Insulin Errors How to avoid common errors that can impede treatment success in dogs and cats with diabetes. See page 29.

Critical News, Expert Insights in Animal Health and Medicine 5.18 | V. 3 | N. 4

AVMA PURDUE Respiratory Unique Aspects Complications of Feline of Trauma Lymphoma raumatic injury can result in ymphoma is different in cats multiple respiratory complica- than in dogs, emphasized Jenni- Ttions, according to Lori Waddell, L fer Pierro, MS, DVM, DACVIM DVM, DACVECC, clinical professor of (Oncology), an oncologist at Veterinary critical care medicine Cancer Group in Los Angeles, Califor- at the University of nia. Presenting at the 2017 Purdue Vet- Pennsylvania School erinary Conference in West Lafayette, of Veterinary Medicine Indiana, Dr. Pierro discussed updates (PennVet) in Phila- in feline lymphoma and shared some delphia. At the 2017 unique aspects of how the disease dif- American Veterinary fers in cats compared with dogs. Natalie Stilwell, DVM, MS, PhD Medical Association In dogs, the typical presentation of Convention in Indianapolis, Indiana, lymphoma is high-grade multicentric Dr. Waddell drew from her years of nodal disease. However, cats more specialty training and clinical ex- commonly develop gas- perience to educate the audience trointestinal (GI) lym- on this important topic in emer- SPECIAL FEATURE phoma, typically with- gency medicine. out generalized lym- The various causes of thoracic In Time of Need: Veterinary Practices phadenopathy. Clinical trauma, whether accidental or inten- and Natural Disaster Preparedness signs of lymphoma in tionally caused by abuse, are gener- Nicola M. Parry, BVSc, cats also tend to be ally categorized as blunt or pene- By Don Vaughan MRCVS, MSc, DACVP, ELS nonspecific, mimicking trating, she said. Blunt trauma most s Hurricane Irma menaced South Florida in September 2017, Christina those of a range of other conditions commonly occurs from a fall or Wood’s thoughts turned to her dog, Loki. The 9-year-old mixed breed such as pancreatitis and renal failure. (continued on page 16) Awas so sensitive to loud noises that he would cower under the couch (continued on page 23) during thunderstorms. How, she wondered, would Loki react to hours of deafening wind and rain? “I was afraid it was going to be a rough ride,” recalled AVMA Wood, a freelance writer based in Delray Beach. “I had given Loki Xanax for the ACVC Why “Dental” (continued on page 25) Critical Care Is a Dirty Word INVMA PAIN MANAGEMENT Nutrition bout 75% of dogs and cats seen ritically ill animals require nu- in practice have dental disease, Managing Tramadol: tritional support. Patients with A but how many are receiving Invertebrates Limited Benefit Cchronic diseases also have nu- dental care? Dentistry is one of the for OA Pain tritional requirements that should be most overlooked and underappreciated in Practice addressed as part of their treatment plan. services in veterinary medicine. But it ccording to Jörg Mayer, DVM, ramadol is commonly used in “When patients are critically ill, they can also be one of the most profitable. MS, DABVP (ECM), DECZM, dogs to manage pain associated are constantly in a breakdown state,” At the 2017 American Veterinary A DACZM, associate professor of T with osteoarthritis (OA), a con- said David Liss, RVT, VTS (ECC, SAIM), Medical Association Convention in zoological and exotic animal medicine dition estimated to affect more than CVPM, in a presentation at the 2017 Indianapolis, Indiana, Kris Bannon, at the University of Georgia College 20% of the adult canine population.1,2 Atlantic Coast Veterinary Conference DVM, FAVD, DAVDC, owner of Vete- of Veterinary Medicine in Athens, in- Recent study findings, however, sug- in Atlantic City, New Jersey. Seriously rinary Dentistry & Oral Surgery of vertebrates are becoming increasingly gest that tramadol may offer limited ill patients burn calories constantly. If New Mexico in Albuquerque, urged popular as pets. therapeutic benefit. they do not receive adequate nutrients veterinarians to appreciate what it Presenting at the Indiana Veterinary Tramadol hydrochloride is a weak through feeding, their bodies begin takes to provide quality dental care. Medical Association’s 2018 annual μ-opioid receptor agonist that provides to break down skeletal muscle in an By doing so, she said, your prac- meeting in Indianapolis, Dr. Mayer centrally acting analgesia via 2 major effort to recruit protein. Catabolism tice will see an increase in compli- discussed some common problems in metabolites: O-desmethyltramadol and of protein adversely affects wound ance, staff satisfaction, and revenue. invertebrates and shared some basic N,O-didesmethyltramadol. Although healing, immune function, and strength. (continued on page 19) (continued on page 20) (continued on page 28) (continued on page 14)

AmericanVeterinarian.com Jimmer-focused on soaring to new heights. PROZINC-focused on Jimmer.

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That’s because PROZINC puts diabetic cats fi rst with e cacy proven to improve clinical signs,1 a duration of action appropriate for felines,2,3 and expert veterinary support. Plus, PROZINC is the only veterinary insulin recommended by the AAHA for the initial treatment of diabetic cats.3

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Important Safety Information: For use in cats only. Animals presenting with severe ketoacidosis, anorexia, lethargy, and/or vomiting should be stabilized with short-acting insulin and appropriate supportive therapy until their condition is stabilized. As with all insulin products, careful patient monitoring for hypoglycemia and hyperglycemia is essential to attain and maintain adequate glycemic control and to prevent associated complications. Overdosage can result in profound hypoglycemia and death. Progestogen and glucocorticoid use should be avoided. PROZINC insulin is contraindicated in cats during episodes of hypoglycemia and in cats sensitive to protamine zinc recombinant human insulin or any other ingredients in the PROZINC product.

References: 1. Nelson RW, Henley K, Cole C; PZIR Clinical Study Group. Field safety and e cacy of protamine zinc recombinant human insulin for treatment of diabetes mellitus in cats. J Vet Intern Med. 2009;23(4):787–793. 2. Nelson RW. Disorders of the endocrine pancreas. In: Nelson RW, Cuoto CG, eds. Small Animal Internal Medicine. 4th ed. St. Louis, MO: Mosby Elsevier; 2008:764–802. 3. Rucinsky R, Cook A, Haley S, Nelson R, Zoran DL, Poundstone M; American Animal Hospital Association (AAHA). AAHA diabetes management guidelines for dogs and cats. J Am Anim Hosp Assoc. 2010;46(3):215–224.

PROZINC is a registered trademark of Boehringer Ingelheim Vetmedica, Inc. © 2018 Boehringer Ingelheim Vetmedica, Inc. PRO0315001 18212 NADA 141-297, Approved by FDA ProZinc® (protamine zinc recombinant human insulin)

Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Three cats had injection site reactions, which were described as either small, punctate, red Description: ProZinc® insulin is a sterile aqueous protamine zinc suspension of recombinant lesions; lesions on neck; or palpable subcutaneous thickening. All injection site reactions human insulin. resolved without cessation of therapy. Each mL contains: Four cats developed diabetic neuropathy during the study as evidenced by plantigrade recombinant human insulin 40 International Units (IU) stance. Three cats entered the study with plantigrade stance, one of which resolved by protamine sulfate 0.466 mg Day 45. Four cats were diagnosed with diabetic ketoacidosis during the study. Two were zinc oxide 0.088 mg euthanized due to poor response to treatment. Five other cats were euthanized during the glycerin 16.00 mg study, one of which had hypoglycemia. Four cats had received ProZinc insulin for less than dibasic sodium phosphate, heptahydrate 3.78 mg a week and were euthanized due to worsening concurrent medical conditions. phenol (added as preservative) 2.50 mg The following additional clinical observations or diagnoses were reported in cats during hydrochloric acid 1.63 mg the effectiveness field study: vomiting, lethargy, diarrhea, cystitis/hematuria, upper water for injection (maximum) 1005 mg respiratory infection, dry coat, hair loss, ocular discharge, abnormal vocalization, black pH is adjusted with hydrochloric acid and/or sodium hydroxide. stool, and rapid breathing. Indication: ProZinc (protamine zinc recombinant human insulin) is indicated for the Extended Use Field Study reduction of hyperglycemia and hyperglycemia-associated clinical signs in cats with Cats that completed the effectiveness study were enrolled into an extended use field diabetes mellitus. study. In this study, 145 cats received ProZinc insulin for up to an additional 136 days. Dosage and Administration: USE OF A SYRINGE OTHER THAN A U-40 SYRINGE WILL Adverse reactions were similar to those reported during the 45-day effectiveness study RESULT IN INCORRECT DOSING. and are listed in order of decreasing frequency: vomiting, hypoglycemia, anorexia/ poor appetite, diarrhea, lethargy, cystitis/hematuria, and weakness. Twenty cats had FOR SUBCUTANEOUS INJECTION IN CATS ONLY. signs consistent with hypoglycemia described as: sluggish, lethargic, unsteady, wobbly, DO NOT SHAKE OR AGITATE THE VIAL. seizures, trembling, or dazed. Most of these were treated by the owner or veterinarian ProZinc insulin should be mixed by gently rolling the vial prior to withdrawing each dose with oral glucose supplementation or food; others received intravenous glucose. One from the vial. Once mixed, ProZinc suspension has a white, cloudy appearance. Clumps cat had a serious hypoglycemic event associated with seizures and blindness. The cat or visible white particles can form in insulin suspensions: do not use the product if clumps fully recovered after supportive therapy and finished the study. All cases of hypoglycemia or visible white particles persist after gently rolling the vial. Using a U-40 insulin syringe, resolved with appropriate therapy and if needed, a dose reduction. the injection should be administered subcutaneously on the back o f the neck or on the Fourteen cats died or were euthanized during the extended use study. In two cases, continued side of the cat. use of insulin despite anorexia and signs of hypoglycemia contributed to the deaths. In one Always provide the Cat Owner Information Sheet with each prescription. case, the owner decided not to continue therapy after a presumed episode of hypoglycemia. The initial recommended ProZinc dose is 0.1 – 0.3 IU insulin/pound of b ody weight The rest were due to concurrent medical conditions or worsening of the diabetes mellitus. (0.2 – 0.7 IU/kg) every 12 hours. The dose should be given concurrently with or right after To report suspected adverse reactions, or to obtain a copy of the Material Safety Data a meal. The veterinarian should re-evaluate the cat at appropriate intervals and adjust the Sheet (MSDS), call 1-866-638-2226. dose based on both clinical signs and glucose nadirs until adequate glycemic control has Information for Cat Owners: Please refer to the Cat Owner Information Sheet for more been attained. In the effectiveness field study, glycemic control was considered adequate if information about ProZinc insulin. ProZinc insulin, like othe r insulin products, is not free the glucose nadir from a 9-hour blood glucose curve was between 80 and 150 mg/dL and from adverse reactions. Owners should be advised of the potential for adverse reactions clinical signs of hyperglycemia such as polyuria, polydipsia, and weight loss were improved. and be informed of the associated clinical signs. Potential adverse reactions include: Further adjustments in the dosage may be necessary with changes in the cat’s diet, hypoglycemia, insulin antagonism/resistance, rapid insulin metabolism, insulin-induced body weight, or concomitant medication, or if the cat develops concurrent infection, hyperglycemia (Somogyi Effect), and local or systemic reactions. The most common inflammation, neoplasia, or an additional endocrine or other medical disorder. adverse reaction observed is hypoglycemia. Signs may include: weakness, depression, Contraindications: ProZinc insulin is contraindicated in cats sensitive to protamine zinc behavioral changes, muscle twitching, and anxiety. In severe cases of hypoglycemia, recombinant human insulin or any other ingredients in the ProZinc product. ProZinc seizures and coma can occur. Hypoglycemia can be fatal if an affected cat does not receive insulin is contraindicated during episodes of hypoglycemia. prompt treatment. Appropriate veterinary monitoring of blood glucose, adjustment of insulin dose and regimen as needed, and stabilization of diet and activity help minimize Warnings: User Safety: For use in cats only. Keep out of the reach of children. Avoid the risk of hypoglycemic episodes. The attending veterinarian should evaluate other contact with eyes. In case of contact, immediately flush eyes with running water for at adverse reactions on a case-by-case basis to determine if an adjustment in therapy is least 15 minutes. Accidental injection m ay cause hypoglycemia. In case of accidental appropriate, or if alternative therapy should be considered. injection, seek medical attention immediately. Exposure to product may induce a local or systemic allergic reaction in sensitized individuals. Effectiveness: A total of 187 client-owned cats were enrolled in a 45-day field study, with 176 receiving ProZinc insulin. One hundred and fifty-one cats were included in Animal Safety: Owners should be advised to observe for signs of hypoglycemia (see the effectiveness analysis. The patients included various purebred and mixed breed cats Cat Owner Information Sheet). Use of this product, even at established doses, has been ranging in age from 3 to 19 years and in weight from 4.6 to 20.8 pounds. Of the cats associated with hypoglycemia. An animal with signs of hypoglycemia should be treated included in the effectiveness analysis, 101 were castrated males, 49 were spayed females, immediately. Glucose should be given orally or intravenously as dictated by clinical signs. and 1 was an intact female. Insulin should be temporarily withheld and, if indicated, the dosage adjusted. Cats were started on ProZinc insulin at a dose of 0.1-0.3 IU/lb (0.2-0.7 IU/kg) twice daily. Cats Any change in insulin should be made cautiously and only under a veterinarian’s were evaluated at 7, 14, 30, and 45 days after initiation of therapy, and the dose was adjusted supervision. Changes in insulin strength, manufacturer, type, species (human, animal) or based on clinical signs and results of 9-hour blood glucose curves on Days 7, 14, and 30. method of manufacture (rDNA versus animal-source insulin) may result in the need for a change in dosage. Effectiveness was based on successful control of diabetes, which was defined as improvement in at least one blood glucose variable (glucose curve mean, nadir, or fructosamine) and Appropriate diagnostic tests should be performed to rule out other endocrinopathies in at least one clinical sign (polyuria, polydipsia, or body weight). Based on this definition, diabetic cats that are difficult to regulate. 115 of 151 cases (76.2%) were considered successful. Blood glucose curve means decreased Precautions: Animals presenting with severe ketoacidosis, anorexia, lethargy, and/or from 415.3 mg/dL on Day 0 to 203.2 mg/dL by Day 45, and the mean blood glucose nadir vomiting should be stabilized with short-acting insulin and appropriate supportive decreased from 407.9 mg/dL on Day 0 to 142.4 mg/dL on Day 45. Mean fructosamine values therapy until their condition is stabilized. As with all insulin products, careful patient decreased from 505.9 µmol/L on Day 0 to 380.7 µmol/L on Day 45. monitoring for hypoglycemia and hyperglycemia is essential to attain and maintain Cats that completed the effectiveness study were enrolled in an extended use field study. adequate glycemic control and to prevent associated complications. Overdosage can The mean fructosamine value was 342.0 µmol/L after a total of 181 days of ProZinc therapy. result in profound hypoglycemia and death. Progestogens, certain endocrinopathies and glucocorticoids can have an antagonistic effect on insulin activity. Progestogen How Supplied: ProZinc insulin is supplied as a sterile injectable suspension in 10-mL and glucocorticoid use should be avoided. multidose vials. Each mL of ProZinc product contains 40 IU recombinant human insulin. Reproductive Safety: The safety and effectiveness of ProZinc insulin in breeding, Storage Conditions: Store in an upright position under refrigeration at 36-46°F (2-8°C). pregnant, and lactating cats has not been evaluated. Do not freeze. Protect from light. Use in Kittens: The safety and effectiveness of ProZinc insulin in kittens h as not been evaluated. Manufactured for: Boehringer Ingelheim Vetmedica, Inc. Adverse Reactions: St. Joseph, MO 64506 U.S.A. Effectiveness Field Study In a 45-day effectiveness field study, 176 cats received ProZinc insulin. Hypoglycemia Manufactured by: (defined as a blood glucose value of <50 mg/dL) occurred in 71 of the cats at various Alcami Carolinas Corporation, times throughout the study. Clinical signs of hypoglycemia were generally mild in nature Charleston, SC 29405 (described as lethargic, sluggish, weak, trembling, uncoordinated, groggy, glassy-eyed or ProZinc® is a registered trademark of Boehringer Ingelheim Vetmedica, Inc. dazed). In 17 cases, the veterinarian provided oral glucose supplementation or f ood as © 2016 Boehringer Ingelheim Vetmedica, Inc. All Rights Reserved. treatment. Most cases were not associated with clinical signs and received no treatment. 449901-02 One cat had a serious hypoglycemic event associated with stupor, lateral recumbency, Revised 06/2016 hypothermia and seizures. All cases of hypoglycemia resolved with appropriate therapy Code 449911 and, if needed, a dose reduction. EDITORIAL ADVISORY BOARD

EDITORIAL ADVISORY BOARD

Eric Ako, DVM William Ray Folger, DVM, MS, DABVP Diane Levitan, VMD, DACVIM Lisa Penny, RPh, FSVHP, FACVP Executive Vice President (Feline Practice) (Small Animal) Pharmacy Director Hawaii Veterinary Medical Association Memorial Cat Hospital Peace Love Pets Veterinary Care, PLLC Cornell University Hospital for Animals Honolulu, HI Houston, TX Commack, NY Ithaca, NY

Jan Bellows, DVM, DAVDC, DABVP Jennifer Graham, DVM, DABVP Ellen M. Lindell, VMD, DACVB Amy L. Pike, DVM, DACVB (Canine & Feline Practice) (Avian/Exotic Companion Mammal Veterinary Behavior Consultations Chief, Behavior Medicine Division All Pets Dental Practice), DACZM New York/Connecticut Veterinary Referral Center of Northern Weston, FL Associate Professor of Zoological Virginia Companion Animal Medicine Heidi Lobprise, DVM, DAVDC Manassas, VA Philip J. Bergman DVM, MS, PhD, Department of Clinical Sciences Dental Referral Specialist DACVIM (Oncology) Cummings School of Veterinary Medicine Main Street Veterinary Hospital and Narda G. Robinson, CO, DVM, MS Director, Clinical Studies, VCA Tufts University Dental Clinic President and CEO Oncologist, Katonah-Bedford Veterinary North Grafton, MA Flower Mound, TX CuraCore Integrative Medicine & Center Education Center Bedford Hills, NY Gregg Griffenhagen, DVM, MS, DACVAA Khursheed Mama, DVM, DACVAA United States, Canada Anesthesiologist and Clinical Instructor Professor of Veterinary Anesthesiology Kurt E. Blaicher, DVM, Veterinary Teaching Hospital Department of Clinical Sciences Deborah C. Silverstein, DVM, BS, DABVP (Canine & Feline Practice) Colorado State University College of Veterinary Medicine and DACVECC Blaicher Veterinary Health Care College of Veterinary Medicine and Biomedical Sciences Associate Professor Bedminster, NJ Biomedical Sciences Colorado State University Department of Clinical Sciences Fort Collins, CO Fort Collins, CO University of Pennsylvania Matt Brunke, DVM, CCRP, School of Veterinary Medicine CVPP, CVA Margaret Gruen, DVM, MVPH, Debbie Martin, CPDT-KA, KPA CTP, LVT, Philadelphia, PA Veterinary Orthopedic & Sports PhD, DACVB VTS (Behavior) Medicine Group (VOSM) Duke University Canine Cognition Animal Behavior Technician Karen Todd-Jenkins, VMD Annapolis Junction, MD Center Veterinary Behavior Consultations, LLC Owner, Independent Veterinary Relief Durham, NC Co-owner, TEAM Education in Animal Services Meghan E. Burns, DVM Adjunct Professor, North Carolina State Behavior, LLC Ewing, NJ Connect Veterinary Consulting University Spicewood, TX Kansas City, MO Raleigh, NC Bryan Torres, DVM, PhD, Erica Mattox, CVT, VTS (ECC) DACVS-SA, DACVSMR Hazel C. Carney, DVM, MS, DABVP Don J. Harris, DVM Clinical Manager Assistant Professor of Small Animal (Canine & Feline Practice) Medical Director, Avian & Exotic Species WestVet Orthopedic Surgery Feline Behavior Medicine Clinician Avian & Exotic Animal Medical Center Garden City, ID Director, Motion Analysis Laboratory Westvet Emergency and Specialty Miami, FL University of Missouri Center Emily McCobb, DVM, MS, DACVAA Columbia, MO Garden City, ID Laurie Hess, DVM, DABVP Clinical Associate Professor (Avian Practice) Director, Shelter Medicine Program Huisheng Xie, DVM, PhD Elizabeth J. Colleran, DVM, MS, DABVP Owner and Medical Director Cummings School of Veterinary Owner and President (Feline Practice) Veterinary Center for Birds & Exotics Medicine Chi Institute Cat Hospital of Portland Bedford Hills, NY Tufts University Reddick, FL Portland, OR North Grafton, MA Tracy Jensen, DVM, DABVP (Canine & Michael Dutton, DVM, MS, DABVP Feline Practice) Brook A. Niemiec DVM, (Canine & Feline Practice, Avian/Exotic Founding Partner DAVDC, DEVDC, FAVD Companion Mammal Practice), CVPP Wellington Veterinary Hospital Chief of Staff Owner, Weare Animal Hospital Wellington, CO Veterinary Dental Specialties and Weare, NH Oral Surgery Matthew Krecic, DVM, MS, MBA, San Diego, CA David Dycus, DVM, MS, CCRP, DACVS DACVIM (SAIM) Orthopedic Staff Surgeon Sr. Technical Services Manager Nicola M. Parry, BVSc, MRCVS, MSc, Veterinary Orthopedic & Sports Medicine US Diagnostics DACVP, ELS Group (VOSM) Zoetis Founder, Midwest Veterinary Co-Founder/Co-Director Parsippany, NJ Pathology, LLC For more clinical research, Veterinary Sports Medicine and Lafayette, IN news, conference updates, Rehabilitation Institute (VSMRI) Amanda Landis-Hanna, DVM and video expert advice, visit Annapolis Junction, MD Senior Manager, Veterinary Outreach AmericanVeterinarian.com. PetSmart Charities Phoenix, AZ

Interested in contributing to our magazine by joining our Editorial Advisory Board or by writing an article? Email Associate Editorial Director Maureen McKinney at [email protected].

