In Flea and Heartworm Protection*

INCLUDES THE

Flea Control

When accidental eyelid injury occurs, followow this stestep-by-stepp by step gguideuide to

Image Quiz Eyelid A dog with fragile, LACERATION hyperextensible skin 210

Journal Scan Is oral electrolyte REPAIR delivery as effective p238238 as intravenous? 215

CVC Highlights ▸ When to refer for advanced imaging 218 ▸ How to hunt for grass awns 227 ▸ A 4-tier dental home care regimen 229 ▸ What you may be missing on your lab work 235 ▸ More from the CVC 248

July 2014 | Volume 109 | Number 7 | PEER-REVIEWED | dvm360.com

magentablackcyanyellow ES459702_vetm0714_CV1.pgs 06.25.2014 23:56 ADV Take diet off the suspect list.

In an eight- to twelve-week diet elimination trial, Royal Canin Anallergenic™ can help you confidently identify if food allergens are the cause of severe skin reactions in your canine patients. Using breakthrough technology, the proteins in Anallergenic are broken down into amino acids and very small chain peptides to significantly reduce the possibility of an adverse food reaction. And with exceptional palatability and digestibility, Anallergenic is the first choice for both food allergy detection and long-term therapeutic feeding of patients with confirmed food allergy. To learn more about the science behind Anallergenic and to start your diet elimination trial, call your Royal Canin District Manager or 1-800-592-6687.

Veterinary Exclusive Formulas

magentablackcyanyellow ES460588_VETM0714_CV2_FP.pgs 06.26.2014 17:23 ADV Mission Content Group Veterinary Medicine is a peer-reviewed journal dedicated Editor/Medicine Channel Director | Mindy Valcarcel [email protected] to providing concise, credible, and essential information Medical Editor | Heather Lewellen, DVM on the most common and crucial clinical problems seen in companion-animal practice. Content Manager | Adrienne Wagner Senior Content Specialists | Alison Fulton | Heather Biele, DVM Editorial Advisory Board Assistant Content Specialist | Victoria Biondi Leading specialists who direct our content and ensure Technical Editor | Jennifer Vossman, RVT our editorial quality and integrity Consulting Technical Editor | Avi Blake, DVM Joseph W. Bartges, DVM, PhD, DACVIM, DACVN Editor, E-media | Jessica Zemler David S. Bruyette, DVM, DACVIM Senior Designer/Web Developer | Ryan Kramer Barret Bulmer, DVM, MS, DACVIM Art Director | Steph Bentz John Ciribassi, DVM, DACVB Multimedia Contributor | Troy Van Horn Timothy M. Fan, DVM, DACVIM Juliet R. Gionfriddo, DVM, MS, DACVO Advanstar Veterinary Karen A. Moriello, DVM, DACVD Vice President/General Manager | Becky Turner Chapman Jennifer Wardlaw, DVM, MS, DACVS Group Content Director | Marnette Falley Medical Director | Theresa Entriken, DVM Practitioner Advisory Board Director, Electronic Communications | Mark Eisler Progressive practitioners who keep our content Director, The CVC Group | Peggy Shandy Lane practical, timely, and relevant Sales Group Mili Bass, DVM, DABVP Sales Director | David Doherty Robin Downing, DVM Corey Entriken, DVM Senior Account Managers, Advertising Terry Reilly | Chris Larsen Wayne L. Hunthausen, DVM Account Manager, Advertising | Angela Paulovcin Thomas McCoy, DVM Senior Account Manager, Projects | Jed Bean Melissa M. Mckendry, DVM, DABVP Sales and Projects Coordinator | Anne Belcher Fred L. Metzger Jr., DVM, DABVP Books/Resource Guides | Maureen Cannon Robert M. Miller, DVM (440) 891-2742 Gary D. Norsworthy, DVM, DABVP List Rental Sales | Renée Schuster R. Wayne Randolph, VMD (440) 891-2613, [email protected] Michael H. Riegger, DVM, DABVP David Robbins, DVM Philip VanVranken, DVM Chief Executive Offi cer | Joe Loggia Laura L. Wade, DVM, DABVP Chief Executive Offi cer Fashion Group, Executive Vice President | Tom Florio Executive Vice President, Chief Administrative Offi cer & Chief Financial Offi cer | Tom Ehardt Executive Vice President | Georgiann DeCenzo Executive Vice President | Chris DeMoulin Subscriber Services: Call (800) 815-3400 in the United States, or (888) 527-7008 or (218) 740-6477 in Canada; fax (218) 740-6417; or write to: Executive Vice President, Business Systems | Rebecca Evangelou Veterinary Medicine, 131 W. 1st St., Duluth, MN 55802-2065. If you are un- Executive Vice President, Human Resources | Julie Molleston able to connect with the 800 numbers, email fulfi ll@superfi ll.com. Reprint Senior Vice President | Tracy Harris Services: Call 1-877-652-5295 ext. 121 or email bkolb@wrightsmedia. com. Outside US, UK, direct dial: 281-419-5725. ext. 121 Back Issues: Vice-President, General Manager Pharm/Science Group | Dave Esola Individual copies are available for one year; to order, call (800) 598-6008. Vice President, Legal | Michael Bernstein Permissions/International Licensing. Call Maureen Cannon at (440) 891- Vice President, Media Operations | Francis Heid 2742. List Sales: Please contact List Account Executive Renée Schuster at (440) 891-2613. Editorial Offi ces: Write to 8033 Flint, Lenexa, KS Vice-President, Treasurer & Controller | Adele Hartwick 66214; or call (913) 871-3800. Visit our websites: dvm360.com; thecvc.com; industrymatter.com.

Veterinary Medicine (ISSN 8750-7943 print; ISSN 1939-1919 online) is published monthly by Advanstar Communications Inc., 131 West First St., Duluth, MN 55802-2065. One year subscription rates: $60 in the United States and Possessions; $72 in Canada and Mexico; $97 in all other countries. Single issue orders: $18 in the United States and Possessions; $22 in Canada and Mexico; $24 in all other countries. Periodicals postage paid at Duluth, MN 55806 and additional mailing off ces. POSTMASTER: Please send address changes to Veterinary Medicine, P.O. Box 6087, Duluth, MN 55806-6087. Canadian GST Number: R-124213133RT001. Publications Mail Agreement Number: 40612608. Return undeliverable Canadian addresses to: IMEX Global Solutions, P.O. Box 25542, London, ON N6C 6B2, Canada. Printed in the U.S.A. © 2014 Advanstar Communications Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording, or information storage and retrieval without permission in writing from the publisher. Authorization to photocopy items for internal/educational or personal use, or the internal/educational or personal use of specif c clients is granted by Advanstar Communications Inc. for libraries and other users registered with the Copyright Clearance Center, 222 Rosewood Dr. Danvers, MA 01923, 978-750-8400 fax 978-646-8700 or visit http://www.copyright.com online. For uses beyond those listed above, please direct your written request to Permission Dept. fax 440-756-5255 or email: [email protected]. Advanstar Communications provides certain customer contact data (such as customers’ names, addresses, phone numbers, and e-mail addresses) to third parties who wish to promote relevant products, services, and other opportunities which may be of interest to you. If you do not want Advanstar Communications to make your contact information available to third parties for marketing purposes, simply call toll-free (866) 529-2922 between the hours of 7:30 a.m. and 5 p.m. CST and a customer service representative will assist you in removing your name from Advanstar’s lists. Outside the United States, please call (218) 740-6477. Veterinary Medicine does not verify any claims or other information appearing in any of the advertisements contained in the publication, and cannot take responsibility for any losses or other damages incurred by readers in reliance on such content. Publisher assumes no responsibility for unsolicited manuscripts, photographs, art, and other material. Unsolicited material will not be returned. Address correspondence to Veterinary Medicine, 8033 Flint, Lenexa, KS 66214; (913) 871-3800; e-mail [email protected]. To subscribe, call toll-free 888-527-7008. Outside the U.S. call 218-740-6477.

dvm360.com | Veterinary Medicine | July 2014 | 209

magentablackcyanyellow ES459550_vetm0714_209.pgs 06.25.2014 23:33 ADV IMAGE QUIZ scan the photos, spot the answers

FRAGILE, HYPEREXTENSIBLE skin in a dog By Julie Ann Luiz Adrian, DVM 1-year-old spayed female Chihuahua-terrier mix with a 1 A history of hyperextensible, fragile, pendulous-folding skin; excoriations; pyoderma; and repetitive lacerations originat- ing from the slightest trauma presented to a veterinary center for evaluation of alopecia and a large laceration on the dorsolateral aspect of the dog’s right shoulder (Figures 1-4). At presentation, all other physical examination results were unremarkable. T e dog’s medical history included having received cephalexin on numerous occasions, ketoconazole after a positive result for Microsporum canis on a der- matophyte test medium culture, trime- thoprim-sulfamethoxazole, and amoxicillin-clavunanic acid. Excoriations had been cleaned with chlorhexidine solution, and various medicated shampoos had been administered. T e dog had also worn an Elizabethan collar from time to time to prevent 2 further trauma to various lacerations and the formation of new lacerations. A skin biopsy of the shoulder, taken during the surgical apposition of the laceration, was sent for histologic evaluation. T e f ndings revealed “perivascular dermatitis with edema, excess telogen hair fol- licles, and an equivocal reduction in dermal collagen that may represent some defect in metabolism of the tissue.”

210 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES459567_vetm0714_210.pgs 06.25.2014 23:34 ADV IMAGE QUIZ scan the photos, spot the answers

>>>1. Laceration on dorsolateral aspect of the right shoulder. 3 >>>2. Left lateral recumbency with evident skin hyperextensibility (skin fold at dorsum).

>>>3. Right hock with evident skin hyperextensibility.

>>>4. Right rear limb with evident skin hyperextensibility.

1. Which is the most likely differential diagnosis for hyperextensible skin and repetitive lacerations due to delicate skin? a) Cutaneous asthenia b) A metabolic disorder c) A food allergy d) Pemphigus foliaceus

2. How is this disease commonly diagnosed? a) Results from physical and ocular examinations b) Results from a physical examination, complete blood count, and urinalysis c) Results from a physical examination and skin biopsy and by using the skin 4 extensibility index d) Results from physical and thoracic radiographic examinations

3. What is the next step for a deﬁ nitive diagnosis? a) Perform cytology b) Perform biochemical studies on the dermal collagen biopsy or electron microscopy on the skin biopsy sample c) Perform abdominal ultrasonography d) Perform thoracic radiography

4. How would you treat this patient? a) Administer a round of f rst-tier antibiotics b) Administer corticosteroids c) Administer cyclosporine d) Recommend supportive care, such as environmental alterations

See the answers, starting on page 212.

dvm360.com | Veterinary Medicine | July 2014 | 211

magentablackcyanyellow ES459561_vetm0714_211.pgs 06.25.2014 23:33 ADV IMAGE QUIZ scan the photos, spot the answers

Answers predominantly collagen ings and histologic results of 1. a) Cutaneous asthenia dysplasia, categorized by weak a skin biopsy. Using the skin is correct. and hyperextensible integu- extensibility index, which is a Cutaneous asthe- ment as well as poor wound measurement of the degree of nia, also known as healing, delicate vasculature, skin extensibility, together with More online dermatosparaxis, subcutaneous hematomas, physical and histologic and Test your skills resembles Ehlers- joint hypermobility and laxity, physical examination f ndings with more Image Danlos syndrome in elbow hygromas, and infre- will generally suf ce for a con- 1-3 1-3,7-10 3,9,10 Quizzes by visiting people. It is a rare quent ocular signs. vincing diagnosis. dvm360.com/ skin disease in dogs ImageQuiz. and other species, 2. c) Results from a physical 3. b) Perform biochemical such as sheep, cattle, examination and skin biopsy studies on the dermal col- mink, and cats.1-6 T e and by using the skin extensi- lagen biopsy or electron mi- syndrome is part of bility index is correct. croscopy on the skin biopsy a set of congenital, Cutaneous asthenia is com- sample is correct. hereditary connec- monly diagnosed based on The histologic findings of tive tissue disorders, physical examination f nd- “perivascular dermatitis with

212 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES459565_vetm0714_212.pgs 06.25.2014 23:34 ADV quellin™ (carprofen) soft chewable tablets

take the pain out of treating pain.

Help alleviate canine osteoarthritis pain with quellin™ (carprofen) soft chewable tablets — designed to encourage at-home compliance. • Meat ﬂ avored with no animal proteins • Easy for dogs to chew • Scored for simple dosing • Soft chews made to strict Bayer quality standards

To learn more about quellin™, go to softquellinchew.com quellin™ is indicated for the relief of pain and inﬂ ammation associated with osteoarthritis and for the control of postoperative pain associated with soft tissue and orthopedic surgeries in dogs.

CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. WARNINGS: Keep out of reach of children. Not for human use. Consult a physician in cases of accidental ingestion by humans. For use in dogs only. Do not use in cats. All dogs should undergo a thorough history and physical examination before initiation of NSAID therapy. Appropriate laboratory tests to establish hematological and serum biochemical baseline data prior to, and periodically during, administration of any NSAID should be considered. See brief summary on page 214. ©2014 Bayer HealthCare LLC, Animal Health, Shawnee Mission, Kansas 66201 Bayer (reg’d), the Bayer Cross (reg’d) and quellin™ are trademarks of Bayer. QL14998

magentablackcyanyellow ES460609_VETM0714_213_FP.pgs 06.26.2014 17:58 ADV IMAGE QUIZ scan the photos, spot the answers

TM (carprofen) soft chewable tablets Non-steroidal anti-infl ammatory drug For oral use in dogs only BRIEF SUMMARY: 10 Before using quellin soft chewable tablets, please consult edema, excess telogen hair fol- carrying the gene ), eliminating the the product insert, a summary of which follows: licles, and an equivocal reduction gene from a breeding program is im- CAUTION: Federal Law restricts this drug to use by or on the order of a licensed veterinarian. in dermal collagen” along with the perative. T us, the patient along with PRODUCT DESCRIPTION: quellin (carprofen) is a physical examination f ndings are its sire and dam should be removed non-steroidal anti-infl ammatory drug (NSAID) of the 3,7,10 propionic acid class that includes ibuprofen, naproxen, and supportive of cutaneous asthenia. from breeding. ketoprofen. For a def nitive diagnosis, biochemi- INDICATIONS: Carprofen is indicated for the relief of pain Acknowledgements and infl ammation associated with osteoarthritis and for the cal studies and electron microscopy Special thanks to the Aloha Veterinary Center in control of postoperative pain associated with soft tissue should be performed on the skin Hilo, Hawaii, which shared this case and permit- and orthopedic surgeries in dogs. ted its publication. 3 CONTRAINDICATIONS: Carprofen should not be used in biopsy sample. dogs exhibiting previous hypersensitivity to carprofen. REFERENCES WARNINGS: Keep out of reach of children. Not for human 1. Barrera R, Mane C, Duran E, et al. Ehlers- use. Consult a physician in cases of accidental ingestion 4. d) Recommend supportive care, Danlos syndrome in a dog. Can Vet J by humans. For use in dogs only. Do not use in cats. All such as environmental alterations, 2004;45:355-356. dogs should undergo a thorough history and physical 2. Bellini MH, Caldini ET, Scapinelli MP, et al. examination before initiation of NSAID therapy. Appropriate is correct. Increased elastic microfi brils and thickening of laboratory tests to establish hematological and serum 3 biochemical baseline data prior to, and periodically during, Cutaneous asthenia is incurable. fi broblastic nuclear lamina in canine cutaneous administration of any NSAID should be considered. If the dog has no signs of joint asthenia. Vet Dermatol 2009;20:139-143. PRECAUTIONS: As a class, NSAIDs may be associated 3. Ehlers-Danlos syndrome: what is it and is there with gastrointestinal, renal and hepatic toxicity. Effects hypermobility and laxity and the a cure? Available at: http://www.cvm.okstate. may result from decreased prostaglandin production owner is compliant with supportive edu/index.php?option=com_content&view=ar and inhibition of the enzyme cyclooxygenase which is ticle&id=219:ehlers-danlos-syndrome-what-is- responsible for the formation of prostaglandins from care, including seeking veterinary it-and-is-there-a-cure&catid=27:small-animal- arachindonic acid. When NSAIDs inhibit prostaglandins care appropriately, then the dog questions&Itemid=315. Accessed April 14, 2014. that cause infl ammation they may also inhibit those 4. Rodriguez F, Herraez P, Espinosa de los prostaglandins which maintain normal homeostatic may live an extensive life.3,8 A dog function. These antiprostaglandin effects may result in Monteros A, et al. Collagen dysplasia in a litter clinically signifi cant disease in patients with underlying or with joint involvement is deemed of Garafi ano shepherd dogs. Zentralbl Veterinar- pre-existing disease more often than in healthy patients. more severe, and the prognosis med A 1996;43:509-512. Carprofen is an NSAID, and as with others in that class, 5. Bernal LJ, Sanchez J. Fragilidad cutanea adverse reactions may occur with its use. The most worsens. Many owners elect to adquirida: caso clinico. Consulta Difus Vet frequently reported effects have been gastrointestinal euthanize dogs with this condition 1998;6:1960-1961. signs. vents involving suspected renal, hematologic, 6. Paciello O, Lamagna F, Lamagna B, et al. and neurologic, dermatologic, and hepatic effects have because of the long-term suf ering Ehlers-Danlos-like syndrome in 2 dogs: clinical, also been reported. Concomitant use of carprofen with other anti-infl ammatory drugs, such as other NSAIDs or experienced.8,10 histologic, and ultrastructural fi ndings. Vet Clin corticosteroids, should be avoided because of the potential Pathol 2003;32:13-18. increase of adverse reactions, including gastrointestinal Appropriate supportive care 7. Poulsen PH, Thomsen MK, Kristensen F. ulcerations and/or perforations. Carprofen is not includes environmental alterations Cutaneous asthenia in the dog. A report of two recommended for use in dogs with bleeding disorders, cases. Nord Vet Med 1985;37:291-297. as safety has not been established in dogs with these such as a padded bed and rounded 8. Scott DW, Miller WH, Griffi n CE. Muller & disorders. The safe use of carprofen in animals less than furniture, gentle handling of the dog, Kirk’s small animal dermatology. 6th ed. Phila- 6 weeks of age, pregnant dogs, dogs used for breeding delphia, Pa: W.B. Saunders Co, 2001;602-604. purposes, or in lactating bitches has not been established. punctual owner attention to any skin 9. Iglauer F, Wilmering G, Huisinga E, et al. [Cu- ADVERSE REACTIONS: condition that may irritate the dog taneous asthenia (Ehlers-Danlos syndrome) in During investigational studies for the caplet formulation with twice-daily administration of 1 mg/lb., no clinically and cause self-mutilation or lacera- a domestic rabbit]. Dtsch Tierarztl Wochenschr signifi cant adverse reactions were reported. Some clinical 1999;106(12):500-505. signs were observed during fi eld studies which were tions, and prompt veterinary atten- 10. Stretchy, saggy, painful skin in dogs. Avail- similar for carprofen caplet and placebo treated dogs. tion for wound cleaning and apposi- able at: http://www.petmd.com/dog/conditions/ Incidences were observed in both groups: vomiting (4%), skin/c_multi_cutaneous_asthenia. Accessed 3,8,10 diarrhea (4%), changes in appetite (3%), lethargy (1.4%), tion. T ere are sources describing March 31, 2014. behavioral changes (1%), and constipation (0.3%). the benef cial use of oral vitamin C For a copy of the Material Safety Data Sheet (MSDS) or to report adverse reactions call Bayer Veterinary to decrease weakened skin.3,8,10 Julie Ann Luiz Adrian, DVM Services at 1-800-422-9874. For consumer questions call 1-800-255-6826. Because cutaneous asthenia is a Department of Pharmacy Practice ANADA 200-555 Approved by FDA congenital, hereditary connective T e Daniel K. Inouye College ©2014 Bayer HealthCare LLC. Bayer (reg’d), the Bayer tissue disorder (it is either dominant of Pharmacy Cross (reg’d), quellin™ are trademarks of Bayer. when both parents carry the mutated University of Hawaii Bayer HealthCare LLC, Animal Health Division, PO Box 390, gene or recessive with one parent Hilo, HI 96720 Shawnee Mission, KS 66201 GHG060514 January 2014 18827

214 | July 2014 | Veterinary Medicine | dvm360.com

blackcyanyellow ES459563_vetm0714_214.pgs 06.25.2014 23:34 ADV JOURNAL SCAN from the literature to your exam room

Is an oral electrolyte solution an ef ective way to treat dehydration in dogs with severe diarrhea? Why they did it line laboratory data tests including Traditionally, intravenous f uid therapy packed cell volume (PCV), a serum has been the treatment of choice for chemistry prof le, a lactate concentra- correcting dehydration. In this study, tion, and venous blood gas were per- researchers sought to determine formed at the time of admission and whether administration of an oral elec- every eight hours during hospitaliza- trolyte solution (OES) would safely and tion. In addition, all dogs received a 1 ef ectively correct dehydration in dogs mg/kg subcutaneous dose of maropi- with acute onset hemorrhagic diarrhea tant for control of emesis. and decrease the cost of care. All enrolled dogs were of ered an OES ≤ f ve hours after admission and What they did every four hours thereafter. As part of a nonrandomized trial, T e amount of OES the authors enrolled 20 dogs was based on the seen between December 2010 calculated f uid and May 2012 that were def cit plus presented for acute onset maintenance of hemorrhagic diarrhea f uid require- T ese “Journal Scan” summaries were contributed (median duration of two ments and by Jennifer L. Garcia, DVM, days). Dogs with > three estimated ongoing DACVIM, a veterinary in- episodes of vomiting in losses. T ere were ternal medicine specialist at Sugar Land Veterinary the previous 24 hours, 13 dogs in the Specialists in Houston, Texas. hypotension (< 100 mm oral replacement Hg systolic pressure), therapy (ORT) < 1 year of age, group, while parvovirus infec- those patients that tion, concurrent refused the OES illness, or an or had persistent incomplete vomiting or evi- Keep on scanning vaccination dence of worsening Read more summaries of current history were dehydration based literature relevant to your excluded. on laboratory pa- veterinary practice by visiting dvm360.com/JournalScan. Base- rameters (n=7) were treated

GETTY IMAGES/CYNOCLUB dvm360.com | Veterinary Medicine | July 2014 | 215

magentablackcyanyellow ES459566_vetm0714_215.pgs 06.25.2014 23:34 ADV JOURNAL SCAN

CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Description: NEXGARD™ (afoxolaner) is available in four sizes of beef-flavored, soft chewables for oral administration to dogs and puppies according to their weight. Each chewable is formulated to provide a minimum afoxolaner dosage of 1.14 mg/lb (2.5 mg/kg). Afoxolaner has the chemical composition 1-Naphthalenecarboxamide, 4-[5- [3-chloro-5-(trifluoromethyl)-phenyl]-4, 5-dihydro-5-(trifluoromethyl)-3-isoxazolyl]-N-[2-oxo-2-[(2,2,2-trifluoroethyl)amino]ethyl. Indications: NEXGARD kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of Black-legged tick (Ixodes scapularis), American Dog tick (Dermacentor variabilis), and Lone Star tick (Amblyomma americanum) infestations in dogs and puppies 8 weeks of age and older, weighing 4 pounds of body weight or greater, for one month. Dosage and Administration: NEXGARD is given orally once a month, at the minimum dosage of 1.14 mg/lb (2.5 mg/kg). Dosing Schedule: Oral replacement therapy can Body Afoxolaner Per Chewables Weight Chewable (mg) Administered 4.0 to 10.0 lbs. 11.3 One 10.1 to 24.0 lbs. 28.3 One be considered for dogs with 24.1 to 60.0 lbs. 68 One 60.1 to 121.0 lbs. 136 One Over 121.0 lbs. Administer the appropriate combination of chewables mild to moderate dehydration NEXGARD can be administered with or without food. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused. If it is suspected that any of the dose has been lost or if vomiting occurs within two hours of administration, redose with another full dose. If secondary to diarrhea, but a dose is missed, administer NEXGARD and resume a monthly dosing schedule. Flea Treatment and Prevention: Treatment with NEXGARD may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with NEXGARD should continue the entire year without interruption. careful patient selection is key. To minimize the likelihood of flea reinfestation, it is important to treat all animals within a household with an approved flea control product. Tick Treatment and Control: Treatment with NEXGARD may begin at any time of the year (see Effectiveness). with intravenous (IV) crystalloid therapy (IVT group). Contraindications: There are no known contraindications for the use of NEXGARD. T e median time from admission to IV therapy was 5.5 Warnings: Not for use in humans. Keep this and all drugs out of the reach of children. In case of accidental ingestion, contact a physician immediately. hours (range = two to eight hours). Precautions: The safe use of NEXGARD in breeding, pregnant or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures (see Adverse Reactions). Adverse Reactions: In a well-controlled US field study, which included a total of 333 households and 615 treated dogs (415 administered What they found afoxolaner; 200 administered active control), no serious adverse reactions were observed with NEXGARD. Over the 90-day study period, all observations of potential adverse reactions were recorded. The most frequent reactions Among the 13 dogs in the ORT group, improvement in reported at an incidence of > 1% within any of the three months of observations are presented in the following table. The most frequently reported adverse reaction was vomiting. The occurrence of vomiting was generally self-limiting and of short duration and tended to decrease with subsequent doses in both groups. Five treated dogs experienced anorexia during the hydration parameters (PCV and serum total protein and study, and two of those dogs experienced anorexia with the first dose but not subsequent doses. Table 1: Dogs With Adverse Reactions. blood urea nitrogen concentrations) was noted eight Treatment Group Afoxolaner Oral active control and 16 hours after admission. T e median duration of N1 % (n=415) N2 % (n=200) hospitalization was the same between the two groups Vomiting (with and without blood) 17 4.1 25 12.5 Dry/Flaky Skin 13 3.1 2 1.0 (21 hours vs. 20 hours for the IVT and ORT group, re- Diarrhea (with and without blood) 13 3.1 7 3.5 Lethargy 7 1.7 4 2.0 spectively; P = 0.45); however, the cost of treatment was Anorexia 5 1.2 9 4.5 1Number of dogs in the afoxolaner treatment group with the identified abnormality. lower among the ORT group compared with the IVT 2Number of dogs in the control group with the identified abnormality. In the US field study, one dog with a history of seizures experienced a seizure on the same day after receiving the first dose and on the same day after receiving the second dose of NEXGARD. This dog experienced a third seizure one week after group (median $433 vs. $589; P = 0.006). receiving the third dose. The dog remained enrolled and completed the study. Another dog with a history of seizures had a seizure 19 days after the third dose of NEXGARD. The dog remained enrolled and completed the study. A third dog with a T e authors acknowledge limitations of the study, history of seizures received NEXGARD and experienced no seizures throughout the study. To report suspected adverse events, for technical assistance or to obtain a copy of the MSDS, contact Merial at 1-888-637- 4251 or www.merial.com/nexgard. For additional information about adverse drug experience reporting for animal drugs, such as the fact that assessment of hydration was sub- contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth. Mode of Action: jective and that dogs were not of ered water, only OES. Afoxolaner is a member of the isoxazoline family, shown to bind at a binding site to inhibit insect and acarine ligand-gated chloride channels, in particular those gated by the neurotransmitter gamma-aminobutyric acid (GABA), thereby blocking pre- and post-synaptic transfer of chloride ions across cell membranes. Prolonged afoxolaner-induced hyperexcitation results in Further studies are needed using objective measures of uncontrolled activity of the central nervous system and death of insects and acarines. The selective toxicity of afoxolaner between insects and acarines and mammals may be inferred by the differential sensitivity of the insects and acarines’ hydration and those that compare water, OES, and IVT GABA receptors versus mammalian GABA receptors. Effectiveness: In a well-controlled laboratory study, NEXGARD began to kill fleas four hours after initial administration and demonstrated for correction of hydration. >99% effectiveness at eight hours. In a separate well-controlled laboratory study, NEXGARD demonstrated 100% effectiveness against adult fleas 24 hours post-infestation for 35 days, and was ≥ 93% effective at 12 hours post-infestation through Day 21, and on Day 35. On Day 28, NEXGARD was 81.1% effective 12 hours post-infestation. Dogs in both the treated and control groups that were infested with fleas on Day -1 generated flea eggs at 12- and 24-hours post-treatment (0-11 eggs and 1-17 eggs in the NEXGARD treated dogs, and 4-90 eggs and 0-118 eggs in the control dogs, at 12- and 24-hours, Take-home message respectively). At subsequent evaluations post-infestation, fleas from dogs in the treated group were essentially unable to produce any eggs (0-1 eggs) while fleas from dogs in the control group continued to produce eggs (1-141 eggs). T e goal of ORT is to promote “physiologic water and In a 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of NEXGARD against fleas on the Day 30, 60 and 90 visits compared with baseline was 98.0%, 99.7%, and 99.9%, respectively. Collectively, the data from the three studies (two laboratory and one field) demonstrate that NEXGARD kills fleas before electrolyte absorption in the gastrointestinal tract” to they can lay eggs, thus preventing subsequent flea infestations after the start of treatment of existing flea infestations. In well-controlled laboratory studies, NEXGARD demonstrated >94% effectiveness against Dermacentor variabilis and safely correct hydration in patients with diarrhea. T is Ixodes scapularis, 48 hours post-infestation, and against Amblyomma americanum 72 hours post-infestation, for 30 days. Animal Safety: method has been used successfully for years in human In a margin of safety study, NEXGARD was administered orally to 8- to 9-week-old Beagle puppies at 1, 3, and 5 times the maximum exposure dose (6.3 mg/kg) for three treatments every 28 days, followed by three treatments every 14 days, for a total of six treatments. Dogs in the control group were sham-dosed. There were no clinically-relevant effects related to and large-animal medicine. ORT can be considered for treatment on physical examination, body weight, food consumption, clinical pathology (hematology, clinical chemistries, or coagulation tests), gross pathology, histopathology or organ weights. Vomiting occurred throughout the study, with a similar incidence in the treated and control groups, including one dog in the 5x group that vomited four hours after treatment. dogs with mild to moderate dehydration secondary to In a well-controlled field study, NEXGARD was used concomitantly with other medications, such as vaccines, anthelmintics, antibiotics (including topicals), steroids, NSAIDS, anesthetics, and antihistamines. No adverse reactions were observed diarrhea, but careful patient selection is key. Physical as- from the concomitant use of NEXGARD with other medications. Storage Information: sessment of the patient as well as laboratory parameters Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F). How Supplied: NEXGARD is available in four sizes of beef-flavored soft chewables: 11.3, 28.3, 68 or 136 mg afoxolaner. Each chewable should be used to assess hydration status. size is available in color-coded packages of 1, 3 or 6 beef-flavored chewables. NADA 141-406, Approved by FDA Marketed by: Frontline Vet Labs™, a Division of Merial Limited. Duluth, GA 30096-4640 USA Reineke EL, Walton K, Otto C. Evaluation of an oral electro- Made in Brazil. lyte solution for treatment of mild to moderate dehydration 1050-4493-02 Rev. 4/2014 in dogs with hemorrhagic diarrhea. J Am Vet Med Assoc ™NexGard and FRONTLINE VET LABS are trademarks of Merial. 2014;243:851-857. ©2014 Merial. All rights reserved.

216 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES459562_vetm0714_216.pgs 06.25.2014 23:33 ADV It’s a soft chew. Kills BOTH ﬂeas and ticks. It’s prescription only.

Now approved to kill more

ticks!

NexGardTM (afoxolaner) is the protection you asked for, and patients will beg for.

NexGard is FDA-approved to kill ﬂeas, prevent ﬂea infestations, and kill Black-Legged (deer) ticks, Lone Star ticks and American Dog ticks. NexGard is available only with a veterinarian’s prescription, and features anti-diversion technology monitored by Pinkerton® Consulting & Investigations.

IMPORTANT SAFETY INFORMATION: For use in dogs only. The most common adverse reaction is vomiting. Other adverse reactions TMNexGard and FRONTLINE VET LABS are trademarks reported are dry/ﬂaky skin, diarrhea, lethargy, and anorexia. The of Merial. ®PINKERTON is a registered trademark of Pinkerton Service Corporation. ©2014 Merial Limited, safe use of NexGard in pregnant, breeding, or lactating dogs has not Duluth, GA. All rights reserved. NEX14TTRADEAD (06/14). been evaluated. Use with caution in dogs with a history of seizures. See brief summary on page 216.

magentablackcyanyellow ES460571_VETM0714_217_FP.pgs 06.26.2014 17:22 ADV CVC HIGHLIGHT

When to refer for ADVANCED IMAGING —and when not to Which form of imaging is most helpful in which cases? Read on to ﬁ nd out. By Ryan King, DVM, DACVR

he opportunity to mography (CT), and magnetic the limited ability to perform refer cases for advanced resonance imaging (MRI). interventional procedures on Timaging on an inpatient Key to a successful patient outpatient cases should be and outpatient basis is increas- referral for diagnostic imaging discussed before referral. T e ing rapidly. Many referral is managing owner expecta- following tells how to deter- hospitals now of er outpatient tions. Cost, risks, benef ts, mine the best modality for ultrasonography, computed to- diagnostic expectations, and your patient as well as which

Dr. King performing ultrasonography on a patient. (Photo by Andrew Cunningham, Cummings School of Veterinary Medicine at Tufts University.)

218 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES461292_vetm0714_218.pgs 06.27.2014 00:10 ADV Help your patients get back to a normal life.

The ONLY nutrition clinically tested to dissolve struvite stones in as little as 7 days1 and reduce the recurrence of FIC signs by 89%2.

CHANGE THEIR FOOD. CHANGE THEIR WORLD.

1Lulich JP, Kruger JM, MacLeay JM, et al. Efﬁcacy of two commercially available, low-magnesium, urine-acidifying dry foods for the dissolution of struvite uroliths in cats. J Am Vet Med Assoc. 2013;243:1147-1153. Average 28 days in vivo study in urolith forming cats. HillsVet.com/cdMulticare 2Kruger JM, Lulich JP, Merrils J, et al. Proceedings. American College of Veterinary Internal Medicine Forum 2013. ©2014 Hill’s Pet Nutrition, Inc. ®/™ Trademarks owned by Hill’s Pet Nutrition, Inc.

magentablackcyanyellow ES460590_VETM0714_219_FP.pgs 06.26.2014 17:24 ADV O # C 1 E IN A G N R E F CVC HIGHLIGHT D IS IE H N T NEW

cases are appropriate for inpatient from obscuring visualization of the great and outpatient imaging. abdomen and also allows for safe use of sedation if deemed necessary. INPATIENT VS. Ideally, fractious, uncooperative, or tasting OUTPATIENT aggressive patients are best suited From an imaging perpective, an outpa- for inpatient referral to allow for Ocean tient is one being referred exclusively adequate observation after the use of for an imaging diagnosis. T is situa- sedation, anesthesia, or both. How- tion is ideal for clients looking to fol- ever, sedation will likely not be given Fish low up with their regular veterinarian for outpatient cases; thus, fractious, for further diagnostics or treatment. uncooperative, aggressive patients However, the lack of familiarity and are best suited for inpatient referral. lack of a doctor-client-patient relation- Ultrasonographic examinations ship may preclude the use of sedatives are becoming more commonplace and interventional procedures. in veterinary medicine and can be a Alternatively, from an imaging useful tool in certain situations. In perspective, an inpatient is simply one managing an owner’s expectations, that has met with, and been exam- it is crucial to communicate that the ined by, a doctor in the specialty prac- majority of ultrasonographic f nd- tice. Although this may yield a more ings are nonspecif c, and additional thorough and complete consultation, diagnostic steps are often required and may allow use of medications, in- to obtain a def nitive diagnosis. terventions, and treatments, this type of referral tends to be more costly. Liver Some specialty practices of er a T ese cases are likely the least appro- mixed model in which a patient is priate outpatient referral cases since referred exclusively for diagnostic 80% leave outpatient imaging for imaging but receives a brief physi- hepatic disease without a diagnosis. cal examination and assessment by a A biopsy or aspirate is often required specialty practice doctor so that seda- to establish a def nitive diagnosis. tion or anesthesia can be performed. Exceptions would be gallbladder T is model is particularly common and biliary disease (e.g. gallbladder at outpatient CT and MRI centers. A mucocele, cholelithiasis, obstruction) discussion with the specialty center in which abdominal ultrasonogra- before referral will help determine phy may be a def nitive test. Patients which imaging modality and referral with suspected portosystemic shunts type is best for an individual patient. should be referred for inpatient ultrasonography since they may require ULTRASONOGRAPHY sedation or further diagnostic tests. It is best practice to instruct owners to fast the patient before an Spleen Go to HillsVet.com ultrasonographic examination. Ultrasonography of the spleen is for more information. T is prevents a food-f lled stomach most often performed to detect

220 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES461290_vetm0714_220.pgs 06.27.2014 00:10 ADV CVC HIGHLIGHT

a mass. However, it can be Gastrointestinal between these two disease dif cult to assess whether the system entities and to dif erentiate the mass is benign or malignant T e utility of ultrasonographic types of neoplasia. with ultrasonography, and examination of the gastrointes- rarely can a def nitive diagno- tinal tract varies. Foreign bod- Thorax sis be reached without further ies can be the most straight- Since it is impractical to exam- diagnostics (e.g. f ne-needle forward diagnosis, whereas ine the entire thorax ultraso- aspiration, biopsy). inf ammatory and neoplastic nographically, a targeted ap- diseases are the least straight- proach based on radiographic Urinary system forward because of the overlap f ndings is usually employed. Suspected ureteroliths, cysto- in ultrasonographic appear- Although pleural ef usion is liths, pyelonephritis, ectopic ance. Generally, further testing easily detected and character- ureters, prostatic abscesses, and in the way of ultrasound- ized, rarely is a def nitive cause cysts make ideal referral ultra- guided diagnostic techniques, found on ultrasonography. sonography cases. A def nitive endoscopy, or laparoscopic or Pulmonary nodules may be diagnosis can often be reached abdominal exploratory surgery detected if they are located based on imaging f ndings. may be necessary to distinguish peripherally. In these cases,

dvm360.com | Veterinary Medicine | July 2014 | 221

magentablackcyanyellow ES461288_vetm0714_221.pgs 06.27.2014 00:11 ADV CVC HIGHLIGHT

ANADA 200-550, approved by the FDA. *Please read entire package insert before use. Meloxidyl® (meloxicam) 1.5 mg/mL Oral Suspension

