Today Veterinary Magazine March 2013

A Peer-Reviewed Journal
GI InterventIon
The Vomiting Patient
neuroloGIc
examInatIon
Abnormal Findings
veterInary
DermatoloGy
Five Common
Mistakes
conSIDer
tHIS caSe
Estrus in a
Spayed Cat
ImaGInG
eSSentIalS
Cervical
Spine
March/April 2013 Volume 3, Issue 2
Dental
DIaGnoSIS
Canine Tooth
Fracture
top ten
Toxicoses in
Dogs & Cats
Presorted Standard
U.S. Postage Paid
Lebanon Junction, KY
Permit No. 794
Subscribe FREE at tvpjournal.com/subscribe
vItal vaccInatIon
Rabies Virus
Get tough on Lyme disease
with a 12 punch.
Nobivac Lyme knocks out OspA, then knocks out
OspC, providing patients with two-fsted protection.
To see Nobivac Lyme
in action
VIeW THe VIDeOS AT
www.merck-animal-health-usa.com/lyme
Reference: 1. LaFleur RL, Dant JC, Wasmoen TL, et al. Bacterin

that induces anti-OspA and anti-OspC borreliacidal antibodies
provides a high level of protection against canine Lyme disease.
Clin Vaccine Immunol. 2009;16(2):253259.
Copyright 2012 Intervet Inc., a subsidiary
of Merck & Co., Inc. All rights reserved. Intervet Inc.
d/b/a Merck Animal Health, Summit, NJ 07901.
MAH-VC-638a
12499
The Borrelia that cause Lyme disease are pretty tricky villains to conquer.
Just when you think you have outer surface protein A (OspA) under
control, it down-regulates and OspC kicks in. Thats why it takes a
dual-acting vaccine like Nobivac Lyme with proven borreliacidal
activity against both OspA and OspC to be successful in the fght
against Lyme disease.1
Without protection against OspC, a Lyme vaccine just isnt in the
heavyweight class. So get tough on Lyme and protect your patients
with the vaccine thats a known champion.
PUBLisHer
Nick Paolo
npaolo@todays
veterinarypractice.com
eDitoriaL DireCtor
Kelly Soldavin
267-228-1640
ksoldavin@todays
art DireCtor
Diane Paolo
dpaolo@todays
saLes & marKetinG

DireCtor
Renee Luttrell
610-558-1819
rluttrell@todays
assistant editor: Amanda Wright
Graphic Designer: Courtney Ballauer
SUBSCRIPTIONS 800-789-6861
subscriptions, Vetmed Communications, inc,
Po Box 390, Glen mills, Pa 19342-0390
subscriptions@todaysveterinarypractice.com
(attach subscription) or fax 610-558-1437
FREE subscription only to qualifying subscribers.*
For a new subscription, confirmation or renewal please
visit todaysveterinarypractice.com/subscriptions to
fill out an online form or download a PDF form. Please
include your subscription ID number on the subscription
form, confirmation or renewal.
Change Name/Address or Cancel: Contact us by
phone, fax or email coa@todaysveterinary practice.
com. Please provide the ID number (directly above your
name on label) for positive identification. If the ID# is
not available or legible, provide name and address as
it appears on the label to allow identification of the
subscription.
*Qualifying Subscribers: Veterinarians, veterinary
technicians, veterinary faculty, and third- and
fourth-year veterinary students in the U.s. Vetmed
Communications, inc reserves the right to determine
eligibility for a free subscription.
eDitor in CHieF
Lesley G. King, MVB,
Diplomate ACVECC, ACVIM
(Small Animal Internal Medicine),
& ECVIM (Companion Animal)
University of Pennsylvania
College of Veterinary Medicine
editorinchief@todays
ContriBUtinG meDiCaL
eDitor
travis meredith, DVM, MBA,
Diplomate ACT
tmeredith@todays
eDitoriaL aDVisorY BoarD

P. Jane armstrong, DVM,
MS, MBA, Diplomate ACVIM
(Small Animal Internal Medicine)
University of Minnesota
mark Cofone, VMD,

Diplomate ACVS
Veterinary Specialty Center
Wilmington, Delaware
sheila Grosdidier, RVT, PHR

Veterinary Management
Consultation
Evergreen, Colorado
rosemary Lombardi, CVT,

VTS (ECC)
University of Pennsylvania
Ryan Veterinary Hospital
Garret Pachtinger, VMD,

Diplomate ACVECC
Veterinary Specialty &
Emergency Center
Levittown, Pennsylvania
michael schaer, DVM,

Diplomate ACVIM & ACVECC
University of Florida
eDitoriaL Peer reVieW BoarD

Kenneth abrams, DVM, Diplomate ACVO
Clarke atkins, DVM, Diplomate ACVIM
Brett Beckman, DVM, FAVD, Diplomate AVDC
& AAPM
Paul Bloom, DVM, Diplomate ACVD & ABVP
(Feline & Canine Practice)
Dwight D. Bowman, MS, PhD
regina J. Brotherton, DVM, CCRP, PhD
Camilo Bulla, DVM, MS, PhD
terry marie Curtis, DVM, MS, Diplomate
ACVB
michael J. Dark, DVM, PhD
Craig Datz, DVM, Diplomate ABVP (Canine &
Feline Practice) & ACVN
mark epstein, DVM, Diplomate ABVP (Canine
& Feline Practice) & AAPM
Derek Fox, DVM, PhD, Diplomate ACVS
Laura Garrett, DVM, Diplomate ACVIM
(Oncology)
Frederic P. Gaschen, DrMedVet, Diplomate
ACVIM (Small Animal Internal Medicine) &
ECVIM (Companion Animal)
Gregory F. Grauer, DVM, MS, Diplomate
ACVIM (Small Animal Internal Medicine)
Deborah Gross saunders, DPT, MSPT, OCS,
CCRP, Diplomate ABPTS
Debra F. Horwitz, DVM, Diplomate ACVB
sandra Koch, DVM, MS, Diplomate ACVD
angela Lennox, DVM, Diplomate ABVP (Avian)
steve martinez, DVM, MS, Diplomate ACVS
Kathryn michel, DVM, MS, Diplomate ACVN
mark oyama, DVM, Diplomate ACVIM
(Cardiology)
mark Papich, DVM, MS, Diplomate ACVCP
r. michael Peak, DVM, Diplomate AVDC
Lysa P. Posner, DVM, Diplomate ACVA
Jody D. ray, DVM, MS
ernest rogers, DVM, PhD
margaret root Kustritz, DVM, PhD,
Diplomate ACT
rose raskin, DVM, PhD, Diplomate ACVP
elizabeth rozanski, DVM, Diplomate ACVIM &
ACVECC
margie scherk, DVM, Diplomate ABVP (Feline
Practice)
J. Catharine scott-moncrieff, VetMB, MS,
MA, Diplomate ACVIM & ECVIM
Claire sharp, BSc, BVMS (Hons), MS, CMAVA,
Diplomate ACVECC
Jrg steiner, MedVet, DrMedVet, PhD,
Diplomate ACVIM & ECVIM (Companion
Animal)
Charles H. Vite, DVM, PhD, Diplomate ACVIM
(Neurology)
Jennifer L. Wardlaw, DVM, MS, Diplomate
ACVS
tina Wismer, DVM, Diplomate ABVT & ABT
James Young, DVM
Warranties, Limitations. except as expressly set forth herein, Vetmed Communications, inc (VmC) makes no warranties whatsoever, express, implied, or statutory. VmC specifically
disclaims any implied warranty of merchantability or fitness for particular purpose. in no event will VmC be liable to you or any third party, for any indirect, punitive, special, incidental, or
consequential damages (including loss of profits, use, data, or other economic advantage), however it arises, even if VmC has previously been advised of the possibility of such damage. all
rights reserved. no part of this publication may be reproduced in any form without written permission from the publisher. entire contents 2012 Vetmed Communications, inc.
March/April 2013 Todays Veterinary Practice
Contents
March/April 2013 Vol 3, No 2
FeATuRes
Cover Story
GI INTERVENTION: APPROACH TO DIAGNOSIS & THERAPY OF
THE VOMITING PATIENT
18
P. Jane Armstrong, DVM, MS, MBA, Diplomate ACVIM

Vomiting is a common clinical complaint in both dogs and cats and a clinical
sign common to diseases of many body systems. Management includes
controlling vomiting, addressing underlying causes, and correcting fluid and
electrolyte abnormalities.
26
IN-CLINIC TABLE
MEDICATIONS FOR ACUTE VOMITING: DOGS & CATS
This comprehensive table outlines drugs commonly used to manage acute vomiting
in dogs and cats, including antiemetic, gastroprotectant and cytoprotective, and
prokinetic agents, organized by classifaction, use, and dose.
34
40
HOW TO AVOID THE FIVE MOST COMMON MISTAKES IN VETERINARY DERMATOLOGY

Lori A. Thompson, DVM, Diplomate ACVD
Discover the five pitfalls most commonly encountered by practitioners when

diagnosing and treating dermatologic conditions in dogs and cats, while learning
how to fine tune your approach to history taking, biopsies, skin scrapings, and
antibiotic selection.
THE NEUROLOGIC EXAMINATION IN COMPANION ANIMALS

PART 2: INTERPRETING ABNORMAL FINDINGS
Helena Rylander, DVM, Diplomate ACVIM (Neurology)
Once a neurologic examination has been completed in a patient, the practitioner

can use the abnormalities, or lack thereof, to help localize the lesion to the brain,
spinal cord, peripheral nervous system, or cauda equine, which provides critical
information on the patients condition.
46
IN-CLINIC TABLE
LESION LOCATION ORGANIZED BY NEUROLOGIC ASSESSMENT & FINDINGS
This chart organizes neurologic findings by the seven assessment tests discussed
in The Neurologic Examination in Companion AnimalsPart 1: Performing the
Examination; then provides potential anatomic locations of neurologic disease
indicated by the findings.
todaysveterinarypractice.com facebook.com/todaysveterinarypractice
Todays Veterinary Practice (ISSN 2162-3872 print and ISSN 2162-3929 online) does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products
and claims contained therein. The publisher, VetMed Communications, Inc (VMC), disclaims any liability for any damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective authors and do not necessarily represent
the opinions of VMC nor its Editorial Advisory Board. VMC does not guarantee nor make any other representation that the material contained in articles herein is valid, reliable, or accurate;
nor does VMC assume any responsibility for injury or death arising from any use, or misuse, of same. There is no implication that the material published herein represents the best or only
procedure for a particular condition. It is the responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly
available. Todays Veterinary Practice is published Jan/Feb, Mar/Apr, May/June, Jul/Aug, Sept/Oct, Nov/Dec (6x per year) by VetMed Communications, Inc, PO Box 390, Glen Mills, PA. 19342.
Todays Veterinary Practice March/April 2013
NEW
*
The TOPICAL ALTERNATIVE for flea and tick control that lasts 8 MONTHS
THE PERFORMANCE YOU EXPECT FROM

A TOPICAL, IN AN EASY-TO-USE COLLAR.
*After day 2, 97.7 100% efficacy against C. felis (dog and cat), I. scapularis (dog)
and A. americanum (cat) was achieved for 8 months.1
Bayers sustained release technology combines two eective

active ingredients, IMIDACLOPRID + FLUMETHRIN
Kills ticks on DOGS OR CATS within 48 hours and
repels and kills reinfesting ticks in as quickly as 6 hours
Quickly kills eas on DOGS OR CATS within 24 hours
and reinfesting eas within 2 hours
1
Data on file.
2013 Bayer HealthCare LLC, Animal Health Division, Shawnee Mission, Kansas 66201
Bayer (regd), the Bayer Cross (regd) and Seresto are trademarks of Bayer. S13017
www.BayerDVM.com
Contents
March/April 2013 Vol 3, No 2
ColuMNs
6 Editors Note
7 Advertiser Index
8 Letters to the Editor
10 Todays Veterinary News
77 Journal Club: Focus on Endocrinology
57 VITAL VACCINATION SERIES

What You Need to Know About Rabies
Richard B. Ford, DVM, MS, Diplomate
ACVIM & ACVPM (Hon)
Dr. Ford presents nine key questions that

address rabies immunization. The answers
address which agencies handle rabies law,
the definitions of exposure and vaccinated,
appropriate diagnostic testing, and more.
28
17 PRODUCT PROFILE
Common Heartworm Preventive &
Intestinal Parasite Medications for
Dogs & Cats
61 CONSIDER THIS CASE

Estrus in a Spayed Cat
This table is the third in our

Product Profile series on parasite
preventives, which provide products
manufacturers, ingredients, species
specifications, and indications.
Erin O. Dresner, DVM, MS, and Gary D.

Norsworthy, DVM, Diplomate ABVP (Feline)
An aging spayed female cat is presented

with signs typical of estrus. A history, physical
examination, and extensive diagnostics are
performed. Can you determine the diagnosis?
50
28 PRACTICE TO PRACTICE
Promoting Parasite Prevention
in Practice
65 NEW DENTAL DIAGNOSIS

Canine Tooth Fracture
Kelly Soldavin
Brook A. Niemiec, DVM, FAVD,

Diplomate AVDC
Todays Veterinary Practice interviewed

Madeleine Womble, the Hospital
Manager at Central Veterinary Hospital
in Knoxville, to learn about how this
busy veterinary practice implements
effective parasites prevention
strategies for their patients.
61
A picture is worth 1000 words, and the

challenge is to determine what type of tooth
fracture is shown in this article as well as the
appropriate therapeutic action.
67 TOP TEN
Toxicoses in Dogs & Cats
48 HEARTWORM HOTLINE
Tina Wismer, DVM, Diplomate ABVT & ABT
The American Heartworm Society

& You
In honor of Poison Prevention Week, Dr.

Wismer of the ASPCAs Poison Control
Center reviews information gathered from
over 180,000 cases to name the top ten
types of poisonings in 2012.
Wallace Graham, DVM
April is National Heartworm Awareness

Month and Dr. Graham, President of
the American Heartworm Society,
tells readers about the ways the AHS
provides information about prevention
and treatment of heartworm disease.
72 TODAYS TECHNICIAN
Assisting the Surgeon: Practical Strategies
for Preventing Nosocomial Infections
67
Noah Jones, RVT
50 IMAGING ESSENTIALS
Postoperative patients are among those

at highest risk for nosocomial infection.
Strategies for disinfecting personnel,
equipment, and the surgical suite are
meticulously outlined.
Small Animal Spinal Radiography

Series: Cervical Spine
Radiography
Danielle Mauragis, CVT, and Clifford R.
Berry, DVM, Diplomate ACVR
Proper technique for routine lateral

and dorsoventral projections as well
as flexed, extended, and oblique
views, is described for cervical and
cervicothoracic radiography.
80 THE BACK PAGE

The Future of Veterinary Medicine
Makes Headlines
72
A Response From Our Editorial Team
todaysveterinarypractice.com facebook.com/todaysveterinarypractice
4
EdiTors NoTE
Dogs Can Get

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

Medicine), & ECVIM (Companion Animal)
ow many of us have
been asked questions
about pet health as
soon as someone finds out
that we are veterinarians?
I was sitting in my doctors office recently, listening to a
nurse tell me about her beloved Yorkie and its worsening
cough. When I commented that her veterinarian might be
able to evaluate the dog for common conditions, such as
collapsing trachea or chronic bronchitis, she looked at me
in surprise and said, Dogs can get chronic bronchitis?
Im sure that many others have had similar experiences,
when both human medical professionals and the lay
public are astonished to find out that animals can suffer
from the same disease conditions as people.
The Knowledge Gap
It is frustrating to confront this misconception. To me, it
suggests that these individuals have not given a great deal
of thought to the similarity of body systems between species. If the pet has a trachea and bronchi, why wouldnt
chronic bronchitis be a possibility, just as it is in that other
animal, the human being?
The sad truth is that many members of the public, including educated medical professionals, dont recognize that
their much loved pets can be afflicted by diseases that also
affect humans. Further, they dont realize that many of these
conditions can be treated, thereby improving the quality
and duration of life of their pets.
This lack of understanding can also manifest as a lack of
respect for veterinary professionals, especially in comparison to the esteem ascribed to human medical professionals.
Promoting the Profession
This combined lack of knowledge and respect regarding veterinary medicine and its professionals highlights
the need for more successful marketing of the profession,
including ourselves. Lately, this has been a hot topic on
some online veterinary list servers (emails that facilitate
discussions among members of a group).
It seems that we, as a profession, might be able to seize
an opportunity: if we can make a special effort to communicate, educate, and collaborate with our human medicine
counterparts, we could advance their understanding of
animal illness and health and the role veterinarians play in
diagnosis and treatment, thereby enhancing our visibility
and status within the community.
6
Uniting Medical Professionals

Thats one of the reasons why I am very interested in the
One Health initiativea worldwide effort to promote,
improve, and defend the health and well-being of all species
by enhancing cooperation and collaboration between physicians, veterinarians, and other scientific health and environmental professionals. This exciting international movement
complements the efforts of individual veterinary professionals to communicate with and educate those outside the profession, especially fellow medical colleagues.
The primary goals of this initiative are to:
Advance biomedical research
Enhance public health with regard to zoonotic and
infectious disease.
It is hoped that if we can open doors of communication between all health-related professions, we can facilitate the discoverydevelopmentdelivery paradigm and,
therefore, accelerate progress in clinical care and medical
education within all disciplines.
Health Care Leadership
Veterinarians have a long track record of using diagnostic tests and therapies that have first been developed and
applied in people. And, of course, research in animals
is routinely used to study human illness and treatment.
But, consider how exciting it would be for veterinarians
to lead health care by developing and testing therapies
in pet animals with naturally occurring diseases that can
then be extrapolated to humans with the same diagnosis.
If the goals of the One Health initiative are achieved, we
can look forward to a future in which the medical community works closely together, with a better understanding
about the similarities between animal and human disease
and the challenges each present.
Im sure those questions about pet health that follow the
disclosure that Im a veterinarian will never go away, but
wouldnt it be wonderful if the questioner wasnt surprised
to find out that dogs can get chronic bronchitis?
Lesley King, Editor in Chief
read more about the One Health Initiative at
onehealthinitiative.com. The One Health 4th Annual
Public Health Symposium takes place April 2, 2013, at
Colorado state University; learn more at publichealth.
colostate.edu/GPPH/2013Symposium.pdf.
AdVerTiser index |
Advertiser Index
Air National Guard, 47
Veterinary Careers
800-598-4759
airguardjobs.com
AllPro Imaging, 53
scanx duo
allproimaging.com/healthcare
Bayer HealthCare Animal
Health Division, 3
seresto
www.BayerdVM.com
Bio-Response Solutions, 16
PeT400 Alkaline Hydrolysis
system
800-253-3684
bioresponsesolutions.com
Elanco, 56, 55
Trifexis Parasite Protection
888-545-5973
trifexis.com/vet
Hills Pet Nutrition, 5
Prescription diet Metabolic
Advanced Weight solution
hillsvet.com/metabolic
Hills Pet Nutrition, 7
Healthy Weight Protocol
diagnostic Tool
hwp.hillsvet.com
IDEXX Laboratories, 60
snap 4dx Plus Test
idexx.com/snap4dxplus
Merck Animal Health, inside
front cover
nobivac Lyme Vaccine
merck-animal-health-usa.com/
lyme
Merck Animal Health, 25
Activyl (for dogs and cats)
us.activyl.com
Merck Animal Health, 27

Activyl TickPlus (for dogs only)
us.activyl.com
Merial, 9
Previcox
previcoxsweepstakes.com
Merial, 11
recombitek Lyme Vaccine
merialconnect.com
Merial, 13
PureVax Feline rabies Vaccine
merialconnect.com
Merial, 15
Frontline Tritak for dogs
(select states)
frontlinetritak.com
Frontline Plus for dogs
(select states) frontline.com
Merial, back cover, inside back
Heartgard Plus
heartgard.com
Midmark, 64
Veterinary dental equipment
800-MIDMARK
midmarkanimalhealth.com
Novartis, 45
Parastar Plus
dogsneedAdventure.com
Putney, 39
Cefpodoxime Proxetil
866-683-0660
putneyvet.com/howtobuy
Todays Veterinary Practice, 71
Website tvpjournal.com
Virbac, 31, 32
iverhart Max
800-338-3659 virbacvet.com
Virbac, 33, 32
easOtic suspension
800-338-3659 virbacvet.com
March/April 2013
Todays Veterinary Practice
LeTTers To The ediTors
Internal Medicine Pearls Rocked

Dear Editor,
I wanted to send a quick note to say that I
thought Dr. Michael Schaers article, Internal
Medicine Practice Pearls (September/October 2012) was the most concise and valuable
piece of veterinary literature I have read in a
long, long time. As the newbies would say, it
rocked! I read every article and thought they
were all excellent. Great issue! Thanks and keep
it up!
Krista Magnifico, DVM
Jarrettsville Veterinary Center
Jarrettsville, Maryland
When to Give Bordetella Boosters

Dear Editor,
I read the article, Canine Vaccination Guidelines:
Key Points for Veterinary Practice (September/
October 2012) by Dr. Richard B. Ford and would
like to ask him a question:
Our veterinary clinic currently administers an initial intranasal or oral vaccine for Bordetella; only 1
initial vaccine is given. Subsequently, we administer
an injectable Bordetella vaccine on an annual basis,
with only 1 vaccine given annually.
Should we be administering a booster of the injectable Bordetella vaccine 2 to 3 weeks after the original injectable vaccine is given? We have assumed
that the pet has an anamnestic response from the
initial nasal/oral vaccine; therefore, we do not
adminster a booster after the injectable is given.
Jerry L. Pearson, DVM
Chillicothe Animal Clinic, Inc
Chillicothe, Ohio
Author Responds
The concept of vaccinating dogs against Bordetella
bronchiseptica infection using an initial intranasal (IN)
dose, followed by annual boosters using the parenteral (monovalent) Bordetella vaccine was advanced over
10 years ago following publication of 2 papers.1,2
However, in 2007, those conclusions were challenged.3
Today, most authors conclude that mucosal (local) immunity derived from IN administration of avirulent live
B bronchiseptica provides a superior level of protective
immunity compared to parenteral administration of a
(inactivated) cellular antigen extract. Recommendations
outlined in the 2011 AAHA Canine Vaccination Guidelines
(available at aahanet.org) reflect these findings.
In addition, while both parenteral and IN vaccines

have been shown to mitigate clinical signs in vaccinates following natural and experimental challenge,
postexposure shedding (of virulent B bronchisep8
tica) is significantly reduced (or

eliminated) in dogs vaccinated
with a single dose of IN vaccine.
However, dogs vaccinated with
the parenteral B bronchiseptica
vaccine experienced shedding
patterns comparable to unvaccinated controls.
The oral B bronchiseptica vaccine was licensed in 2012 and
has not yet been subjected to
comparative efficacy studies.
Other points to consider when
vaccinating dogs against canine infectious respiratory disease (kennel cough) include:
Multiple pathogens other than B bronchiseptica can
cause acute-onset respiratory signs.
Coinfection and comorbidity can be significant factors
in the clinical course of disease.
Most of the IN B bronchiseptica vaccines also contain
attenuated parainfluenza virus, an important cofactor
in canine respiratory infections. Neither the oral nor the
parenteral B bronchiseptica vaccines provide protection against parainfluenza virus. This is an important
consideration when selecting vaccines for dogs housed
in high-density environments (eg, animal shelters, day
care facilities, etc).
Onset of immunity: dogs are protected against B bronchiseptica following administration of a single dose of
either an IN vaccine or the oral vaccine. When administering the parenteral vaccine, 2 initial doses, 2 to 4
weeks apart, are essential.
The duration of immunity against B bronchiseptica
challenge, following administration of a single dose of
the IN vaccine, has been shown to be 12 to 14 months.
The duration of immunity following oral or parenteral
vaccination is not known.
Richard B. Ford, DVM, MS,
Diplomate ACVIM & ACVPM (Hon)
North Carolina State University
References
1. Ellis JA, Haines DM, West KH, et al. Effect of vaccination on experimental
infection with Bordetella bronchiseptica in dogs. JAVMA 2001; 218:367-375.
2. Ellis JA, Krakowka SG, Dayton AD, et al. Comparative efficacy of an injectable vaccine and an intranasal vaccine is stimulating Bordetella bronchiseptica-reactive antibody responses in seropositive dogs. JAVMA 2002;
220:43-48.
3. Davis R, Jayappa H, Abdelmagid OY, et al. Comparison of the mucosal
immune response in dogs vaccinated with either an intranasal avirulent live
culture or a subcutaneous antigen extract vaccine of Bordetella bronchiseptica. Vet Therap 2007; 8:32-40.
Enter today at
PREVICOXsweepstakes.com
You make a difference for your patients every day

we want to help make a difference for you!
Enter for your chance to win:

