetella vaccine was advanced over

10 years ago following publication of 2 papers.1,2 However, in 2007, those conclusions were challenged.3

Today, most authors conclude that mucosal (local) im-

munity derived from IN administration of avirulent live

B bronchiseptica provides a superior level of protective

immunity compared to parenteral administration of a

(inactivated) cellular antigen extract. Recommendations

outlined in the 2011 AAHA Canine Vaccination Guidelines

(available at aahanet.org) reflect these findings.

In addition, while both parenteral and IN vaccines

have been shown to mitigate clinical signs in vac-

cinates following natural and experimental challenge,

postexposure shedding (of virulent B bronchisep-

tica) is significantly reduced (or

eliminated) in dogs vaccinated

with a single dose of IN vaccine.

However, dogs vaccinated with

the parenteral B bronchiseptica

vaccine experienced shedding

patterns comparable to unvacci-

nated controls.

The oral B bronchiseptica vac-

cine was licensed in 2012 and

has not yet been subjected to

comparative efficacy studies.

Other points to consider when

vaccinating dogs against canine infectious respiratory dis-

ease (“kennel cough”) include:

• Multiple pathogens other than B bronchiseptica can

cause acute-onset respiratory signs.

• Coinfection and comorbidity can be significant factors

in the clinical course of disease.

• Most of the IN B bronchiseptica vaccines also contain

attenuated parainfluenza virus, an important cofactor

in canine respiratory infections. Neither the oral nor the

parenteral B bronchiseptica vaccines provide protec-

tion against parainfluenza virus. This is an important

consideration when selecting vaccines for dogs housed

in high-density environments (eg, animal shelters, day

care facilities, etc).

• Onset of immunity: dogs are protected against B bron-

chiseptica following administration of a single dose of

either an IN vaccine or the oral vaccine. When admin-

istering the parenteral vaccine, 2 initial doses, 2 to 4

weeks apart, are essential.

• The duration of immunity against B bronchiseptica

challenge, following administration of a single dose of

the IN vaccine, has been shown to be 12 to 14 months.

The duration of immunity following oral or parenteral

vaccination is not known.

—Richard B. Ford, DVM, MS,

Diplomate ACVIM & ACVPM (Hon)

North Carolina State University

References

1. Ellis JA, Haines DM, West KH, et al. Effect of vaccination on experimental

infection with Bordetella bronchiseptica in dogs. JAVMA 2001; 218:367-375.

2. Ellis JA, Krakowka SG, Dayton AD, et al. Comparative efficacy of an inject-

able vaccine and an intranasal vaccine is stimulating Bordetella bronchi-

septica-reactive antibody responses in seropositive dogs. JAVMA 2002;

220:43-48.

3. Davis R, Jayappa H, Abdelmagid OY, et al. Comparison of the mucosal

immune response in dogs vaccinated with either an intranasal avirulent live

culture or a subcutaneous antigen extract vaccine of Bordetella bronchisep-

tica. Vet Therap 2007; 8:32-40.

Internal Medicine Pearls Rocked

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The Latest News in Veterinary Medicine

ANNOUNCEMENTS

National Pet ID Week

April 14 through 20 is National Pet ID Week,

which provides the perfect opportunity for

practices to emphasize the importance of pet

identification to clients. In addition to identifi-

cation tags on collars, microchips offer a per-

manent identification solution. Remind owners, however, that just implanting

the microchip is not enough—they need to make sure their pets are registered

and contact information keep up to date with the microchip manufacturer. The

AAHA’s website, HealthyPet.com, addresses 8 common myths about microchip-

ping at healthypet.com/petcare/petcarearticle.aspx?title=microchipping.

Pfizer Animal Health Becomes ZoetisPfizer, Inc, sold its former animal health business

unit and is now a standalone company named Zoetis

(zoetis.com), which began trading on the New York

Stock Exchange in February. “With the Zoetis initial public offering, we are

creating the largest standalone company fully devoted to animal health medicines

and vaccines. For Pfizer, we are better positioned to focus on our core business

as an innovative biopharmaceutical company.” said Ian Read, Chairman and Chief

Executive officer of Pfizer.

Canine Cancer Treatments in DevelopmentAbbott Animal Health (abbott.com) has expanded its veterinary oncology

pipeline through an exclusive agreement with Oasmia Pharmaceutical AB. The

agreement grants Abbott global distribution

rights to Paccal Vet and Doxophos Vet, two

human-grade cancer treatments in development

for use in dogs. Paccal Vet and Doxophos Vet are

novel formulations containing paclitaxel, a frequently used chemotherapeutic

agent, and doxorubicin, a common anticancer medication in human and

veterinary oncology, respectively. “We are pleased that this agreement will allow

us to potentially introduce new [canine] cancer treatment options not only in

North America but throughout the world,” said Andrea Wainer, divisional vice

president and general manager, Abbott Animal Health.

Please send any news, press releases, or information relevant to veterinary professionals to KSoldavin@

todaysveterinarypractice.com for publication consideration in Today’s Veterinary News.

For more veterinary news, go to Facebook.com/TodaysVeterinaryPractice

NEW PRODUCTS

Generic Cefpodoxime

Proxetil Introduced

Putney (putneyvet.com)

has introduced its generic

form of cefpodoxime prox-

etil tablets, which are FDA-

approved for veterinary use

and available in 100- and

200-mg tablets in 100-count

bottles. Currently, only 6% of

FDA-approved brand name

pet medications have a ge-

neric equivalent compared

to more than 80% of human

generic prescription drugs.

Putney is specializing in de-

veloping high-quality, gener-

ic medications for pets with

carprofen caplets and ket-

amine HCl for injection C-III

available as well. Additional

information is available on

the company’s website.

http://HealthyPet.com

http://healthypet.com/petcare/petcarearticle.aspx?title=microchipping

http://zoetis.com

http://abbott.com


http://Facebook.com/TodaysVeterinaryPractice

http://putneyvet.com

®RECOMBITEK is a registered trademark of Merial. ©2012 Merial Limited, Duluth, GA. All rights reserved. REC12NARECOMBITEKAD (12/12).

1 Straubinger RK, Chang YF, Jacobson RH, Appel MJ. Sera from OspA-vaccinated dogs, but not those from tick-infected dogs, inhibit in vitro growth of Borrelia burgdorferi. J Clin Microbiol. 1995;33(10):2745-2751.2 Rice Conlon JA, Mather TN, Tanner P, Gallo G, Jacobson RH. Effcacy of a nonadjuvanted, outer surface protein A, recombinant vaccine in dogs after challenge by ticks naturally infected with Borrelia burgdorferi. Vet Ther. 2000;1(2):96-107.3 Probert WS, Crawford M, Cadiz RB, LeFebvre RB. Immunization with outer surface protein (Osp) A, but not OspC, provides cross-protection of mice challenged with North American isolates of Borrelia burgdorferi. J Infect Dis. 1997;175(2):400-405.

Give dogs all the Lyme protection they need and none of the antigens they don’t.

It only takes a single protein, OspA, to block the transmission of Borrelia burgdorferi in the United States.1,2,3

Protect your patients with nothing less, expose them to nothing more.

RECOMBITEK® Lyme - the only vaccine with OspA in a nonadjuvanted formula



ANNOUNCEMENTS

New Name for Brushless Oral CarePKB Animal Health, Inc (petkingbrands.com), has announced that

their Biotene Veterinarian Brushless Oral Care line for pets has changed

its brand name to Oratene Veterinarian

Brushless Oral Care. These brushless

products reduce odor-causing bacteria

and dissolve plaque biofilm, which

is accomplished through a patented

enzyme system. The Oratene line

includes a maintenance oral gel, breath

freshener spray, drinking water additive,

and antiseptic oral gel; all are safe for

dogs and cats and available exclusively

through veterinarians.

VCA West Los Angeles Opens New HospitalEarly this year, VCA West Los Angeles (vcahospitals.com/west-los-

angeles) opened its newly-constructed, 42,000 square feet animal

hospital, making it the largest

small animal hospital in the

western United States. The new

hospital features state-of-the-

art diagnostic and treatment

features, including a linear

accelerator room for cancer patients, MRI and CT imaging, physical

therapy center, bone marrow transplant technology, pituitary tumor

surgery facilities, and cutting edge surgical suites. The hospital is staffed

by board-certified specialists in all areas of veterinary medicine. “We’re

excited to bring this level of veterinarian services to the pet owners and

referring veterinarians of West Los Angeles and surroundings areas,” said

Dr. David Bruyette, VCA West Los Angeles’ Medical Director.

CONFERENCES & EDUCATION

Practice Management Software SummitImproMed, LLC (impromed.com), and McAllister Software Systems,

LLC (avimark.net), are hosting a 3-day Veterinary Technology Summit

in St. Louis, September 18 through

20, 2013. The goal of the Summit is to

bring together practice management

software users in order for them to

gain useful insight from each other and form connections within the

industry. Attendees will receive hands-on training for the AVImark and

ImproMed veterinary software solutions, have the opportunity to earn

RACE-approved CE credit, and be able to browse vendor partner booths.

Learn more and register at vetsummit.com.


NEW PRODUCTS

Canine Oncology Therapy Bioniche Life Sciences, Inc, a re-

search-based Canadian biophar-

maceutical company, introduced

Immunocidin canine oncology

therapy to the North American

market. Immunocidin is an im-

munotherapy for the intratumor-

al treatment of mixed mammary

tumor and mammary adenocar-

cinoma in dogs. Mycobacteria

have been known for many years

to have antitumor activity. Immu-

nocidin is an emulsion of myco-

bacterial cell wall fractions that

have been modified to reduce

their toxic and allergic effect but

retain their anti-tumor activity.

Immunocidin stimulates the ac-

tivation of macrophages and thy-

mic lymphocytes, which destroy

tumor cells. According to Andrew

Grant, President, Bioniche Animal

Health, “We believe there is a tre-

mendous opportunity for a prod-

uct like Immunocidin that does

not require special handling and

can be used by veterinarians in

their own clinics, either alone or

in combination with other thera-

pies.” For more information, call

888-549-4503 in the U.S. or visit

bionicheanimalhealth.com.

http://petkingbrands.com

http://vcahospitals.com/west-los-angeles

http://impromed.com

http://avimark.net

http://vetsummit.com

http://bionicheanimalhealth.com

http://vcahospitals.com/west-los-angeles

®PUREVAX, IMRAB and RECOMBITEK are registered trademarks, SMMERIALconnect.comis a service mark, and TM the Canarypox Technology logo is a trademark, of Merial.©2013 Merial Limited, Duluth, GA. All rights reserved. PUR12PBRABIESAD-R2 (12/12).

1 Greene CE, Levy JK: Chapter 100 Immunoprophylaxis, in Greene CE (Ed.): Infectious Diseases of the Dog and Cat, 4th ed. Philadelphia, Saunders Elsevier; 2012:1163-1205.

2 Day MJ, Schoon HA, Magnol JP, et al. A kinetic study of histopathological changes in the subcutis of cats injected with non-adjuvanted and adjuvanted multi-component vaccines. Vaccine 2007;25:4073-4084.

3 Data on file with Merial.

From the makers of:

• Reduces the potential risks associated with adjuvants, such as injection site reactions,

injection site granuloma and chronic inflammation1,2

• Over 10 years of safe and effective use3

• Recombinant canarypox-vectored vaccines stimulate a comprehensive immune response1

• Available as a single antigen and in combination with RCP and RCCP

Together, that means pure protection for cats

and kittens, and peace of mind for you. For more

information,visit MERIALconnect.comSM.

PUREVAX® Feline Rabies vaccine:

Y O U R C A R E . O U R S C I E N C E .

THE ONLY NONADJUVANTED FELINE RABIES VACCINE.

http://SMMERIALconnect.com



Simplified Insurance for Practitioners & Pet Owners

Trupanion (trupanion.com), which owns and is underwritten by the

American Pet Insurance Company, has launched Trupanion Express, a

new desktop application that can be installed and viewed on practice com-

puters in 15 minutes, and is compatible

with all veterinary practice management

systems. “Trupanion Express enables Tru-

panion to pay claims at the time of invoicing and pay veterinarians directly,

so clients do not have to come up with hard-earned money up front.” said

Howard Robin, Chief Operating Officer. In addition, there are no transac-

tion fees, no administration costs, and no other costs to veterinarians and

their clients associated with use of the software. For further information,

call 800-569-7913 or visit the company’s website.

Organic Odor Control & Cleaner

Alpha Tech Pet, Inc (alphatechpet.com), has introduced OdorPet, an

organic, biodegradable odor counteractant

and cleaner with a near neutral pH. Its

bioactive formulation of stabilized bacterial

spores produces enzymes that break down

immediately and over time in the presence of

organic animal debris, reducing it to a solution

of carbon dioxide and water. This product can

be used on carpeting, furniture, pet bedding,

carriers, indoor and outdoor surfaces, and

litter boxes, and is available in concentrated

or ready-to-use formulations. OdorPet can be ordered directly from the

Alpha Tech Pet website.

PRACTICE RESOURCES

Feline Environmental

Guidelines AvailableThe American Association of Fe-

line Practitioners (AAFP, catvets.

com) and International Society

of Feline Medicine (ISFM, isfm.

net) have released the Environ-

mental Needs Guidelines, which

have been published in the March

issue of the Journal of Feline Medi-

cine and Surgery. The Guidelines

address the needs of pet cats in

any environment, including home,

veterinary hospital, and shelter. By

incorporating these recommenda-

tions, veterinarians and cat own-

ers can help reduce unwanted be-

havior, illness and feline stress,

and improve relationships with

the cats in their practices and lives.

To view the Environmental Needs

Guidelines, visit catvets.com/

guidelines.

NEW PRODUCTS

Two New Dermatology Products

Dechra Veterinary Products (dechra-us.com) has added two new prod-

ucts to their veterinary dermatology line—EpiTreats Healthy Canine

Snacks and Gentacalm Topical Spray. EpiTreats Snacks contain a hydro-

lyzed protein and single carbohydrate source and can be used as a reward

and treat for dogs, including those with skin sensitivities, of all ages. Gen-

tacalm Spray is used for the treatment of dogs with infected superficial

lesions caused by bacteria susceptible to the broad-spectrum antibiotic

gentamicin. Its other ingredient, betamethasone valerate, provides anti-

inflammatory and antipruritic activity. Read more about these products

on the company’s website.


Veterinary Products Catalog Animal Health International’s

Spring 2013 Veterinary Products

Catalog is now available online

at animalhealthinternational.

com/VetGuide2/2013VetGuide.

html. The catalog offers a selec-

tion of products from hundreds

of key manufacturing partners

ranging from equipment and vac-

cines to surgical supplies and

pharmaceuticals, providing choic-

es to best fit the needs of the vet-

erinary practice.

http://trupanion.com

http://alphatechpet.com

http://dechra-us.com

http://catvets.com/guidelines

http://catvets.com/guidelines

When clients buy FRONTLINE® Plus from you, they get more. They get

proven ingredients that kill adult feas, eggs, and larvae, as well as ticks.

They also get peace of mind from the vet exclusive SATISFACTION

PLUS GUARANTEETM – if they aren’t completely satisfed, they call

us directly for technical help and if eligible* we’ll give them a

replacement, a refund, or a one-time visit from TERMINIX® to

inspect and treat their home, if necessary. That’s all there is to it.

The science that’s in it.

The exclusive guarantee behind it.

–

®FRONTLINE is a registered trademark, and ™SATISFACTION PLUS GUARANTEE is a trademark, of Merial. ®TERMINIX is a registered trademark of the Terminix International Limited Partnership. ©2012 Merial Limited, Duluth, GA. All rights reserved. FLE12PBTRADEADGRMN (12/12).

*For more information and complete details visit FRONTLINE.com

http://FRONTLINE.com



CONFERENCES & EDUCATION

Excellent Experiences at WVCNearly 14,500 attendees, includ-

ing 6000 veterinarians, 1500 vet-

erinary technicians and practice

managers, 500 veterinary and tech-

nician students, and 3500 exhibi-

tors, partici-

pated in the

“Dr. Jack

W a l t h e r ”

85th Annu-

al Western Veterinary Conference

(WVC, wvc.org), February 17 to

21, 2013, in Las Vegas. More than

87% of attendees surveyed rated

their overall experience as “excel-

lent” or “very good,” and about

90% gave the same ratings for the

quality and professionalism of

the scientific sessions. This year’s

conference name honored WVC

Clinical Proficiency Coordinator,

Dr. Jack Walther, a conference at-

tendee for over 4 decades who has

been a driving force behind WVC’s

success and a leader in the area of

student scholarships.

Radiology Summit for ACVIM

MembersThe American College of Veteri-

nary Internal Medicine (ACVIM,

acvim.org) and Infiniti Medical,

LLC (infinitimedical.com), are

offering the Veterinary Interven-

tional Radiology Summit at the

Oquendo Center for Clinical Edu-

cation in Las Vegas. This 8-hour

practicum for ACVIM members

combines “how to” lectures and

laboratory training in vascular and

nonvascular image-guided proce-

dures. The first course was held

March 8; two additional courses

will be offered on June 29 and

November 2, 2013. For more in-

formation and to register, visit the

ACVIM’s website, contact Infiniti

Medical at 650-327-5000, or email

[email protected].

AWARDS

2013 Veterinary Excellence AwardsPetplan Pet Insurance (gopetplan.com) awarded the 2013 Veterinary Ex-

cellence Awards on February 17 in Las Vegas. The winners, chosen from

2200 nominations, were: Veterinarian of the Year: Dr. Natalie Marks,

Blum Animal Hospital, Chicago, IL; Practice Manager of the Year: Su-

zanne Cross, Brighton-Eggert Animal Clinic, Tonawanda, NY; and Vet-

erinary Technician of the Year: Kim Franck, Adamstown Veterinary Hos-

pital, Denver, PA. Each recipient received $1000 to donate to the animal

charity of her choice and has been invited to participate in judging for

the 2014 awards.

Left to right: Natasha Ashton, Dr. Natalie Marks, Kim Franck;

Suzanne Cross, and Chris Ashton


http://wvc.org

http://acvim.org

http://infinitimedical.com


http://gopetplan.com


Preventive insecticides sPecies indications

MONTHLY CHEWABLE TABLETS

Heartgard(Merial)

Ivermectin Dogs (≥ 6 wks)Cats (≥ 6 wks)

• Preventsheartwormdisease

HeartgardPlus(Merial)

IvermectinPyrantel

Dogs (≥ 6 wks)Not for use in cats

• Preventsheartwormdisease• Treatsandcontrolsroundwormsandhookworms

Interceptor(Novartis)

Milbemycin oxime

Dogs (≥ 4 wks, > 2 lb )Cats (≥ 6 wks, > 1.5 lb)

• Preventsheartwormdisease• Dogs:Treatsandcontrolsroundworms,hookworms,andwhipworms

• Cats:Treatsandcontrolsroundwormsandhookworms

IverheartMax(Virbac)

IvermectinPraziquantelPyrantel

Dogs (≥ 8 wks, ≥ 6 lb)Not for use in cats

• Preventsheartwormdisease• Treatsandcontrolsroundworms,hookworms,andtapeworms

IverheartPlus(Virbac)

IvermectinPyrantel


• Preventsheartwormdisease• Treatsandcontrolsroundwormsandhookworms

Sentinel(Novartis)

LufenuronMilbemycin

oxime


• Preventsheartwormdisease• Treatsandcontrolsroundworms,hookworms,andwhipworms

• Controlsfleapopulations

Trifexis(Elanco)

Milbemycin oxime

Spinosad


• Preventsheartwormdisease• Treatsandcontrolsroundworms,hookworms,andwhipworms

• Preventsdevelopmentoffleaeggs

MONTHLYTOPICALSOLUTIONS

AdvantageMulti(Bayer)

Imidacloprid Moxidectin

Dogs (≥ 7 wks, > 3 lb )Cats (≥ 9 wks, > 3 lb)

• Preventsheartwormdisease• Killsroundworms,hookworms,andwhipworms• Killsfleasandfleaeggs• Treatsandcontrolsearmiteinfestations

Revolution(Pfizer)

Selamectin Dogs (≥ 6 wks)Cats (≥ 8 wks)

• Preventsheartwormdisease• Killsroundwormsandhookworms• Killsfleas,fleaeggs,andticks• Treatssarcopticmange(dogs)andcontrolsearmiteinfestations

ONE-TIME CHEWABLE TABLET

Cestex(Pfizer)

Epsiprantel Dogs (≥ 7 wks)Cats (≥ 7 wks)

• Killstapeworms

Droncit(Bayer)

Praziquantel Dogs (≥ 4 wks)Cats (≥ 6 wks)

• Killstapeworms

Drontal(Bayer)

Praziquantel Pyrantel

Cats (≥ 4 wks, > 1.5 lb) • Killsroundworms,hookworms,andtapeworms

DrontalPlus(Bayer)

Febantel Praziquantel Pyrantel

Dogs (> 3 wks; > 2 lb) • Killsroundworms,hookworms,tapeworms,andwhipworms

ONE-TIMETOPICALSOLUTION

Profender(Bayer)

Emodepside Praziquantel

Cats (≥ 8 wks) • Killsroundworms,hookworms,andtapeworms

Caution:Studieshaveindicatedthatcolliesandcertainherdingbreedsofdogsaremoresensitivetotheeffectsofavermectins.

To view Product Profiles coveringcommonfleaandtickpreventivemedications,gototodaysveterinarypractice.com and select Resourcesfromthetopnavigationbar;ProductProfilescanbedownloadedandprintedforuseinyourclinic.

Today’s Veterinary Practice PRODUCTPROfILE

Common HEARTWORM PREVENTIVE & INTESTINAL PARASITE mediCations for dogs & Cats

This table can be downloaded and printed for use in your practice at todaysveterinarypractice.com (see Resources).




Vomiting is a very common clinical complaint

in both dogs and cats. It is also a clinical sign

seen in diseases of many body systems. Clini-

cians must avoid assuming vomiting is synonymous

with gastrointestinal (GI) disease.

DEFINITION

Vomiting is the active expulsion of gastric, some-

times duodenal, contents and is typically preceded

by apparent nausea and retching. However, it can

often be confused with:

• Regurgitation associated with esophageal disor-

ders

• Gagging/coughing associated with respiratory

disease

• Oropharyngeal dysphagia.

CLINICAL SIGNS

Key elements of vomiting are:

• Forceful abdominal contractions (one of the

most reliable ways to confirm vomiting)

• Retching and presence of bile.

A thorough history will usually confirm whether

the pet is vomiting. If doubt remains, attempt to visu-

alize the behavior by asking the owner to video it

or provocatively feeding the patient in the hospital.

GI INTErvENTION

P. Jane Armstrong, DVM, MS, MBA,

Diplomate ACVIM

Peer reViewed

Approach to diagnosis and Therapy of the

VomiT ing P a T i e n T

In a large national survey, GI signs

accounted for 4% of visits at

primary care clinics.1


gi inTerVenTion: aPProach To Diagnosis anD TheraPy of The VomiTing PaTienT |

Be cautious in overinterpreting the timing of the

event in relation to consumption of meals. In some

cases, regurgitating animals can passively expel esoph-

ageal or gastric contents hours after ingestion of a

meal.

PATHOPHYSIOLOGY

Vomiting is a complex, protective reflex that occurs

in carnivores but is not well developed in all species.

Although several afferent pathways may be responsi-

ble for initiating emesis, it is coordinated by the emetic

(or vomiting) center in the medulla (Table).

An important concept of vomiting is that it occurs

through activation of the:

• Chemoreceptor trigger zone (CRTZ) by blood-borne

substances (humoral pathway)

•Emetic center by vagosympathetic, vestibular, or

cerebrocortical neurons (neural pathway).

Many spontaneous vomiting disorders of cats and

dogs, particularly those due to primary GI disease, are

believed to result from activation of the neural pathway.

• Visceral afferent input to the emetic center arises

from receptors located throughout the body.

• Most are distributed in the abdominal viscera, with

the largest number in the duodenum.

• Visceral receptors are sensitive to chemical irrita-

tion, inflammation, distention, and changes in

osmolality.

Several neurotransmitters and their respective recep-

tors stimulate the emetic center; these form the basis

for antiemetic classification.

CHrONIC vOMITING

Chronic vomiting is commonly defined as persistent

vomiting of variable frequency and, typically, duration

of 3 weeks or longer.

In cases of chronic vomiting, relatively extensive diag-

nostic evaluation is almost always warranted in order

to determine a cause rather than solely providing sup-

portive and symptomatic care. See Determining Rea-

sons for Vomiting & Appropriate Diagnostics, page

21, for further information. The remainder of this over-

view will focus on acute vomiting.

ACUTE vOMITING: DIAGNOSTICS

Acute vomiting is commonly defined as vomiting of

variable frequency over a period of less than 7 days,

although, in practical terms, acute vomiting is usually

of 1 to 3 days’ duration since owners will commonly

seek medical attention within this interval.

From the signalment, history, and physical examina-

tion, the clinician should be able to:

1. Categorize the patient as:

• Stable, with no criteria for further immediate

assessment or treatment

• Unstable, with 1 or more criteria for intervention.

2. Establish a differential list.

3. Identify appropriate diagnostic interventions and

therapy.

Table. Four Main Stimulating Pathways

of the Vomiting Center

1. Peripheral Sensory receptors• intra-abdominal

» stomach, intestines, pancreas, liver, gallbladder, peritoneum, kidneys, ureter, urinary bladder

» Visceral afferent fibres in sympathetic and vagal nerves

•heart and large vessels via vagus nerve•Pharynx via glossopharyngeal nerve

2. Stimulation of the Chemoreceptor Trigger

Zone•Uremia•electrolyte imbalances•Toxins•Drugs

3. vestibular Input• inflammatory disorders•motion sickness via acoustic nerve

4. Higher Central Nervous System Centers

•Psychogenic (eg, fear, stress, excitement) via catecholamine release• inflammatory cns lesions

Courtesy Susan Little, DVM, Diplomate ABVP (Feline Practice);

modified with permission

Mild Acute vomiting

Pets with a history of mild, acute vomiting (with or with-

out concurrent diarrhea) that have a normal physical

examination and no other concurrent signs usually have

self-limiting signs and can be treated symptomatically or

simply monitored. In such cases, signs resolve after 1 to 2

days, with or without supportive therapy.2

The suggested minimum diagnostic evaluation of a

healthy vomiting animal includes:

• Packed cell volume and total protein (provides a crude

assessment of hydration status)

• Fecal flotation.