1RQVWHURLGDODQWLLQÀDPPDWRU\GUXJIRURUDOXVHLQGRJVRQO\ Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Indications: Meloxidyl Oral Suspension is indicated for the control of pain and LQÀDPPDWLRQDVVRFLDWHGZLWKRVWHRDUWKULWLVLQGRJV Contraindications: Dogs with known hypersensitivity to meloxicam should not receive Meloxidyl Oral Suspension. Do not use Meloxidyl Oral Suspension in cats. Acute renal failure and death have been associated with the use ultrasonography is used to help guide clinical signs). Owners should be of meloxicam in cats. Warning: Repeated use of meloxicam in cats has been associated with f ne-needle aspiration or biopsy to prepared for surgical intervention if acute renal failure and death. Do not administer additional injectable or oral meloxicam to cats. See Contraindications, Warnings, and Precautions for detailed information. help make a def nitive diagnosis. indicated. Surgical planning of large Warnings: Not for use in humans. Keep this and all medications out of reach of children. Consult a physician in case of accidental ingestion by humans. For intra-abdominal or body wall masses oral use in dogs only. As with any NSAID all dogs should undergo a thorough history and physical COMPUTED are also common referral cases. examination before the initiation of NSAID therapy. Appropriate laboratory testing to establish hematological and serum biochemical baseline data is TOMOGRAPHY recommended prior to and periodically during administration. Owner should be advised to observe their dog for signs of potential drug toxicity and be given a CT is performed on an inpatient or Thorax client information sheet about Meloxidyl Oral Suspension. Precautions: The safe use of Meloxidyl Oral Suspension in dogs younger mixed inpatient-outpatient basis. As Conditions that would benef t from than 6 months of age, dogs used for breeding, or in pregnant or lactating dogs has not been evaluated. Meloxicam Oral Suspension is not recommended for use in dogs with bleeding disorders, as safety has not been established for all referral cases, ensure owners evaluation by a thoracic CT scan in- in dogs with these disorders. As a class, cyclo-oxygenase inhibitory NSAIDs may be associated with gastrointestinal, renal and hepatic toxicity. Sensitivity are aware of the costs, necessity and clude primary lung tumors, metastatic to drug-associated adverse events varies with the individual patient. Dogs that have experienced adverse reactions from one NSAID may experience risks of anesthesia, and duration of disease, evaluation of thoracic lymph adverse reactions from another NSAID. Patients at greatest risk for renal toxicity are those that are dehydrated, on concomitant diuretic therapy, or those with existing renal, cardiovascular, and/or hepatic dysfunction. hospitalization. Like ultrasonography, nodes, and interstitial pneumonias. A Concurrent administration of potentially nephrotoxic drugs should be carefully approached. NSAIDs may inhibit the prostaglandins that maintain normal additional diagnostics may be re- number of diseases (e.g. lung lobe tor- homeostatic function. Such antiprostaglandin effects may result in clinically VLJQL¿FDQWGLVHDVHLQSDWLHQWVZLWKXQGHUO\LQJRUSUHH[LVWLQJGLVHDVHWKDW has not been previously diagnosed. Since NSAIDs possess the potential to quired to reach a def nitive diagnosis. sion, pulmonary metastases) can be induce gastrointestinal ulcerations and/or perforations, concomitant use with RWKHUDQWLLQÀDPPDWRU\GUXJVVXFKDV16$,'VRUFRUWLFRVWHURLGVVKRXOGEH Almost all cases referred for CT ben- def nitively diagnosed without further avoided. If additional pain medication is needed after administration of the total daily dose of Meloxidyl Oral Suspension, a non-NSAID or non-corticosteroid ef t from preemptive communication work-up. However, owners should be class of analgesia should be considered. The use of another NSAID is not recommended. Consider appropriate washout times when switching from corticosteroid use or from one NSAID to another in dogs. The use of between the referring doctor and the prepared for the need for additional concomitantly protein-bound drugs with Meloxidyl Oral Suspension has not been studied in dogs. Commonly used protein-bound drugs include cardiac, referral center to discuss the imaging diagnostics such as f ne-needle aspira- DQWLFRQYXOVDQWDQGEHKDYLRUDOPHGLFDWLRQV7KHLQÀXHQFHRIFRQFRPLWDQW drugs that may inhibit metabolism of Meloxidyl Oral Suspension has not procedures, risks, and likelihood of tion, biopsy, transtracheal wash, or been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy. reaching a def nitive diagnosis. bronchoalveolar lavage based on the Adverse Reactions: Field safety was evaluated in 306 dogs. Based on the results of two studies, GI abnormalities (vomiting, soft stools, diarrhea, and inappetance) were the most common adverse reactions associated with the initial imaging results. administration of meloxicam. The following table lists adverse reactions and the numbers of dogs that experienced them during the studies. Dogs may have Nasal experienced more than one episode of the adverse reaction during the study. In foreign suspected adverse drug reaction (SADR) reporting over a 9 year CT of the nasal cavity is the most Orthopedic period, incidences of adverse reactions related to meloxicam administration included: auto-immune hemolytic anemia (1 dog), theromabocytopenia (1 dog), common referral case. Clearly ag- Elbow, hip, shoulder, and tarsal dis- polyarthritis (1 dog), nursing puppy lethargy (1 dog), and pyoderma (1 dog).

Adverse Rections Observed During Two Field Studies gressive and clearly nonaggressive ease in young patients are commonly Clinical Observation Meloxicam (n+157) Placebo (n+149) Vomiting 40 23 Diarrhea/Soft Stool 19 11 cases are easy to categorize, but a evaluated with CT scans. Most often Bloody Stool 1 0 Inappapertance 5 1 Bleeding Gums After Dental Procedure 1 0 histologic diagnosis cannot be estab- a def nitive diagnosis is made with- Lethargy/Swollen Campus 1 0 Epiphora 1 0 Post-Approval Experience: (Rev 2010) lished without performing a biopsy. out further work-up. The following adverse events are based on post-approval adverse drug experience reporting. Not all adverse reactions are reported to FDA/CVM. It is not A common source of frustration always possible to reliably estimate the adverse event frequency or establish a causal relationship to product exposure using these data. The following for owners is a report without clear Brain adverse events are listed in decreasing order of frequency by body system. Gastrointestinal: vomiting, anorexia, diarrhea, melena, gastrointestinal dif erential diagnoses. Most often, Brain CT is also a common referral ulceration Urinary: azotemia, elevated creatinine, renal failure Neurological/Behavioral: lethargy, depression these cases benef t from inpatient case. T ese patients are generally Hepatic: elevated liver enzymes Dermatologic: pruritus imaging, where CT or rhinoscopic- exhibiting signs of a large neoplastic Death has been reported as an outcome of the adverse events listed above. Acute renal failure and death have been associated with use of guided biopsies can be performed to lesion (e.g. adult-onset seizures, men- meloxicam in cats. Effectiveness: 7KHHIIHFWLYHQHVVRIPHOR[LFDPZDVGHPRQVWUDWHGLQWZR¿HOG obtain tissue samples. tation changes, clinical signs consis- studies involving a total of 227 dogs representing various breeds, betweens six months and sixteen years of age, all diagnosed with osteoarthritis. Both tent with pituitary disease). When of the placebo-controlled, masked studies were conducted for 14 days. All dogs received 0.2 mg/kg on day 1. All dogs were maintained on 0.1 mg/kg oral meloxicam from days 2 through 14 of both studies. Parameters evaluated Abdomen possible, these cases are often more by veterinarians included lameness, weight-bearing, pain on palpation, and overall improvement. Parameters assessed by owners included mobility, Some referral centers perform a appropriately assessed with MRI. DELOLW\WRULVHOLPSLQJDQGRYHUDOOLPSURYHPHQW,QWKH¿UVW¿HOGVWXG\ Q GRJVVKRZHGFOLQLFDOLPSURYHPHQWZLWKVWDWLVWLFDOVLJQL¿FDQFHDIWHU CT scan to identify and categorize GD\VRIPHOR[LFDPWUHDWPHQWIRUDOOSDUDPHWHUV,QWKHVHFRQG¿HOGVWXG\ Q 48), dogs receiving meloxicam showed a clinical improvement after 14 days of WKHUDS\IRUDOOSDUDPHWHUVKRZHYHUVWDWLVWLFDOVLJQL¿FDQFHZDVGHPRQVWUDWHG suspected portosystemic shunts on Spinal only for the overall investigator evaluation on day 7, and for the owner evaluation on day 14. a referral basis. Most often there is Referral of patients for neurologic How Supplied: Meloxidyl® 1.5 mg/mL Oral Suspension: 10, 32, 100 and 200 mL bottles with small and large dosing syringes. high suspicion for a shunt (bile acids (spinal) imaging is usually on an Storage: Store at controlled room temperature 68-77° F (20-25° C). Manufactured for: Ceva Santé Animale, Libourne, France > 100 μmol/L with concomitant inpatient basis given the necessity Marketed by: Ceva Animal Health, LLC, Lenexa, KS 66215 Meloxidyl® is a registered trademark of Ceva Sante Animale, France

222 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES461291_vetm0714_222.pgs 06.27.2014 00:10 ADV See brief summary on page 222.

magentablackcyanyellow ES460574_VETM0714_223_FP.pgs 06.26.2014 17:23 ADV CVC HIGHLIGHT

to proceed to surgery if a com- component. Similar to CT, neoplastic lesion (experiencing pressive lesion is found. Pre- clearly aggressive and clearly adult-onset seizures, mentation pare owners for this outcome nonaggressive cases are easy changes, clinical signs con- before imaging, as discussions to categorize, but a histologic sistent with pituitary disease) regarding surgery, prognosis, diagnosis cannot be established or inf ammatory lesions. A and risks are best held prior to without performing a biopsy. cerebrospinal f uid tap is often anesthesia. T us, these cases often benef t performed, particularly if an in- T e best candidates for spinal from inpatient imaging so that f ammatory lesion is suspected. CT are middle-aged, small- rhinoscopic biopsies may be breed dogs with suspected cer- performed. Spinal vical or lumbar lesions with an As with CT, patients needing acute onset and worsening of Abdomen neurologic (spinal) imaging are clinical signs. Large-breed pa- MRI is rarely used to evaluate usually referred on an inpatient tients, patients with static signs, the abdomen. Occasionally MRI basis given the necessity to pro- or patients suspected of having may be helpful in evaluating for ceed to surgery if a compressive parenchymal cord disease (e.g. portosystemic shunts or for ad- lesion is found. It is important f brocartilagenous embolism, renal gland and hepatic imaging. to discuss with the owners the degenerative myelopathy, possible need for surgery, the lymphoma) would likely benef t Thorax prognosis, and the risks before from MRI rather than CT. Pulmonary parenchyma does the patient is anesthetized and not image well with MRI. Most undergoes imaging. MAGNETIC magnetic resonance thoracic Large-breed patients, RESONANCE imaging is performed for fur- patients with static signs, or IMAGING ther dif erentiation and surgical patients suspected of having Although some referral centers planning of chest wall, medias- parenchymal cord disease (e.g. of er outpatient MRI, it is gen- tinal, or pleural lesions, though f brocartilagenous embolism, Hear all erally performed on an inpa- some centers also perform degenerative myelopathy, about it! tient basis. As with CT, owners cardiac MRI. lymphoma) may benef t from To hear Dr. King should be aware of the costs, MRI’s ability to evaluate spinal provide a quick overview of which necessity and risk of anesthesia, Orthopedic cord parenchyma. imaging modality and duration of hospitalization. MRI is rarely used for or- is best in which A discussion with a referral thopedic disease except for Other cases, scan the center can help determine if soft tissue stif e and shoulder MRI is the imaging modality QR code below or CT or MRI is most appropriate imaging (e.g. cranial cruci- of choice in cases of suspected visit dvm360.com/ CVC14King. and is often benef cial when ate ligament, and biceps and brachial plexus injury and counseling owners on what to supraspinatous tendons). nerve sheath and soft tissue expect during the referral visit. tumors. Brain Nasal Evaluation of the brain and Ryan King, DVM, DACVR MRI is becoming increasingly central nervous system are the Cummings School of Veterinary popular for evaluating nasal most common referral cases Medicine at Tufts University disease, particularly if there for MRI. T ese patients are TuftsVETS is concern for an intracranial generally suspected to have a North Grafton, MA

224 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES461289_vetm0714_224.pgs 06.27.2014 00:10 ADV SPOTLIGHT ON RESEARCH

How residual speed of kill affects ﬂea control in dogs and cats

Sponsored by

magentablackcyanyellow ES460734_VETM0714_MERCK1_FP.pgs 06.26.2014 19:45 ADV Residual speed of kill: Understanding its importance in eliminating ﬂeas from a household