4 | American Veterinarian® | May 2018 5.18 | V.3 | N.4 CONTENTS

SPECIAL FEATURE

25 In Time of Need: Veterinary Practices and Natural Disaster Preparedness By Don Vaughan Veterinarians are uniquely positioned to help their clients and communities when natural disasters strike. Is your practice ready? Client Handout: Traveling With Pets Page 30

VETERINARY WORLD NEWS CONFERENCE COVERAGE CLINICAL FOCUS DEPARTMENTS

PAIN MANAGEMENT CLINICAL TIDBITS 8 Treatment Options for ACVC Feline Splenic Mast Cell 14 Critical Care Nutrition 28 Tramadol: Limited Benefit 7 Advice and insight from veterinary Tumors for OA Pain experts throughout the country. Nutrition is a vital aspect of treatment planning for hospitalized patients Recent study findings show that Feline Mesenchymal Stem UNIVERSITY REPORT Cells: What’s Known with severe illnesses and those with this popular pain reliever offers no improvement over placebo treatment and What’s Possible chronic diseases. 34 Veterinary Students Stand for elbow and stifle joint pain. Together for Suicide AVMA Awareness ENDOCRINOLOGY 10 Gonadectomy Status and Veterinary students have created Aggression in Dogs 16 Respiratory Complications 29 How to Avoid Common Insulin the #VetMedUnited movement to of Trauma Therapy Errors spread awareness of suicide and Thoracic injury can cause a variety break down the stigma associated Giving proper advice to clients of 11 Tick Exposure and Kidney of complications in the small animal with asking for help. diabetic pets requires an understanding Disease Risk in Dogs patient, including pneumothorax, of the many problems that can result diaphragmatic hernia, and rib fracture. Unregulated Backyard from mistakes made in the choice, use, DISEASE STATE WATCH Chickens Pose Health Risk, and monitoring of insulin. Results Find AVMA 36 This month’s focus: parasitology.

19 Why “Dental” Is a Dirty Word MAKING A DIFFERENCE Providing quality oral care to your 37 Legacy of Love: patients and conveying the value of One Woman’s Journey that care to your clients will improve to Help Domestic compliance, staff satisfaction, and Violence Victims practice profit. Lucy’s Project shines a light on a largely unaddressed—and often INVMA ONE HEALTH unrecognized—issue: animals affected by violence at home. 20 Managing Invertebrates 32 In the Trenches: The in Practice Veterinarian’s Role in the One When veterinarians are presented Health Movement with an invertebrate animal, what By the nature of their knowledge and 12 How “The Pet Effect” Can they need most is an understanding expertise, it is incumbent on veterinarians Affect Your Practice of the husbandry needs and to promote this global initiative and Living Environment behaviors of that particular species. educate medical doctors as equal partners Influences Allergy Risk in improving health around the world. in Dogs, People PURDUE PRODUCT SPOTLIGHT 23 Unique Aspects of Feline Lymphoma 38 A look at some of the latest Diagnosis, treatment, and prognosis and greatest products in of this common cancer are more veterinary medicine. successful with an understanding of the many differences in the disease between dogs and cats.

AmericanVeterinarian.com | 5 CHAIRMAN’S LETTER

EDITORIAL & PRODUCTION Making Connections

Associate Editorial Director Maureen McKinney Editor Amanda Carrozza he prevalence of diabetes mellitus in dogs and chief medical officer of US diagnostics for Zoetis, the Assistant Editor Kerry Lengyel cats is on the rise. According to Banfield’s program features Ruth MacPete, DVM, a practitioner in Copy Chief Jennifer Potash State of Pet Health 2016 Report, the incidence San Diego, California, and Brittney Cirone, a veterinary Copy Editors Maggie Shaw | Rachelle Laliberte T of feline diabetes increased by 18.1% between 2006 technician in Langhorne, Pennsylvania. The group is Senior Art Director Ray Pelesko Designer Wassana Techadilok and 2015—from 57.2 to 67.6 cases per 10,000 cats. joined by Azi Chegini and her 3-year-old dog, Spider, And, although the prevalence is not nearly who has diabetes. SALES & MARKETING as high in dogs, the spike in canine diabetes With the look and feel of an intimate talk Publisher Chris Hennessy incidence over the same time period was show, Pet Connections™ is both informative and Yousef Elhusseini Business Development Manager much more drastic—from 13.1 to 23.6 cases conversational, touching on advances in diabe- Director of Client Relations Kim Long National Accounts Associate Andrew Tornabene per 10,000 dogs, or 79.7%. tes diagnosis and management, and addressing Diabetes in pets requires lifelong care and the concerns of pet owners caring for a diabetic OPERATIONS & FINANCE monitoring. It’s a diagnosis that can be over- animal. The 14 segments in the series range from Circulation Director Jon Severn whelming to pet owners, particularly those 3 to 10 minutes in length and encompass an array [email protected] Vice President, Finance Leah Babitz, CPA who have no familiarity with the disease. To of important topics, including the signs of undiag- Accountant Katherine Wyckoff ensure the best care for these patients, it’s nosed diabetes, the important role of veterinary vital that veterinary teams remain up-to-date on all technicians in the management process, and how to CORPORATE OFFICERS aspects of this disease to provide clients with the best educate pet owners about home monitoring. Chairman and CEO Mike Hennessy, Sr support and most accurate advice on how to manage “One of the things that has changed, one of the things Vice Chairman Jack Lepping President Mike Hennessy, Jr their pet’s condition. we do so much better now than we used to, is monitor- Chief Financial Officer Neil Glasser, CPA/CFE Even with the best intentions, many problems can ing,” Dr. Goldstein explained. “There was a time when I Senior Vice President of Operations Tom Tolvé result from mistakes in insulin choice, handling, or was a resident and the only really reliable piece of data Warren Dardine Chief Marketing Officer administration; errors in monitoring; and inappro- we had was owner perception.” Chief Digital Strategy Officer Steve Ennen Vice President, Editorial Services priate feeding protocols. In this issue, J. Catharine Also included in the program are 2 in-clinic videos and Production Kerrie Keegan Scott-Moncrieff, VetMB, MA, MS, professor of small hosted by Gary Edelson, DVM, owner of Imperial Point Vice President, Digital Media Jung Kim animal internal medicine and head of the Department Animal Hospital of Delray in Delray Beach, Florida. Dr. Chief Creative Officer Jeff Brown Director of Human Resources Shari Lundenberg of Veterinary Clinical Sciences at Purdue University’s Edelson provides viewers with an overview of insulin, College of Veterinary Medicine, outlines how to avoid including how to handle, store, and administer it, and the many common errors that can affect a diabetic pet’s discusses why monitoring is so important. Included response to treatment (page 29). is a demonstration of how to set up, use, and read a As part of our multifaceted approach to providing glucose meter—invaluable hands-on information for pet expert veterinary insight, we’re also proud to announce owners. All of the Pet Connections™ videos are available our inaugural Pet Connections™ video series. This inno- at AmericanVeterinarian.com/Pet-Connections. 2 Clarke Drive, Suite 100, Cranbury, NJ 08512 (609) 716-7777 vative series—the first of its kind in veterinary medi- Of course, diabetes will also be covered in depth at the cine—features candid discussions between pet owners 2018 Atlantic Coast Veterinary Conference. American and veterinary professionals on diseases and conditions Veterinarian® has the great privilege of hosting this affecting companion animals. long-running conference from October 8 to 11 at the Scan the QR code for Diabetes was purposefully selected as the first Pet Atlantic City Convention Center in Atlantic City, New complete back issues, Connections™ topic because of its pervasiveness and the Jersey. Check out ACVC.org for the complete conference clinical and research news, important role the veterinarian-client relationship plays agenda, and be sure to take advantage of early-bird and expert video insight. in ensuring that diabetic pets live long, happy lives. registration, which is available until June 30. The program, which focuses on home management of Thank you for reading! pets with diabetes, is as valuable for veterinary profes- American Veterinarian® is published eight times a year in January, February, April, May, July, August, sionals as it is for pet owners. Moderated by Richard Mike Hennessy, Sr October, and November by Intellisphere LLC, 2 Clarke Goldstein, DVM, DACVM, executive director and Chairman and CEO Drive, Suite 100, Cranbury, NJ 08512. Application to mail at Periodicals prices is pending at Trenton, NJ. Postmaster: Send address changes to American Veterinarian®, 2 Clarke Drive, Suite 100, Cranbury,

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accuracy, timeliness, reliability, or suitability of any of Is Bad Behavior in Dogs Linked to One Health: Canine, Human Cancer the information, including content or advertisements, Get the latest clinical news Owner Personality? Organizations Fund Shared Study Many studies have investigated associations Earlier this week, the American Kennel Club contained in this publication and expressly disclaims between owner personality and canine behavior, Canine Health Foundation and the V Foundation but can a dog owner’s personalityUniversity and mental Audiologistsfor Cancer Research Assess, announced a collaboration to s life are considered liability for any errors and omissions that may be presented Puppy Owners Not Providing Proper health status actually be linked toAssist behavior Hearing-Impairedfund cancer research Animals for dogs. They’re confident

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6 | American Veterinarian® | May 2018 Advice and insight from veterinary experts throughout the country CLINICAL TIDBITS

THE HEALTH RISK OF HERBS MULTIMODAL ANESTHESIA “Several herbs can cause deleterious MISCONCEPTION effects,” says Narda G. Robinson, DO, Gregg M. Griffenhagen, DVM, MS, DACVAA, DVM, MS, FAAMA, president and CEO anesthesiologist and clinical instructor at Colorado of CuraCore Integrative Medicine and State University, says the biggest misconception Education Centers. Some herbs within he hears from other veterinarians about multi- the Chinese medical system can be toxic, modal anesthesia is that they must use it all the including herbal strychnine, which can time. “Multimodal anesthesia or analgesia just harm the nervous system, and aconite, refers to minimizing side effects by combining which is neurotoxic and cardiotoxic. Some herbs dissolve tissue when applied topically, and others, multiple drugs with different sets of pharmaco- such as comfrey and chaparral, could be toxic to the liver when ingested. “Something that is normal for logic actions,” Dr. Griffenhagen says. a person to use, such as tea tree oil, could be lethal for a small dog or cat even when applied topically, “People think they have to use 7 different drugs depending on the amount and its concentration,” Dr. Robinson adds. with 7 different modes of action to accomplish a Her advice: “When asking about medications during a patient history, also inquire about any herbs the single goal.” While he acknowledges that there are pet is taking,” she says. “It’s equally important, however, for veterinarians to understand the pharmaco- certainly patients for which you may need to do logic—and potentially toxic—effects of those herbs and not to rely on folklore and mysticism.” this, “it’s not always necessary. Sometimes a single drug will do just fine to accomplish exactly what you need it to do,” he says.

SEIZURES: WHEN LONG-TERM MEDICATIONS ARE NEEDED There are several indications for starting a long-term medication when a seizure is diagnosed, says Andrew Linklater, DVM, DACVECC, clinical instructor at Lakeshore Veterinary Specialists in Wisconsin. “If a patient presents in status epilepticus, is having cluster seizures, or experiences several seizures over a 3- to 4-month period,” he says, “those are indications that we should start the patient on medication so CARDIOLOGY CONCERNS? we can control the seizures and prevent the CANNABIS IN VETERINARY MEDICINE: DON’T SKIP THIS QUESTION seizure disorder from affecting the patient WATCH YOUR WORDS H. Edward Durham Jr, CVT, RVT, LATG, more frequently later in life.” With few Part of the problem with discussing cannabis- VTS (Cardiology), senior anesthesia techni- exceptions, he says, when a long-term oral based products in the veterinary community cian at Ross University School of Veterinary antiepileptic drug is prescribed, the animal is the misunderstanding that stems from Medicine, says too often veterinary profes- will need to remain on the medication for using improper terminology, according sionals fail to ask about clinical signs the the rest of its life, although the dose and to Stephen F. Cital, RVT, SRA, RLAT, patient displays at night. “Many people even the medication itself may be changed VTS-Lab Animal, who serves on the board forget that orthopnea often presents as the over time. of Phyto Animal Health. “We have to be inability to become comfortable and sleep careful with the term medical marijuana,” he at night,” he says. “Clients will often report says. “Marijuana is a breed of plants we use that their dog is pacing at night or lying INCORPORATING PHEROMONES that has a large THC component that has the down and getting up repeatedly, and that’s TO RELIEVE ANXIETY potential for some pretty negative side effects actually a form of orthopnea.” In failing to Julie Reck, DVM, founder and owner of the that we want to avoid in our companion ask about nighttime habits, a veterinarian Veterinary Medical Center of Fort Mill, South animals.” Instead of marijuana, he advises, might miss subtle signs that a patient might Carolina, says she can’t go a day in practice veterinary professionals should be using the be in or on the verge of heart failure. anymore without using pheromones. “But what’s term cannabis or hemp, each of which is a really beneficial,” she says, “is to layer the pher- plant that has a higher concentration of other omones by diffusing them in the air and placing cannabinoids such as cannabidiol. THE ROLE OF STAFF IN RADIOGRAPHY them directly in contact with patients. Some of the basis for using cannabis in “Performing proper orthopedic examinations and For dogs, her practice uses inexpensive veterinary medicine stems from research getting a diagnosis efficiently hinges a lot on your seasonal fabrics and cuts out bandanas in in human medicine, Cital says. More than support staff,” says W. Preston Stubbs, DVM, 3 sizes. Then, they spray the bandanas with 10,000 studies have been published using DACVS, staff surgeon and owner of Mile High Adaptil and place them on patients. For cats, cannabis products for varying ailments Veterinary Surgical Specialists. Empowering a Feliway-sprayed towel with catnip is applied in people, but the veterinary field is now them to take a good patient history and follow up directly to the front of the carrier. “Before we conducting research on companion animals, on that history is very important. “Your team also started doing this, we had about 20% of cats as well, with studies under way at Colorado needs to be trained to assist in orthopedic exam- willingly come out of their carriers,” she notes. State University and Cornell University, inations, understand proper restraint techniques, “Now it’s 75% to 80%, and it’s amazing how among others. “Veterinarians are demanding and know how to obtain high-quality, well-posi- much better the exam goes when they volunteer research,” he says.

tab62, Vera Kuttelvaserova, kaninstudio, Yakov, greshnikov1973/ Adobe Stock Adobe greshnikov1973/ Yakov, kaninstudio, Kuttelvaserova, tab62, Vera tioned radiographs,” he says. to come out.”

AmericanVeterinarian.com | 7 S 8 By Natalie Stilwell, DVM, MS,PhD Treatment Options for Feline Splenic Mast Cell Tumors 13 years and there was an equal distribution of males and females. females. and of males distribution equal an 13 years was there and was age (n median inclusion met =9). the care that the cats 64 criteria, the Of adjuvant chemotherapy (n =20), chemotherapy alone (n =15), supportive and splenectomy group: to treatment (n according =20),gorized splenectomy with were Cases cate care. supportive as wereproton designated inhibitors pump and blockers histamine and treatment, steroid included Chemotherapy ment. involve MCT and/or visceral cutaneous concurrent included with Cases those splenectomy. after or histopathology cytology via confirmed was MCT diagnosis splenic and signs, gastrointestinal nonspecific Most presented cats with tals. on splenic care MCT outcome supportive and cats. in role to of evaluate the chemotherapy cases of study 64 conducted aretrospective adjuvant chemotherapy andsteroids, furtherincreasesurvival. treatment ofchoice,yet it isunknown whetheradditionaltherapies, including cytemia, anincreaseincirculating mastcells. Splenectomyisconsideredthe The investigators examined patient records from 3 veterinary teaching hospi- teaching 3veterinary from patient records examined investigators The hospitals Recently, US several veterinary of from investigators agroup | S include downregulation ofT-cell activity, reduced expansion andclinicalapplicationincats. cell death. Theseinfected MSClinescanlimitinvitro infect upto 50%offeline MSClines,ultimately causing repair, indamaged andinhibitionoffibrosis organs. include enhancedangiogenesis, tissuegeneration and Biologicalfunctionsoffelineand remodeling). MSCs and celladhesion)CD105(vascular development antigens CD44 (involved surface incell–cellinteractions Feline and fibroblasts MSCs resemble express the cell BIOLOGY ANDIMMUNOLOGY By JoAnnaPendergrass, DVM Feline Mesenchymal Stem Cells:What’s Known and What’s Possible evaluated potential therapeutic the cells’ incats. biology andimmunologyhighlighted that studies whatisknownMedicine, described aboutfeline MSC Davis,University of California, School of Veterinary of pathology, microbiology, andimmunologyatthe DVM, L.Borjesson, BA, MPVM,PhD,professor Dori at TheOhioState University in Columbus,and ofVeterinary cine inthe ClinicalSciences Department PhD, DACVIM, associate professor of internal medi- potential clinicalapplications. easily, they have beenusedcommonlyto evaluate simpleMSCs (aMSCs) are to and proliferate obtain and fetal fat Because adipose-derivedfrom fluid. American Veterinarian The immunomodulatory properties of feline MSCs offeline MSCs properties The immunomodulatory Up to 80% ofcatshave feline foamy which can virus, For review arecent paper, JessicaM.Quimby, DVM, splenic, orintestinal—thisneoplasiatypicallycausesanemiaandmasto- of breedorsex. Generally classified into 1 of3categories—cutaneous, plenic mastcelltumor(MCT)commonlyaffectsgeriatric cats, regardless chymal stem cells(MSCs)have beenisolated in 2002, feline bone marrow from mesen- ince their initial isolation and characterization ® |May 2018 equine, andcanineMSCs. biological andimmunologicfunctionswith human, mediators. Feline many MSCsshare nomodulatory and gene expression immu- ofnumerous upregulation ofreactiveproduction oxygen speciesby neutrophils, dilator and corticosteroid therapydilator with andcorticosteroid noguarantee Feline asthma involves treatment lifelong broncho- Feline Asthma the noted. authors Theautologouscure. aMSCsmay effective, bemore amarkedreported clinicalimprovement andeven or allogeneic aMSCsintravenously incatswith FCGS cells. Investigators who administered autologous B lesions characterized by ofTand apredominance gingivostomatitis diseasewith (FCGS),adebilitating could provide benefit therapeutic for feline chronic abilitytoFeline MSCs’ downregulate T-cell activation Feline Gingivostomatitis Chronic noted. authors the use, clinical for factors of MSC-associated an optimal combination for need the warrants efficacy overall Variable route. administration and dose cell including ciated factors, asso other of variations tested and MSCs allogeneic autologous have and used evaluating this possibility Studies diseases. feline degenerative and mediated, potential fortherapeutic inflammatory, immune- suggest properties Feline immunomodulatory MSCs’ CLINICAL APPLICATIONS - - Evans BJ,et al.Vet Comp Oncol.2018;16(1):20-17.doi:10.1111/vco.12305. supportive care in the outcome the unclear. in splenic of  feline MCT care remains supportive of choice. treatment itsplenic the role The MCT, of chemotherapy making and liver or nodes lymph were to the not metastasis negative factors. and prognostic mastocytemia, sample anemia, size, Despite study’s small the treatment. after of 58 days 10 amedian noted whichwas in of 22mastocytemia, occurred cats, of regression Complete chemotherapy. adjuvant after 1 and alone nectomy causes. tumor-related rates; 70% from died survival increase notdid further 342(856 vs days); however, adjuvant chemotherapy splenectomy adding after or laparotomy. ultrasound abdominal via evaluated cases of the 40% in node lymph involvement samples. aspirate Abdominal noted was or fine-needle presentsamples, liver was 52% respectively, to the in of metastasis biopsy and were 47% noted in 35%MCT. and mastocytemia and of blood evaluated Anemia splenomegaly cutaneous revealed had 30% 44% of concurrent and cats, in (48%), (45%), (42%). vomiting lethargy and Physical examination anorexia The conclusion: Splenectomy significantly improves survival time for cats with for with cats time conclusion:The improves survival Splenectomy significantly 4of 19 sple in MCT 3after regressed cutaneous including cats, Concurrent longer had for asplenectomy that cats significantly was survival Median were weight loss (56%), signs clinical most recorded The commonly - 10.1177/1098612X18758590. Quimby JM,Borjesson DL.JFeline MedSurg . 2018;20(3):208-216.doi: improvement  with aMSCadministration. for acute kidney didnot butresults injury, indicate unproven therapy.” feline anexperimental CKD shouldbeconsidered and “At this time,” the noted, authors “MSCtherapy for aMSCs in cats with variable CKD produced efficacy. mately unrewarding. ofallogeneic IVadministration autologous diseasedcatsisulti- elderly MSCsfrom is not andsufficiently clinicallypractical, expanding determinedtreatment administration that intrarenal ofMSCsfor studies chronic kidneyEarly disease(CKD) Kidney Disease adverse events. improvedthies reportedly clinicaloutcomewith few ofaMSCstoistration catswith chronic enteropa - Intravenoussatisfying clinicalresponses. (IV)admin- donotmanagement leadto andcorticosteroids) for treatments chronic enteropathiesCurrent (dietary Enteropathies Chronic for remodeling acuteairway andchronic asthma. for acute asthma anddecreased hyperresponsiveness showed markedly eosinophiliaand airway reduced evaluating this approach for inducedfeline asthma inflammation.Severaleasing airway pilotstudies administered intravenously canreach the lungs, of adequate diseasemanagement. Notably, MSCs Treatment with aMSCsalsohasbeenevaluated -

to come 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), Lone Star tick (Amblyomma americanum), and Brown dog tick (Rhipicephalus sanguineus) 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: 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 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 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 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. 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). Contraindications: There are no known contraindications for the use of NexGard. 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. 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 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 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 study, and two of those dogs experienced anorexia with the first dose but not subsequent doses. Table 1: Dogs With Adverse Reactions. Treatment Group Afoxolaner Oral active control N1 % (n=415) N2 % (n=200) Vomiting (with and without blood) 17 4.1 25 12.5 Dry/Flaky Skin 13 3.1 2 1.0 Diarrhea (with and without blood) 13 3.1 7 3.5 Lethargy 7 1.7 4 2.0 Anorexia 5 1.2 9 4.5