Even with more extensive diagnostic evaluation, a diag-

nosis may not be reached unless the history suggests a

likely cause, such as dietary indiscretion.

Cats appear to be less likely than dogs to present with

acute, self-limiting vomiting (“acute gastritis”) and are rel-

atively more likely than dogs to require diagnostic investi-

gation and treatment.3 Feline acute hemorrhagic vomiting

syndrome has been reported in the UK.3 This self-limiting

syndrome occurs in cats in rescue shelters and catteries;

etiology has yet to be determined.

Severe Acute vomiting

Some characteristics of acute vomiting may indicate

serious, even potentially life-threatening, diseases and

| gi inTerVenTion: aPProach To Diagnosis anD TheraPy of The VomiTing PaTienT


Maropitant: A Multimodal Antiemetic maropitant citrate (cerenia, zoetis.com), a potent selective nK1 receptor antagonist, plays an important role in managing vomiting, mediated via both the vomiting center and crTZ (ie, humoral and neural pathways).3-5 The drug is effective for: • Prevention of motion sickness in dogs• chemotherapy-induced nausea and vomiting

• management of vomiting due to other causes.

Nauseanausea cannot be reliably assessed in animals, but signs interpreted as nausea include salivation, increased frequency of or exaggerated swallowing motions, and licking of lips. a recent study evaluating maropitant as an antiemetic for dogs premedicated with hydromorphone found that maropitant effectively prevented vomiting, retching, and nausea associat-ed with hydromorphone administration.6

AnalgesiaTwo recent studies indicate that maropitant also provides vis-ceral analgesia in dogs and cats.7,8 During visceral ovarian and ovarian ligament stimulation, maropitant decreased anesthet-ic requirements. This analgesic property makes maropitant especially suitable for managing vomiting caused by painful intra-abdominal conditions, such as pancreatitis and cholan-gitis, and painful gastric or intestinal disorders. Note: At this

time, this use of maropitant should only be considered adjunc-

tive to other methods of pain control.

Administrationcommon doses for maropitant are given in Medications for

vomiting: Dogs & Cats, page 26. maropitant is commonly administered off label in both dogs and cats. hickman and colleagues reported on the pharmacokinetics of Po, sc, and iV use in cats.5 Because maropitant is metabolized by the liver, a lower dosage of 0.5 mg/kg iV is sometimes used for treatment or prevention of vomiting in both species, if there is concern about liver function.

The label states that using cerenia for treatment or preven-tion of acute emesis should not last longer than 5 consecutive days. • maropitant has nonlinear pharmacokinetics in dogs.

Pharmacokinetic studies conducted since the approval of cerenia have shown that a steady state is reached in dogs in 4 days (at 2 mg/kg daily). a steady state is reached in cats in 7 days. • another reason for this concern is that, if vomiting persists

longer than 5 days, the underlying cause needs to be thor-oughly reinvestigated. in dogs, the injectable solution and tablets may be used

interchangeably for once daily dosing to prevent acute vomiting.

Safetycerenia has been tested for safety in both dogs and cats at 1×, 3×, and 5× the label dose for 15 days (3× the duration of treatment recommended on the label) as required by the fDa.

warrant immediate diagnostic investigation

and treatment. This category includes patients

with:

• Hematemesis (vomiting blood) or melena

• Frequent vomiting (8–10 times in 1 day)

• Concurrent signs (such as anorexia; lethar-

gy; fever; apparent abdominal pain; or pale,

“muddy,” congested, or jaundiced mucous

membranes).

Diagnostic evaluation is mandatory to attempt

to determine the underlying cause and guide

therapy, and includes:

• Survey abdominal radiographs

• CBC, serum biochemical profile, urinalysis

• SNAP Parvo Test (idexx.com) (puppies or kit-

tens), regardless of vaccination history.

Additional diagnostic studies may include fur-

ther laboratory testing, such as:

• Canine or feline pancreatic lipase (Spec cPL

or fPL Tests, idexx.com)

• Resting cortisol and/or adrenocorticotropic

hormone (ACTH) stimulation testing

• Abdominal ultrasonography

• Upper GI endoscopy and/or barium contrast

series

• Surgical exploration of abdomen.

ACUTE vOMITING: MEDICAL THErAPY

The goals of symptomatic or supportive thera-

py for acute vomiting are:

• Treating or removing the underlying cause

• Controlling the vomiting episodes

• Addressing abdominal pain, if present

• Correcting the fluid, electrolyte, and acid–

base abnormalities that may occur as a con-

sequence of frequent vomiting.

Antiemetic Therapy

Antiemetic therapy is warranted when:

1. Vomiting is frequent or severe, making the

animal uncomfortable

2. Persistent vomiting puts the animal at risk

for aspiration pneumonia or acid–base and

electrolyte disturbances

3. The animal is not suffering from GI obstruc-

tion or toxicity.

Antiemetics control emesis by either central

or peripheral blockade of neurotransmission at

receptor sites (see Medications for Vomiting:

Dogs & Cats, page 26).

• In the emetic center, neurokinin (NK)1

receptors and alpha-2 adrenergic receptors

are the most clinically important. Selective

NK1 receptor antagonists (ie, maropitant)

act by blocking the binding of substance P

within the emetic center and CRTZ; there-

fore, they uniquely inhibit vomiting through

both the humoral and neural pathways.

http://zoetis.com

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Vomiting can be caused by a wide variety of gi, intra-abdominal, metabolic, systemic, and neurologic diseas-es. an efficient clinical approach is to determine wheth-er vomiting results from a: • Primary gi problem• metabolic problem secondarily causing gi signs.

CLINICAL APPrOACHPrimary disease is most likely when:• an abnormality is palpable in the gut (eg, foreign

body, intussusception).• Vomiting is associated with significant diarrhea. • if the animal is otherwise historically and clinically

normal. in the case of an animal with acute vomiting, it is

important to rule out obstructions or other disorders that might require emergency surgical intervention.

in chronic vomiting, emergency surgical procedures are usually not needed. in that case, it is less invasive, less expensive and usually faster to first investigate whether a metabolic problem is causing secondary gi signs with appropriate laboratory tests; then investigate primary gi disease if clinical pathology results are normal.

CAUSES & DIAGNOSTICSThe many causes of vomiting pose a challenge when determining the degree of diagnostic evaluation warrant-ed. This clinical decision is largely based on:• chronicity and frequency of vomiting• Presence or absence of other historical and/or physi-

cal examination abnormalities.

Dogsrosé & colleagues. in a recent publication, 213 dogs that had vomiting as the main, or one of the main, signs were evaluated at a referral institution to determine which diagnostic tests were of greatest value.10 a diag-nosis was reached in 203 dogs (95.3%). see Tables 1 and 2 for study results. overall, there was a high inci-dence of nongastrointestinal diseases, especially renal, which emphasizes the need to perform a urinalysis in association with a serum biochemical profile in most animals with vomiting as the major complaint.

Leib & colleagues. in another study, the diagnos-tic utility of abdominal ultrasound was evaluated in 89 dogs with chronic vomiting.11 Ultrasound examination was considered to be vital or beneficial to diagnosis in 22.5% of dogs. increasing age and a final diagnosis of gastric adenocarcinoma or gi lymphoma were associ-ated with increased diagnostic utility.

CatsBatchelor & colleagues. a recent evidence-based review of mechanisms, causes, diagnostic investigation, and management of vomiting in cats evaluated the most common causes (Table 3).2

most notable is the fact that vomiting in cats might be associated with a wide range of diseases originating outside of the gi tract, such as neoplasia, splenic dis-ease, infectious disorders, chronic nasal disease, pyo-thorax, aortic thromboembolism, and bronchial disease. however, the authors noted that further exploration was needed and vomiting may have been incidental.

Additional causes. cats frequently vomit trichobe-zoars (hairballs) and also vomit after administration of alpha-2 adrenergic drugs, such as xylazine and dexme-detomidine, reflecting the importance of these recep-tors in the brainstem areas that control vomiting.12,13

Table 1. Diagnoses by Category10

1. gastrointestinal (43.7%)2. systemic (27.7%)3. nongastrointestinal abdominal (16.4%)4. miscellaneous (6.1%)5. neurological (1.4%)

Primary GI Disease Diagnostics • survey and contrast radiographs • abdominal ultrasonography • endoscopy • exploratory laparotomy

Table 2. value of Diagnostic Tests10

Enabled Diagnosis

Assisted Diagnosis

Blood analysis 12.2% 26.8%

Cytology 3.3% 4.2%

Fecal analysis 6.6% 1.4%

radiographs 1.9% 8.5%

Ultrasound 5.2% 17%

Urinalysis 2.3% 9.9%

Table 3. Common Causes of vomiting in Cats2

vomiting (Overall)

• adverse reactions to food• infectious agents, such as panleukopenia and

feline infectious peritonitis• acute self-limiting emesis of undetermined cause

(so-called “acute gastritis”)

Chronic vomiting

• inflammatory bowel disease• adverse reactions to food• Liver disease• Uremia• hyperthyroidism

determining reasons for Vomiting & Appropriate diagnostics



• In the CRTZ in dogs, dopamine and histamine are

significant neurotransmitters, making dopaminergic

and histaminergic receptor antagonists important anti-

emetic classes.

• In the CRTZ in cats, alpha-2 adrenergic and 5-HT3

serotonergic receptors are the significant neurotrans-

mitters.

Specific Notes. An antiemetic is commonly admin-

istered concurrently with a prokinetic agent. In addi-

tion, antiemetics with different modes of action may

be combined in patients with refractory vomiting.• Maropitant, ondansetron, and dolasetron are very

effective antiemetics for cats.

• In dogs with uremia, the central component of vomit-

ing can be treated with antiemetics; the peripheral

component is best treated with gastroprotectants.

• Chemotherapy drugs induce vomiting by stimulating

5-HT3 serotonergic receptors; effective antiemetics

include dolasetron, maropitant, and ondansetron.

Metoclopramide is less effective but less expensive; if

administered to dogs, it should be used at high doses

(1 mg/kg).

• Metoclopramide is considered a weak prokinetic agent.

Higher doses (up to 4 mg/kg/day CRI or 1 mg/kg PO Q

8 H) are occasionally used in dogs but patients must

be carefully monitored for extrapyramidal side effects.

Side Effects. The main side effects of antiemetics

include:

• Systemic hypotension: Chlorpromazine and pro-

chlorperazine

• Sedation: Phenothiazines (chlorpromazine and pro-

chlorperazine), antihistamines, and yohimbine

• Behavioral changes (eg, dose-related excitation):

Metoclopramide

Only administer chlorpromazine or prochlorperazine

if the patient is normotensive or is receiving adequate IV

fluid support. These drugs were thought to reduce the sei-

zure threshold but clinical experience suggests they can

be used in patients with seizure disorder histories.

Patients with GI obstruction should not receive proki-

netic agents, including metoclopramide. However, many

experienced clinicians report that serious adverse effects

have not been seen when these agents have been inadver-

tently given to such patients, with the exception of those

with linear foreign bodies.

Gastroprotective or Cytoprotective Agents

Peripheral pathways are mediated through irritation and

inflammation of the GI mucosa. Therefore, another com-

mon approach to therapy is administration of gastropro-

tective agents, such as drugs that:

• Inhibit gastric acid production: H2 histaminergic

receptor antagonists and proton pump inhibitors

• Act locally on the gastric mucosa: Sucralfate.

Histamine H2 receptor Antagonists

Histamine H2-receptor antagonists are the most commonly

used drugs to manage gastric ulceration or severe gastritis.

These agents competitively block the H2 receptor on the

parietal cell, reducing gastric acid secretion.

• Cimetidine is the least potent of the H2 receptor

antagonists and also inhibits the cytochrome P-450

enzyme system, potentially altering metabolism of co-

administered drugs that are metabolized by the same

enzyme system.

• Ranitidine also inhibits the cytochrome P-450 enzyme

system, but much less so than cimetidine.

• Famotidine and nizatidine are more potent than

cimetidine and famotidine and do not inhibit the

cytochrome P-450 enzyme system. In addition, they

might stimulate gastric emptying in the cat and dog by

inhibiting acetylcholinesterase activity.

Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are currently the most

potent inhibitors of gastric acid secretion. They irrevers-

ibly block the gastric proton pump (hydrogen-potassium

ATPase), causing a marked decrease in gastric acid secre-

tion.

PPIs are recommended for use in small animals diag-

nosed with severe reflux esophagitis or gastric ulceration.

• Omeprazole (0.7 mg/kg PO Q 24 H, dogs and cats) is

now available over the counter, markedly reducing its

cost and increasing its availability and usage in small ani-

mals. It has come into common use (perhaps overuse) in

vomiting animals without hematemesis.

• Pantoprazole (0.7–1 mg/kg PO or IV PO Q 24 H, dogs

and cats) is a newer PPI available for oral or IV use.

Sucralfate

Sucralfate (0.25–1 g PO Q 8–12 H, dogs and cats) is a

basic aluminum salt of a sulfated disaccharide that selec-

tively binds to proteins at sites of ulceration.

• This drug has a sustained local protective effect

against acid, pepsin, and bile at the ulcer site, forming

a protective barrier.

• It also increases the luminal concentration of prosta-

glandin E2, which protects against ulcerogenic factors.

• Because sucralfate is not absorbed from the GI tract, it

has virtually no systemic toxicity.

Constipation is a rare side effect that occurs because

of the aluminum moiety. Sucralfate may also inhibit the

absorption of other drugs, including doxycycline and,

potentially, H2 receptor antagonists.

Prokinetic Agents

Agents that enhance gastrointestinal motility may be

indicated for:

• Vomiting associated with delayed gastric emptying

• Vomiting caused by gastritis, metabolic derangements,

and postoperative gastric dilatation volvulus

• Dogs that vomit bile in the morning prior to eating

(bilious vomiting syndrome).

Therapeutic choices for prokinetics include:

• 5-HT4 serotonergic agonists: Cisapride, metoclo-

pramide



MoTion SiCkneSS: HelPing PeTS & THeir ownerS

With warmer weather quickly approaching, many pet owners will be eager to head outside—

and, for many, back on the road—with their pets. however, motion sickness in pets creates an

unpleasant situation that often results in the pet being left out of the fun. it may even deter owners

from bringing their pets to the clinic for veterinary care.

natalie marks, DVm, of Blum animal hospital in chicago, has worked with families that have

pets with motion sickness. “as veterinarians, we want to do all we can to enhance the human–

animal bond for our clients,” marks says. “for many pet owners, companionship—both off and

on the road—is central to the relationships with their pets. having a pet that doesn’t enjoy those

experiences can leave the owner and pet’s bond unfulfilled.”

These 3 steps outline a therapeutic approach to motion sickness in pets:

1Start the Motion Sickness Conversation“many times, motion sickness is brought up to us as veterinarians. Pet owners are generally

very in tune with their pets and, unfortunately, may see the problem immediately in their cars,”

marks explains. however, while owners of severely stressed

pets are well aware when their pets exhibit the main sign of

motion sickness—vomiting—others may not recognize the

less obvious signs, such as drooling, panting, licking lips, or

yawning.

Veterinarians can begin a pet’s appointment by asking the

owner about the ride to the clinic. This simple question may

lead to discovery of motion sickness in the pet.

2Make Travel a Positive Experiencemarks says that many cases of motion sickness can be

addressed through simple training methods and adjustments

to the travel process, such as making sure the pet does not

eat 30 minutes prior to any trip.

“in these cases, i encourage pet owners to start slowly and remove any fear the pet may have of

the car itself. This may begin by (1) showing the pet the car without going anywhere, (2) letting the

pet take in the sights and smells, and (3) rewarding the pet with a treat. This process can evolve to

a short trip to the post office, again offering a reward after completing the trip,” marks explains.

she also encourages pet owners to make sure the car is welcoming to the pet by setting a lower

temperature, cracking open a window for air circulation and, of course, making sure the pet is

properly restrained facing forward in either a seat harness or carrier.

3Consider Treatment Optionsif motion sickness is chronic or cannot be resolved with behavioral methods, marks

recommends a prescribed treatment program to pet owners. “i like to discuss all the options with

pet owners to find treatments that best fit their pets’ needs and the family’s lifestyle.”

marks says. “There are excellent options available. for example, veterinarians recognize that

antiemetics are excellent for gi cases, but i’m not sure everyone realizes that some are fDa-

approved, and very effective, for motion sickness.”

marks sums up the motion sickness discussion with, “The most important element of our

work is building trust with our clients and letting them know we are there for them completely—

not just for wellness, illness, or injury—but for their overall lifestyle experiences with their pets.

helping manage motion sickness can be an important part of ensuring the human–animal bond is

developed to the fullest.”



• D2 dopaminergic antagonist/5-HT3 serotonergic

antagonist: Metoclopramide

• Cholinesterase inhibitors: Ranitidine, nizatidine

• Motilin agonists: Low-dose erythromycin (dogs only).

Cisapride is superior to metoclopramide for treating

gastric emptying disorders in cats and dogs. Cisapride

stimulates GI motility from the lower esophageal sphinc-

ter to the colon (through stimulation of 5-HT4 seroto-

nergic receptors), with minimal direct antiemetic effects.

Metoclopramide is used to increase gastroesopha-

geal sphincter tone, and as a prokinetic for treating gas-

tric emptying disorders and enhancing the coordination

of antropyloroduodenal contractions. The prokinetic

effects of metoclopramide are not readily or exclusively

explained by dopamine receptor antagonism. However,

metoclopramide has other pharmacologic properties,

including stimulation of 5-HT4 receptors, which may

better explain some of its effects on the GI tract.

Erythromycin stimulates phase III migrating myo-

electric complex activity in the dog, but the physiologic

regulation of migrating spike complex activity in the

cat is different; therefore, erythromycin is not used as

a prokinetic in cats.

When these drugs are used for delayed gastric emp-

tying, they should be administered 30 minutes prior to

feeding. Metoclopramide has a short half-life (60–90

min) in dogs, and is best given as a CRI for maximal effect.

Antibiotics

Antibiotics are not routinely used for empirical therapy

in acute vomiting unless the patient is febrile or has an

abnormal CBC that suggests systemic infection.

When indicated, broad-spectrum antibiotics, such as

amoxicillin combined with enrofloxacin, provide excel-

lent coverage against most bacteria associated with infec-

tion following breakdown of the GI mucosal barrier.

Probiotics or an antibiotic (metronidazole, tylosin)

may be useful for controlling acute diarrhea accompa-

nying vomiting.

ACUTE vOMITING: ADDITIONAL THErAPY

Dietary Management

Dogs or cats presenting with acute vomiting are com-

monly held NPO (nothing per os) for 12 to 24 hours

until the vomiting ceases. While a period of NPO has

not been evaluated in an evidence-based manner, its

prevention of aspiration pneumonia, additional fluid

losses, and discomfort of the patient are excellent rea-

sons to use this approach.

After vomiting has been controlled or has ceased for

several hours, a small volume of a digestible intestinal

formula or elimination diet (containing a novel, single

protein source or hydrolyzed peptides) should be fed.

• A highly digestible, low-fat diet is usually selected

for dogs, but dietary fat content appears to play a

smaller role in gastric emptying in cats.

• Cats do not need a carbohydrate source and are

sometimes best managed with a single-protein

source, such as cooked chicken breast.

Feeding small meals frequently will minimize gastric

distention and gastric acid secretion. A gradual transi-

tion to the pet’s usual diet is made over 2 to 3 days, pro-

viding that signs have resolved.

Fluid Therapy

Vomiting of gastric and intestinal contents usually

involves:

• Loss of fluid containing chloride, potassium, sodium,

and bicarbonate

• Dehydration accompanied to a variable extent by

hypochloremia, hypokalemia, and hyponatremia.

Subcutaneous fluids are useful for mild dehydration.

• Isotonic fluids should be used, with no more than

10 to 20 mL/kg administered at each injection site.

The rate of SC fluid flow usually is governed by

patient comfort.

• Acetated polyionic solutions, such as Normosol-R

and Plasmalyte, should not be administered SC due

to discomfort associated with administration.

• Generally, all SC fluids are absorbed within 6 to 8

hours. If pockets of SC fluid are still present after this

time, use of IV fluids to reestablish peripheral perfu-

sion should be considered.

Fluids should be administered IV to animals that are

moderately to severely dehydrated (≥ 7%).

• Potassium supplementation to replace that lost in

vomitus is usually necessary, since whole body deple-

tion of potassium can cause GI hypomotility.

• Metabolic acidosis is the most common acid–base

alteration in dogs with GI disease and is usually cor-

rected by appropriate fluid therapy with lactated

Ringer’s solution or 0.9% saline.

• Foreign bodies causing GI obstruction that involves

the stomach or proximal duodenum can result in

metabolic alkalosis, but such patients can also have

metabolic acidosis or normal acid–base status, so

no presumption should be made without laboratory

evaluation.9

IN SUMMArY

There are many causes of vomiting and evaluation of

the vomiting dog or cat requires consideration of the

whole animal, not just the GI tract.

BILIOUS vOMITING SYNDrOMEDogs that suffer from this syndrome can be treated with prokinetic agents. other therapeutic approach-es, alone or in combination, include:• Dividing the total daily food amount into an extra

meal that can be given late in the evening• Using an acid inhibitor (h2 receptor antagonist)

once daily in the evening• administering a calcium-containing antacid (such

as Tums [gsk.com]) late in the evening.

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DRUG NAME(alpha order)

CLASSIFICATION USEDOSE (for cats and dogs unless otherwise noted)

Chlorpromazine Alpha-2 adrenergic antagonist

D2 dopaminergic antagonist

H1 histaminergic antagonist

M1 muscarinic cholinergic

antagonist

Antiemetic 0.2–0.4 mg/kg SC or IM Q 8 H

Cisapride 5-HT4 serotonergic agonist Prokinetic agent 0.5–1 mg/kg PO Q 8 H or

1–1.5 mg/kg PO Q 12 H or

Up to 3 mg/kg divided into equal

doses based on number of daily

feedings; administered 30 min

before each feeding

Dimenhydrinate H1 histaminergic antagonist Antiemetic 4–8 mg/kg PO Q 8 H

Diphenhydramine H1 histaminergic antagonist Antiemetic 2–4 mg/kg PO or IM Q 8 H

Dolasetron 5-HT3 serotonergic

antagonist

Antiemetic 0.5–1 mg/kg PO or IV Q 12 H or 30

min before chemotherapy

Domperidone D2 dopaminergic antagonist Antiemetic

Increases gastroesopha-

geal sphincter tone

0.05–0.1 mg/kg PO Q 12–24 H*

Erythromycin Motilin agonist Prokinetic agent 0.5–1 mg/kg PO or IV Q 8 H (dogs)

Famotidine Histamine H2 receptor

antagonist

Gastroprotective agent 0.5–1 mg/kg IV or PO Q 12–24 H

Maropitant NK1 receptor antagonist Antiemetic

Visceral analgesic

1 mg/kg SC or IV Q 24 H; administer

SC injection cold to reduce pain

2 mg/kg PO (dogs) and 1 mg/kg PO

(cats)

8 mg/kg PO for motion sickness

(dogs)

Metoclopramide D2 dopaminergic antagonist

5-HT3 serotonergic

antagonist

5-HT4 serotonergic agonist

Antiemetic**

Prokinetic agent

Increases gastroesopha-

geal sphincter tone

0.2–0.5 mg/kg PO, SC, or IM Q 8 H

1–2 mg/kg/day CRI

Nizatidine Cholinesterase inhibitor

Histamine H2 receptor antag-

onist

Gastroprotective agent

Prokinetic agent

2.5–5 mg/kg PO Q 12 H

Omeprazole Proton pump inhibitor Gastroprotective agent 0.7 mg/kg PO Q 24 H

Ondansetron 5-HT3 serotonergic

antagonist

Antiemetic 0.5 mg/kg PO or IV Q 12–24 H or 30

min before chemotherapy

Doses up to 1 mg/kg IV Q 12–24 H

are occasionally needed

Pantoprazole Proton pump inhibitor Gastroprotective agent 0.7–1 mg/kg PO or IV Q 24 H

Prochlorperazine Alpha-2 adrenergic antagonist

D2 dopaminergic antagonist

H1 histaminergic antagonist


antagonist

Antiemetic 0.5 mg/kg SC, IM, or suppository

Q 8 H

Ranitidine Histamine H2 receptor

antagonist

Gastroprotective agent

Prokinetic agent

1–2 mg/kg PO Q 12 H

Scopolamine or

Hyoscine


antagonist

Antiemetic 0.03 mg/kg SC or IM Q 6 H

Sucralfate Sucrose sulfate-aluminum

complex

Cytoprotective agent 0.25–1 g PO Q 8–12 H

Yohimbine Alpha-2 adrenergic antagonist Antiemetic 0.25–0.5 mg/kg SC or IM Q 12 H

Note: Mirtazapine, commonly used as an appetite stimulant, most likely also has an antiemetic effect based on data from human studies.

* There is scant clinical experience with this drug in dogs and cats

** Useful in dogs; questionable efficacy in cats

MEDICATIONS FOR ACUTE VOMITING: DOGS & CATSP. Jane Armstrong, DVM, MS, MBA, Diplomate ACVIM

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GI INTeRVeNTION |

An assessment as to whether the

dog or cat has a self-limiting or

potentially serious cause of vomit-

ing is crucial and depends on a:

• Thorough history and careful

physical examination

• Sound understanding of the dif-

ferential diagnoses for acute vom-

iting

• Clinical judgment.

If in doubt, especially in cats, err

on the side of caution and evalu-

ate the animal more extensively

to assess for potentially serious

problems.