Two important, distinct evaluations can bias the results. of fea adulticides are initial speed of ■ Animals in the control and kill studies and residual speed of kill treatment groups are initially studies.1-5 Initial speed of kill studies infested with a known number measure how quickly a fea adulticide of feas before application of kills feas when it is frst adminis- the product, so that the time to tered; these studies do not indicate signifcant efcacy of a product the speed of fea kill of the product can be determined. Te day that at other times during the treatment the animals are treated is usually period. In contrast, residual speed of called Day 0. kill studies are more clinically relevant ■ Live feas are carefully counted and provide fea kill information for on animals in the treatment and the entire post-treatment interval. control groups at preselected Michael W. Dryden, DVM, MS, PhD, In addition, a third type of study, time points (4, 8, 12, 24, and DAVCM (Parasitology) which can be combined with a residu- 48 hours; more or fewer time University Distinguished Professor of al speed of kill study, is a reproductive points can be chosen). Efcacy Veterinary Parasitology breakpoint study.6-9 Tis type of study is calculated at each time point Department of Diagnostic measures whether a residual fea based on the number of live feas Medicine and Pathobiology control treatment can prevent a fea on control animals compared College of Veterinary Medicine population from maintaining itself. with the number of live feas on Kansas State University In this Spotlight on Research, I treated animals. Tis portion Manhattan, Kansas will explain the diferent studies of the study gives an indication and discuss which results are most of how quickly a fea-infested important in evaluating the efcacy animal becomes fea-free afer of fea-control products. the frst product application. When it comes to controlling Tis is an initial speed of kill flea infestations, one thing Typical study protocols study and indicates the time to more important than the initial Speed of kill studies of a product tend potential therapeutic efcacy of a speed of kill of a flea adulticide to follow the same pattern, whether fea product. is the residual speed of kill of they are designed to examine the ■ At selected intervals thereafer the adulticide. That is, the adul- time from product administration to (typically weekly) throughout ticide’s speed of kill throughout statistically signifcant efcacy against the entire post-treatment period, the entire treatment interval — resident feas or the time to signifcant control and treatment group on every day between the initial efcacy against newly arriving feas. animals are reinfested with a application of and retreatment Efcacy of the product against feas is known number of new feas, and with the product. The speed of calculated by comparing the num- the process of counting live feas kill and resulting efficacy of the ber of feas remaining on animals is repeated at each preselected product at the end of the treat- in a treated group compared with time point (4, 8, 12, 24, and 48 ment interval is likely more im- the number of feas remaining on hours; 12 and 24 hours or 24 portant than the product’s ef- animals in a negative control group and 48 hours are ofen selected ficacy at the start of treatment. at preselected time points. Ofen a because of cost constraints). If a flea adulticide loses signifi- diferent group of treated animals For a monthly fea treatment, cant speed of kill throughout and control animals is used for each efcacy could be measured every the month after its application, of the preselected time points. Less week (on Days 0, 7, 14, 21, and it allows fleas to feed long commonly, repeated measurements 28) or possibly even beyond the enough that they could elicit an are made using the same animals at monthly treatment interval. allergic reaction in pets and, if the preselected time points. Because speed of kill typically the fleas live for 24 hours, they Te typical speed of kill experi- slows with time, this portion of could lay eggs that repopulate mental protocol involves these steps: the study gives an indication of the environment. ■ Dogs or cats that are known to the time required to kill newly To appreciate the diferences in be good fea hosts are selected arriving feas throughout the residual adulticide fea control treat- for inclusion in the study. treatment period. For example, a ments for dogs and cats, it’s helpful to Some individual animals are fea treatment that kills 100% of understand the experimental meth- not good fea hosts, and includ- feas within eight hours on Day 7 ods used in fea treatment studies. ing these animals in a study post-treatment likely will not

2 Spotlight on Research

magentablackcyanyellow ES460735_VETM0714_MERCK2_FP.pgs 06.26.2014 19:45 ADV treatment, then no amount of the approximate time post-treatment treating can ever eliminate feas when viable fea eggs are frst pro- kill newly arriving feas from the household. duced from feas that reinfest treated with the same speed animals. Tis time post-treatment 30 days later. Tis is the residual Does the product is considered the reproductive break speed of kill portion of the study. prevent fleas from point. reproducing? Once the reproductive break point To get a true picture of fea treat- We evaluate a product’s ability to is passed, then the fea treatment will ment efcacy, you need to understand prevent reproduction between treat- allow feas to deposit viable eggs into a few facts about the reproduction of ment applications with a reproduc- the environment, thereby maintain- the cat fea, Ctenocephalides felis. Cat tive break point study. Tis study ing the local population. Counting feas initiate feeding within seconds assesses the time following product feas on these treated animals 48 or 72 to minutes of acquiring a host, mate administration when residual speed hours post-infestation may still show within the frst 12 hours, and females of kill slows sufciently, or ovicidal excellent efcacy against adult feas; typically start producing eggs at activity drops below 100%, to allow however, this may be false assur- 24 hours post-infestation.10 Tese viable egg production.7-9 In this study ance because the feas may have laid females will continue to produce eggs design, treated and control animals eggs before dying and reinfested the every day for several months, produc- are reinfested with a known number environment, thus the fea problem ing up to 40 eggs/day/female fea.11 of feas at specifc intervals afer treat- will persist. Terefore, a topical or systemic fea ment (ofen weekly, such as on Day When evaluating the residual treatment that has a rapid residual 7, 14, 21, 28, 35, or 42). Forty-eight to performance of a fea product, an efective product’s reproductive break A topical or systemic flea treatment succeeds or fails point will occur at some time point afer the next labeled reapplication based on its ability to control or not control flea interval. If a product is labeled for reproduction. If fleas can reproduce in spite of the once-a-month administration and flea treatment, then no amount of treating can ever the reproductive break point occurs eliminate fleas from the household. around Day 21, then the product will probably not be efective in eliminating a fea infestation. Considering speed of kill, dispatching every fea 72 hours afer each reinfestation, re- the results of a residual speed of kill within 24 hours, can prevent egg searchers carefully collect and count and a reproductive break point study production. Preventing fea repro- any fea eggs falling from the treated together gives the best indication of duction means that the environ- and control animals. Tese eggs are the real clinical efcacy of a fea treat- mental fea population load will then incubated to determine their ment. A treatment that can control steadily decrease.12 If a population viability, as indicated close to 100% of fea adults cannot reproduce, it will go extinct by the percentage of within 24 hours for the within one generation. However, eggs emerging to full duration of its this rapid 24-hour kill rate must be adult feas. Tus we treatment interval maintained at 100% throughout the can determine when (as shown in post-treatment period, otherwise feas efcacy of a residual a speed will survive and egg-laying will start. fea adulticide of kill Ten the only way a product can stop drops below 100% reproduction is if it also has ovicidal within 24 hours properties.7,9 If the reproduction of fea reinfesta- inhibition drops below 100% before tion and whether the 24-hour mark on any day during the product has the treatment interval, then feas additional ovi- will reproduce and will reseed the cidal activity. Te environment with eggs. A topical or study identifes systemic fea treatment succeeds or fails based on its ability to control or not control fea reproduction. If feas can reproduce in spite of the fea

Spotlight on Research 3

magentablackcyanyellow ES460736_VETM0714_MERCK3_FP.pgs 06.26.2014 19:45 ADV orally administered spinosad tablets against the KS1 study) and that also does not allow because there is always the possibil- fea strain infesting dogs. Intern J Appl Res Vet Med production of viable fea eggs within ity that feas will be reintroduced 20111;9(2):123-128. its treatment interval can be used to into your client’s household from 6. Payne PA, Dryden MW, Smith V, et al. Efect of 0.29% w/w fpronil spray on adult fea mortality and egg drive feas to extinction in a house- fea populations on wildlife or from production of three diferent cat fea, Ctenocephalides hold. Tis is because the treatment untreated households. As veterinar- felis (Bouche), strains infesting cats. Vet Parasitol will not allow adult feas to survive ians, we need to persuade owners to 2001;102(4):331-340. 7. Dryden M, Payne P, Smith V. Efcacy of selamectin long enough to reproduce, and no routinely reapply an efective product and fpronil/(s)-methoprene spot-on formulations new viable fea eggs are being added at the recommended retreatment applied to cats against the adult cat fea, Ctenocephali- des felis, fea eggs and adult fea emergence. Vet Ter to the environment. interval. In most locations, this needs 2007;8(4):255-262. A recent reproductive break point to be continued year round. A treat- 8. Dryden M, Payne P, Lowe A, et al. Efcacy of a topi- study9 demonstrated that the data ment gap will allow feas to reseed the cally applied formulation of metafumizone on cats against the adult cat fea, fea egg hatch and adult fea generated in the laboratory was then environment with viable eggs. emergence. Vet Parasitol 2007;150:263-267. directly applicable in a feld study in 9. Dryden MW, Payne PA, Smith V, et al. Efcacy of the high-challenge environment of REFERENCES indoxacarb applied to cats against the adult cat fea, Ctenocephalides felis, fea eggs and adult fea emer- 13 1. Dryden MW, McCoy CM, Payne PA. Speed of kill with Tampa, Fla. Te reproductive break gence. Parasites & Vectors 2013;6:126. Available at: nitenpyram tablets, compared to imidacloprid spot-on http://www.parasitesandvectors.com/content/6/1/126 point of an indoxacarb-based fea and fpronil spot-on on dogs. Comp Cont Ed Pract Vet. 10. Blagburn BL, Dryden MW. Biology, treatment and 2001;23(3[A]):24-27. adulticide product in the laboratory control of fea and tick infestations. Vet Clin N Am 2. Dryden MW, Smith V, Payne PA, et al. Comparative trial was well beyond the 30-day 2009;39(6):1173-1200. speed of kill of selamectin, imidacloprid, and fpronil– 9 11. Dryden M. Host association, on host longevity and retreatment interval. When tested in (s)-methoprene spot-on formulations against feas on egg production of Ctenocephalides felis. Vet Parasitol cats. Vet Ter 2005;6(3):228-236. a feld trial, regular monthly applica- 1989;34:117-122. 3. Blagburn BL, Young DR, Moran C, et al. Efects of 12. Dryden MW. How you and your clients can win the tions of the product almost com- orally administered spinosad (Comfortis) in dogs on fea control battle. Vet Med 2009;104(3, suppl):17-26. pletely eliminated fea infestation on adult and immature stages of the cat fea (Ctenoce- 13. Dryden MW, Payne PA, Smith V, et al. Evaluation of phalides felis). Vet Parasitol 2010; 168:312–317. pets and in their home environments indoxacarb and fpronil (s)-methoprene topical spot-on 4. Dryden MW, Payne PA, Smith V, et al. Efcacy of 13 formulations to control fea populations in naturally within 60 days. imidacloprid + moxidectin and selamectin topical so- infested dogs and cats in private residences in Tampa lutions against the KS1 Ctenocephalides felis fea strain Te use of a fea treatment that FL. USA. Parasites & Vectors 2013;6:366. Available infesting cats. Parasites & Vectors 2011;4:174. eliminates feas within a household at http://www.parasitesandvectors.com/content/ 5. Dryden MW, Payne PA, Vicki S, et al. Efcacy of pdf/1756-3305-6-366.pdf is still not quite the end of the story topically applied dinotefuran formulations and

Dr. Dryden’s viewpoint: The clinical relevance of speed of kill In clinical veterinary practice, topical or oral residual flea adulticide products’ speed of kill claims can often be confusing. Keep in mind that a product’s initial speed of kill is likely much different from its residual speed of kill. Although initial speed of kill immediately after dosing is clearly important in deliver- ing initial relief for pets, it is the persistency of the product’s speed of kill that is more critical to resolving and preventing flea infestations. A flea adulticide’s residual speed of kill should be rapid enough to prevent newly acquired fleas—those that emerge from cocoons—from achieving viable reproduction. This means that newly acquired fleas must be killed or rendered moribund within 24 hours of the time they jump onto a treated dog or cat. If newly acquired fleas are killed fast enough, reproduction is prevented and the flea life cycle is stopped. In addition, if newly acquired fleas are killed fast enough, pets’ exposure to flea bites and flea salivary proteins will be minimized, thus flea allergy dermatitis can be effec- tively managed. Perhaps most importantly, if fleas are killed quickly initially and continue to be killed rapidly throughout the treatment period, clients will see very few fleas and will be pleased with the success of your flea control program. Apart from safety, I’m not sure anything is more important than a topical or oral flea adulticide’s residual speed of kill.

The views expressed are solely those of Dr. Dryden. Dr. Dryden received compensation for his time associated with this project and occasionally collaborates with Merck Animal Health.

4 Spotlight on Research ©Merck Animal Health 2014

magentablackcyanyellow ES460733_VETM0714_MERCK4_FP.pgs 06.26.2014 19:45 ADV INTRODUCING…

FLEA AND TICK MANAGEMENT JUST TOOK A GREAT LEAP FORWARD— 12-WEEK PROTECTION,* ONE ORAL CHEW1

That was then. This is now.

Order BRAVECTO today—contact your Merck Animal Health sales representative or distributor partner.

* Bravecto kills fl eas, prevents fl ea infestations, and kills ticks (black-legged tick, American dog tick, and brown dog tick) for 12 weeks. Bravecto also kills lone star ticks for 8 weeks. IMPORTANT SAFETY INFORMATION: The most common adverse reactions recorded in clinical trials were vomiting, decreased appetite, diarrhea, lethargy, polydipsia, and fl atulence. Bravecto has not been shown to be effective for 12-weeks’ duration in puppies less than 6 months of age. Bravecto is not effective against lone star ticks beyond 8 weeks after dosing. Please see Brief Summary on following page. Reference: 1. Bravecto [prescribing information]. Summit, NJ: Merck Animal Health; 2014. Available by veterinary prescription only. www.BravectoVets.com Copyright © 2014 Intervet Inc., a subsidiary of Merck & Co., Inc. All rights reserved. Intervet Inc. d/b/a/ Merck Animal Health, Summit, NJ 07901. US/BRV/0514/0026

magentablackcyanyellow ES461281_VETM0714_225_FP.pgs 06.27.2014 00:01 ADV NADA 141-426, Approved by FDA

BRIEF SUMMARY (For full Prescribing Information, see package insert)

Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.

Indications: Bravecto kills adult ﬂeas and is indicated for the treatment and prevention of ﬂea infestations (Ctenocephalides felis) and the treatment and control of tick infestations [Ixodes scapularis (black-legged tick), Dermacentor variabilis (American dog tick), and Rhipicephalus sanguineus (brown dog tick)] for 12 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater.

Bravecto is also indicated for the treatment and control of Amblyomma americanum (lone star tick) infestations for 8 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater.

Contraindications: There are no known contraindications for the use of the product.

Warnings: Not for human use. Keep this and all drugs out of the reach of children. Keep the product in the original packaging until use, in order to prevent children from getting direct access to the product. Do not eat, drink or smoke while handling the product. Wash hands thoroughly with soap and water immediately after use of the product.

Precautions: Bravecto has not been shown to be effective for 12-weeks duration in puppies less than 6 months of age. Bravecto is not effective against Amblyomma americanum ticks beyond 8 weeks after dosing.