1Number of dogs in the afoxolaner treatment group with the identified abnormality. 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 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 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, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth. Mode of Action: 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 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’ 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 >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, 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). 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 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 >97% effectiveness against Dermacentor variabilis, >94% effectiveness against Clients want to fi ght fl eas Ixodes scapularis, and >93% effectiveness against Rhipicephalus sanguineus, 48 hours post-infestation for 30 days. At 72 hours post- infestation, NexGard demonstrated >97% effectiveness against Amblyomma americanum for 30 days. and ticks – not their dogs. Animal Safety: 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 Protect dogs with the beef- were sham-dosed. There were no clinically-relevant effects related to 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 fl avored chew they love.1 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. 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 from the concomitant use of NexGard with other medications. Storage Information: 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 size is available in color-coded packages of 1, 3 or 6 beef-flavored chewables. 1Data on fi le at Merial. ® IMPORTANT SAFETY INFORMATION: NexGard is for use in dogs only. The most frequently reported adverse NADA 141-406, Approved by FDA ®NexGard is a registered trademark, and reactions included pruritus, vomiting, dry/fl aky skin, diarrhea, lethargy, and lack of appetite. The safe use of Marketed by: Frontline Vet Labs™, a Division of Merial, Inc. TMFRONTLINE VET LABS is a trademark, of Duluth, GA 30096-4640 USA Merial. ©2016 Merial, Inc., Duluth, GA. All NexGard in pregnant, breeding, or lactating dogs has not been evaluated. Use with caution in dogs with a Made in Brazil. rights reserved. NEX16TRADEADS3 (01/17). history of seizures. For more information, see full prescribing information or visit www.NexGardForDogs.com. ®NexGard is a registered trademark, and TMFRONTLINE VET LABS is a trademark, of Merial. ©2015 Merial. All rights reserved. 1050-4493-03 Rev. 1/2015

xng270940_AV-NG-SoGood-10.75x13.75_rsg.inddNexguard.indd 28 1 8/1/17 3:245:01 PM 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 controlBy of JoAnna Black-legged Pendergrass, tick (Ixodes scapularis), DVM American Dog tick (Dermacentor variabilis), Lone Star tick (Amblyomma americanum), and Gonadectomy Status Brown dog tick (Rhipicephalus sanguineus) 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: and Aggression in Dogs NexGard is given orally once a month, at the minimum dosage of 1.14 mg/lb (2.5 mg/kg). Dosing Schedule: Body Afoxolaner Per Chewables By Natalie Stilwell, DVM, MD, PhD Weight Chewable (mg) Administered 4.0 to 10.0 lbs. 11.3 One 10.1 to 24.0 lbs. 28.3 One onadectomy has historically been recommended as a modifi- 24.1 to 60.0 lbs. 68 One cation method for behavioral issues in both male and female 60.1 to 121.0 lbs. 136 One dogs; however, existing literature provides conflicting informa- Over 121.0 lbs. Administer the appropriate combination of chewables G tion on this method’s level of benefit. According to the authors of a 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 new study, “every prospective, controlled study that examined the lost or if vomiting occurs within two hours of administration, redose with another full dose. If a dose is missed, administer NexGard and resume a monthly dosing schedule. effects of gonadectomy on the aggressive behavior of dogs demon- Flea Treatment and Prevention: strated either no change in aggressive behavior or an increase in 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. aggressive behavior after gonadectomy.” To minimize the likelihood of flea reinfestation, it is important to treat all animals within a household with an approved flea control product. For the present study, the investigators examined the relationship Tick Treatment and Control: Treatment with NexGard may begin at any time of the year (see Effectiveness). between canine gonadectomy and aggression toward familiar people, Contraindications: strangers, and other dogs. Multiple age classes of dogs were exam- There are no known contraindications for the use of NexGard. Warnings: ined using a validated behavioral questionnaire known as the Canine 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. Behavioral Assessment and Research Questionnaire (C-BARQ). 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 Developed by researchers at the University of Pennsylvania, (see Adverse Reactions). Adverse Reactions: C-BARQ is used to assess canine behavior and temperament and can In a well-controlled US field study, which included a total of 333 households and 615 treated dogs (415 administered afoxolaner; 200 evaluate dogs in preparation for service and guide work. The survey 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 reported at an is available online for owners to complete and includes 26 ques- incidence of > 1% within any of the three months of observations are presented in the following table. The most frequently reported adverse tions related to aggression toward familiar humans, strangers, and 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 study, and two of those dogs experienced anorexia with the first other dogs. Questions address various forms of aggressive behavior, dose but not subsequent doses. Table 1: Dogs With Adverse Reactions. including food and toy guarding, behavior toward children, and Treatment Group lunging or barking at others while leashed or in the car. Afoxolaner Oral active control Owner responses to the questionnaire were compiled and exam- N1 % (n=415) N2 % (n=200) Vomiting (with and without blood) 17 4.1 25 12.5 ined. The major variables examined were gonadectomy versus intact Dry/Flaky Skin 13 3.1 2 1.0 status and age at gonadectomy. Dog ages were categorized as follows: Diarrhea (with and without blood) 13 3.1 7 3.5 • Puppy (6 weeks to 6 months) Lethargy 7 1.7 4 2.0 Anorexia 5 1.2 9 4.5 • Juvenile (7 to 12 months)

1Number of dogs in the afoxolaner treatment group with the identified abnormality. • Adolescent (13 to 18 months) 2Number of dogs in the control group with the identified abnormality. • Adult (older than 18 months) 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 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 history of seizures received NexGard and experienced no seizures throughout the study. Survey responses were excluded from the study if signalment or 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. health history information was incomplete or if gonadectomy was merial.com/NexGard. 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. performed either before 6 weeks of age or to correct a behavioral Mode of Action: problem. Answer scores ranging from 0 to 4 categorized aggression 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 level as none, mild, moderate, or severe, respectively. chloride ions across cell membranes. Prolonged afoxolaner-induced hyperexcitation results in 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 C-BARQ questionnaires completed by 15,370 dog owners between the differential sensitivity of the insects and acarines’ GABA receptors versus mammalian GABA receptors. 2004 and 2011 were included in the study. Of the responses, 13,795 Effectiveness: In a well-controlled laboratory study, NexGard began to kill fleas four hours after initial administration and demonstrated >99% effectiveness (89.7%) reported some level of aggression toward familiar people, 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% 13,498 (87.8%) toward strangers, and 13,237 (86.1%) toward other dogs. 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, The investigators determined that gonadectomy status gener- at 12- and 24-hours, respectively). At subsequent evaluations post-infestation, fleas from dogs in the treated group were essentially unable to ally had no effect on aggressive behavior toward familiar people, produce any eggs (0-1 eggs) while fleas from dogs in the control group continued to produce eggs (1-141 eggs). In a 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of NexGard against strangers, or other animals. Similarly, the age at which gonadec- fleas on the Day 30, 60 and 90 visits compared with baseline was 98.0%, 99.7%, and 99.9%, respectively. tomy was performed had no significant relationship with aggressive Collectively, the data from the three studies (two laboratory and one field) demonstrate that NexGard kills fleas before they can lay eggs, thus preventing subsequent flea infestations after the start of treatment of existing flea infestations. behavior. However, the investigators noted that gonadectomy during In well-controlled laboratory studies, NexGard demonstrated >97% effectiveness against Dermacentor variabilis, >94% effectiveness against the juvenile (7 to 12 month) stage correlated with a low but significant Clients want to fi ght fl eas Ixodes scapularis, and >93% effectiveness against Rhipicephalus sanguineus, 48 hours post-infestation for 30 days. At 72 hours post- infestation, NexGard demonstrated >97% effectiveness against Amblyomma americanum for 30 days. (22%) increase in moderate or severe aggression toward strangers and ticks – not their dogs. Animal Safety: 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 compared to aggression levels in intact dogs. (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 According to the results of this study, intact dogs are not more Protect dogs with the beef- were sham-dosed. There were no clinically-relevant effects related to 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 likely to display aggression toward humans or other dogs, and gona- fl avored chew they love.1 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. In a well-controlled field study, NexGard was used concomitantly with other medications, such as vaccines, anthelmintics, antibiotics dectomy is not protective against aggressive behavior. The authors (including topicals), steroids, NSAIDS, anesthetics, and antihistamines. No adverse reactions were observed from the concomitant use of emphasized that canine aggression is likely influenced by a complex NexGard with other medications. Storage Information: combination of factors, including genetics, owner behavior (eg, level Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F). of training and a history of neglect or abuse), lifestyle (isolation vs How Supplied: NexGard is available in four sizes of beef-flavored soft chewables: 11.3, 28.3, 68 or 136 mg afoxolaner. Each chewable size is available in socialization), and medical issues.  color-coded packages of 1, 3 or 6 beef-flavored chewables. 1Data on fi le at Merial. IMPORTANT SAET INORMATION: NexGard is for use in dogs only. The most frequently reported adverse NADA 141-406, Approved by FDA Farhoody P, et al. Front Vet Sci. 2018; 5:18. doi: 10.3389/fvets.2018.00018. ®NexGard is a registered trademark, and reactions included pruritus, vomiting, dry/fl aky skin, diarrhea, lethargy, and lack of appetite. The safe use of Marketed by: Frontline Vet Labs™, a Division of Merial, Inc. TMFRONTLINE VET LABS is a trademark, of Duluth, GA 30096-4640 USA Merial. ©2016 Merial, Inc., Duluth, GA. All NexGard in pregnant, breeding, or lactating dogs has not been evaluated. Use with caution in dogs with a Made in Brazil. rights reserved. NEX16TRADEADS3 (01/17). history of seizures. For more information, see full prescribing information or visit www.NexGardForDogs.com. ®NexGard is a registered trademark, and TMFRONTLINE VET LABS is a trademark, of Merial. ©2015 Merial. All rights reserved. ® 1050-4493-03 10 | American Veterinarian | May 2018 Rev. 1/2015

xng270940_AV-NG-SoGood-10.75x13.75_rsg.indd 1 8/1/17 3:24 PM Nexguard.indd 29 8/1/17 5:01 PM Tick Exposure and Kidney Unregulated Backyard Chickens Pose Health Risk, Results Find More people are raising Disease Risk By Amanda Carrozza chickens today, but are they considering the potential health risks? in Dogs lthough not considered part of the By Kerry Lengyel poultry industry, chicken owner- Aship among US households has ith another higher-than-average tick risen over the past decade. Some poultry season looming, veterinarians should fanatics have even gone so far as to declare prepare for an onslaught of related veter- the chicken the new dog. W But investigators and health advocates inary visits—even pet owners who know about the dangers of tickborne illnesses continue to put off are calling foul. The chief complaint: annual screenings. New study findings aim to When it comes to chickens being raised change that narrative. in homes and backyards, local ordinances Conducting a retrospective study, Idexx inves- and laws do not address human and tigators set out to determine whether exposure to animal health adequately. tickborne disease is associated with an increased Recently, a University of California, Davis risk of chronic kidney disease (CKD) in dogs in (UC Davis), study called for more laws to endemic areas. mandate the proper care of chickens in nonfarm The CDC begs to differ. In an October 2017 report A total of 846,626 canine chemistry and urinal- settings. The study’s primary author, Catherine from the Associated Press, the CDC confirmed that ysis samples were obtained from the Idexx Brinkley, PhD, said current laws for urban farming do more than 1100 people that year had contracted Reference Laboratories database between July not keep pace with those for commercial growers. Salmonella poisoning from chickens and ducks. Almost 13, 2015, and January 17, 2017. Dogs ranged in “Ironically, as people seek to take control over 250 were hospitalized, and 1 person died—an overall age from 1 to 25 years, with all breeds and gen- the way their food is grown, most ordinances fail infection rate that was 4 times higher than in 2015. ders represented. to ensure basic health and welfare for birds and The UC Davis study focused on 100 municipalities For the samples evaluated, patients exposed humans,” she said. in Colorado, the only state to compile public data to infected ticks were defined as having at least It is difficult to pinpoint the number of Americans for animal shelter surrenders and other statistics. 1 positive vector-borne disease test result in their who are raising chickens in urban and suburban According to the investigators, the most common available history. CKD was defined as concurrent environments, but a US Department of Agriculture guidelines for poultry regulations focused on housing increased symmetric dimethylarginine (SDMA; (USDA) survey of homeowners in 4 major US design, placement, and gender. Ordinances pertaining >14 mcg/dL) and creatinine (>1.5 mg/dL) for a cities (Denver, Colorado; Los Angeles, California; to the sex of the birds varied greatly from town to minimum of 25 days with inappropriate urine Miami, Florida; and New York, New York) found that town, with some municipalities banning roosters alto- specific gravity (<1.030) during that time. 0.8% owned chickens in 2013. An additional 4% said gether and others permitting 1 rooster per a certain Patient results were analyzed according to geog- they planned to own chickens in the next 5 years, number of hens; still others had no related laws. raphies known for transmission of both Borrelia and nearly 40% were in favor of allowing chickens in Regulations were also lacking regarding cleanli- burgdorferi and Ehrlichia canis, and then CKD their communities and would not mind if their neigh- ness, ventilation, and food and water requirements. risk was calculated. An association was identi- bors owned the birds. Investigators found that just half of the Colorado fied between dogs with positive Lyme disease or But what are the health ramifications? “Provisions municipalities had ordinances governing the slaughter Ehrlichia test results and an increased risk of CKD governing animal slaughter and routine veterinary of backyard chickens—and many were vague. Even in endemic areas. care are rare, presenting a concern for monitoring with the seemingly slim decrees surrounding chicken The investigators found that dogs from E canis– and intervening in public health crises,” according ownership, Dr. Brinkley said, “more poultry ordi- endemic areas with 1 vector-borne disease had a to the UC Davis study. Yet, although over half of the nances have been passed or modified in Colorado in 300% increased risk of developing kidney disease USDA survey respondents believed that the presence the last five years than in the previous 100.” when Ehrlichia antibodies were present and a of chickens in urban areas will lead to more illnesses Dr. Brinkley recommends passing more laws 43% increased risk when Borrelia antibodies were in humans, most believed that eggs from home- that mandate vaccinations, manure management, present. These results reinforce the need to screen raised chickens are healthier than those purchased and general animal welfare in urban and suburban dogs annually to identify exposure to infected at a grocery store. Just 10.5% of Denver respondents settings—similar to policies and regulations imposed ticks and various tickborne diseases. to the USDA survey strongly agreed with the state- on commercial chicken ranches.  ment that chickens in urban areas will lead to more From a public health perspective, annual Brinkley C, et al. J Commun Health. Published online January 25, 2018. screening is critical to help people better under- illnesses in humans. doi: 10.1007/s10900-017-0462-0. stand potential tick-related risks in their area, as well as help veterinarians provide better care for a discussion with those pet owners to build research. The study design indicated a statistically their pets, according to Jennifer Ogeer, DVM, MSS, compliance around managing and monitoring significant association between tickborne disease MBA, MA, medical affairs marketing manager for that disease earlier, potentially [improving] and CKD but did not allow inference of a causal rela- Idexx Laboratories, Inc. “By doing that, we’re in outcome and maybe even life expectancy for tionship. In addition, the data did not identify the a much better position as veterinarians to iden- these dogs.” time of tick exposure or onset of tickborne disease, tify if these dogs are going to develop kidney The investigators acknowledged several nor did it evaluate clinical presentation, treatment,

Kamil Kurus/ Adobe Stock Adobe Kurus/ Kamil disease,” Dr. Ogeer said. “Then we’re able to have limitations that should be addressed in future or patient outcome. 

AmericanVeterinarian.com | 11 How “The Pet Effect” Can Living Environment Influences Affect Your Practice Allergy Risk in Dogs, People By Kerry Lengyel By JoAnna Pendergrass, DVM

ost pet owners are intuitively • Obesity: Adults who walk their dogs regu- or humans, the relationship between living environment and aware of the many physical and larly may be less likely to become obese. allergies is well established. Interestingly, interactions between Mmental benefits of pet owner- • Blood pressure: People with pets may Fa host’s microbiota and environmental microbes are thought to ship, but backing up these instinctive have lower resting blood pressure. influence allergy development—specifically, urban living decreases beliefs with real data can have a massive • Depression: Pets can help alleviate exposure to immune-modulating environmental microbes, altering a effect—The Pet Effect, to be exact. A joint several symptoms of depression. person’s microbiota and increasing allergy risk. venture by Zoetis and the Human Animal • Posttraumatic stress disorder: Pets help The effect of living environment on canine allergies, though, has Bond Research Institute, The Pet Effect alleviate PTSD symptoms. been rarely studied, even though dogs are the ideal animal model campaign promotes the idea that by for exploring that relationship. Dogs and humans share similar aller- keeping pets healthy, veterinarians and Although those health effects are important, gies such as atopic dermatitis, as well as similar living environments other pet health professionals play key it is at least as vital that veterinarians and lifestyles. Also, compared with laboratory mice, dogs are more roles in both human and public health. understand how The Pet Effect can benefit genetically, physiologically, and clinically similar to humans. “How much more relevant is the veter- their practice. In the age of Dr. Google, pet In a Finnish study that sought to identify environmental risk inarian when the pet owner becomes owners often seek pet care information factors for canine allergies, nearly 6000 dog owners completed a acutely aware of the impact that a healthy from online sources. The Pet Effect has the survey about the allergy histories of their dogs, themselves, and their relationship with a pet can have on their power to change that. “The more the veter- families. The dogs’ histories included details about signs of allergy, own health and well-being or their fami- inarian can educate the pet owner about outdoor activity, and diet, and the investigators used the data to ly’s health and well-being?” asked Michael their pet’s needs, [as well as] how their pet develop scores indicating allergy severity. They also quantified the McFarland, DVM, DABVP, executive director can influence the health and well-being of environmental land use of where the dogs were born and currently of pet care marketing at Zoetis. their family, [the more] that veterinarian lived (urban or rural) and analyzed the role of several lifestyle factors The Pet Effect website (thepeteffect.org) becomes…relevant in the eyes of the pet on allergy scores in dogs. promotes pets’ positive impact on people owner,” Dr. McFarland said. Because breed heavily influences allergy risk and could be a by providing research-backed evidence— The Pet Effect better defines the rela- confounding factor, the investigators controlled for those effects presented in clever, fun, and unique ways— tionship between the veterinarian and by creating 2 study subsets that excluded known allergy-prone of the many health benefits of having a pet owner, and actively discussing breeds: allergy-tolerant breeds and common breeds (the 5 most furry friend. Pets can help people with: The Pet Effect can encourage clients to represented breeds in the study data). • Childhood allergies: Having a dog early schedule more wellness visits for their About 70% of dogs were born in rural areas, and about 50% lived in life can affect immune development pets. Research shows that top-performing in rural and urban environments during the survey period. For dogs and may reduce the development of cer- practices put more stock in improving the with either low or high allergy scores, living in a rural environment tain allergies. human–animal bond than in improving the decreased allergy risk. Birth environment did not influence risk, • Cardiovascular disease: Being around pets bond between the practice and pet owners. possibly because puppies are removed from it at an early age. can lower cholesterol and triglyceride “Companion animal veterinarians…are Several aspects of rural living were associated with lower allergy levels. Also, people who never owned also a key contributor to public health,” scores in dogs: never visiting city areas, outdoor exposure and a cat have a 40% higher relative risk of Dr. McFarland said. “The more pet owners activities, frequent contact with farm animals, and 3 or more chil- death from a heart attack. understand that, the more I think they are dren in the family. The finding on family size could suggest bidirec- • Autism: Children with autism spectrum going to consider veterinarians first and tional protection, the investigators believed, given previous studies disorder often exhibit positive behav- foremost as a credible source of informa- reporting pet dogs’ ability to provide allergy protection. ioral changes when around animals. tion about their pet.”  Analysis of the relationship between house type (farm, house, row house, flat) and allergy score revealed higher scores in urban than in rural areas. However, because house type was significantly associ- The beneficial health effects of ated with both allergy score and living environment, interpretation of pet ownership offer these allergy scores was not clear, the investigators acknowledged. veterinary practices the For dog owners and their families, allergies were more common opportunity to bolster their bottom line. in urban areas than in rural areas. Allergies in dogs and their owners were often present concurrently, even when controlling for breed. The study results suggest that, overall, rural living lowers the risk of allergies in dogs. At the individual level, though, the effect of breed is likely evident, the researchers believed. The similar findings on allergy risk in dog owners indicates a general influence of living environment and lifestyle on mammalian health, the investigators noted. To improve pet health and decrease allergy risk, they recom- mended incorporating more green space into cities to increase time spent outdoors. 

