wendy blount, dvm things we don’t do that we should things we do that we shouldn’t
TRANSCRIPT
Wendy Blount, DVMWendy Blount, DVM
Things We Don’t DoThings We Don’t Dothat we Shouldthat we Should
Things We DoThings We Dothat we Shouldn’tthat we Shouldn’t
Wendy Blount, DVMWendy Blount, DVM
• DVM TAMU 1992• Private Practice Houston 2 years
– Westbury Animal Hospital
• Small Animal Internal Medicine Residency– TAMU 1994-1997
• Private Practice 1997-present– Nacogdoches and Lufkin, TX– See appointments at 3 practices– CE for groups and in-house
Upper Respiratory Infections - CatsUpper Respiratory Infections - Cats
• How do many of us treat feline URI?– Penicillins (Amoxidrops, Clavamox)– Eye ointment (triple antibiotic)– Supportive
• antihistamines• Fluids if needed
Upper Respiratory Infections - CatsUpper Respiratory Infections - Cats
• What causes feline URI?– Feline calicivirus– Feline herpesvirus (FHV-1)– Feline Infectious Peritonitis (FIP) coronavirus– Chlamydia psittaci var. felis– Mycoplasma spp.– (Maybe Bordetella bronchiseptica)– Other bacteria can be secondary invaders
Upper Respiratory Infections - CatsUpper Respiratory Infections - Cats
• How primary organisms treated?– Feline calicivirus
• supportive– Feline herpesvirus
• Lysine• Vaccination if naive• Anti-herpetics (acyclovir) – don’t work well
– FIP• (pentoxyphylline, prednisone)
– Chlamydia psittaci, Mycoplasma spp.• Tetracyclines, quinolones
Upper Respiratory Infections - CatsUpper Respiratory Infections - Cats
• So how can we tell the cause?– Conjunctivitis
• NOT Mycoplasma or Bordetella– Oral ulcers
• FHV-1, FCV– Keratitis
• FHV-1– Coughing
• FHV-1, Mycoplasma, Bordetella• More commonly lower respiratory disease
– Lameness• FCV, (Chlamydia)
Upper Respiratory Infections - CatsUpper Respiratory Infections - Cats
• So how should we treat?– Supportive
• Fluids, decongestants, mucolytics– Antivirals?
• You can try them if FHV-1 is suspected• Recurring disease, oral ulceration,
conjunctivitis, keratitis– Lysine?
• If FHV-1 is suspected– Antibiotics and eye ointment?
• PO - Tetracyclines or quinolones• OU – tetracyclines, chloramphenicol
• Can we tell whether a skin mass should be removed, just by looking at it?– Sebaceous gland adenoma - 98% benign
• Differential diagnoses for hairless skin masses
Identifying Skin MassesIdentifying Skin Masses
•Histiocytoma - benign•Plasmacytoma – malignant or benign•Mast cell tumor - malignant•Melanosarcoma - malignant
•Fibroma - benign•Follicular tumor - benign•SGA - benign•Perianal gland tumor – benign or malignant
Identifying Skin MassesIdentifying Skin Masses
• So what should we do to decide whether a skin mass should be removed?– Cytology
• Inflammatory, or non-inflammatory?• What is the cell type?• Characteristics of malignancy or not?
– If malignant, is it a tumor that metastasizes?• If so, do met check prior to removing skin mass• Draining lymph nodes• Chest x-rays, abdominal US
Identifying Skin MassesIdentifying Skin Masses
• Differential diagnosis for a fully haired dermal mass– Epidermal inclusion cyst - benign– Mast cell tumor – malignant (grade III metastasizes)– Fibrosarcoma – malignant (locally invasive)– Hemangiopericytoma – malignant (locally invasive)– Hemangiosarcoma – malignant (metastasizes)– Lipoma – benign– Malignant histiocytosis – malignant (metastasizes)
CytologyCytology
• Inflammatory or Non-inflammatory?