$10,000 for you,
$10,000 for your practice and
$10,000 for your alma mater!
PREVICOX is a registered trademark of Merial.
2013 Merial Limited, Duluth, GA. All rights reserved.
PVX13PRDIFFERAD (02/13).
Ask your Merial Representative or visit

PREVICOXsweepstakes.com for details and official rules.
Todays VeTerinary news
The Latest News in Veterinary Medicine

ANNOUNCEMENTS
National Pet ID Week

April 14 through 20 is National Pet ID Week,
which provides the perfect opportunity for
practices to emphasize the importance of pet
identification to clients. In addition to identification tags on collars, microchips offer a permanent identification solution. Remind owners, however, that just implanting
the microchip is not enoughthey need to make sure their pets are registered
and contact information keep up to date with the microchip manufacturer. The
AAHAs website, HealthyPet.com, addresses 8 common myths about microchipping at healthypet.com/petcare/petcarearticle.aspx?title=microchipping.
NEW PRODUCTS
Generic Cefpodoxime
Proxetil Introduced
Putney (putneyvet.com)
Pfizer Animal Health Becomes Zoetis

Pfizer, Inc, sold its former animal health business
unit and is now a standalone company named Zoetis
(zoetis.com), which began trading on the New York
Stock Exchange in February. With the Zoetis initial public offering, we are
creating the largest standalone company fully devoted to animal health medicines
and vaccines. For Pfizer, we are better positioned to focus on our core business
as an innovative biopharmaceutical company. said Ian Read, Chairman and Chief
Executive officer of Pfizer.
has introduced its generic

form of cefpodoxime proxetil tablets, which are FDAapproved for veterinary use
and available in 100- and
200-mg tablets in 100-count
bottles. Currently, only 6% of
FDA-approved brand name
pet medications have a ge-
Canine Cancer Treatments in Development
neric equivalent compared
Abbott Animal Health (abbott.com) has expanded its veterinary oncology

pipeline through an exclusive agreement with Oasmia Pharmaceutical AB. The
agreement grants Abbott global distribution
rights to Paccal Vet and Doxophos Vet, two
human-grade cancer treatments in development
for use in dogs. Paccal Vet and Doxophos Vet are
novel formulations containing paclitaxel, a frequently used chemotherapeutic
agent, and doxorubicin, a common anticancer medication in human and
veterinary oncology, respectively. We are pleased that this agreement will allow
us to potentially introduce new [canine] cancer treatment options not only in
North America but throughout the world, said Andrea Wainer, divisional vice
president and general manager, Abbott Animal Health.
to more than 80% of human

generic prescription drugs.
Putney is specializing in developing high-quality, generic medications for pets with
carprofen caplets and ketamine HCl for injection C-III
available as well. Additional
information is available on
the companys website.
Please send any news, press releases, or information relevant to veterinary professionals to KSoldavin@
todaysveterinarypractice.com for publication consideration in Todays Veterinary News.
For more veterinary news, go to Facebook.com/TodaysVeterinaryPractice
10
Give dogs all the Lyme protection they need

and none of the antigens they dont.
It only takes a single protein, OspA, to block the transmission of Borrelia burgdorferi in the United States.1,2,3
Protect your patients with nothing less, expose them to nothing more.
RECOMBITEK Lyme - the only vaccine with OspA in a nonadjuvanted formula

1
RECOMBITEK is a registered
trademark of Merial. 2012
Merial Limited, Duluth, GA.
All rights reserved.
REC12NARECOMBITEKAD (12/12).
Straubinger RK, Chang YF, Jacobson RH, Appel MJ. Sera from OspA-vaccinated dogs, but not those from tick-infected dogs,
inhibit in vitro growth of Borrelia burgdorferi. J Clin Microbiol. 1995;33(10):2745-2751.
Rice Conlon JA, Mather TN, Tanner P, Gallo G, Jacobson RH. Effcacy of a nonadjuvanted, outer surface protein A, recombinant
vaccine in dogs after challenge by ticks naturally infected with Borrelia burgdorferi. Vet Ther. 2000;1(2):96-107.
Probert WS, Crawford M, Cadiz RB, LeFebvre RB. Immunization with outer surface protein (Osp) A, but not OspC, provides
cross-protection of mice challenged with North American isolates of Borrelia burgdorferi. J Infect Dis. 1997;175(2):400-405.

ANNOUNCEMENTS
NEW PRODUCTS
New Name for Brushless Oral Care
Canine Oncology Therapy
PKB Animal Health, Inc (petkingbrands.com), has announced that

their Biotene Veterinarian Brushless Oral Care line for pets has changed
its brand name to Oratene Veterinarian
Brushless Oral Care. These brushless
products reduce odor-causing bacteria
and dissolve plaque biofilm, which
is accomplished through a patented
enzyme system. The Oratene line
includes a maintenance oral gel, breath
freshener spray, drinking water additive,
and antiseptic oral gel; all are safe for
dogs and cats and available exclusively
through veterinarians.
Bioniche Life Sciences, Inc, a research-based Canadian biopharmaceutical company, introduced

Immunocidin canine oncology
therapy to the North American
market. Immunocidin is an im-
VCA West Los Angeles Opens New Hospital

Early this year, VCA West Los Angeles (vcahospitals.com/west-losangeles) opened its newly-constructed, 42,000 square feet animal
hospital, making it the largest
small animal hospital in the
western United States. The new
hospital features state-of-theart diagnostic and treatment
features, including a linear
accelerator room for cancer patients, MRI and CT imaging, physical
therapy center, bone marrow transplant technology, pituitary tumor
surgery facilities, and cutting edge surgical suites. The hospital is staffed
by board-certified specialists in all areas of veterinary medicine. Were
excited to bring this level of veterinarian services to the pet owners and
referring veterinarians of West Los Angeles and surroundings areas, said
Dr. David Bruyette, VCA West Los Angeles Medical Director.
CONFERENCES & EDUCATION
Practice Management Software Summit

ImproMed, LLC (impromed.com), and McAllister Software Systems,
LLC (avimark.net), are hosting a 3-day Veterinary Technology Summit
in St. Louis, September 18 through
20, 2013. The goal of the Summit is to
bring together practice management
software users in order for them to
gain useful insight from each other and form connections within the
industry. Attendees will receive hands-on training for the AVImark and
ImproMed veterinary software solutions, have the opportunity to earn
RACE-approved CE credit, and be able to browse vendor partner booths.
Learn more and register at vetsummit.com.
12
munotherapy for the intratumoral treatment of mixed mammary

tumor and mammary adenocarcinoma in dogs. Mycobacteria
have been known for many years
to have antitumor activity. Immunocidin is an emulsion of mycobacterial cell wall fractions that
have been modified to reduce
their toxic and allergic effect but
retain their anti-tumor activity.
Immunocidin stimulates the activation of macrophages and thymic lymphocytes, which destroy
tumor cells. According to Andrew
Grant, President, Bioniche Animal
Health, We believe there is a tremendous opportunity for a product like Immunocidin that does
not require special handling and
can be used by veterinarians in
their own clinics, either alone or
in combination with other therapies. For more information, call
888-549-4503 in the U.S. or visit
bionicheanimalhealth.com.
YO U R
C A R E .
O U R
S C I E N C E .
THE ONLY NONADJUVANTED

FELINE RABIES VACCINE.
PUREVAX Feline Rabies vaccine:
Reduces the potential risks associated with adjuvants, such as injection site reactions,
injection site granuloma and chronic inammation1,2
Over 10 years of safe and effective use3
Recombinant canarypox-vectored vaccines stimulate a comprehensive immune response1
Available as a single antigen and in combination with RCP and RCCP
Together, that means pure protection for cats

and kittens, and peace of mind for you. For more
information, visit MERIALconnect.com .
SM
From the makers of:
PUREVAX, IMRAB and RECOMBITEK are registered trademarks, SMMERIALconnect.com

is a service mark, and TM the Canarypox Technology logo is a trademark, of Merial.
2013 Merial Limited, Duluth, GA. All rights reserved. PUR12PBRABIESAD-R2 (12/12).
Greene CE, Levy JK: Chapter 100 Immunoprophylaxis, in Greene CE (Ed.):

Infectious Diseases of the Dog and Cat, 4th ed. Philadelphia, Saunders
Elsevier; 2012:1163-1205.
Day MJ, Schoon HA, Magnol JP, et al. A kinetic study of histopathological
changes in the subcutis of cats injected with non-adjuvanted and
adjuvanted multi-component vaccines. Vaccine 2007;25:4073-4084.
Data on le with Merial.

NEW PRODUCTS
PRACTICE RESOURCES
Two New Dermatology Products
Feline Environmental
Guidelines Available
Dechra Veterinary Products (dechra-us.com) has added two new products to their veterinary dermatology lineEpiTreats Healthy Canine
Snacks and Gentacalm Topical Spray. EpiTreats Snacks contain a hydrolyzed protein and single carbohydrate source and can be used as a reward
and treat for dogs, including those with skin sensitivities, of all ages. Gentacalm Spray is used for the treatment of dogs with infected superficial
lesions caused by bacteria susceptible to the broad-spectrum antibiotic
gentamicin. Its other ingredient, betamethasone valerate, provides antiinflammatory and antipruritic activity. Read more about these products
The American Association of Feline Practitioners (AAFP, catvets.

com) and International Society
of Feline Medicine (ISFM, isfm.
net) have released the Environmental Needs Guidelines, which
have been published in the March
issue of the Journal of Feline Medicine and Surgery. The Guidelines
on the companys website.
Simplified Insurance for Practitioners & Pet Owners

Trupanion (trupanion.com), which owns and is underwritten by the
American Pet Insurance Company, has launched Trupanion Express, a
call 800-569-7913 or visit the companys website.
address the needs of pet cats in

any environment, including home,
veterinary hospital, and shelter. By
incorporating these recommendations, veterinarians and cat owners can help reduce unwanted behavior, illness and feline stress,
and improve relationships with
the cats in their practices and lives.
To view the Environmental Needs
Guidelines, visit catvets.com/
guidelines.
Organic Odor Control & Cleaner
Veterinary Products Catalog
Alpha Tech Pet, Inc (alphatechpet.com), has introduced OdorPet, an

organic, biodegradable odor counteractant
and cleaner with a near neutral pH. Its
bioactive formulation of stabilized bacterial
spores produces enzymes that break down
immediately and over time in the presence of
organic animal debris, reducing it to a solution
of carbon dioxide and water. This product can
be used on carpeting, furniture, pet bedding,
carriers, indoor and outdoor surfaces, and
litter boxes, and is available in concentrated
or ready-to-use formulations. OdorPet can be ordered directly from the
Alpha Tech Pet website.
Animal Health Internationals

Spring 2013 Veterinary Products
Catalog is now available online
at animalhealthinternational.
com/VetGuide2/2013VetGuide.
html. The catalog offers a selection of products from hundreds
of key manufacturing partners
ranging from equipment and vaccines to surgical supplies and
pharmaceuticals, providing choices to best fit the needs of the veterinary practice.
new desktop application that can be installed and viewed on practice computers in 15 minutes, and is compatible
with all veterinary practice management
systems. Trupanion Express enables Trupanion to pay claims at the time of invoicing and pay veterinarians directly,
so clients do not have to come up with hard-earned money up front. said
Howard Robin, Chief Operating Officer. In addition, there are no transaction fees, no administration costs, and no other costs to veterinarians and
their clients associated with use of the software. For further information,
14

The science thats in it.
The exclusive guarantee behind it.
When clients buy FRONTLINE Plus from you, they get more. They get
proven ingredients that kill adult feas, eggs, and larvae, as well as ticks.
They also get peace of mind from the vet exclusive SATISFACTION
PLUS GUARANTEETM if they arent completely satisfed, they call
us directly for technical help and if eligible* well give them a
replacement, a refund, or a one-time visit from TERMINIX to
inspect and treat their home, if necessary. Thats all there is to it.
*For more information and complete details visit FRONTLINE.com
FRONTLINE is a registered trademark, and SATISFACTION
PLUS GUARANTEE is a trademark, of Merial. TERMINIX is
a registered trademark of the Terminix International Limited
Partnership. 2012 Merial Limited, Duluth, GA. All rights
reserved. FLE12PBTRADEADGRMN (12/12).

AWARDS
CONFERENCES & EDUCATION
2013 Veterinary Excellence Awards
Excellent Experiences at WVC
Petplan Pet Insurance (gopetplan.com) awarded the 2013 Veterinary Excellence Awards on February 17 in Las Vegas. The winners, chosen from
2200 nominations, were: Veterinarian of the Year: Dr. Natalie Marks,
Blum Animal Hospital, Chicago, IL; Practice Manager of the Year: Suzanne Cross, Brighton-Eggert Animal Clinic, Tonawanda, NY; and Veterinary Technician of the Year: Kim Franck, Adamstown Veterinary Hospital, Denver, PA. Each recipient received $1000 to donate to the animal
charity of her choice and has been invited to participate in judging for
the 2014 awards.
Nearly 14,500 attendees, including 6000 veterinarians, 1500 veterinary technicians and practice
managers, 500 veterinary and technician students, and 3500 exhibitors, participated in the
Dr. Jack
Wa lt her
85th Annual Western Veterinary Conference
(WVC, wvc.org), February 17 to
21, 2013, in Las Vegas. More than
87% of attendees surveyed rated
their overall experience as excellent or very good, and about
90% gave the same ratings for the
quality and professionalism of
the scientific sessions. This years
conference name honored W VC
Clinical Proficiency Coordinator,
Dr. Jack Walther, a conference attendee for over 4 decades who has
been a driving force behind WVCs
success and a leader in the area of
student scholarships.
Left to right: Natasha Ashton, Dr. Natalie Marks, Kim Franck;

Suzanne Cross, and Chris Ashton
Radiology Summit for ACVIM

Members
The American College of Veterinary Internal Medicine (ACVIM,
acvim.org) and Infiniti Medical,
LLC (infinitimedical.com), are
offering the Veterinary Interventional Radiology Summit at the
Oquendo Center for Clinical Education in Las Vegas. This 8-hour
practicum for ACVIM members
combines how to lectures and
laboratory training in vascular and
nonvascular image-guided procedures. The first course was held
March 8; two additional courses
will be offered on June 29 and
November 2, 2013. For more information and to register, visit the
ACVIMs website, contact Infiniti
Medical at 650-327-5000, or email
training@infinitimedical.com.
16
Todays Veterinary Practice PRODUCT PROfILE

Common HEARTWORM PREVENTIVE & INTESTINAL PARASITE mediCations for dogs & Cats
Preventive
insecticides sPecies
indications
MONTHLY CHEWABLE TABLETS

Heartgard
Ivermectin
Dogs ( 6 wks)
Cats ( 6 wks)
Prevents heartworm disease
Ivermectin
Pyrantel
Dogs ( 6 wks)
Not for use in cats

Treats and controls roundworms and hookworms
Milbemycin
oxime
Dogs ( 4 wks, > 2 lb )

Cats ( 6 wks, > 1.5 lb)

Dogs: Treats and controls roundworms, hookworms, and
whipworms
Cats: Treats and controls roundworms and hookworms
Treats and controls roundworms, hookworms, and
tapeworms
Treats and controls roundworms and hookworms
(Merial)
Heartgard Plus
(Merial)
Interceptor
(Novartis)
Iverheart Max Ivermectin

(Virbac)
Praziquantel
Pyrantel
Iverheart Plus Ivermectin
Dogs ( 8 wks, 6 lb)

Not for use in cats
Dogs ( 6 wks)
Not for use in cats
(Virbac)
Pyrantel
Sentinel
Lufenuron
Milbemycin
oxime
Dogs ( 4 wks)
Not for use in cats
Milbemycin
oxime
Spinosad
Dogs ( 8 wks)
Not for use in cats
(Novartis)
Trifexis
(Elanco)

whipworms
Controls flea populations
whipworms
Prevents development of flea eggs
MONTHLY TOPICAL SOLUTIONS

Advantage Multi
(Bayer)
Imidacloprid
Moxidectin
Dogs ( 7 wks, > 3 lb )

Cats ( 9 wks, > 3 lb)
Revolution
Selamectin
Dogs ( 6 wks)
Cats ( 8 wks)
(Pfizer)

Kills roundworms, hookworms, and whipworms
Kills fleas and flea eggs
Treats and controls ear mite infestations
Kills roundworms and hookworms
Kills fleas, flea eggs, and ticks
Treats sarcoptic mange (dogs) and controls ear mite infestations
ONE-TIME CHEWABLE TABLET

Cestex
Epsiprantel
Dogs ( 7 wks)
Cats ( 7 wks)
Kills tapeworms
Praziquantel
Dogs ( 4 wks)
Cats ( 6 wks)
Kills tapeworms
Praziquantel
Pyrantel
Cats ( 4 wks, > 1.5 lb)
Kills roundworms, hookworms, and tapeworms
Febantel
Praziquantel
Pyrantel
Dogs (> 3 wks; > 2 lb)
Kills roundworms, hookworms, tapeworms, and whipworms
Cats ( 8 wks)
Kills roundworms, hookworms, and tapeworms
(Pfizer)
Droncit
(Bayer)
Drontal
(Bayer)
Drontal Plus
(Bayer)
ONE-TIME TOPICAL SOLUTION

Profender
(Bayer)
Emodepside
Praziquantel
Caution: Studies have indicated that collies and certain herding breeds of dogs are more sensitive to the effects of avermectins.
To view Product Profiles covering common flea and tick preventive medications, go to todaysveterinarypractice.com and select
Resources from the top navigation bar; Product Profiles can be downloaded and printed for use in your clinic.
This table can be downloaded and printed for use in your practice at todaysveterinarypractice.com (see Resources).
17
Peer reViewed
GI INTErvENTION
Approach to
diagnosis and
Therapy of the
VomiTing
PaTienT
P. Jane Armstrong, DVM, MS, MBA,
Diplomate ACVIM
omiting is a very common clinical complaint

in both dogs and cats. It is also a clinical sign
seen in diseases of many body systems. Clinicians must avoid assuming vomiting is synonymous
with gastrointestinal (GI) disease.
In a large national survey, GI signs

accounted for 4% of visits at
primary care clinics.1
DEFINITION
Vomiting is the active expulsion of gastric, sometimes duodenal, contents and is typically preceded
by apparent nausea and retching. However, it can
often be confused with:
Regurgitation associated with esophageal disorders
Gagging/coughing associated with respiratory
disease
Oropharyngeal dysphagia.
CLINICAL SIGNS
Key elements of vomiting are:
Forceful abdominal contractions (one of the
most reliable ways to confirm vomiting)
Retching and presence of bile.
A thorough history will usually confirm whether
the pet is vomiting. If doubt remains, attempt to visualize the behavior by asking the owner to video it
or provocatively feeding the patient in the hospital.
18
gi inTerVenTion: aPProach To Diagnosis anD TheraPy of The VomiTing PaTienT |
Be cautious in overinterpreting the timing of the

event in relation to consumption of meals. In some
cases, regurgitating animals can passively expel esophageal or gastric contents hours after ingestion of a
meal.
PATHOPHYSIOLOGY
Vomiting is a complex, protective reflex that occurs
in carnivores but is not well developed in all species.
Although several afferent pathways may be responsible for initiating emesis, it is coordinated by the emetic
(or vomiting) center in the medulla (Table).
An important concept of vomiting is that it occurs
through activation of the:
Chemoreceptor trigger zone (CRTZ) by blood-borne
substances (humoral pathway)
Emetic center by vagosympathetic, vestibular, or
cerebrocortical neurons (neural pathway).
Many spontaneous vomiting disorders of cats and
dogs, particularly those due to primary GI disease, are
believed to result from activation of the neural pathway.
Visceral afferent input to the emetic center arises
from receptors located throughout the body.
Most are distributed in the abdominal viscera, with
the largest number in the duodenum.
Visceral receptors are sensitive to chemical irritation, inflammation, distention, and changes in
osmolality.
Several neurotransmitters and their respective receptors stimulate the emetic center; these form the basis
for antiemetic classification.
CHrONIC vOMITING
Chronic vomiting is commonly defined as persistent
vomiting of variable frequency and, typically, duration
of 3 weeks or longer.
In cases of chronic vomiting, relatively extensive diagnostic evaluation is almost always warranted in order
to determine a cause rather than solely providing supportive and symptomatic care. See Determining Reasons for Vomiting & Appropriate Diagnostics, page
21, for further information. The remainder of this overview will focus on acute vomiting.
ACUTE vOMITING: DIAGNOSTICS
Acute vomiting is commonly defined as vomiting of
variable frequency over a period of less than 7 days,
although, in practical terms, acute vomiting is usually
of 1 to 3 days duration since owners will commonly
seek medical attention within this interval.
From the signalment, history, and physical examination, the clinician should be able to:
1. Categorize the patient as:
Stable, with no criteria for further immediate
assessment or treatment
Unstable, with 1 or more criteria for intervention.
2. Establish a differential list.
3. Identify appropriate diagnostic interventions and
therapy.
Table. Four Main Stimulating Pathways

of the Vomiting Center
1. Peripheral Sensory receptors
intra-abdominal
stomach, intestines, pancreas, liver,
gallbladder, peritoneum, kidneys, ureter,
urinary bladder
Visceral afferent fibres in sympathetic and
vagal nerves
heart and large vessels via vagus nerve
Pharynx via glossopharyngeal nerve
2. Stimulation of the Chemoreceptor Trigger

Zone
Uremia
electrolyte imbalances
Toxins
Drugs
3. vestibular Input
inflammatory disorders
motion sickness via acoustic nerve
4. Higher Central Nervous System Centers
Psychogenic (eg, fear, stress, excitement) via
catecholamine release
inflammatory cns lesions
Courtesy Susan Little, DVM, Diplomate ABVP (Feline Practice);
modified with permission
Mild Acute vomiting