Hakanen E, et al. Nat Sci Rep. 2018;8:1585. doi: 10.1038/s41598-018-19953-3. Robert Stock Hainer/ Adobe

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AmVet-FullPageAd_0418_r2.indd 1 5/1/2018 8:59:25 AM Conference Coverage ACVC

Enteral feeding, such as through a gastrostomy tube, supplies nutrients directly to the digestive tract.

Critical Care Nutrition Nutrition is a vital aspect of treatment planning for hospitalized patients with severe illnesses and those with chronic diseases. By Laurie Anne Walden, DVM, ELS

(continued from front cover) used. Tube selection depends on the patient’s needs. For example, All hospitalized patients should receive nutritional assess- nasoesophageal tubes are intended for short-term use, whereas ment, said Liss, who directs the veterinary technology program gastrostomy tubes can be used long term and require endoscopic at Platt College in Los Angeles and works as a relief intensive or surgical placement. Various calorie-dense diets are available care unit technician at VCA Veterinary Specialists of the Valley for tube feeding. The amount to feed is based on the patient’s rest- in Woodland Hills, California. Nutritional management should be ing energy requirement. included in the treatment plan from the beginning, not added as an afterthought. Parenteral Nutrition LAURIE ANNE WALDEN, Parenteral nutrition, which bypasses the digestive tract, is deliv- DVM, ELS FEEDING ROUTES ered intravenously. This type of feeding is used for patients who Dr. Walden received her Hospitalized patients can receive nutrients through either enteral cannot receive enteral nutrition. Total parenteral nutrition typi- doctorate in veterinary or parenteral feeding. Enteral feeding—nutrition delivered via cally requires a central venous catheter. Patients receiving paren- medicine from North the gastrointestinal tract—is preferred when possible because it teral nutrition need intensive monitoring because of the increased Carolina State University supplies nutrients directly to the cells of the digestive tract. risk of sepsis and metabolic complications. in 1994. After an internship at Auburn University College of Enteral Nutrition NUTRITION IN CHRONIC ILLNESS Veterinary Medicine, Voluntary feeding, force feeding, and tube feeding are all methods Nutrition can be part of the treatment of nearly every disease, she returned to North of enteral feeding. Liss does not recommend force feeding because Liss said. He discussed the nutritional management of 5 diseases Carolina, where she it increases the risk of aspiration and can cause patients to common in veterinary patients. has been in companion animal general practice develop food aversion. Force-fed patients also may not receive the for over 20 years. Dr. intended amount of food, because rejected food tends to be slung Kidney Disease Walden is also a board- onto walls or into towels. However, he noted that oral feeding via Chronic kidney disease (CKD) progresses slowly over time, and certified editor in the life syringe is suitable if a patient readily accepts it. patients may not present for treatment until they are quite sick. sciences and owner of Feeding tubes are helpful for many hospitalized patients, Liss Testing blood symmetric dimethylarginine (SDMA) levels may Walden Medical Writing. noted. Nasoesophageal tubes can be placed noninvasively and are enable practitioners to diagnose the disease earlier, Liss said. usually well tolerated, especially by cats, he added. Nasogastric, The International Renal Interest Society (IRIS) has published esophagostomy, gastrostomy, and jejunostomy tubes can also be guidelines for staging kidney disease. IRIS kidney disease

14 | American Veterinarian® | May 2018 classifications are based on blood creatinine pancreatic enzyme production, exacerbating inflam- Complex carbohydrates and soluble fiber reduce levels, with suggested modifications based on mation. Liss said that this theory was based on results nitrogen production by gut bacteria and therefore blood SDMA concentrations. IRIS treatment from decades-old studies in humans that show that are helpful for patients with liver disease, Liss said. recommendations for each stage include dietary patients with acute pancreatitis became nauseated Patients may also need mineral supplementation. modifications that may mitigate the clinical when they smelled food. However, prolonged fasting However, those with copper storage disease (which effects and slow disease progression. is no longer recommended. is hereditary in Bedlington terriers) or elevated blood Patients with CKD often have hyperphosphate- Current evidence suggests that patients with copper levels secondary to liver disease require mia as a result of decreased renal excretion of phos- acute pancreatitis should receive enteral nutri- dietary copper restriction and possibly chelation ther- phorus. Elevated blood phosphate levels can lead to tion as early as possible. Feeding does not appear apy. Vitamin supplements, particularly vitamins E and secondary hyperparathyroidism. Some patients to worsen nausea or abdominal pain and may help K, may help patients with liver disease. Nutraceuticals, have elevated parathyroid hormone levels even if patients recover, Liss said. Patients with acute such as S-adenosylmethionine, are often part of the they have normal blood phosphate levels. Reducing pancreatitis should first be stabilized and treated treatment plan and have few adverse effects, Liss said. phosphate intake is recommended for patients in all with intravenous fluids and antiemetics. Ideally, but the earliest stage of feeding should begin within Urinary Tract Disorders CKD. Phosphate restric- 48 hours after presentation; Liss discussed 2 dietary modifications for patients tion can be accomplished however, it can be initiated with urinary tract disorders: increasing water in 2 ways: feeding a phos- Nutrition can be part of within 12 to 24 hours in intake and, if applicable, acidifying the diet to help phate-restricted diet and some patients, he said. dissolve stones. Urinary tract diets typically have adding enteric phosphate the treatment of nearly Extremely low-fat diets elevated sodium levels to encourage water drinking, binders to the food. every disease. have traditionally been he said. For this reason, these diets are not suitable Strict dietary protein recommended for dogs for patients who also have heart disease. Liss also restriction is not recom- with acute pancreatitis. discussed increasing cats’ water intake by feeding mended for patients with Liss suggested that unless a canned diet, using a water fountain, or adding CKD, Liss said, as dietary protein deficiency can patients have a known disorder of fat metabo- flavorings to water. lead to muscle wasting. However, mild protein lism (eg, hypertriglyceridemia in schnauzers), Struvite calculi form in alkaline urine. They can restriction may be indicated in some stages. strict fat restriction may not be necessary. Highly often be dissolved over time by feeding a diet that Dietary protein should be highly digestible. digestible diets, preferably with polyunsaturated acidifies the urine and is low in the minerals that Serum potassium levels are often low in patients fatty acids as the fat component, should be used. make up struvites, Liss said. Calcium oxalate calculi with CKD. For this reason, most clinical renal diets Cats with pancreatitis do not require dietary fat form in a wider range of pH levels and cannot be include extra potassium. restriction, he said. dissolved with diet. These stones require surgical Patients with CKD also may develop metabolic Patients with acute pancreatitis often benefit from or other types of physical removal. acidosis, which can be diagnosed with blood gas feeding tube placement. Liss said in his practice analysis. Renal diets usually contain alkaliniz- nasogastric tubes are typically placed in patients with Heart Disease ing agents to help restore the acid–base balance. acute pancreatitis within 1 or 2 days of presentation. Nutritional goals for patients with heart disease Polyunsaturated fatty acids, such as omega-3 fatty include restricting sodium, maintaining protein acids, can help preserve renal blood flow, Liss said. Liver Disease intake, and correcting nutrient deficiencies, Liss They are typically added to clinical renal diets. The liver is responsible for metabolizing and said. Salt intake increases intravascular volume, Because patients with renal disease are polyuric, synthesizing protein. It also regulates the detoxifica- which can lead to pulmonary edema in patients with their stores of water-soluble vitamins, particularly tion process. Dietary protein is the main concern in cardiac insufficiency. The degree of dietary sodium B and C vitamins, become depleted. Some need patients with liver disease, Liss said. Whether dietary restriction depends on the patient’s stage of heart supplementation of B vitamins beyond the levels protein levels should be adjusted depends on the type disease. Because these patients may lose muscle included in renal diets, Liss noted. of liver disease and the patient’s protein tolerance. mass, it is important to ensure that they continue Liss recommended monitoring body condi- Patients with some liver diseases, such as chol- to eat and that their diets contain sufficient protein. tion scores to ensure that patients are receiving angitis and feline hepatic lipidosis, may not need Taurine is a dietary requirement for cats. A defi- sufficient calories. Appetite stimulants, such as dietary protein restriction. In these diseases, the ciency of this amino acid causes dilated cardio- mirtazapine, can help in the short term but are liver does not metabolize amino acids normally. If myopathy. Complete and balanced commercial cat not intended for long-term use. He stressed the patients with these conditions do not receive enough foods include taurine, but cats that eat homemade importance of continuing to monitor calorie intake dietary protein, their bodies will catabolize their or vegetarian diets can develop taurine deficiency. in patients receiving appetite stimulants. “Just own lean muscle for protein, potentially increasing This deficiency can also occur in certain canine because you give mirtazapine and the patient eats blood ammonia levels. If the disease progresses, breeds, so dogs that develop dilated cardiomyopathy a couple of kibbles doesn’t mean it’s eating the full patients who did not need dietary protein restric- may need to have their blood tested for taurine level. caloric requirement,” he said. tion at first may require it later. Omega-3 fatty acids may benefit patients with Patients with portosystemic shunts, congenital heart disease. Some cardiologists recommend fatty Pancreatitis or acquired, require a protein-restricted diet. These acid supplementation, and some diets formulated Pancreatitis occurs when pancreatic enzymes that patients’ livers cannot adequately detoxify ammo- for patients with heart disease contain fatty acids. usually digest food are activated abnormally and nia in the blood. Elevations in blood ammonia can begin autodigesting the pancreas. The disease is cause hepatic encephalopathy, which is character- CONCLUSION often idiopathic, and the inciting causes are not ized by neurologic signs ranging from mild dullness Hospitalized critically ill patients and those with fully known, but dietary fat has not been proven to seizures. Patients with portosystemic shunts or chronic diseases need nutritional support to recover definitely to cause pancreatitis, Liss said. evidence of hepatic encephalopathy also may need from illness and to prevent breakdown of fat and In the past, the mainstay of pancreatitis treatment diets with dairy- or vegetable-based protein rather lean muscle. Nutrition affects outcome in patients was fasting the patient to “rest the gut.” The idea was than meat protein because the former are less likely with chronic illnesses and can be part of the treat- that the taste, or even odor, of food could stimulate to increase blood ammonia levels. ment plan for most conditions.

AmericanVeterinarian.com | 15 Conference Coverage AVMAXXXX

The most common causes of blunt thoracic trauma are falls and vehicle strikes.

Respiratory Complications of Trauma Thoracic injury can cause a variety of complications in the small animal patient, including pneumothorax, diaphragmatic hernia, and rib fracture. By Natalie Stilwell, DVM, MS, PhD

(continued from front cover) Diagnostic Imaging vehicle strike, whereas penetrating trauma may involve a gun- Thoracic radiography is often recommended after suspected shot, knife, or bite wound, or impalement by a foreign object such trauma, but Dr. Waddell noted that ultrasound can be a helpful as a stick or rod. alternative for detecting certain complications, such as pulmo- nary contusions, pneumothorax, hemothorax, and diaphragmatic INITIAL PATIENT ASSESSMENT hernia, in patients that are too unstable for restraint or sedation. Physical Examination Thoracic focused assessment with sonography for trauma NATALIE STILWELL, A thorough physical examination is valuable for identifying and (TFAST) examination serves as a rapid, noninvasive screening DVM, MS, PHD localizing respiratory distress in patients that have experienced tool for triage of the thorax and can be performed in stand- Dr. Stilwell received trauma, Dr. Waddell emphasized. During the initial examination, ing patients or in lateral or sternal recumbency if the patient her DVM from Auburn the veterinarian must determine whether the injured patient is is particularly stressed or compromised. Standard TFAST University, followed hypoxemic or hypoventilating. approaches include diaphragmatic-hepatic and bilateral pericar- by an MS in fisheries Hypoxemia results from ventilation-perfusion mismatch in dial and chest tube sites. “The pericardial and diaphragmatic-he- and aquatic sciences, and a PhD in veterinary the lungs as the lungs fill with blood or fluid. As blood flow to patic views are ideal for detecting smaller volumes of free fluid,” medical sciences the affected area continues, fluid accumulation may prevent she said. The chest tube sites are used to detect pneumothorax as from University of normal ventilation and oxygen exchange from occurring. well as evaluate the lungs. She described normal lung movement Florida. She provides This often results from pulmonary contusion or pleural space as a smooth, gliding motion along the thoracic wall, whereas air freelance medical disease such as pneumothorax, which can result in atelectasis or fluid between the lung and thoracic wall may impair move- writing and aquatic of the lung. ment. Ultrasound can identify pulmonary parenchymal disease veterinary consulting services through her Hypoventilation arises from a variety of causes, including (eg, pulmonary contusion) by the presence of so-called B lines or business, Seastar airway obstruction, pleural space disease, and diaphragmatic rocket tails that look like search spotlights within the lung. Communications hernia, as well as severe neurologic injury to the brain, cervical Although rarely performed on her trauma patients, Dr. Waddell and Consulting. spinal cord, or peripheral nerves innervating the diaphragm and said computed tomography may be a useful diagnostic tool for

intercostal muscles. patients that are stable enough for sedation or anesthesia. coffeemill/ Stock Adobe Thornton. Kim Campbell by provided Images

16 | American Veterinarian® | May 2018 Images provided by Kim Campbell Thornton. bite wounds) necessitates surgical lavage and cleaning. bite cleaning. lavage wounds) and necessitates surgical from (eg, pneumothorax continuous Open suction. with tube placement of a chestcentesis. require may Severe cases also spot.”you’re right the in bit,” fogs up alittle how she “that’s tubing tell you said, can placement the space.cates “When correct pleural into the - indi positive pressure it advances until and to arib cranial syringe and a3-way toattached extension stop-cock, tubing, aneedle inserts site prepped aseptically, veterinarian is the the and or recumbency lateral patient sternal placed is in the After equipment. minimal requires and straightforward is procedure the that reassurance she offering thorax,” said, airways. and vessels peripheral of the visibility decreased and lungs, retracted and collapsed sternum, the position elevated off abnormally heart an Thoracic may radiography reveal appearance. barrel-chested may develop a animal present,a tension is the pneumothorax on physical sounds if exam; lung dull has and breaths shallow rapid, takes patient The typically blunt trauma. thoracic with chest wound present, is but she patients says common in it also is patients.” affected caution she “so extreme in thorax,” said, it with should used be exacerbate ventilation can tension“Positive-pressure pneumo compromise. cardiovascular in lower resulting blood pressure, and heart, to the venous reduce return compress lungs, the can and pressure intrathoracic increases space,thoracic gradually the within buildup due to air progressive occurs cation that hospital 3days later. the from successfully discharged patient wound the closed, was and chest the and lavaged was the under anesthesia, removed was carefully rod The ination. on physical exam distress respiratory minimal in appeared thorax, cranial the impaling rod alarge despite with presenting at acase PennVet recalled that, a2-year-old poodle involving it may collapse. She lead to removing respiratory chest, while the within negative pressure ventilation by aid maintaining ally place object in may actu impaling of impalement, the keeping case the impalement. In or wound, from or knife bite, gunshot, due to a occurs typically pneumothorax Open airways. small or parenchyma pulmonary of the rupture by causing mothorax lead to closed can pneu space. Blunt trauma thoracic pleural the within ventilate negative due pressure to loss normal of the emergency; patient the may not able be to alife-threatening is open pneumothorax An wound. presence ofthe apenetrating aheight. from fall that cats dogs and in observes frequently after being hit by a car experience pneumothorax, experience by hit acar being after bones 45% fractured that to of 50% patientsShe estimated with ( thorax to the blunt trauma from patients suffering in encounters Dr. Waddell complication common most the space—is pleural the in air free of collection abnormal Pneumothorax—an Pneumothorax offered detailsforeach. rax, diaphragmatic hernia,ribfracture,andtrachealinjury. She Dr. Waddell said:pneumothorax,pulmonarycontusion,hemotho- Thoracic traumacanleadtoseveral commoncomplications, COMPLICATIONS OFTHORACIC TRAUMA Most patients with closed pneumothorax will respond to thora will closedMost pneumothorax patients with for treatment pneumo a lifesaving be “Thoracentesis can Dr. whenever Waddell pneumothorax apenetrating suspects compli life-threatening potentially a Tension pneumothorax, on open or as closed, depending classified is Pneumothorax 1 which she Figure 1 Figure ). ). ------by a car had clinically significant hemothorax. significant had clinically by acar hit being from 10% fractures less than that of sustained dogs that however, trauma; indicated after 1study volume of fluid a small Dr. indicate often Waddelltrauma. radiographs thoracic that said complication of thoracic significant but uncommon clinically an is space, or hemothorax, pleural the of bloodAccumulation in Hemothorax she said. it occurs, if only should treated be Pneumonia pneumonia. into develop and overgrow may bacteria prophylactic patients—resistant these using therapy in antibiotic low, is risk the Because added. however, against she advised Dr. Waddell growth, for bacterial medium ideal an as blood serves worsenand bleeding. dramatically blood pressure may increase saline hypertonic and needed, as only should used should be avoided. be Crystalloids and blood products to absorb than more difficult colloids are enter lung.” the Synthetic will fluids “assume administered that contusion,” Dr. pulmonary patients Waddell with therapy in said, fluid choosing acceptable. doses “When are fluid maintenance which after system stabilized, is cardiovascular slowly the until exacerbate and should contusions.administered lung be Fluids blood volume into the may worsen increasing bleeding because caution, with should administered be intravenous fluids that Dr. lung. Waddell the ventilation to recruit warned tive-pressure contusions. pulmonary identifying in aid can TFAST examination fluid. blood-tinged up may contusion blood or cough also pulmonary Patients with exchange. air presence normal of the blood as hinders sounds, lung decrease severe contusions may Also, actually time. with worsen and initially seem minor may sounds lung abnormal that (crackles).sounds She emphasized lung harsh and effort respiratory increased which reveals ination, on physical exam diagnosed cally function significantly. lung normal impair can rhage severe, and associated hemorsevere, associated and to mild from Contusions range pneumothorax. and/or fracture rib with associated often is and most common complicationshe observes of trauma thoracic chest 1 to the (see Figure injury crushing adirect from results usually vasculature nary pulmo to the by caused damage lung the Hemorrhage within Contusion Pulmonary Dr. Waddell estimated. Traumatic rupture typically occurs occurs typically Waddell Traumatic rupture estimated. Dr. patients, 2% to 5% in of trauma occurs hernia Diaphragmatic Hernia Diaphragmatic thoracotomy. emergency necessitates uncommon, although hemothorax, Severe tract. bladder gastrointestinal and urinary the from contamination potential from protected is cavity thoracic the blood in because acceptable an is therapy for volume. hemothorax Autotransfusion low compromise and blood volemic respiratory shock, with Pulmonary contusions can cause pneumonia in rare cases, as as cases, rare cause pneumonia in contusions can Pulmonary Treatment includes oxygen supplementation severe, posi- if and, typi is contusion Pulmonary She patients cautioned may these present that severe hypo in ). Dr. second the is Waddell this said - - - certain complications. certain fordetecting helpful alternative trauma, butultrasoundcanbea recommended aftersuspected Thoracic radiography isoften 1 AmericanVeterinarian. >> 2 - -

17 com | 17 Conference Coverage AVMA

1 1 3

2 Figure 1. (Left) Severe right-sided pulmonary contusions and a small-volume left-sided pneumothorax with collapsed left lung in a dog that was hit by a car. (Right) Pneumothorax in a domestic shorthair cat that fell from a third-story window. Note the retracted lung lobes, especially in the caudodorsal lung fields, and the heart lifting slightly away from the sternum.

Figure 2. Diaphragmatic hernia in a dog that was hit by a car. The diaphragm cannot be seen ventrally, a soft tissue opacity is present in the ventral chest, and the cardiac silhouette cannot be visualized.