When treating a patient symptom-

atically for acute vomiting, further

evaluation is indicated if:

• Signs do not resolve in 2 to 3 days

• Additional clinical signs develop.n

ACTH = adrenocorticotropic hormone; CRTZ = chemoreceptor trigger zone; GI = gastrointestinal; PPI = proton pump inhibitor

References

1. Lund EM, Armstrong PJ, Kirk CA, et al. Health status and population characteristics of dogs and cats examined at private veterinary practices in the United States. JAVMA 1999; 214:1336-1341.

2. Batchelor DJ, Devauchelle P, Elliott J, et al. Mechanisms, causes, investigation and management of vomiting disorders in cats: A literature review. J Feline Med Surg 2013; Feb 12 (Epub ahead of print).

3. Sedlacek HS, Ramsey DS, Boucher JF, et al. Comparative efficacy of maropitant and selected drugs in preventing emesis induced by centrally or peripherally acting emetogens in dogs. J Vet Pharmacol Ther

2008; 31:533-537.

4. de la Puente-Redondo VA, Siedek EM,

Benchaoui HA, et al. Anti-emetic efficacy

of maropitant in the treatment of ongoing

emesis caused by a wide range of

underlying clinical aetiologies in canine

patients in Europe. J Small Anim Pract

2007; 48:93-98.

5. Hickman MA, Cox SR, Mahabir S, et al.

Safety, pharmacokinetics and use of the

novel NK-1 receptor antagonist maropitant

(Cerenia) for the prevention of emesis and

motion sickness in cats. J Vet Pharmacol

Ther 2008; 31:220-229.

6. Hay Kraus BL. Efficacy of maropitant in

preventing vomiting in dogs premedicated

with hydromorphone. Vet Anaesth Analg

2013; 40:28-34.

7. Boscan P, Monnet E, Mama K, et al. Effect

of maropitant, a neurokinin-1 receptor

antagonist, on anesthetic requirements

during noxious visceral stimulation of the

ovary in dogs. Am J Vet Res 2011; 72:1576-

1579.

8. Niyom S, Boscan P, Twedt DC, et al. Effect

of maropitant, a neurokinin-1 receptor

antagonist, on the minimum alveolar

concentration of sevoflurane during

stimulation of the ovarian ligament in cats.

Vet Anaesth Analg 2013; doi: 10.1111/

vaa.12017 (Epub ahead of print).

9. Boag AK, Coe RJ, Martinez TA, Hughes D.

Acid–base and electrolyte abnormalities in

dogs with gastrointestinal foreign bodies. J

Vet Intern Med 2005; 19:816-821.

10. Rosé A, Neiger R. Causes of vomiting

in dogs and usefulness of clinical

investigations. Tierarztl Prax Ausg K

Kleintiere Heimtiere 2013; 41:16-22.

11. Leib MS, Larson MM, Panciera DL,

et al. Diagnostic utility of abdominal

ultrasonography in dogs with chronic

vomiting. J Vet Intern Med 2010; 24:803-

808.

12. Trepanier L. Acute vomiting in cats: Rational

treatment selection. J Feline Med Surg

2010; 12:225-230.

13. Cannon M. Hair balls in cats: A normal

nuisance or a sign that something is wrong?

J Feline Med Surg 2013; 15:21-29.

P. Jane Armstrong, DVM, MS, MBA, Dip-

lomate ACVIM (Small Animal Internal Medi-

cine), is a professor in the Department of

Veterinary Clinical Sciences at University of

Minnesota College of Veterinary Medicine.

She is also a member of the World Small

Animal Veterinary Association (WSAVA)

Liver Standardization Group. Her clinical

and research interests include gastrointes-

tinal disease, feline medicine, integrative

medicine, clinical nutrition, and canine genetics. Dr. Armstrong

is a past president of the American College of Veterinary Internal

Medicine (Small Animal) and Comparative Gastroenterology Soci-

ety and an Editorial Advisory Board member for Today’s Veteri-nary Practice. She received her DVM from Ontario Veterinary Col-

lege, University of Guelph; then completed an internship at Uni-

versity of Illinois and residency and Master’s degree at Michigan

State University.


PracTice To PracTice

Each interaction a veterinary team has

with a pet owner is an opportunity

to provide vital information about a

number of wellness issues, one of the most

important being parasite prevention.

However, today’s world of economic

hardships and Internet “dependence”

has made the veterinary practice’s role in

promoting parasite prevention much more

challenging.

• Pet owners are looking for less expensive

products—turning to sources, such

as online pharmacies, for their pets’

prescription fulfillment.

• Many preventive products are now

available over the counter, outside of the

veterinary practice.

• Owners are making fewer appointments to

save money and missing out on important

conversations about their pets’ health.

• Without a trusted resource, owners

are turning to the Internet for facts on

pet health; however, is this information

correct?

Your approach to parasite prevention may

need to change in order for pet owners to:

1. View your practice team as a key source

for information

2. Consider your products’ quality and

pricing in line with competitive businesses.

Kelly Soldavin

Promoting

Parasite

Prevention

in Practice

Meet MAdeleine

Today’s Veterinary Practice reached out through sev-

eral sources to find someone who has helped imple-

ment practice protocols that effectively influence

owners to maintain consistent, high-quality parasite

prevention for their pets.

Therefore, meet Madeleine Womble—the Hospi-

tal Manager at Central Veterinary Hospital (central-

vethospital.com) in Knoxville, Tennessee.

Madeleine has been with CVH for 14 years, origi-

nally joining its team to help with the practice’s book-

keeping. Her work grew into a managerial position,

launching Madeleine into her current career.

She oversees a veterinary hospital that is open 6 days

a week, with 12-hour days Monday through Friday. As

her bio on the hospital’s website says, “From employ-

ment opportunities to special dietary and medicating

needs, Madeleine coordinates it all.”

it tAkes A teAM

The 3 owners of the practice—Drs. Robert Black,

William Martin, and Penelope Iannacone—are com-

plemented by 3 associate veterinarians, a licensed

veterinary technician, and 10 veterinary assistants

who handle responsibilities, such as assisting specific

veterinarians, specializing in anesthetic recovery, and

caring for the kennels.

At CVH, a client relations manager heads up a

6-member team of client relation specialists who su-

pervise client communication, including scheduling

appointments, greeting pet owners, and facilitating

prescription refills and check in/out.

In addition to standard veterinary care, the hospital

Madeleine Womble

http://centralvethospital.com

http://centralvethospital.com


Pro

mo

tin

g P

ara

site

Pre

ventio

n in

Pra

ctice

PracTice To PracTice |

offers hospitalization, boarding, and grooming. After

hours cases are referred to an emergency clinic that is

2 miles down the road.

Clients of CVH are treated to a practice that has the

personnel and capabilities to offer the best care for

their pets. The question is—with so many team mem-

bers and such a busy schedule, how does CVH imple-

ment effective parasite prevention strategies for their

patients?

GettinG A HeAd stArt

At CVH, parasite prevention begins as soon as the

patient comes in the door. When the owner checks in,

the client relationship specialist asks:

• In addition to the reason for the visit, are there any

other concerns the client has about his or her pet?

• What medication or products need to be refilled

(specifically parasite prevention)? These refills are

then prepared and ready at check out.

If the client declines refills on parasite preventives,

the specialist makes a note, alerting the veterinarian

that prevention needs to be discussed during the ex-

amination.

MAkinG tiMe to tAlk

The appointment schedule at CVH allows veterinar-

ians ample time to talk with clients. The technician

or assistant provides support by sharing their own

experiences, helping clients realize that the veterinary

team understands the challenges of choosing preven-

tives, consistent administration, and budgeting cost.

Much of the conversation about parasite prevention

can be covered in the patient’s history. Common ques-

tions include:

• How is the current preventive(s) working? Are there

any questions or concerns?

• Has a parasite-related disease or situation, such as a

flea infestation in the home, occurred?

• How often is the preventive administered?

With new clients, additional questions include:

• What is the pet’s preventive history—what has been

used and is the pet currently receiving any preven-

tive?

• When was the pet’s last heartworm test?

CoMMuniCAtinG key Points

Madeleine shares, “One of the key things our vet-

erinarians, technicians, and assistants convey to our

clients is the fact that we live in an area that is highly

endemic for parasites, but that they can easily be

killed and repelled by preventives.”

She goes on to say, “Many clients are concerned about

the cost of preventives, but our team points out that

cost of treatment for diseases caused by these parasites

is much higher than the cost of prevention. In addition,

we discuss the current challenges with obtaining adul-

ticide, which could jeopardize treatment if the owner’s

pet were to become infected with heartworms.”

Madeleine adds, “Thankfully, we have had no is-

sues in securing medication for treatment of heart-

worm disease.”

tAilorinG tHe PlAn

Madeleine highlights a critical point in CVH’s approach

to pet owners: compromise. “We offer all prevention

and treatment options to clients; then let them decide

how they would like to proceed. Each pet has a cus-

tomized plan developed that addresses both the pet

and owner’s needs.”

“What we want to avoid,” Madeleine says, “is making

a client feel ‘bad’ if he or she is unable or chooses not

to follow our recommendations. Instead, we make a

note to revisit the topic at the next appointment, hop-

ing that the client will decide to follow our advice then.”

CVH offers a selection of 3 to 4 parasite preventives.

“No one preventive works for every case. Discussing

various options emphasizes that most preventives ad-

dress more than one parasite and assures clients that

they are making informed decisions,” notes Madeleine.

With regard to heartworm disease treatment, Made-

leine says, “Of the pets that test positive for heartworm

infection, most are new patients. And the majority of

clients choose to treat their pets.”

FindinG FinAnCiAl FeAsibility

When a client finishes an appointment at CVH:

• The veterinary team has discussed parasite preven-

tion, diagnostics, and/or treatment and developed a

plan with the client that addresses the pet’s specific

needs.

• The client relations specialist is aware of the plan

and confirms the preventive chosen and the amount

the client would like to purchase.

With CVH’s emphasis on client compromise, the

HeArtworM testinG—PArt

oF wellness CArecVH’s wellness testing includes blood analysis for heartworms (for cats, it’s included in the test for FeLV). By including heartworm testing as part of the wellness examination, the hospital elevates the importance of parasite control, demonstrating to clients that parasite prevention is integral to wellness care.


| PracTice To PracTice

hospital works with each cli-

ent to make prevention afford-

able. Madeleine shares, “Cli-

ents can purchase 1 dose at a

time or a year’s worth. While

we had concerns about wheth-

er 1-dose purchasers would re-

turn regularly, we have found

that these pet owners are very

dedicated to buying preven-

tive each month and keeping

their pets protected, despite fi-

nancial challenges that prevent

purchase of a 6- or 12-month

supply.”

CVH also has several proto-

cols in place to keep the hospi-

tal competitive with stores and online suppliers that

offer prescription and OTC preventive products.

• CVH’s prices are competitive with pharmacies,

stores, and other local clinics; this competitive

pricing is enhanced by manufacturer coupons and

rebates.

• When clients request written prescriptions, client

relations specialists explain the hospital’s competi-

tive pricing, and point out that CVH can often offer

a better “deal” on preventives.

• All rebates and coupons are processed in the clinic

and mailed for the clients—one less thing clients

have to worry about.

Madeleine says, “At the end of each day or week we

print reports for the coupons/rebates collected and

mail them to the manufacturers in weekly batches.

Once a system is established, it’s a straightforward pro-

cess and one that our clients very much appreciate.”

oFFerinG eduCAtion & resourCes

Madeleine notes that CVH’s relationships with manu-

facturer representatives are valuable when it comes

to providing employee education. “A representative

who does his or her job well is always willing to help.

When we need education about specific topics or

products, these representatives provide this informa-

tion to our team.”

CVH also provides ongoing training for personnel,

with parasite preventive protocols discussed on a reg-

ular basis.

For both hospital personnel and clients, Madeleine

ensures that there are plenty of handouts—often pro-

vided by manufacturers for specific products—and

printed materials available in the waiting and exami-

nation rooms that can be shared, discussed, and sent

home with clients for further review.

The CVH website also offers several resources that

help promote wellness care, including parasite pre-

vention:

• A Topic of the Month page provides information

on a specific health topic and special incentive

tHe Power oF 12 At CVH

Last year, 12.12.12 became the mantra

for an initiative focused on increasing, by

12%, the number of year-round (12-month)

doses of heartworm preventive sold in

2012.

Madeleine shared how the program

impacted cVH: “12.12.12 reminded our

team that we really should be encouraging

clients to buy 12 months of preventive

at a time. This recommendation was

backed up by the great rebates offered by

Merial—it was an incentive clients couldn’t

pass up.”

She added, “clients didn’t always

understand that year-round prevention

is needed in our area. 12.12.12 helped

educate our employees on this topic,

which allowed them to educate our

clients. The program’s measurement

system showed that our sales of

12-dose heartworm preventive products

increased.”

“The best part was finding out that

the hospital was above average when

compared to national statistics with regard

to percentage of clients purchasing year-

round prevention. i really gained a new

appreciation for our team, knowing our

patients were reaping the benefits of a job

well done by everyone at cVH.”

© 2013 Virbac AH, Inc. All Rights Reserved. IVERHART MAX is a registered trademark of

Virbac Corporation in the US and a trademark of Virbac Corporation in Canada. 1/13PREVENT • TREAT • CONTROL

“I WAS MORTIFIED.”

All dogs should be tested for heartworm infection before starting a preventive program. Following use of IVERHART MAX Chewable

Tablets, digestive and neurological side effects have rarely been reported. Use with caution in sick, debilitated or underweight

animals and dogs weighing less than 10 lbs. See brief summary on page for additional information.

CLIENTS NEVER EXPECT THEIR DOGS TO GET TAPEWORMS.

Fortunately, IVERHART MAX® (ivermectin/pyrantel pamoate/praziquantel)

Chewable Tablets can spare clients the shock of seeing their dogs get

them. Choose the only monthly heartworm preventative that treats

and controls tapeworms.

Help clients avoid nasty tapeworm surprises. Call 1-800-338-3659

or visit www.virbacvet.com.

(ivermectin/pyrantel pamoate/praziquantel)

“HOW COULD MY QUEENIE HAVE

REVOLTING TAPEWORMS?”

32

http://www.virbacvet.com


| PracTice To PracTice

pricing for products or services

related to it; parasite prevention

is addressed at least twice a year.

• Petly accounts (petly.com; pri-

vate website that allows pet own-

ers to directly access and man-

age their pets’ health care) allow

clients to request appointments,

check wellness history, and order

prescription refills.

• Links to further information on

topics of interest for pet owners

are available.

The existence of these resources

is highlighted on the hospital’s Face-

book page and monthly client news-

letter.

in suMMAry

Madeleine’s thoughts on implement-

ing a successful and effective para-

site prevention program made it

obvious that a process of simple

steps can result in big changes.

1. Define each team member’s

role in helping pet owners make

the right decisions about parasite

prevention for their pets.

2. Have honest conversations with

clients about what does or does

not work with regard to their pets’

parasite prevention.

3. Integrate parasite testing and

prevention into wellness visits,

reinforcing its importance as a key

to having a healthy pet.

4. Develop a preventive program

that works for each person and

pet, which increases compliance

and decreases the possibility a

client will purchase products else-

where.

5. Become THE source for client

questions on pet health care—

pet owners should come to you

and your clinic for advice rather

than relying on dubious Internet

information.

“Our hospital is dedicated to pro-

viding the highest quality of care for

our patients,” Madeleine says. “By

making sure our employees share

that vision, our clients are offered a

full range of options for their pets’

health care, and the hospital team

works with clients to implement best

care in light of each individual’s sit-

uation.” n

CAUTION: Federal (US) law restricts this drug to use by or on

the order of a licensed veterinarian.

BRIEF SUMMARY: Please consult package insert for com-

plete product information.

Indications: For use in dogs to prevent canine heartworm

disease by eliminating the tissue stage of heartworm larvae

(Diroflaria immitis) for a month (30 days) after infection and

for the treatment and control of roundworms (Toxocara canis,

Toxascaris leonina), hookworms (Ancylostoma caninum,

Uncinaria stenocephala, Ancylostoma braziliense), and

tapeworms (Dipylidium caninum, Taenia pisiformis).

WARNINGS: For use in dogs only. Keep this and all drugs

out of reach of children. In safety studies, testicular hypoplasia

was observed in some dogs receiving 3 and 5 times the

maximum recommended dose monthly for 6 months (see

Animal Safety). In case of ingestion by humans, clients should

be advised to contact a physician immediately. Physicians

may contact a Poison Control Center for advice concerning

cases of ingestion by humans.

PRECAUTIONS: Use with caution in sick, debilitated, or

underweight animals and dogs weighing less than 10 lbs.

The safe use of this drug has not been evaluated in preg-

nant or lactating bitches.

All dogs should be tested for existing heartworm infection

before starting treatment with IVERHART MAX Chewable

Tablets, which are not effective against adult D. immitis.

Infected dogs should be treated to remove adult heart-

worms and microflariae before initiating a heartworm preven-

tion program.

While some microflariae may be killed by the ivermectin

in IVERHART MAX Chewable Tablets at the recommended

dose level, IVERHART MAX Chewable Tablets are not effec-

tive for microflariae clearance. A mild hypersensitivity-type

reaction, presumably due to dead or dying microflariae and

particularly involving transient diarrhea, has been observed

in clinical trials with ivermectin alone after treatment of

some dogs that have circulating microflariae.

ADVERSE REACTIONS: In clinical feld trials with ivermectin/

pyrantel pamoate, vomiting or diarrhea within 24 hours of

dosing was rarely observed (1.1% of administered doses).

The following adverse reactions have been reported

following the use of ivermectin: depression/lethargy, vomiting,

anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions

and hypersalivation.

ANIMAL SAFETY: Studies with ivermectin indicate that

certain dogs of the Collie breed are more sensitive to the

effects of ivermectin administered at elevated dose levels

(more than 16 times the target use level of 6 mcg/kg) than

dogs of other breeds. At elevated doses, sensitive dogs

showed adverse reactions which included mydriasis,

depression, ataxia, tremors, drooling, paresis, recumbency,

excitability, stupor, coma and death. No signs of toxicity were

seen at 10 times the recommended dose (27.2 mcg/lb) in

sensitive Collies. Results of these studies and bioequivalence

studies support the safety of ivermectin products in dogs,

including Collies, when used as recommended by the label.

In a laboratory safety study, 12-week-old Beagle puppies

receiving 3 and 5 times the recommended dose once weekly

for 13 weeks demonstrated a dose-related decrease in

testicular maturation compared to controls.

HOW SUPPLIED: IVERHART MAX Chewable Tablets

are available in four dosage strengths for dogs of

different weights. Each strength comes in a box

of 6 chewable tablets and in a box of 12 chewable tablets,

packed 10 boxes per display box.

STORAGE CONDITIONS: Store at controlled room temper-

ature of 59°-86° F (15°-30° C). Protect product from light.

For technical assistance or to report adverse drug reactions,

please call 1-800-338-3659.

Manufactured by: Virbac AH, Inc. Fort Worth, TX 76137

NADA 141-257, Approved by FDA

IVERHART MAX is a registered trademark of Virbac Corporation

in the US and a trademark of Virbac Corporation in Canada.

(ivermectin/pyrantel pamoate/praziquantel)

© 2013 Virbac AH, Inc. All Rights Reserved. 1/13

EASOTIC®

Otic suspension(hydrocortisone aceponate, miconazole nitrate, gentamicin sulfate) Anti-inflammatory, antifungal, and antibacterial

For Otic Use in Dogs Only

CAUTION

Federal law restricts this drug to use by or on the order of a licensed veterinarian.

BRIEF SUMMARY: Please consult package insert for complete product information.

INDICATIONS

EASOTIC® suspension is indicated for the treatment of otitis externa in dogs

associated with susceptible strains of yeast (Malassezia pachydermatis) and

bacteria (Staphylococcus pseudintermedius).

CONTRAINDICATIONS

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.

WARNINGS

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).

PRECAUTIONS

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 feld 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.

ANIMAL SAFETY

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

fndings 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.

STORAGE INFORMATION: Store at temperatures between 20º C-25º C (68º F-77º F),

with excursions permitted between 15º C-30º C (59º F-86º F).

HOW SUPPLIED: 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.

© 2013 Virbac Corporation.

All Rights Reserved. Rev 8/2011

http://petly.com

Introducing the new blueprint for easy, effective treatment of otitis externa.

For information, call 800-338-3659

Flexible Nozzle:

Gentle on sensitive

canine ears.

• One pump delivers an exact 1 mL dose

every time.

• No messy drops to count. No more

mystery.

Unique Airless Delivery System:

If you could design the ideal treatment for otitis externa in dogs, it might just be EASOTIC

®

Suspension. It makes treating otitis so easy and accurate your clients will happily comply, and the novel formulation makes short work of infl ammation, bacteria and yeast. To learn more, visit www.virbacvet.com.

Three Powerful Actives including Hydrocortisone

Aceponate (HCA) - A potent new generation glucocorticoid.

Precise dosing in any position.

No more wrestling matches. One pump, once daily, for 5 days for any size dog.

Eliminates dosing frustration.

(hydrocortisone aceponate, miconazole nitrate, gentamicin sulfate)

Otic Suspension For Dogs

Ease and otic together at last.

EASOTIC®

Suspension is contraindicated in dogs with known or suspected hypersensitivity to corticosteroids, imidazole antifungals, or aminoglycoside antibiotics. Do not use in dogs with known tympanic membrane perforation. The safe use of EASOTIC Suspension in dogs used for breeding purposes, during pregnancy, or in lactating bitches, has not been evaluated. See brief summary for additional product information.

© 2013 Virbac Corporation. All Rights Reserved. EASOTIC is a registered trademark of Virbac S.A. in the US. 3/13

13770

http://www.virbacvet.com


Practicing medicine is called “practicing” for a

reason. Typically, there is no ONE correct route

of reaching the appropriate diagnosis. Many of

us find the answers by traveling along our own

path, sometimes multiple paths, with a few detours

along the way.

Veterinary dermatology focuses on the management

of chronic diseases and, therefore, is subject to errors

because of judgment calls and assumptions. This article

focuses on common diagnostic pitfalls seen in veteri-

nary dermatology, with an emphasis on spotting oppor-

tunities for improvement.

PITFALL 1: FAILure To obTAIn A CoMPLeTe

HIsTory

In veterinary medicine, the history often plays an

essential role in helping us formulate a list of dif-

ferential diagnoses. Obtaining a thorough history is

CRITICAL and one of the most important parts of the

dermatologic examination.

Two ways to ensure that a comprehensive history is

obtained are:

1. Have clients fill out dermatologic history forms.

2. Train your technicians to help obtain informa-

tion.

How to Avoid

the Five Most

CoMMon

MistAkes in

veterinAry

DerMAtologyLori A. Thompson, DVM, Diplomate ACVD

Peer reviewed

By having clients fill out history forms and training

technicians to ask questions about potential dermato-

logic issues, the practitioner can narrow the diagnosis.

For example, if the owner told the technician that the pet

is itching, ask the following questions (these questions can

be applied to many dermatologic conditions):

•Whendidtheitchingstart?

If pruritus started at less than 6 months of age, ecto-

parasites or other infectious causes, along with cutane-

ous adverse food reaction, jump to the top of the list (as

opposed to atopy).

• Areanyotheranimalsinthehouseaffected?Hasa

newpetbeenbroughtintothehome?

If the answer is yes, then again, ectoparasites rise to

the top of the differential list. Consider the atopic dog

that was managed well with allergen-specific immuno-

therapy, but develops intense pruritus and alopecia on

the dorsal rump a few weeks after a new kitten joins

the home—there’s a good chance that flea allergies are

playing a part in the dog’s signs.

Sometimes the addition of a new pet means adding

another food source, such as puppy or kitten food that

includes a protein or carbohydrate source that may

affect a food-allergic pet. A pet in the house with food


How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology |

allergies that manages to “snack” on the new puppy

or kitten’s food (or manages to get into the kitten’s

litter box) may experience a surge in pruritus.

Keep in mind that dogs and cats have individual

thresholds for pruritus and their responses to vari-

ous triggers may vary in intensity.

• Arepeopleinthehouseaffected?

Beware of the owner that “just has a rash from

working outside.” This owner’s pet most likely

needs treatment for parasites prior to further allergy

workup.

• Aretheclinicalsignsseasonalornonseasonal?

In many regions of the country, there are variations

in seasonal pollen levels. A dog that is pruritic each

year from June through August is much more likely

to be atopic versus having a cutaneous adverse food

reaction (which would be present year round).

•Have the clinical signs changed or have they

remainedthesame?

Consider the geriatric patient that has always been

treated in the spring and summer for allergies;

however, this year, the pet is presented for recur-

rent infections with minimal pruritus. Focus on

changes in behavior, drinking, appetite, urination,

and appearance of skin and hair coat. Occasionally,

geriatric dogs with chronic atopy become less pru-

ritic after developing an endocrinopathy, such as

hyperadrenocorticism, due to increased levels of

endogenous cortisol.

•Hasthepatientbeentreatedinthepast?Ifso,

when, with which medications, and what was

theresponse?

Patients that have been treated with several differ-

ent antibiotics yet still exhibit generalized pyoderma

may be infected with drug-resistant bacteria. These

pets require culture and sensitivity in order to deter-

mine the bacteria present and their antimicrobial

sensitivity, allowing the clinician to select the appro-

priate antibiotic.

• Additionalquestionsinclude:

» How many times a day do you observe your pet

scratching?

» Does your pet scratch all over its body or focus on

a few specific areas?

» Is the itching worse in the morning or the same

throughout the day?

» Does the pet lick its paws?

» Does the pet travel or has it been boarded or

groomed recently?

PITFALL 2: HIsToPATHoLogy—PerForMIng

IT Too LATe In THe Course oF DIseAse

The main pitfall encountered with regard to histo-

pathology in veterinary dermatology is performing

biopsies too late in the course of disease or biopsying

lesions that are unlikely to give an accurate diagnosis.

Key points to consider include:

• Knowwhentobiopsy.

Biopsying lesions early in the course of disease

(Figure 1) is important. In addition, selecting biopsy

sites along a continuum of the disease process (early-,

mid-, and late-stage lesions) can greatly assist the der-

matohistopathologist reading the samples.