Adverse Reactions: In a well-controlled U.S. ﬁeld study, which included 294 dogs (224 dogs were administered Bravecto every 12 weeks and 70 dogs were administered an oral active control every 4 weeks and were provided with a tick collar); there were no serious adverse reactions. All potential adverse reactions were recorded in dogs treated with Bravecto over a 182-day period and in dogs treated with the active control over an 84-day period. The most frequently reported adverse reaction in dogs in the Bravecto and active control groups was vomiting.

Percentage of Dogs with Adverse Reactions in the Field Study Bravecto Group: Percentage of Active Control Group: Percentage Adverse Reaction (AR) Dogs with the AR During the of Dogs with the AR During the 182-Day Study (n=224 dogs) 84-Day Study (n=70 dogs) Vomiting 7.1 14.3 Decreased Appetite 6.7 0.0 Diarrhea 4.9 2.9 Lethargy 5.4 7.1 Polydipsia 1.8 4.3 Flatulence 1.3 0.0

In a well-controlled laboratory dose conﬁrmation study, one dog developed edema and hyperemia of the upper lips within one hour of receiving Bravecto. The edema improved progressively through the day and had resolved without medical intervention by the next morning.

For technical assistance or to report a suspected adverse drug reaction, contact Merck Animal Health at 1-800-224-5318. Additional information can be found at www.bravecto.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/ SafetyHealth.

How Supplied: Bravecto is available in ﬁve strengths (112.5, 250, 500, 1000, and 1400 mg ﬂuralaner per chew). Each chew is packaged individually into aluminum foil blister packs sealed with a peelable paper backed foil lid stock. Product may be packaged in 1, 2, or 4 chews per package.

Distributed by: Intervet Inc (d/b/a Merck Animal Health) Summit, NJ 07901

141487 R2

black ES461280_VETM0714_226_FP.pgs 06.27.2014 00:01 ADV CVC HIGHLIGHT

T e hunt for grass awns These sneaky foreign bodies can cause major problems if not addressed appropriately. By Emily Klocke, DVM, DACVS

igrating plant foreign swelling or a draining tract when bodies, which are the paw is af ected. Lumbar pain Mseen most commonly or swelling and pain at the costal in hunting dogs, cannot only region caudal to the last rib may be uncomfortable, but can also be present if an abscess has de- quickly cause serious health veloped. Other signs of a plant problems. Here is when to foreign body include a superf - suspect such foreign body inva- cial abscess that is drained and sion and how to eliminate the treated with antibiotics but then unwanted invaders. recurs soon after the antibiotics are f nished. Increased respira- How they get in tory ef ort or dyspnea when a Grass awns and plant material pyothorax is present may be are thought to enter the mouth seen. Signs can also be vague, or nose when a dog is breath- such as decreased performance, ing hard as it runs through a decreased exercise tolerance, f eld. T e plant material can lethargy, fever, and weight loss. migrate through the respiratory or gastrointestinal tract or The concurrent other tissues, or it can penetrate bacterial invasion— through the skin and migrate and how to attack it elsewhere. Grass awns have Infection associated with backward-pointing barbs that migrating grass awns is often a prevent retrograde movement. mixed population of bacteria. amination of f uid. T ey can be T is makes normal clearing Grass awns become inoculated dif cult to culture, particularly mechanisms inef ective, and with commensals of the oral if antibiotics have been admin- grass awns will migrate deeper cavity and respiratory tract istered before obtaining the with normal motion. when they enter via these sample. T erefore, any patient routes. Common organisms that has a conf rmed migrating What owners found include Staphylococcus, grass awn but a negative culture may notice Streptococcus, and Pasteurella result should still be considered Clinical signs will depend on the species and Escherichia coli. to have a bacterial infection and location of the plant material. Actinomyces and Nocardia spe- be treated empirically, making T e most common location is cies (soil-borne organisms) are sure that antibiotics chosen are the ear, and clinical signs are also often associated with grass appropriate for Actinomyces often those of otitis externa. awns and are seen as f lamen- and Nocardia species. Patients may have an interdigital tous rods on cytologic ex- Penicillin derivatives are

GETTY IMAGES/MAGDALENA PODGORSKA dvm360.com | Veterinary Medicine | July 2014 | 227

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generally a good f rst choice. I body and whether multiple for- drainage of the thorax. typically start with amoxicillin- eign bodies are present. If locat- Surgery is also indicated if a clavulanic acid orally or amox- ing it intraoperatively is dif cult, pulmonary abscess, lung lobe icillin-sulbactam intravenously. intraoperative ultrasonography torsion, Actinomyces species, Administer the antibiotics can be performed. Once the or a foreign body is identif ed. long-term—four to eight weeks foreign body is located by ultra- Ultrasonographic examina- depending on the primary prob- sound, a needle can be inserted tions or computed tomography lem—but for no less than four with ultrasonographic guidance scans of the thoracic cavity can weeks. If culture results do show to pinpoint its location. be helpful in identifying these growth, base your antibiotic Respiratory migration. For pathologic conditions. selection on the sensitivity. dogs presenting with respiratory signs, thoracic radiography of- What if you The real hunt begins ten reveals pleural ef usion, and can’t ﬁ nd it? A migrating grass awn should thoracocentesis is performed to For cases in which the foreign be high on your dif erential list analyze the f uid. Fluid analysis body cannot be found, the best for any hunting dog showing the helps in the diagnosis of pyotho- approach is drainage of infected clinical signs previously men- rax in many of these cases. f uid, débridement of associated tioned. Physical examination A variety of treatment tissue, placement of a drain, and f ndings (e.g. a subcutaneous regimens have been recom- long-term antibiotic therapy. In abscess, pain on lumbar palpa- mended, including thoracocen- cases such as these, antibiotic tion, decreased lung sounds) will tesis, thoracic drain placement therapy should be administered narrow where to look for the with lavage, and thoracotomy. for at least eight weeks. T e problem. A baseline complete Determining which treatment hope in these situations is that blood count may demonstrate a is appropriate depends on many the body will wall of the foreign leukocytosis. Imaging will be the factors. body and that surgical drainage most benef cial diagnostic tool. If the foreign body has been or débridement and long- Hear all T e goals to achieve a success- present for some time, sig- term antibiotics will control about it! ful outcome are removal of the nif cant loculation can occur the infection. However, these Listen in as Dr. foreign body, débridement and from f brinous deposits that cases are at risk for recurrence, Klocke describes drainage of infected tissue, and results in the formation of f uid particularly after the antibi- the typical long-term antibiotic therapy. pockets that can be dif cult otic regimen is complete, and presentation of Abscesses. For abscesses in to drain, leading to failure of owners should be vigilant in these cases by scanning the QR hunting dogs, ultrasonographic medical management. Surgical watching for return of clinical code below or by examination has been extremely exploration and débridement signs. Also, don’t forget that the visiting dvm360 useful in identifying and con- of the thoracic cavity through grass awn could have migrated .com/CVC14Klocke. f rming a foreign body in our a median sternotomy is often elsewhere, and that might be clinic. A skilled ultrasonogra- recommended in these cases. why it couldn’t be found. pher who has experience locat- A foreign body is rarely found, ing this type of foreign body but the débridement and lavage Emily Klocke, DVM, DACVS can help the surgeon know its is benef cial in resolving the Department of Clinical Sciences exact location using anatomical pyothorax. Leave thoracic drains College of Veterinary Medicine landmarks and give information in place after the surgery to Kansas State University regarding the size of the foreign facilitate continued lavage and Manhattan, KS 66506

228 | July 2014 | Veterinary Medicine | dvm360.com

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A 4-tiered approach to considering the ef cacies of dental home care techniques Take a look at these building blocks to create individualized home care regimens for each of your patients. By Christopher Snyder, DVM, DAVDC

umerous studies with various levels Nof evidence have been published regarding the benef ts of a variety of oral health products, techniques, and medications. But what is lacking is a compilation of all of these options into a logical approach to dental care at home. I like to think of these dif er- ent products or techniques as having positives and negatives and, along with that, dif er- ent ef cacies for preventing periodontal disease. When considering these materials’ functionality and ef cacy as proven by the veterinary and human literature, you can use a general tiered system. T e organization of these products represents my personal

GETTY IMAGES/RYERSON CLARK dvm360.com | Veterinary Medicine | July 2014 | 229

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Verafl ox (pradofl oxacin) Oral Suspension for Cats 25 mg/mL For the treatment of skin infections (wounds and abscesses) in cats. Do not use in dogs. BRIEF SUMMARY: understanding of the human and tion. If unappreciated areas of disease Before using Verafl ox Oral Suspension for Cats, please consult the product insert, a summary of which follows: veterinary literature and combines are unknowingly contacted by the CAUTION: my own personal experience. toothbrush, the pain may result in Federal law restricts this drug to use by or on the order of a licensed veterinarian. Federal law prohibits the extra-label use of the client being bitten or the animal this drug in food-producing animals. PRODUCT DESCRIPTION: Tier 1: Tooth brushing associating the toothbrush as some- Pradofl oxacin is a fl uoroquinolone antibiotic and belongs to the class of quinolone carboxylic acid derivatives. Each mL of Daily tooth brushing remains the thing that causes pain. Verafl ox Oral Suspension provides 25 mg of pradofl oxacin. gold standard to prevent periodon- INDICATIONS: Verafl ox is indicated for the treatment of skin infections (wound tal disease and maintain good oral Tier 2: Food and abscesses) in cats caused by susceptible strains of Pasteurella multocida, Streptococcus canis, Staphylococcus aureus, health. I recommend brushing once When it comes to feeding, in most Staphylococcus felis, and Staphylococcus pseudintermedius. CONTRAINDICATIONS: a day before feeding. Owners should situations dry food results in less DO NOT USE IN DOGS. Pradofl oxacin has been shown to cause bone marrow suppression in dogs. Dogs may be particularly not use human toothpaste since the plaque and tartar accumulation. It has sensitive to this effect, potentially resulting in severe amount of f uoride contained in also been shown that a 50% increase thrombocytopenia and neutropenia. Quinolone-class drugs have been shown to cause arthropathy in immature animals of these products is not meant to be in kibble size results in a 42% decrease most species tested, the dog being particularly sensitive to this side effect. Pradofl oxacin is contraindicated in cats with a known swallowed and may cause f uorosis in calculus accumulation in dogs.2 hypersensitivity to quinolones. HUMAN WARNINGS: of the kidneys. Veterinary studies In addition, veterinary therapeutic Not for human use. Keep out of reach of children. Individuals with a history of quinolone hypersensitivity should avoid this have suggested that brushing with diets such as Prescription Diet t/d product. Avoid contact with eyes and skin. In case of ocular contact, immediately fl ush eyes with copious amounts of water. water versus veterinary toothpaste Dental Health (Hill’s Pet Nutrition) In case of dermal contact, wash skin with soap and water for at least 20 seconds. Consult a physician if irritation persists demonstrates no signif cant dif er- and Royal Canin Veterinary Diet following ocular or dermal exposure or in case of accidental ingestion. In humans, there is a risk of photosensitization within ence in the amount of plaque and Dental (Royal Canin) incorporate a few hours after exposure to quinolones. If excessive accidental exposure occurs, avoid direct sunlight. Do not eat, drink or tartar accumulation. T e mechanical technology that causes the f ber smoke while handling this product. For customer service or to obtain product information, including a Material Safety Data action of the bristles and brushing within the food to orient in a manner Sheet, call 1-800-633-3796. For medical emergencies or to 1 report adverse reactions, call 1-800-422-9874. provides the greatest benef t. But that predictably af ects the way the ANIMAL WARNINGS: veterinary toothpaste tastes good to food breaks when chewed. Repeated For use in cats only. The administration of pradofl oxacin for longer than 7 days induced reversible leukocyte, neutrophil, dogs and cats and functions more as chewing creates a mechanical disrup- and lymphocyte decreases in healthy, 12-week-old kittens. PRECAUTIONS: a reward than a primary cause for tion of plaque before it can mineral- The use of fl uoroquinolones in cats has been associated with the development of retinopathy and/or blindness. Such products plaque reduction. ize into calculus. should be used with caution in cats. Quinolones have been shown to produce erosions of cartilage of weight-bearing joints and other So which pets should be condi- Some pet food products (e.g. Iams signs of arthropathy in immature animals of various species. The safety of pradofl oxacin in cats younger than 12 weeks of age tioned to a toothbrush? T e short Dental Defense—Iams; Royal Canin has not been evaluated. The safety of pradofl oxacin in immune- compromised cats (i.e., cats infected with feline leukemia virus answer is the safe ones. Owners of Veterinary Diet Dental) contain and/or feline immune-defi ciency virus) has not been evaluated. Quinolones should be used with caution in animals with known an unpredictable pet, a fear biter, or polyphosphates, which are respon- or suspected central nervous system (CNS) disorders. In such animals, quinolones have, in rare instances, been associated with an animal that has a history of biting sible for chelating calcium found in CNS stimulation that may lead to convulsive seizures. The safety of pradofl oxacin in cats that are used for breeding or that are should not be coached into tooth saliva. When the salivary calcium pregnant and/or lactating has not been evaluated. brushing. Putting a pet owner at risk is rendered unavailable to plaque, ADVERSE REACTIONS: In a multi-site fi eld study, the most common adverse reactions is not worthwhile. In addition, since plaque mineralization and subse- seen in cats treated with Verafl ox were diarrhea/loose stools, leukocytosis with neutrophilia, elevated CPK levels, and sneezing. periodontal disease in the classic quent calculus formation slows. ANIMAL SAFETY: In a target animal safety study in 32, 12-week-old kittens dosed sense will not af ect animals under at 0, 1, 3, and 5 times the recommended dose for 21 consecutive days. One 3X cat and three 5X cats had absolute neutrophil 6 months of age, save tooth brush- Tier 3: Treats, toys, counts below the reference range. The most frequent abnormal clinical fi nding was soft feces. While this was seen in both ing recommendations for animals 6 and sealants treatment and control groups, it was observed more frequently in the 3X and 5X kittens. months of age or older. Careful selection of appropriate treats U.S Patent No. 6,323,213 Also, do not encourage tooth and toys that are not so hard that they May, 2012 84364593/84364607, R.0 brushing in animals more than 1 fracture teeth is important. A good NADA141-344, Approved by FDA Made in Germany year of age without performing an rule of thumb for clients: If you can Bayer, the Bayer Cross and Verafl ox are registered trademarks of Bayer. anesthetized thorough oral examina- hit yourself in the knee with it and it GHG052714 Bayer HealthCare LLC Animal Health Division Shawnee Mission, Kansas 66201, U.S.A.