Figure 3. Multiple rib fractures (5th-8th) on the left side of the chest in a dog that was hit by a car. Subcutaneous emphysema is also present along the left side of the chest wall. when the patient’s glottis is open and the muscular Dr. Waddell said, “but many patients aren’t so Tracheal Injury portion of the diaphragm is stretched forward, fortunate, and gastric or intestinal dilation within Tracheal injury typically results from pene- making it easier to tear. Abdominal organs then the thorax can be a life-threatening complication trating trauma but can also be seen with blunt herniate through the ruptured portion of the of diaphragmatic hernia.” trauma. A classic clinical sign is subcutaneous diaphragm into the thoracic cavity (Figure 2). emphysema in the neck that can progress to Diaphragmatic hernia is typically diagnosed by Rib Fracture the rest of the body. Patients may also exhibit a a combination of physical examination and imag- Both blunt and penetrating forms of trauma can variety of nonspecific signs, such as respiratory ing. Affected patients usually show increased fracture ribs (Figure 3). The presence of a rib frac- distress, lethargy, gagging, excessive drooling, abdominal effort and distress with respiration. ture always causes Dr. Waddell to search for nearby vomiting, coughing, and shock. Imaging tools, Auscultation may reveal cranially shifted heart soft tissue lesions, she said, including pulmonary including radiography and tracheoscopy, can be sounds and comparatively dull respiratory contusions. On physical examination, animals with helpful for diagnosis. sounds on the injured side of the chest. Although rib fractures are typically painful, exhibit shallow Treatment should be tailored to whether the extremely useful, thoracic radiographs may be respiration, and may have conformational changes patient is stable or compromised, Dr. Waddell said. difficult to obtain until the patient is stabilized. of the chest. Patients with flail chest, which occurs Although oxygen therapy may be adequate for “We use a standing lateral radiographic view or when consecutive rib fractures cause paradoxic mild tracheal defects, surgical repair is usually TFAST ultrasound for particularly compromised chest movement, are especially likely to be hypoxic indicated for severe cases. As with cases of tension patients,” Dr. Waddell said. A gastrointestinal due to extensive contusions and pain. Interestingly, pneumothorax, positive-pressure ventilation can barium series can help identify herniated stom- she noted, patients with flail chest appear to be worsen emphysema and should be avoided during ach or intestine within the thoracic cavity in more comfortable when placed in lateral recum- surgery. Subcutaneous emphysema associated stable patients. bency with the affected side down. with tracheal injury can be resolved more quickly Diaphragmatic hernia should be repaired surgi- Radiographs are key for diagnosis, and Dr. by placing the patient into a 100% oxygen cham- cally once the patient is stable enough for anes- Waddell shared a few tricks of the trade to better ber for approximately 4 hours, she said—oxygen thesia. Dr. Waddell revealed creative methods visualize fractures. For example, she flips film will replace nitrogen in the tissues and absorb for replacing herniated abdominal organs. One radiographs upside down to better focus on the ribs, more quickly. method involves standing the patient on its hind and she inverts the color on digital images to view legs to shift abdominal contents using gravity, bones as black instead of white. REFERENCES which reduces pressure on the lungs. She recalled Dr. Waddell emphasized the importance of 1. Spackman CJ, Caywood DD, Feeney DA, Johnston GR. Thoracic Lucky, a canine patient at PennVet that, after being providing analgesia and managing associated wall and pulmonary trauma in dogs sustaining fractures as a result of motor vehicle accidents. J Am Vet Med Assoc. struck by a vehicle, herniated the entire stomach injuries such as pulmonary contusions. Surgical 1984;185:975-977. through the diaphragm and into the thorax. “Lucky stabilization, including internal fixation to 2. Cockshutt JR. Management of fracture-associated thoracic had a smooth recovery after surgical replacement realign the ribs, may rarely be required for trauma. Vet Clin North Am Small Anim Pract. 1995;25:1031-1046. doi: 10.1016/S0195-5616(95)50102-0. of the stomach and closure of the diaphragm,” severe fractures. Thornton. Kim Campbell by provided Images

18 | American Veterinarian® | May 2018 AVMA

Why “Dental” Is a Dirty Word Providing quality oral care to your patients and conveying the value of that care to your clients will improve compliance, staff satisfaction, and practice profit. By Kerry Lengyel

(continued from front cover) • Open the mouth and check the temporomandibular joint for DON’T CALL IT A “DENTAL” crevices and pain. Dr. Bannon explained that by referring to all dental procedures • Check for malocclusion and related problems. simply as “dentals,” veterinarians are doing a disservice to them- • Count the teeth, checking for missing, fractured, or extra teeth. selves, their staff, and their clients, because “this simplistic term • Look for oral masses, lacerations, and foreign bodies. negates the value of what you are doing.” The word dental is an adjective, she noted. “If you were to say ‘I’m going to do a ‘cardiac’ Scaling above the gum line is an important part of a dental right now,’ what would that mean?” cleaning, she said, but scaling below the gum line is more A good dental cleaning takes time, Dr. Bannon noted. Beyond important. “If you’re not going under the gum line, then you’re lowering the value of the services being provided, the term going to have progression of gum disease,” dental also likely blocks the time incorrectly. Instead, she Dr. Bannon said, “and that’s the spot you suggested several alternate phrases that are easy to record in want to focus on.” a scheduler: Dr. Bannon recommended dedicating One of the most important • Complete dental cleaning (CDC) an anesthesia technician specifically • Comprehensive oral health assessment and treatment (COHAT) for dental procedures and staying on steps in showing the value • Oral assessment, treatment, and prevention (oral ATP) top of blood pressure monitoring, intu- of an oral procedure to • Periodontal therapy and surgery bation, and fluids during the procedure. clients is providing them • Prophylactic (prophy; although this is often a misnomer because While the pet is anesthetized, conduct it’s unlikely that oral disease is being prevented) a detailed physical examination. Use a with the results. probe to wiggle each tooth during the “[In most cases], this is oral surgery,” she said, “and veterinarians exam, Dr. Bannon suggested; otherwise, need to start thinking of it as such.” Portraying it in this light to you won’t pick up subtle mobility. Check pet owners highlights its importance and the amount of time and each tooth for fractures, cavities, irregular surfaces, signs of skill it will take to complete. resorption, and discoloration, and photograph any abnormalities. “There are 42 teeth in the dog mouth, 30 in the cat mouth. That TRAIN YOUR SUPPORT STAFF is 42 different physical exams that you’re doing,” Dr. Bannon “The support staff in dentistry is huge, huge, huge,” Dr. Bannon said. “Palpate the tongue, the palate, the tonsils, the inside of the said. “I could not do my job without my technicians, without my cheeks, the buccal mucosa, the sublingual tissues. This is the support staff. It is important that they are trained well.” best time to examine all that because you’re right there.” In most of the United States, veterinary technicians are not Full-mouth intraoral radiographs should be taken as a baseline, legally allowed to extract teeth, but they can conduct and assist then as needed thereafter, Dr. Bannon said. She urged veterinari- with other aspects of the exam. Dr. Bannon recommended that ans: “Don’t give the owner the option to decline the radiographs.” support staff do 90% of the work during oral procedures, allow- ing the veterinarian to focus on what only he or she can do. Results and Follow-Up “Veterinarians are the ones making the decisions about what One of the most important steps in showing the value of an needs to be done and how it can be of value,” she said, “but the oral procedure to clients is providing them with the results. technicians make the procedure valuable by doing a fantastic job.” “Don’t let the clients pay their bill until you or the technician has talked to them about what was wrong and what was done SHOW CLIENTS THE VALUE to correct the problem,” Dr. Bannon said. Showing the before Most clients are worried about the cost of veterinary dental photos, the radiographs, and the after photos helps clients better care, Dr. Bannon said, but what they really want is value. “Value understand why they now have a $1000-plus bill and makes means quality, which is vastly different than cost,” she said. them more willing to pay it. “Cost is important, but don’t just talk about the bottom line. Talk Dr. Bannon noted that on-site follow-up is important. At her about the value of what they’re getting.” Dr. Bannon laid out a few clinic, this is done at no charge 1 to 2 weeks after the procedure. steps that will help veterinarians show clients the real value of “During the follow-up, let your technicians talk to the client about oral procedures. healing, home care, and helpful dental products.” She also advises her entire team to remind the clients that dental care is an ongo- The Exam ing need. “They have to keep coming back,” she said. Conduct a thorough oral exam before the pet is placed under anes- thesia, checking as much as you can in the awake patient so the CONCLUSION owner is well prepared for what will happen when the pet is anes- If you stop thinking, “It’s just a dental” and remember the im- thetized. “Do a good thorough awake exam and show the owner portant steps of conducting a valuable oral procedure, your what you find,” Dr. Bannon said. clients will be happier and more loyal, your staff will be more • Palpate the extraoral facial features, evaluating for symmetry, excited about coming to work, and your bottom line will pain, and swelling. reflect your success.

AmericanVeterinarian.com | 19 Conference Coverage INVMAXXXX

Managing Invertebrates in Practice When veterinarians are presented with an invertebrate animal, what they need most is an understanding of the husbandry needs and behaviors of that particular species. By Nicola M. Parry, BVSc, MRCVS, MSc, DACVP, ELS

(continued from front cover) this case, do not offer the spider a water bowl because it may be approaches and techniques to help general practice veterinari- weak and could drown in the bowl. Instead, soak a sponge in ans manage these patients. water, he advised, and place it on a dish for the spider to drink When dealing with invertebrates in practice, he explained, from. In severe cases of dehydration, lactated Ringer solution veterinarians must tailor their management approach depend- can be injected to replenish the spider’s fluid levels. ing on whether they are presented with an individual pet animal Dr. Mayer also reminded veterinarians to check invertebrate or a problem in a collection of invertebrates. For an individual patients for mite infestations and to be aware of which inver- NICOLA M. PARRY, animal, the approach is similar to that for a dog or cat. “Examine tebrates carry beneficial symbiotic mites. For example, centi- BVSc, MRCVS, MSc, the patient systematically, just as you would with a mammalian pedes do not carry beneficial mites, he said, so the presence DACVP, ELS patient,” he said. “But when dealing with a collection of inver- of any mites on these animals should prompt the veterinarian Dr. Parry, a board- tebrates, think herd health. You may need to sacrifice a few to check the husbandry conditions. Disinfection of the insect’s certified veterinary pathologist, graduated normal or sick animals as part of your investigation.” environment, and quarantine, might be necessary. from the University He also stressed the importance of knowing the sex of the “And don’t mess around with a tarantula that is shedding,” Dr. of Liverpool in 1997. animal because this can affect the approach to certain health Mayer said. This is a vulnerable time for the animal, and its new After 13 years in problems. For example, the typical life span of a male taran- exoskeleton is very soft. “For a few days, avoid feeding it crick- academia, she founded tula is 2 years, whereas a female can live to age 25. If an owner ets, which may eat the spider’s new soft exoskeleton. Let the new Midwest Veterinary requests help because several tarantulas have died between 18 exoskeleton harden before feeding,” he stressed. Pathology, LLC, where she now works as a months and 2 years of age, the veterinarian will need to investi- Another husbandry-related problem for many invertebrates in private consultant. gate whether the deceased spiders were all female. If they were captivity relates to stress associated with exposure to visitors Dr. Parry writes male, however, the veterinarian can explain that this merely and continual handling. In such cases, an animal may flick its regularly for veterinary reflects the typical life span of a male tarantula. legs as a stress response when it feels threatened. This action organizations and When investigating any health problem, veterinarians results in loss of hair on the dorsal abdomen, which produces publications. should initially examine the animal and its behavior while it bald spots, Dr. Mayer explained. is still in the container, said Dr. Mayer. If the animal needs to Similarly, excessive handling often leads to animals being be handled, veterinarians should do so with care. Be aware dropped. These traumatic incidents can present as emergencies, of the dangers involved in handling invertebrates, including Dr. Mayer said, because the resulting hemolymph loss is a big what weapons (stinger, fangs, etc) they have. “Be gentle and problem. Hemolymph is not contained in vessels in the inver- move slowly—most invertebrates that bite or sting will only do tebrate body, so it just leaks from the traumatized exoskeleton. so if they feel threatened,” he said. “And avoid breath- ing on the animal. A tarantula, for example, sees SIMPLE WOUND REPAIR this as a threat.” The number 1 rule is “do no Dr. Mayer discussed how to repair simple wounds on the exoskel- harm” to either the patient or yourself, Dr. eton of a tarantula. To anesthetize the tarantula, he advised Mayer emphasized. soaking a piece of cotton wool in isoflurane and simply placing it in the container with the spider. Wait about 5 minutes, he added, HUSBANDRY ISSUES until a sufficient plane of anesthesia results. Veterinarians Many diseases of invertebrates should not be too concerned about using too much isoflurane kept as pets are related to poor because this is difficult to achieve in spiders, he added. husbandry, which often is associ- When repairing wounds, veterinarians should avoid using ated with provision of an inappro- sutures, Dr. Mayer said. The spider’s body naturally responds to priate substrate for the animal injury by producing a mold that has wound-healing properties. One important to live on. A substrate that is “Suture material can interfere with shedding of the old mold,” factor to consider too wet may result in fungal he explained. when investigating health concerns in disease, Dr. Mayer said; one that Instead, when repairing wounds on insects or spiders, he invertebrates is sex. is too dry may lead to dysecdysis advised using surgical tissue glue, bone wax, or household (abnormal shedding of the outer superglue to stop hemolymph leakage. skin in reptiles). “Correcting the husbandry issue can often cure CONCLUSION the presenting problem.” To deal effectively with an uncommon species, Dr. Mayer high- Inappropriate husbandry is lighted the need for veterinarians to familiarize themselves common in the spider trade, he said, with what different invertebrates’ behaviors mean in different and often results in dehydration of environments. When faced with an uncommon patient, it is the animals. Dr. Mayer noted that the important to know what normal behavior and body condition abdomen of a healthy tarantula should be look like for that species, he said. Plenty of literature and rounded. A deflated-balloon appearance books are available to help with this, he stressed. “Knowledge

indicates that the animal is dehydrated. In is power.” Stock Daniel/ Adobe Thornton. Kim Campbell by provided Images

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PURDUE

Cats with lymphoma do not respond as well to chemotherapy as dogs do.

Unique Aspects of Feline Lymphoma Diagnosis, treatment, and prognosis of this common cancer are more successful with an understanding of the many differences in the disease between dogs and cats. By Nicola M. Parry, BVSc, MRCVS, MSc, DACVP, ELS

(continued from front cover) do, Dr. Pierro said. “Between 50% and 75% of cats will go into PROGNOSIS remission, but those that go into complete remission can do “The prognostic factors in cats are very frustrating and not better than dogs,” she emphasized. quite as cut-and-dried as in dogs,” Dr. Pierro said. In dogs, She also noted that cats with feline leukemia virus that lymphoma immunophenotype (B cell vs T cell) is the most develop lymphoma are more difficult to treat—and they are about important prognostic factor: “B is better, and T is tougher,” she 40 times more likely to develop lymphoma in the first place. said. However, in cats, different lymphoma immunophenotypes tend to be “associated with different disease locations but don’t SMALL CELL GASTROINTESTINAL LYMPHOMA affect the outcome.” Dr. Pierro noted that affected cats with small cell GI lymphoma According to Dr. Pierro, histologic subtype is an import- typically present with a variety of nonspecific clinical signs, ant prognostic factor in cats, with small cell (also known as including weight loss, appetite changes, vomiting, and diarrhea. low-grade) lymphoma carrying a better prognosis than that Ultrasonographic findings in these cases commonly include of large cell (high-grade) lymphoma. Small cell lymphoma is thickening of the intestinal muscularis layer, altered wall composed of proliferations of mature lymphocytes, and the layering, and lymphadenopathy, she said.1 disease usually has an indolent course. It most commonly Dr. Pierro reminded veterinarians that a diagnosis of small arises in the GI tract but can also occur in other locations, Dr. cell lymphoma cannot be made on the basis of fine-needle Pierro said. aspiration cytology of lymph nodes alone. However, she recom- Disease location is another prognostic indicator, she added. mended still collecting an aspirate from enlarged lymph nodes For example, cats with nasal lymphoma can survive for to rule out other diagnoses such as large cell lymphoma and years, whereas those with renal lymphoma tend to survive mast cell tumor. only months. Definitive diagnosis of small cell GI lymphoma requires Response to treatment is a third prognostic indicator. Cats biopsy, she said, especially to differentiate it from inflammatory with lymphoma do not respond as well to chemotherapy as dogs bowel disease. Biopsy samples can be obtained surgically or >>

AmericanVeterinarian.com | 23 Conference Coverage PURDUE

endoscopically. Endoscopy is less invasive and requires a cystitis in dogs as a result of an inactive metabolite shorter hospitalization time. Although endoscopy allows of the drug, but this does not occur in cats, Dr. Pierro visualization of the intestinal mucosa,2 Dr. Pierro noted said. And although doxorubicin can cause cumulative that it does not allow access to every region of the GI cardiac toxicity in dogs, it does not cause clinical cardiac tract. Because lymphoma may arise only in the ileum in toxicity in cats, she added. However, it can cause cardiac some cats, using endoscopy to obtain biopsies requires muscle damage in cats, which may be seen histolog- both upper endoscopic and colonoscopic approaches.3 ically after postmortem examination. Nevertheless, Additionally, endoscopy does not allow for collection of Dr. Pierro stressed that doxorubicin therapy is associ- full-thickness biopsy samples, she said. ated with renal toxicity in cats and advised veterinarians In addition to enabling collection of full-thickness to monitor urine specific gravity in their feline patients samples from multiple parts of the small intestine, that receive this drug. surgical biopsy allows veterinarians to obtain samples Lomustine tends to be associated with an unpredict- of lymph node and liver, she added. And although the able neutropenia in cats, she noted, compared with a surgical approach is more invasive than endoscopy, more predictable neutropenia in dogs. However, this drug Dr. Pierro noted that cats with lymphoma do not seem causes minimal hepatotoxicity in cats, unlike in dogs. to be at high risk for postoperative dehiscence after Myelosuppression most commonly arises in cats full-thickness GI surgery.4 receiving prednisone and chlorambucil, Dr. Pierro said, although rare cases of idiosyncratic liver toxicity CHEMOTHERAPY PROTOCOLS FOR LYMPHOMA have been reported, as well as 1 case of central nervous Although most dogs will achieve clinical remission system toxicity. with standard-of-care CHOP chemotherapy (vincristine, cyclophosphamide, doxorubicin, and prednisone) for a OTHER UNIQUE LYMPHOPROLIFERATIVE DISEASES median survival time of 1 year, she noted that cats with In concluding, Dr. Pierro also discussed 2 other lymph- large cell lymphoma that receive oproliferative diseases that may arise in cats. CHOP respond to treatment 50% to 75% of the time, with a median Hodgkin-like Lymphoma Definitive diagnosis of small cell survival time of 6 to 9 months. Hodgkin-like lymphoma is similar clinically and histo- GI lymphoma requires biopsy, However, cats with lymphoma logically to Hodgkin lymphoma in humans. It is a local- that do go into remission with ized disease that involves lymph nodes of the head and especially to differentiate it from CHOP frequently outlive dogs that neck and typically carries a relatively favorable prog- inflammatory bowel disease. go into remission, she emphasized. nosis. Histologically, Hodgkin-like lymphoma predom- Data from a 2005 study showed inantly comprises proliferations of small lymphocytes, that overall median survival time along with the presence of characteristic large Reed- of cats treated with CHOP was 7 Sternberg–like cells. Dr. Pierro emphasized that this months, but the median survival time for those achieving form of lymphoma is considered slowly progressive and complete remission was almost 2 years.5 treatment usually involves a combination of surgery, The CHOP protocol is also generally well tolerated in radiation, and, potentially, chemotherapy. cats, said Dr. Pierro. In dogs, doxorubicin is the most effective drug in the CHOP protocol and is sometimes Cutaneous Lymphocytosis used as single-agent therapy. However, single-agent Cutaneous lymphocytosis (also known as pseudolym- doxorubicin does not seem to be as effective for high- phoma) presents as seborrheic and plaque-like lesions grade feline lymphoma as it is for dogs with lymphoma.6 of the skin.8 In some cases, this condition can look like However, a COP-based protocol (vincristine, cyclo- allergic skin disease, Dr. Pierro said. Histologically, cuta- phosphamide, prednisone) has been shown to be effec- neous lymphocytosis comprises proliferations of hetero- tive in many cases of feline lymphoma. And, as with geneous but well-differentiated lymphocytes. Because CHOP protocols, cats that go into clinical remission with the diagnosis is not always cut-and-dried, however, COP chemotherapy can have extended survival times, she advised veterinarians to submit biopsy specimens Dr. Pierro said. to a dermatopathologist for evaluation. This disease Treatment of cats with small cell lymphoma includes progresses slowly, but “we don’t really know how to prednisone and the oral chemotherapy agent chlorambu- treat it,” she noted. As a consequence, no established cil. This protocol has minimal adverse effects, and most treatment protocols exist to help veterinarians manage cats respond well, with a median survival of 1 to 3 years, these cases. However, according to Dr. Pierro, treatment Dr. Pierro said.7 “I find that most of these cats do not die often involves using prednisone and oral chemotherapy because of their lymphoma,” she added. agents. Although chemotherapy may not always be very effective, it may help slow progression of the disease, she CHEMOTHERAPY-ASSOCIATED TOXICITIES added. In general, this disease has a waxing and waning In cats receiving CHOP chemotherapy, “anorexia is nature, but it does not seem to cause many problems by far the most common toxicity that we see,” said Dr. long term, Dr. Pierro said, and most cats with cutaneous Pierro. Dogs receiving CHOP have unique toxicities lymphocytosis can live a long time. associated with cyclophosphamide and doxorubicin, she noted. Cyclophosphamide can cause sterile hemorrhagic References available at AmericanVeterinarian.com.