– Are inflammatory cells present?• Neutrophils• Macrophages• Lymphoid/plasma cells• Eosinophils
CytologyCytology
• Cell Type?– Epithelial cells
• Round to oval in shape• Distinct cytoplasmic borders• Lines of cell-to-cell adherance (clumps of cells)
– Round cells• Round in shape• Distinct cytoplasmic borders• Cells are single
– Mesenchymal cells• oval to cigar shaped nuclei • Diffuse-fading cytoplasmic borders• Cells are single
CytologyCytology
• Characteristics of Malignancy?– Variation in the size and shape of nuclei– Multinucleation and indentation of nuclei as a result of
abnormal mitosis (especially odd numbers)– Increase in the number and size of nucleoli– Abnormal (asymmetrical) or frequent mitosis– Increase in the nucleus-to-cytoplasm ratio (nucleus too
big)– Increased basophilia of the cytoplasm (cytoplasm too
purple)
CytologyCytology
• Examples– Subcutaneous mass mammary area 10 yr female poodle
• Moderately inflammatory, epithelial tumor with characteristics of malignancy
• Suspect mammary carcinoma• Aspirate local lymph nodes, take chest x-rays• Then excise
– Raised, hairless pink skin mass 1 cm diameter• Non-inflammatory epithelial tumor with no
characteristics of malignancy• Suspect basal cell or other adnexal tumor
CytologyCytology
• Examples– Raised, hairless pink skin mass 1 cm diameter on lip
• Non-inflammatory, round cell tumor with characteristics of malignancy
• Aspirate local lymph nodes• Then excise
– Raised, hairless pink skin mass 1 cm diameter• Inflammatory (eosinophils) round cell tumor with no
characteristics of malignancy• Suspect agranular mast cell tumor• Aspirate local lymph nodes, then excise
CytologyCytology
• Examples– Raised, hairless pink skin mass 1 cm diameter
• Mildly inflammatory, mesenchymal cell tumor with characteristics of malignancy
• Suspect sarcoma• Aspirate local lymph nodes, do chest x-rays• Then excise
– Hairless pink skin mass 1 cm diameter, 1 week after vaccination
• Pyogranulomatous inflammation, with no organisms• Suspect vaccination granuloma• Observe, excise if gets bigger or not resolved in 3-4
weeks
CytologyCytology
• Examples– Hairless pink skin mass 1 cm diameter, 1 week
after vaccination• Non-inflammatory mesenchymal tumor with
strong characteristics of malignancy• Suspect vaccine associated sarcoma• Excise immediately, with wide borders
Spot Checking DiabeticsSpot Checking Diabetics
Quiz – Spot glucose checks at insulin time
What Would you do?
1. 250, 260
2. 350, 335
3. 245, 265
4. 200,200
Spot Checking DiabeticsSpot Checking Diabetics
• Which values in a glucose curve are used to determine dose?– Nadir (lowest glucose values - insulin peak)– Lowest glucose value should be around 100
• Which values on a glucose curve are used to determine interval and insulin type?– Peak glucose values (insulin nadir)– If glucose nadir is ideal, and glucose peaks are
too high, then you need to give insulin more often, or you need a longer acting insulin
• Ideally, a majority of the time, glucose should be between 100 and 200– Never go lower than 80-90
Spot Checking DiabeticsSpot Checking Diabetics
Doing glucose curves– If patient doing well, do fructosamine first. If
normal, no need to do a glucose curve– Begin when insulin given and fed– Every 2 hours until 2 values in a row with a
significant uptrend– Every hour when glucose <80– If your curve is not finished at the end of the
business day, it must be finished in order to know how to give insulin properly• Have owners finish at home, with their
own glucometer• Transfer to emergency clinic if you have
one available
Spot Checking DiabeticsSpot Checking Diabetics
Interpreting glucose curves
1. Duration of curve –– If your curve is 10 hours or less, you need
to give insulin BID, not SID
2. Glucose range– If all values are 100-200, leave it alone– Consider the same if 100-250, if clinical
signs are controlled
Spot Checking DiabeticsSpot Checking Diabetics
Interpreting glucose curves3. Glucose nadir
– If < 90-100, reduce the insulin dose– If >100-150 and glucose peak too high,
increase insulin dose
4. Glucose peak– If nadir OK and peak too high, change to
longer duration insulin– NPH – shortest– Then Vetsulin (Lente)– Then PZI– Lantus longest (not for most dogs)
Spot Checking DiabeticsSpot Checking Diabetics
Interpreting glucose curves3. Glucose nadir
– If < 90-100, reduce the insulin dose– If >100-150 and glucose peak too high,
increase insulin dose
4. Glucose peak– If nadir OK and peak too high, change to
longer duration insulin– NPH – shortest– Then Vetsulin (Lente)– Then PZI– Lantus longest (not for most dogs)
Spot Checking DiabeticsSpot Checking Diabetics
If you were only allowed two glucose checks in every 24 hour period, when would you want to take them?
At Insulin Time?
5-7 hours after insulin?
One of each?