An earlier stage lesion (such as a pustule or pap-

ule) or one that has not become chronic and scarred

(Figures 2 and 3, page 36) is more likely to reveal

diagnostic changes.

Toviewanexampleofadermatologic

historyform, visit animaldermatology.

com/new-patient-form.

Veterinarytechnicians provide a valuable service by giving you a “heads up” before you enter the examination room. not only can they ask questions to help narrow the diagnostic process, but they can also provide their own observations, such as whether a patient is showing dermatologic signs (ie, intense itching or alopecia).

Figure 1. Early stage epitheliotropic lymphoma

lesions of the nose (A, depigmented areas) and

skin (B).

A

b

| How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology


• Knowthepropertechnique.

Avoid prepping the sample by doing a surgical

scrub. Submit the crusts—even if they fall off the

sample—in formalin with the biopsy. The crust can

contain important diagnostic information that may

help distinguish an autoimmune disease from an

infectious process.

• Site selection is important and selecting the

propersitecomeswithpractice.

Clinicians should pick lesions that are typical for the

disease process they suspect. This requires some

knowledge of the suspected disease process. For

example:

» Intact pustules for pemphigus foliaceus

» Early depigmentation for discoid lupus erythe-

matosus (which is more helpful than a chronic,

crusted erosion).

•Contactalocaldermatologist and ask if he or she

can recommend a dermatohistopathologist.

• Select adermatohistopathologist anddevelop

aworkingrelationship.

Send this person a detailed synopsis of the patient’s

history; describe whether:

» Patient is pruritic and/or systemically ill

» Lesions are acute or chronic, localized or general-

ized, or have seasonal variation

» Mucocutaneous junctions appear to be involved

» Diagnostic tests have been performed and their

results (eg, skin scrapings, cytology, culture/sen-

sitivity, previous biopsies)

» Patient responded to treatment and which thera-

pies did/did not elicit a response.

•Many dermatohistopathologists appreciate

digitalimages.

Today’s technology allows you to send an email to

the pathologist and attach digital images that are

representative of the disease process. Remember,

the pathologist is only looking at small, 6-mm sam-

ples that have been sectioned into smaller pieces.

Digital images provide a much clearer picture of the

entire disease process and the likelihood of a more

definitive diagnosis.

PITFALL 3: APProPrIATe AnTIbIoTIC use

In the past, antibiotic use in dermatology was syn-

onymous with use of cephalosporins. Now, with the

advent of the many methicillin-resistant infections

(and the social awareness this has created), choosing

the appropriate antibiotic, the proper dose, and the

correct length of treatment is critically important.

Culture&Sensitivity

A common challenge is whether to select an antibiotic

empirically or perform a culture and sensitivity first. A

sample should be submitted for culture if the follow-

ing indicators are present:

• Organisms other than cocci on cytology

• Unusual lesions

• Persistent or recurrent infections.

In cases of suspected otitis media, the presence of

rod-shaped bacteria on cytology indicates that an ear

culture should be performed.

ObtainingCultures

Speak with the diagnostic laboratory the practice

employs to determine the best way to obtain and

submit a skin sample for culture. They may prefer a

culturette swab or a biopsy punch of the skin sub-

mitted in sterile saline for macerated tissue culture.

Following the laboratory’s suggestions maximizes the

chance of obtaining the best result.

Additional tips to help obtain a good specimen

include:

• Swabs for bacterial culture should be taken from

new lesions or recently ruptured pustules or vesi-

cles, not from older, excoriated lesions.

• An intact pustule should be ruptured with a sterile

needle and the contents absorbed on a sterile swab.

• Some authors recommend a light surgical prep with

alcohol, but this may lead to false–negative cultures

if the alcohol penetrates or ruptures the fragile stra-

tum corneum overlying the pustule or the pustule

Figure 2. Squamous cell carcinoma that is likely to

yield a diagnostic biopsy

Figure 3. Squamous cell carcinoma that is unlikely

to be diagnostic due to severe pyogranulomatous

response


How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology |

opens before the alcohol has evaporated.

• Preparing a site for a biopsy that will be used for

macerated tissue culture (described below) is not

the same as preparing the site for a biopsy that

will be submitted for histopathology (described in

Pitfall 2).

» To avoid culturing contaminants, prep the skin

first by gently clipping the affected area, then

gently wiping once with an alcohol swab in the

direction of the hair coat.

» A 4- to 6-mm punch biopsy sample is then

obtained and inserted into the appropriate culture

medium or sterile saline for submission.

AntibioticTherapy

Occasionally you will see multiple isolates on your

culture report. When in doubt, it is best to choose

your initial antibiotic therapy based on Staphylococcus

species sensitivity because this bacteria creates a tissue

environment favorable for replication of secondary

invaders. However, combination therapy is occasion-

ally necessary.

Duration of treatment is critical. The recommended

duration of treatment for superficial pyoderma is a

minimum of 3 weeks (or 10 days past clinical resolu-

tion). Deep pyodermas may require 8 to 12 weeks of

antibiotic therapy; it is best to continue treatment for

15 to 30 days past clinical resolution.

PITFALL 4: NOTObTAININggOOdSKIN

sCrAPIngs

Skin scrapings and cytologic samples are the heart of

dermatology diagnostics. These diagnostics:

• Are simple to perform

• Help narrow the differential list considerably

• Provide additional clinic income.

However, not all skin scrapings are created equal.

The key is deciding what parasite is suspected—this

information determines where and how the scrapings

are obtained.

Scabies= SuperficialScrapes

Scabies mites live in the superficial epidermis.

Unfortunately, these mites are often difficult to find,

given the small number typically present and intense

pruritus present in the patients.

• Multiple superficial scrapings are recommended,

with a focus on the elbows, hocks, pinnal margins,

and ventral chest.

• It is important to remember that negative skin scrap-

ings do NOT rule out scabies in a dog. If suspicion

index is high, therapeutic treatment trials are in

order.

The process for obtaining superficial skin scrapings

includes:

1. Appling a drop or 2 of mineral oil onto the skin site

being scraped. I find it useful to also dip the scalpel

blade in the oil, which enhances the adherence of

the scale and flaky material.

2.Holding the blade at a 45-degree angle; then, with

moderate pressure, scraping the affected area in the

direction of hair growth.

3. “Scooping” the collected material with the blade

and transferring it to the microscope slide. Repeat

scrapings to accumulate a fairly extensive amount of

material.

4. Applying a coverslip and reviewing the slide under

low-power objective (4× or 10×), with low-light

intensity and closure of the iris diaphragm on the

condenser to provide increased contrast between

the mites and mineral oil background (see Figure

4—condenser not adapted—versus Figure 5—con-

denser lowered and low light).

Demodex=Deepscrapes

In general, multiple scrapings from new lesions are

best. The process of acquiring deep skin scrapes

includes:

1. Squeezing the affected skin to obtain mites that live

deep in the hair follicles; then scraping with a scal-

pel blade and mineral oil until there is true capillary

bleeding.

Figure 4. demodex canis: High-light intensity and

unadjusted condenser leads to the “washed-out”

appearance, which can result in missed mites when

examining samples.

Figure 5. demodex canis: Low-light intensity and

closure of the iris diaphragm on the condenser pro-

vide increased contrast between the mites and min-

eral oil background.

| How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology


2. Collecting each sample and placing on individual

slides. Label the slides to indicate the location of

the scrapes, which is important for monitoring mite

counts at subsequent visits.

3. Applying a coverslip and reviewing under low-power

objective (4× or 10×), with low-light intensity and

closure of the iris diaphragm on the condenser to

provide increased contrast between the mites and

mineral oil background.

4. Determining whether mites are present, counting

the number of mites per low-power field, and decid-

ing whether the patient has localized or generalized

disease.

5. Monitoring treatment progress by distinguishing

eggs, larva, nymphs, and adults, along with live and

dead mites, each time scrapings are acquired.

PITFALL 5: FOrgeTTINgTHePOWerOFTHe

FLeA

Despite modern advances in flea control, flea allergic

dermatitis is the most common skin disease seen in

small animal practice around the world.

Why is this the case when newer, more effective prod-

ucts are available and most small animal practitioners

are very aware of flea allergic dermatitis in dogs and

cats? Not surprisingly, the most difficult task in cases

of flea allergy dermatitis is convincing owners that the

correct diagnosis has been made. This can be due to

the fact that owners don’t see fleas on the pet or won’t

accept that their homes have ectoparasites (because it

is considered “dirty”), among other reasons.

ProductFailure

When a flea product “fails,” many pet owners view this

as the development of resistance. However, the major-

ity of flea product failures are due to poor compliance.

The most common causes of treatment failure are

some or all of the following:

• Failure to treat all in-contact animals, including

indoor/outdoor cats and visitors

• Failure to use the flea product properly (eg, dividing

large tube of product between 3 Chihuahuas, result-

ing in inaccurate dosing)

• Failure to maintain consistent treatment

• Failure to address environmental issues (especially

in severe cases).

Ownereducation

Owner education is critical. Create a “buy in” to the

diagnosis before revealing it:

• Discuss the 3 most common allergic skin diseases in

dogs:

1. Atopic dermatitis

2. Food allergic dermatitis

3. Flea allergic dermatitis.

• Talk about the distribution pattern of these diseases’

lesions and let owners begin to draw their own con-

clusions.

• If possible, explain potential reasons for treatment

failure if previous flea control methods have been

ineffective.

CustomizingPrograms

It is important to tailor every flea control program to

the client’s individual life situation. This is where his-

tory plays a role yet again.

• Do you have a client that is afraid of using topical

“pesticides”? Perhaps an oral flea preventive is a bet-

ter solution.

• The frequently bathed, indoor Chihuahua will most

likely have a very different treatment recommenda-

tion than the German shorthaired pointer that goes

hunting and competes in field trials every weekend.

» For example, the indoor Chihuahua may be well

maintained with regular, monthly oral or topical

flea preventive that does not provide protection

from ticks. The German shorthaired pointer hunts

in an area where tick-borne disease is prevalent

and may require monthly oral or topical flea pre-

ventive AND an additional product for protection

from ticks prior to hunting.

» Similarly, if these patients live in a household that

has several cats that are frequently sleeping with

the dogs, it is important to avoid flea products that

contain pyrethrins or other compounds that can

be harmful to cats.

Consider providing a client handout that describes

the various flea products your clinic offers and why

YOU have chosen to carry those particular products.

They trust you and want to know what you think. n

Lori Thompson, DVM,

Diplomate ACVD, is the

co-owner of Animal

Dermatology Clinic

Indianapolis in Indianapolis,

Indiana. She is the imme-

diate past president of

the Indiana Veterinary

Medical Association and

is very active in organized veterinary medicine.

Dr. Thompson’s clinical interests include allergic

skin and respiratory disease, equine dermatology,

and immunomodulatory therapies. She lectures

nationally on these topics in addition to perform-

ing volunteer work. Dr. Thompson is the author of

several peer-reviewed articles and is a past recipi-

ent of the ACVD Resident Research Award and

the Bastien Award for Excellence in Canine Care.

View ProductProfile:Common

FleaPreventiveMedicationsfor

dogs&Catsin the resources section of

todaysveterinarypractice.com.


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A complete neurologic examination should be

done in all animals presenting with suspected

neurologic disease. Abnormalities found during

the neurologic examination can reflect the location of

the lesion, but not the cause, requiring further tests,

such as blood analysis, electrodiagnostic tests, and

advanced imaging, to determine a diagnosis.

The neurologic examination evaluates different parts

of the nervous system; the findings from the examina-

tion help localize the lesion to the:

• Brain

• Spinal cord

• Peripheral nervous system

• Cauda equina.

A fundic examination is recommended, especially in

patients with brain disorders. Repeat neurologic exami-

nations are helpful to discover subtle abnormalities and

assess progression of disease.

Neurologic

examiNatioN

Peer reviewed


In the January/February issue of

Today’s Veterinary Practice, Part 1

of this article discussed performing

a neurologic examination; Part

2 will address interpretation of

abnormal findings.

THE BRAIN

Lesions in the brain can be localized to the:

• Cerebrum and thalamus (ie, prosencephalon)

• Brainstem

• Cerebellum.

In order to localize the lesion to a specific part of

the brain, an understanding of the anatomy and func-

tion of the brain is necessary (see Brain Anatomy &

Related Functions).

Ataxia

A patient with ataxia may have a lesion in the proprio-

ceptive pathways (peripheral nerves, spinal cord, or

cerebrum), vestibular system, or cerebellum. Ataxia

can be described as an uncoordinated gait, with cross-

ing of the limbs and, sometimes, listing or falling to 1

or both sides. Ataxia can be further characterized as:

• Proprioceptive: Mild, usually bilateral ataxia

• Vestibular: Moderate, asymmetric ataxia

• Cerebellar: Symmetric, truncal ataxia.

Circling

The direction of circling is usually toward the side

with the lesion. The circles tend to be larger with le-

sions in the prosencephalon than with lesions in the

vestibular system.

Part 2: Interpreting

Abnormal Findings

The Neurologic

examiNatioN in Companion Animals

Read The Neurologic Examination

in Companion Animals—Part 1:

Performing the Examination (January/February

2013) at todaysveterinarypractice.com.



The NeuRologic exAmiNATioN iN comPANioN ANimAls, PART 2 |

Cranial Nerve Abnormalities

Cranial nerve abnormalities are

signs of either a peripheral neu-

ropathy or brainstem lesion.

Brainstem lesions can be local-

ized to the part of the brain-

stem where the cranial nerve

nucleus is located. Peripheral

neuropathy may affect only 1

nerve (eg, idiopathic facial pa-

ralysis) or be part of a polyneu-

ropathy.

Decerebellate Posture

This rare posture is seen with a

severe lesion in the cerebellum.

Findings include:

• A mentally alert patient

• Opisthotonus (dorsiflexion of

the head and neck)

• Increased extensor tone in

the thoracic limbs due to

loss of inhibition from the

cerebellum to the extensor

muscles

• Pelvic limbs with reduced

muscle tone that are usually

flexed.

Decerebrate Posture

This rare posture is seen with

a severe lesion in the midbrain

or pons.

• The mentation in these

patients is severely affected

(stupor or coma).

• Opisthotonus may be present

if the animal has a cerebel-

lar lesion in addition to the

brainstem lesion.

• Increased extensor tone in

all limbs is a result of loss

of inhibitory function from

the pontomedullary reticular

formation (RF or RAS), which

affects extensor tone of the

limbs.

Hemineglect (Hemiinatten-

tion)

Hemineglect is a reduced re-

action to a stimulus (body or

head) contralateral to a lesion

in the cerebrum. To test for

hemineglect observe the pa-

tient’s reaction (turning the

head around, whining, trying

to bite) while pinching the side

BRAIN ANAToMy & RElATED FuNCTIoNsCerebrum & Thalamus

The cerebrum initiates movements; the thalamus executes movements. • A common finding in cats with a large meningioma compressing the

cerebrum is difficulty initiating movements and continuous, aimless walking in large circles. • A patient with a thalamic lesion may have a compulsive behavior: if

restrained, the patient may struggle, vocalize, and try to keep walking.

Brainstem

The brainstem connects the cerebrum with the spinal cord and body. All information to and from the body (which is examined by postural reaction assessment) passes through the brainstem and thalamus to leave or reach the cerebrum.

The brainstem includes the midbrain (mesencephalon), pons, and medulla oblongata. localizing to one specific part of the brainstem is often not pos-sible; however, cranial nerve deficits may help pinpoint the lesion.

The brainstem contains the cranial nerve cell bodies (except cN i and ii). • The midbrain contains the reflex center for vision and hearing (colliculi)

and the nuclei of CN III and IV. • The pons lies between the midbrain and medulla oblongata and contains

the nucleus of CN V. in addition, some of the vestibular nuclei are partially in the pons. • The medulla oblongata, the most caudal part of the brainstem, contains

the respiratory and blood pressure regulation centers, nuclei of CN VI to

XII, and the vestibular nuclei (4 vestibular nuclei on each side).

Cerebellum

The cerebellum adjusts and moderates all movements initiated by the cerebrum and executed by the thalamus. clinical signs that may indicate a cerebellar lesion include: • cerebellar ataxia • Variable and intermittent loss of the menace response• ipsilateral postural reaction deficits and/or hypermetria• intention tremor.

Lisa wirth, vMd

Cross-section of cerebrum and thalamus and lateral aspect of brainstem

| The NeuRologic exAmiNATioN iN comPANioN ANimAls, PART 2


of the trunk with hemostats. Compare reac-

tions when pinching the other side.

Mental status

A change in mental status is caused by a lesion

in the prosencephalon or brainstem (the re-

ticular activating system is diffusely spread in

the brainstem and responsible for our aware-

ness and arousability).

• Owner’s knowledge of his or her pet’s

personality plus observations at home are

essential to assess the patient’s mental sta-

tus, especially when there are subtle menta-

tion changes.

• Repeat examinations and observation of the

animal over a longer time period and in dif-

ferent surroundings are also helpful.

Figure 1. Myotat-

ic and withdraw-

al reflex pathways;

thoracic and pel-

vic limbs

Figure 2. C1 to

C5 myelopathy:

Postural reactions

are delayed or ab-

sent in all limbs

(red lines); spinal

reflexes are nor-

mal or increased

(green lines)

Figure 3. T3 to L3

myelopathy: Pos-

tural reactions and

spinal reflexes in

thoracic limbs are

normal; postur-

al reactions are

delayed or ab-

sent (red lines)

but spinal reflex-

es are normal or

increased (green

lines) in pelvic

limbs

Figure 4. C6 to T2

myelopathy: Pos-

tural reactions are

delayed or absent

in all limbs; spi-

nal reflexes are re-

duced or absent in

thoracic limbs (red

lines) and normal

or increased in

pelvic limbs (green

lines)

Figure 5. L4 to

S3 myelopathy:

Postural reac-

tions and spinal

reflexes in thorac-

ic limbs are nor-

mal (green lines);

postural reactions

are delayed or ab-

sent and spinal re-

flexes are reduced

or absent in pelvic

limbs (red lines)

1

2

3

4

5

HoRNER’s syNDRoME &

ANIsCoRIAHorner’s syndrome is caused by a lack of sympathetic innervation to the eye. in patients with other neurologic dysfunction, it is most commonly seen with peripheral vestibular dysfunction, c6 to T2 myelopathy, or brachial plexus injury (ie, outside the spinal canal). clinical signs include: •Miosis(constrictedpupil)

• Enophthalmia(sunkeneye)

• Ptosis(droopingeyelid)

• Protrusionofthethirdeyelid.

Anisocoria refers to pupils of unequal size. • Lossofsympathetictone(ie,

horner’s syndrome) results in one pupil failing to dilate (remaining constricted) in darkness. • Aparasympatheticlesion(ie,

deficit of the oculomotor nerve cNiii) results in one pupil failing to constrict (remaining dilated) when exposed to light. • Brainedemaandbrainherniation

may cause compression of the cNiii nucleus in the midbrain, resulting in anisocoria, pinpoint pupils that do not dilate in the dark or respond to light, or fixed and dilated pupils. in these patients mental status is also altered (stuporous or coma-tose). This is a serious finding that requires immediate attention and treatment.


The NeuRologic exAmiNATioN iN comPANioN ANimAls, PART 2 |

Paresis

A patient with a cerebral lesion usually has mild,

almost unnoticeable paresis. Patients with brain-

stem lesions have more pronounced paresis and

ataxia ipsilateral to the lesion.

seizures

If there is a history of seizures, the lesion can be

localized to the prosencephalon, even if the neu-

rologic examination is normal.

THE sPINAl CoRD

Patients with spinal cord lesions have normal

mental status and cranial nerves. Spinal cord le-

sions can be localized based on:

• Gait abnormalities

• Postural reaction deficits

• Spinal reflex abnormalities.

The spinal cord is divided into 4 functional

regions: (1) C1 to C5, (2) C6 to T2, (3) T3 to L3,

and (4) L4 to S3.

• A lesion in the C1 to C5 or C6 to T2 spi-

nal cord segment results in tetraparesis and

often postural reaction deficits in all limbs.

Sometimes the pelvic limbs are more affected

than the thoracic limbs.

• A lesion in the T3 to L3 or L4 to S3 spinal

cord segment results in paraparesis and pos-

tural reaction deficits in the pelvic limbs.

The C6 to T2 and L4 to S3 spinal cord seg-

ments are anatomically enlarged (thus, cervical

and lumbar intumescences) because they contain

the nerve cell bodies of the peripheral nerves

to the limbs and tail. It is important to under-

stand that these enlarged spinal cord segments

are normal anatomy when evaluating images of

the spinal cord.

PosTuRAl REACTIoN AssEssMENTAll postural reaction tests assess the sensory path-

way from the paw to the brain stem and contralateral cerebrum (through the limb and spinal cord) and the motor pathway that returns the same way to the paw (Figures A and B).

conscious recognition is required from the cere-brum in order for the patient to replace the paw cor-rectly; a slow or absent response indicates a problem somewhere along the pathway. The pathways to and from the cerebellum contribute to the response and, in patients with cerebellar lesions, cause altered pos-tural reactions.

other findings help pinpoint the lesion to a spe-cific area. • Inpatientswithbraindisorders,posturalreaction

deficits are ipsilateral (both thoracic and pelvic limbs) to a lesion in the brainstem and contra-

lateral to a lesion in the cerebrum and thalamus (Figure C). • Apatientwithacervicalmyelopathy(C1–C5 or

C6–T2) has postural reaction deficits in all limbs; a patient with a thoracolumbar myelopathy (T3–l3

or l4–s3) or cauda equina syndrome has postural reaction deficits only in the pelvic limbs.

Figure A. Thoracic limb left (black) and right (blue) postural reaction pathways

Figure B. Pelvic limb left (black) and right (blue) postural reaction pathways

Figure C. With a left-sided brainstem lesion or right-sided cerebral lesion, postural reactions are affected in the left thoracic and pelvic limbs (red lines) but normal on the right side (green lines)

sIgNs oF VEsTIBulAR sysTEM

DysFuNCTIoN

spontaneous nystagmus, vestibular

ataxia, positional strabismus, head tilt,

and circling are all signs of vestibular

system dysfunction. The lesion may

be in the inner ear or eighth cranial

nerve (peripheral vestibular system) or

in the brainstem or cerebellum (central

vestibular system). Additional signs of

brainstem dysfunction that are used

to localize the lesion to the central

vestibular system include:

• Ipsilateralposturalreactiondeficits

• Changesinmentalstatus

• Deficitsinothercranialnerves.

| The Neurologic examiNaTioN iN compaNioN aNimals, parT 2

Today’s Veterinary practice March/April 201344

In addition to postural reaction assessment, these

areas are also evaluated by testing the spinal reflex-

es (Figure 1).

• A lesion in the C1 to C5 or T3 to L3 spi-

nal cord segment results in normal (sometimes

increased) spinal reflexes (upper motor neuron

signs) (Figures 2 and 3).

• A lesion in the C6 to T2 or L4 to S3 spinal

cord segment results in reduced muscle tone and

reduced spinal reflexes in the thoracic limbs (C6–

T2) or pelvic limbs (L4–S3) (lower motor neuron

signs) (Figures 4 and 5).

Paresis

Tetraparesis without cranial nerve deficits or other

brainstem signs suggests a cervical myelopathy; para-

paresis is suggestive of a thoracolumbar myelopathy.

Schiff-Sherrington Posture

This posture is seen with severe spinal cord injury be-

tween the T3 and L4 spinal cord segments. There

is increased tone in the thoracic limbs, and normal or

reduced tone with paralysis of the pelvic limbs; the

prognosis is guarded but not hopeless.

The posture results from loss of normal inhibition

of the thoracic limb extensor muscle tone, which is

normally controlled by the border cells in the lumbar

spinal cord. Axons of these cells ascend the spinal cord

to reach the cervical intumescence, where they inhibit

the thoracic limb extensor motor neurons.

THE PERIPHERAL NERVOUS SYSTEM

The peripheral nervous system includes the:

• Neuromuscular system (peripheral motor nerves,

muscles, and neuromuscular junctions)

• Sensory nervous system

• Autonomic nervous system.

Peripheral nervous system diseases can be diffi-

cult to diagnose, with signs of neurologic dysfunc-

tion being vague or nonexistent. The following infor-

mation does not pertain to diseases of the autonomic

nervous system.

• Patients with neuromuscular disease can have both

paresis and muscular weakness as well as exercise

intolerance.

• Sometimes muscle pain is present.

• Postural reaction deficits and reduced spinal reflex-

es may be present.

• The history may reveal signs of neuromuscular

disease, such as exercise intolerance, generalized

weakness, voice change, and neurogenic muscle

atrophy; these signs may be intermittent.

THE CAUDA EQUINA

The cauda equina are the spinal nerves (L6–L7, S1–

S3, and Cd1–Cd5) caudal to the spinal cord in the

lumbar vertebral canal.

• Compression of the cauda equina initially results in

pain, followed by paraparesis and postural reaction

deficits.

• Later in the disease, reduced spinal reflexes to the

pelvic limbs, anus, and urinary sphincter are pres-

ent.

•A history that includes slowly progressive parapa-

resis (over many months) and pain on palpation of

the lumbosacral area can help localize a lesion to

the cauda equina.

FURTHER DIAGNOSIS

Once the lesion is localized to a specific area of the

nervous system, a list of differential diagnoses can

be made. Based on lesion localization and differen-

tial diagnoses, appropriate diagnostic tests can be

chosen. n

Suggested Reading

DeLahunta A, Glass E (ed). The neurologic examination.

Veterinary Neuroanatomy and Clinical Neurology, 3rd ed.

Philadelphia: WB Saunders, 2009, pp 487-501.

Dewey C. Functional and dysfunctional neuroanatomy: The

key to lesion localization. In Dewey C (ed): A Practical

Guide to Canine and Feline Neurology, 2nd ed. Ames, IA:

Blackwell Publishing, 2003, pp 17-52.

Garosi L. Lesion localization and differential diagnosis. In

Platt SR, Olby NJ (ed): BSAVA Manual of Canine and

Feline Neurology, 3rd ed. Quedgeley, Gloucestershire,

UK: BSAVA, 2004, pp 24-34.