24 | American Veterinarian® | May 2018 Special Feature

Volunteers with the California Veterinary Medical Reserve Corps examine a burned cat.

In Time of Need: Veterinary Practices and Natural Disaster Preparedness Veterinarians are uniquely positioned to help their clients and communities when natural disasters strike. Is your practice ready? By Don Vaughan

(continued from front cover) Hurricane Irma was just one of several extreme weather events first time on July 4. He was still frightened, but it did help, so I to hit the United States in 2017, a cycle that also included devas- was hoping it might help him through the hurricane as well.” tating wildfires, tornadoes, floods, ice storms, and more. During Wood reached out to her veterinarian, who answered Wood’s such times of need, veterinarians have a unique opportunity to questions about dosing and worked with her to figure out a assist both their clients and their communities, experts say. It medication schedule that would keep Loki calm. “As the storm takes forethought, planning, and dedication, but the end result— approached, I was taking Loki outside to do his business as often happy clients and healthy patients—makes it worth the effort. as I could,” Wood said. “I was afraid that once things really started getting rough, he wouldn’t want to go outside, but the medicine TYPES OF NATURAL DISASTERS was so effective that the rough weather didn’t bother him at all. Natural disasters occur throughout the United States, but some He was running around in the yard, and I was the one anxiously events are more common to specific regions. The South and clinging to the doorframe.” Northeast, for example, face a greater risk from hurricanes, while But there was more: Wood’s 17-year-old domestic shorthair western states such as California traditionally see more wildfires cat, Tut, was on prescription medications for a thyroid condi- and mudslides. In the Midwest, the greatest concerns are torna- tion. That, too, was a concern. “My veterinarian was really good does and winter blizzards, with the latter also affecting the New about making sure I had an adequate supply of all prescriptions,” England states. And flooding can occur almost anywhere. Wood said. “But I think the most important thing my veterinary Each type of natural disaster presents a unique threat to pets office gave me was confidence and peace of mind in the face of a and their owners, noted John Haven, CPA, executive director pending natural disaster. I was very glad I called.” of the University of Florida College of Veterinary Medicine >>

AmericanVeterinarian.com | 25 Special Feature

Left: A stray animal is evaluated following Hurricane Irma. Right: University of Florida veterinary student Rose Worobec calms a stressed patient. Bottom: Irma left power outages, water shortages, refuse, and debris in her wake.

in Gainesville and head of the college’s Veterinary Emergency means that no matter what type of disaster occurs, animal owners Treatment Service (VETS), which deploys throughout Florida when- have anticipated their needs and created a plan of action to respond,” ever a natural disaster occurs. Hurricanes and tornadoes can result he explained. “Of course, if a certain type of disaster is more likely in blunt-force trauma and lacerations from flying debris, drowning than others to occur in a geographic area, such as a hurricane being and contamination issues from more likely than an earthquake, those types of disasters should be flooding, encounters with panicked considered first.” Box 1. Preparing an Evacuation Bag wildlife fleeing the storm, and Beyond distributing the local animal disaster plan to clients, All client discussions about disaster preparedness disease from insects that flourish in veterinarians should discuss some of the anticipated needs for their should include mention of an evacuation bag. This the aftermath. Wildfires can result clients’ pets, such as a provision for food, water, and medications; is a duffel bag or other container filled in advance in burns and smoke inhalation, and identification for the animal and proof of ownership; and a crate or with everything pet owners will need should they blizzards and ice storms can cause carrier (Box 1). “Setting these aside ahead of time in a convenient, have to evacuate their home with their animal. The frostbite and hypothermia. single, ‘grab and go’ location may make the difference between bag should be in a set location and ready to go at life and death for their animal,” Dr. Miller said. “Having enough a moment’s notice. Items to consider: BEFORE THE EVENT supplies for at least 72 hours is a solid start, but the more an owner Tornadoes and earthquakes occur can do to prepare, the better.” • A week’s worth of food and water, in sealable with little to no warning, but hurri- Veterinarians can spread the word by making disaster prepared- containers canes, wildfires, floods, and bliz- ness a frequent topic in office newsletters and on practice websites. • A week’s worth of medication zards usually offer residents time These platforms are the perfect place to promote links to reputable • Cage, leash, bowls, and toys to prepare. Grant Miller, DVM, sites that offer additional preparedness information and advice, such • Veterinary documents, including proof of director of regulatory affairs for as the Red Cross, the Centers for Disease Control and Prevention, vaccinations, in a sealable plastic bag the California Veterinary Medical and the American Society for the Prevention of Cruelty to Animals. • A recent photo of the owner with the pet for Association and state coordinator for identification purposes the California Veterinary Medical DURING THE EVENT • Information on feeding schedules, medical Reserve Corps, encourages veteri- It’s vital that veterinary practices have a disaster plan in place conditions, behavior problems, and the name narians to become familiar with the (Box 2) and that staff members know what their responsibilities are and number of the pet’s veterinarian disaster plan for their city or county when an event occurs, Lorna Lanman, DVM, a member of the Texas- before a disaster strikes. based Veterinary Emergency & Critical Care Foundation, said. “Many municipalities have written plans that are available to “A written disaster plan is very important,” she explained. “Once the public, and some even have annexes specific to animals,” Dr. we have taken care of ourselves, we can help our clients prepare for Miller noted. “The plans often address evacuation and transpor- their own issues.” tation procedures and name animal-specific shelter locations. The services a practice can offer during a natural disaster are Veterinarians should share this information with clients because predicated on the type of disaster and how it will affect the practice this type of information helps guide people during critical times itself. A practice in the path of a Category 4 hurricane, a rapidly in disasters.” moving wildfire, or a raging flood isn’t in a position to assist When veterinarians talk with clients about disaster planning, anyone—their thoughts are only of self-preservation. But practices Dr. Miller advised that they take an “all hazards” approach. “This that will be lightly or not at all affected can assist in many ways.

26 | American Veterinarian® | May 2018 Left: Florida Veterinary Corps volunteer May-Li Cuypers, DVM, DACVIM (right) and University of Florida veterinary student Jennifer Wade assess and treat a local pet following Hurricane Irma. The Florida Veterinary Corps is a project of the Florida Veterinary Medical Association, the University of Florida College of Veterinary Medicine, and the Florida Department of Agriculture and Consumer Services. Right: University of Florida veterinary student Sarah Klatzkow checks a patient’s heart rate following the hurricane.

One of the most appreciated services is boarding contend with patients being off medications that “Addressing fatigue is a huge part of managing animals for clients facing relocation. The PETS Act, they otherwise would have received. For instance, stress,” Dr. Lanman noted. “We go and go and forget enacted following Hurricane Katrina, ensures that animals with diabetes or epilepsy may not be to take care of ourselves. Then the exhaustion sets state and local emergency preparedness operational medicated adequately due to not receiving medi- in, and stress really hits us hard.” Self-care includes plans address the needs of individuals with house- cations on their regular schedule.” getting plenty of rest and not taking on more than hold pets and service animals following a major the practice can handle safely, Dr. Lanman said. disaster or emergency. However, owners with older Box 2. Disaster Preparedness for A final consideration is what to charge for animals or pets with chronic illnesses may feel better Veterinary Practices services in the aftermath of a natural disaster. if their veterinarian can provide temporary boarding. Clients may be facing financial calamity because All veterinary practices should have a prepared- Clinics in a safe zone may also assist colleagues of the cost of recovery and/or long-term unem- ness plan in place well before a disaster occurs. whose practices are in danger by taking some or all ployment, which can make it difficult for them to The American Veterinary Medical Association and of the endangered practice’s boarded patients. pay for services. But at the same time, no practice other agency websites offer guidelines on what “If a veterinarian is faced with the responsibility can afford to provide services pro bono for an ex- such a plan should entail, but the basics include: of having to shelter animals during a disaster, tended period. the veterinarian should keep up periodic contact • Continuity of operations “Practitioners have to decide where they are with animal authorities to inform them of any • The emergency relocation of animals going to draw the line and how they will do stray animals being sheltered,” Dr. Miller advised. • Fire prevention that,” Haven said. “Perhaps they could charge “Veterinarians should document and photograph • General emergency planning a minimum fee to help offset expenses. This is stray animals being sheltered, since there is a very • Insurance and legal issues something they must consider and determine good chance that they are a beloved pet and that • Medical records backup before a disaster hits.” someone is desperately searching for them.” • Security Haven added that it’s sometimes possible for prac- Another suggested service is a hotline that tices to enter into an agreement with their county concerned pet owners can call if they have questions With this in mind, veterinarians seeing patients under the PETS Act to provide care following a or concerns about their pet’s health during a natural after a disaster must ensure that their staff is ready disaster and later seek reimbursement from the disaster. This kind of access can give clients tremen- to handle the anticipated uptick in cases, that the county and the Federal Emergency Management dous peace of mind, as demonstrated by Wood’s clinic is adequately supplied, and that electricity, Agency. However, such arrangements must be experience with the approach of Hurricane Irma. water, and other vital utilities are unaffected. made in advance. Reimbursement for pro bono or Veterinarians should also be prepared to deal reduced-fee care may also be obtained through AFTER THE EVENT with the emotional issues that occur commonly in grants provided by the American Veterinary Veterinarians can expect animals to come in the aftermath of a natural disaster. “You’re dealing Medical Foundation and some state veterinary for several weeks following a natural disaster. with a lot of really stressed-out people,” Haven said. medical associations. “The nature of the illnesses and injuries varies “They have no power, no water, perhaps no home, so Emergency and disaster preparedness should be widely depending on the type of disaster that has they are on their last nerve when they come to see an ongoing discussion with staff so that everyone occurred,” Dr. Miller observed. “Generally, dehy- you. And your staff may also be stressed because of understands what to do and where to go should dration, GI issues, eye and skin injuries, malnu- issues going on in their own homes post disaster.” a disaster strike. Make sure new hires are made trition, and stress-related illness are common. In In addition, animals may exhibit signs of stress aware of the plan as soon as possible after they the wake of disasters, veterinarians often must because their routine has been severely disrupted. begin employment.

AmericanVeterinarian.com | 27 Clinical Focus PAIN MANAGEMENT

Tramadol: Limited Benefit for OA Pain Recent study findings show that this popular pain reliever offers no improvement over placebo treatment for elbow and stifle joint pain. By Natalie Stilwell, DVM, MS, PhD

(continued from front cover) 8 hours in the event of unacceptable pain. Dogs were 2 groups, and the order in which dogs received O-desmethyltramadol is the primary metabolite withdrawn from the study if they were intolerant of treatment had no influence on outcome. associated with μ-opioid receptor effects, results the medications or if the owners perceived them to Rescue medication was necessary for 3 dogs of a 2011 pharmacokinetic study in greyhound have an unacceptable level of pain. during the placebo session and 1 dog during the dogs demonstrated that it had low peak plasma Baseline health data were recorded via physical carprofen session; however, no dogs were with- concentrations and a short half-life, indicating examination, complete blood count, serum biochem- drawn from the study due to adverse treatment low bioavailability.3 ical analysis, and urinalysis. Radiography was also effects or unmanageable pain levels. Then, in 2012, researchers at the University of performed to confirm OA in at least 1 elbow or Wisconsin-Madison School of Veterinary Medicine stifle joint, and the most clinically affected joint Kinetic Gait Analysis compared 3 medications—ABT-116, carprofen, and was designated the joint of interest for the duration Vertical impulse and peak vertical force scores were tramadol—with a placebo control for their relative of the study. Dogs were further excluded from the statistically similar at baseline (pretreatment) and therapeutic effect on OA-associated pain of the hip study if they demonstrated OA in joints other than at day 10 after placebo and tramadol treatments. joint in dogs.4 In the study, owners were asked to the elbow or stifle or had any other systemic or local By contrast, values increased significantly from rate their dogs’ perceived levels of pain before and diseases, joint instability, or joint surgery within baseline after treatment with carprofen, and this after each treatment. Although the owners noted the previous 12 months. change was significantly higher than the changes improved pain levels with tramadol use, kinetic The study was randomized and blinded and after tramadol or placebo treatment. data obtained from force-plate analysis indicated had placebo and positive treatment controls. The similar values between placebo and tramadol treat- crossover design allowed each dog to serve as its Owner-Perceived Pain Levels ments, suggesting the possible involvement of care- own control by receiving 3 treatments in random The owners of 33 of 35 dogs completed the giver bias in perceived pain improvement. order. Owners and investigators were blinded to pain inventory assessment. They perceived that treatment, and medications were dispensed by the 14 (42%) dogs had a positive response with STUDY DESIGN pharmacy to owners in identical opaque capsules carprofen treatment, which was statistically Citing the limited availability of pharmacokinetic that were administered 3 times per day (morning, significantly higher than the 8 (24%) dogs that data and peer-reviewed support for tramadol, in- midday, and night) for 10 days. The negative control had a positive response with tramadol treatment vestigators at the University of Georgia recently (placebo) treatment consisted of lactose powder, and 7 (21%) with placebo treatment. examined the effectiveness of tramadol for elbow and the positive control (carprofen 2.2 mg/kg) was and stifle OA pain in dogs.5 The study took place administered at morning and night, with a placebo IMPLICATIONS FOR TRAMADOL USE from January 2015 to May 2017 at the University capsule for the midday dose. Tramadol hydrochlo- These study results indicated that tramadol offered of Georgia College of Veterinary Medicine. Client- ride was dosed at 5 mg/kg. no therapeutic improvement over placebo for owned dogs were eligible for study participation A baseline gait assessment was performed by elbow or stifle OA pain in the participating dogs. if they weighed between 15 and 50 kg and had 1 of 2 board-certified veterinary surgeons before Kinetic gait analysis values were similar at base- OA-associated signs in the elbow and/or stifle joints. each treatment period and on the final day (day 10) line and after 10 days of tramadol use, and owners Owners were required to maintain a stable activity of treatment. Two established parameters for perceived similar rates of success with tramadol routine for their dogs throughout the study, and the kinetic gait analysis, vertical impulse and peak and placebo treatment. Carprofen was the only dogs were unable to receive corticosteroid medica- vertical force, were measured by trotting dogs over treatment that resulted in improved vertical tions or polysulfated glycosaminoglycans 30 days force platforms at similar velocity and accelera- ground reaction force values and significantly before or during the study. Washout tion rates. Five valid trials per dog were used for decreased pain levels, as perceived by owners. periods for analgesic medications analysis, and values were recalculated to represent This latest study supports the growing evidence were performed before the percentage of body weight to normalize the data for tramadol’s limited analgesic properties for study and between treat- for statistical analysis. canine OA. The drug has a brief half-life in dogs, ment periods. Codeine- In addition to kinetic gait analysis, owners and plasma tramadol values are shown to decrease acetaminophen, chosen were asked to assess pain levels in their dogs at with repeated doses.3,6 Also, tramadol use does for its short-acting the beginning and end of each treatment period. not significantly alter thermal or mechanical effects, was given Owners provided scores ranging from 0 to 10 for nociception in dogs.7 Nevertheless, the drug has to owners to use as the degree of perceived pain severity and the degree been widely promoted in veterinary medicine a rescue medica- to which pain interfered with daily activities. during the past 10 to 15 years for the treatment of tion to be dosed at OA-associated pain. The caregiver placebo effect, 1 to 2 mg/kg every COMPARISON OF TRAMADOL, CARPROFEN, which has now been observed in multiple animal AND PLACEBO TREATMENTS studies,4,5 may play a role in tramadol’s perceived Thirty-five dogs completed the study, satisfying the benefits. This latest study further emphasizes the a priori sample size calculation for 80% statistical importance of using scientific, peer-reviewed power to detect treatment differences. Participants evidence to avoid bias when choosing and included 11 (31%) dogs with elbow joint OA and promoting treatments in veterinary medicine.  24 (69%) dogs with stifle joint OA. Age and body

weight did not differ significantly between the References available at AmericanVeterinarian.com. Stock Adobe Andrii Muzyka/

28 | American Veterinarian® | May 2018 ENDOCRINOLOGY

Insulin administration errors are a common cause of poor patient response.

How to Avoid Common Insulin Therapy Errors Giving proper advice to clients of diabetic pets requires an understanding of the many problems that can result from mistakes made in the choice, use, and monitoring of insulin. By J. Catharine Scott-Moncrieff, VetMB, MA, MS

iabetes mellitus (DM) is a common disorder in dogs have type 2 DM, but progressive loss of beta cells may lead and cats. Learning how to care for a pet with diabetes to type 1 disease. Dcan overwhelm clients, especially those with no prior Diagnosis of DM relies on identification of character- medical experience. To ensure appropriate patient care and istic historical and physical examination findings, such as provide clients with the best support and advice, the entire polyuria, polydipsia, polyphagia, and weight loss, together veterinary team should be well informed about the diagnosis with documentation of hyperglycemia and glycosuria. and treatment of this disease. Detection of serum or urine ketones also supports the Treatment of DM requires attention to detail and a consis- diagnosis. In cats, it is particularly important to differ- tent protocol. It is very easy for small errors to creep into a entiate stress hyperglycemia from DM. Increased serum J. CATHARINE SCOTT- management protocol, leading to poor glycemic control and fructosamine concentration is suggestive of DM, whereas MONCRIEFF, VetMB, MA, MS potentially life-threatening events such as diabetic ketoac- in stress hyperglycemia, fructosamine is typically within Dr. Scott-Moncrieff, a idosis and hypoglycemia. An understanding of appropriate reference range. professor of small animal protocols and potential treatment errors by the entire team Treatment of DM in dogs and cats should include insulin internal medicine and will improve patient care and lead to better outcomes for administration, dietary manipulation, obesity management, head of the Department of 1 diabetic patients and their owners. treatment of concurrent illness, and withdrawal of medica- Veterinary Clinical Sciences tions that cause insulin resistance. Insulin treatment is the at Purdue University, has ABOUT DIABETES MELLITUS cornerstone of therapy. authored more than 70 peer DM is caused by an absolute or relative insulin deficiency reviewed publications in that results in decreased glucose uptake into cells, increased COMMON TREATMENT ERRORS small animal endocrinology hepatic glucose production, hyperglycemia, and glucosuria. Many common errors can interfere with the response and internal medicine. Type 1 DM, the more common form in dogs, is caused by to treatment of a diabetic dog or cat. Common problems Her research and clinical irreversible loss of beta cell function, whereas type 2 DM include poor insulin choice, errors in insulin handling or interests are canine and results from impaired insulin secretion and insulin resis- administration, errors in monitoring, and inappropriate feline endocrinology.