Spot Checking DiabeticsSpot Checking Diabetics
Correct Your Quiz
1. 250, 260• Need to decrease insulin
2. 350, 335• Increasing insulin would probably make this
dog or cat hypoglycemic• Need to change insulins instead
3. 245, 265• Need to increase insulin
4. 200,200• Insulin should not be changed
Surgery Without IV CatheterizationSurgery Without IV Catheterization
12 of 58 (20%) of systemically healthy dogs undergoing anesthesia for orthopedic surgery experienced clinically significant hypotension (<60 mm Hg MP) during the short anesthetic period prior to surgery
Use of ephedrine and dopamine in dogs for the management of hypotension in routine clinical cases under isoflurane anesthesia
Vet Anaesth Analg. September 2007;34(5):301-11.Hui C Chen1, Melissa D Sinclair, Doris H Dyson
Surgery Without IV CatheterizationSurgery Without IV Catheterization
• MP < 60 mm HG compromises renal perfusion, and could result in renal failure in dogs with– subclinical upper urinary tract infection– subclinical renal disease– Rx ACE-inhibitor, diuretics, NSAIDs– Dehydration (NPO overnight??)
• We get away with it on a regular basis
• Would our A+ clients appreciate it, if the knew?
Surgery Without IV CatheterizationSurgery Without IV Catheterization
• The cost of an IV catheter and IV fluids is minimal
• IV catheter can be put in in minutes
• Doing surgery on systemically ill animals without IV fluid support is probably outside protection by standard of care
Surgery Without IV CatheterizationSurgery Without IV Catheterization
• Using pre-operative NSAIDs without IV fluid support is probably outside protection by standard of care
• Owners who “shop” elective surgeries can accept lack of IV support/access at their own risk, if you wish to allow that
Perioperative NSAIDsPerioperative NSAIDs
Deramaxx and Rimadyl Package Inserts:• Laboratory tests to establish …baseline data prior
to, and periodically during, administration of any NSAID should be considered
• Owners should be advised of the potential for adverse reactions and be informed of the clinical signs associated with drug intolerance
• The use of parenteral fluids during surgery should be considered to reduce the potential risk of renal complications when using NSAIDs perioperatively
Perioperative NSAIDsPerioperative NSAIDs
Rimadyl Package Insert:
• Always provide Client Information Sheet with prescription
• For control of postoperative pain, administer approximately 2 hours before the procedure
Perioperative NSAIDsPerioperative NSAIDs
Deramaxx Package Insert:
• Appropriate monitoring procedures should be employed during all surgical procedures
Deworm Vomiting Dogs & CatsDeworm Vomiting Dogs & Cats
Why should we deworm vomiting dogs and cats?– Worms can make dogs and cats vomit– Physaloptera spp.– Obscure?– Found on endoscopy in dogs and cats
referred for chronic vomiting– Easily treated with pyrental pamoate
Nutrition for Diabetic CatsNutrition for Diabetic Cats
For many years, we fed diabetic cats high fiber, low fat diets, just like dogs & people
• 2000 - Randomized, controlled crossover study• Improved glycemic control when fed 12% insoluble fiber• Both diets high in carbs (~35%)
J Am Vet Med Assoc. 2000 Apr 1;216(7):1082-8. Effect of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. Nelson RW, Scott-Moncrieff JC, Feldman EC, DeVries-Concannon SE, Kass PH, Davenport DJ,
Kiernan CT, Neal LA.
Nutrition for Diabetic CatsNutrition for Diabetic Cats
2001 – ACVIM Abstract• Low carb-low fiber diet (canned Hill’s Feline Growth)
compared to high carb-high fiber diet (canned W/D)• 31% fed LC diet were able to d/c insulin, and an
additional 46% decreased insulin dose• None of the HC cats were able to reduce or discontinue
insulin
Comparison of a low carbohydrate versus high fiber diet in cats with diabetes mellitus. Bennet N, Greco DS. ACVIM 2001. 13 cats.
J Feline Med Surg. April 2006;8(2):73-84. 63 cats.
Nutrition for Diabetic CatsNutrition for Diabetic Cats
Since 2001• Goal of treatment is remission rather than merely good
control• Achieved by using low carb-high protein diets with long
acting insulin (glargine - Lantus)• 1998 ACVIM article - median survival 2 years• Some papers have reported remission rate as high as
68%• Chances of remission increases four-fold by feeding low
carb-high protein diet
Nutrition for Diabetic CatsNutrition for Diabetic Cats
Use of a High-Protein Diet in the Management of Feline Diabetes Mellitus. Vet Ther 2[3]:238-246 Summer'01 Clinical Study 14 Refs. G Frank; W Anderson; H Pazak; E Hodgkins; J Ballam; D Laflamme.