Pets with a history of mild, acute vomiting (with or without concurrent diarrhea) that have a normal physical
examination and no other concurrent signs usually have
self-limiting signs and can be treated symptomatically or
simply monitored. In such cases, signs resolve after 1 to 2
days, with or without supportive therapy.2
The suggested minimum diagnostic evaluation of a
healthy vomiting animal includes:
Packed cell volume and total protein (provides a crude
assessment of hydration status)
Fecal flotation.
Even with more extensive diagnostic evaluation, a diagnosis may not be reached unless the history suggests a
likely cause, such as dietary indiscretion.
Cats appear to be less likely than dogs to present with
acute, self-limiting vomiting (acute gastritis) and are relatively more likely than dogs to require diagnostic investigation and treatment.3 Feline acute hemorrhagic vomiting
syndrome has been reported in the UK.3 This self-limiting
syndrome occurs in cats in rescue shelters and catteries;
etiology has yet to be determined.
Severe Acute vomiting
Some characteristics of acute vomiting may indicate
serious, even potentially life-threatening, diseases and
19
| gi inTerVenTion: aPProach To Diagnosis anD TheraPy of The VomiTing PaTienT
warrant immediate diagnostic investigation

and treatment. This category includes patients
with:
Hematemesis (vomiting blood) or melena
Frequent vomiting (810 times in 1 day)
Concurrent signs (such as anorexia; lethargy; fever; apparent abdominal pain; or pale,
muddy, congested, or jaundiced mucous
membranes).
Diagnostic evaluation is mandatory to attempt
to determine the underlying cause and guide
therapy, and includes:
Survey abdominal radiographs
CBC, serum biochemical profile, urinalysis
SNAP Parvo Test (idexx.com) (puppies or kittens), regardless of vaccination history.
Additional diagnostic studies may include further laboratory testing, such as:
Canine or feline pancreatic lipase (Spec cPL
or fPL Tests, idexx.com)
Resting cortisol and/or adrenocorticotropic
hormone (ACTH) stimulation testing
Abdominal ultrasonography
Upper GI endoscopy and/or barium contrast
series
Surgical exploration of abdomen.
ACUTE vOMITING: MEDICAL THErAPY
The goals of symptomatic or supportive therapy for acute vomiting are:
Treating or removing the underlying cause
Controlling the vomiting episodes
Addressing abdominal pain, if present
Correcting the fluid, electrolyte, and acid
base abnormalities that may occur as a consequence of frequent vomiting.
Antiemetic Therapy
Antiemetic therapy is warranted when:
1. Vomiting is frequent or severe, making the
animal uncomfortable
2. Persistent vomiting puts the animal at risk
for aspiration pneumonia or acidbase and
electrolyte disturbances
3. The animal is not suffering from GI obstruction or toxicity.
Antiemetics control emesis by either central
or peripheral blockade of neurotransmission at
receptor sites (see Medications for Vomiting:
Dogs & Cats, page 26).
In the emetic center, neurokinin (NK)1
receptors and alpha-2 adrenergic receptors
are the most clinically important. Selective
NK1 receptor antagonists (ie, maropitant)
act by blocking the binding of substance P
within the emetic center and CRTZ; therefore, they uniquely inhibit vomiting through
both the humoral and neural pathways.
20
Maropitant: A Multimodal Antiemetic

maropitant citrate (cerenia, zoetis.com), a potent selective
nK1 receptor antagonist, plays an important role in managing
vomiting, mediated via both the vomiting center and crTZ (ie,
humoral and neural pathways).3-5 The drug is effective for:
Prevention of motion sickness in dogs
chemotherapy-induced nausea and vomiting
management of vomiting due to other causes.
Nausea
nausea cannot be reliably assessed in animals, but signs
interpreted as nausea include salivation, increased frequency
of or exaggerated swallowing motions, and licking of lips. a
recent study evaluating maropitant as an antiemetic for dogs
premedicated with hydromorphone found that maropitant
effectively prevented vomiting, retching, and nausea associated with hydromorphone administration.6
Analgesia
Two recent studies indicate that maropitant also provides visceral analgesia in dogs and cats.7,8 During visceral ovarian and
ovarian ligament stimulation, maropitant decreased anesthetic requirements. This analgesic property makes maropitant
especially suitable for managing vomiting caused by painful
intra-abdominal conditions, such as pancreatitis and cholangitis, and painful gastric or intestinal disorders. Note: At this
time, this use of maropitant should only be considered adjunctive to other methods of pain control.
Administration
common doses for maropitant are given in Medications for
vomiting: Dogs & Cats, page 26. maropitant is commonly
administered off label in both dogs and cats. hickman and
colleagues reported on the pharmacokinetics of Po, sc, and
iV use in cats.5 Because maropitant is metabolized by the
liver, a lower dosage of 0.5 mg/kg iV is sometimes used for
treatment or prevention of vomiting in both species, if there is
concern about liver function.
The label states that using cerenia for treatment or prevention of acute emesis should not last longer than 5 consecutive
days.
maropitant has nonlinear pharmacokinetics in dogs.
Pharmacokinetic studies conducted since the approval of
cerenia have shown that a steady state is reached in dogs
in 4 days (at 2 mg/kg daily). a steady state is reached in
cats in 7 days.
another reason for this concern is that, if vomiting persists
longer than 5 days, the underlying cause needs to be thoroughly reinvestigated.
in dogs, the injectable solution and tablets may be used
interchangeably for once daily dosing to prevent acute
vomiting.
Safety
cerenia has been tested for safety in both dogs and cats at
1, 3, and 5 the label dose for 15 days (3 the duration of
treatment recommended on the label) as required by the fDa.
determining reasons for Vomiting & Appropriate diagnostics

Vomiting can be caused by a wide variety of gi, intraabdominal, metabolic, systemic, and neurologic diseases. an efficient clinical approach is to determine whether vomiting results from a:
Primary gi problem
metabolic problem secondarily causing gi signs.
CLINICAL APPrOACH
Primary disease is most likely when:
an abnormality is palpable in the gut (eg, foreign
body, intussusception).
Vomiting is associated with significant diarrhea.
if the animal is otherwise historically and clinically
normal.
in the case of an animal with acute vomiting, it is
important to rule out obstructions or other disorders
that might require emergency surgical intervention.
Primary GI Disease Diagnostics
survey and contrast radiographs

abdominal ultrasonography
endoscopy
exploratory laparotomy
in chronic vomiting, emergency surgical procedures are

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

The many causes of vomiting pose a challenge when
determining the degree of diagnostic evaluation warranted. This clinical decision is largely based on:
chronicity and frequency of vomiting
Presence or absence of other historical and/or physical examination abnormalities.
Dogs
ros & colleagues. in a recent publication, 213 dogs
that had vomiting as the main, or one of the main, signs
were evaluated at a referral institution to determine
which diagnostic tests were of greatest value.10 a diagnosis was reached in 203 dogs (95.3%). see Tables 1
and 2 for study results. overall, there was a high incidence of nongastrointestinal diseases, especially renal,
which emphasizes the need to perform a urinalysis in
association with a serum biochemical profile in most
animals with vomiting as the major complaint.
Table 2. value of Diagnostic Tests10

Enabled
Diagnosis
Assisted
Diagnosis
Blood analysis
12.2%
26.8%
Cytology
3.3%
4.2%
Fecal analysis
6.6%
1.4%
radiographs
1.9%
8.5%
Ultrasound
5.2%
17%
Urinalysis
2.3%
9.9%
Leib & colleagues. in another study, the diagnostic utility of abdominal ultrasound was evaluated in 89
dogs with chronic vomiting.11 Ultrasound examination
was considered to be vital or beneficial to diagnosis in
22.5% of dogs. increasing age and a final diagnosis of
gastric adenocarcinoma or gi lymphoma were associated with increased diagnostic utility.
Cats
Batchelor & colleagues. a recent evidence-based
review of mechanisms, causes, diagnostic investigation,
and management of vomiting in cats evaluated the most
common causes (Table 3).2
most notable is the fact that vomiting in cats might
be associated with a wide range of diseases originating
outside of the gi tract, such as neoplasia, splenic disease, infectious disorders, chronic nasal disease, pyothorax, aortic thromboembolism, and bronchial disease.
however, the authors noted that further exploration was
needed and vomiting may have been incidental.
Table 3. Common Causes of vomiting in Cats2

vomiting (Overall)
adverse reactions to food
infectious agents, such as panleukopenia and
feline infectious peritonitis
acute self-limiting emesis of undetermined cause
(so-called acute gastritis)
Chronic vomiting
inflammatory bowel disease

adverse reactions to food
Liver disease
Uremia
hyperthyroidism
Table 1. Diagnoses by Category10

1.
2.
3.
4.
5.
gastrointestinal (43.7%)
systemic (27.7%)
nongastrointestinal abdominal (16.4%)
miscellaneous (6.1%)
neurological (1.4%)
Additional causes. cats frequently vomit trichobezoars (hairballs) and also vomit after administration of
alpha-2 adrenergic drugs, such as xylazine and dexmedetomidine, reflecting the importance of these receptors in the brainstem areas that control vomiting.12,13
21
In the CRTZ in dogs, dopamine and histamine are

significant neurotransmitters, making dopaminergic
and histaminergic receptor antagonists important antiemetic classes.
In the CRTZ in cats, alpha-2 adrenergic and 5-HT3
serotonergic receptors are the significant neurotransmitters.
Specific Notes. An antiemetic is commonly administered concurrently with a prokinetic agent. In addition, antiemetics with different modes of action may
be combined in patients with refractory vomiting.
Maropitant, ondansetron, and dolasetron are very
effective antiemetics for cats.
In dogs with uremia, the central component of vomiting can be treated with antiemetics; the peripheral
component is best treated with gastroprotectants.
Chemotherapy drugs induce vomiting by stimulating
5-HT3 serotonergic receptors; effective antiemetics
include dolasetron, maropitant, and ondansetron.
Metoclopramide is less effective but less expensive; if
administered to dogs, it should be used at high doses
(1 mg/kg).
Metoclopramide is considered a weak prokinetic agent.
Higher doses (up to 4 mg/kg/day CRI or 1 mg/kg PO Q
8 H) are occasionally used in dogs but patients must
be carefully monitored for extrapyramidal side effects.
Side Effects. The main side effects of antiemetics
include:
Systemic hypotension: Chlorpromazine and prochlorperazine
Sedation: Phenothiazines (chlorpromazine and prochlorperazine), antihistamines, and yohimbine
Behavioral changes (eg, dose-related excitation):
Metoclopramide
Only administer chlorpromazine or prochlorperazine
if the patient is normotensive or is receiving adequate IV
fluid support. These drugs were thought to reduce the seizure threshold but clinical experience suggests they can
be used in patients with seizure disorder histories.
Patients with GI obstruction should not receive prokinetic agents, including metoclopramide. However, many
experienced clinicians report that serious adverse effects
have not been seen when these agents have been inadvertently given to such patients, with the exception of those
with linear foreign bodies.
Gastroprotective or Cytoprotective Agents
Peripheral pathways are mediated through irritation and
inflammation of the GI mucosa. Therefore, another common approach to therapy is administration of gastroprotective agents, such as drugs that:
Inhibit gastric acid production: H2 histaminergic
receptor antagonists and proton pump inhibitors
Act locally on the gastric mucosa: Sucralfate.
Histamine H2 receptor Antagonists
Histamine H2-receptor antagonists are the most commonly
used drugs to manage gastric ulceration or severe gastritis.
22
These agents competitively block the H2 receptor on the

parietal cell, reducing gastric acid secretion.
Cimetidine is the least potent of the H2 receptor
antagonists and also inhibits the cytochrome P-450
enzyme system, potentially altering metabolism of coadministered drugs that are metabolized by the same
enzyme system.
Ranitidine also inhibits the cytochrome P-450 enzyme
system, but much less so than cimetidine.
Famotidine and nizatidine are more potent than
cimetidine and famotidine and do not inhibit the
cytochrome P-450 enzyme system. In addition, they
might stimulate gastric emptying in the cat and dog by
inhibiting acetylcholinesterase activity.
Proton Pump Inhibitors
Proton pump inhibitors (PPIs) are currently the most
potent inhibitors of gastric acid secretion. They irreversibly block the gastric proton pump (hydrogen-potassium
ATPase), causing a marked decrease in gastric acid secretion.
PPIs are recommended for use in small animals diagnosed with severe reflux esophagitis or gastric ulceration.
Omeprazole (0.7 mg/kg PO Q 24 H, dogs and cats) is
now available over the counter, markedly reducing its
cost and increasing its availability and usage in small animals. It has come into common use (perhaps overuse) in
vomiting animals without hematemesis.
Pantoprazole (0.71 mg/kg PO or IV PO Q 24 H, dogs
and cats) is a newer PPI available for oral or IV use.
Sucralfate
Sucralfate (0.251 g PO Q 812 H, dogs and cats) is a
basic aluminum salt of a sulfated disaccharide that selectively binds to proteins at sites of ulceration.
This drug has a sustained local protective effect
against acid, pepsin, and bile at the ulcer site, forming
a protective barrier.
It also increases the luminal concentration of prostaglandin E2, which protects against ulcerogenic factors.
Because sucralfate is not absorbed from the GI tract, it
has virtually no systemic toxicity.
Constipation is a rare side effect that occurs because
of the aluminum moiety. Sucralfate may also inhibit the
absorption of other drugs, including doxycycline and,
potentially, H2 receptor antagonists.
Prokinetic Agents
Agents that enhance gastrointestinal motility may be
indicated for:
Vomiting associated with delayed gastric emptying
Vomiting caused by gastritis, metabolic derangements,
and postoperative gastric dilatation volvulus
Dogs that vomit bile in the morning prior to eating
(bilious vomiting syndrome).
Therapeutic choices for prokinetics include:
5-HT4 serotonergic agonists: Cisapride, metoclopramide
MoTion SiCkneSS: HelPing PeTS & THeir ownerS

With warmer weather quickly approaching, many pet owners will be eager to head outside
and, for many, back on the roadwith their pets. however, motion sickness in pets creates an
unpleasant situation that often results in the pet being left out of the fun. it may even deter owners
from bringing their pets to the clinic for veterinary care.
natalie marks, DVm, of Blum animal hospital in chicago, has worked with families that have
pets with motion sickness. as veterinarians, we want to do all we can to enhance the human
animal bond for our clients, marks says. for many pet owners, companionshipboth off and
on the roadis central to the relationships with their pets. having a pet that doesnt enjoy those
experiences can leave the owner and pets bond unfulfilled.
These 3 steps outline a therapeutic approach to motion sickness in pets:
Start the Motion Sickness Conversation
many times, motion sickness is brought up to us as veterinarians. Pet owners are generally
very in tune with their pets and, unfortunately, may see the problem immediately in their cars,
marks explains. however, while owners of severely stressed
pets are well aware when their pets exhibit the main sign of
motion sicknessvomitingothers may not recognize the
less obvious signs, such as drooling, panting, licking lips, or
yawning.
Veterinarians can begin a pets appointment by asking the
owner about the ride to the clinic. This simple question may
lead to discovery of motion sickness in the pet.
Make Travel a Positive Experience
marks says that many cases of motion sickness can be

addressed through simple training methods and adjustments
to the travel process, such as making sure the pet does not
eat 30 minutes prior to any trip.
in these cases, i encourage pet owners to start slowly and remove any fear the pet may have of
the car itself. This may begin by (1) showing the pet the car without going anywhere, (2) letting the
pet take in the sights and smells, and (3) rewarding the pet with a treat. This process can evolve to
a short trip to the post office, again offering a reward after completing the trip, marks explains.
she also encourages pet owners to make sure the car is welcoming to the pet by setting a lower
temperature, cracking open a window for air circulation and, of course, making sure the pet is
properly restrained facing forward in either a seat harness or carrier.
Consider Treatment Options
if motion sickness is chronic or cannot be resolved with behavioral methods, marks

recommends a prescribed treatment program to pet owners. i like to discuss all the options with
pet owners to find treatments that best fit their pets needs and the familys lifestyle.
marks says. There are excellent options available. for example, veterinarians recognize that
antiemetics are excellent for gi cases, but im not sure everyone realizes that some are fDaapproved, and very effective, for motion sickness.
marks sums up the motion sickness discussion with, The most important element of our
work is building trust with our clients and letting them know we are there for them completely
not just for wellness, illness, or injurybut for their overall lifestyle experiences with their pets.
helping manage motion sickness can be an important part of ensuring the humananimal bond is
developed to the fullest.
23
BILIOUS vOMITING SYNDrOME

Dogs that suffer from this syndrome can be treated
with prokinetic agents. other therapeutic approaches, alone or in combination, include:
Dividing the total daily food amount into an extra
meal that can be given late in the evening
Using an acid inhibitor (h2 receptor antagonist)
once daily in the evening
administering a calcium-containing antacid (such
as Tums [gsk.com]) late in the evening.
D2 dopaminergic antagonist/5-HT3 serotonergic

antagonist: Metoclopramide
Cholinesterase inhibitors: Ranitidine, nizatidine
Motilin agonists: Low-dose erythromycin (dogs only).
Cisapride is superior to metoclopramide for treating
gastric emptying disorders in cats and dogs. Cisapride
stimulates GI motility from the lower esophageal sphincter to the colon (through stimulation of 5-HT4 serotonergic receptors), with minimal direct antiemetic effects.
Metoclopramide is used to increase gastroesophageal sphincter tone, and as a prokinetic for treating gastric emptying disorders and enhancing the coordination
of antropyloroduodenal contractions. The prokinetic
effects of metoclopramide are not readily or exclusively
explained by dopamine receptor antagonism. However,
metoclopramide has other pharmacologic properties,
including stimulation of 5-HT4 receptors, which may
better explain some of its effects on the GI tract.
Erythromycin stimulates phase III migrating myoelectric complex activity in the dog, but the physiologic
regulation of migrating spike complex activity in the
cat is different; therefore, erythromycin is not used as
a prokinetic in cats.
When these drugs are used for delayed gastric emptying, they should be administered 30 minutes prior to
feeding. Metoclopramide has a short half-life (6090
min) in dogs, and is best given as a CRI for maximal effect.
Antibiotics
Antibiotics are not routinely used for empirical therapy
in acute vomiting unless the patient is febrile or has an
abnormal CBC that suggests systemic infection.
When indicated, broad-spectrum antibiotics, such as
amoxicillin combined with enrofloxacin, provide excellent coverage against most bacteria associated with infection following breakdown of the GI mucosal barrier.
Probiotics or an antibiotic (metronidazole, tylosin)
may be useful for controlling acute diarrhea accompanying vomiting.
ACUTE vOMITING: ADDITIONAL THErAPY
Dietary Management
Dogs or cats presenting with acute vomiting are commonly held NPO (nothing per os) for 12 to 24 hours
until the vomiting ceases. While a period of NPO has
24
not been evaluated in an evidence-based manner, its

prevention of aspiration pneumonia, additional fluid
losses, and discomfort of the patient are excellent reasons to use this approach.
After vomiting has been controlled or has ceased for
several hours, a small volume of a digestible intestinal
formula or elimination diet (containing a novel, single
protein source or hydrolyzed peptides) should be fed.
A highly digestible, low-fat diet is usually selected
for dogs, but dietary fat content appears to play a
smaller role in gastric emptying in cats.
Cats do not need a carbohydrate source and are
sometimes best managed with a single-protein
source, such as cooked chicken breast.
Feeding small meals frequently will minimize gastric
distention and gastric acid secretion. A gradual transition to the pets usual diet is made over 2 to 3 days, providing that signs have resolved.
Fluid Therapy
Vomiting of gastric and intestinal contents usually
involves:
Loss of fluid containing chloride, potassium, sodium,
and bicarbonate
Dehydration accompanied to a variable extent by
hypochloremia, hypokalemia, and hyponatremia.
Subcutaneous fluids are useful for mild dehydration.
Isotonic fluids should be used, with no more than
10 to 20 mL/kg administered at each injection site.
The rate of SC fluid flow usually is governed by
patient comfort.
Acetated polyionic solutions, such as Normosol-R
and Plasmalyte, should not be administered SC due
to discomfort associated with administration.
Generally, all SC fluids are absorbed within 6 to 8
hours. If pockets of SC fluid are still present after this
time, use of IV fluids to reestablish peripheral perfusion should be considered.
Fluids should be administered IV to animals that are
moderately to severely dehydrated ( 7%).
Potassium supplementation to replace that lost in
vomitus is usually necessary, since whole body depletion of potassium can cause GI hypomotility.
Metabolic acidosis is the most common acidbase
alteration in dogs with GI disease and is usually corrected by appropriate fluid therapy with lactated
Ringers solution or 0.9% saline.
Foreign bodies causing GI obstruction that involves
the stomach or proximal duodenum can result in
metabolic alkalosis, but such patients can also have
metabolic acidosis or normal acidbase status, so
no presumption should be made without laboratory
evaluation.9
IN SUMMArY
There are many causes of vomiting and evaluation of
the vomiting dog or cat requires consideration of the
whole animal, not just the GI tract.
Highly eective
ea control
theyll both appreciate.
Both patients and clients want a product
that really gets rid of eas.
Activyl, the latest innovation in monthly
spot-on ea control, features indoxacarb
and bioactivation a mode of action that
uses enzymes inside the ea to activate
Activyls full ea-killing power.
Available strictly through veterinarians.