Andrii Muzyka/ Adobe Stock Adobe Andrii Muzyka/ tance and is seen more often in cats. At diagnosis, most cats feeding protocols (Box). >>

AmericanVeterinarian.com | 29 Clinical Focus ENDOCRINOLOGY

Box. Common Errors in Diabetes Management Figure. Potential problems with insulin administration and monitoring, as shown on a blood glucose curve. INSULIN-RELATED ERRORS

Insulin Choice 500 - • Inappropriate insulin type 450 - • Use of compounded insulin 400 - 350 • Mixing of different insulin products - 300 - Insulin Handling 250 - • Inappropriate dilution 200 • Inadequate mixing -

Blood Glucose mg/dL 150 Reference • Inappropriate storage 100 - range 50 - Insulin Administration 0 - |||||| • Incorrect insulin syringes 8 10 12 2 4 6 8 • Incorrect/inaccurate dosing Time • Once- vs twice-daily dosing Insulin • Failure to rotate insulin injection site Rapid metabolism Insulin-induced hypoglycemia Ideal curve Poor owner compliance • Poor injection technique or insulin resistance

MONITORING ERRORS Insulin Choice life. Insulin dilution does, however, make it easier BG Curve Errors The most common insulin products used for initial to draw up small volumes of insulin accurately. • Missing hypoglycemia management of diabetic dogs and cats are shown Unfortunately, most commercial insulin products in the Table.2-4 Neutral protamine Hagedorn (NPH) cannot be diluted because dilution changes critical • Missing diabetic remission insulin is not recommended for diabetic cats parameters such as pH, pharmacokinetic properties, • Relying on spot-check BG measurements because it is very short acting in that species and and stability of insulin formulations. NPH is the • Obtaining BG curves in stressed patients usually does not result in good glycemic control. only insulin product that can be diluted with either Use of compounded insulin products is also not a commercial diluent or sterile saline, but doing • Obtaining BG curves in noisy or stressful recommended. In a study of compounded protamine so decreases the stability of the insulin. For small locations zinc insulin (PZI), the authors documented incorrect insulin doses, it is preferable to use U40 insulin and • Not keeping same routine between home insulin concentration, incorrect pH, inter-lot vari- syringes or insulin pens with 0.5U markings. and clinic ability in potency, and inappropriate zinc content Another important aspect of handling— in insulins purchased from many compounding depending on the type of insulin used—is how to • Using BG meters not validated for dogs and cats pharmacies.4 Inappropriate concentrations of free mix insulin prior to administration. Some insulin • Failure to recognize expected day-to-day insulin in solution and inappropriate endotoxin products such as insulin zinc suspension (Lente) variability in BG curves concentrations were also documented. These devi- should be shaken thoroughly; others, such as PZI ations from United States Pharmacopeia guidelines and NPH insulin, should be rolled or inverted Treatment Errors for compounded insulin products have the poten- gently until fully suspended. Insulin solutions • Increasing insulin dose too rapidly or frequently tial to cause clinically significant adverse effects such as glargine do not need to be mixed. in diabetic pets. Although most insulin products are stable at Other Errors In dogs, long-acting insulins such as PZI and room temperature, it is recommended that they • Not performing regular physical examinations glargine are not recommended for initial treatment are stored in the refrigerator in an upright posi- • Missing signs of concurrent illness of newly diagnosed diabetic patients; however, these tion. Refrigeration prolongs the shelf life and insulins may be useful in select patients with rapid decreases the likelihood of bacterial growth. • Administering medications that cause insulin metabolism. Refrigeration is particularly important for clients insulin resistance Lastly, it is important to remember that different who—because of both the small insulin doses brands of the same insulin formulation (eg, Humulin needed by many patients and the cost of insulin— INAPPROPRIATE FEEDING PROTOCOLS N and Novolin N) are not interchangeable because do not always discard the insulin at the time recom- • Relying on dietary management alone of differences in manufacturing techniques. It is mended by the manufacturer. also important to avoid mixing different insulin It is very important to inspect insulin products • Not feeding when insulin is administered formulations together. before each injection. Insulin suspensions such as • Failing to consider other health conditions when PZI, Lente, and NPH should be uniformly white making a dietary change Insulin Handling and cloudy, with no particulate matter or crystals. Dilution of insulin products is not recommended as Insulin solutions such as glargine should be clear • Feeding an unpalatable prescription diabetic diet standard practice for most diabetic patients, not only with no particulate matter or crystals present. If because communication errors can lead to mistakes abnormalities are noted, the insulin bottle should BG, blood glucose. but also because dilution shortens the insulin’s shelf be discarded and replaced.

30 | American Veterinarian® | May 2018 Insulin Administration not be increased more frequently than every 7 days. If BG Because the concentration of insulin products varies, it is very is measured in the first few days, the measurement should important to use the appropriate insulin syringe for each formula- be used only to detect hypoglycemia. When performing a BG tion. If U40 syringes are used to deliver U100 insulin, the insulin curve, every attempt should be made to minimize the stress of dose will be 2.5 times the intended dose, whereas if U100 syringes the experience and keep the conditions as similar as possible are used to deliver U40 insulin, the dose will be 2.5 times too low. to a normal day. BG is typically measured every 2 hours for 8 to 12 hours, starting 2 hours Table. Common Insulin Products for Dogs and Cats2-4 after the morning insulin dose and finishing just before the Shelf Life evening dose. In some circum- Species Insulin Type Trade Name Characteristics Starting Dose After Opening stances, BG measurement every Dogs Insulin zinc Vetsulin Pork insulin, 40 U/mL 0.25-0.5 U/kg 42 days 3 to 4 hours is adequate. Even suspension (lente) every 12 hours if the curve is performed in the Dogs NPH Humulin N, Human recombinant 0.25-0.5 U/kg 42 days clinic, it is ideal if the patient Novolin N insulin, 100 U/mL every 12 hours is fed and dosed at home prior Cats PZI ProZinc Human recombinant 1-2 U/cat every 60 days to arrival. The most important insulin, 40 U/mL 12 hours para- meters to evaluate when Cats Glargine Lantus Human recombinant 1-2 U/cat every 28 days performing a BG curve are the analog insulin, 100 U/mL 12 hours BG nadir and the duration of effect. The BG nadir should be NPH, neutral protamine Hagedorn; PZI, protamine zinc insulin. between 80 and 150 mg/dL, and the duration of effect should Adjusting the insulin dose to account for use of incorrect insulin ideally last 10 to 12 hours (BG <300 mg/dL). It is important syringes is not recommended because this can lead to serious to remember that the BG curve should be interpreted in light dosing errors. of the clinical signs, serum fructosamine concentration, and Poor administration technique is a common cause of poor response any other information such as urine glucose. to insulin. Numerous resources, including videos available online, outline the correct technique for insulin injection. Instructions for COMMON DIETARY ERRORS use of insulin pens are also available online. Owners should be Low-carbohydrate, high-protein diets are recommended in newly taught proper injection technique and appropriate injection loca- diagnosed diabetic cats,9 while most dogs should be fed high-fiber tions by veterinarians or veterinary technicians. If there is any and low- to moderate-fat diets. Diets for diabetic dogs and cats concern about a good response to treatment, the owner’s tech- must be palatable and, if appropriate, calorie restricted to control nique should be reevaluated. Common injection errors include not obesity. It is recommended that the daily portion is divided into 2 ejecting air bubbles from the syringe, not priming insulin pens, meals fed at the time of each insulin injection, although many cats and not rotating the site of insulin injection. prefer to nibble throughout the day. Most diabetic cats and dogs should be treated with insulin twice Common errors in feeding diabetic dogs and cats include relying daily. Although clinical signs may be controlled using once-daily on diet alone to control BG in a newly diagnosed diabetic cat, failing insulin in some animals, the risk of hypoglycemia is higher and to feed at the time of the insulin injection, not taking into account it is less likely that good glycemic control will be achieved. In the dietary requirements of

cats, once-daily insulin treatment may decrease the chance of other medical conditions, and TM americanveterinarian.com/pet-connections diabetic remission. continuing to feed a prescription diabetic diet that is not palat- COMMON MONITORING ERRORS able. Excessive use of snacks Response to insulin treatment should be assessed by evaluation and snacks that contain simple of clinical signs, blood glucose (BG) concentrations, and measure- sugars may also cause problems ment of urine glucose and fructosamine concentrations. In dogs in diabetes control. and cats predisposed to development of ketoacidosis, urine ketones should also be measured. Common errors in insulin monitoring SUMMARY include failing to identify hypoglycemia or diabetic remission,7 Management of diabetic patients increasing the insulin dose too quickly, and relying on spot-check requires attention to detail, and BG measurements alone to adjust insulin therapy. errors may lead to poor diabetic In most patients, BG curves should be performed every 3 to management. Some of the most Watch veterinary experts and an owner of a diabetic dog share their 6 months to adjust insulin dose and detect occult hypoglycemia common errors that lead to poor insights and experiences in managing and monitoring diabetic pets. (Figure). BG curves should also be performed in any diabetic glycemic control in veterinary patient with poor control of clinical signs and 10 to 14 days after a patients include failing to account for stress hyperglycemia on dose or formulation change. BG curves are ideally performed using a BG curve, missing diabetic remission in cats, and misinterpre- home monitoring but can be performed in the clinic. Day-to-day tation of BG curves in both dogs and cats. Insulin-induced hypo- variability should be expected whether the cat or dog is in the glycemia is also a common cause of poor glycemic control in both clinic or at home.8 dogs and cats.  It is very important not to evaluate the pet’s response to insulin until adequate time has elapsed. The insulin dose should References available at AmericanVeterinarian.com.

AmericanVeterinarian.com | 31 Clinical Focus ONE HEALTH

In the Trenches: The Veterinarian’s Role in the One Health Movement By the nature of their knowledge and expertise, it is incumbent on veterinarians to promote this global initiative and educate medical doctors as equal partners in improving health around the world.

ne Health—the global initiative to achieve optimal health for entire health landscape—here’s this piece that you have, and here’s this people, animals, and the environment—is more important today piece that we have, let’s work together to see how they fit together.” We Othan ever. Experts estimate that more than two-thirds of emerging have some really good examples in the past few decades where we have and reemerging infectious diseases are vector-borne formed very successful teams of One Health practitioners: MDs and DVMs or zoonotic, and that most of these zoonoses originate with different specialties like oncology, toxicology, and virology. When we from wildlife.1,2 bring a whole team together we can solve the puzzle faster than any one There is no doubt that this collaborative, species-span- of us could on our own. ning approach to health care has grown exponentially Lyme and other vector-borne diseases are great examples of this as over the past 2 decades, but there remains much the geographic ranges of vectors are changing. Say you’re seeing the ground to cover for full acceptance and application. incidence of Lyme disease increase in your practice area. Do you keep Audrey Ruple, DVM, MS, Audrey Ruple, DVM, MS, PhD, DACVPM, MRCVS, PhD, DACVPM, MRCVS that information in your silo, or do you share it with other health care assistant professor of One Health epidemiology at professionals in your area either by contacting physicians directly or by the Purdue University College of Veterinary Medicine in West Lafayette, talking to the local health department? Missing that opportunity to work Indiana, spoke with American Veterinarian® about this important health with other health care professionals can have real consequences, as MDs care initiative and how it is incumbent on veterinarians—who, by the nature may not have Lyme disease on their differential list if they are not yet of their work, play a significant role in both human and animal aware of its spread into the area. In a sense, animals can serve as health—to advance the cause. sentinels of disease spread for humans, and it is part of our job to ensure the right alarm bells are rung on Are veterinarians thinking as much as they the human side of health care to ensure accurate should about One Health? diagnoses are being made in the human popu- Audrey Ruple, DVM, MS, PhD, DACVPM, lation in the area. MRCVS: The One Health mindset is inherent to being a veterinarian. I think Are some medical specialties more all veterinarians are One Health prac- in tune than others with One titioners, trained to see the entire Health? world through a One Health lens, Obviously, any veterinarian working but some veterinarians may not be with zoonotic diseases is closely consciously aware that this is their attuned to the overlap between human perspective. Veterinarians are an and animal health, but one specialty integral part of the One Health move- that has really embraced the One ment, and we are seeing a change in Health approach is oncology. In this how other medical professionals are field, the canine spontaneous tumor recognizing our value as part of the model is gaining traction as a model entire medical community, which I like for human health because many cancers to think of as a puzzle with many inter- are molecularly identical between the 2 locking pieces. Veterinarians own a big species. This makes it possible for us to part of this One Health puzzle that physi- leverage the data from 1 species to provide cians don’t have, as physicians are not routinely help for the other and vice versa. By utilizing data trained in zoonotic diseases in the same way veter- from both dogs and humans, we can get a complete inarians are. picture of what’s happening in terms of both the preven- tion and treatment of many cancers. How can veterinarians spread the word to MDs? The One Health approach has been embraced by the National When I do One Health talks for veterinarians and I ask if people have Institutes of Health, which has created a comparative oncology program heard of One Health, almost everyone raises their hand. When I ask the that studies cancers in dogs as models for human health.3 Another same question in a room full of MDs, almost no one has ever heard of example of this is Stephen Withrow, DVM, DACVS, DACVIM (oncology), One Health. It’s a message that our profession has done a really good surgical oncologist and retired founding director of the Colorado State job in communicating to each other, but we haven’t been as great about University Flint Animal Cancer Center, who pioneered a treatment for spreading the word outside of our profession. I think many veterinarians canine patients with bone cancer in which the diseased area of bone see themselves as working in a silo rather than seeing how their work is replaced with healthy bone. This was developed in parallel with interlocks with the rest of the puzzle. human limb-sparing techniques, and the procedure is now used across To get the message out, we should talk to our counterparts in human the nation to prevent amputation in both dogs and children diagnosed 4

medicine as our equal partners in health care. We should say: “Here’s the with osteosarcoma. Techadilok Wassana by jihane37, elena3567 edited © Fiedels, Verzh,

32 | American Veterinarian® | May 2018 090340591/0 NADA 141-273, Approved by FDA ® Vetmedin (pimobendan) Chewable Tablets Cardiac drug for oral use in dogs only Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Description: Vetmedin (pimobendan) is supplied as oblong half-scored chewable tablets containing 1.25, 2.5, 5 or 10 mg pimobendan per tablet. Pimobendan, a benzimidazole-pyridazinone derivative, is a non-sympathomimetic, non-glycoside inotropic drug with vasodilatative properties. Pimobendan exerts a stimulatory myocardial effect by a dual mechanism of action consisting of an increase in calcium sensitivity of cardiac myofilaments and inhibition of phosphodiesterase (Type III). Pimobendan exhibits vasodilating activity by inhibiting phosphodiesterase III activity. The chemical name of How are zoos working with public-health professionals pimobendan is 4,5-dihydro-6-[2-(4-methoxyphenyl)-1H-benzimidazole-5-yl]-5-methyl-3(2H)-pyridazinone. to address conservation and public-health issues? Indications: Vetmedin (pimobendan) is indicated for the management of the signs of mild, moderate, or severe (modified NYHA Class IIa, IIIb, or IVc) congestive heart failure in dogs due to atrioventricular valvular insufficiency (AVVI) or Zoos have become increasingly active in conservation measures dilated cardiomyopathy (DCM). Vetmedin is indicated for use with concurrent therapy for congestive heart failure (e.g., as well as in research and education—almost all of which furosemide, etc.) as appropriate on a case-by-case basis. involves the One Health perspective. The St. Louis Zoo, for a A dog with modified New York Heart Association (NYHA) Class II heart failure has fatigue, shortness of breath, coughing, example, has demonstrated how zoos can partner with schools etc. apparent when ordinary exercise is exceeded. of public health to create a learning environment in which b A dog with modified NYHA Class III heart failure is comfortable at rest, but exercise capacity is minimal. students integrate their public-health knowledge into the envi- c A dog with modified NYHA Class IV heart failure has no capacity for exercise and disabling clinical signs are present ronmental and animal health model provided by zoologic soci- even at rest. eties. The zoo’s partnership with the School of Public Health at Contraindications: Vetmedin should not be given in cases of hypertrophic cardiomyopathy, aortic stenosis, or any other clinical condition where an augmentation of cardiac output is inappropriate for functional or anatomical reasons. the University of Missouri–Columbia has led to collaborations Warnings: Only for use in dogs with clinical evidence of heart failure. At 3 and 5 times the recommended dosage, in which human health outcomes associated with visiting the administered over a 6-month period of time, pimobendan caused an exaggerated hemodynamic response in the normal zoo are examined. Through this collaboration they have noted dog heart, which was associated with cardiac pathology. health outcomes such as lowered blood pressure and decreased Human Warnings: Not for use in humans. Keep this and all medications out of reach of children. Consult a physician in stress in humans following a zoo visit.5 The zoo has also done case of accidental ingestion by humans. projects in Africa and on the Galapagos Islands.5 This approach Precautions: The safety of Vetmedin has not been established in dogs with asymptomatic heart disease or in heart failure caused by etiologies other than AVVI or DCM. The safe use of Vetmedin has not been evaluated in dogs younger than provides a One Health educational experience for students of 6 months of age, dogs with congenital heart defects, dogs with diabetes mellitus or other serious metabolic diseases, dogs public health, veterinary medicine, human medicine, and envi- used for breeding, or pregnant or lactating bitches. ronmental health. Adverse Reactions: Clinical findings/adverse reactions were recorded in a 56-day eldfi study of dogs with congestive heart failure (CHF) due to AVVI (256 dogs) or DCM (99 dogs). Dogs were treated with either Vetmedin (175 dogs) or the active control enalapril maleate (180 dogs). Dogs in both treatment groups received additional background cardiac therapy. How else can veterinarians get involved, or more The Vetmedin group had the following prevalence (percent of dogs with at least one occurrence) of common adverse involved, in One Health? reactions/new clinical findings (not present in a dog prior to beginning study treatments): poor appetite (38%), Veterinarians need to recognize that they own a part of the lethargy (33%), diarrhea (30%), dyspnea (29%), azotemia (14%), weakness and ataxia (13%), pleural effusion (10%), syncope (9%), cough (7%), sudden death (6%), ascites (6%), and heart murmur (3%). Prevalence was similar in the One Health landscape. There is a big piece of this puzzle that active control group. The prevalence of renal failure was higher in the active control group (4%) compared to the Vetmedin is completely ours, and no other health practitioner can do group (1%). what we do. We also need to do a better job at communicating Adverse reactions/new clinical findings were seen in both treatment groups and were potentially related to CHF, the what we are already doing in One Health. We need to continue therapy of CHF, or both. The following adverse reactions/new clinical findings are listed according to body system and are not in order of prevalence: CHF death, sudden death, chordae tendineae rupture, left atrial tear, arrhythmias overall, to be active, show up, and speak the One Health language, tachycardia, syncope, weak pulses, irregular pulses, increased pulmonary edema, dyspnea, increased respiratory rate, because the importance of the communication part can’t be coughing, gagging, pleural effusion, ascites, hepatic congestion, decreased appetite, vomiting, diarrhea, melena, weight loss, lethargy, depression, weakness, collapse, shaking, trembling, ataxia, seizures, restlessness, agitation, pruritus, understated. We need to toot our own horn as a profession, increased water consumption, increased urination, urinary accidents, azotemia, dehydration, abnormal serum electrolyte, because we don’t do a very good job at that. If people don’t know protein, and glucose values, mild increases in serum hepatic enzyme levels, and mildly decreased platelet counts. what we are doing and how important our piece of this puzzle Following the 56-day masked field study, 137 dogs in the Vetmedin group were allowed to continue on Vetmedin in an open-label extended-use study without restrictions on concurrent therapy. The adverse reactions/new clinical findings in is, how can we complain when they don’t take us seriously as the extended-use study were consistent with those reported in the 56-day study, with the following exception: One dog in health care professionals? the extended-use study developed acute cholestatic liver failure after 140 days on Vetmedin and furosemide. I think there are still opportunities in veterinary medicine In foreign post-approval drug experience reporting, the following additional suspected adverse reactions were reported in that we haven’t created yet. It’s going to take a person—and dogs treated with a capsule formulation of pimobendan: hemorrhage, petechia, anemia, hyperactivity, excited behavior, erythema, rash, drooling, constipation, and diabetes mellitus. it often literally comes down to a single individual—who says, Effectiveness: In a double-masked, multi-site, 56-day field study, 355 dogs with modified NYHA Class II, III, or IV “I see a gap here and I’m passionate about this and I’m going CHF due to AVVI or DCM were randomly assigned to either the active control (enalapril maleate) or the Vetmedin to figure out how to close this gap for the betterment of both (pimobendan) treatment group. Of the 355 dogs, 52% were male and 48% were female; 72% were diagnosed with AVVI and 28% were diagnosed with DCM; 34% had Class II, 47% had Class III, and 19% had Class IV CHF. Dogs ranged humans and animals.” I believe a lot of progress in terms of in age and weight from 1 to 17 years and 3.3 to 191 lb, respectively. The most common breeds were mixed breed, One Health is going to happen at a grassroots level. It is going Doberman Pinscher, Cocker Spaniel, Miniature/Toy Poodle, Maltese, Chihuahua, Miniature Schnauzer, Dachshund, and Cavalier King Charles Spaniel. The 180 dogs (130 AVVI, 50 DCM) in the active control group received enalapril maleate to happen at the local levels where individuals are willing to (0.5 mg/kg once or twice daily), and all but 2 received furosemide. Per protocol, all dogs with DCM in the active control dig in and do the work of creating a healthier society. On a group received digoxin. The 175 dogs (126 AVVI, 49 DCM) in the Vetmedin group received pimobendan (0.5 mg/kg/ day divided into 2 portions that were not necessarily equal, and the portions were administered approximately 12 hours national level, we need to do a better job at representing what apart), and all but 4 received furosemide. Digoxin was optional for treating supraventricular tachyarrhythmia in either we are doing not just at veterinary conferences but at physi- treatment group, as was the addition of a β-adrenergic blocker if digoxin was ineffective in controlling heart rate. After initial treatment at the clinic on Day 1, dog owners were to administer the assigned product and concurrent medications cian conferences as well. We need to come to the table as their for up to 56±4 days. equals, their peers. The determination of effectiveness (treatment success) for each case was based on improvement in at least 2 of the 3 Research has shown that 50% of physicians acknowledge that following primary variables: modified NYHA classification, pulmonary edema score by a masked veterinary radiologist, and they don’t know anything about zoonotic diseases or that they the investigator’s overall clinical effectiveness score (based on physical examination, radiography, electrocardiography, 6 and clinical pathology). Attitude, pleural effusion, coughing, activity level, furosemide dosage change, cardiac size, body are uncomfortable with their knowledge of zoonotic diseases. weight, survival, and owner observations were secondary evaluations contributing information supportive to product Those same doctors also recognize that veterinarians are the best effectiveness and safety. Based on protocol compliance and individual case integrity, 265 cases (134 Vetmedin, 131 active control) were evaluated for treatment success on Day 29. At the end of the 56-day study, dogs in the Vetmedin group were sources of information on zoonotic disease. So while there may enrolled in an unmasked field study to monitor safety under extended use, without restrictions on concurrent medications. be some physicians who will be resistant to seeing us as their Vetmedin was used safely in dogs concurrently receiving furosemide, digoxin, enalapril, atenolol, spironolactone, peers, there are others who will walk with us to the table and nitroglycerin, hydralazine, diltiazem, antiparasitic products (including heartworm prevention), antibiotics (metronidazole, cephalexin, amoxicillin-clavulanate, fluoroquinolones), topical ophthalmic and otic products, famotidine, theophylline, work together to solve major health problems in all species. We levothyroxine sodium, diphenhydramine, hydrocodone, metoclopramide, and butorphanol, and in dogs on will never know how much support we will get in this One Health sodium-restricted diets. adventure until we begin to show up consistently and speak up Manufactured for: about own our piece of the puzzle.  Boehringer Ingelheim Vetmedica, Inc. St. Joseph, MO 64506 U.S.A. Vetmedin® is a registered trademark of Boehringer Ingelheim Vetmedica GmbH licensed to Boehringer Ingelheim Fiedels, Verzh, jihane37, elena3567 edited by Wassana Techadilok Wassana by jihane37, elena3567 edited © Fiedels, Verzh, References available at AmericanVeterinarian.com. Vetmedica, Inc. Copyright © 2017 Boehringer Ingelheim Vetmedica, Inc. or an affiliated company. All Rights Reserved. 448005-00 AmericanVeterinarian.com | 33 Revised 01/2017 University Report