The Effect Of High Protein, High Fat Or High Carbohydrate Diets On Postprandial Glucose And Insulin Concentrations In Normal Cats. ACVIM 2002. H A Farrow, J S Rand, G D Sunvold.
Use of glargine and lente insulins in cats with diabetes mellitus. J Vet Intern Med. 2006 Mar-Apr;20(2):234-8. KE Weaver, EA Rozanski, OM Mahony, DL Chan, LM Freeman.
Nutrition for Diabetic CatsNutrition for Diabetic Cats
Ideal diet for diabetic cats• >40% protein and <8% carbs, as % of calories• A little different from DM basis (fat is 2x as calorie
dense as protein & carbohydrate)• Only one dry diet on the market that fits the bill
– Innova EVO (California Naturals - Natura)– Purina DM and Hill’s R Diet M/D dry - 15% carbs, protein
OK
• Many commercial canned diets fit the bill– Handout
Nutrition for Diabetic CatsNutrition for Diabetic Cats
Myth #1: Diabetic cats should be meal fed if they are to be well regulated
• Fresh food BID – allowed to eat ad lib• Multiple small meals eaten throughout the day and night • 24 hour glucose curve done (q2h)• no correlation between blood glucose and the amount
of food consumed over the previous 2-h • overnight fast did not significantly alter morning blood
glucose
J Feline Med Surg. 1999 Dec;1(4):241-51. Food intake and blood glucose in normal and diabetic cats fed ad libitum. Martin GJ, Rand JS.
Nutrition for Diabetic CatsNutrition for Diabetic Cats
Myth #2: You shouldn’t give insulin to pets who aren’t eating
• If glucose >300 for any period of time, insulin needs to be given to prevent diabetic ketoacidosis
• Dogs and cats with DKA will remain acidotic until they get insulin
• If you are chicken, give small amounts only as needed • A small amount of insulin can do a great deal of good in
a DKA patient
Nutrition for Diabetic CatsNutrition for Diabetic Cats
Flop• Day 0
– not feeling well, abscess on toe, Tx clindamycin PO BID
• Day 3– still not feeling well, not eating– UA shows ketones and glucose, blood glucose 298– Treated with IV fluids and IV antibiotics– No insulin given because not eating
• Day 6– Very weak, vomiting blood– BUN 41, glucose 290, venous pH 7.035, K+ <2.0, Phos 1.6– Diabetic ketoacidosis with pancreatitis
Annual VaccinationAnnual Vaccination
Appropriate for bacterins• Leptospirosis• Bordetella• Lyme Disease (in endemic areas)
Reasonable for Feline Leukemia• No published studies investigating
duration of immunity beyond 1 year
Annual VaccinationAnnual Vaccination
In 1978, University of WI-Madison recommended ideal MLV protocol
• Puppy/kitten series, boost a 1 year of age• Then every 3 years
No one is recommending that we don’t vaccinate
• puppy/kitten vaccines, and boosters at 1 year are crucial
• We shouldn’t overvaccinate adult pets
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)• Rabies
– Vaccine manufacturers have known for decades that rabies vaccines protect very well for at least 3 years
– They are under no obligation to share any data they may have that shows longer DOI
– Only 5 states have ever required use of rabies vaccine more often than on the label
– The rest of the world has used rabies vaccines according to the label for more than 50 years with exceedingly rare vaccine failure
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)• Rabies
– No person has ever contracted rabies from any domestic animal that has ever received a rabies vaccine
– 1-year and 3-year vaccines are in almost all cases the same vaccine
– 1999 – RD Schulz DOI Study • single rabies vaccine given to puppy• no booster at 1 year of age• 95%+ protection by challenge at 3 years• 95%+ protection by titers at 7 years
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)
• Distemper– Vaccinated or not, it is exceedingly rare for
adult dogs to get this disease– Don’t confuse “old dog distemper” with active
disease– 1999 – RD Schulz DOI Study
• single distemper vaccine given to puppy• no boosters• 95%+ protection by challenge at 5-7 years• 95%+ protection by titers at 9-15 years
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)• Parvovirus
– Vaccinated or not, it is exceedingly rare for adult dogs to get this disease
– 1999 – RD Schulz DOI Study • single parvo vaccine given to puppy• no boosters• 95%+ protection by challenge at 7 years
– Giving parvo boosters every 6 months• started in the 70’s when panleukopenia