Lorenz MD, Kornegay JN. Localization of lesions in the ner-

vous system. Handbook of Veterinary Neurology, 4th ed.

Philadelphia: WB Saunders, 2004, pp 45-74.

Helena Rylander,

DVM, Diplomate

ACVIM (Neurology),

is a clinical assistant

professor in the

Department of Medical

Sciences at University

of Wisconsin–

Madison’s School of

Veterinary Medicine.

Her clinical interests include spinal surgery,

electrophysiology, and diagnostic imaging.

Dr. Rylander has published several articles

and a book chapter as well as presented

at national and international meetings.

She received her veterinary degree from

University of Agricultural Sciences in Uppsala,

Sweden. After 10 years in private practice in

Sweden, Dr. Rylander completed a residency

in neurology/neurosurgery at University

of California–Davis. She also completed

the Educational Commission for Foreign

Veterinary Graduates (ECFVG) certification

program and received her DVM.

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FINDINgs loCATIoN oF NEuRologIC DIsEAsE

MENTATIoN AssEssMENT

Mental status • Brainstem (see also decerebrate posture)

•Central vestibular system

• Prosencephalon

PosTuRE AssEssMENT

Decerebellate

Posture

•Cerebellum (normal mental status, opisthotonus, increased extensor tone in thoracic limbs, flexed

pelvic limbs with reduced muscle tone)

Decerebrate

Posture

•Midbrain or pons (severely affected mentation, increased extensor tone in all limbs, opisthotonus if

cerebellar lesion present)

Schiff-Sherrington

Posture

• T3–l4 spinal cord segments (increased tone in thoracic limbs; normal to reduced tone and

paralysis of pelvic limbs)

gAIT AssEssMENT

Ataxia •Cerebellum: symmetric, truncal (bouncy gait/good muscle tone)

•Proprioceptive pathways: mild, usually bilateral

• Vestibular system: Asymmetric, moderate

Circling • Prosencephalon: circles larger

• Vestibular system: circles smaller

• Directionofcirclingisusuallytowardsidewithlesion

Paresis • Brainstem: Paresis and ataxia ipsilateral to lesion

•Cauda equina: Paraparesis

•Cerebrum: mild, almost unnoticeable paresis

•Cervical myelopathy (C1–C5 or C6–T2): Tetraparesis

•Neuromuscular system: Various grade of para- or tetraparesis (also muscular weakness, exercise

intolerance)

• Thoracolumbar myelopathy (T3–l3 or l4–s3): Paraparesis

CRANIAl NERVE AssEssMENT

Cranial Nerve

Abnormalities

• Brainstem: localized to part of brainstem where nucleus is located

• Central vestibular system

• Peripheral nervous system: may affect one nerve or be part of a polyneuropathy

PosTuRAl REACTIoN AssEssMENT

Postural

Reaction

Deficits

• Brainstem: ipsilateral to lesion

•Cauda equina: Pelvic limbs

•Central vestibular system: ipsilateral to lesion

•Cerebrum/thalamus: contralateral to lesion

• C1–C5orC6–T2spinalcordsegments: All limbs (pelvic limbs may be more affected than thoracic

limbs)

• T3–L3orL4–S3spinalcordsegments: Pelvic limbs

• Neuromusculardisease:Postural reaction deficits may be present

sPINAl NERVE AssEssMENT

spinal Reflexes • Caudaequina: Reduced reflexes to pelvic limbs, anus, and urinary sphincter may be present

• C1–C5 or T3–l3 spinal cord segment: Normal to increased reflexes (upper motor neuron signs)

• C6–T2 or l4–s3 spinal cord segment: Reduced reflexes (lower motor neuron signs); reduced muscle tone

• Neuromuscular system: Reduced reflexes may be present in either thoracic or pelvic limbs

PAIN AssEssMENT

Pain on spinal

Palpation

• Brain: Pain on cervical flexion may sometimes be found

•Cauda equina: Pain on palpation of the lumbosacral area

•Neuromuscular: muscle pain in some myopathies

• spinal cord: Pain on palpation of affected area may or may not be present

oTHER AssEssMENTs

Hemineglect •Cerebrum: Reduced reaction to stimulus contralateral side to lesion

seizures • Prosencephalon: Neurologic examination may be normal

Vestibular

signs

•Central vestibular system: Brainstemorcerebellarlesion

• Peripheral vestibular system: inner ear lesion

lEsIoN loCATIoN oRgANIzED By NEuRologIC AssEssMENT & FINDINgsHelena Rylander, DVM, Diplomate ACVIM (Neurology)

This table can be downloaded and printed for use in your practice at todaysveterinarypractice.com.


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heArTworm

SocieTy & youWallace E. Graham, Jr, DVM, President

For this issue’s Heartworm Hotline column, our regular author, Dr. Clarke Atkins,

handed over the reins to Dr. Wallace Graham—the President of the American

Heartworm Society (AHS). Because April is National Heartworm Awareness

Month, Dr. Graham shares the mission of the AHS and how the society can help

you provide the best heartworm-related care to your patients.

The American Heartworm Society was founded in

1974 by and for veterinarians with one purpose

in mind: To understand heartworms and the

disease they cause, and to pass that understanding

along to practicing veterinarians. Along the way,

many outstanding scientists have contributed to this

understanding and continue to do so today.

Many of the Society’s officers and board members

are practicing veterinarians; therefore, it is an organi-

zation keenly focused on practitioners, their patients,

and their clients. To this end, the AHS has developed

initiatives and programs with the practicing veterinar-

ian in mind. Following is a brief description of each

and its benefits to you.

ConferenCes & Meetings

triennial symposium

The Triennial Symposium was the

first initiative of the AHS, and is

the foremost heartworm continu-

ing education event worldwide.

The latest, clinically relevant re-

search is presented by experts

from around the world in a forum that is scientifically

stimulating and practitioner friendly. The 2013 Trien-

nial Symposium—Heartworms Today: The Search for

Solutions—will be held in New Orleans, September 8

through 10. Registration is open at heartwormsociety.

org/annual/2013symposium.html.

nAVC symposium

Each year the AHS sponsors a half-day program of cut-

ting-edge information at the NAVC Conference (navc.

org) in Orlando, Florida. This program draws large,

enthusiastic crowds and generates significant inter-

est, which was demonstrated this past January by the

hour-long, impromptu question and answer session

held by Dr. Matthew Miller after his presentation con-

cluded our 2013 NAVC program.

Heartworm University

Recognizing that many practitioners are unable to at-

tend destination-based, national meetings, the AHS

has taken its message “on the road.” Heartworm Uni-

versity is a 6-hour, RACE-approved case-based pro-

gram that equips practitioners with the latest infor-

mation on heartworm disease, prevention, and

therapy.

Most of these programs are held in conjunction

with other meetings, such as state veterinary med-

ical association meetings, or are stand-alone meet-

ings. Worried that you can’t sit through a 6-hour

discussion on heartworms? Be aware that the pro-

gram always receives rave reviews from attendees. A

friend of mine who attended the San Antonio meeting

said it best: “Wally, I didn’t know what I didn’t know

about heartworms!”

Read about course content and upcoming meeting

dates at heartwormsociety.org/hwu.

http://heartwormsociety.org/hwu


american hearTworm SocieTy’S hearTworm hoTline |

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edUCAtionAl MAteriAls

incidence survey & Map

Every 3 years, the AHS surveys every animal hospital in

the country to identify trends in the incidence of heart-

worm disease. The maps developed from survey data

have been instrumental in documenting the continu-

ing spread of the disease. In addition, the maps are an

effective client education tool for practitioners inter-

ested in increasing compliance with heartworm pre-

vention recommendations.

Download the maps at heartwormsociety.org/

veterinary-resources/incidence-maps.html.

Canine & feline guidelines

The AHS has published guidelines for the diagnosis,

prevention, and treatment of heartworm disease al-

most since its inception. These guidelines represent

the standard of care for heartworm disease and are

the definitive “go-to” documents for the practitioner.

In the past, the guidelines were published after each

triennial symposium. However, thanks to the advent

of the digital age, new information is being generat-

ed too quickly for a triennial cycle and, therefore, the

Guidelines are now updated on an “as-needed” basis,

with press releases issued each time changes are made.

The latest versions are available at:

• Canine Guidelines: heartwormsociety.org/

veterinary-resources/canine-guidelines.html

• Feline Guidelines: heartwormsociety.org/

veterinary-resources/feline-guidelines.html

MediA oUtreACH

AHs Website

This is the definitive digital source for all things

heartworm. There are various information resources

for practitioners and pet owners,

including a children’s section.

The Think 12 section, available at

heartwormsociety.org/think12,

provides you, the practitioner, with

fresh, up-to-date information, ideas,

and client handouts to help you improve your clients’

compliance.

Quarterly Bulletin

As new information becomes available, the quarterly

AHS Bulletin is published in an easily digestible format

4 times a year. This publication is mailed or emailed

to our members, and past issues are available on our

website. Case discussions are common and relevant to

the many nuances of decision-making required of the

practitioner with regard to this complex parasite.

ongoing Media outreach

In an effort to keep practitioners and the public abreast

of the latest information on our website and other ven-

ues, the AHS reaches out to industry and select con-

sumer media, including blogs, with well-researched

and fact-based information. Often, heartworm-related

articles that practitioners read are published as a result

of, or in cooperation with, an AHS initiative.

social Media

Recognizing the impact of Facebook and Twitter on

today’s information superhighway, the AHS is using

these tools to reach out and provide quality informa-

tion to interested veterinarians, other veterinary team

members, and pet owners.

MeMBersHip Benefits

The partnership between the AHS and practitioners

provides a great opportunity for symbiosis. While you

do not need to be a member to enjoy the offerings of

the AHS, joining the society not only gives you the

best tools to care for your patients and communicate

with clients but also supports practical research for

improved methods of treating and preventing heart-

worm disease.

The American Heartworm Society exists for the bene-

fit of the entire profession and its patients—it is our only

reason for being. I hope you will avail yourself of the

great resources the AHS has to offer and that you will

see immediate benefits in the lives of your patients. n

Wallace E. Graham,

Jr, DVM, is the current

President of the American

Heartworm Society and

has previously served as

Secretary-Treasurer and

as a board member for

AHS. He is an associate

veterinarian at VCA Oso

Creek Animal Hospital in Corpus Christi. Dr.

Graham has been an active member of the

Texas Veterinary Medical Association, serving

as an executive board member and on the

Peer Assistance and Ethics and Grievance

committees. He served in the U.S. Army’s

Veterinary Corps upon receiving his DVM from

Texas A&M University.

http://heartwormsociety.org/think12

http://heartwormsociety.org/veterinary-resources/incidence-maps.html

http://heartwormsociety.org/veterinary-resources/incidence-maps.html

http://heartwormsociety.org/veterinary-resources/canine-guidelines.html

http://heartwormsociety.org/veterinary-resources/canine-guidelines.html

http://heartwormsociety.org/veterinary-resources/feline-guidelines.html

http://heartwormsociety.org/veterinary-resources/feline-guidelines.html


ImagIng EssEnTIals Peer reviewed

Small animal Spinal RadiogRaphy SeRieS

CerviCal Spine radiographyDanielle Mauragis, CVT, and Clifford R. Berry, DVM, Diplomate ACVR

Imaging Essentials provides comprehensive

information on small animal radiography techniques.

This article is the first in a 3-part series covering

cervical, thoracic, and lumbar spine radiography.

The following anatomic areas have been addressed

in previous columns; these articles are available at

todaysveterinarypractice.com (search “Imaging

Essentials”).

• Thorax

• scapula, shoulder, and humerus

• abdomen

• Elbow and antebrachium

• Pelvis

• Carpus and manus

• stifle joint and crus

• Tarsus and pes

Spinal radiographs are indicated for:

• Evaluation of traumatic injuries

• Neck and back pain

• Pain or neurologic issues associated with tho-

racic or pelvic limb lameness isolated to these

regions.

Each radiographic projection is a separate study and

should be radiographed as such. High quality, correctly

positioned and collimated radiographs are required in

order to provide an accurate assessment of the area of

interest, especially for surgical planning.

as a general rule, general anesthesia or heavy

sedation is necessary to evaluate the spine

because, in most cases, spinal images taken in

nonsedated patients are nondiagnostic. In addi-

tion, the presence or absence of disk space nar-

rowing cannot be determined from a nonsedated

animal’s radiographs due to unavoidable posi-

tioning artifacts.

MEAsurIng thE CErvICAl spInE Measure the thickest portion of the

neck that is within the area of collimation.

Due to thickness differences of the

cranial and caudal parts of the neck in

large-breed dogs, such as Doberman

pinschers, great Danes, or mastiffs:

• For lateral imaging, measure mid

cervical and at the level of the shoulder.

• For ventrodorsal imaging, measure

mid cervical and at the level of the

manubrium.

These techniques result in 2 separate

radiographic images—cranial and caudal

radiographs of the cervical spine.



ImagIng EssEnTIals |

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lateral projection: Cervical spine

For the lateral projection, position the patient in lateral recumbency (Figure 1). • Tapethethoraciclimbstogetherevenlyandpull

caudally. • Tapeorsandbagthethoraciclimbsinthis

caudal position, which places the humerus and glenohumeral joint below the cervical spine, eliminating superimposition. There will always be some degree of superimposition of the scapula. •Movethelumbarareaofthedogdorsally,allowing

the cervical spine to align with the horizontal collimation light.• Placetheskullinlateralposition;thenextendthe

skull and spine naturally and pull them straight cranially.

If the patient is a large-breed dog, place a sponge under the cervical spine and skull cranial to the shoulder. The sponge elevates the cranial portion of the cervical spine, making it level and lateral with the caudal portion of the cervical spine.

Collimated projection: Cervicothoracic spine

The collimated lateral image is centered over the cervicothoracic spine, and extends from the mid cervical

spine (cranial limit of field of view [FOV]) to just caudal to the scapulohumeral joint.

lateral Collimation

For the lateral projection, the FOV excludes the ventral and dorsal soft tissues of the neck, only including the cervical vertebral bodies and immediate soft tissues adjacent to the spine.

For all patients: • Palpate the vertebrae of the cervical spine

and place the horizontal line of the FOV at this plane.• For smaller patients, collimate the

FOV to include the caudal portion of the skull (cranial limit) to just caudal of the scapulohumeral joint (caudal limit).• For larger patients (cranial and caudal

images): » The cranial projection FOv should include the caudal portion of the skull to just cranial to the level of the scapulohumeral joint.

» The caudal projection FOv is centered just dorsal to the humeral scapular joint and first rib; it should extend cranially to the mid cervical spine and caudally to approximately the third rib.

The radiographic marker is placed along the dorsal and cranial aspect of the collimated FOV.

rOutInE vIEWs

Lateral and ventrodorsal views are consid-

ered the minimum orthogonal radiographs for

the spine. Due to the angled, divergent nature

of the x-ray beam, the area of the spine in the

center of the field of collimation will be the

area that provides the correct anatomic detail

and intervertebral disk space widths.

If there is a suspected abnormality at the

edge of the image, a repeat collimated image

centered at the area of interest is required for

complete evaluation. Recollimated images are

important because they depict common areas of

disease (ie, intervertebral disk spaces) that are

typically at the edge of the film/image, which

could be misinterpreted as narrowed due to the

divergent nature of the x-ray beam.

A routine cervical spine study includes:

1. Open lateral image of entire cervical spine

2. Open ventrodorsal image of entire cervical

spine

3. Collimated image of lateral cervicotho-

racic spine

4. Collimated image of ventrodorsal cervico-

thoracic spine.

B

A

Figure 1. Dog positioned for lateral projection of the cervi-

cal spine (A) and corresponding radiograph (B).

| ImagIng EssEnTIals


Figure 2. Dog positioned for ventrodorsal projection of the

cervical spine (A) and corresponding radiograph (B).

ventrodorsal projection: Cervical spine

Position the patient in dorsal recumbency (Figure 2).

• Ifapositioningtroughisused,placetheentire

cervical spine within the trough to eliminate any

edge artifacts associated with the imaging tray.

• Extendtheskullandneckandalignthemwith

the manubrium.

• Pullthethoraciclimbscaudallyandeithertape

together or individually.

Collimated projection: Cervicothoracic spine

The caudal ventrodorsal projection used for large-breed dogs (see ventrodorsal

Collimation) also serves as the collimated cervicothoracic image for all dogs and cats.

ventrodorsal Collimation

For the ventrodorsal projection, the FOV excludes the lateral soft tissues of the neck, only

including the central cervical vertebral bodies and immediate soft tissues adjacent to the

vertebral column.

For all patients:

• Palpate the vertebrae of the cervical spine and place the horizontal line of the FOV at

this plane.

• For smaller patients, collimate the FOV to include the caudal portion of the skull and

caudal to approximately the third rib.

• For larger patients (cranial and caudal images):

» The cranial projection FOv should include the caudal portion of the skull to just

cranial to the manubrium.

» The caudal projection FOv should extend to mid cervical spine cranially and

extend caudally to approximately the third rib. If allowable, the tube head should

be angled approximately 10° toward the dog or cat’s head, which aligns the angle

of the x-ray beam with the angle of the caudal cervical intervertebral disk spaces,

eliminating superimposition of the vertebral body over the intervertebral disk space.

The radiographic marker is placed along the right cranial aspect of the image in the

collimated FOV.

BA



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ADDItIOnAl vIEWs

lateral Oblique projection: Cervical spine

Trauma or congenital malformation may cause atlanto-

axial luxation or instability of the joint between cervi-

cal vertebra 1 and 2. To visualize the dens, an oblique

projection from the lateral position is obtained.

If an atlantoaxial instability is suspected, it is impera-

tive that care be taken not to luxate the vertebra further,

resulting in spinal cord trauma. Sedation is highly recom-

mended for these patients to avoid additional movement.

Position the patient in lateral recumbency (Figure 3).

• Tape the forelimbs and pull caudally with gentle

pressure.

• Obliquely angle the spine in a ventral direction,

which is achieved by placing a sponge under the

dorsal skull and shoulder.

For collimation, the FOV is centered at the atlan-

toaxial joint. The cranial border is at mid skull, while

the caudal border includes cervical vertebra 3 and 4.

Figure 3. Dog positioned for lateral oblique projection of the cervical spine (A) and corresponding radio-

graph (B). Note that the dens of C2 is normal in this dog.

A B

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| ImagIng EssEnTIals


A

Figure 5. Dog positioned for lateral flexed projection

of the cervical spine (A) and corresponding

radiograph (B).

A

Figure 4. Dog positioned for lateral extended

projection of the cervical spine (A) and

corresponding radiograph (B).

lateral Flexed & Extended projections:

Cervical spine

Flexed and extended projections are used for cervical

vertebral malformation (CVM) or Wobbler’s syndrome.

Compression of the spinal cord due to abnormali-

ties occurs mainly in large-breed dogs and affects the

caudal cervical vertebrae and their articulations, result-

ing in paraparesis, tetraparesis, or ataxia. The large-

breed dog will need a cranial and caudal projection as

with a naturally positioned cervical spine projection.

For both projections, position the patient in lateral

recumbency, with the forelimbs taped and pulled cau-

dally.

For the extended projection (Figure 4), push the

skull and cervical spine dorsally.

• Ensure that the caudal cervical vertebra are angled

dorsally, not merely pivoted at the mid cervical

spine.

• Hold the skull in place with a sandbag or tape.

For the flexed projection (Figure 5), pull the skull

and cervical spine ventrally toward the forelimbs.

• Ensure that the cervical spine is flexed at the level of

the caudal cervical vertebra and not merely arched

at the mid cervical spine.

• Hold the skull in place with a sandbag or tape.

For collimation, due to the flexion and extension

of the cervical spine, the FOV includes most of the soft

tissues of the neck.

B B

ventrodorsal Oblique projection: Cervical spine

Subtle lesions, fractures, and intervertebral disk disease are a

few of the conditions that may require a ventrodorsal oblique

projection of the spine.

From the straight ventrodorsal position of the cervical spine,

obliquely rotate the patient to the left approximately 10° to 15°;

then take the radiograph. Then rotate the patient to the right

approximately 10° to 15° and take another radiograph.

Set the collimation of the oblique ventrodorsal projections

as described for the ventrodorsal projection of the cervical

spine.

QuAlItY COntrOl

To make certain the desired technique has been achieved, use

the following guidelines to determine whether the appropri-

ate anatomy is included in the images.

For both lateral and ventrodorsal projections of the cervi-

cal spine:

• The cranial border should include the caudal aspect of the

skull.

• The caudal border should, at least, include T1.

For the lateral projection of the cervical spine:

• The wings of the Atlas (C1) should be even and superim-

posed.

• Each cervical vertebral body should be even with the super-

imposed transverse processes.



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For quality control of any diagnostic image, follow a

simple 3-step approach:

1. Is the technique adequate (appropriate exposure and development factors)?

2. Is the correct anatomy present within the image? 3. Is the positioning anatomically correct and straight?

Danielle Mauragis, CVT, is a radiology

technician at University of Florida College

of Veterinary Medicine. She teaches vet-

erinary students all aspects of the physics

of diagnostic imaging, quality control of

radiographs, positioning of small and large

animals, and radiation safety. Ms. Mauragis

coauthored the Handbook of Radiographic Positioning for Veterinary Technicians

(2009) and was the recipient of the Florida

Veterinary Medical Association’s 2011

Certified Veterinary Technician of the Year Award. This award recog-

nizes an individual for the many outstanding contributions that person

has made to the overall success of a veterinary practice operated or

staffed by an FVMA member veterinarian.

Clifford R. Berry, DVM, Diplomate ACVR,

is a professor in diagnostic imaging at the

University of Florida College of Veterinary

Medicine. His research interests include

cross-sectional imaging of the thorax, nuclear

medicine applications in veterinary medicine,

and biomedical applications of imaging in

human and veterinary medicine. Dr. Berry

has been a faculty member at North Carolina

State University and University of Missouri. He received his DVM from

University of Florida and completed a radiology residency at University

of California–Davis.

• On a straight cervical spine, the wings of C1 will overlap each other

and be superimposed over the dens, which is not visualized.

For the ventrodorsal projection of the cervical spine:

• The spinous processes should be superimposed over the vertebral

bodies.

• The spinous process over the Axis (C2) should resemble a thin line

bisecting the vertebral body. n

Suggested Reading

Burk rL, Feeney dA. Small Animal Radiology and Ultrasonography: A Diagnostic Atlas and Text, 3rd

ed. Philadelphia: Saunders elsevier, 2003.

Keely JK, McAllister H, Graham JP. Diagnostic Radiology and Ultrasonography of the Dog and Cat,

5th ed. Philadelphia: Saunders elsevier, 2011.

Sirois M, Anthony e, Mauragis d. Handbook of Radiographic Positioning for Veterinary Technicians.

Clifton Park, NY: delmar Cengage Learning, 2010.

Thrall de (ed). Textbook of Veterinary Radiology, 5th ed. Philadelphia: Saunders elsevier, 2008.

Thrall de, robertson id. Atlas of Normal Radiographic Anatomy and Anatomic Variants in the Dog

and Cat. Philadelphia: elsevier Saunders, 2011.


VITAL VACCINATION SERIES

What You Need

to Know About

R a b i e sRichard B. Ford, DVM, MS, Diplomate ACVIM & ACVPM (Hon)

PEER REVIEWEd

Today, one only has to read the eloquently written

introduction to Bill Wasik and Monica Murphy’s

book, Rabid: A Cultural History of the World’s

Most Diabolical Virus (Viking, 2012), to be reminded of

the impact the rabies virus has had on wildlife, domestic

animals, and humans for thousands of years.

Two facts make this infection particularly noteworthy:

1. Rabies virus is well known for its ability to be trans-

mitted from an infected animal to humans.

2. With rare exception, infection is 100% fatal in suscep-

tible species.

RAbies stAtistics

Currently, the World Health Organization estimates

that between 50,000 and 60,000 human fatalities from

rabies occur annually. According to the Centers for

Disease Control and Prevention:

• Over 90% of rabies exposure in humans is due to

exposure to rabid dogs.

• Exposure to rabid dogs is the cause of more than

99% of human deaths from rabies worldwide.

In North America, routine vaccination of pet dogs,

cats, and even ferrets, has played a critical public health

role in mitigating human risk for exposure to rabies

virus.

• For example, in the last decade in the U.S., only 2 to

3 human infections have been typically confirmed

each year.1 Most of those infections were acquired

outside the U.S. or resulted from exposure to bats.

• However, in Africa, India, and several locations in

Asia, where dogs are rarely vaccinated against rabies,

its prevalence in animals and risk for human expo-

sure through dogs is significant.

However, even in the U.S., rabies virus exposure,

whether known or suspected, carries a significant cost,

particularly when an unvaccinated pet that has been po-

tentially exposed to a rabid animal has contact with hu-

mans. It is estimated that 40,000 people undergo rabies

post-exposure prophylaxis (PEP) per year, at a potential

cost of thousands of dollars per person.

iMMunizAtion RequiReMents

In states and local municipalities (cities or counties)

where rabies vaccination is required,2 it is the:

• Pet owner’s responsibility to comply with rabies

law and ensure a pet is vaccinated at the appropriate

age and interval

• Veterinarian’s responsibility to ensure that rabies

vaccines are administered in accordance with exist-

ing laws or ordinances.

Following are 9 questions that address rabies and ra-

bies immunization. This information should be in your

“must know” category of knowledge.

• Because rabies laws vary significantly among states,

and even within states, the following responses pro-

vided are not universally applicable. They are, how-

ever, representative of what many states recognize or

require.

• If answers to any of the questions are unclear, con-

tact the appropriate agency to determine the most

suitable action needed to comply with state or

local law.

…that dogs suffer from the madness. This causes

them to become very irritable and all animals they

bite become diseased.

Attributed to Aristotle, 4th century BC

1in your state or city/county, which agency is

responsible for developing and enforcing rabies

laws, including vaccination requirements?

The answer varies considerably throughout the U.S. In

fact, for some states, the agency responsible for develop-

ing rabies law may be different from the agency charged

with enforcing rabies law. Furthermore, cities and coun-

ties may impose rabies regulations for pets that are strict-

er, but never more lenient, than state law.