Protected by Merck Animal Health Track & Trace technology.
Quick-Drying Fragrance-Free Waterproof
us.activyl.com
Copyright 2013 Intervet Inc., a subsidiary of Merck & Co., Inc. All rights reserved.
Intervet Inc. d/b/a Merck Animal Health, Summit, NJ, 07901 MAH-ACT-14B
MEDICATIONS FOR ACUTE VOMITING: DOGS & CATS

DRUG NAME
(alpha order)
Chlorpromazine
CLASSIFICATION
USE
Cisapride
Alpha-2 adrenergic antagonist Antiemetic

D2 dopaminergic antagonist
H1 histaminergic antagonist
M1 muscarinic cholinergic
antagonist
5-HT4 serotonergic agonist
Prokinetic agent
Dimenhydrinate
DOSE (for cats and dogs unless

otherwise noted)
0.20.4 mg/kg SC or IM Q 8 H
Antiemetic
0.51 mg/kg PO Q 8 H or
11.5 mg/kg PO Q 12 H or
Up to 3 mg/kg divided into equal
doses based on number of daily
feedings; administered 30 min
before each feeding
48 mg/kg PO Q 8 H
Diphenhydramine H1 histaminergic antagonist
Antiemetic
24 mg/kg PO or IM Q 8 H
Dolasetron
Antiemetic
0.51 mg/kg PO or IV Q 12 H or 30
min before chemotherapy
0.050.1 mg/kg PO Q 1224 H*
Domperidone
5-HT3 serotonergic
antagonist
Erythromycin
Motilin agonist
Famotidine
Histamine H2 receptor
antagonist
NK1 receptor antagonist
Gastroprotective agent
0.51 mg/kg IV or PO Q 1224 H
Antiemetic
Visceral analgesic
5-HT3 serotonergic
antagonist
5-HT4 serotonergic agonist
Cholinesterase inhibitor
Histamine H2 receptor antagonist
Proton pump inhibitor
Antiemetic**
Prokinetic agent
Increases gastroesophageal sphincter tone
Prokinetic agent
1 mg/kg SC or IV Q 24 H; administer
SC injection cold to reduce pain
2 mg/kg PO (dogs) and 1 mg/kg PO
(cats)
8 mg/kg PO for motion sickness
(dogs)
0.20.5 mg/kg PO, SC, or IM Q 8 H
12 mg/kg/day CRI
Maropitant
Metoclopramide
Nizatidine
Omeprazole
Antiemetic
Increases gastroesophageal sphincter tone
Prokinetic agent
0.51 mg/kg PO or IV Q 8 H (dogs)
2.55 mg/kg PO Q 12 H
0.7 mg/kg PO Q 24 H
Antiemetic
0.5 mg/kg PO or IV Q 1224 H or 30

min before chemotherapy
Doses up to 1 mg/kg IV Q 1224 H
are occasionally needed
0.71 mg/kg PO or IV Q 24 H
Ondansetron
5-HT3 serotonergic
antagonist
Pantoprazole
Proton pump inhibitor
Prochlorperazine
Alpha-2 adrenergic antagonist

antagonist
Histamine H2 receptor
antagonist
antagonist
Sucrose sulfate-aluminum
complex
Alpha-2 adrenergic antagonist
Antiemetic
0.5 mg/kg SC, IM, or suppository

Q8H
Prokinetic agent
Antiemetic
12 mg/kg PO Q 12 H
0.03 mg/kg SC or IM Q 6 H
Cytoprotective agent
0.251 g PO Q 812 H
Antiemetic
0.250.5 mg/kg SC or IM Q 12 H
Ranitidine
Scopolamine or
Hyoscine
Sucralfate
Yohimbine
Note: Mirtazapine, commonly used as an appetite stimulant, most likely also has an antiemetic effect based on data from human studies.
* There is scant clinical experience with this drug in dogs and cats
** Useful in dogs; questionable efficacy in cats
26
GI INTeRVeNTION |
An assessment as to whether the

dog or cat has a self-limiting or
potentially serious cause of vomiting is crucial and depends on a:
Thorough history and careful
physical examination
Sound understanding of the differential diagnoses for acute vomiting
Clinical judgment.
If in doubt, especially in cats, err
on the side of caution and evaluate the animal more extensively
to assess for potentially serious
problems.
When treating a patient symptomatically for acute vomiting, further
evaluation is indicated if:
Signs do not resolve in 2 to 3 days
Additional clinical signs develop.n
ACTH = adrenocorticotropic
hormone; CRTZ = chemoreceptor
trigger zone; GI = gastrointestinal;
PPI = proton pump inhibitor
References
1. Lund EM, Armstrong PJ, Kirk CA, et al.
Health status and population characteristics
of dogs and cats examined at private
veterinary practices in the United States.
JAVMA 1999; 214:1336-1341.
2. Batchelor DJ, Devauchelle P, Elliott J, et
al. Mechanisms, causes, investigation and
management of vomiting disorders in cats:
A literature review. J Feline Med Surg 2013;
Feb 12 (Epub ahead of print).
3. Sedlacek HS, Ramsey DS, Boucher JF,
et al. Comparative efficacy of maropitant
and selected drugs in preventing emesis
induced by centrally or peripherally acting
emetogens in dogs. J Vet Pharmacol Ther
2008; 31:533-537.
de la Puente-Redondo VA, Siedek EM,
Benchaoui HA, et al. Anti-emetic efficacy
of maropitant in the treatment of ongoing
emesis caused by a wide range of
underlying clinical aetiologies in canine
patients in Europe. J Small Anim Pract
2007; 48:93-98.
5. Hickman MA, Cox SR, Mahabir S, et al.
Safety, pharmacokinetics and use of the
novel NK-1 receptor antagonist maropitant
(Cerenia) for the prevention of emesis and
motion sickness in cats. J Vet Pharmacol
Ther 2008; 31:220-229.
6. Hay Kraus BL. Efficacy of maropitant in
preventing vomiting in dogs premedicated
with hydromorphone. Vet Anaesth Analg
2013; 40:28-34.
7. Boscan P, Monnet E, Mama K, et al. Effect
of maropitant, a neurokinin-1 receptor
antagonist, on anesthetic requirements
during noxious visceral stimulation of the
ovary in dogs. Am J Vet Res 2011; 72:15761579.
8. Niyom S, Boscan P, Twedt DC, et al. Effect
of maropitant, a neurokinin-1 receptor
antagonist, on the minimum alveolar
concentration of sevoflurane during
stimulation of the ovarian ligament in cats.
Vet Anaesth Analg 2013; doi: 10.1111/
vaa.12017 (Epub ahead of print).
9. Boag AK, Coe RJ, Martinez TA, Hughes D.
Acidbase and electrolyte abnormalities in
dogs with gastrointestinal foreign bodies. J
Vet Intern Med 2005; 19:816-821.
10. Ros A, Neiger R. Causes of vomiting
in dogs and usefulness of clinical
investigations. Tierarztl Prax Ausg K
Kleintiere Heimtiere 2013; 41:16-22.
11. Leib MS, Larson MM, Panciera DL,
et al. Diagnostic utility of abdominal
ultrasonography in dogs with chronic
vomiting. J Vet Intern Med 2010; 24:803808.
12. Trepanier L. Acute vomiting in cats: Rational
treatment selection. J Feline Med Surg
2010; 12:225-230.
13. Cannon M. Hair balls in cats: A normal
nuisance or a sign that something is wrong?
J Feline Med Surg 2013; 15:21-29.
4.
P. Jane Armstrong, DVM, MS, MBA, Diplomate ACVIM (Small Animal Internal Medicine), is a professor in the Department of
Veterinary Clinical Sciences at University of
Minnesota College of Veterinary Medicine.
She is also a member of the World Small
Animal Veterinary Association (WSAVA)
Liver Standardization Group. Her clinical
and research interests include gastrointestinal disease, feline medicine, integrative
medicine, clinical nutrition, and canine genetics. Dr. Armstrong
is a past president of the American College of Veterinary Internal
Medicine (Small Animal) and Comparative Gastroenterology Society and an Editorial Advisory Board member for Todays Veterinary Practice. She received her DVM from Ontario Veterinary College, University of Guelph; then completed an internship at University of Illinois and residency and Masters degree at Michigan
State University.
Get rid of ticks,

too!
Activyl Tick Plus adds the proven
eective tick control of permethrin
to the innovative, highly eective
ea control in Activyl.
Available strictly through veterinarians.
Protected by Merck Animal Health
Track & Trace technology.
Copyright 2013 Intervet Inc., a subsidiary of Merck & Co., Inc.

All rights reserved. Intervet Inc. d/b/a Merck Animal Health,
Summit, NJ, 07901 MAH-ACT-16
27
PracTice To PracTice
Promoting
Parasite
Prevention
in Practice
Kelly Soldavin
Madeleine Womble
ach interaction a veterinary team has

with a pet owner is an opportunity
to provide vital information about a
number of wellness issues, one of the most
important being parasite prevention.
However, todays world of economic
hardships and Internet dependence
has made the veterinary practices role in
promoting parasite prevention much more
challenging.
Pet owners are looking for less expensive
productsturning to sources, such
as online pharmacies, for their pets
prescription fulfillment.
Many preventive products are now
available over the counter, outside of the
veterinary practice.
Owners are making fewer appointments to
save money and missing out on important
conversations about their pets health.
Without a trusted resource, owners
are turning to the Internet for facts on
pet health; however, is this information
correct?
Your approach to parasite prevention may
need to change in order for pet owners to:
1. View your practice team as a key source
for information
2. Consider your products quality and
pricing in line with competitive businesses.
28
Meet MAdeleine
Todays Veterinary Practice reached out through several sources to find someone who has helped implement practice protocols that effectively influence
owners to maintain consistent, high-quality parasite
prevention for their pets.
Therefore, meet Madeleine Womblethe Hospital Manager at Central Veterinary Hospital (centralvethospital.com) in Knoxville, Tennessee.
Madeleine has been with CVH for 14 years, originally joining its team to help with the practices bookkeeping. Her work grew into a managerial position,
launching Madeleine into her current career.
She oversees a veterinary hospital that is open 6 days
a week, with 12-hour days Monday through Friday. As
her bio on the hospitals website says, From employment opportunities to special dietary and medicating
needs, Madeleine coordinates it all.
it tAkes A teAM
The 3 owners of the practiceDrs. Robert Black,
William Martin, and Penelope Iannaconeare complemented by 3 associate veterinarians, a licensed
veterinary technician, and 10 veterinary assistants
who handle responsibilities, such as assisting specific
veterinarians, specializing in anesthetic recovery, and
caring for the kennels.
At CVH, a client relations manager heads up a
6-member team of client relation specialists who supervise client communication, including scheduling
appointments, greeting pet owners, and facilitating
prescription refills and check in/out.
In addition to standard veterinary care, the hospital
offers hospitalization, boarding, and grooming. After

hours cases are referred to an emergency clinic that is
2 miles down the road.
Clients of CVH are treated to a practice that has the
personnel and capabilities to offer the best care for
their pets. The question iswith so many team members and such a busy schedule, how does CVH implement effective parasite prevention strategies for their
patients?
GettinG A HeAd stArt
At CVH, parasite prevention begins as soon as the
patient comes in the door. When the owner checks in,
the client relationship specialist asks:
In addition to the reason for the visit, are there any
other concerns the client has about his or her pet?
What medication or products need to be refilled
(specifically parasite prevention)? These refills are
then prepared and ready at check out.
If the client declines refills on parasite preventives,
the specialist makes a note, alerting the veterinarian
that prevention needs to be discussed during the examination.
MAkinG tiMe to tAlk
The appointment schedule at CVH allows veterinarians ample time to talk with clients. The technician
or assistant provides support by sharing their own
experiences, helping clients realize that the veterinary
team understands the challenges of choosing preventives, consistent administration, and budgeting cost.
Much of the conversation about parasite prevention
can be covered in the patients history. Common questions include:
How is the current preventive(s) working? Are there
any questions or concerns?
Has a parasite-related disease or situation, such as a
flea infestation in the home, occurred?
How often is the preventive administered?
With new clients, additional questions include:
What is the pets preventive historywhat has been
used and is the pet currently receiving any preventive?
When was the pets last heartworm test?
CoMMuniCAtinG key Points
Madeleine shares, One of the key things our veterinarians, technicians, and assistants convey to our
clients is the fact that we live in an area that is highly
endemic for parasites, but that they can easily be
killed and repelled by preventives.
She goes on to say, Many clients are concerned about
the cost of preventives, but our team points out that
cost of treatment for diseases caused by these parasites
is much higher than the cost of prevention. In addition,
we discuss the current challenges with obtaining adulticide, which could jeopardize treatment if the owners
pet were to become infected with heartworms.
HeArtworM testinGPArt
oF wellness CAre
cVHs wellness testing includes blood
analysis for heartworms (for cats, its
included in the test for FeLV). By including
heartworm
testing as part
of the wellness
examination, the
hospital elevates
the importance of
parasite control,
demonstrating
to clients
that parasite
prevention
is integral to
wellness care.
Madeleine adds, Thankfully, we have had no issues in securing medication for treatment of heartworm disease.
tAilorinG tHe PlAn
Madeleine highlights a critical point in CVHs approach
to pet owners: compromise. We offer all prevention
and treatment options to clients; then let them decide
how they would like to proceed. Each pet has a customized plan developed that addresses both the pet
and owners needs.
What we want to avoid, Madeleine says, is making
a client feel bad if he or she is unable or chooses not
to follow our recommendations. Instead, we make a
note to revisit the topic at the next appointment, hoping that the client will decide to follow our advice then.
CVH offers a selection of 3 to 4 parasite preventives.
No one preventive works for every case. Discussing
various options emphasizes that most preventives address more than one parasite and assures clients that
they are making informed decisions, notes Madeleine.
With regard to heartworm disease treatment, Madeleine says, Of the pets that test positive for heartworm
infection, most are new patients. And the majority of
clients choose to treat their pets.
FindinG FinAnCiAl FeAsibility
When a client finishes an appointment at CVH:
The veterinary team has discussed parasite prevention, diagnostics, and/or treatment and developed a
plan with the client that addresses the pets specific
needs.
The client relations specialist is aware of the plan
and confirms the preventive chosen and the amount
the client would like to purchase.
With CVHs emphasis on client compromise, the
29
Promoting Parasite Prevention in Practice
PracTice To PracTice |
| PracTice To PracTice
hospital works with each client to make prevention affordable. Madeleine shares, Clients can purchase 1 dose at a
time or a years worth. While
we had concerns about whether 1-dose purchasers would return regularly, we have found
that these pet owners are very
dedicated to buying preventive each month and keeping
their pets protected, despite financial challenges that prevent
purchase of a 6- or 12-month
supply.
CVH also has several protocols in place to keep the hospital competitive with stores and online suppliers that
offer prescription and OTC preventive products.
CVHs prices are competitive with pharmacies,
stores, and other local clinics; this competitive
pricing is enhanced by manufacturer coupons and
rebates.
When clients request written prescriptions, client
relations specialists explain the hospitals competitive pricing, and point out that CVH can often offer
a better deal on preventives.
All rebates and coupons are processed in the clinic
and mailed for the clientsone less thing clients
have to worry about.
Madeleine says, At the end of each day or week we
print reports for the coupons/rebates collected and
mail them to the manufacturers in weekly batches.
Once a system is established, its a straightforward process and one that our clients very much appreciate.
oFFerinG eduCAtion & resourCes
Madeleine notes that CVHs relationships with manufacturer representatives are valuable when it comes
to providing employee education. A representative
who does his or her job well is always willing to help.
When we need education about specific topics or
products, these representatives provide this information to our team.
CVH also provides ongoing training for personnel,
with parasite preventive protocols discussed on a regular basis.
For both hospital personnel and clients, Madeleine
ensures that there are plenty of handoutsoften provided by manufacturers for specific productsand
printed materials available in the waiting and examination rooms that can be shared, discussed, and sent
home with clients for further review.
The CVH website also offers several resources that
help promote wellness care, including parasite prevention:
A Topic of the Month page provides information
on a specific health topic and special incentive
30
tHe Power oF 12 At CVH

Last year, 12.12.12 became the mantra
for an initiative focused on increasing, by
12%, the number of year-round (12-month)
doses of heartworm preventive sold in
2012.
Madeleine shared how the program
impacted cVH: 12.12.12 reminded our
team that we really should be encouraging
clients to buy 12 months of preventive
at a time. This recommendation was
backed up by the great rebates offered by
Merialit was an incentive clients couldnt
pass up.
She added, clients didnt always
understand that year-round prevention
is needed in our area. 12.12.12 helped
educate our employees on this topic,
which allowed them to educate our
clients. The programs measurement
system showed that our sales of
12-dose heartworm preventive products
increased.
The best part was finding out that
the hospital was above average when
compared to national statistics with regard
to percentage of clients purchasing yearround prevention. i really gained a new
appreciation for our team, knowing our
patients were reaping the benefits of a job
well done by everyone at cVH.
I WAS MORTIFIED.
HOW COULD MY QUEENIE HAVE
REVOLTING TAPEWORMS?
CLIENTS NEVER EXPECT THEIR DOGS TO GET TAPEWORMS.
Fortunately, IVERHART MAX (ivermectin/pyrantel pamoate/praziquantel)
Chewable Tablets can spare clients the shock of seeing their dogs get
them. Choose the only monthly heartworm preventative that treats
and controls tapeworms.
(ivermectin /pyrantel pamoate/praziquantel)
Help clients avoid nasty tapeworm surprises. Call 1-800-338-3659

or visit www.virbacvet.com.
All dogs should be tested for heartworm infection before starting a preventive program. Following use of IVERHART MAX Chewable
Tablets, digestive and neurological side effects have rarely been reported. Use with caution in sick, debilitated or underweight
animals and dogs weighing less than 10 lbs. See brief summary on page 32 for additional information.
PREVENT TREAT CONTROL
2013 Virbac AH, Inc. All Rights Reserved. IVERHART MAX is a registered trademark of
Virbac Corporation in the US and a trademark of Virbac Corporation in Canada. 1/13
| PracTice To PracTice
(ivermectin /pyrantel pamoate/praziquantel)
pricing for products or services

related to it; parasite prevention
is addressed at least twice a year.
Petly accounts (petly.com; private website that allows pet owners to directly access and manage their pets health care) allow
clients to request appointments,
check wellness history, and order
prescription refills.
Links to further information on
topics of interest for pet owners
are available.
The existence of these resources
is highlighted on the hospitals Facebook page and monthly client newsletter.
in suMMAry
Madeleines thoughts on implementing a successful and effective parasite prevention program made it
obvious that a process of simple
steps can result in big changes.
1. Define each team members
role in helping pet owners make
the right decisions about parasite
prevention for their pets.
2. Have honest conversations with
clients about what does or does
not work with regard to their pets
parasite prevention.
3. Integrate parasite testing and
prevention into wellness visits,
reinforcing its importance as a key
to having a healthy pet.
4. Develop a preventive program
that works for each person and
pet, which increases compliance
and decreases the possibility a
client will purchase products elsewhere.
5. Become THE source for client
questions on pet health care
pet owners should come to you
and your clinic for advice rather
than relying on dubious Internet
information.
Our hospital is dedicated to providing the highest quality of care for
our patients, Madeleine says. By
making sure our employees share
that vision, our clients are offered a
full range of options for their pets
health care, and the hospital team
works with clients to implement best
care in light of each individuals situation. n
32
CAUTION: Federal (US) law restricts this drug to use by or on

the order of a licensed veterinarian.
BRIEF SUMMARY: Please consult package insert for complete product information.
Indications: For use in dogs to prevent canine heartworm
disease by eliminating the tissue stage of heartworm larvae
(Diroflaria immitis) for a month (30 days) after infection and
for the treatment and control of roundworms (Toxocara canis,
Toxascaris leonina), hookworms (Ancylostoma caninum,
Uncinaria stenocephala, Ancylostoma braziliense), and
tapeworms (Dipylidium caninum, Taenia pisiformis).
WARNINGS: For use in dogs only. Keep this and all drugs
out of reach of children. In safety studies, testicular hypoplasia
was observed in some dogs receiving 3 and 5 times the
maximum recommended dose monthly for 6 months (see
Animal Safety). In case of ingestion by humans, clients should
be advised to contact a physician immediately. Physicians
may contact a Poison Control Center for advice concerning
cases of ingestion by humans.
PRECAUTIONS: Use with caution in sick, debilitated, or
underweight animals and dogs weighing less than 10 lbs.
The safe use of this drug has not been evaluated in pregnant or lactating bitches.
All dogs should be tested for existing heartworm infection
before starting treatment with IVERHART MAX Chewable
Tablets, which are not effective against adult D. immitis.
Infected dogs should be treated to remove adult heartworms and microflariae before initiating a heartworm prevention program.
While some microflariae may be killed by the ivermectin
in IVERHART MAX Chewable Tablets at the recommended
dose level, IVERHART MAX Chewable Tablets are not effective for microflariae clearance. A mild hypersensitivity-type
reaction, presumably due to dead or dying microflariae and
particularly involving transient diarrhea, has been observed
in clinical trials with ivermectin alone after treatment of
some dogs that have circulating microflariae.
ADVERSE REACTIONS: In clinical feld trials with ivermectin/
pyrantel pamoate, vomiting or diarrhea within 24 hours of
dosing was rarely observed (1.1% of administered doses).
The following adverse reactions have been reported
following the use of ivermectin: depression/lethargy, vomiting,
anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions
and hypersalivation.
ANIMAL SAFETY: Studies with ivermectin indicate that
certain dogs of the Collie breed are more sensitive to the
effects of ivermectin administered at elevated dose levels
(more than 16 times the target use level of 6 mcg/kg) than
dogs of other breeds. At elevated doses, sensitive dogs
showed adverse reactions which included mydriasis,
depression, ataxia, tremors, drooling, paresis, recumbency,
excitability, stupor, coma and death. No signs of toxicity were
seen at 10 times the recommended dose (27.2 mcg/lb) in
sensitive Collies. Results of these studies and bioequivalence
studies support the safety of ivermectin products in dogs,
including Collies, when used as recommended by the label.
In a laboratory safety study, 12-week-old Beagle puppies
receiving 3 and 5 times the recommended dose once weekly
for 13 weeks demonstrated a dose-related decrease in
testicular maturation compared to controls.
HOW SUPPLIED: IVERHART MAX Chewable Tablets
are available in four dosage strengths for dogs of
different weights. Each strength comes in a box
of 6 chewable tablets and in a box of 12 chewable tablets,
packed 10 boxes per display box.
STORAGE CONDITIONS: Store at controlled room temperature of 59-86 F (15-30 C). Protect product from light.
EASOTIC
Otic suspension
(hydrocortisone aceponate, miconazole nitrate,
gentamicin sulfate) Anti-inammatory, antifungal,
and antibacterial
For Otic Use in Dogs Only
CAUTION
Federal law restricts this drug to use by or on the order of a licensed veterinarian.
BRIEF SUMMARY: Please consult package insert for complete product information.
INDICATIONS
EASOTIC suspension is indicated for the treatment of otitis externa in dogs
associated with susceptible strains of yeast (Malassezia pachydermatis) and
bacteria (Staphylococcus pseudintermedius).
CONTRAINDICATIONS
Do not use in dogs with known tympanic membrane perforation.
EASOTIC suspension is contraindicated in dogs with known or suspected
hypersensitivity to corticosteroids, imidazole antifungals, or aminoglycoside
antibiotics.
WARNINGS
Human Warnings: Not for use in humans. Keep this and all drugs out of reach
of children.
Humans with known or suspected hypersensitivity to hydrocortisone,
aminoglycoside antibiotics, or azole antifungals should not handle this product.
Animal Warnings: As a class, aminoglycoside antibiotics are associated with
ototoxicity, vestibular dysfunction and renal toxicity. The use of EASOTIC
suspension in a dog with a damaged tympanic membrane can result in damage to
the structures of the ear associated with hearing and balance or in transmission of
the infection to the middle or inner ear. Immediately discontinue use of EASOTIC
suspension if hearing loss or signs of vestibular dysfunction are observed during
treatment (see ADVERSE REACTIONS).
PRECAUTIONS
Do not administer orally.
Concurrent administration of potentially ototoxic drugs should be avoided.
Use with caution in dogs with impaired hepatic or renal function
(see ANIMAL SAFETY).
Long-term use of topical otic corticosteroids has been associated with
adrenocortical suppression and iatrogenic hyperadrenocorticism in dogs
(see ANIMAL SAFETY).
The safe use of EASOTIC suspension in dogs used for breeding purposes,
during pregnancy, or in lactating bitches, has not been evaluated.
ADVERSE REACTIONS
In a feld study conducted in the United States, there were no adverse reactions
reported in 145 dogs administered EASOTIC suspension.
In foreign market experience, reports of hearing loss and application site erythema
have been received. In most reported cases, the hearing loss and erythema were
transient and resolved with discontinuation of EASOTIC suspension.
To report suspected adverse drug events, or for technical assistance contact
Virbac at 800-338-3659.
ANIMAL SAFETY
Aural administration of EASOTIC suspension to 12 week old Beagle dogs at
1, 3, and 5 times the recommended dose (1 mL/ear/day) for 15 days (three
times the treatment length) was associated with alterations of the hypothalamicpituitary-adrenal axis as evidenced by the ACTH stimulation results. Other
fndings considered to be related to treatment include the development of aural
hyperemia; the presence of renal tubular crystals and possibly renal tubular
basophilia and atrophy; elevated liver weights; the development of otitis externa
and media; and elevations in alanine aminotransferase, alkaline phosphatase,
total protein, albumin, and cholesterol levels.
STORAGE INFORMATION: Store at temperatures between 20 C-25 C (68 F-77 F),
with excursions permitted between 15 C-30 C (59 F-86 F).
HOW SUPPLIED: EASOTIC suspension is supplied in a polyethylene canister, with
a soft applicator canula.
Distributed by:
Virbac AH, Inc.
Fort Worth, TX
76137 USA
For technical assistance or to report adverse drug reactions,

please call 1-800-338-3659.
NADA 141-330, Approved by FDA.
Manufactured by: Virbac AH, Inc. Fort Worth, TX 76137
2013 Virbac Corporation.