Veterinary Students Stand Together for Suicide Awareness Veterinary students have created the #VetMedUnited movement to spread awareness of suicide and break down the stigma associated with asking for help. By Kerry Lengyel

early 1 in 6 veterinarians will consider suicide at some and suicide in teens and young adults. Then, a group from High point during their career, according to CDC survey data.1 Performance Vets, which helps coach veterinarians on how to NThis startling statistic, and others like it, has sparked the succeed professionally, educated students one-on-one about #VetMedUnited movement, which aims to remember the veteri- starting their careers on the right foot. The chapter also organized narians and veterinary students who have been lost to suicide, a dinner talk on self-care and the tools students can use to help to raise awareness about mental health in the profession, and manage their well-being. promote more wellness initiatives throughout veterinary schools Students also tye-dyed 600 #VetMedUnited T-shirts and wore and hospitals. them when they gathered for a moment of silence outside their Every year on April 4, the Student American Veterinary Medical classrooms, commemorating the week of wellness with a group Association (SAVMA) Wellness Committee encourages chapters photo. “In addition to all of this,” MSU SAVMA President Chelsea across the globe to participate in this day of remembrance in Woodcock said, “we distributed #VetMedUnited ribbons, badge whatever way they can. Among the many campus events this year, holders, silicon bracelets, stickers, and buttons throughout the students held vigils, made signs, participated in wellness semi- MSU Veterinary Medical Center for faculty, staff, [and] third- and nars, and more to stand up against mental health stigmas and fourth-year veterinary students, and in the veterinary medical demonstrate their hope for the future of the profession. building for first- and second-year veterinary students, faculty, Here is a sampling of the many #VetMedUnited events SAVMA and staff.” chapters organized on and about April 4. LOUISIANA STATE UNIVERSITY MICHIGAN STATE UNIVERSITY The LSU SAVMA board partnered with the LSU Wellness A week of wellness and awareness at MSU started with a talk Committee to sponsor several events for #VetMedUnited Day. on signs and stressors related to suicide given by DASIUM, an “The main event was a wellness picnic to encourage students organization dedicated to the prevention of depression, addiction, to get outside and take a break from the classroom,” Morgan

34 | American Veterinarian® | May 2018 University Report Credit: Henry Moore Jr, CVM/BCU, Washington State University State Washington CVM/BCU, Credit: Henry Moore Jr,

Richard, LSU SAVMA senior delegate, said. Veterinary students PURDUE UNIVERSITY played various outdoor games, flew kites, and participated in different The theme of #VetMedUnited Day at Purdue was “Togetherness Is Sweet.” sports activities. To fit with that theme, the Purdue SAVMA chapter created an ice cream “We also made a sign and asked students to share encouraging words bar, stocked to the brim with blue toppings—one of the colors of suicide for their fellow students on it,” Richard said. This #VetMedUnited sign awareness. Students could also sign a poster and express what they love now hangs proudly in a hallway near the veterinary school classrooms about the veterinary profession. and will remain there until summer break. “We wanted to bring greater awareness to this day and educate our students on what it signifies,” Purdue SAVMA President-elect Kristi NORTH CAROLINA STATE UNIVERSITY Mariko said. “We wanted to make this an interactive event where veter- NC State SAVMA celebrated #VetMedUnited Wellness Week right before inary students, veterinary technician students, faculty, and staff could finals week. Students made wellness kits filled with reusable heating come together and remind each other of why they got into veterinary pads, stress balls, and facial scrubs and listened to a #StoptheStigma talk medicine and what they love about the veterinary community.” on wellness by NC State College of Veterinary Medicine Dean David Paul Mariko said this event was extremely important to her because she Lunn, BVSc, MS, PhD, MRCVS, DACVIM. has taken an interest in mental health in the veterinary industry. “I am “We incorporated students, faculty and staff with the events and excited to grow this event for future years,” she continued. focused on taking time for what makes you happy,” Madeline Zurowsky, NC State SAVMA delegate, said, “and finding your ‘why’—why you chose LINCOLN MEMORIAL UNIVERSITY veterinary medicine.” Every veterinary student and faculty member received a #VetMedUnited The dean, along with university faculty and counseling staff, spoke to pin to commemorate this special day, according to Lincoln Memorial students about the rising levels of suicide, how to reduce stress after SAVMA Treasurer Cortney Curtis. difficult cases of euthanasia, and the importance of stopping the stigma “We also had a really awesome US map up for the week,” she continued. associated with discussing mental health issues. “Students would pin the locations where they lived or had a connection to, as well as where they thought they might end up in the future. After OHIO STATE UNIVERSITY that, they tied a string connecting all of their pins.” This allowed the OSU SAVMA brought its university community together for students to see where everyone would be located and to remind them #VetMedUnited Day to raise awareness for suicide across the board. The that there will always be classmates close by to help out in a time of need. event consisted of one-on-one discussions between interested students and a clinical therapist or clinical psychologist about available mental WASHINGTON STATE UNIVERSITY health resources as well as posters for veterinary students to sign and WSU veterinary students showed their support by placing purple and pledge their support for their peers. teal handprints for suicide prevention on a #VetMedUnited banner. But the student group wasn’t just raising awareness for veterinarian “It was incredible to see such great support from our faculty and staff as suicide prevention. “Since SAVMA has a large community outreach well,” Jacqueline Alford, WSU SAVMA senior delegate, said. “Our counselors, component,” Megan Parry, health and wellness chair for OSU SAVMA, faculty, and staff, and our media crew all came out to support the event.” said, “we worked that into the event by raising money for Mission 22, Students also wrote on poster boards labeled “What’s Your Why?” to a suicide prevention organization that aims to provide resources to encourage one another to share why they chose veterinary medicine. veterans and their families.” Participants could donate to the organi- “Overall, it was an awesome opportunity for the WSU College of Veterinary zation by purchasing raffle tickets, which put them in the running to Medicine to come together and break the stigma behind mental health and win gift baskets. seeking help for issues that students may be facing,” Alford said. “Overall, the event went very well,” Parry said. “We had many students stop by and sign the posters and meet the clinical therapist REFERENCE 1. Nett RJ, Witte TK, Holzbauer SM, et all. Risk factors for suicide, attitudes toward men- and psychologist, and I felt that we were able to bring awareness to tal illness, and practice-related stressors among US veterinarians. J Am Vet Med Assoc. the issue.” 2015;247(8):945-955. doi: 10.2460/javma.247.8.945.

AmericanVeterinarian.com | 35 Disease State Watch PARASITOLOGY

Heartworm and Lyme Disease Forecasts Borrelia burgdorferi Look Gloomy Infection in Metropolitan THE COMPANION ANIMAL PARASITE COUNCIL (CAPC) has released its annual parasite fore- New York City cast, and the outlook for 2018 is not optimistic. Heartworm disease will continue to “aggressively spread” across the United States, the groups says, and Lyme disease prevalence will increase in RESULTS OF A RECENT STUDY SHOWED that canine areas east of the Rockies. seroprevalence for antibodies to Borrelia burgdorferi Heartworm prevalence has increased 20% over the past 5 years, according to CAPC, and the accurately predicted the risk of Lyme disease infection upward trend is expected to continue. Hot, wet conditions and shifting weather patterns over in humans in metropolitan New York City, including 30 the past 2 years have created ideal breeding conditions for mosquitoes. In addition, many heart- counties and about 20 million people. worm-positive dogs were relocated across the country following last year’s hurricanes, potentially The investigators used categorical analysis to analyze adding to the spread of the disease. CAPC predicts the following geographic spread of heartworm multiple factors, including SNAP3Dx and SNAP4Dx test disease this year: results, population density, percent forested area, and • Heartworm infections are expected to be above average nationwide. CDC-reported human Lyme disease cases. Regression • Prevalence in the lower Mississippi River region will be much higher than normal. analysis was performed for detailed variables, such as • Northern states, from Washington to Vermont, may experience a rise in heart- precipitation, fall temperatures and vegetation, and level worm infections. of urbanization in each county. Finally, the investigators performed a backward-stepwise regression analysis to Although Lyme disease occurs more commonly in areas with dense tick populations—New England, determine whether the variables could accurately predict the East Coast, and the upper Midwest and West Coast states—CAPC predicts that non-endemic the prevalence of Lyme disease in dogs or humans. areas will start to see a rise in Lyme disease cases, including in North Dakota, South Dakota, Iowa, A total of 234,633 SNAP test results from 2001 to Missouri, southern Illinois, Ohio, Kentucky, Tennessee, North Carolina, western Pennsylvania, 2010 were analyzed. Positive tests for B burgdorferi eastern Ohio, West Virginia, and the Appalachian region in Virginia. A less active year is predicted ranged from 1.2% to 27.3% by county, while human for areas from Washington, DC, to Philadelphia, Pennsylvania, and eastward, as well as the Boston/ Lyme disease cases ranged from 0.5 to 438.7 cases per Cape Cod, Massachusetts region. 100,000 people by county. CAPC also notes 2 other parasitic diseases that may cause trouble. Anaplasmosis prevalence is The percentage of positive canine tests was signifi- forecasted to be average for much of the United States, except for Minnesota, which is expected to cantly higher in counties with low population density have an active year. The Wisconsin/Minnesota border area and the Boston/Cape Cod region should (18%) than in those with moderate (8%) or high (5%) see less activity than normal. Ehrlichiosis prevalence is expected to be higher than normal in the populations. Positive tests were also more likely in southern Virginia and northern North Carolina regions, with normal prevalence elsewhere. counties with high amounts of forested area (21%) than in those with medium (15%) or low (6%) forestation. Similarly, human Lyme disease prevalence was significantly higher in counties with low and medium population densities than in counties with high popu- Feline Tickborne Pathogen Prevalence lation densities (113, 10, and 3 cases per 100,000 in the United Kingdom people, respectively). Also, more cases were reported in counties with high or medium forestation than UK RESEARCHERS RECENTLY PERFORMED a nationwide survey to determine the prevalence of in counties with low forestation (165, 66, and 11 per several pathogens in ticks collected from domestic cats. Although most (93.5%) of the ticks were 100,000 people, respectively). Human and canine cases pathogen-free, several tickborne pathogens were widely distributed throughout the country. correlated strongly with each other on both categorical A total of 540 ticks were collected during examination at 278 veterinary hospitals in 2016, most and regression analyses. removed from cats in England. Before processing, each tick was spiked with an internal amplifica- Regression analysis also revealed that several envi- tion control to monitor successful DNA extraction and rule out polymerase chain reaction (PCR) ronmental factors known to influence tick populations, inhibition. The researchers also used primers for feline 28S rDNA to serve as an endogenous positive including forest cover and November temperatures, control. Several conventional and quantitative PCR assays for tickborne pathogens were performed. significantly correlated with positive canine SNAP tests Specific qualitative PCR assays targeted Anaplasma phagocytophilum; Bartonella spp (positive and human Lyme disease cases. samples were also screened for B henselae); and 3 hemoplasma species (Mycoplasma hemofelis, Backward-stepwise regression revealed 3 factors that “Candidatus Mycoplasma hemominutum,” and “Candidatus Mycoplasma turicensis”). Hepatozoon could be used to accurately predict the percentage of spp were detected using conventional PCR. DNA sequencing was performed to identify pathogens positive canine tests: human case reports and population in positive samples to the species level. density, maximum temperature and precipitation during The internal amplification control successfully amplified in all 540 samples, while 475 (88%) November, and deciduous or mixed forest areas. Likewise, samples detected feline 28S rDNA, suggesting that most ticks had a blood meal prior to collection. the percentage of positive canine tests can also accurately Nineteen tick samples (3.5%) were positive for a single pathogen: 5 (0.9%) with A phagocytophilum, predict the prevalence of human Lyme disease. 7 (1.3%) with Bartonella spp, 5 (0.9%) with hemoplasma DNA, and 2 (0.4%) with Hepatozoon spp. The authors cautioned that these results may not apply All pathogens were distributed widely throughout the United Kingdom except for Hepatozoon to other regions of the United States, however, given the spp, which were detected only in Wales and southeastern England. In a previous study with the unique, endemic nature of Lyme disease in the Northeast. same 540 tick samples, investigators determined that 6 (1.1%) samples contained Babesia spp and Herrin B, Beall MJ, Feng X, Papes M, Little SE. Canine and human infection 10 (1.9%) contained Borrelia burgdorferi. with Borrelia burgdorferi in the New York City metropolitan area. Parasites Vectors. 2018;11(1):187. doi: 10.1186/s13071-018-2774-z. Florent Duplan F, Davies S, Filler S, et al. Anaplasma phagocytophilum, Bartonella spp., haemoplasma species and Hepatozoon spp. in ticks infesting cats: a large-scale survey. Parasites Vectors. 2018;11(1):201. doi: 10.1186/s13071-018-2789-5.

36 | American Veterinarian® | May 2018 Making a Difference

Legacy of Love: One Woman’s Journey to Help Domestic Violence Victims Lucy’s Project shines a light on a largely unaddressed—and often unrecognized—issue: animals affected by violence at home. By Kerry Lengyel

ucy’s Project, a network of services for victims of currently unfunded and run en- domestic violence and their companion animals tirely by volunteers in Adelaide L throughout Australia, was created after its founder, and surrounding areas. But Anna Ludvik, experienced a tragic but eye-opening event. Lucy’s Project is helping to pilot Grieving for her stillborn daughter, Lucy, in 2013, Ludvik a chapter in Lismore, and even- struggled to make sense of it all. She ultimately realized that tually plans to create an opera- despite her suffering, she was alive and she was safe—unlike tional template that would enable the many women who face every day in fear and pain as a other communities in Australia result of domestic abuse. Ludvik decided that, in her daugh- to set up chapters. ter’s name, she would help domestic violence victims and their pets. FOCUSING ON THE FUTURE “I didn’t want [Lucy’s] life and death to be in vain, and I Activism is the lifeblood of wanted to turn such tragedy into beauty,” Ludvik said. “I Lucy’s Project, but the network loved the idea that her beautiful name could shine a light on also started holding conferences a relatively unheard-of issue—animals affected by domestic in 2015, with its first interna- violence—and help protect other innocent animals, children, tional conference about domestic violence and pets held Lismore Mayor Isaac Smith presenting Anna Ludvik with the and women.” in 2016. These conferences attract a wide range of people, 2018 Citizen of the Year award. As an animal advocate, Ludvik saw how poorly under- from domestic violence service providers to animal refuge Credit: Terra Sword. stood this aspect of domestic violence was, with no move- workers to veterinarians to the general public looking to get ment around it in her home country of Australia. “I found more involved. “We all work together so we find it beneficial out quickly that ours is an ‘aha!’ cause,” she said. “As soon to hear the many perspectives,” Ludvik said. “Anyone with as people hear about it, it makes sense to them, and they get an interest in the field is welcome.” on board.” This year’s Lucy’s Project Domestic Violence and Animal With the help of like-minded individuals across Australia, Abuse Strategic and Practical Perspectives conference Ludvik got Lucy’s Project off the ground. Today, with an will be held in November in Melbourne, Australia. “We are extended network of more than 200 domestic violence and focusing on practical aspects of building the infrastructure animal welfare organizations, it leads the global movement to needed to support human domestic violence victims and raise awareness about the grave effect of domestic violence their animals,” Ludvik said. on pets. The conference will also host crisis foster care workshops to help those who wish to set up similar networks in their GROWING A NETWORK OF SUPPORT regions, as well as sessions led by cohousing refuges, shel- Lucy’s Project promotes the work of member organizations ters, transitional homes, and more. A specific workshop for and recognizes that animal abuse can be an indicator of abuse veterinarians will cover how to react when they suspect that against people. Although the project doesn’t help domestic an animal, and possibly its owner, may be victims of domestic violence survivors and their pets directly, it supports organi- violence. “There are so many considerations for veterinar- zations around the world that do. For example, if a domestic ians, and it can be daunting, so we want to support them,” violence refuge wants to become companion animal–friendly, she said. Lucy’s Project helps it access the necessary resources, The project has no US chapters, but Ludvik encourages information, tools, and skills. The project also ensures that anyone based in the United States to become involved in the domestic violence organizations are established when a National Link Coalition (nationallinkcoalition.org), a network community may be in need. of US organizations that addresses the intersection between “When visiting a local no-kill animal shelter recently, I was animal abuse and domestic violence. Lucy’s Project held its horrified to hear how 50% of their surrenders were due to 2016 conference in conjunction with the coalition and prides domestic violence and that the shelter was already beyond itself on being the coalition’s Australian counterpart. capacity and forced to turn people in need with animals away,” Much of the work done by Lucy’s Project involves helping Ludvik said. If a domestic violence victim returns home with people make connections that allow them to aid people his or her pet after being turned away from a shelter or aban- and animals in need. The more the endeavor grows, the dons the pet, both of their lives will be at risk, Ludvik said, so more lives are saved, Ludvik said. “When I hear that the For more information Lucy’s Project helped set up a local crisis foster care network work of Lucy’s Project inspired someone to build animal about Lucy’s Project, the that allows animals and survivors to stay together. “No one housing, make all future buildings animal-friendly, or take intersection between animal wants to surrender a beloved companion animal, but [people] on projects to support domestic violence victims and their abuse and domestic violence, often feel they have no choice,” she said. animals, I imagine the lives saved as a consequence,” she and how you can help, visit Safe Pets Safe Families, which offers foster care services said. “Every time, that floors me, because that’s why I do LucysProject.com. for pets and people leaving domestic violence situations, is what I do.” 

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38 | American Veterinarian® | May 2018 BECAUSE OF VETMEDIN

I have clients who notice a great response with VETMEDIN. Their animal feels perkier at home, they’re brighter, their heart failure is well-controlled, they really feel like themselves. Or they feel like a puppy again, a lot of people say. Which I think is what we all want for our pet.

–Dr Danielle Laughlin Cardiologist Blue Pearl Specialty + Emergency Pet Hospital Sandy Springs, GA

See more stories at DecadeOfVetmedin.com.

DR LAUGHLIN VETMEDIN PRESCRIBER FOR 6 YEARS

This testimonial is provided by an actual veterinarian who prescribes VETMEDIN and has been compensated for providing this statement. Individual results may vary. VETMEDIN can only be prescribed by a licensed veterinarian. Please consult a veterinary professional before starting treatment with VETMEDIN.

IMPORTANT SAFETY INFORMATION: Use only in dogs with clinical evidence of heart failure. The most common side effects reported in fi eld studies were poor appetite, lethargy, diarrhea, dyspnea, azotemia, weakness, and ataxia. If side effects should occur, pet owners should contact their veterinarian. The safety of VETMEDIN has not been established in dogs with asymptomatic heart disease or in heart failure caused by etiologies other than atrioventricular valvular insuffi ciency or dilated cardiomyopathy. VETMEDIN should not be given in case of hypertrophic cardiomyopathy, aortic stenosis, or any other clinical condition where an augmentation of cardiac output is inappropriate for functional or anatomical reasons. The safe use of VETMEDIN has not been evaluated in dogs younger than 6 months of age, dogs with congenital heart defects, dogs with diabetes mellitus or other serious metabolic diseases, dogs used for breeding, or pregnant or lactating bitches. Please refer to the package insert for complete product information or visit www.vetmedin.com.

Please see Brief Summary on page 33.

VETMEDIN is a registered trademark of Boehringer Ingelheim Vetmedica GmbH, licensed to Boehringer Ingelheim Vetmedica, Inc. © 2018 Boehringer Ingelheim Vetmedica, Inc. PET-0325-VETM0617 18257 #1 USED PET GLUCOMETER

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1. Data on file, Zoetis Market Research: Blood Glucose Monitoring Report, July 2017, Zoetis Inc. All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted. © 2017 Zoetis Services LLC. All rights reserved. ATK-00175