Having the contact information for the appropriate

agency or individual is critical when the need arises

to address difficult questions or take specific action, es-

pecially when it concerns possible human or pet expo-

sure to rabies.

2 What constitutes exposure to rabies virus?

Circumstances defining exposure to rabies virus vary

among states and may even vary among cities or counties

within a state. Although regulatory descriptions of rabies

exposure are typically limited to humans, some loca-

tions have specific ordinances in place for pets exposed

to a potentially rabid animal.

Exposure to rabies virus constitutes any known or

suspected bite, scratch, or other incident in which sa-

liva, central nervous system (brain or spinal cord) tissue,

or cerebrospinal fluid of a potentially rabid animal enters

an open, fresh wound or comes in contact with mucous

membranes by entering the eye, mouth, or nose.

When characterizing human exposure due to an en-

counter with a pet dog, cat, or ferret, other factors may

be considered, such as:

• Was the bite incidence provoked or non-provoked?

• Is the animal involved available?

• If available, can the animal’s vaccination status be con-

firmed?

3 What constitutes a currently vaccinated versus

unvaccinated dog, cat, or ferret?

This is an important question—most states and local

municipalities conform to recommendations

outlined in the Compendium of Animal

Rabies Prevention and Control.

This publication states: an animal is

currently vaccinated, and is con-

sidered immunized, if the initial

vaccination was administered at

least 28 days previously or boost-

er vaccinations have been ad-

ministered in accordance with

the product label (ie, either as a

1- or 3-year product).

Consider this: A dog or cat that

bites a human within 28 days fol-

lowing its initial rabies inoculation

is not considered to be immunized.

Additionally, a dog or cat can be

considered unvaccinated if only 1

day overdue for a 3-year booster.

4 Which of the following tests can be used in the

u.s. to confirm a diagnosis of rabies virus infec-

tion? identify all that you consider confirmatory.

A. Routine histopathology of formalin-fixed brain tissue

B. Direct fluorescent antibody (DFA) on whole blood

C. Fluorescent antibody virus neutralization (FAVN) test

D. Direct fluorescent antibody (DFA) of intact brain tissue

E. Direct rapid immunohistochemical test (DRIT) of

brain tissue

F. Rapid fluorescent foci inhibition test (RFFIT)

The correct answer is D: the DFA test performed on in-

tact brain tissue by a qualified laboratory constitutes a di-

agnosis of rabies. When feasible, isolation of rabies virus

from tissue may also be performed to confirm infection.

The DRIT has been used as a screening test but cur-

rently must be confirmed by DFA. The FAVN test measures

serum levels of rabies virus neutralizing antibody in vac-

cinated animals traveling to rabies-free countries/regions.

5 What is the youngest age a dog or cat residing

in the u.s. should be vaccinated against rabies?

Currently, in the U.S., rabies vaccines may be admin-

istered to dogs and cats as early as 12 weeks of age,

but not younger. This applies to all states and all rabies

vaccines, regardless of manufacturer. Some cities/coun-

ties, however, may require owners to have pets vaccinat-

ed at an age other than 12 weeks of age (eg, 16 weeks).

6 under what circumstances can a rabies antibody

titer be used to establish immunity in a dog or cat?

Rabies serology (antibody titer), regardless of the

methodology used, does not directly correlate with

| ViTAl VACCinATion SerieS: VACCine AdVerSe eVenTS


sAMple subMission foR fAVn:

pets traveling to Rabies-free

countries or Regions• Collect 1- to 2-ml of serum in a 5-ml test

tube (cold packed, with no additives).• each sample must be submitted with a FAVn

report Form (available at vet.k-state.edu/

depts/dmp/service/rabies/pdf/fAVn_test_

submission_form.pdf).• Submit the sample and form to the rabies

laboratory, Kansas State University, 2005 research Park Circle, Manhattan, KS 66502; phone: 785-532-4483; FAX: 785-532-4474.• Current cost is $83 per sample.

Turn-around times may vary depending on laboratory workload; expect approximately 3 weeks. Contact the laboratory directly for questions related to animals traveling within 3 weeks. in addition, veterinarians can contact the laboratory for a current list of countries that require FAVn antibody titers prior to importation of a pet dog or cat.

http://www.vet.k-state.edu/depts/dmp/service/rabies/pdf/favn_test_submission_form.pdf


ViTAl VACCinATion SerieS: VACCine AdVerSe eVenTS |

protection and, therefore, cannot be interpreted

as a legal index of immunity. Immunologic factors

other than antibodies (eg, cell-mediated immunity)

are important in protection from rabies infection.

However, a “positive” rabies antibody titer does

demonstrate that a postvaccinal immune response has

developed. Although an antibody titer can be shown

to correlate with protective immunity, an antibody

titer cannot, by law, be used in lieu of revaccination.

7 if presented with a dog that is several months

overdue for a 3-year rabies booster, what is the

most appropriate vaccination recommendation?

The answer varies, as one might expect, from one

state or location to another.

In the U.S., states that do address this issue (many

don’t), tend to conform with booster recommendations

published in the Compendium of Animal Rabies Pre-

vention and Control. These recommendations state:

an animal is considered immediately vaccinated

after a booster vaccine, even if overdue.

The duration of immunity is dictated by the product

label (ie, either a 1- or 3-year rabies vaccine). When in

doubt, contact the appropriate agency for a definitive

legal perspective.

8 is it appropriate to discontinue routine rabies

vaccination for a strictly indoor pet dog or cat?

Where rabies vaccination is required, it cannot be dis-

continued, no matter what the pet’s age or lifestyle.

Rabies vaccines should be administered, at appro-

priate intervals (usually every 3 years), for the life

of the pet.

9 Vaccines are specifically recommended for

administration to healthy animals (by the man-

ufacturer). Does a veterinarian have the author-

ity to exempt an individual dog or cat that has a

significant illness (eg, chronic renal failure) from

rabies vaccination?

A veterinarian licensed to practice in the U.S.

must not assume he or she is authorized to grant

a rabies vaccination exemption on the grounds

an animal has been diagnosed with any illness

(ie, is not “healthy”). Today, most states do not spe-

cifically address rabies exemption for veterinarians,

although cities or counties within a state may. Indi-

vidual cities or counties within a state that recognizes

rabies vaccination exemptions may specifically deny

that authority.

In locations that do grant rabies exemption author-

ity to veterinarians, the terms of that authority must be

clearly understood before implementing a waiver. For

example, veterinarians practicing in localities where

rabies exemptions are recognized may be required to

submit supporting documentation to the appropriate

agency (public health) and wait for official approval,

a process that can take days to weeks to complete. n

Footnotes

1. In the U.S., the latest human fatality was attributed to exposure

to a bat in Contra Costa County, California, in 2012.

2. In the U.S., some states do not require rabies vaccination

of dogs and cats (although certain cities/counties may).

In Canada, Ontario is the only province in which rabies

vaccination of dogs and cats is required by law.

Suggested Reading

Greene CE. Rabies and other Lyssa virus infections. In Greene

CE (ed): Infectious Diseases of the Dog and Cat, 4th ed. St.

Louis: Elsevier-Saunders, 2012, pp 179-197.

National Association of State Public Health Veterinarians.

Compendium of Animal Rabies Prevention and Control,

2011; available online at nasphv.org/documents/

RabiesCompendium.pdf.

Wasik B, Murphy M. Rabid: A Cultural History of the World’s

Most Diabolical Virus. New York: Viking, 2012.

World Health Organization. Rabies: A Neglected Zoonotic

Disease, 2013; available at who.int/rabies/en/index.html.

Resources

The Rabies Laboratory, College of Veterinary Medicine, Kansas

State University; available at vet.k-state.edu/depts/dmp/

service/rabies/index.htm.

Richard B. Ford, DVM,

MS, Diplomate ACVIM &

ACVPM (Hon), is Emeritus

Professor of Medicine at

North Carolina State Uni-

versity’s College of Vet-

erinary Medicine. He is

a retired Brigadier Gen-

eral from the USAF Re-

serve, where he was assigned to the Office of

the Surgeon General at the Pentagon. Dr. Ford

is also a past president of the NAVC Confer-

ence and continues his role as a member of

the scientific program committee. His clinical

interests are in the field of companion animal

infectious disease; he is a prolific author and

serves on both the AAHA Canine Vaccination

Task Force and AAFP Feline Vaccination Ad-

visory Panel. Dr. Ford received his DVM from

Ohio State University and completed an inter-

nal medicine residency at Michigan State Uni-

versity. He held a previous faculty position at

Purdue University.

Key point: even in states/locations that

recognize a veterinarian’s authority to exempt

(for health reasons) a dog/cat from rabies

vaccination requirements, dogs and cats that have

exceeded the duration of immunity for the vaccine

administered (ie, 1 or 3 years) are considered

unvaccinated (not immunized), even if the patient

has a “positive” rabies titer.

http://nasphv.org/documents/rabiescompendium.pdf

http://who.int/rabies/en/index.html

http://www.vet.k-state.edu/depts/dmp/service/rabies/index.htm

http://www.vet.k-state.edu/depts/dmp/service/rabies/index.htm

http://nasphv.org/documents/rabiescompendium.pdf

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Consider THis CasePeer reviewed

History

• Behavior: The owner reported unusual behavior that

included roaming throughout the house, loud vocal-

ization, and increased affection; however, the cat had

been spayed as a kitten, with no history of this recent

behavior.

• Clinical signs: The owner also noted that the cat had

recently exhibited decreased appetite and thirst but

was unable to recall changes in urine output.

• Environment: The cat was housed exclusively indoors

and fed commercial dry cat food. There was no history

of travel.

• Medical history: The cat was current for core vac-

cinations, tested negative for retroviruses as a kitten,

and received only monthly parasite preventive medica-

tions.

iNitiAL DiAGNostiCs & tHErAPyPhysical Examination

The cat had a body condition score of 4/9, with a consis-

tent weight history over the past year. Rectal tempera-

ture, heart rate, and respiratory rate were within normal

limits. Abdominal palpation and examination of exter-

nal genitalia were unremarkable; no vaginal discharge

was observed.

Laboratory Analysis

The initial laboratory database included a complete

blood count, serum biochemistry, electrolytes, total thy-

roxine (T4), and urinalysis and culture. The only abnor-

malities were:

• Mild creatinine elevation (2.2 mg/dL; reference range,

0.3–2.1 mg/dL)

• Mild hematuria.

imaging

Ultrasound of the urinary bladder did not reveal masses,

uroliths, or thickening or irregularity of the bladder wall.

therapeutic Plan

A diagnosis of urinary tract infection was considered

pending culture results, and an empirical trial of marbo-

floxacin (25 mg PO Q 24 H for 10 days) was initiated. The

owner was instructed to report if no improvement was

observed within 72 hours.

ADDitioNAL DiAGNostiCsFour days later, the cat was presented again with contin-

ued signs of estrus. According to the owner, no improve-

ment in the cat’s behavior had been observed.

Physical examination findings were unremarkable.

The urine culture exhibited no aerobic bacteria growth

at 72 hours.

Hormone Analysis

Because increased estrogen levels trigger a negative feed-

back mechanism that results in reduced luteinizing hor-

mone (LH) levels, a serum sample was submitted for LH

analysis. Results were < 1 ng/mL, suggesting the presence

of an endogenous or exogenous source of estrogen.

imaging

Abdominal radiography revealed no abdominal mass-

es. Ultrasonographic evaluation of the abdomen (by

a board-certified veterinary radiologist) revealed no evi-

dence of ovarian tissue. The left adrenal gland was of

normal size (3.7 × 8.4 mm) and architecture; the right

adrenal gland was not found.

One week following initial presentation, the cat was

still exhibiting signs of estrus.

estrus in a Spayed CatErin O. Dresner, DVM, MS, and Gary D. Norsworthy, DVM, Diplomate ABVP (Feline)

A 13-year-old, 4.54-kg (10-lb) spayed female

domestic medium-hair cat presented with a

1-day history of typical signs of estrus.

QuEstioN: What are the differ-

ential diagnoses for this case? Considering the information provided, what

differential diagnoses would you pursue?

Feline FriendlyArticle

| Consider THis Case


DisCoVEriNG tHE DiAGNosisAt this point—1-week following initial presentation—the

owner disclosed that she was prescribed transdermal

hormone replacement therapy (HRT) containing estra-

diol, progesterone, and dehydroepiandrosteron (DHEA)

in emu oil. The owner described a daily routine of ap-

plying the cream to her forearms and, shortly thereaf-

ter, picking up and cradling the cat for several minutes.

The owner began using the medication approximately

12 days before the cat’s initial presentation to the clinic.

Final Diagnostics

Following this disclosure, serum estradiol analysis was

performed because estradiol was a component of the

owner’s HRT and, most likely, the cause of the cat’s es-

trous-like behavior. The patient’s serum estradiol was

measured at 71.06 pg/mL (reference ranges; < 15 pg/

mL for a spayed cat, < 20 pg/mL for pregnant queen or

queen in diestrus, and 25–50 pg/mL for queen in pro-

estrus or estrus).

ANsWEr: Differential diagnoses

to consider include: • exposure to exogenous estrogens• increased production of sex hormones (due

to pathology of the zona reticularis of the adrenal cortex1,2) • ovarian remnant syndrome• Presence of accessory ovaries (congenital

anomaly)• adrenocortical carcinoma (which was recent-

ly reported to cause estrous-like behavior in a spayed female cat).3

treatment

A therapeutic trial of megestrol acetate (5 mg

PO Q 24 H) was initiated because this drug

has been used to terminate estrus. Megestrol

is a synthetic progestin that exerts an inhibi-

tory effect on the secretion of pituitary gonad-

otropins.

Two days later, the cat’s signs of estrus were

resolved and therapy was discontinued.

Follow-up

Recheck examinations performed 18, 36, and

90 days post megestrol treatment revealed

serum estradiol concentrations of 32.4 pg/mL,

35.6 pg/mL, and 20.4 pg/mL, respectively.

The pharmacokinetics of estradiol in compan-

ion animals are largely unknown. Estrogens and

their metabolites accumulate in adipose tissue,

are excreted into urine and bile, and those in

bile are reabsorbed by the gastrointestinal tract,

which may explain the persistent, increased es-

trogen levels observed in this case.

Case Conclusion

The owner is currently using a sublingual route of HRT ad-

ministration to eliminate exposure of the cat to the medica-

tion. According to the owner, all previously reported signs of

estrus have resolved, and the patient has not exhibited any

signs for over 12 months.

CAsE DisCussioNHyperestrogenism and estrogen toxicity in pets due to expo-sure to human HRTs are a growing veterinary medical con-cern.

reported Cases

More than 100 suspected cases are reported anecdotally, with most involving canine patients.4 Despite the existence of this phenomenon, we are aware of but 1 single case re-ported in the literature.5 To our knowledge, no feline cases have been reported.

rEtrosPECtiVE CAsE rEViEWa weakness in this case’s workup was failure to visualize the right adrenal gland on ultrasound. an estrogen secreting tumor could have been missed if one was present.

When a cat’s right adrenal gland is healthy, it is difficult for even board-certified radiologists to identify; however, the presence of an adrenal tumor increases the organ’s size, which makes it easier to locate.

We believe that the presence of an adrenal tumor can be ruled out because the cat remained estrus-free for 12 months following discontinuation of the owner’s transdermal hormone use.


Consider THis Case |

est

rus

in a

sp

aye

d C

at

Human risks

The danger of exposing children and other family mem-

bers to HRTs has been acknowledged and was explained

to the owner by her physician. Awareness of the issue has

increased due in part to recent attention by the United

States Food and Drug Administration.6,7 However, physi-

cians typically do not warn patients about the potential

dangers of exposing pets to these hormones.

Companion Animal risks

Chronic exposure to high doses of endogenous estro-

gens is toxic to mammals. Susceptibility to estrogen

toxicity in cats is greater than it is in dogs, ferrets, rats,

and mice.8

Prolonged hyperestrogenism in the cat is associated

with:8,9

• Steroid alopecia

• Mammary tissue growth

• Hepatic pathology

• Pancreatic hypertrophy

• Pancytopenia.

As in the bitch, cats may be at risk for coagulopathies

and stump pyometra secondary to pancytopenia in-

duced by hyperestrogenism.

Diagnosis of Estrus

Diagnosis of exposure to exogenous estrogens and sub-

sequent hyperestrogenism in the feline patient is con-

founded by the difficulties in detecting estrus in the

species.

Dogs Versus Cats. In the bitch, estrus is diagnosed

by several distinct signs, including vulvar enlargement,

vaginal hemorrhage, and perivulvar alopecia. However,

the feline vulvar labia do not respond to estradiol and,

therefore, do not typically change appearance during

estrus as in the bitch.10

Feline Behavior. Feline behavioral signs, such as

rolling, head rubbing, hindlimb treading, posturing,

vocalization, and permitting mounting by male cats,

are generally the only indication of estrus in queens.11

Although these changes may be quite dramatic in some

individuals, in others, they may be difficult to distin-

guish from normal affectionate behavior.

Vaginal Cytology. Estrus in the bitch is easily con-

firmed by vaginal cytology, but it is not a routine diag-

nostic tool used in feline medicine given the anatomic

limitations of the feline vagina.10

Diagnostics in this Case

One could take the position that vaginal cytology

should be performed in cats with the history and clini-

cal signs seen in this case. It could even be argued that

it was a significant oversight. However, we chose not to

perform vaginal cytology based on its cited limitations.10

Instead, documentation of very elevated serum estradi-

ol concentrations confirmed that the clinical signs were

due to estrus.

To eliminate any doubts regarding the cause of this

patient’s signs, a trial of re-exposure to the transder-

mal cream with documentation of identical signs would

be ideal, however, impractical. Further testing for po-

tential ovarian remnant syndrome with GnRH-induced

ovulation and subsequent measurement of serum pro-

gesterone was declined by the owner due to resolution

of clinical signs. n

dHea = dehydroepiandrosteron; HrT = hormone re-

placement therapy; LH = luteinizing hormone

References

1. eilts B. Feline ovarian remnant syndrome. Louisiana VMA Winter Meeting

Proceedings, 2012, pp 231-237.

2. Grundy SA, davidson AP. Feline reproduction. in ettinger SJ, Feldman

eC (eds): Textbook of Veterinary Internal Medicine, 6th ed. St Louis:

elsevier Science, 2005, pp 1696-1707.

3. Meler e, Scott-Moncrieff JC, Peter AT, et al. Cyclic estrous-like behavior

in a spayed cat associated with excessive sex-hormone production by

an adrenocortical carcinoma. J Fel Med Surg 2011; 13:473-478.

4. Lau e. researcher promotes awareness of accidental hormone

exposure in pets. Veterinary Information Network News Service, news.

vin.com; assessed June 8, 2011.

5. Schwarze rA, Threlfall wr. Theriogenology question of the month.

JAVMA 2008; 233:235-237.

6. Lau e. FdA investigating accidental hormone exposure problem.

Veterinary Information Network News Service, news.vin.com; assessed

July 29, 2010.

7. Franklin SL. effects of unintentional exposure of children to compounded

transdermal sex hormone therapy. Ped Endocrinol Rev 2011; 8:208-212.

8. Hart Je. endocrine pathology of estrogens: Species differences.

Pharmacol Thera 1990; 47:203-218.

9. Amorim da Costa Fv, Moreira de Souza HJ. Granulosa cell tumor.

in Norsworthy Gd (ed): The Feline Patient, 4th ed. Ames, iA: wiley

Blackwell, 2010, pp 207-208.

10. Feldman eC, Nelson rw. Canine and Feline Endocrinology and

Reproduction, 3rd ed. Philadelphia: wB Saunders, 2004, pp 1018-1020.

11. voith vL. Female reproductive behavior. in Morrow de (ed): Current Therapy

in Theriogenology. Philadelphia: wB Saunders, 1980, pp 845-848.

Erin O. Dresner, MS, DVM, is currently completing a small animal rotating internship at North Houston Veterinary Specialists in Spring, Texas. She received her DVM from Western University of Health Sci-ences College of Veterinary Medi-cine in 2012. Prior to her veterinary education, Dr. Dresner completed

an MS focused on parasitology at Texas State Univer-sity. Her clinical and research interests include feline internal medicine and infectious disease.

Gary D. Norsworthy, DVM, Dip-lomate ABVP (Feline), is the owner of Alamo Feline Health Center in San Antonio, Texas, where he practices full time. His 40 years of private practice include 15 years specializing in feline medicine. Dr. Norsworthy also holds adjunct pro-fessorships in clinical medicine at

Mississippi State University and Western University of Health Sciences. He has lectured to veterinary asso-ciations on feline topics in the United States, Canada, Brazil, and Australia and is the editor of 6 feline text-books. Dr. Norsworthy received his DVM from Texas A&M University.

http://vin.com

http://news.vin.com

I may look serious, but I’m smiling inside.

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you time and increasing the number of patients you treat. To learn more, call 888-981-3174 or visit: midmarkanimalhealth.com/tvpjanfeb13.

http://midmarkanimalhealth.com/tvpjanfeb13


DENTAL DIAGNOSISPeer reviewed

Tooth fractures are very common

in dogs. The most commonly

fractured teeth are the canines

and carnassials (maxillary fourth

premolars and mandibular first

molars).

Fractures are further characterized

as complicated or uncomplicated.

Complicated crown fractures have

direct pulp (nerve) exposure, whereas

uncomplicated crown fractures have

direct dentin but no pulp exposure.1

Both types of tooth fractures

require therapy; however, treatment

differs depending on the physical and

radiographic appearance.

Question

Based on the clinical

evidence, what type of

fracture is shown in Figure 1?

(answer next page)

Canine TooTh FrActureBrook A. Niemiec, DVM, FAVD, Diplomate AVDC

Read the following articles by Dr. Brook

Niemiec at todaysveterinarypractice.com:

•Diagnosis&TreatmentofCrownFractures

(July/August 2011)

•Bonded sealant Application for crown

Fractures (July/August 2011)

•DentalExtractions:FiveStepstoImprove

ClientEducation,SurgicalProcedures,&

Patient care (May/June 2012)

Brook A. Niemiec, DVM,

FAVD, Diplomate AVDC, is

chief of staff of Southern

California Veterinary Dental

Specialties. He is the author

of Small Animal Dental, Oral

and Maxillofacial Disease: A

Colour Handbook (Manson

Publishing) and Veterinary Periodontology (Wiley

Blackwell). He founded the veterinary dental

telemedicine website vetdentalrad.com, lectures

at national and international conferences, and is

the coordinator and instructor of the San Diego

Veterinary Dental Training Center (vetdentaltraining.

com). He received his DVM from University of

California–Davis.

to view an informational video on fractured

teeth, visit dogbeachdentistry.com.

1

http://vetdentalrad.com

http://dogbeachdentistry.com

| DENTAL DIAGNOSIS


AnswerBased on the clinical evidence, what type of

fracture is shown in Figure 1?

This patient has an uncomplicated crown fracture,1

which is very common in large-breed dogs. These

types of fractures occur when a piece of the crown is

broken, exposing the dentin but not the pulp.

The radiograph (Figure 2) reveals that this tooth is

nonvital and infected, both of which are evidenced by

the periapical rarefaction surrounding all 3 roots (red

arrows).2 Additional radiographic signs of endodontic

disease include a wider endodontic space (or on occa-

sion, narrower) and internal or external resorption.2

Figures courtesy vetdentalrad.com (Importance of Dental Radiology client educational poster)

QuESTIon&AnSwErwhat therapeutic measures should be pursued—

keepaneyeonthefracture,extractthetooth,or

perform a restoration or root canal?

Hopefully your answer was not “keep an eye on the fracture.” Despite the fact that veterinary patients rarely show clinical signs, uncomplicated crown frac-tures can be very painful.3

roleofDentinalTubules

Dentinal tubules surround the tooth, running from the root canal to the enamel. Each tubule contains an odontoblastic process—basically a nerve supply that is limited to sensory function. There are approximately 50,000 dentinal tubules per mm2 coronal dentin, which is about twice the number found in human teeth.4,5

When enamel is lost, the dentin is exposed; there-fore, a 1-cm area of enamel loss in a canine tooth exposes 3 to 4 million odontoblasts. This exposure leads to quicker dentinal fluid flow out through the dentinal tubules via the capillary effect. The increase in flow deforms the A-delta fibers and C-fibers, which is perceived by the patient as pain.3

Factors, such as heat, cold, and desiccation, change the flow rate, cause the nerves to fire, and result in pain (sensitivity).6 Sensitivity is actually a sign of low-grade pulp inflammation called pulpitis.

Bacterial infiltration

Loss of enamel also allows bacteria to potentially ingress into the root canal system.3,7 In some cases,

these bacteria can result in endodontic infection and subsequent abscessation, which can occasionally manifest clinically as a swelling or draining tract, but is generally subclinical and, therefore, undiagnosed. The only way to definitively diagnose this infection is via dental radiographs.

therapeutic Measures1,7,8

There are 2 options for nonvital and infected teeth:

root canal therapy or extraction.

•Treatmentofinfectedteethwithrootcanalshasasim-

ilar success rate as vital teeth treated with root canals;

therefore, root canal therapy should be considered.

•Ifextractioniselected,postoperativedentalradio-

graphs should be taken because retained roots are

a common complication of these extractions.

treatment for this Patient

Because the tooth was nonvital and infected, I elected

to perform a root canal, based on the success of this

therapy in my experience. If root resorption had been

seen on the radiograph, extraction would have been

the selected therapy.

Bonded sealant therapy

If no radiographic evidence of disease had been pres-

ent in this case, the tooth would have been treated

with a bonded sealant.9 This therapy resolves sensi-

tivity, blocks off the pathway for infection, improves

aesthetics, and smooths the tooth to decrease plaque

accumulation, retarding periodontal disease. n

References

1. duPont GG. Problems with the dental hard tissues.

in niemiec Ba (ed): Small Animal Dental, Oral and

Maxillofacial Disease: A Colour Handbook. London:

Manson Publishing, 2010, pp 127-156.