All Rights Reserved. Rev 8/2011
NADA 141-257, Approved by FDA

IVERHART MAX is a registered trademark of Virbac Corporation
in the US and a trademark of Virbac Corporation in Canada.
2013 Virbac AH, Inc. All Rights Reserved. 1/13
Introducing the new blueprint for

easy, effective treatment of otitis externa.
Flexible Nozzle:
Gentle on sensitive
canine ears.
Unique Airless Delivery System:

One pump delivers
an exact 1 mL dose
every time.
No messy drops
to count. No more
mystery.
Precise dosing in any position.

No more wrestling matches.
One pump, once daily,

for 5 days for any size dog.
Eliminates dosing frustration.
Three Powerful Actives

including Hydrocortisone
Aceponate (HCA) - A potent new
generation glucocorticoid.
(hydrocortisone aceponate, miconazole

nitrate, gentamicin sulfate)
Otic Suspension For Dogs
Ease and otic together at last.
If you could design the ideal

treatment for otitis externa in
dogs, it might just be EASOTIC

Suspension. It makes treating
otitis so easy and accurate your
clients will happily comply, and
the novel formulation makes
short work of inammation,
bacteria and yeast. To learn
more, visit www.virbacvet.com.
EASOTIC Suspension is contraindicated in dogs with known or suspected hypersensitivity to corticosteroids,

imidazole antifungals, or aminoglycoside antibiotics. Do not use in dogs with known tympanic membrane
perforation. The safe use of EASOTIC Suspension in dogs used for breeding purposes, during pregnancy,
or in lactating bitches, has not been evaluated. See brief summary for additional product information.
For information, call 800-338-3659
2013 Virbac Corporation. All Rights Reserved. EASOTIC is a registered trademark of Virbac S.A. in the US. 3/13
13770
Peer reviewed
How to Avoid
the Five Most
CoMMon
MistAkes in
veterinAry
DerMAtology
Lori A. Thompson, DVM, Diplomate ACVD
racticing medicine is called practicing for a

reason. Typically, there is no ONE correct route
of reaching the appropriate diagnosis. Many of
us find the answers by traveling along our own
path, sometimes multiple paths, with a few detours
along the way.
Veterinary dermatology focuses on the management
of chronic diseases and, therefore, is subject to errors
because of judgment calls and assumptions. This article
focuses on common diagnostic pitfalls seen in veterinary dermatology, with an emphasis on spotting opportunities for improvement.
PITFALL 1: FAILure To obTAIn A CoMPLeTe

HIsTory
In veterinary medicine, the history often plays an
essential role in helping us formulate a list of differential diagnoses. Obtaining a thorough history is
CRITICAL and one of the most important parts of the
dermatologic examination.
Two ways to ensure that a comprehensive history is
obtained are:
1. Have clients fill out dermatologic history forms.
2. Train your technicians to help obtain information.
34
By having clients fill out history forms and training

technicians to ask questions about potential dermatologic issues, the practitioner can narrow the diagnosis.
For example, if the owner told the technician that the pet
is itching, ask the following questions (these questions can
be applied to many dermatologic conditions):
When did the itching start?
If pruritus started at less than 6 months of age, ectoparasites or other infectious causes, along with cutaneous adverse food reaction, jump to the top of the list (as
opposed to atopy).
Are any other animals in the house affected? Has a
new pet been brought into the home?
If the answer is yes, then again, ectoparasites rise to
the top of the differential list. Consider the atopic dog
that was managed well with allergen-specific immunotherapy, but develops intense pruritus and alopecia on
the dorsal rump a few weeks after a new kitten joins
the hometheres a good chance that flea allergies are
playing a part in the dogs signs.
Sometimes the addition of a new pet means adding
another food source, such as puppy or kitten food that
includes a protein or carbohydrate source that may
affect a food-allergic pet. A pet in the house with food
How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology |
allergies that manages to snack on the new puppy

or kittens food (or manages to get into the kittens
litter box) may experience a surge in pruritus.
Keep in mind that dogs and cats have individual
thresholds for pruritus and their responses to various triggers may vary in intensity.
Are people in the house affected?
Beware of the owner that just has a rash from
working outside. This owners pet most likely
needs treatment for parasites prior to further allergy
workup.
Are the clinical signs seasonal or nonseasonal?
In many regions of the country, there are variations
in seasonal pollen levels. A dog that is pruritic each
year from June through August is much more likely
to be atopic versus having a cutaneous adverse food
reaction (which would be present year round).
Veterinary technicians provide a valuable service

by giving you a heads up before you enter the
examination room. not only can they ask questions
to help narrow the diagnostic process, but they
can also provide their own observations, such as
whether a patient is showing dermatologic signs
(ie, intense itching or alopecia).
PITFALL 2: HIsToPATHoLogyPerForMIng
IT Too LATe In THe Course oF DIseAse
The main pitfall encountered with regard to histopathology in veterinary dermatology is performing
biopsies too late in the course of disease or biopsying
lesions that are unlikely to give an accurate diagnosis.
Key points to consider include:
Have the clinical signs changed or have they Know when to biopsy.
remained the same?
Biopsying lesions early in the course of disease
Consider the geriatric patient that has always been
(Figure 1) is important. In addition, selecting biopsy
treated in the spring and summer for allergies;
sites along a continuum of the disease process (early-,
however, this year, the pet is presented for recurmid-, and late-stage lesions) can greatly assist the derrent infections with minimal pruritus. Focus on
matohistopathologist reading the samples.
changes in behavior, drinking, appetite, urination,
An earlier stage lesion (such as a pustule or papand appearance of skin and hair coat. Occasionally,
ule) or one that has not become chronic and scarred
geriatric dogs with chronic atopy become less pru(Figures 2 and 3, page 36) is more likely to reveal
ritic after developing an endocrinopathy, such as
diagnostic changes.
hyperadrenocorticism, due to increased levels of
endogenous cortisol.
Has the patient been treated in the past? If so,
when, with which medications, and what was
the response?
Patients that have been treated with several different antibiotics yet still exhibit generalized pyoderma
may be infected with drug-resistant bacteria. These
pets require culture and sensitivity in order to determine the bacteria present and their antimicrobial
sensitivity, allowing the clinician to select the appropriate antibiotic.
Additional questions include:
How many times a day do you observe your pet
scratching?
Does your pet scratch all over its body or focus on
a few specific areas?
Is the itching worse in the morning or the same
throughout the day?
Does the pet lick its paws?
Does the pet travel or has it been boarded or
groomed recently?
To view an example of a dermatologic

history form, visit animaldermatology.
com/new-patient-form.
Figure 1. Early stage epitheliotropic lymphoma

lesions of the nose (A, depigmented areas) and
skin (B).
35
| How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology
Lesions are acute or chronic, localized or generalized, or have seasonal variation

Mucocutaneous junctions appear to be involved
Diagnostic tests have been performed and their
results (eg, skin scrapings, cytology, culture/sensitivity, previous biopsies)
Patient responded to treatment and which therapies did/did not elicit a response.
Figure 2. Squamous cell carcinoma that is likely to

yield a diagnostic biopsy
Many dermatohistopathologists appreciate

digital images.
Todays technology allows you to send an email to
the pathologist and attach digital images that are
representative of the disease process. Remember,
the pathologist is only looking at small, 6-mm samples that have been sectioned into smaller pieces.
Digital images provide a much clearer picture of the
entire disease process and the likelihood of a more
definitive diagnosis.
PITFALL 3: APProPrIATe AnTIbIoTIC use

In the past, antibiotic use in dermatology was synonymous with use of cephalosporins. Now, with the
advent of the many methicillin-resistant infections
(and the social awareness this has created), choosing
the appropriate antibiotic, the proper dose, and the
correct length of treatment is critically important.
Figure 3. Squamous cell carcinoma that is unlikely
to be diagnostic due to severe pyogranulomatous
response
Know the proper technique.
Avoid prepping the sample by doing a surgical
scrub. Submit the crustseven if they fall off the
samplein formalin with the biopsy. The crust can
contain important diagnostic information that may
help distinguish an autoimmune disease from an
infectious process.
Culture & Sensitivity

A common challenge is whether to select an antibiotic
empirically or perform a culture and sensitivity first. A
sample should be submitted for culture if the following indicators are present:
Organisms other than cocci on cytology
Unusual lesions
Persistent or recurrent infections.
In cases of suspected otitis media, the presence of
rod-shaped bacteria on cytology indicates that an ear
culture should be performed.
Obtaining Cultures
Speak with the diagnostic laboratory the practice
employs to determine the best way to obtain and
submit a skin sample for culture. They may prefer a
culturette swab or a biopsy punch of the skin submitted in sterile saline for macerated tissue culture.
Following the laboratorys suggestions maximizes the
chance of obtaining the best result.
Additional tips to help obtain a good specimen
include:
Swabs for bacterial culture should be taken from
new lesions or recently ruptured pustules or vesi Contact a local dermatologist and ask if he or she
cles, not from older, excoriated lesions.
can recommend a dermatohistopathologist.
An
intact pustule should be ruptured with a sterile
Select a dermatohistopathologist and develop
needle
and the contents absorbed on a sterile swab.
a working relationship.
Some
authors
recommend a light surgical prep with
Send this person a detailed synopsis of the patients
alcohol,
but
this
may lead to falsenegative cultures
history; describe whether:
if
the
alcohol
penetrates
or ruptures the fragile stra Patient is pruritic and/or systemically ill
tum corneum overlying the pustule or the pustule
Site selection is important and selecting the
proper site comes with practice.
Clinicians should pick lesions that are typical for the
disease process they suspect. This requires some
knowledge of the suspected disease process. For
example:
Intact pustules for pemphigus foliaceus
Early depigmentation for discoid lupus erythematosus (which is more helpful than a chronic,
crusted erosion).
36
How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology |
opens before the alcohol has evaporated.

Preparing a site for a biopsy that will be used for
macerated tissue culture (described below) is not
the same as preparing the site for a biopsy that
will be submitted for histopathology (described in
Pitfall 2).
To avoid culturing contaminants, prep the skin
first by gently clipping the affected area, then
gently wiping once with an alcohol swab in the
direction of the hair coat.
A 4- to 6-mm punch biopsy sample is then
obtained and inserted into the appropriate culture
medium or sterile saline for submission.
Antibiotic Therapy
Occasionally you will see multiple isolates on your
culture report. When in doubt, it is best to choose
your initial antibiotic therapy based on Staphylococcus
species sensitivity because this bacteria creates a tissue
environment favorable for replication of secondary
invaders. However, combination therapy is occasionally necessary.
Duration of treatment is critical. The recommended
duration of treatment for superficial pyoderma is a
minimum of 3 weeks (or 10 days past clinical resolution). Deep pyodermas may require 8 to 12 weeks of
antibiotic therapy; it is best to continue treatment for
15 to 30 days past clinical resolution.
PITFALL 4: NOT ObTAININg gOOd SKIN

sCrAPIngs
Skin scrapings and cytologic samples are the heart of
dermatology diagnostics. These diagnostics:
Are simple to perform
Help narrow the differential list considerably
Provide additional clinic income.
However, not all skin scrapings are created equal.
The key is deciding what parasite is suspectedthis
information determines where and how the scrapings
are obtained.
Scabies = Superficial Scrapes

Scabies mites live in the superficial epidermis.
Unfortunately, these mites are often difficult to find,
given the small number typically present and intense
pruritus present in the patients.
Multiple superficial scrapings are recommended,
with a focus on the elbows, hocks, pinnal margins,
and ventral chest.
It is important to remember that negative skin scrapings do NOT rule out scabies in a dog. If suspicion
index is high, therapeutic treatment trials are in
order.
The process for obtaining superficial skin scrapings
includes:
1. Appling a drop or 2 of mineral oil onto the skin site
being scraped. I find it useful to also dip the scalpel
blade in the oil, which enhances the adherence of
the scale and flaky material.

2. Holding the blade at a 45-degree angle; then, with
moderate pressure, scraping the affected area in the
direction of hair growth.
3. Scooping the collected material with the blade
and transferring it to the microscope slide. Repeat
scrapings to accumulate a fairly extensive amount of
material.
4. Applying a coverslip and reviewing the slide under
low-power objective (4 or 10), with low-light
intensity and closure of the iris diaphragm on the
condenser to provide increased contrast between
the mites and mineral oil background (see Figure
4condenser not adaptedversus Figure 5condenser lowered and low light).
Demodex = Deep scrapes

In general, multiple scrapings from new lesions are
best. The process of acquiring deep skin scrapes
includes:
1. Squeezing the affected skin to obtain mites that live
deep in the hair follicles; then scraping with a scalpel blade and mineral oil until there is true capillary
bleeding.
Figure 4. demodex canis: High-light intensity and

unadjusted condenser leads to the washed-out
appearance, which can result in missed mites when
examining samples.
Figure 5. demodex canis: Low-light intensity and

closure of the iris diaphragm on the condenser provide increased contrast between the mites and mineral oil background.
37
| How To AVoid THe FiVe MosT CoMMon MisTAkes in VeTerinAry derMATology
2. Collecting each sample and placing on individual

slides. Label the slides to indicate the location of
the scrapes, which is important for monitoring mite
counts at subsequent visits.
3. Applying a coverslip and reviewing under low-power
objective (4 or 10), with low-light intensity and
closure of the iris diaphragm on the condenser to
provide increased contrast between the mites and
mineral oil background.
4. Determining whether mites are present, counting
the number of mites per low-power field, and deciding whether the patient has localized or generalized
disease.
5. Monitoring treatment progress by distinguishing
eggs, larva, nymphs, and adults, along with live and
dead mites, each time scrapings are acquired.
PITFALL 5: FOrgeTTINg THe POWer OF THe

FLeA
Despite modern advances in flea control, flea allergic
dermatitis is the most common skin disease seen in
small animal practice around the world.
Why is this the case when newer, more effective products are available and most small animal practitioners
are very aware of flea allergic dermatitis in dogs and
cats? Not surprisingly, the most difficult task in cases
of flea allergy dermatitis is convincing owners that the
correct diagnosis has been made. This can be due to
the fact that owners dont see fleas on the pet or wont
accept that their homes have ectoparasites (because it
is considered dirty), among other reasons.
Product Failure
When a flea product fails, many pet owners view this
as the development of resistance. However, the majority of flea product failures are due to poor compliance.
The most common causes of treatment failure are
some or all of the following:
Failure to treat all in-contact animals, including
indoor/outdoor cats and visitors
Failure to use the flea product properly (eg, dividing
large tube of product between 3 Chihuahuas, resulting in inaccurate dosing)
Failure to maintain consistent treatment
Failure to address environmental issues (especially
in severe cases).
Owner education
Owner education is critical. Create a buy in to the
diagnosis before revealing it:
Discuss the 3 most common allergic skin diseases in
dogs:
1. Atopic dermatitis
2. Food allergic dermatitis
3. Flea allergic dermatitis.
Talk about the distribution pattern of these diseases
lesions and let owners begin to draw their own conclusions.
38
If possible, explain potential reasons for treatment

failure if previous flea control methods have been
ineffective.
Customizing Programs
It is important to tailor every flea control program to
the clients individual life situation. This is where history plays a role yet again.
Do you have a client that is afraid of using topical
pesticides? Perhaps an oral flea preventive is a better solution.
The frequently bathed, indoor Chihuahua will most
likely have a very different treatment recommendation than the German shorthaired pointer that goes
hunting and competes in field trials every weekend.
For example, the indoor Chihuahua may be well
maintained with regular, monthly oral or topical
flea preventive that does not provide protection
from ticks. The German shorthaired pointer hunts
in an area where tick-borne disease is prevalent
and may require monthly oral or topical flea preventive AND an additional product for protection
from ticks prior to hunting.
Similarly, if these patients live in a household that
has several cats that are frequently sleeping with
the dogs, it is important to avoid flea products that
contain pyrethrins or other compounds that can
be harmful to cats.
Consider providing a client handout that describes
the various flea products your clinic offers and why
YOU have chosen to carry those particular products.
They trust you and want to know what you think. n
View Product Profile: Common
Flea Preventive Medications for
dogs & Cats in the resources section of
todaysveterinarypractice.com.
Lori Thompson, DVM,

Diplomate ACVD, is the
co-owner of Animal
Dermatology Clinic
Indianapolis in Indianapolis,
Indiana. She is the immediate past president of
the Indiana Veterinary
Medical Association and
is very active in organized veterinary medicine.
Dr. Thompsons clinical interests include allergic
skin and respiratory disease, equine dermatology,
and immunomodulatory therapies. She lectures
nationally on these topics in addition to performing volunteer work. Dr. Thompson is the author of
several peer-reviewed articles and is a past recipient of the ACVD Resident Research Award and
the Bastien Award for Excellence in Canine Care.
Labradoodle
Putney Cefpodoxime Proxetil
The perfect combination of

Labrador Retriever and Poodle
The perfect combination of

quality and affordability
FDA Approved for Veterinary Use: Putney Cefpodoxime Proxetil.

Putney Cefpodoxime Proxetil is a generic Simplicef available for a better price.
Our FDA-approved veterinary generic is available in 100 and

200 mg tablets in 100 count bottles.
When prescribing Cefpodoxime Proxetil tablets for your patients,
choose quality and affordability. Choose Putney.
Committed to quality. Delivering affordability.
www.putneyvet.com
Find Putney distributors at: www.putneyvet.com/howtobuy or call 866-683-0660.

PUTNEY VETERINARY GENERICS:
SIMPLICEF is a registered trademark of PAH P&U LLC.
CEFPODOXIME PROXETIL
CARPROFEN CAPLETS
KETAMINE HCl
2013 Putney, Inc. All rights reserved. 0105-1009-13
Peer reviewed
The Neurologic
examiNatioN in
Companion Animals
Part 2: Interpreting
Abnormal Findings
complete neurologic examination should be

done in all animals presenting with suspected
neurologic disease. Abnormalities found during
the neurologic examination can reflect the location of
the lesion, but not the cause, requiring further tests,
such as blood analysis, electrodiagnostic tests, and
advanced imaging, to determine a diagnosis.
The neurologic examination evaluates different parts
of the nervous system; the findings from the examination help localize the lesion to the:
Brain
Spinal cord
Peripheral nervous system
Cauda equina.
A fundic examination is recommended, especially in
patients with brain disorders. Repeat neurologic examinations are helpful to discover subtle abnormalities and
assess progression of disease.
Read The Neurologic Examination

in Companion AnimalsPart 1:
Performing the Examination (January/February
2013) at todaysveterinarypractice.com.
40
In the January/February issue of

Todays Veterinary Practice, Part 1
of this article discussed performing
a neurologic examination; Part
2 will address interpretation of
abnormal findings.
THE BRAIN
Lesions in the brain can be localized to the:
Cerebrum and thalamus (ie, prosencephalon)
Brainstem
Cerebellum.
In order to localize the lesion to a specific part of
the brain, an understanding of the anatomy and function of the brain is necessary (see Brain Anatomy &
Related Functions).
Ataxia
A patient with ataxia may have a lesion in the proprioceptive pathways (peripheral nerves, spinal cord, or
cerebrum), vestibular system, or cerebellum. Ataxia
can be described as an uncoordinated gait, with crossing of the limbs and, sometimes, listing or falling to 1
or both sides. Ataxia can be further characterized as:
Proprioceptive: Mild, usually bilateral ataxia
Vestibular: Moderate, asymmetric ataxia
Cerebellar: Symmetric, truncal ataxia.
Circling
The direction of circling is usually toward the side
with the lesion. The circles tend to be larger with lesions in the prosencephalon than with lesions in the
vestibular system.
The NeuRologic exAmiNATioN iN comPANioN ANimAls, PART 2 |
Cranial Nerve Abnormalities

Cranial nerve abnormalities are
signs of either a peripheral neuropathy or brainstem lesion.
Brainstem lesions can be localized to the part of the brainstem where the cranial nerve
nucleus is located. Peripheral
neuropathy may affect only 1
nerve (eg, idiopathic facial paralysis) or be part of a polyneuropathy.
Decerebellate Posture
This rare posture is seen with a
severe lesion in the cerebellum.
Findings include:
A mentally alert patient
Opisthotonus (dorsiflexion of
the head and neck)
Increased extensor tone in
the thoracic limbs due to
loss of inhibition from the
cerebellum to the extensor
muscles
Pelvic limbs with reduced
muscle tone that are usually
flexed.
Decerebrate Posture
This rare posture is seen with
a severe lesion in the midbrain
or pons.
The mentation in these
patients is severely affected
(stupor or coma).
Opisthotonus may be present
if the animal has a cerebellar lesion in addition to the
brainstem lesion.
Increased extensor tone in
all limbs is a result of loss
of inhibitory function from
the pontomedullary reticular
formation (RF or RAS), which
affects extensor tone of the
limbs.
Hemineglect (Hemiinattention)
Hemineglect is a reduced reaction to a stimulus (body or
head) contralateral to a lesion
in the cerebrum. To test for
hemineglect observe the patients reaction (turning the
head around, whining, trying
to bite) while pinching the side
BRAIN ANAToMy & RElATED FuNCTIoNs

Cerebrum & Thalamus
The cerebrum initiates movements; the thalamus executes movements.
A common finding in cats with a large meningioma compressing the
cerebrum is difficulty initiating movements and continuous, aimless
walking in large circles.
A patient with a thalamic lesion may have a compulsive behavior: if
restrained, the patient may struggle, vocalize, and try to keep walking.
Brainstem
The brainstem connects the cerebrum with the spinal cord and body. All
information to and from the body (which is examined by postural reaction
assessment) passes through the brainstem and thalamus to leave or reach
the cerebrum.
The brainstem includes the midbrain (mesencephalon), pons, and medulla
oblongata. localizing to one specific part of the brainstem is often not possible; however, cranial nerve deficits may help pinpoint the lesion.
The brainstem contains the cranial nerve cell bodies (except cN i and ii).
The midbrain contains the reflex center for vision and hearing (colliculi)
and the nuclei of CN III and IV.
The pons lies between the midbrain and medulla oblongata and contains
the nucleus of CN V. in addition, some of the vestibular nuclei are partially
in the pons.
The medulla oblongata, the most caudal part of the brainstem, contains
the respiratory and blood pressure regulation centers, nuclei of CN VI to
XII, and the vestibular nuclei (4 vestibular nuclei on each side).
Cerebellum
The cerebellum adjusts and moderates all movements initiated by the
cerebrum and executed by the thalamus. clinical signs that may indicate a
cerebellar lesion include:
cerebellar ataxia
Variable and intermittent loss of the menace response
ipsilateral postural reaction deficits and/or hypermetria
intention tremor.
Lisa wirth, vMd
Cross-section of cerebrum and thalamus and lateral aspect of brainstem
41
| The NeuRologic exAmiNATioN iN comPANioN ANimAls, PART 2
of the trunk with hemostats. Compare reactions when pinching the other side.
Mental status
A change in mental status is caused by a lesion
in the prosencephalon or brainstem (the reticular activating system is diffusely spread in
the brainstem and responsible for our awareness and arousability).
Owners knowledge of his or her pets
personality plus observations at home are
essential to assess the patients mental status, especially when there are subtle mentation changes.
Repeat examinations and observation of the
animal over a longer time period and in different surroundings are also helpful.
Figure 1. Myotatic and withdrawal reflex pathways;

thoracic and pelvic limbs
HoRNERs syNDRoME &

ANIsCoRIA
Horners syndrome is caused by a
lack of sympathetic innervation to the
eye. in patients with other neurologic
dysfunction, it is most commonly
seen with peripheral vestibular
dysfunction, c6 to T2 myelopathy, or
brachial plexus injury (ie, outside the
spinal canal). clinical signs include:
Miosis (constricted pupil)
Enophthalmia (sunken eye)
Ptosis (drooping eyelid)
Protrusion of the third eyelid.
Anisocoria refers to pupils of
unequal size.
Loss of sympathetic tone (ie,
horners syndrome) results in one
pupil failing to dilate (remaining
constricted) in darkness.
A parasympathetic lesion (ie,
deficit of the oculomotor nerve
cNiii) results in one pupil failing to
constrict (remaining dilated) when
exposed to light.
Brain edema and brain herniation
may cause compression of the cNiii
nucleus in the midbrain, resulting
in anisocoria, pinpoint pupils that
do not dilate in the dark or respond
to light, or fixed and dilated pupils.
in these patients mental status is
also altered (stuporous or comatose). This is a serious finding that
requires immediate attention and
treatment.
42
Figure 2. C1 to
C5 myelopathy:
Postural reactions
are delayed or absent in all limbs
(red lines); spinal
reflexes are normal or increased
(green lines)
Figure 3. T3 to L3
myelopathy: Postural reactions and
spinal reflexes in
thoracic limbs are
normal; postural reactions are
delayed or absent (red lines)
but spinal reflexes are normal or
increased (green
lines) in pelvic
limbs
Figure 4. C6 to T2
myelopathy: Postural reactions are
delayed or absent
in all limbs; spinal reflexes are reduced or absent in
thoracic limbs (red
lines) and normal
or increased in
pelvic limbs (green
lines)
Figure 5. L4 to
S3 myelopathy:
Postural reactions and spinal
reflexes in thoracic limbs are normal (green lines);
postural reactions
are delayed or absent and spinal reflexes are reduced
or absent in pelvic
limbs (red lines)
The NeuRologic exAmiNATioN iN comPANioN ANimAls, PART 2 |
PosTuRAl REACTIoN AssEssMENT