230 | July 2014 | Veterinary Medicine | dvm360.com

magentablackcyanyellow ES459552_vetm0714_230.pgs 06.25.2014 23:33 ADV Discover the science. Veraflox® (pradofloxacin) Oral Suspension for Cats Efficacy. Safety. Ease-of-use.

Find out more at www.Verafl oxOS.com CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Federal law prohibits the extra label use of this drug ® in food-producing animals. WARNINGS: For use in cats only. PRECAUTIONS: (pradofloxacin) The safety of pradofl oxacin in cats younger than 12 weeks of age has not been evaluated. Oral Suspension for Cats ©2014 Bayer HealthCare LLC, Animal Health, Shawnee Mission, Kansas 66201 Bayer, the Bayer Cross and Verafl ox are registered trademarks of Bayer. Designed specifically for the needs of cats. V14975 See brief summary on page 230.

magentablackcyanyellow ES460575_VETM0714_231_FP.pgs 06.26.2014 17:23 ADV CVC HIGHLIGHT

hurts, it’s probably too hard for the teeth f rst that day, and well as the anti-inf ammatory them to chew on. Chew treats then apply the treatment. ef ects make doxycycline a and toys of er a limited mecha- Twenty-four hours after Ora- good choice for patients nism of periodontal disease Vet is applied, it is thought to requiring long-term therapy. prevention. While mechanical have repelled itself all around Doxycycline is best titrated to disruption of plaque may be the exposed tooth surface. the lowest ef ective dose and helpful, chew treats and toys do consistently administered. not reach below the gum line Tier 4: Water where periodontal disease-asso- additives, rinses, Conclusion ciated bacteria accumulate. and antibiotics No simple equation exists T e Veterinary Oral Health Use water additives, oral rinses, for creating the perfect home Council website (VOHC.org) and prescription antibiotics care treatment plan for every is a great source for clients and carefully and sparingly. T e patient. Having realistic ex- veterinarians to f nd reliable ultimate challenge with rinses pectations about what various information about which oral and water additives, even when dental home care products health products have been used properly, is that they will provide is the f rst step in proven with science to be ef- require suf cient contact time coaching clients to play a pro- fective. Many more products to be ef ective and do not active role in maintaining their may be safe and ef cacious penetrate well into the targeted pets’ oral health. than are presented on this list. area where periodontal disease Remember: “An ounce of T ese manufacturers have develops—subgingivally. prevention is better than a gone through great expense to Antibiotics mostly act as a pound of cure.” Coach clients perform high-quality scientif c Band-Aid for the long-term early and often to prevent the experiments to prove their management of periodontal development of periodontal products work. disease. With extended use, disease, and those yearly dental Barrier sealants such as selection for resistant bacteria cleanings will become quicker OraVet (Merial) have also been is expected. T e use of “pulse and less costly and will involve shown to reduce plaque and dosing” antibiotics can be fewer expensive and invasive tartar buildup. helpful in cyclically reducing treatments in the long run. While Ora- the load of subgingival bac- Hear all about it! Vet is not a teria colony-forming units. A REFERENCES 1. Roudebush P, Logan E, Hale FA. What about electric replacement commonly used pulse-dosing Evidence-based veterinary dentistry: a toothbrushes for pets? for brushing, schedule involves medicating systemic review of homecare for preven- Hear Dr. Snyder’s thoughts tion of periodontal disease in dogs and it can be used the patient for the f rst f ve to cats. J Vet Dent 2005;22(1):6-15. by scanning the QR in patients in seven days of each month. 2. Hennet P, Servet E, Soulard Y, et al. Ef- code below or by visiting fect of pellet food size and polyphosphates which daily Drugs used for the treatment in preventing calculus accumulation in dvm360.com/CVC14Snyder. tooth brushing and management of periodon- dogs. J Vet Dent 2007;24(4):236-239. is taking place. tal disease include clindamycin, Remind clients potentiated amoxicillin and Christopher Snyder, DVM, DAVDC that when they clavulanic acid, metronidazole, Department of Surgical Sciences are applying and doxycycline. T e concen- School of Veterinary Medicine OraVet, they trating ability of doxycycline in University of Wisconsin should brush the gingival crevicular f uid as Madison, WI 53706

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magentablackcyanyellow ES459551_vetm0714_232.pgs 06.25.2014 23:33 ADV This month, 3 cases of corneal ulcer.

But only 1 Buster.

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*When compared to clients without pet insurance. Source: VPI® Consumer Awareness & Usage Study, 2013. Insurance plans are of ered and administered by Veterinary Pet Insurance Company in California and DVM Insurance Agency in all other states. Underwritten by Veterinary Pet Insurance Company (CA), Brea, CA, an A.M. Best A rated company (2012); National Casualty Company (all other states), Madison, WI, an A.M. Best A+ rated company (2012). ©2014 Veterinary Pet Insurance Company. Veterinary Pet Insurance, VPI, and the VPI logo are service marks of Veterinary Pet Insurance Company. Nationwide Insurance is a service mark of Nationwide Mutual Insurance Company. 14VET2728_VETECON

magentablackcyanyellow ES460566_VETM0714_233_FP.pgs 06.26.2014 17:22 ADV magentablackcyanyellow ES460573_VETM0714_234_FP.pgs 06.26.2014 17:23 ADV CVC HIGHLIGHT Get the most laboratoryOUT OF work YOUR Analyze these pointers about how to not be so routine about this routine form of testing. By Adam Birkenheuer, DVM, DACVIM, PhD ou run and review the analysis. Here are a few com- f nd in the laboratory data. results of complete blood mon areas you might overlook. In many ways the laboratory Ycounts and serum chemis- data should be conf rmatory, try prof les all the time. But im- Have a hypothesis not exploratory. T e very best portant conclusions may elude Always have a hypothesis or clinicians are thinking two or you if you rush through your prediction about what you will three steps ahead. Not only do they have a hypothesis about what they will f nd, they already know what they will do next based on whether or not their hypothesis was correct. Keep your hypothesis in mind while interpreting the laboratory data. Even if your hypothesis is not true, it helps you understand what you know about your patient and you have important information to communicate to the client.

Don’t forget the total protein Many commercial veterinary laboratories don’t include a total protein (or total solids) concentration on a complete blood count (CBC), which makes it dif cult to interpret the packed cell volume (PCV) in an anemic animal. I suggest

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that you determine a PCV and reviewing your patients’ blood to get a preantibiotic sample for total protein concentration on smears. In my opinion, on a PCR testing or checking some- every sample before you send it CBC, an experienced indi- thing that wasn’t on the original to the laboratory. vidual should always look at a laboratory work. It’s better to blood smear in sick patients. have it and not need it than to Run a In-hospital analyzers can need it and not have it. reticulocyte count easily miss important clues or If you follow the advice above even the diagnosis. T ey can’t Don’t fear and measure a PCV and total identify nucleated red blood the ﬂ ow sheet protein concentration before cells, spherocytes, schistocytes, Take full advantage of tech- you send a sample to the labora- Babesia species, Cytauxzoon nology and critically evaluate tory, you will know to order a re- species, Ehrlichia species, laboratory work, especially data ticulocyte count right of the bat. bands, immature granulocytes, collected during wellness evalu- Another excellent option is toxic changes, and much more. ations. Trends are often appar- ref ex testing. T is is an option You can train your staf ent long before your patient that most commercial laborato- to help in analysis with little shows signs of illness. Decreas- ries will set up for your hospital. ef ort. You likely send at least ing renal function is frequently Basically, any CBC you submit one CBC a week to a reference identif ed by gradual increases that has a PCV below the refer- laboratory. Before you send in creatinine concentrations or ence interval (or a PCV value of out the sample, have your staf persistent isosthenuria before it your choosing) will automatical- members perform their own exceeds the reference interval. ly trigger a reticulocyte count. white blood cell dif erential T is may gain you as much as and comment on morphol- Look past two days’ time working up the ogy. When the analysis comes the Hs and Ls case. Some reference laborato- back from the laboratory, make Unfortunately, reference inter- ries already report reticulocyte sure you are “giving them a vals can’t always tell the entire counts on every CBC. grade” and rewarding good story. Many reference intervals performances, or they won’t be are created using apparently Never invested in getting better. T is healthy pets that can have sub- trust a will be incredibly helpful when clinical disease. Some values Hear all about it! computer you need a sample interpreta- tend to have wide reference Listen to Dr. Birkenheuer In-hospital tion immediately. intervals. Examples include explain the relevance of analyzers have serum albumin, globulin, and Occam’s razor in lab work come a long Get more blood than creatinine concentrations: by scanning the QR code way since you think you need • Many albumin reference below or visiting dvm360 the days of Don’t fear the jugular vein (un- intervals include values below .com/CVC14Birkenheuer. the Coulter less a patient has a bleeding dis- 3 g/dl and over 4 g/dl. Any counter. But order). Get an extra EDTA tube albumin concentration below there is no and serum in case your empiri- 3 g/dl raises a red f ag for me substitute for cal treatments don’t work. We and prompts a search for de- an experienced save every sample for at least creased production or loss. technologist seven days. I can’t tell you how • Globulin intervals are often or pathologist many times we have gone back even wider, and panhypo-

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proteinemia is often missed When I see a PCV toward examination. T e urinary tract because the low end of the the lower end of the reference is a frequent source of inf am- reference interval is ≤ 2 g/dl. interval, I think hard about mation or infection, and the Any globulin concentration decreased production, destruc- kidneys are common bystand- ≥ 3.6 g/dl might indicate tion, or loss of red blood cells. ers that can be injured in times an inf ammatory or even a Some platelet count reference of crisis. Examining an air-dried neoplastic process. intervals dip below 200,000/ modif ed Wright’s-stained • Never ignore a high normal μl. Platelet counts ≤ 200,000/μl urine sediment increases both or mildly increased creati- always raise a red f ag for me. sensitivity and specif city of nine concentration since you bacterial identif cation. have to lose 75% of kidney Don’t forget function before creatinine the urinalysis Adam Birkenheuer, DVM, becomes elevated. A complete urinalysis can hold DACVIM, PhD a treasure trove of information. Department of Clinical Sciences Troublesome reference inter- A dipstick and specif c grav- College of Veterinary Medicine vals on a CBC include hemato- ity are great, but sick animals North Carolina State University crit/PCV and platelet counts. should always have a sediment Raleigh, NC 27607

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Eyelid laceration REPAIR: A step-by-step guide Use care when repairing lacerations of the eyelid to ensure that functionality of the eye and cosmetic appeal are maintained for the patient. By Juliet R. Gionfriddo, DVM, MS, DACVO he surgical repair of eyelid lacerations need to maintain a functional eyelid and ensure a dif ers somewhat from that of most skin cosmetic outcome as well as the fact that the eyelid Tlacerations. T e reasons for this include the is more vascularized than many other skin regions.