2. niemiec Ba. veterinary dental radiology. in niemiec Ba

(ed): Small Animal Dental, Oral and Maxillofacial Disease:

A Colour Handbook. London: Manson Publishing, 2010,

pp 63-87.

3. Startup S. Tooth response to injury. in niemiec Ba (ed):

Veterinary Endodontics. Tustin, Ca: Practical veterinary

Publishing, 2011.

4. Theuns P. endodontic anatomy. in niemiec Ba (ed):

Veterinary Endodontics. Tustin, Ca: Practical veterinary

Publishing, 2011.

5. Lewis Jr, reiter aM. anatomy and physiology. in niemiec

Ba (ed): Small Animal Dental, Oral and Maxillofacial

Disease: A Colour Handbook. London: Manson

Publishing, 2010.

6. Trowbridge ho, Syngcuk K, hideaki S. Structure and

functions of the dentin-pulp complex. in Cohen S, Burns

rC (eds): Pathways of the Pulp, 8th ed. St Louis: Mosby,

2002, pp 411-456.

7. woodward TM. Bonded sealants for fractured teeth. Top

Companion Anim Med 2008; 23(2):91-96.

8. niemiec Ba. oral pathology. Top Companion Anim Med

2008; 23(2):59-71.

9. Theuns P, niemiec Ba. Bonded sealants for

uncomplicated crown fractures. J Vet Dent 2011;

28(2):130-132.

2

http://vetdentalrad.com


ToP TenPeer reviewed

March 17 through 23, 2013, is designated

as Poison Prevention Week by the

Poison Prevention Week Council

(poisonprevention.org).

The U.S. Congress established national Poison

Prevention Week on September 16, 1961, and the

Poison Prevention Week Council was organized

shortly thereafter to coordinate this annual event

and promote poison prevention. Last year’s

Poison Prevention Week marked the week’s 50th

anniversary.

As highlighted in this article, the best resource

for poison prevention in pets is the ASPCA’s

Poison Control Center website—aspca.org/

pet-care/poison-control. The website not only

provides a “hotline” number for pet owners or

veterinary professionals to call in case of a pet’s

potential poisoning, but also offers a number of

resources on toxicities in pets.

Highlight Poison Prevention Week in your

practice to increase your clients’ awareness of

potential toxins in their homes and other areas

their pets may visit. Use our Poison Prevention

in Pets handout, available for download and use

in your clinic at todaysveterinarypractice.com,

to help staff and pet owners identify common

household items that may be dangerous to pets.

Toxicoses

in dogs &

caTsTina Wismer, DVM, Diplomate ABVT & ABT

“Common things happen commonly” is a good

adage for veterinary toxicology.

To help veterinary professionals and pet owners with

poison-related emergencies, the American Society for the

Prevention of Cruelty to Animals (ASPCA) Animal Poison

Control Center (APCC) offers a valuable resource: phone

consultations with veterinary toxicologists, 24 hours a

day, 365 days a year (888-426-4435).

Last year, the APCC compiled data from 180,000 cases

received during 2012 to help increase both veterinary and

consumer knowledge about poisoning in pets.1

•Domestic dogs were most often exposed to toxins

(79.3%), followed by cats (13.2%), birds and small

mammals (ferrets, lagomorphs, rodents) (3.8%), and

large animals (horses, cows) (2.13%).

•Most dogs and cats are accidentally exposed to poi-

sons, with most exposures resulting from ingestion of

human medication.

•Malicious poisonings account for less than 1% of

reported situations.

Datafromthecallsalsoidentifiedthetop10pettoxins

evaluated by the APCC in 2012.

While not all poisonings are reported to the

APCC, the information gained by identification

of toxins and trends associated with expo-

sure can help veterinarians efficiently determine

a differential diagnosis.

http://poisonprevention.org


http://aspca.org/pet-care/poison-control

http://aspca.org/pet-care/poison-control


| ToP Ten

1 HuMAn PreSCriPtion MediCAtionS The number one group of substances the APCC

received calls about in 2012 was human prescription

medications, accounting for 25,200 calls.1 The number

of people prescribed medications for chronic disease is

continually growing and so are accidental ingestions of

these medications by pets (such as consuming dropped

pills or getting into pill organizers).

• Cardiac medications are the largest group of human

medications ingested, ranging from relatively safe (ie,

diuretics, ACE inhibitors) to life-threatening (ie, cal-

cium channel blockers, digoxin) products.

• Antidepressants, thyroid, and attention deficit hyper-

activity disorder (ADHD) medications are also com-

monly ingested. Cats are not normally attracted to

large pills but they are strangely drawn to venlafaxine

(Effexor, pfizer.com) capsules.

Veterinarians should counsel owners to:

• Store and take their medications in a place

away from pets to prevent them from ingesting any

dropped pills.

• Keep medication bottles out of reach of pets to

prevent dogs from chewing on the bottles/caps and

gaining access to the pills (unfortunately, child-safety

caps are not pet-safe!).

• Store pet and human medications separately to

avoid accidental administration of human medications

to pets or vice versa.

2 inSeCtiCideSAs new products have become more specific for

insect physiology in the past 10 to 20 years, insec-

ticideshavebecomemuchsaferformammals.However,

insecticide granules, yard sprays, and preventives used on

pets can cause serious problems if not administered correctly.

Eleven percent of phone calls to the APCC were in regard to

insecticide exposure.1

Veterinarians should emphasize that:

• Owners read the label and follow directions before

using any insecticide

• Products labeled for dogs only should NOT be used

for cats. Applying permethrin products that are labeled

for dogs on cats can cause tremors and seizures, and

require immediate medical intervention.2

• Cats may have taste reactions (hypersalivation) that

can occur when a spray or spot-on product is applied and

the cat grooms itself, ingesting the product.

Cats are over-represented in the insecticide category due

to taste reactions. These reactions are not poisonings, but

cats foaming at the mouth obviously make owners very con-

cerned. The best treatment is to offer food to the cat (eg,

milk, canned food, tuna), which removes the bad taste.

3 over-tHe-Counter HuMAn ProduCtSManypetownersdonotrealizethatOTCmedications

are dangerous.

• IbuprofenisthemostcommonOTCmedicationingested

by pets.

• The toxin with the biggest gain in this category is vitamin

D(cholecalciferol).1Manyphysiciansarenowprescribing

large doses of vitamin D for patients, and manufactur-

ers have responded by producing products with higher

amounts of this vitamin (which can be available as highly

palatable chocolate-flavored or gummy chews).

•ManypetsarealsoattractedtoOTCjointcareproducts

and nutraceuticals due to their animal origins.

1

25

2

2

3

3 4

5

5

5

5

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8 8

8

9

9

9 10

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Veterinarians need to inform pet owners that:

• OTC medications, such as ibuprofen and acetamin-

ophen, can kill their pets.

• OTC human products should never be adminis-

tered to a pet without consulting a veterinarian

first.

4 veterinAry ProduCtSChewable medications are a double-edged sword

in veterinary medicine. They are easy to administer

to dogs or cats; however, these tasty medications can also

mean that the pet, if given access, will ingest all the tablets

inthebottle.ExamplesincludeveterinaryNSAIDs,phenyl-

propanolamine, jointcare supplements,andheartworm

medications, which are all commonly sold in chewable

formulations.

Avermectin toxicity is a concern in collie-type breeds;

however, the dose of avermectin in canine heartworm preven-

tatives is safe for these breeds. Toxicity can occur when:

•Ownersuseivermectinhorsedewormers,whichhavea

much higher concentration of avermectin, for their dogs.

• A dog consumes dewormer paste that has dropped on

the ground from the horse’s mouth or the tube.

Veterinarians should always make sure to:

• Remind owners to keep pet medications out of

their pets’ reach.

• Recommend that pets be separated during pill

administration, if there are multiple pets in the house-

hold.

5 HouSeHold iteMSThe APCC received approximately 10,000 calls

about household items in 2012.1

Paint, cleaning products, and laundry detergents are only

a few types of items that pets may ingest in the home. Some

household items may only cause gastrointestinal upset,

whilesomecanbedeadly.Otheritems,suchasdrywall,

fire logs, and polyurethane glues, are not poisonous but

can cause gastrointestinal obstructions requiring surgery.

Veterinarians can help prevent tragedies by instructing

owners or providing resources on how to pet-proof homes;

for example, crate training, cabinet locks, and baby gates

can provide safe areas for pets. The APCC offers a helpful

checklist—A Poison Safe Home—at aspca.org/pet-care/

poison-control/a-poison-safe-home.

6 HuMAn FoodS (other than Chocolate)The most common toxicosis in this group is xylitol

(a sugar substitute) toxicity.1 Xylitol can be found

in sugarless gums, candies, mints, and baked goods, and

can cause low blood sugar, seizures, and liver failure in

dogs.4Manyownersarenotawareofthedangerthistoxin

presents to their dogs.

Otherfooditemsthatcauseconcernaregrapes/raisins,

onions/garlic, and avocados.5

• Grapes and raisins can cause kidney failure; signs may be

more dramatic in animals that have concurrent illness.

•Onionsandgarlic cancausegastrointestinal irritation

and may lead to red blood cell damage. Cats are most

susceptible, but dogs that consume a large amount of

these vegetables/herbs are also at risk.

• Avocados are dangerous to birds and rabbits, but only

cause gastrointestinal upset in dogs and cats (the pit can

become a foreign body if ingested).

Finally, moldy food can grow toxins that cause tremors

and seizures if ingested.6 A comprehensive list—People

Foods to Avoid Feeding Your Pets—can be found at

aspca.org/pet-care/poison-control/people-foods.aspx.

7 CHoColAteWhile the word has been out for a while that choco-

late can be toxic to pets, it is still the number one

human food that pets ingest. The APCC received 8575

calls about chocolate in 2012, about 23.5 a day.1 The darker

the chocolate, the higher the methylxanthine content and

higher the risk of toxicity.3

Because cats do not have the same “sweet” taste buds as

dogs and humans, dogs are the most likely species to be

poisoned by chocolate. Signs of chocolate toxicosis include

vomiting, diarrhea, agitation, high heart rate, tremors, sei-

zures, and death.

8 PlAntSAbout 4% of APCC phone calls were about animals

that had consumed plants.1 This is another category

inwhichcatsareover-represented.Houseplants,especially

ones containing insoluble calcium oxalates (eg, Dieffenba-

chia, Philodendron) are the most common type ingested.

Fortunately, most cases of plant ingestion cause non–life-

threatening illness and minimal clinical signs (ie, drooling,

vomiting). Lilies and sago palms are probably the most

dangerous to cats and dogs, respectively. The APCC offers

a list—17 Poisonous Plants—at aspca.org/pet-care/poi-

son-control/17-common-poisonous-plants.aspx.

9 rodentiCideS Rodenticides are designed to kill rodents, but they can

be deadly for other mammals and birds. The APCC

handled approximately 6965 cases of rodenticide inges-

tion in 2012.1 Anticoagulants are still the primary type of

rodenticide used, but bromethalin and cholecalciferol are

gaining market share.

Veterinarians should counsel owners to:

• Be very careful when setting out rodent bait—the

resourcefulness of pets, especially dogs that are attract-

ed to grain-based baits, should never be underestimated.

• Keep all rodenticide labels because many baits look

identical but cause very different clinical signs

10 lAWn & GArden ProduCtS ManyAmericansareobsessedwithcreatingthe

perfect lawn and, likewise, the APCC received

almost 3500 calls about noninsecticidal lawn and garden

items in 2012.1

Lawn products can range from tasty fertilizers (bone

meal and blood meal) and herbicides that are only expected

http://aspca.org/pet-care/poison-control/people-foods.aspx

http://aspca.org/pet-care/poison-control/a-poison-safe-home

http://aspca.org/pet-care/poison-control/a-poison-safe-home

http://aspca.org/pet-care/poison-control/17-common-poisonous-plants.aspx

http://aspca.org/pet-care/poison-control/17-common-poisonous-plants.aspx


| ToP Ten

References

1. data from the asPca aPcc regarding animal poisonings in 2012.

2. richardson Ja. Permethrin spot-on toxicoses in cats. J Vet Emerg Crit

Care 2000; 10:103-106.

3. gwaltney-Brant s. chocolate intoxication. Vet Med 2001; 96:108-111.

4. dunayer eK. Hypoglycemia following canine ingestion of xylitol containing

gum. Vet Human Toxicol 2004; 46(2):87-88.

5. asPca animal Poison control center. People foods to avoid feeding your

pets. aspca.org/pet-care/poison-control/people-foods.aspx.

6. schell MM. Tremorgenic mycotoxin intoxication. Vet Med 2000;

95(4):283-286.

7. dolder LK. Metaldehyde toxicosis. Vet Med 2003; 98:213-215.

8. Forrester MB, stanley sK. Patterns of animal poisonings reported to

the Texas Poison center network: 1998-2002. Vet Hum Toxicol 2004;

46(2):96-99.

to cause gastrointestinal signs, to more toxic products,

such as the snail and slug bait metaldehyde, which can be

deadly.7

Veterinarians should encourage pet owners to read and fol-

low label directions, which greatly minimizes the risk to pets.

exPoSure vAriAntSFortunately, most animal exposures to toxic agents result

in no or mild clinical signs.8 This may be due to a small

exposure dose of the toxicant or decontamination by the

owner and/or veterinarian.

Exposure to toxicants can vary depending on the:

• Pet’s environment

• Time of year

• Geographical location.

For example, the APCC sees an increase in rodenticide

poisoning in the northern U.S. in the fall (crop harvesting

and cold weather drives rodents inside).1

Client eduCAtionEducating the public about potential toxins lurking in the

house and yard is a very important part of veterinary care.

It is much easier to prevent poisonings than to attempt to

treat them.

• Placing information in puppy/kitten packs, on your web-

site, and in other communication with clients is a good

way to start educating owners.

• Seasonal topics, such as Easter lilies and chocolate, can

be included in newsletters and on websites, Facebook,

and other social media outlets.

• Provide the APCC’s website link, aspca.org/home/pet-

care/poison-control, to clients, which allows them to

access additional information on pets and poison preven-

tion concerns.n

Tina Wismer, DVM,

Diplomate ABVT & ABT,

is the senior director of

veterinary educational

outreach at the ASPCA

Animal Poison Control

Center in Urbana, Illinois.

She is also an adjunct

instructor at the University of

Illinois and a consultant for the Veterinary Information

Network. Dr. Wismer received her DVM from Purdue

University. Prior to her current position, she worked

in small animal practice in Michigan and emergency

practice in Indiana.

ToP 10 Toxicoses in dogs & caTs in 2012

rAnK CAllS PotentiAl toxin exAMPleS

1 25,200 Human prescription medications Cardiac, antidepressant, thyroid, ADHD medications

2 20,400 insecticides Insecticide granules, yard sprays, preventives for pets

3 18,400 over-the-counter human

medicationsAcetaminophen, ibuprofen, vitamin D

4 10,700 veterinary productsnSAIDs, phenylpropanolamine, joint products, heart-worm medications

5 10,000 Household items Paint, cleaning products, laundry detergent

6 9400Human food (other than

chocolate)Xylitol, grapes, raisins, onions, garlic, avocados

7 8575 Chocolate Chocolate candy, baked goods

8 7100 Plants Lilies, sago palms, house plants

9 6965 rodenticides Anticoagulants, bromethalin, cholecalciferol

10 3500 lawn & garden products Fertilizers, herbicides, snail/slug bait

Learn more about rodenticide poisoning by

reading rodenticide Poisoning: What to

do After exposure (March/April 2012), available at

todaysveterinarypractice.com.


http://aspca.org/pet-care/poison-control/people-foods.aspx.6

http://aspca.org/home/petcare/poison-control

http://aspca.org/home/petcare/poison-control


Today’s Technician Peer reviewed

Noah Jones, RVT

Assisting the surgeon

Practical strategies for Preventing nosocomiAl infections

nosocomial infections increase morbidity and

mortality in patients as well as cost to clients.

Antimicrobial resistance further complicates

nosocomial infections by increasing morbidity, mor-

tality, and cost.

RISK FACTORS

Postoperative patients are among those at highest risk

for nosocomial infection because these patients:1

•Arefrequentlyfasted

•Haveongoingdiseaseprocesses

•Undergo procedures in which multiple medical

devices are inserted into the body

•Receivedrugs that alter thenormalphysiologyof

the patient.

All of these factors can modulate a patient’s immune

system. Veterinary health care teams must take pre-

cautions to minimize the risk of transferring patho-

gens between patients and maximize their ability to

fight infection.

SIGNS OF INFECTION

Patients at risk for nosocomial infections (see Poten-

tial Risk Factors for Nosocomial Infection) should

be monitored closely for signs of infection, such as:

•Increasinglethargy

•Edema,redness,pain,and/orheat(orfever)

•Dischargefromwoundsorsurgicalsites.

POTENTIAl RISK FACTORS FOR

NOSOCOMIAl INFECTION1

Patient Condition

• immune deficiency (ie, neutropenia, diabetes

mellitus, immunosuppresive drugs)

• Malnutrition

• open wounds

Patient Environment

• Prolonged hospitalization,

surgical preparation, or

surgery/anesthesia time

Medical Procedures

• Blood product administration

• central venous

catheterization

• concurrent antibiotic therapy

• Frequent bandage changes

• Prolonged catheterization (of any type)

Inappropriate Care

• improper aseptic/sterile technique, care of

catheters, and/or tissue handling

• inexperienced surgeon


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HAND HYGIENE

Pathogen transmission in hospitals occurs most

often via contaminated hands of health care work-

ers.2 Although our patients are handled different-

ly than human patients, it is likely that pathogen

transmission still occurs frequently via contaminat-

ed hands. Therefore, hand hygiene should be a high

priority in any health care setting.

Proper hand hygiene consists of hand disinfection:

•Before

» Direct contact with a patient or its environment

» Placement of any type of catheter

» Movement from a contaminated to a clean site

on a patient

•After

» Direct contact with a patient or its environment

» Contact with patient bodily fluids

» Removal of gloves.2

Disinfection

Disinfection for vis-

ibly soiled hands is

achieved by (Fig-

ure 1):2

1. Washing hands

in running warm

water, with suf-

ficient volume

of antimicrobi-

al soap to cover

all surfaces of

hands/fingers in

lather.

2. Rubbing for at least 15 seconds before rinsing.

3. Using paper towels or single-use cloth towels to

dry hands.

4. Turning the faucet off using the towel.

Alcohol-based sanitizers are the preferred method

of hand hygiene in human medicine and have shown

better bactericidal activity than that of soap and

water.2 Hands that require disinfection but are not

visibly soiled can be effectively disinfected by:2

1. Using a sufficient volume of alcohol-based hand

sanitizer to cover all surfaces of hands/fingers.

2. Rubbing for at least 15 seconds before hands are

dry.

Gloves

Gloves can be used to prevent gross contamina-

tion of the hands, but are not an alternative to

proper hand disinfection. Gloves should be worn

while handling every patient and hand disinfec-

tion should be performed after carefully remov-

ing contaminated gloves. Even though clean gloves

are used with each patient, hands can become con-

taminated during glove removal and hand disinfec-

tion prevents any transfer of pathogens from one

patient to another.

NOSOCOMIAL OR RESISTANT?

Nosocomial Infections

A nosocomial infection is defined as an infection that

is acquired or occurs in a hospital.1

Extensive research has been performed in the

human medical field due to the frequency of occur-

rence, increased costs, and large number of deaths

associated with nosocomial infections:

•In the U.S., annual costs related to nosocomial

infections in human medicine are reported to be

over $4 billion.1

•Over 2 million patients (5% to 10% of the total

patient population) are affected, causing over

80,000deathseachyear.2

Due to lack of uniform reporting and surveillance,

veterinary nosocomial infection rates are unknown,

though it has been found to be a common problem

encountered in veterinary teaching hospitals.3 Addi-

tional research is needed to determine the frequency

of nosocomial infections in private veterinary practice

as this data does not exist at this time.

Antimicrobial Resistance

Antimicrobial resistance (AMR) occurs when a patho-

gen develops resistance to 1 or more agents to which

the pathogen was previously sensitive.1 AMR is a

growing problem in both human and veterinary med-

icine.1 AMR has become more common in nosocomial

infections, although the 2 are not synonymous.

AMR often occurs due to inappropriate antimicro-

bial administration, causing selection for resistant

organisms, but can also occur in the face of appropri-

ate antibiotic administration.1 In the latter case, the

gastrointestinal tract is a reservoir for resistant organ-

isms, which can then be transferred from patient to

patient.

The rate of AMR in veterinary medicine is largely

unknown.Inarecentstudyof10privateveterinary

hospitals,3 Enterococcus contamination was found at

all10hospitals,withapproximately20%oftheisolates

havingAMR.OftheAMRisolates:

•About30%werefoundonstethoscopes,with50%

of personnel reporting that they almost never

cleaned their stethoscopes.

•6% were found on thermometers, with 30% of

hospitals reporting that thermometers were not

cleaned between patients.

•60%werefoundoncagedoors,with30%ofhospi-

tals reporting that cage doors were not disinfected

between patients.

Anotherstudyshowedthat44%ofdogswithpyo-

derma were infected with resistant isolates, mostly

Staphylococcus pseudintermedius, which is the most

frequently isolated Staphylococcus species in canine

and feline patients.4

Figure 1. Proper hand

hygiene is critical for preven-

tion of nosocomial infection.


| Today’s Technician

Education

Despite health care workers acknowledging the

importance of hand hygiene, compliance rates are

very low.2,5,6

•Recentveterinarystudiesreporthandhygienecom-

pliance to be between 20% to 40%, with 85% of

workers feeling they should be washing their hands

morefrequently.5

•One veterinary study showed that implementing a

comprehensive education program could increase

compliance, which is consistent with human data on

the same subject.6

TheInstituteforHealthcareImprovement(IHI)rec-

ommends implementing an intervention package con-

sisting of 4 items to increase hand hygiene compliance:

1. Educate staff on the

importance of prop-

er hand hygiene: Staff

should understand why

hand hygiene is impor-

tant and the implications

ofpoorhandhygiene.In-

service educational pro-

grams, posters, and other

literature can be useful as

educational tools.

2. Verify appropriate hand

hygiene technique: Prop-

er technique should be

demonstrated to all staff

members. Reminders of

proper techniquemay be

posted at sinks and other

hand hygiene stations

(Figure 2).

3. Ensure hand hygiene is available at point of

care: Ideally,someoneisassignedthetaskofrefill-

ingdispensersandensuringavailabilityofadequate

supplies. Checklists may be especially useful for this

purpose.

4. Continually monitor compliance while provid-

ing feedback: Staff shouldbe regularly evaluated

onpropertechniquetoensureongoingpatientsafe-

ty. Written examinations and direct observation are

useful in monitoring compliance.

SURFACE DISINFECTION

Additional routes of transmission include contami-

natedenvironmental surfacesandequipment.3 Prop-

er environmental disinfection is challenging for vet-

erinary teams as patients are not usually confined to

a hospital bed.

The appropriate disinfectant is dependent on the

surface or device. Disinfectants are divided into 3

categories:

1. Low level

2.Intermediatelevel

3.Highlevelorsterilization.

low-level Disinfectants

Low-level disinfectants are used for noncritical sur-

faces that touch intact skin or do not come in

contact with the patient, such as floors, tables, food

bowls, cages, and stethoscopes.7Examplesinclude:

•70%isopropylalcohol

•Quaternaryammoniumcompounds

•Peroxygencompounds

•0.05%chlorhexidine

•Sodiumhypochlorite(1:100).

Whileverypopularintheveterinaryindustry,qua-

ternary ammonium compounds have been shown to

have poor virucidal and sporucidal activity (despite

label claims) and are not recommended for disinfec-

tion of contaminated or potentially contaminated sur-

faces, such as floors.7,8 Additionally these compounds

are bacteriostatic and can cause pathogens to become

disinfectant-resistant.7

Intermediate-level Disinfectants

Intermediate-leveldisinfectantsareusedforsemicrit-

ical surfaces that will contact mucous membranes

or intact skin, such as laryngoscopes, thermometers,

and endotracheal tubes.7Examplesinclude:

•70%ethanol

•Peroxygencompounds

•0.5%chlorhexidine

•Sodiumhypochlorite(1:10;contacttimewillbelon-

ger compared to low-level use7).

High-level Disinfectants

High-leveldisinfectantsorsterilizersareusedforcrit-

ical surfaces that enter the bloodstream or a body

cavity, such as intravenous catheters, surgical instru-

ments, and laparoscopes.7Examplesinclude:

•Ethyleneoxidegas

•Hydrogenperoxidegas(low-temperatureplasma)

•2%activatedglutaraldehyde

•Steam(121°F).

Figure 2. Various methods,

such as posting reminders

in patient care areas, are

useful in promoting proper

hand hygiene.

The Centers for Disease Control and Preven-

tion have published guidelines outlining meth-

ods of disinfection and sterilization, available

agents, concentrations, contact times, and spe-

cial considerations. These guidelines are avail-

able at cdc.gov/hicpac/pdf/guidelines/Dis

infection_Nov_2008.pdf.

Many disinfectants become unstable after

dilution, and must be changed daily, while

others may be stable for months.7,8 consultation

with your disinfectant manufacturer for stability-

in-solution information is recommended.

http://cdc.gov/hicpac/pdf/guidelines/Disomfection_nov_2008.pdf


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Two percent activated glutaraldehyde is often ade-

quate for critical items that cannot be sterilized.7

Step-by-Step Disinfection

Surface disinfection should be a 2-step process con-

sisting of:

1. Organic debris removal

2. Disinfection using appropriate contact time.

However, consideration of proper disinfectants, dilu-

tion, and contact times are not sufficient.

•Prepared scrub gauze and items from cold ster-

ile trays should be removed by tongs. Weekly steril-

ization of these items

is necessary to pre-

vent multidrug-resis-

tant colonization.7

•Mop heads and

solutions (Fig-

ure 3) should

be changed at

least twice daily,

preferably at the

beginning of the

day and before

final mopping

at closing time;

sooner if visible

soil is present.7

» A separate mop bucket/head should be used for

the surgical suite to minimize potential for cross

contamination.

» Periodic scrubbing with an intermediate-level dis-

infectant should be performed on all mop buck-

ets and handles.