All postural reaction tests assess the sensory pathway from the paw to the brain stem and contralateral
cerebrum (through the limb and spinal cord) and the
motor pathway that returns the same way to the
paw (Figures A and B).
conscious recognition is required from the cerebrum in order for the patient to replace the paw correctly; a slow or absent response indicates a problem
somewhere along the pathway. The pathways to and
from the cerebellum contribute to the response and,
in patients with cerebellar lesions, cause altered postural reactions.
other findings help pinpoint the lesion to a specific area.
In patients with brain disorders, postural reaction
deficits are ipsilateral (both thoracic and pelvic
limbs) to a lesion in the brainstem and contralateral to a lesion in the cerebrum and thalamus
(Figure C).
A patient with a cervical myelopathy (C1C5 or
C6T2) has postural reaction deficits in all limbs;
a patient with a thoracolumbar myelopathy (T3l3
or l4s3) or cauda equina syndrome has postural
reaction deficits only in the pelvic limbs.
Figure A. Thoracic limb left (black) and right (blue)

postural reaction pathways
Paresis
A patient with a cerebral lesion usually has mild,
almost unnoticeable paresis. Patients with brainstem lesions have more pronounced paresis and
ataxia ipsilateral to the lesion.
seizures
If there is a history of seizures, the lesion can be
localized to the prosencephalon, even if the neurologic examination is normal.
THE sPINAl CoRD
Patients with spinal cord lesions have normal
mental status and cranial nerves. Spinal cord lesions can be localized based on:
Gait abnormalities
Postural reaction deficits
Spinal reflex abnormalities.
The spinal cord is divided into 4 functional
regions: (1) C1 to C5, (2) C6 to T2, (3) T3 to L3,
and (4) L4 to S3.
A lesion in the C1 to C5 or C6 to T2 spinal cord segment results in tetraparesis and
often postural reaction deficits in all limbs.
Sometimes the pelvic limbs are more affected
than the thoracic limbs.
A lesion in the T3 to L3 or L4 to S3 spinal
cord segment results in paraparesis and postural reaction deficits in the pelvic limbs.
The C6 to T2 and L4 to S3 spinal cord segments are anatomically enlarged (thus, cervical
and lumbar intumescences) because they contain
the nerve cell bodies of the peripheral nerves
to the limbs and tail. It is important to understand that these enlarged spinal cord segments
are normal anatomy when evaluating images of
the spinal cord.
sIgNs oF VEsTIBulAR sysTEM

DysFuNCTIoN
Figure B. Pelvic limb left (black) and right (blue)

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

ataxia, positional strabismus, head tilt,
and circling are all signs of vestibular
system dysfunction. The lesion may
be in the inner ear or eighth cranial
nerve (peripheral vestibular system) or
in the brainstem or cerebellum (central
vestibular system). Additional signs of
brainstem dysfunction that are used
to localize the lesion to the central
vestibular system include:
Ipsilateral postural reaction deficits
Changes in mental status
Deficits in other cranial nerves.
43
| The Neurologic examiNaTioN iN compaNioN aNimals, parT 2
In addition to postural reaction assessment, these

areas are also evaluated by testing the spinal reflexes (Figure 1).
A lesion in the C1 to C5 or T3 to L3 spinal cord segment results in normal (sometimes
increased) spinal reflexes (upper motor neuron
signs) (Figures 2 and 3).
A lesion in the C6 to T2 or L4 to S3 spinal
cord segment results in reduced muscle tone and
reduced spinal reflexes in the thoracic limbs (C6
T2) or pelvic limbs (L4S3) (lower motor neuron
signs) (Figures 4 and 5).
Paresis
Tetraparesis without cranial nerve deficits or other
brainstem signs suggests a cervical myelopathy; paraparesis is suggestive of a thoracolumbar myelopathy.
Schiff-Sherrington Posture
This posture is seen with severe spinal cord injury between the T3 and L4 spinal cord segments. There
is increased tone in the thoracic limbs, and normal or
reduced tone with paralysis of the pelvic limbs; the
prognosis is guarded but not hopeless.
The posture results from loss of normal inhibition
of the thoracic limb extensor muscle tone, which is
normally controlled by the border cells in the lumbar
spinal cord. Axons of these cells ascend the spinal cord
to reach the cervical intumescence, where they inhibit
the thoracic limb extensor motor neurons.
THE PERIPHERAL NERVOUS SYSTEM
The peripheral nervous system includes the:
Neuromuscular system (peripheral motor nerves,
muscles, and neuromuscular junctions)
Sensory nervous system
Autonomic nervous system.
Peripheral nervous system diseases can be difficult to diagnose, with signs of neurologic dysfunction being vague or nonexistent. The following information does not pertain to diseases of the autonomic
nervous system.
Patients with neuromuscular disease can have both
paresis and muscular weakness as well as exercise
intolerance.
Sometimes muscle pain is present.
Postural reaction deficits and reduced spinal reflexes may be present.
The history may reveal signs of neuromuscular
disease, such as exercise intolerance, generalized
weakness, voice change, and neurogenic muscle
atrophy; these signs may be intermittent.
THE CAUDA EQUINA
The cauda equina are the spinal nerves (L6L7, S1
S3, and Cd1Cd5) caudal to the spinal cord in the
lumbar vertebral canal.
Compression of the cauda equina initially results in
44
Todays Veterinary practice March/April 2013
pain, followed by paraparesis and postural reaction

deficits.
Later in the disease, reduced spinal reflexes to the
pelvic limbs, anus, and urinary sphincter are present.
A history that includes slowly progressive paraparesis (over many months) and pain on palpation of
the lumbosacral area can help localize a lesion to
the cauda equina.
FURTHER DIAGNOSIS
Once the lesion is localized to a specific area of the
nervous system, a list of differential diagnoses can
be made. Based on lesion localization and differential diagnoses, appropriate diagnostic tests can be
chosen. n
Suggested Reading
DeLahunta A, Glass E (ed). The neurologic examination.
Veterinary Neuroanatomy and Clinical Neurology, 3rd ed.
Philadelphia: WB Saunders, 2009, pp 487-501.
Dewey C. Functional and dysfunctional neuroanatomy: The
key to lesion localization. In Dewey C (ed): A Practical
Guide to Canine and Feline Neurology, 2nd ed. Ames, IA:
Blackwell Publishing, 2003, pp 17-52.
Garosi L. Lesion localization and differential diagnosis. In
Platt SR, Olby NJ (ed): BSAVA Manual of Canine and
Feline Neurology, 3rd ed. Quedgeley, Gloucestershire,
UK: BSAVA, 2004, pp 24-34.
Lorenz MD, Kornegay JN. Localization of lesions in the nervous system. Handbook of Veterinary Neurology, 4th ed.
Philadelphia: WB Saunders, 2004, pp 45-74.
Helena Rylander,
DVM, Diplomate
ACVIM (Neurology),
is a clinical assistant
professor in the
Department of Medical
Sciences at University
of Wisconsin
Madisons School of
Veterinary Medicine.
Her clinical interests include spinal surgery,
electrophysiology, and diagnostic imaging.
Dr. Rylander has published several articles
and a book chapter as well as presented
at national and international meetings.
She received her veterinary degree from
University of Agricultural Sciences in Uppsala,
Sweden. After 10 years in private practice in
Sweden, Dr. Rylander completed a residency
in neurology/neurosurgery at University
of CaliforniaDavis. She also completed
the Educational Commission for Foreign
Veterinary Graduates (ECFVG) certification
program and received her DVM.
DOGS
NEED
ADVENTURE
TICK AND
FLEA-FREE
From the backyard to the backcountry,

make sure dogs are protected on every
adventure with Parastar Plus.
Starts killing ticks and eas
in as little as one hour
Long-lasting
Waterproof
Exclusively for
veterinary hospitals
You and your clients can share adventurous

dog photos like these for a chance to be featured
in Outside magazine and win outdoor gear.
DogsNeedAdventure.com
Tick and flea protection
for adventurous dogs
2013 Novartis Animal Health US, Inc. Parastar is a registered trademark of Novartis AG. PPL130020A
lEsIoN loCATIoN oRgANIzED By NEuRologIC AssEssMENT & FINDINgs

FINDINgs
loCATIoN oF NEuRologIC DIsEAsE
MENTATIoN AssEssMENT
Mental status Brainstem (see also decerebrate posture)
Central vestibular system
Prosencephalon
PosTuRE AssEssMENT
Decerebellate Cerebellum (normal mental status, opisthotonus, increased extensor tone in thoracic limbs, flexed
Posture
pelvic limbs with reduced muscle tone)
Decerebrate
Midbrain or pons (severely affected mentation, increased extensor tone in all limbs, opisthotonus if
Posture
cerebellar lesion present)
Schiff-Sherrington T3l4 spinal cord segments (increased tone in thoracic limbs; normal to reduced tone and
Posture
paralysis of pelvic limbs)
gAIT AssEssMENT
Ataxia
Cerebellum: symmetric, truncal (bouncy gait/good muscle tone)
Proprioceptive pathways: mild, usually bilateral
Vestibular system: Asymmetric, moderate
Circling
Prosencephalon: circles larger
Vestibular system: circles smaller
Direction of circling is usually toward side with lesion
Paresis
Brainstem: Paresis and ataxia ipsilateral to lesion
Cauda equina: Paraparesis
Cerebrum: mild, almost unnoticeable paresis
Cervical myelopathy (C1C5 or C6T2): Tetraparesis
Neuromuscular system: Various grade of para- or tetraparesis (also muscular weakness, exercise
intolerance)
Thoracolumbar myelopathy (T3l3 or l4s3): Paraparesis
CRANIAl NERVE AssEssMENT
Cranial Nerve
Brainstem: localized to part of brainstem where nucleus is located
Abnormalities Central vestibular system
Peripheral nervous system: may affect one nerve or be part of a polyneuropathy
PosTuRAl REACTIoN AssEssMENT
Postural
Brainstem: ipsilateral to lesion
Reaction
Cauda equina: Pelvic limbs
Deficits
Central vestibular system: ipsilateral to lesion
Cerebrum/thalamus: contralateral to lesion
C1C5 or C6T2 spinal cord segments: All limbs (pelvic limbs may be more affected than thoracic
limbs)
T3L3 or L4S3 spinal cord segments: Pelvic limbs
Neuromuscular disease: Postural reaction deficits may be present
sPINAl NERVE AssEssMENT
spinal Reflexes Cauda equina: Reduced reflexes to pelvic limbs, anus, and urinary sphincter may be present
C1C5 or T3l3 spinal cord segment: Normal to increased reflexes (upper motor neuron signs)
C6T2 or l4s3 spinal cord segment: Reduced reflexes (lower motor neuron signs); reduced muscle tone
Neuromuscular system: Reduced reflexes may be present in either thoracic or pelvic limbs
PAIN AssEssMENT
Pain on spinal Brain: Pain on cervical flexion may sometimes be found
Palpation
Cauda equina: Pain on palpation of the lumbosacral area
Neuromuscular: muscle pain in some myopathies
spinal cord: Pain on palpation of affected area may or may not be present
oTHER AssEssMENTs
Hemineglect
Cerebrum: Reduced reaction to stimulus contralateral side to lesion
seizures
Prosencephalon: Neurologic examination may be normal
Vestibular
Central vestibular system: Brainstem or cerebellar lesion
signs
Peripheral vestibular system: inner ear lesion
This table can be downloaded and printed for use in your practice at todaysveterinarypractice.com.
46
the greatest
leaders
are those that also serve.
Leadership is more than a skill. Its a way of life. One where you step up and take command of those who look to you
for guidance. A great way to exercise your abilities by serving part-time in the Air National Guard. Your professional
skills as a veterinarian are needed as a public health offcer. Youll develop plans and programs meant to combat the
spread of communicable diseases when natural disasters strike. And since you serve part-time, you can continue
your civilian career and family life as well. Talk to an Air Guard recruiter today to learn more.
Become an Offcer in the Air National Guard.

airguardjobs.com 1-800-598-4759
Peer reviewed
hearTworm hoTline
The AmericAn
heArTworm
SocieTy & you
Wallace E. Graham, Jr, DVM, President
For this issues Heartworm Hotline column, our regular author, Dr. Clarke Atkins,
handed over the reins to Dr. Wallace Grahamthe President of the American
Heartworm Society (AHS). Because April is National Heartworm Awareness
Month, Dr. Graham shares the mission of the AHS and how the society can help
you provide the best heartworm-related care to your patients.
he American Heartworm Society was founded in

1974 by and for veterinarians with one purpose
in mind: To understand heartworms and the
disease they cause, and to pass that understanding
along to practicing veterinarians. Along the way,
many outstanding scientists have contributed to this
understanding and continue to do so today.
Many of the Societys officers and board members
are practicing veterinarians; therefore, it is an organization keenly focused on practitioners, their patients,
and their clients. To this end, the AHS has developed
initiatives and programs with the practicing veterinarian in mind. Following is a brief description of each
and its benefits to you.
ConferenCes & Meetings
triennial symposium
The Triennial Symposium was the
first initiative of the AHS, and is
the foremost heartworm continuing education event worldwide.
The latest, clinically relevant research is presented by experts
from around the world in a forum that is scientifically
stimulating and practitioner friendly. The 2013 Triennial SymposiumHeartworms Today: The Search for
Solutionswill be held in New Orleans, September 8
through 10. Registration is open at heartwormsociety.
org/annual/2013symposium.html.
48
nAVC symposium
Each year the AHS sponsors a half-day program of cutting-edge information at the NAVC Conference (navc.
org) in Orlando, Florida. This program draws large,
enthusiastic crowds and generates significant interest, which was demonstrated this past January by the
hour-long, impromptu question and answer session
held by Dr. Matthew Miller after his presentation concluded our 2013 NAVC program.
Heartworm University
Recognizing that many practitioners are unable to attend destination-based, national meetings, the AHS
has taken its message on the road. Heartworm University is a 6-hour, RACE-approved case-based program that equips practitioners with the latest information on heartworm disease, prevention, and
therapy.
Most of these programs are held in conjunction
with other meetings, such as state veterinary medical association meetings, or are stand-alone meetings. Worried that you cant sit through a 6-hour
discussion on heartworms? Be aware that the program always receives rave reviews from attendees. A
friend of mine who attended the San Antonio meeting
said it best: Wally, I didnt know what I didnt know
about heartworms!
Read about course content and upcoming meeting
dates at heartwormsociety.org/hwu.
edUCAtionAl MAteriAls
incidence survey & Map
Every 3 years, the AHS surveys every animal hospital in
the country to identify trends in the incidence of heartworm disease. The maps developed from survey data
have been instrumental in documenting the continuing spread of the disease. In addition, the maps are an
effective client education tool for practitioners interested in increasing compliance with heartworm prevention recommendations.
Download the maps at heartwormsociety.org/
veterinary-resources/incidence-maps.html.
Quarterly Bulletin
As new information becomes available, the quarterly
AHS Bulletin is published in an easily digestible format
4 times a year. This publication is mailed or emailed
to our members, and past issues are available on our
website. Case discussions are common and relevant to
the many nuances of decision-making required of the
practitioner with regard to this complex parasite.
ongoing Media outreach
In an effort to keep practitioners and the public abreast
of the latest information on our website and other venues, the AHS reaches out to industry and select consumer media, including blogs, with well-researched
and fact-based information. Often, heartworm-related
articles that practitioners read are published as a result
of, or in cooperation with, an AHS initiative.
social Media
Recognizing the impact of Facebook and Twitter on
todays information superhighway, the AHS is using
these tools to reach out and provide quality information to interested veterinarians, other veterinary team
members, and pet owners.
Canine & feline guidelines

The AHS has published guidelines for the diagnosis,
prevention, and treatment of heartworm disease almost since its inception. These guidelines represent
the standard of care for heartworm disease and are
the definitive go-to documents for the practitioner.
In the past, the guidelines were published after each
triennial symposium. However, thanks to the advent
of the digital age, new information is being generated too quickly for a triennial cycle and, therefore, the
Guidelines are now updated on an as-needed basis,
with press releases issued each time changes are made.
The latest versions are available at:
Canine Guidelines: heartwormsociety.org/
veterinary-resources/canine-guidelines.html
Feline Guidelines: heartwormsociety.org/
veterinary-resources/feline-guidelines.html
MediA oUtreACH
AHs Website
This is the definitive digital source for all things
heartworm. There are various information resources
for practitioners and pet owners,
including a childrens section.
The Think 12 section, available at
heartwormsociety.org/think12,
provides you, the practitioner, with
fresh, up-to-date information, ideas,
and client handouts to help you improve your clients
compliance.
MeMBersHip Benefits
The partnership between the AHS and practitioners
provides a great opportunity for symbiosis. While you
do not need to be a member to enjoy the offerings of
the AHS, joining the society not only gives you the
best tools to care for your patients and communicate
with clients but also supports practical research for
improved methods of treating and preventing heartworm disease.
The American Heartworm Society exists for the benefit of the entire profession and its patientsit is our only
reason for being. I hope you will avail yourself of the
great resources the AHS has to offer and that you will
see immediate benefits in the lives of your patients. n
Wallace E. Graham,
Jr, DVM, is the current
President of the American
Heartworm Society and
has previously served as
Secretary-Treasurer and
as a board member for
AHS. He is an associate
veterinarian at VCA Oso
Creek Animal Hospital in Corpus Christi. Dr.
Graham has been an active member of the
Texas Veterinary Medical Association, serving
as an executive board member and on the
Peer Assistance and Ethics and Grievance
committees. He served in the U.S. Armys
Veterinary Corps upon receiving his DVM from
Texas A&M University.
March/April 2013
Todays Veterinary Practice
49
The american heartworm Society & you
american hearTworm SocieTyS hearTworm hoTline |
Peer reviewed
ImagIng EssEnTIals
Small animal Spinal RadiogRaphy SeRieS
CerviCal Spine radiography

Danielle Mauragis, CVT, and Clifford R. Berry, DVM, Diplomate ACVR
Imaging Essentials provides comprehensive

information on small animal radiography techniques.
This article is the first in a 3-part series covering
cervical, thoracic, and lumbar spine radiography.
The following anatomic areas have been addressed
in previous columns; these articles are available at
todaysveterinarypractice.com (search Imaging
Essentials).
Thorax
scapula, shoulder, and humerus
abdomen
Elbow and antebrachium
Pelvis
Carpus and manus
stifle joint and crus
Tarsus and pes
pinal radiographs are indicated for:

Evaluation of traumatic injuries
Neck and back pain
Pain or neurologic issues associated with thoracic or pelvic limb lameness isolated to these
regions.
Each radiographic projection is a separate study and
should be radiographed as such. High quality, correctly
positioned and collimated radiographs are required in
order to provide an accurate assessment of the area of
interest, especially for surgical planning.
as a general rule, general anesthesia or heavy

sedation is necessary to evaluate the spine
because, in most cases, spinal images taken in
nonsedated patients are nondiagnostic. In addition, the presence or absence of disk space narrowing cannot be determined from a nonsedated
animals radiographs due to unavoidable positioning artifacts.
50
MEAsurIng thE CErvICAl spInE

Measure the thickest portion of the
neck that is within the area of collimation.
Due to thickness differences of the
cranial and caudal parts of the neck in
large-breed dogs, such as Doberman
pinschers, great Danes, or mastiffs:
For lateral imaging, measure mid
cervical and at the level of the shoulder.
For ventrodorsal imaging, measure
mid cervical and at the level of the
manubrium.
These techniques result in 2 separate
radiographic imagescranial and caudal
radiographs of the cervical spine.
rOutInE vIEWs
Lateral and ventrodorsal views are considered the minimum orthogonal radiographs for
the spine. Due to the angled, divergent nature
of the x-ray beam, the area of the spine in the
center of the field of collimation will be the
area that provides the correct anatomic detail
and intervertebral disk space widths.
If there is a suspected abnormality at the
edge of the image, a repeat collimated image
centered at the area of interest is required for
complete evaluation. Recollimated images are
important because they depict common areas of
disease (ie, intervertebral disk spaces) that are
typically at the edge of the film/image, which
could be misinterpreted as narrowed due to the
divergent nature of the x-ray beam.
A routine cervical spine study includes:
1. Open lateral image of entire cervical spine
2. Open ventrodorsal image of entire cervical
spine
3. Collimated image of lateral cervicothoracic spine
4. Collimated image of ventrodorsal cervicothoracic spine.
lateral projection: Cervical spine

For the lateral projection, position the patient in lateral
recumbency (Figure 1).
Tape the thoracic limbs together evenly and pull
caudally.
Tape or sandbag the thoracic limbs in this
caudal position, which places the humerus and
glenohumeral joint below the cervical spine,
eliminating superimposition. There will always be
some degree of superimposition of the scapula.
Move the lumbar area of the dog dorsally, allowing
the cervical spine to align with the horizontal
collimation light.
Place the skull in lateral position; then extend the
skull and spine naturally and pull them straight
cranially.
If the patient is a large-breed dog, place a sponge
under the cervical spine and skull cranial to the shoulder.
The sponge elevates the cranial portion of the cervical
spine, making it level and lateral with the caudal portion
of the cervical spine.
Collimated projection: Cervicothoracic spine
The collimated lateral image is centered over the
cervicothoracic spine, and extends from the mid cervical
spine (cranial limit of field of view [FOV]) to
just caudal to the scapulohumeral joint.
Figure 1. Dog positioned for lateral projection of the cervical spine (A) and corresponding radiograph (B).
lateral Collimation
For the lateral projection, the FOV excludes
the ventral and dorsal soft tissues of the neck,
only including the cervical vertebral bodies
and immediate soft tissues adjacent to the
spine.
For all patients:
Palpate the vertebrae of the cervical spine
and place the horizontal line of the FOV at
this plane.
For smaller patients, collimate the
FOV to include the caudal portion of the
skull (cranial limit) to just caudal of the
scapulohumeral joint (caudal limit).
For larger patients (cranial and caudal
images):
The cranial projection FOv should
include the caudal portion of the
skull to just cranial to the level of the
scapulohumeral joint.
The caudal projection FOv is centered
just dorsal to the humeral scapular joint
and first rib; it should extend cranially to
the mid cervical spine and caudally to
approximately the third rib.
The radiographic marker is placed along the
dorsal and cranial aspect of the collimated
FOV.
51
Cervical spine Radiography
ImagIng EssEnTIals |
| ImagIng EssEnTIals
Figure 2. Dog positioned for ventrodorsal projection of the

cervical spine (A) and corresponding radiograph (B).
ventrodorsal projection: Cervical spine

Position the patient in dorsal recumbency (Figure 2).
If a positioning trough is used, place the entire
cervical spine within the trough to eliminate any
edge artifacts associated with the imaging tray.
Extend the skull and neck and align them with
the manubrium.
Pull the thoracic limbs caudally and either tape
together or individually.
Collimated projection: Cervicothoracic spine
The caudal ventrodorsal projection used for large-breed dogs (see ventrodorsal
Collimation) also serves as the collimated cervicothoracic image for all dogs and cats.
ventrodorsal Collimation
For the ventrodorsal projection, the FOV excludes the lateral soft tissues of the neck, only
including the central cervical vertebral bodies and immediate soft tissues adjacent to the
vertebral column.
For all patients:
Palpate the vertebrae of the cervical spine and place the horizontal line of the FOV at
this plane.
For smaller patients, collimate the FOV to include the caudal portion of the skull and
caudal to approximately the third rib.
For larger patients (cranial and caudal images):
The cranial projection FOv should include the caudal portion of the skull to just
cranial to the manubrium.
The caudal projection FOv should extend to mid cervical spine cranially and
extend caudally to approximately the third rib. If allowable, the tube head should
be angled approximately 10 toward the dog or cats head, which aligns the angle
of the x-ray beam with the angle of the caudal cervical intervertebral disk spaces,
eliminating superimposition of the vertebral body over the intervertebral disk space.
The radiographic marker is placed along the right cranial aspect of the image in the
collimated FOV.
52
ADDItIOnAl vIEWs
lateral Oblique projection: Cervical spine
Trauma or congenital malformation may cause atlantoaxial luxation or instability of the joint between cervical vertebra 1 and 2. To visualize the dens, an oblique
projection from the lateral position is obtained.
If an atlantoaxial instability is suspected, it is imperative that care be taken not to luxate the vertebra further,
resulting in spinal cord trauma. Sedation is highly recommended for these patients to avoid additional movement.
Position the patient in lateral recumbency (Figure 3).