238 | July 2014 | Veterinary Medicine | dvm360.com GETTY IMAGES/IANG

magentablackcyanyellow ES459595_vetm0714_238.pgs 06.25.2014 23:36 ADV PROVEN efficacy. PROVEN SAFETy. PURRING.And a whole lot of

Protect cats with safe, effective broad-spectrum parasite control.

in Flea and Heartworm Protection*

IMPORTANT SAFETY INFORMATION: Do not use REVOLUTION on sick, weak, or underweight cats. Use only on cats 8 weeks and older. Side ef ects may include digestive upset and temporary hair loss at application site with possible inﬂ ammation. In people, REVOLUTION may be irritating to skin and eyes. Wash hands after use. See Brief Summary of full Prescribing Information on page 240.

magentablackcyanyellow ES460572_VETM0714_239_FP.pgs 06.26.2014 17:23 ADV SKILLS LABORATORY peer-reviewed ® (selamectin) Topical Parasiticide For Dogs and Cats BRIEF SUMMARY: See package insert for full prescribing information. CAUTION: US Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATIONS: Revolution is recommended for use in dogs six weeks of age or older and cats eight weeks of age and older for the following parasites and indications: Dogs: Revolution kills adult fleas and prevents flea eggs from hatching for one month and is indicated for the prevention and control of flea infestations (Ctenocephalides felis), prevention of heartworm disease caused by Dirofilaria immitis, and the treatment and control of ear mite (Otodectes cynotis) infestations. Revolution also is indicated for the treatment and control of sarcoptic mange (Sarcoptes scabiei) and for the control of tick infestations due to Derma centor variabilis. Cats: Revolution kills adult fleas and prevents flea eggs from hatching for one month and is indicated for the prevention and control of flea infestations (Ctenocephalides felis), prevention of heartworm disease caused by Diro filaria immitis, and the treatment and control of ear mite (Otodectes cynotis) infestations. Revolution is also indicated for the treatment and control of roundworm (Toxocara cati) and intestinal hookworm (Ancylostoma tubaeforme) infections in cats. WARNINGS: Not for human use. Keep out of the reach of children. In humans, Revolution may be irritating to skin and eyes. Reactions such as hives, itching and skin redness have been reported in humans in rare instances. Individuals with known hypersensitivity to Revolution should use the product with caution or consult a health care professional. Revolution contains isopropyl alcohol and the preservative butylated hydroxytoluene >>>1. A lower eyelid (BHT). Wash hands after use and wash off any product in contact with the laceration in a horse. skin immediately with soap and water. If contact with eyes occurs, then flush eyes copiously with water. In case of ingestion by a human, contact Notice how narrow a physician immediately. The material safety data sheet (MSDS) provides more detailed occupational safety information. For a copy of the MSDS the lacerated eyelid or to report adverse reactions attributable to exposure to this product, tissue piece is near the call 1-888-963-8471. Flammable - Keep away from heat, sparks, open flames or other sources lateral canthus. The of ignition. eyelid has an excellent Do not use in sick, debilitated or underweight animals (see SAFETY). blood supply, so there PRECAUTIONS: is no need to trim off Prior to administration of Revolution, dogs should be tested for existing 1 heartworm infections. At the discretion of the veterinarian, infected dogs this piece unless it is should be treated to remove adult heartworms. Revolution is not effective against adult D. immitis and, while the number of circulating microfilariae obviously necrotic. may decrease following treatment, Revolution is not effective for microfilariae clearance. Hypersensitivity reactions have not been observed in dogs with patent heartworm infections administered three times the recommended dose of Revolution. Higher doses were not tested. ADVERSE REACTIONS: Background than one-third of the eyelid margin Pre-approval clinical trials: Following treatment with Revolution, transient localized alopecia with or A functional upper eyelid is essen- is missing cannot be repaired by without inflammation at or near the site of application was observed in approximately 1% of 691 treated cats. Other signs observed rarely ()0.5% of 1743 treated cats and dogs) included vomiting, loose stool or diarrhea tial to maintain the health of the primary closure but require the use with or without blood, anorexia, lethargy, salivation, tachypnea, and muscle tremors. Post-approval experience: globe itself. If the eyelid is incom- of a grafting technique to establish a In addition to the aforementioned clinical signs that were reported in pre-approval clinical trials, there have been reports of pruritus, urticaria, plete or immobile, it is unable to functional eyelid. T us, in order to erythema, ataxia, fever, and rare reports of death. There have also been rare reports of seizures in dogs (see WARNINGS). physically protect the eye and is maintain eyelid function, débride- SAFETY: Revolution has been tested safe in over 100 different pure and mixed breeds of healthy dogs and over 15 different pure and mixed breeds of unable to spread the tear f lm over ment of wounds must be minimal. healthy cats, including pregnant and lactating females, breeding males and females, puppies six weeks of age and older, kittens eight weeks of age and older, and avermectin-sensitive collies. A kitten, estimated to be the ocular surface. 1 5–6 weeks old (0.3 kg), died 8 ⁄2 hours after receiving a single treatment of Revolution at the recommended dosage. The kitten displayed clinical In most species, the upper eyelid signs which included muscle spasms, salivation and neurological signs. Surgical considerations The kitten was a stray with an unknown history and was malnourished and underweight (see WARNINGS). is more mobile and, therefore, more Cosmesis is an important factor DOGS: In safety studies, Revolution was administered at 1, 3, 5, and 10 times the recommended dose to six-week-old puppies, and no adverse reactions were observed. The safety of Revolution administered orally also was important in protecting the eye than when performing eyelid surgeries. tested in case of accidental oral ingestion. Oral administration of Revolution at the recommended topical dose in 5- to 8-month-old beagles did not cause the lower eyelid. Animals that are Owners may carefully inspect wound any adverse reactions. In a pre-clinical study selamectin was dosed orally to ivermectin-sensitivetext_sans_indent collies. Oral administration of 2.5, 10, and 15 mg/kg in this dose escalating study did not cause any adverse reactions; how- unable to spread tears have a severe closures and look at their dogs’ eyes ever, eight hours after receiving 5 mg/kg orally, one avermectin-sensitive collie became ataxic for several hours, but did not show any other adverse keratoconjunctivitis even though on a daily basis. Although it may be reactions after receiving subsequent doses of 10 and 15 mg/kg orally. In a topical safety study conducted with avermectin-sensitive collies at 1, 3 and 5 times the recommended dose of Revolution, salivation was observed in they may have normal tear produc- functional, a poorly aligned eyelid is all treatment groups, including the vehicle control. Revolution also was administered at 3 times the recommended dose to heartworm infected dogs, and no adverse effects were observed. tion (as measured by Schirmer tear often a constant reminder of “sloppy CATS: In safety studies, Revolution was applied at 1, 3, 5, and 10 times the recommended dose to six-week-old kittens. No adverse reactions were tests). T is causes severe drying of the work” to an owner. T us, every ef ort observed. The safety of Revolution administered orally also was tested in case of accidental oral ingestion. Oral administration of the recommended topical dose of Revolution to cats caused salivation and intermittent cornea, which often leads to nonheal- should be made to achieve the most vomiting. Revolution also was applied at 4 times the recommended dose to patent heartworm infected cats, and no adverse reactions were observed. ing corneal ulcers and eventually loss cosmetic closure possible. In order In well-controlled clinical studies, Revolution was used safely in animals receiving other frequently used veterinary products such as vaccines, anthelmintics, antiparasitics, antibiotics, steroids, collars, shampoos and of corneal integrity. Because of this, to do this, using magnif cation and dips. STORAGE CONDITIONS: Store below 30°C (86°F). all full-thickness eyelid lacerations bright light is recommended for HOW SUPPLIED: Available in eight separate dose strengths for dogs and cats of different weights (see DOSAGE). Revolution for puppies and kittens must be repaired surgically, either by suturing as well as the use of appro- is available in cartons containing 3 single dose tubes. Revolution for cats and dogs is available in cartons containing 3 or 6 single dose tubes. primary closure or by grafting. priate ophthalmic instruments. NADA 141-152, Approved by FDA In most dogs, except those with re- Fortunately, the eyelids are highly

Distributed by: dundant eyelids (e.g. Shar-Peis, basset vascularized, so primary closure may Zoetis Inc. www.revolutionpet.com Kalamazoo, MI 49007 10309504 hounds), lacerations in which more be achieved more ef ectively than in

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other cutaneous regions. Small, T e downside of having this ing. T e objectives of all eyelid triangular-shaped f aps of skin blood supply is that the eyelids laceration repairs are to achieve that might necrose elsewhere will bleed markedly when cut, the best possible alignment, to often survive quite well in the which may obscure visualization protect the eye from further eyelid (Figure 1). T is allows for of the surgery site. trauma during suturing, and the salvaging of skin that would Reconstruction of an eyelid keep any suture material from need débridement in other less- after a traumatic laceration can rubbing on the cornea once the vascularized cutaneous lesions. be straightforward or challeng- repair is complete.

Step 1 Anesthetize the animal, and assess the wound for a veterinary ophthalmology specialist for eyelid feasibility of closure by primary suturing. If this laceration closure is always appropriate and must is not possible, the animal should be referred for be of ered to owners in patients with large eyelid eyelid grafting and reconstruction. Referral to lacerations or marked loss of eyelid tissue.

Step 2 Only minimal, gentle clipping and cleaning should be performed. Place topical, ocular lubricant ointment in the eye to protect it during this process. Manually remove large clumps of hair and debris, and f ush out f ne debris using gentle irrigation with sterile saline solution. Cut the eyelashes with small scissors coated with ophthalmic ointment to catch the cut hairs. After clipping, gently clean the area with 2 dilute (1:2) baby shampoo followed by dilute (1:50) povidone-iodine solution (do not use an iodine scrub) (Figure 2). Special ocular drapes that stick on the skin (Figure 3) or disposable paper drapes from which a hole a little larger than the size of the eye has been cut can be used to cover the face.

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Step 3 A one- or two-layer closure can be performed. I prefer a two-layer closure because I think this method provides the best strength and apposition. T e f rst layer of closure is the muscle and subcutaneous tissue. Use small-gauge absorbable suture material, such as 5-0 Dexon (Covidien) or Vicryl (Ethicon), in a simple con- tinuous pattern. (T ese suture materials have a small swaged needle.) Place the f rst suture in this layer close to the eyelid 4 margin so that it exactly apposes the two sides. Some- times this requires minor trimming, as one side of the laceration may be longer and thinner than the other. In some cases (e.g. oblique laceration), one side of the lacerated eyelid skin margin can be slid slightly over the other. While suturing this layer, it is important to make sure that the suture material stays in the subcutaneous and subconjunctival tissues and does not penetrate the conjunctiva. T e knots on either end of the laceration should be buried in the tissue and should never rub on the cornea (Figure 4).

Step 4 Closure of the skin is important to the strength and cosmesis of the eyelid. I use 5-0 nylon suture material in the skin layer, but many people use 5-0 silk. First, close the eyelid margin, apposing the edges precisely (Figures 5 & 6). You can align the margin manually and place a suture in the 5 skin directly anterior to the margin. T is has to be done with great care so as not to place a knot in a position where it can rub on the cornea. T e margin in this illustration has been closed with a suture whose knot is just below the eyelid margin, and the ends are cut very short so as not to rub on the cornea. T is method should not be used if there is a tendency for the eyelid to roll in after the surgery, as the knot could rub on the cornea. T e remainder of the eyelid is closed with a simple interrupted suture pattern. 6

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Step 4, cont’d An alternative to this method is the f gure-of-eight suturing pattern (Figure 7). T is method is more dif cult to place but is safer in that it allows you to tie the marginal knot well below the margin. It is very important when using this method to not take large bites and to place the sutures at exactly the same points away from the eyelid margins on each side of the suture line. 7

After placing the f rst knot, the rest of the defect is closed with a simple interrupted pattern (Figure 8). T e suture ends closest to the eyelid can be cut very short so they do not rub on the eye. Alternately, they can be left long and caught up in the sutures distal to it. T e secret to obtaining perfect alignment of the eyelid is to use 8 small suture material, take small bites, and place the sutures relatively close together. T is allows you to “take up” small areas where the skin might wrinkle.

Continued on page 244 >

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Postoperative care T e completed repair should achieve perfect alignment (Figure 9). Aftercare includes the administration of broad-spectrum systemic antibiotics and a topical triple antibiotic ophthalmic ointment three to four times daily in the af ected eye. T e patient should have an Elizabe- than collar in place to prevent rubbing of the suture line, which could lead to loosening of the sutures, swelling, infection, and corneal laceration.

Juliet R. Gionfriddo, DVM, MS, DACVO 9 Department of Clinical Sciences College of Veterinary Medicine and Biomedical Sciences Colorado State University Fort Collins, CO 80523

Perfect your ophthalmology surgical skills with hands-on CE Sign up for the Eyelid and Corneal Repair Surgeries Clinical Techniques Course at the SHOW YOUR SUPPORT FOR CVC in Kansas City, Sunday, Aug. 24. Veterinary TRAP-NEUTER-RETURN ophthalmologist Dr. Reuben Merideth will provide step-by-step instructions on entropion It’s easy, visit www.alleycat.org/Veterinary and add your correction, eyelid reconstruction, prolapsed name to the hundreds of veterinarians who endorse TNR! third eyelid gland replacement, and much more. Sign up at thecvc.com/kc.

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More articles… Ouch! How do you know your feline patient hurts? Watch for subtle signs in the veterinary hospital—and educate clients to recognize common changes in behavior at home, says Ilona Rodan, DVM, DABVP. dvm360.com/CVCFelinePain

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248 | July 2014 | Veterinary Medicine | dvm360.com GETTY IMAGES/MARSER, RICARDO’S SNAPSHOT

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The TOPICAL ALTERNATIVE for flea and tick control that lasts 8 MONTHS

THE PERFORMANCE YOU EXPECT FROM A TOPICAL, IN AN EASY-TO-USE COLLAR. *Achieves 100% efficacy against fleas within 2 days of treatment and maintains efficacy above 90% for over 7 months. After day 2, 97.7 – 100% efficacy against I. scapularis (dog) and A. americanum (cat) was achieved for 8 months.1

» Bayer’s sustained release technology combines two effective active ingredients, IMIDACLOPRID + FLUMETHRIN » Kills ticks on DOGS OR CATS within 48 hours and repels and kills reinfesting ticks on dogs in as quickly as 6 hours » Quickly kills fleas on DOGS OR CATS within 24 hours and reinfesting fleas within 2 hours

1Data on file.

magentablackcyanyellow ES460587_VETM0714_CV4_FP.pgs 06.26.2014 17:24 ADV