•Floor drains should be disinfected weekly with a

1:50 bleach solution.7

•High-touch surfaces, such as computers, handsets,

mobile phones, door handles, and cage handles,

should receive low- or intermediate-level disinfec-

tion.

•Stethoscopes, pulse oximetry probes, Dop-

pler probes, blood pressure cuffs, and other

monitoring equipment must be cleaned between

patients and at least once daily. Isopropyl alcohol

(70%) is reportedly most effective when proper con-

tact times are observed.3,7

•Laundry should be collected in leak-proof contain-

ers and washed in hot water (> 160°F) for at least

25 minutes.7 A 1% bleach solution should be used for

laundry disinfection, although polyester fabric may

be resistant to this form of disinfection, with further

disinfection necessary.7

SURGICAL SUITE

Special precautions must be made in the surgical suite

as these patients may be at high risk for nosocomial

infection due to anesthetic-related immune suppres-

sion and exposure of tissues (Figure 4). The anes-

thesia work area can become contaminated, caus-

ing spread of resistant bacterial organisms between

patients.9

Area Designation

•Aclean area should be used to store new items and

drugs; a dirty area should be used to store items

specific to the current patient, such as monitoring

equipment and predrawn drugs.

•Aplasticbagortubworkswellasadirty area to iso-

late patient-specific items while maintaining porta-

bility throughout the hospital.

•All surfaces and equipment should be disinfected

between patients using an appropriate disinfectant

and contact time.

Personnel

•Surgical personnel shouldpracticebarrierprecau-

tions, such as gowns, gloves, masks, and face shields

specific to that patient, when a known or suspected

infectious patient, such as one with a positive cul-

ture or zoonotic disease, is in the surgical suite.

•Street clothes should never be worn in the oper-

ating theatre. Research has shown that, when

compared to street clothes, scrubs reduced air-

borne S aureus levels by 75%.10 Therefore, scrubs

should not be worn outside the hospital and sur-

gical personnel should change into clean scrubs

before entering the surgical suite.

•The addition of masks and gowns only improved

the reduction of S aureus levels to 82%, which

emphasizes the importance of wearing clean scrubs

in the surgical suite.10

Modifiable Risk Factors

Perioperative hypothermia has been shown to sup-

press immune function and should, therefore, be

avoided in patients.11

Figure 4. Patients under anesthesia for surgical pro-

cedures are at higher risk for nosocomial infection.

Figure 3. Effective disinfection

is ensured by proper disinfec-

tion protocols and care of dis-

infection equipment.


| Today’S TechNIcIaN

•Using forced-air blankets, heating pads, heat-

moisture exchangers, low-flow oxygen, and mini-

mizing surgical preparation time can all reduce the

likelihood and severity of perioperative hypother-

mia.

•Use of forced air blankets, however, should be

delayed until final sterile draping of the patient

to minimize the likelihood of foreign material or

pathogens being blown into the surgical field.

Impaired tissue oxygenation has been shown to

delay wound healing and increase infection rates; sup-

plemental oxygen should be provided to all anesthe-

tized patients.11

Shaving patients with a razor has been shown to

increase infection rates; patients should be clipped

with clippers in the immediate preoperative period if

hair removal is necessary.11

Protocols

Prophylactic antibiotics must be present in suffi-

cient concentration in the tissues at time of contam-

ination in order to effectively prevent nosocomial

infection.12 The American Society of Health System

Pharmacists recommends administration of cefazolin,

20 to 30 mg/kg IV, at induction of anesthesia for most

surgical procedures; however, specific veterinary data

on the appropriate dosage and frequency of perioper-

ative antibiotics is lacking.12,13

Aseptic technique is essential, and any breach of

the sterile field should be immediately brought to the

surgeon’s attention.

Surgical instruments should be immediately pro-

cessed after the procedure, including:14

•Manualscrubbingtoremovegrosscontamination

•Ultrasoniccleaning

•Lubrication,ifnecessary

•Appropriatesterilization

•Careful inspection toensureproper functionand

decontamination.

Minimizing anesthesia and surgery time is

likely the most important intervention in pre-

venting nosocomial infections.15

IN SUMMARY

Nosocomial infections and AMR are life-threaten-

ing problems for veterinary patients, especially sur-

gical patients. Proper hand hygiene, surface disinfec-

tion, and surgical etiquette are essential in minimiz-

ing risk and obtaining positive outcomes in veterinary

patients. Further research is necessary to determine

the rate of nosocomial infection, organisms responsi-

ble, risk factors, and recommended interventions for

patients at risk. n

aMR = antimicrobial resistance;

IhI = Institute for healthcare Improvement

References

1. Ogeer-Gyles JS, Mathews KA, Boerlin P. Nosocomial

infections and antimicrobial resistance in critical care

medicine. J Vet Emerg Crit Care 2006; 16(1):1-18.

2. Institute for Healthcare Improvement. How-To Guide:

Improving Hand Hygiene. Available at shea-online.org/

assets/files/IHI_hand_hygiene.pdf, assessed June 16,

2012.

3. KuKanich KS, Ghosh A, Skarbek JV, et al. Surveillance of

bacterial contamination in small animal veterinary hospitals

with special focus on antimicrobial resistance and virulence

traits of enterococci. JAVMA 2012; 240(4):437-445.

4. Eckholm NG, Outerbridge CA, White SD, Sykes JE.

Prevalence of and risk factors for isolation of methicillin-

resistant Staphylococcus spp. from dogs with pyoderma in

northern California, USA. Vet Derm 2013; 24(1):154-234.

5. Nakamura RK, Tompkins E, Braasch EL, et al. Hand

hygiene practices of veterinary support staff in small animal

private practice. J Small Anim Pract 2012; 53(3):155-160.

6. Shea A, Shaw S. Evaluation of an educational campaign to

increase hand hygiene at a small animal veterinary teaching

hospital. JAVMA 2012; 240(1):61-64.

7. Portner JA, Johnson JA. Guidelines for reducing pathogens

in veterinary hospitals: Disinfectant selection, cleaning

protocols, and hand hygiene. Compend Contin Educ Vet

2010; 53(3):E1-E12.

8. Eleraky NZ, Potgieter LN, Kennedy MA. Virucidal efficacy of

four new disinfectants. JAAHA 2002; 38(3):231-234.

9. Loftus RW, Koff MD, Burchman CC, et al. Transmission

of pathogenic bacterial organisms in the anesthesia work

area. Anesthesiol 2008; 109:399-407.

10. Bischoff WE, Tucker BK, Wallis ML, et al. Preventing

airborne spread of Staphylococcus aureus by persons with

the common cold: Effects of surgical scrubs, gowns, and

masks. Infect Control Hosp Epidemiol 2007; 28(10):1148-

1154.

11. Sessler DI. Non-pharmacological prevention of surgical

wound infection. Anesthesiol Clin 2006; 24(2):279-297.

12. American Society of Health System Pharmacists. ASHP

Therapeutic Guidelines on Antimicrobial Prophylaxis in

Surgery. Available at ashp.org/s_ashp/docs/files/BP07/TG_

surgical.pdf, assessed January 31, 2013.

13. Knights CB, Mateus A, Baines SJ. Current British veterinary

attitudes to the use of perioperative antimicrobials in small

animal surgery. Vet Rec 2012; 170(25):646.

14. Crow S. Protecting patients, personnel, instruments in the

OR. J AORN 1993; 58(4):771-774.

15. Nicholson M, Beal M, Shofer F, Brown DC. Epidemiology

evaluation of postoperative wound infection in clean-

contaminated wounds: A retrospective study of 239 dogs

and cats. Vet Surg 2012; 31:577-581.

Noah Jones, RVT,

specializes in emergency

and critical care

practice. He has worked

in private emergency/

referral practice as well

as in academia at the

University of California–

Davis Veterinary Medical

Teaching Hospital. Mr. Jones has a strong

interest in infectious disease prevention and

critical care nursing of infectious patients.

http://ashp.org/s_ashp/docs/files/BP07/TG_surgical.pdf

http://shea-online.org/assets/files/IHI_hand_hygiene.pdf

http://shea-online.org/assets/files/IHI_hand_hygiene.pdf

http://ashp.org/s_ashp/docs/files/BP07/TG_surgical.pdf

Journal Club


Diabetes mellitus is a common condition in both dogs and cats, and small animal practitio-

ners need to feel comfortable with the long-term management of these patients. The fol-

lowing 4 abstracts highlight articles that provide useful insight into the management of both

feline and canine diabetics.

• The study by Hafner and colleagues looked at placement sites for continuous glucose monitor-

ing systems (CGMS) in cats. CGMS are routinely used in human diabetics and are now appear-

ing in veterinary referral centers and emergency clinics. Successful sensor placement can be

problematic, but this study shows that the dorsal neck region is both a reliable and comfortable

site for feline patients.

• borin-Crivellenti and colleagues evaluated the carpal pad as a potential site for blood glucose

testing in dogs. as home monitoring becomes a routine part of diabetic management for dogs

and cats, information such as this—sample collection techniques—is timely and relevant.

Samples were reliably obtained from this site and patient discomfort was minimal. blood

glucose measurements were comparable to those obtained from the ear vein in both diabetic

and healthy dogs.

• The study by niessen and colleagues provides useful insight into the concerns of owners with

diabetic dogs. as clinicians, we tend to focus on the pet’s immediate health needs, and may fail

to consider the owner’s worries and perceptions. This report describes owner responses to a

series of questions regarding quality of life issues and provides a reliable tool for future clinical

studies.

• In the study by Hofer-Inteeworn and colleagues, the impact of hypothyroidism on glucose

homeostasis was investigated using dogs with experimentally induced thyroid deficiency.

although hypothyroidism is routinely listed as a cause of insulin resistance, this paper provides

the first clear evidence of this association and demonstrates the mechanism. Diabetic dogs

with insulin resistance should be screened for hypothyroidism, particularly if weight gain is

noted despite persistent hyperglycemia.

Effective care for diabetic patients requires partnership between the owner and the veterinary

team. These recent studies improve our ability to manage these patients and provide optimal

service to our clients.—Audrey K. Cook, BVM&S, MRCVS, Diplomate ACVIM (Small Animal Internal

Medicine) & ECVIM (Companion Animal), Texas A&M College of Veterinary Medicine and Biomedical

Sciences

FOCUS ON DIABETES MELLITUS

Journal Club


CONTINUOUS GLUCOSE MONITORING IN CATS

Continuous glucose monitoring systems (CGMS) can be used to measure glucose concentrations

in interstitial fluid every 5 minutes for up to 72 hours. In humans, the monitors are often placed in

the abdominal para-umbilical region, however, glucose levels from this placement are 20% lower

than reference glucose concentrations or readings from sensors placed in the forearm. There are

no specific recommendations for sensor placement in cats at this time.

This study evaluated 3 sites for placement of a Guardian real-Time CGMS (medtronic.com) in

18 client-owned diabetic cats. Monitors were placed in (1) subcutaneous tissue of the lateral chest

wall in all cats, (2) subcutaneous tissue of the knee fold in 10 cats, and (3) dorsal neck area in 10

cats. Two cats had all 3 sensors in place at the same time.

The first calibration was evaluated 2 hours after the initialization period per the manufacturer’s

instructions. after that, calibrations were conducted after 6 hours; then every 10 hours. The

alphaTrak portable blood glucose meter (abbottanimalhealth.com) was used to evaluate glucose

concentrations from the capillary blood of the inner pinna, which were used as reference

calibrations.

Successful calibrations were achieved in:

• 15/20 (75%) of the sensors placed in the lateral chest wall

• 9/10 (90%) of the sensors placed in the neck region

• 3/10 (30%) sensors in the lower knee region.

uninterrupted glucose concentration recordings over a 48-hour period occurred in 17/20 (85%)

of the sensors placed in the lateral chest wall and in 7/10 (70%) of the sensors placed in alternate

locations. one sensor in the lateral chest wall and 1 sensor in the lower knee region were never

successfully calibrated; however, sensors were well tolerated in all 3 locations.

overall, the results of this study indicated that placement of the CGMS in the dorsal neck region

was superior to the other sites tested; however, further investigation is needed.

Hafner M, Lutz, Reusch CE, Zini E. Evaluation of sensor sites for continuous glucose monitoring in cats with

diabetes mellitus. J Fel Med Surg 15:117, 2013; DOI: 10.1177/1098612X12463925.


COLLECTING BLOOD FROM CARPAL PADS

a study was conducted to investigate the feasibility and validity of using the carpal pad in dogs to

collect blood for glucose monitoring. Sixty client-owned dogs were used in the study, including 30

healthy dogs and 30 dogs with diabetes mellitus. The metacarpal pad was cleaned with alcohol

and a blood sample was obtained with a 25 × 0.77 mm hypodermic needle; an ear vein nick

sample was obtained at the same time. The dogs were minimally restrained during sampling.

Glucose was measured with a glucometer that had previously been validated for use in dogs.

• Glucose values were not significantly different between sampling sites and the dogs tolerated

both collected methods.

• Twitching was observed in 10% of the dogs during ear sampling and 6.7% during carpal pad

sampling. Growling was observed in 2 dogs from both groups (3.3%).

The results of this study indicate that the carpal pad provides a good alternative sampling site for

monitoring of blood glucose in diabetic dogs.

Borin-Crivellenti S, Crivellenti Z, Tinucci-Costa M. The carpal pad as an alternative sampling site for blood

glucose testing in dogs. J Small Anim Pract 53:684-686, 2012.

http://medtronic.com

http://abbottanimalhealth.com


Journal Club |

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QUALITY OF LIFE: DIABETIC PETS & OWNERS

Evaluating quality of life (Qol) in companion animals is important, especially when the animal is suffering from a chronic condition, such as diabetes mellitus (DM). There is a perceived lack of attention by veterinary clinicians and researchers regarding the psychological and social impact of DM on both the animal and the owner.

The authors of this study designed a diabetic pet- and owner-centered, individualized measure of the impact of DM on Qol of diabetic dogs and their owners (DIa-Qol-pet), and had previously validated its use for a diabetic cat population. This study evaluated 101 insulin-treated diabetic dogs and their owners, and included 29 specific DM-associated Qol questions.

Various methods were used to evaluate the survey, which identified specific areas that most negatively impacted dogs and their owners’ Qol, including worries/concern about:• Medical issues, such as diabetes, potential vision problems due to cataracts, and development of

hypoglycemia • leaving the dog with friends or family or at a kennel • The negative impact the care associated with a pet’s DM will have on the owner’s life • Cost of care and whether the owner will be able to take care of the pet in the future. Concerns listed in the free comments section included: • lack of support from the veterinary team• Difficulties involved with the monitoring and stabilization process• Concurrent diseases affecting the dog. These issues should be considered for future questionnaires. However, many owners felt they had a

special bond with their dogs and that living with a pet with DM was a positive experience.

Niessen SJM, Powney S, Guitian J, et al. Evaluation of a quality-of-life tool for dogs with diabetes mellitus. J Vet

Intern Med 26:953-961, 2012.

CONCURRENT DIABETES MELLITUS & HYPOTHYROIDISM

Dogs are frequently diagnosed with concurrent diabetes mellitus and hypothyroidism. Hypothyroidism has been associated with poor glycemic control in diabetic dogs, but it has been suggested that it is not a common cause of insulin resistance. a study was conducted to:• Evaluate whether hypothyroidism caused insulin resistance• Determine the overall effect of hypothyroidism on glucose tolerance in dogs• Characterize the secretion profiles of hormones that are counter-regulatory to insulin.Sixteen anestrous mixed-breed bitches were used in the study. Hypothyroidism was chemically

induced in 8 of the dogs, with the remaining dogs acting as euthyroid controls.• an insulin-modified, frequently sampled IV glucose tolerance test (FSIGT) and minimal model

analysis determined basal plasma insulin and glucose concentrations, insulin sensitivity, glucose effectiveness, and disposition index • Stimulation and suppression tests assessed growth hormone response• Dual energy x-ray absorptiometry evaluated body composition • Basal serum growth hormone (GH) and insulin-like growth factor-1 (IGF-1) concentrations and

urine cortisol-to-creatinine concentration ratios were also measured. This study suggested that dogs with hypothyroidism had substantial insulin resistance. Hypothyroid

dogs were able to maintain glucose tolerance by a compensatory increase in insulin secretion. They also had an increase in abdominal fat and high serum GH and IGF-1 concentrations, which may have affected insulin sensitivity. In dogs with impaired insulin secretion, such as those with diabetes mellitus, concurrent hypothyroidism can have important clinical implications.

Hofer-Inteeworn N, Panciera DL, Monroe WE, et al. Effect of hypothyroidism on insulin sensitivity and glucose

tolerance in dogs. Am J Vet Res 73:529-538, 2012.


The Future of Veterinary Medicine Makes HeadlinesA RESPONSE FROM OUR EDITORIAL TEAM

The Back Page: VeTerinary ViewPoinTs

Did the Veterinary Community Respond?

The article created a stir both within and outside

veterinary circles. Dr. Deborah Kochevar, Dean of

Tufts University’s Cummings School of Veterinary

Medicine and President of the Association of

American Veterinary Medical Colleges (AAVMC)

responded to the article with an open letter to the

veterinary medical community, acknowledging

some of the issues raised but also countering

other conclusions, citing data from an AAVMC

survey of recent graduates.

Was The New York Times Article Right?

It’s not our job to determine that answer. As

with many commentaries written by those with a

limited understanding of an industry, the article

based many of its conclusions on inaccurate

or skewed perspectives. In fact, several

inaccuracies were corrected in a later issue of the

newspaper.

However, the article does identify several, very

real challenges that exist in our vital branch of

health care. The article, Dr. Kochevar’s response,

and ensuing dialogue in many circles effectively

raises awareness of several issues that are front

and center to veterinarians across this industry.

What Challenges Will Define Our Future?

Today’s challenges and issues will have a long-

lasting effect on the industry, including:

• Is truly objective data available about the

economic climate of veterinary medicine?

• For today’s veterinary students, are the costs of

veterinary education out of control?

It was the 1950 movie Born Yesterday that

made famous the quote, “Never do nothing you

wouldn’t want printed on the front page of The

New York Times.” While it wasn’t the front page,

veterinary medicine found itself in the Business

Section of that very publication just a few short

weeks ago.

On February 23, David Segal’s article,

High Debt and Falling Demand Trap New

Vets, brought public attention to some of the

challenges facing veterinarians and the industry

as a whole. In short, the article:

• Outlined the trials and tribulations of a “typical”

new graduate during her first year of clinical

practice

• Cited industry “experts” and quoted

employment and industry data about falling

demand for veterinary care

• Painted a gloomy picture for the future of

veterinary medicine and those choosing to

pursue it as a career.

Travis Meredith, DVM, MBa, Diplomate acT

March/April 2013 Today’s Veterinary Practice

The Back Page |

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Up to 25 lb 1 68 mcg 57 mg Blue26 to 50 lb 1 136 mcg 114 mg Green51 to 100 lb 1 272 mcg 227 mg Brown

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CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian.

INDICATIONS: For use in dogs to prevent canine heartworm disease by eliminating the tissue stage of heartwormlarvae (Dirofilaria immitis) for a month (30 days) after infection and for the treatment and control of ascarids (Toxocaracanis, Toxascaris leonina) and hookworms (Ancylostoma caninum, Uncinaria stenocephala, Ancylostoma braziliense).

DOSAGE: HEARTGARD® Plus (ivermectin/pyrantel) should be administered orally at monthly intervals at therecommended minimum dose level of 6 mcg of ivermectin per kilogram (2.72 mcg/lb) and 5 mg of pyrantel (as pamoatesalt) per kg (2.27 mg/lb) of body weight. The recommended dosing schedule for prevention of canine heartwormdisease and for the treatment and control of ascarids and hookworms is as follows:

HEARTGARD Plus is recommended for dogs 6 weeks of age and older.For dogs over 100 lb use the appropriate combination of these chewables.

ADMINISTRATION: Remove only one chewable at a time from the foil-backed blister card. Return the card with theremaining chewables to its box to protect the product from light. Because most dogs find HEARTGARD Plus palatable,the product can be offered to the dog by hand. Alternatively, it may be added intact to a small amount of dog food.Thechewable should be administered in a manner that encourages the dog to chew, rather than to swallow withoutchewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole.

Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a fewminutes after administration to ensure that part of the dose is not lost or rejected. If it is suspected that any of thedose has been lost, redosing is recommended.

HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors),potentially carrying infective heartworm larvae, are active. The initial dose must be given within a month (30 days)after the dog’s first exposure to mosquitoes. The final dose must be given within a month (30 days) after the dog’s lastexposure to mosquitoes.

When replacing another heartworm preventive product in a heartworm disease preventive program, the first dose ofHEARTGARD Plus must be given within a month (30 days) of the last dose of the former medication.

If the interval between doses exceeds a month (30 days), the efficacy of ivermectin can be reduced. Therefore, foroptimal performance, the chewable must be given once a month on or about the same day of the month. If treatment isdelayed, whether by a few days or many, immediate treatment with HEARTGARD Plus and resumption of therecommended dosing regimen will minimize the opportunity for the development of adult heartworms.

Monthly treatment with HEARTGARD Plus also provides effective treatment and control of ascarids (T. canis, T. leonina)and hookworms (A. caninum, U. stenocephala, A. braziliense). Clients should be advised of measures to be taken toprevent reinfection with intestinal parasites.

EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective againstthe tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development ofthe adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) andhookworms (A. caninum, U. stenocephala, A. braziliense).

ACCEPTABILITY: In acceptability and field trials, HEARTGARD Plus was shown to be an acceptable oral dosage formthat was consumed at first offering by the majority of dogs.

PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment withHEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adultheartworms and microfilariae before initiating a program with HEARTGARD Plus.

While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level,HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due todead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials withivermectin alone after treatment of some dogs that have circulating microfilariae.

Keep this and all drugs out of the reach of children.In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact aPoison Control Center for advice concerning cases of ingestion by humans.

Store between 68°F - 77°F (20°C - 25°C). Excursions between 59°F - 86°F (15°C - 30°C) are permitted. Protectproduct from light.

ADVERSE REACTIONS: In clinical field trials with HEARTGARD Plus, vomiting or diarrhea within 24 hours ofdosing was rarely observed (1.1% of administered doses). The following adverse reactions have been reportedfollowing the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering,convulsions and hypersalivation.

SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability ofivermectin. The dose regimens of HEARTGARD Plus and HEARTGARD are the same with regard to ivermectin (6mcg/kg). Studies with ivermectin indicate that certain dogs of the Collie breed are more sensitive to the effects ofivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds.At elevated doses, sensitive dogs showed adverse reactions which included mydriasis, depression, ataxia, tremors,drooling, paresis, recumbency, excitability, stupor, coma and death. HEARTGARD demonstrated no signs of toxicity at10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies,support the safety of HEARTGARD products in dogs, including Collies, when used as recommended.

HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant orbreeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea collars,dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered withHEARTGARD Plus in a heartworm disease prevention program.

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For customer service, please contact Merial at 1-888-637-4251.

• Are increased class sizes and the emergence of

new schools really dictated by market demand or,

instead, attempts to increase tuition revenues in

times of budgetary contraction?

• Is there an over or under supply of veterinarians in

the market?

• Does the growth of foreign training institutions

truly influence the supply of veterinarians in the

U.S.? Does that negatively impact today’s market?

• How do we, as an industry, bring veterinary

medicine to underserved areas of this country?

• What is the impact of the increasing percentage of

female veterinarians in the workplace?

• How do our responses to these issues impact

consumers’ views of our industry?

Can My Voice Be Heard?

The Today’s Veterinary Practice team would like

to explore these questions and, therefore, we are

planning to bring together individuals from all walks

of veterinary medicine—private practice, academia,

industry, government, practice development/

finance—for our first Challenges & Opportunities

in Veterinary Medicine roundtable.

We want you, the reader and today’s practitioner,

to have a voice in this session: Please send

your comments and questions to tmeredith@

todaysveterinarypractice.com or editorinchief@

todaysveterinarypractice.com, which will allow our

roundtable participants to address the issues most

important to you.

We look forward to bringing you a comprehensive

overview of this roundtable event in a future issue of

Today’s Veterinary Practice! n

READ ALL ABOUT IT

• High Debt and Falling Demand Trap New

Vets, The New York Times, February

23: nytimes.com/2013/02/24/business/high-debt-and-falling-demand-trap-new-veterinarians.html?pagewanted=all&_r=0• Dr. Deborah Kochevar’s response to the

article: aavmc.org/events/?id=52• Survey of Recent DVM Graduates

of Schools and Colleges of

Veterinary Medicine in the United

States: aavmc.org/data/images/research/aavmc%20data%20reports/aavmcsurveyofrecentdvmgraduates.pdf• Corrections, The New York Times,

March 3: nytimes.com/2013/03/03/pageoneplus/corrections-march-3-2013.html?pagewanted=all

http://nytimes.com/2013/02/24/business/high-debt-and-falling-demand-trap-new-verterinarinarians.html?pagewanted=all&r=0

http://aavmc.org/events/?id=52

http://nytimes.com/2013/03/03/pageoneplus/corrections-march-3-2013.html?pagewnated=all





http://aavmc.org/data/images/research/aavmc%20data%20reports/aavmcsurveyofrecentdvmgraduates.pdf



Clients prefer

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®HEARTGARDand theDog&Hand logoare registered trademarksofMerial.

®INTERCEPTOR isa registered trademarkofNovartisCorporation.®FLAVORTABS

isa registered trademarkofNovartisAG.©2013Merial Limited,Duluth,GA.All rights

reserved.HGD13TRMARCHAD(02/13).

1OpinionResearchCorporation,HeartwormPreventionMedicationStudy, 2012.DataonfileatMerial.

2Ofdogsshowingapreference in threestudies,dogspreferredHEARTGARD®Chewablesover

INTERCEPTOR®(milbemycinoxime)FlavorTabs®byamarginof37 to1;dataonfileatMerial.

3AskyourMerialSalesRepresentative for full guaranteedetails.

Easy to give. Protection to live.

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Today veterinary magazine march 2013

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