Tape the forelimbs and pull caudally with gentle
pressure.
Obliquely angle the spine in a ventral direction,
which is achieved by placing a sponge under the
dorsal skull and shoulder.
For collimation, the FOV is centered at the atlantoaxial joint. The cranial border is at mid skull, while
the caudal border includes cervical vertebra 3 and 4.
Figure 3. Dog positioned for lateral oblique projection of the cervical spine (A) and corresponding radiograph (B). Note that the dens of C2 is normal in this dog.
Your Complete Digital Dental Solution!

Incomparable Digital Imaging in all Dental Sizes.
In our practice the great benet of the
ScanX Duo is the fact that it is so much
easier to take larger views using the range
of plate sizes.
Jan Bellows, DVM

All Pets Dental Clinic and
Hometown Animal Hospital
Weston, Florida
V er satile Digital I maging
All Your Imaging Needs in a Single System!

Our comprehensive, user-friendly ScanX Duo packages
include everything you need: Imaging Software, laptop
computer, imaging plates and accessories.
visible during a routine exam without radiographs.

- Enhance patient care and generate additional income.
ScanX Duo at a glance:

- Exceptional quality, high resolution digital imaging
in all dental sizes.
- Dual imaging plate scanning capability.
- Detect pathologies under the gum that are not
To learn more or to schedule an in ofce demonstration,

please visit www.allproimaging.com/healthcare.
53
| ImagIng EssEnTIals
Figure 4. Dog positioned for lateral extended

projection of the cervical spine (A) and
corresponding radiograph (B).
lateral Flexed & Extended projections:

Cervical spine
Flexed and extended projections are used for cervical
vertebral malformation (CVM) or Wobblers syndrome.
Compression of the spinal cord due to abnormalities occurs mainly in large-breed dogs and affects the
caudal cervical vertebrae and their articulations, resulting in paraparesis, tetraparesis, or ataxia. The largebreed dog will need a cranial and caudal projection as
with a naturally positioned cervical spine projection.
For both projections, position the patient in lateral
recumbency, with the forelimbs taped and pulled caudally.
For the extended projection (Figure 4), push the
skull and cervical spine dorsally.
Ensure that the caudal cervical vertebra are angled
dorsally, not merely pivoted at the mid cervical
spine.
Hold the skull in place with a sandbag or tape.
For the flexed projection (Figure 5), pull the skull
and cervical spine ventrally toward the forelimbs.
Ensure that the cervical spine is flexed at the level of
the caudal cervical vertebra and not merely arched
at the mid cervical spine.
Hold the skull in place with a sandbag or tape.
For collimation, due to the flexion and extension
of the cervical spine, the FOV includes most of the soft
tissues of the neck.
54
Figure 5. Dog positioned for lateral flexed projection

of the cervical spine (A) and corresponding
radiograph (B).
ventrodorsal Oblique projection: Cervical spine

Subtle lesions, fractures, and intervertebral disk disease are a
few of the conditions that may require a ventrodorsal oblique
projection of the spine.
From the straight ventrodorsal position of the cervical spine,
obliquely rotate the patient to the left approximately 10 to 15;
then take the radiograph. Then rotate the patient to the right
approximately 10 to 15 and take another radiograph.
Set the collimation of the oblique ventrodorsal projections
as described for the ventrodorsal projection of the cervical
spine.
QuAlItY COntrOl
To make certain the desired technique has been achieved, use
the following guidelines to determine whether the appropriate anatomy is included in the images.
For both lateral and ventrodorsal projections of the cervical spine:
The cranial border should include the caudal aspect of the
skull.
The caudal border should, at least, include T1.
For the lateral projection of the cervical spine:
The wings of the Atlas (C1) should be even and superimposed.
Each cervical vertebral body should be even with the superimposed transverse processes.
For quality control of any diagnostic image, follow a

simple 3-step approach:
1. Is the technique adequate (appropriate exposure and
development factors)?
2. Is the correct anatomy present within the image?
3. Is the positioning anatomically correct and straight?
On a straight cervical spine, the wings of C1 will overlap each other

and be superimposed over the dens, which is not visualized.
For the ventrodorsal projection of the cervical spine:
The spinous processes should be superimposed over the vertebral
bodies.
The spinous process over the Axis (C2) should resemble a thin line
bisecting the vertebral body. n
Suggested Reading
Burk rL, Feeney dA. Small Animal Radiology and Ultrasonography: A Diagnostic Atlas and Text, 3rd
ed. Philadelphia: Saunders elsevier, 2003.
Keely JK, McAllister H, Graham JP. Diagnostic Radiology and Ultrasonography of the Dog and Cat,
5th ed. Philadelphia: Saunders elsevier, 2011.
Sirois M, Anthony e, Mauragis d. Handbook of Radiographic Positioning for Veterinary Technicians.
Clifton Park, NY: delmar Cengage Learning, 2010.
Thrall de (ed). Textbook of Veterinary Radiology, 5th ed. Philadelphia: Saunders elsevier, 2008.
Thrall de, robertson id. Atlas of Normal Radiographic Anatomy and Anatomic Variants in the Dog
and Cat. Philadelphia: elsevier Saunders, 2011.
Danielle Mauragis, CVT, is a radiology

technician at University of Florida College
of Veterinary Medicine. She teaches veterinary students all aspects of the physics
of diagnostic imaging, quality control of
radiographs, positioning of small and large
animals, and radiation safety. Ms. Mauragis
coauthored the Handbook of Radiographic
Positioning for Veterinary Technicians
(2009) and was the recipient of the Florida
Veterinary Medical Associations 2011
Certified Veterinary Technician of the Year Award. This award recognizes an individual for the many outstanding contributions that person
has made to the overall success of a veterinary practice operated or
staffed by an FVMA member veterinarian.
Clifford R. Berry, DVM, Diplomate ACVR,

is a professor in diagnostic imaging at the
University of Florida College of Veterinary
Medicine. His research interests include
cross-sectional imaging of the thorax, nuclear
medicine applications in veterinary medicine,
and biomedical applications of imaging in
human and veterinary medicine. Dr. Berry
has been a faculty member at North Carolina
State University and University of Missouri. He received his DVM from
University of Florida and completed a radiology residency at University
of CaliforniaDavis.
55
55.
PEER REVIEWEd
VITAL VACCINATION SERIES
What You Need

to Know About
Rabies
Richard B. Ford, DVM, MS, Diplomate ACVIM & ACVPM (Hon)
that dogs suffer from the madness. This causes

them to become very irritable and all animals they
bite become diseased.
Attributed to Aristotle, 4th century BC
oday, one only has to read the eloquently written

introduction to Bill Wasik and Monica Murphys
book, Rabid: A Cultural History of the Worlds
Most Diabolical Virus (Viking, 2012), to be reminded of
the impact the rabies virus has had on wildlife, domestic
animals, and humans for thousands of years.
Two facts make this infection particularly noteworthy:
1. Rabies virus is well known for its ability to be transmitted from an infected animal to humans.
2. With rare exception, infection is 100% fatal in susceptible species.
RAbies stAtistics
Currently, the World Health Organization estimates
that between 50,000 and 60,000 human fatalities from
rabies occur annually. According to the Centers for
Disease Control and Prevention:
Over 90% of rabies exposure in humans is due to
exposure to rabid dogs.
Exposure to rabid dogs is the cause of more than
99% of human deaths from rabies worldwide.
In North America, routine vaccination of pet dogs,
cats, and even ferrets, has played a critical public health
role in mitigating human risk for exposure to rabies
virus.
For example, in the last decade in the U.S., only 2 to
3 human infections have been typically confirmed
each year.1 Most of those infections were acquired
outside the U.S. or resulted from exposure to bats.
However, in Africa, India, and several locations in
Asia, where dogs are rarely vaccinated against rabies,
its prevalence in animals and risk for human exposure through dogs is significant.
However, even in the U.S., rabies virus exposure,
whether known or suspected, carries a significant cost,
particularly when an unvaccinated pet that has been potentially exposed to a rabid animal has contact with humans. It is estimated that 40,000 people undergo rabies
post-exposure prophylaxis (PEP) per year, at a potential
cost of thousands of dollars per person.
iMMunizAtion RequiReMents
In states and local municipalities (cities or counties)
where rabies vaccination is required,2 it is the:
Pet owners responsibility to comply with rabies
law and ensure a pet is vaccinated at the appropriate
age and interval
Veterinarians responsibility to ensure that rabies
vaccines are administered in accordance with existing laws or ordinances.
Following are 9 questions that address rabies and rabies immunization. This information should be in your
must know category of knowledge.
Because rabies laws vary significantly among states,
and even within states, the following responses provided are not universally applicable. They are, however, representative of what many states recognize or
require.
If answers to any of the questions are unclear, contact the appropriate agency to determine the most
suitable action needed to comply with state or
local law.
57
| ViTAl VACCinATion SerieS: VACCine AdVerSe eVenTS
in your state or city/county, which agency is

responsible for developing and enforcing rabies
laws, including vaccination requirements?
The answer varies considerably throughout the U.S. In
fact, for some states, the agency responsible for developing rabies law may be different from the agency charged
with enforcing rabies law. Furthermore, cities and counties may impose rabies regulations for pets that are stricter, but never more lenient, than state law.
Having the contact information for the appropriate
agency or individual is critical when the need arises
to address difficult questions or take specific action, especially when it concerns possible human or pet exposure to rabies.
What constitutes exposure to rabies virus?

Circumstances defining exposure to rabies virus vary
among states and may even vary among cities or counties
within a state. Although regulatory descriptions of rabies
exposure are typically limited to humans, some locations have specific ordinances in place for pets exposed
to a potentially rabid animal.
Exposure to rabies virus constitutes any known or
suspected bite, scratch, or other incident in which saliva, central nervous system (brain or spinal cord) tissue,
or cerebrospinal fluid of a potentially rabid animal enters
an open, fresh wound or comes in contact with mucous
membranes by entering the eye, mouth, or nose.
When characterizing human exposure due to an encounter with a pet dog, cat, or ferret, other factors may
be considered, such as:
Was the bite incidence provoked or non-provoked?
Is the animal involved available?
If available, can the animals vaccination status be confirmed?
sAMple subMission foR fAVn:

pets traveling to Rabies-free
countries or Regions
Collect 1- to 2-ml of serum in a 5-ml test
tube (cold packed, with no additives).
each sample must be submitted with a FAVn
report Form (available at vet.k-state.edu/
depts/dmp/service/rabies/pdf/fAVn_test_
submission_form.pdf).
Submit the sample and form to the rabies
laboratory, Kansas State University, 2005
research Park Circle, Manhattan, KS 66502;
phone: 785-532-4483; FAX: 785-532-4474.
Current cost is $83 per sample.
Turn-around times may vary depending on
laboratory workload; expect approximately
3 weeks. Contact the laboratory directly for
questions related to animals traveling within 3
weeks. in addition, veterinarians can contact
the laboratory for a current list of countries that
require FAVn antibody titers prior to importation
of a pet dog or cat.
58
What constitutes a currently vaccinated versus

unvaccinated dog, cat, or ferret?
This is an important questionmost states and local
municipalities conform to recommendations
outlined in the Compendium of Animal
Rabies Prevention and Control.
This publication states: an animal is
currently vaccinated, and is considered immunized, if the initial
vaccination was administered at
least 28 days previously or booster vaccinations have been administered in accordance with
the product label (ie, either as a
1- or 3-year product).
Consider this: A dog or cat that
bites a human within 28 days following its initial rabies inoculation
is not considered to be immunized.
Additionally, a dog or cat can be
considered unvaccinated if only 1
day overdue for a 3-year booster.
Which of the following tests can be used in the

u.s. to confirm a diagnosis of rabies virus infection? identify all that you consider confirmatory.
A. Routine histopathology of formalin-fixed brain tissue
B. Direct fluorescent antibody (DFA) on whole blood
C. Fluorescent antibody virus neutralization (FAVN) test
D. Direct fluorescent antibody (DFA) of intact brain tissue
E. Direct rapid immunohistochemical test (DRIT) of
brain tissue
F. Rapid fluorescent foci inhibition test (RFFIT)
The correct answer is D: the DFA test performed on intact brain tissue by a qualified laboratory constitutes a diagnosis of rabies. When feasible, isolation of rabies virus
from tissue may also be performed to confirm infection.
The DRIT has been used as a screening test but currently must be confirmed by DFA. The FAVN test measures
serum levels of rabies virus neutralizing antibody in vaccinated animals traveling to rabies-free countries/regions.
What is the youngest age a dog or cat residing

in the u.s. should be vaccinated against rabies?
Currently, in the U.S., rabies vaccines may be administered to dogs and cats as early as 12 weeks of age,
but not younger. This applies to all states and all rabies
vaccines, regardless of manufacturer. Some cities/counties, however, may require owners to have pets vaccinated at an age other than 12 weeks of age (eg, 16 weeks).
under what circumstances can a rabies antibody

titer be used to establish immunity in a dog or cat?
Rabies serology (antibody titer), regardless of the
methodology used, does not directly correlate with
ViTAl VACCinATion SerieS: VACCine AdVerSe eVenTS |
protection and, therefore, cannot be interpreted

as a legal index of immunity. Immunologic factors
other than antibodies (eg, cell-mediated immunity)
are important in protection from rabies infection.
However, a positive rabies antibody titer does
demonstrate that a postvaccinal immune response has
developed. Although an antibody titer can be shown
to correlate with protective immunity, an antibody
titer cannot, by law, be used in lieu of revaccination.
if presented with a dog that is several months

overdue for a 3-year rabies booster, what is the
most appropriate vaccination recommendation?
The answer varies, as one might expect, from one
state or location to another.
In the U.S., states that do address this issue (many
dont), tend to conform with booster recommendations
published in the Compendium of Animal Rabies Prevention and Control. These recommendations state:
an animal is considered immediately vaccinated
after a booster vaccine, even if overdue.
The duration of immunity is dictated by the product
label (ie, either a 1- or 3-year rabies vaccine). When in
doubt, contact the appropriate agency for a definitive
legal perspective.
Key point: even in states/locations that

recognize a veterinarians authority to exempt
(for health reasons) a dog/cat from rabies
vaccination requirements, dogs and cats that have
exceeded the duration of immunity for the vaccine
administered (ie, 1 or 3 years) are considered
unvaccinated (not immunized), even if the patient
has a positive rabies titer.
is it appropriate to discontinue routine rabies

vaccination for a strictly indoor pet dog or cat?
Where rabies vaccination is required, it cannot be discontinued, no matter what the pets age or lifestyle.
Rabies vaccines should be administered, at appropriate intervals (usually every 3 years), for the life
of the pet.
Vaccines are specifically recommended for

administration to healthy animals (by the manufacturer). Does a veterinarian have the authority to exempt an individual dog or cat that has a
significant illness (eg, chronic renal failure) from
rabies vaccination?
A veterinarian licensed to practice in the U.S.
must not assume he or she is authorized to grant
a rabies vaccination exemption on the grounds
an animal has been diagnosed with any illness
(ie, is not healthy). Today, most states do not specifically address rabies exemption for veterinarians,
although cities or counties within a state may. Indi-
vidual cities or counties within a state that recognizes

rabies vaccination exemptions may specifically deny
that authority.
In locations that do grant rabies exemption authority to veterinarians, the terms of that authority must be
clearly understood before implementing a waiver. For
example, veterinarians practicing in localities where
rabies exemptions are recognized may be required to
submit supporting documentation to the appropriate
agency (public health) and wait for official approval,
a process that can take days to weeks to complete. n
Footnotes
1. In the U.S., the latest human fatality was attributed to exposure
to a bat in Contra Costa County, California, in 2012.
2. In the U.S., some states do not require rabies vaccination
of dogs and cats (although certain cities/counties may).
In Canada, Ontario is the only province in which rabies
vaccination of dogs and cats is required by law.
Suggested Reading
Greene CE. Rabies and other Lyssa virus infections. In Greene
CE (ed): Infectious Diseases of the Dog and Cat, 4th ed. St.
Louis: Elsevier-Saunders, 2012, pp 179-197.
National Association of State Public Health Veterinarians.
Compendium of Animal Rabies Prevention and Control,
2011; available online at nasphv.org/documents/
RabiesCompendium.pdf.
Wasik B, Murphy M. Rabid: A Cultural History of the Worlds
Most Diabolical Virus. New York: Viking, 2012.
World Health Organization. Rabies: A Neglected Zoonotic
Disease, 2013; available at who.int/rabies/en/index.html.
Resources
The Rabies Laboratory, College of Veterinary Medicine, Kansas
State University; available at vet.k-state.edu/depts/dmp/
service/rabies/index.htm.
Richard B. Ford, DVM,

MS, Diplomate ACVIM &
ACVPM (Hon), is Emeritus
Professor of Medicine at
North Carolina State Universitys College of Veterinary Medicine. He is
a retired Brigadier General from the USAF Reserve, where he was assigned to the Office of
the Surgeon General at the Pentagon. Dr. Ford
is also a past president of the NAVC Conference and continues his role as a member of
the scientific program committee. His clinical
interests are in the field of companion animal
infectious disease; he is a prolific author and
serves on both the AAHA Canine Vaccination
Task Force and AAFP Feline Vaccination Advisory Panel. Dr. Ford received his DVM from
Ohio State University and completed an internal medicine residency at Michigan State University. He held a previous faculty position at
Purdue University.
59
55
53
77
56
57
54
58
59
61
62
60
63
76
64 65
52
74
66
68
67
72
75
3
4
5 6
73
69
8
71
70
51
10
12
15
11
13
16
50
14
17
18
19
49
20
48
47
46
21
45
22
44
32 31
42
43
36
41
35
34
37
33
38
40
39
30
29
28
27
23
26
25
24
Connect the dots between

individual results and
vector-borne disease prevalence
One dogs positive result can reveal risk to your entire patient population
Broadest available screen using a single sample; six pathogens from ve vectors
Will not generate false positives on Lyme-vaccinated dogs*
Discover what proven accuracy can do for your patients, clients
and practice at idexx.com/snap4dxplus.
*The Borrelia burgdorferi assay detects antibody induced as a result of natural infection with the organism and not following immunization with the following
commercial vaccines: Recombitek Lyme, LymeVax, Galaxy Lyme and Nobivac Lyme.
2013 IDEXX Laboratories, Inc. All rights reserved. 102890-00 SNAP and 4Dx are trademarks or registered trademarks of IDEXX Laboratories, Inc. or its
afliates in the United States and/or other countries. All other product and company names are trademarks or registered trademarks of their respective holders.
The IDEXX Privacy Policy is available at idexx.com.
The SNAP 4Dx Plus Test

Know more with every result, including the
vector-borne disease risks in your area
Consider THis Case
Peer reviewed
estrus in a Spayed Cat

Erin O. Dresner, DVM, MS, and Gary D. Norsworthy, DVM, Diplomate ABVP (Feline)
13-year-old, 4.54-kg (10-lb) spayed female

domestic medium-hair cat presented with a
1-day history of typical signs of estrus.
History
Behavior: The owner reported unusual behavior that
included roaming throughout the house, loud vocalization, and increased affection; however, the cat had
been spayed as a kitten, with no history of this recent
behavior.
Clinical signs: The owner also noted that the cat had
recently exhibited decreased appetite and thirst but
was unable to recall changes in urine output.
Environment: The cat was housed exclusively indoors
and fed commercial dry cat food. There was no history
of travel.
Medical history: The cat was current for core vaccinations, tested negative for retroviruses as a kitten,
and received only monthly parasite preventive medications.
iNitiAL DiAGNostiCs & tHErAPy