vaccines were given to dogs• Not based on any study - empirical
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)
• Canine Infectious Hepatitis– 1999 – RD Schulz DOI Study
• single CAV-1 vaccine given to puppy• no boosters• protection by challenge at 7 years• Protection by titers at 9 years
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)• Feline Parvovirus (panleukopenia)
– Vaccinated or not, it is exceedingly rare for adult cats to get this disease
– 1999 –Scott & Geissinger DOI Study • SPF cats vaccinated at 8 & 12 weeks• no boosters• 95%+ protection by challenge at 7.5 years• Protection also evaluated by titers
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)• Feline Calicivirus (FCV)
– Considerable genetic variation results in resistant strains
– Multivalent vaccines may be more effective– Vaccine does not prevent infection, just
minimizes clinical signs– Does not eliminate the carrier state– 1999 –Scott & Geissinger DOI Study
• SPF cats vaccinated at 8 & 12 weeks• no boosters• Titers begin falling after 3-4 years• 63% protection by challenge at 7.5 years
Annual VaccinationAnnual Vaccination
Duration of Immunity (DOI)• Feline Herpesvirus (FHV-1)
– Vaccine does not prevent infection, just minimizes clinical signs
– Does not eliminate the carrier state, though period of shedding is shortened
– 1999 –Scott & Geissinger DOI Study • SPF cats vaccinated at 8 & 12 weeks• no boosters• Titers begin falling after 3-4 years• 52% protection by challenge at 7.5 years
Annual VaccinationAnnual Vaccination
Adverse Reactions to vaccines• Attention began in 1990’s with the first
articles associating vaccines with IMHA and VAS
• 1999 – DOI studies published• Vaccinating older dogs and cats
– Adverse reactions to vaccines may be significantly more likely than getting the disease
– FPV, CPV, CDV, ICH
Annual VaccinationAnnual Vaccination
Adverse Reactions to vaccines• Life threatening:
– acute anaphylaxis– vaccine associated sarcomas
• 22,000 cases per year• Risk is 1 in 10,000
– post vaccinal encephalitis • CDV and CAV• especially MLV in pups <6 weeks
– IMHA
Annual VaccinationAnnual Vaccination
Adverse Reactions to vaccines• Life threatening:
– post-vaccinal infection• Increased virulence of vaccine• Patient immunosuppression• Greyhounds - hot CDV vaccine• Snyder Hill CDV on exotic animals
– fetal malformation/abortion – hypertrophic osteodystophy
• especially Weimeraners
Annual VaccinationAnnual Vaccination
Adverse Reactions to vaccines• Potentially serious:
– local allergic reaction • Swelling of face, paws, hives
– Panniculitis - rabies – Puppy strangles– Vaccine contamination
• No preservatives in MLV• Mycoplasma has been found in vaccines• CAV has been isolated from feline vaccines• Canine parvo conspiracy theory
Annual VaccinationAnnual Vaccination
Adverse Reactions to vaccines• Potentially serious:
– multifocal ischemic dermatopathy - rabies– hypothyroidism – Facial/nasal dermatitis, stomatitis - IN – Polyarthritis– Vaccines given by wrong route
• IN vaccines given SC– Inflammatory disease– Liver failure and occasionally death
• SC vaccines given IN – Severe necrosing facial/nasal dermatitis
Annual VaccinationAnnual Vaccination
Adverse Reactions to vaccines• Usually self-limiting:
– Itching, redness, sneezing– Pain, soreness, lethargy fever– Local reaction
• Swelling• Ulceration, irritation, Hair loss
– Thrombocytopenia• CDV MLV
– Behavior changes
Annual VaccinationAnnual Vaccination
Vaccination protocols• Titers validated for all but rabies• Vaccine manufacturers guarantee MLV
vaccines for 3 years– Including FeLV
• All vet schools in US for 10 yrs+– triennial vaccination for MLV vaccines
• AAFP, AAHA, ACVIM, AVMA and TVMA reports – extended vaccine intervals
AAFP Report AAHA Report
Annual VaccinationAnnual Vaccination
Vaccination protocols• Nov 2005 - TSBVME Policy on
Vaccination an Informed Consent– Followed Feb 2003 open letter and Nov 2004
Reminder to review vaccine protocols– Reminds DVMs to stay informed– DVMs must communicate possible adverse
vaccine reactions and get informed consent– Must be documented in the record– Specifically recommends against CCV
It takes less time to do things right It takes less time to do things right than to explain why you did it than to explain why you did it wrong.wrong.
----Henry Wadsworth LongfellowHenry Wadsworth Longfellow