Physical Examination
The cat had a body condition score of 4/9, with a consistent weight history over the past year. Rectal temperature, heart rate, and respiratory rate were within normal
limits. Abdominal palpation and examination of external genitalia were unremarkable; no vaginal discharge
was observed.
Laboratory Analysis
The initial laboratory database included a complete
blood count, serum biochemistry, electrolytes, total thyroxine (T4), and urinalysis and culture. The only abnormalities were:
Mild creatinine elevation (2.2 mg/dL; reference range,
0.32.1 mg/dL)
Mild hematuria.
imaging
Ultrasound of the urinary bladder did not reveal masses,
uroliths, or thickening or irregularity of the bladder wall.
Feline
Friendly
Article
therapeutic Plan
A diagnosis of urinary tract infection was considered
pending culture results, and an empirical trial of marbofloxacin (25 mg PO Q 24 H for 10 days) was initiated. The
owner was instructed to report if no improvement was
observed within 72 hours.
ADDitioNAL DiAGNostiCs
Four days later, the cat was presented again with continued signs of estrus. According to the owner, no improvement in the cats behavior had been observed.
Physical examination findings were unremarkable.
The urine culture exhibited no aerobic bacteria growth
at 72 hours.
Hormone Analysis
Because increased estrogen levels trigger a negative feedback mechanism that results in reduced luteinizing hormone (LH) levels, a serum sample was submitted for LH
analysis. Results were < 1 ng/mL, suggesting the presence
of an endogenous or exogenous source of estrogen.
imaging
Abdominal radiography revealed no abdominal masses. Ultrasonographic evaluation of the abdomen (by
a board-certified veterinary radiologist) revealed no evidence of ovarian tissue. The left adrenal gland was of
normal size (3.7 8.4 mm) and architecture; the right
adrenal gland was not found.
One week following initial presentation, the cat was
still exhibiting signs of estrus.
uEstioN: What are the differential diagnoses for this case?
Considering the information provided, what

differential diagnoses would you pursue?
61
| Consider THis Case
treatment
A therapeutic trial of megestrol acetate (5 mg
PO Q 24 H) was initiated because this drug
has been used to terminate estrus. Megestrol
is a synthetic progestin that exerts an inhibitory effect on the secretion of pituitary gonadotropins.
Two days later, the cats signs of estrus were
resolved and therapy was discontinued.
Follow-up
Recheck examinations performed 18, 36, and
90 days post megestrol treatment revealed
serum estradiol concentrations of 32.4 pg/mL,
35.6 pg/mL, and 20.4 pg/mL, respectively.
The pharmacokinetics of estradiol in companion animals are largely unknown. Estrogens and
their metabolites accumulate in adipose tissue,
are excreted into urine and bile, and those in
bile are reabsorbed by the gastrointestinal tract,
which may explain the persistent, increased estrogen levels observed in this case.
NsWEr: Differential diagnoses

to consider include:
exposure to exogenous estrogens

increased production of sex hormones (due
to pathology of the zona reticularis of the
adrenal cortex1,2)
ovarian remnant syndrome
Presence of accessory ovaries (congenital
anomaly)
adrenocortical carcinoma (which was recently reported to cause estrous-like behavior in
a spayed female cat).3
DisCoVEriNG tHE DiAGNosis

At this point1-week following initial presentationthe
owner disclosed that she was prescribed transdermal
hormone replacement therapy (HRT) containing estradiol, progesterone, and dehydroepiandrosteron (DHEA)
in emu oil. The owner described a daily routine of applying the cream to her forearms and, shortly thereafter, picking up and cradling the cat for several minutes.
The owner began using the medication approximately
12 days before the cats initial presentation to the clinic.
Final Diagnostics
Following this disclosure, serum estradiol analysis was
performed because estradiol was a component of the
owners HRT and, most likely, the cause of the cats estrous-like behavior. The patients serum estradiol was
measured at 71.06 pg/mL (reference ranges; < 15 pg/
mL for a spayed cat, < 20 pg/mL for pregnant queen or
queen in diestrus, and 2550 pg/mL for queen in proestrus or estrus).
62
Case Conclusion
The owner is currently using a sublingual route of HRT administration to eliminate exposure of the cat to the medication. According to the owner, all previously reported signs of
estrus have resolved, and the patient has not exhibited any
signs for over 12 months.
rEtrosPECtiVE CAsE rEViEW

a weakness in this cases workup was failure to
visualize the right adrenal gland on ultrasound. an
estrogen secreting tumor could have been missed if
one was present.
When a cats right adrenal gland is healthy, it
is difficult for even board-certified radiologists to
identify; however, the presence of an adrenal tumor
increases the organs size, which makes it easier to
locate.
We believe that the presence of an adrenal tumor
can be ruled out because the cat remained estrusfree for 12 months following discontinuation of the
owners transdermal hormone use.
CAsE DisCussioN
Hyperestrogenism and estrogen toxicity in pets due to exposure to human HRTs are a growing veterinary medical concern.
reported Cases
More than 100 suspected cases are reported anecdotally,
with most involving canine patients.4 Despite the existence
of this phenomenon, we are aware of but 1 single case reported in the literature.5 To our knowledge, no feline cases
have been reported.
Human risks
The danger of exposing children and other family members to HRTs has been acknowledged and was explained
to the owner by her physician. Awareness of the issue has
increased due in part to recent attention by the United
States Food and Drug Administration.6,7 However, physicians typically do not warn patients about the potential
dangers of exposing pets to these hormones.
Companion Animal risks
Chronic exposure to high doses of endogenous estrogens is toxic to mammals. Susceptibility to estrogen
toxicity in cats is greater than it is in dogs, ferrets, rats,
and mice.8
Prolonged hyperestrogenism in the cat is associated
with:8,9
Steroid alopecia
Mammary tissue growth
Hepatic pathology
Pancreatic hypertrophy
Pancytopenia.
As in the bitch, cats may be at risk for coagulopathies
and stump pyometra secondary to pancytopenia induced by hyperestrogenism.
Diagnosis of Estrus
Diagnosis of exposure to exogenous estrogens and subsequent hyperestrogenism in the feline patient is confounded by the difficulties in detecting estrus in the
species.
Dogs Versus Cats. In the bitch, estrus is diagnosed
by several distinct signs, including vulvar enlargement,
vaginal hemorrhage, and perivulvar alopecia. However,
the feline vulvar labia do not respond to estradiol and,
therefore, do not typically change appearance during
estrus as in the bitch.10
Feline Behavior. Feline behavioral signs, such as
rolling, head rubbing, hindlimb treading, posturing,
vocalization, and permitting mounting by male cats,
are generally the only indication of estrus in queens.11
Although these changes may be quite dramatic in some
individuals, in others, they may be difficult to distinguish from normal affectionate behavior.
Vaginal Cytology. Estrus in the bitch is easily confirmed by vaginal cytology, but it is not a routine diagnostic tool used in feline medicine given the anatomic
limitations of the feline vagina.10
Diagnostics in this Case
One could take the position that vaginal cytology
should be performed in cats with the history and clinical signs seen in this case. It could even be argued that
it was a significant oversight. However, we chose not to
perform vaginal cytology based on its cited limitations.10
Instead, documentation of very elevated serum estradiol concentrations confirmed that the clinical signs were
due to estrus.
To eliminate any doubts regarding the cause of this
patients signs, a trial of re-exposure to the transder-
mal cream with documentation of identical signs would

be ideal, however, impractical. Further testing for potential ovarian remnant syndrome with GnRH-induced
ovulation and subsequent measurement of serum progesterone was declined by the owner due to resolution
of clinical signs. n
dHea = dehydroepiandrosteron; HrT = hormone replacement therapy; LH = luteinizing hormone
References
1. eilts B. Feline ovarian remnant syndrome. Louisiana VMA Winter Meeting
Proceedings, 2012, pp 231-237.
2. Grundy SA, davidson AP. Feline reproduction. in ettinger SJ, Feldman
eC (eds): Textbook of Veterinary Internal Medicine, 6th ed. St Louis:
elsevier Science, 2005, pp 1696-1707.
3. Meler e, Scott-Moncrieff JC, Peter AT, et al. Cyclic estrous-like behavior
in a spayed cat associated with excessive sex-hormone production by
an adrenocortical carcinoma. J Fel Med Surg 2011; 13:473-478.
4. Lau e. researcher promotes awareness of accidental hormone
exposure in pets. Veterinary Information Network News Service, news.
vin.com; assessed June 8, 2011.
5. Schwarze rA, Threlfall wr. Theriogenology question of the month.
JAVMA 2008; 233:235-237.
6. Lau e. FdA investigating accidental hormone exposure problem.
Veterinary Information Network News Service, news.vin.com; assessed
July 29, 2010.
7. Franklin SL. effects of unintentional exposure of children to compounded
transdermal sex hormone therapy. Ped Endocrinol Rev 2011; 8:208-212.
8. Hart Je. endocrine pathology of estrogens: Species differences.
Pharmacol Thera 1990; 47:203-218.
9. Amorim da Costa Fv, Moreira de Souza HJ. Granulosa cell tumor.
in Norsworthy Gd (ed): The Feline Patient, 4th ed. Ames, iA: wiley
Blackwell, 2010, pp 207-208.
10. Feldman eC, Nelson rw. Canine and Feline Endocrinology and
Reproduction, 3rd ed. Philadelphia: wB Saunders, 2004, pp 1018-1020.
11. voith vL. Female reproductive behavior. in Morrow de (ed): Current Therapy
in Theriogenology. Philadelphia: wB Saunders, 1980, pp 845-848.
Erin O. Dresner, MS, DVM, is

currently completing a small animal
rotating internship at North Houston
Veterinary Specialists in Spring,
Texas. She received her DVM from
Western University of Health Sciences College of Veterinary Medicine in 2012. Prior to her veterinary
education, Dr. Dresner completed
an MS focused on parasitology at Texas State University. Her clinical and research interests include feline
internal medicine and infectious disease.
Gary D. Norsworthy, DVM, Diplomate ABVP (Feline), is the owner
of Alamo Feline Health Center
in San Antonio, Texas, where he
practices full time. His 40 years of
private practice include 15 years
specializing in feline medicine. Dr.
Norsworthy also holds adjunct professorships in clinical medicine at
Mississippi State University and Western University of
Health Sciences. He has lectured to veterinary associations on feline topics in the United States, Canada,
Brazil, and Australia and is the editor of 6 feline textbooks. Dr. Norsworthy received his DVM from Texas
A&M University.
63
estrus in a spayed Cat
Consider THis Case |
I may look
serious, but
Im smiling
inside.
Better Patient Care. Better Business.

Midmark Total Dental Solutions is the key to taking the best care of
your patients and your bottom line. Weve got the industrys best before,
during and after sale support from installation, in-clinic and online
training resources, and top-notch support services to education and
marketing tools that help improve client awareness of dental health issues
and increase compliance. And, our veterinary-specifc dental equipment
is ergonomically designed to help make treatments more efective, saving
you time and increasing the number of patients you treat. To learn
more, call 888-981-3174 or visit:

midmarkanimalhealth.com/tvpjanfeb13.
Peer reviewed
DENTAL DIAGNOSIS
Canine TooTh FrActure

Brook A. Niemiec, DVM, FAVD, Diplomate AVDC
ooth fractures are very common

in dogs. The most commonly
fractured teeth are the canines
and carnassials (maxillary fourth
premolars and mandibular first
molars).
Fractures are further characterized
as complicated or uncomplicated.
Complicated crown fractures have
direct pulp (nerve) exposure, whereas
uncomplicated crown fractures have
direct dentin but no pulp exposure.1
Both types of tooth fractures
require therapy; however, treatment
differs depending on the physical and
radiographic appearance.
Question
Based on the clinical
evidence, what type of
fracture is shown in Figure 1?
(answer next page)
Read the following articles by Dr. Brook

Niemiec at todaysveterinarypractice.com:
Diagnosis & Treatment of Crown Fractures

(July/August 2011)
Bonded sealant Application for crown
Fractures (July/August 2011)
Dental Extractions: Five Steps to Improve
Client Education, Surgical Procedures, &

Patient care (May/June 2012)
to view an informational video on fractured

teeth, visit dogbeachdentistry.com.
Brook A. Niemiec, DVM,

FAVD, Diplomate AVDC, is
chief of staff of Southern
California Veterinary Dental
Specialties. He is the author
of Small Animal Dental, Oral
and Maxillofacial Disease: A
Colour Handbook (Manson
Publishing) and Veterinary Periodontology (Wiley
Blackwell). He founded the veterinary dental
telemedicine website vetdentalrad.com, lectures
at national and international conferences, and is
the coordinator and instructor of the San Diego
Veterinary Dental Training Center (vetdentaltraining.
com). He received his DVM from University of
CaliforniaDavis.
65
| DENTAL DIAGNOSIS
Answer
Based on the clinical evidence, what type of
fracture is shown in Figure 1?
This patient has an uncomplicated crown fracture,1
which is very common in large-breed dogs. These
types of fractures occur when a piece of the crown is
broken, exposing the dentin but not the pulp.
The radiograph (Figure 2) reveals that this tooth is
nonvital and infected, both of which are evidenced by
the periapical rarefaction surrounding all 3 roots (red
arrows).2 Additional radiographic signs of endodontic
disease include a wider endodontic space (or on occasion, narrower) and internal or external resorption.2
2
Figures courtesy vetdentalrad.com (Importance of Dental
Radiology client educational poster)
QuESTIon & AnSwEr

what therapeutic measures should be pursued
keep an eye on the fracture, extract the tooth, or
perform a restoration or root canal?
Hopefully your answer was not keep an eye on the
fracture. Despite the fact that veterinary patients
rarely show clinical signs, uncomplicated crown fractures can be very painful.3
role of Dentinal Tubules
Dentinal tubules surround the tooth, running from
the root canal to the enamel. Each tubule contains an
odontoblastic processbasically a nerve supply that
is limited to sensory function. There are approximately
50,000 dentinal tubules per mm2 coronal dentin, which
is about twice the number found in human teeth.4,5
When enamel is lost, the dentin is exposed; therefore, a 1-cm area of enamel loss in a canine tooth
exposes 3 to 4 million odontoblasts. This exposure
leads to quicker dentinal fluid flow out through the
dentinal tubules via the capillary effect. The increase
in flow deforms the A-delta fibers and C-fibers, which
is perceived by the patient as pain.3
Factors, such as heat, cold, and desiccation, change
the flow rate, cause the nerves to fire, and result in
pain (sensitivity).6 Sensitivity is actually a sign of lowgrade pulp inflammation called pulpitis.
Bacterial infiltration
Loss of enamel also allows bacteria to potentially
ingress into the root canal system.3,7 In some cases,
References
1. duPont GG. Problems with the dental hard tissues.
in niemiec Ba (ed): Small Animal Dental, Oral and
Maxillofacial Disease: A Colour Handbook. London:
Manson Publishing, 2010, pp 127-156.
2. niemiec Ba. veterinary dental radiology. in niemiec Ba
(ed): Small Animal Dental, Oral and Maxillofacial Disease:
A Colour Handbook. London: Manson Publishing, 2010,
pp 63-87.
3. Startup S. Tooth response to injury. in niemiec Ba (ed):
66
these bacteria can result in endodontic infection and

subsequent abscessation, which can occasionally
manifest clinically as a swelling or draining tract, but
is generally subclinical and, therefore, undiagnosed.
The only way to definitively diagnose this infection is
via dental radiographs.
therapeutic Measures1,7,8
There are 2 options for nonvital and infected teeth:
root canal therapy or extraction.
Treatment of infected teeth with root canals has a similar success rate as vital teeth treated with root canals;
therefore, root canal therapy should be considered.
If extraction is elected, postoperative dental radiographs should be taken because retained roots are
a common complication of these extractions.
treatment for this Patient
Because the tooth was nonvital and infected, I elected
to perform a root canal, based on the success of this
therapy in my experience. If root resorption had been
seen on the radiograph, extraction would have been
the selected therapy.
Bonded sealant therapy
If no radiographic evidence of disease had been present in this case, the tooth would have been treated
with a bonded sealant.9 This therapy resolves sensitivity, blocks off the pathway for infection, improves
aesthetics, and smooths the tooth to decrease plaque
accumulation, retarding periodontal disease. n
Veterinary Endodontics. Tustin, Ca: Practical veterinary

Publishing, 2011.
4. Theuns P. endodontic anatomy. in niemiec Ba (ed):
Veterinary Endodontics. Tustin, Ca: Practical veterinary
Publishing, 2011.
5. Lewis Jr, reiter aM. anatomy and physiology. in niemiec
Ba (ed): Small Animal Dental, Oral and Maxillofacial
Disease: A Colour Handbook. London: Manson
Publishing, 2010.
6. Trowbridge ho, Syngcuk K, hideaki S. Structure and
functions of the dentin-pulp complex. in Cohen S, Burns

rC (eds): Pathways of the Pulp, 8th ed. St Louis: Mosby,
2002, pp 411-456.
7. woodward TM. Bonded sealants for fractured teeth. Top
Companion Anim Med 2008; 23(2):91-96.
8. niemiec Ba. oral pathology. Top Companion Anim Med
2008; 23(2):59-71.
9. Theuns P, niemiec Ba. Bonded sealants for
uncomplicated crown fractures. J Vet Dent 2011;
28(2):130-132.
Peer reviewed
ToP Ten
Toxicoses
in dogs &
caTs
Tina Wismer, DVM, Diplomate ABVT & ABT
arch 17 through 23, 2013, is designated

as Poison Prevention Week by the
Poison Prevention Week Council
(poisonprevention.org).
The U.S. Congress established national Poison
Prevention Week on September 16, 1961, and the
Poison Prevention Week Council was organized
shortly thereafter to coordinate this annual event
and promote poison prevention. Last years
Poison Prevention Week marked the weeks 50th
anniversary.
As highlighted in this article, the best resource
for poison prevention in pets is the ASPCAs
Poison Control Center websiteaspca.org/
pet-care/poison-control. The website not only
provides a hotline number for pet owners or
veterinary professionals to call in case of a pets
potential poisoning, but also offers a number of
resources on toxicities in pets.
Highlight Poison Prevention Week in your
practice to increase your clients awareness of
potential toxins in their homes and other areas
their pets may visit. Use our Poison Prevention
in Pets handout, available for download and use
in your clinic at todaysveterinarypractice.com,
to help staff and pet owners identify common
household items that may be dangerous to pets.
Common things happen commonly is a good

adage for veterinary toxicology.
To help veterinary professionals and pet owners with
poison-related emergencies, the American Society for the
Prevention of Cruelty to Animals (ASPCA) Animal Poison
Control Center (APCC) offers a valuable resource: phone
consultations with veterinary toxicologists, 24 hours a
day, 365 days a year (888-426-4435).
Last year, the APCC compiled data from 180,000 cases
received during 2012 to help increase both veterinary and
consumer knowledge about poisoning in pets.1
Domestic dogs were most often exposed to toxins
(79.3%), followed by cats (13.2%), birds and small
mammals (ferrets, lagomorphs, rodents) (3.8%), and
large animals (horses, cows) (2.13%).
Most dogs and cats are accidentally exposed to poisons, with most exposures resulting from ingestion of
human medication.
Malicious poisonings account for less than 1% of
reported situations.
Data from the calls also identified the top 10 pet toxins
evaluated by the APCC in 2012.
While not all poisonings are reported to the

APCC, the information gained by identification
of toxins and trends associated with exposure can help veterinarians efficiently determine
a differential diagnosis.
67
| ToP Ten
2 5 9
10
1
3
5
The number one group of substances the APCC

received calls about in 2012 was human prescription
medications, accounting for 25,200 calls.1 The number
of people prescribed medications for chronic disease is
continually growing and so are accidental ingestions of
these medications by pets (such as consuming dropped
pills or getting into pill organizers).
Cardiac medications are the largest group of human
medications ingested, ranging from relatively safe (ie,
diuretics, ACE inhibitors) to life-threatening (ie, calcium channel blockers, digoxin) products.
Antidepressants, thyroid, and attention deficit hyperactivity disorder (ADHD) medications are also commonly ingested. Cats are not normally attracted to
large pills but they are strangely drawn to venlafaxine
(Effexor, pfizer.com) capsules.
Veterinarians should counsel owners to:
Store and take their medications in a place
away from pets to prevent them from ingesting any
dropped pills.
Keep medication bottles out of reach of pets to
prevent dogs from chewing on the bottles/caps and
gaining access to the pills (unfortunately, child-safety
caps are not pet-safe!).
Store pet and human medications separately to
avoid accidental administration of human medications
to pets or vice versa.
inSeCtiCideS
As new products have become more specific for

insect physiology in the past 10 to 20 years, insecticides have become much safer for mammals. However,
68
3 4 5
6 7
2 5 9
HuMAn PreSCriPtion MediCAtionS
8
2 9 10
insecticide granules, yard sprays, and preventives used on

pets can cause serious problems if not administered correctly.
Eleven percent of phone calls to the APCC were in regard to
insecticide exposure.1
Veterinarians should emphasize that:
Owners read the label and follow directions before
using any insecticide
Products labeled for dogs only should NOT be used
for cats. Applying permethrin products that are labeled
for dogs on cats can cause tremors and seizures, and
require immediate medical intervention.2
Cats may have taste reactions (hypersalivation) that
can occur when a spray or spot-on product is applied and
the cat grooms itself, ingesting the product.
Cats are over-represented in the insecticide category due
to taste reactions. These reactions are not poisonings, but
cats foaming at the mouth obviously make owners very concerned. The best treatment is to offer food to the cat (eg,
milk, canned food, tuna), which removes the bad taste.
over-tHe-Counter HuMAn ProduCtS
Many pet owners do not realize that OTC medications

are dangerous.
Ibuprofen is the most common OTC medication ingested
by pets.
The toxin with the biggest gain in this category is vitamin
D (cholecalciferol).1 Many physicians are now prescribing
large doses of vitamin D for patients, and manufacturers have responded by producing products with higher
amounts of this vitamin (which can be available as highly
palatable chocolate-flavored or gummy chews).
Many pets are also attracted to OTC joint care products
and nutraceuticals due to their animal origins.
Veterinarians need to inform pet owners that:
OTC medications, such as ibuprofen and acetaminophen, can kill their pets.
OTC human products should never be administered to a pet without consulting a veterinarian
first.
veterinAry ProduCtS
Chewable medications are a double-edged sword

in veterinary medicine. They are easy to administer
to dogs or cats; however, these tasty medications can also
mean that the pet, if given access, will ingest all the tablets
in the bottle. Examples include veterinary NSAIDs, phenylpropanolamine, joint care supplements, and heartworm
medications, which are all commonly sold in chewable
formulations.
Avermectin toxicity is a concern in collie-type breeds;
however, the dose of avermectin in canine heartworm preventatives is safe for these breeds. Toxicity can occur when:
Owners use ivermectin horse dewormers, which have a
much higher concentration of avermectin, for their dogs.
A dog consumes dewormer paste that has dropped on
the ground from the horses mouth or the tube.
Veterinarians should always make sure to:
Remind owners to keep pet medications out of
their pets reach.
Recommend that pets be separated during pill
administration, if there are multiple pets in the household.
HouSeHold iteMS
The APCC received approximately 10,000 calls

about household items in 2012.1
Paint, cleaning products, and laundry detergents are only
a few types of items that pets may ingest in the home. Some
household items may only cause gastrointestinal upset,
while some can be deadly. Other items, such as dry wall,
fire logs, and polyurethane glues, are not poisonous but
can cause gastrointestinal obstructions requiring surgery.
Veterinarians can help prevent tragedies by instructing
owners or providing resources on how to pet-proof homes;
for example, crate training, cabinet locks, and baby gates
can provide safe areas for pets. The APCC offers a helpful
checklistA Poison Safe Homeat aspca.org/pet-care/
poison-control/a-poison-safe-home.
HuMAn FoodS (other than Chocolate)
The most common toxicosis in this group is xylitol

(a sugar substitute) toxicity.1 Xylitol can be found
in sugarless gums, candies, mints, and baked goods, and
can cause low blood sugar, seizures, and liver failure in
dogs.4 Many owners are not aware of the danger this toxin
presents to their dogs.
Other food items that cause concern are grapes/raisins,
onions/garlic, and avocados.5
Grapes and raisins can cause kidney failure; signs may be
more dramatic in animals that have concurrent illness.
Onions and garlic can cause gastrointestinal irritation
and may lead to red blood cell damage. Cats are most
susceptible, but dogs that consume a large amount of
these vegetables/herbs are also at risk.
Avocados are dangerous to birds and rabbits, but only
cause gastrointestinal upset in dogs and cats (the pit can
become a foreign body if ingested).
Finally, moldy food can grow toxins that cause tremors
and seizures if ingested.6 A comprehensive listPeople
Foods to Avoid Feeding Your Petscan be found at
aspca.org/pet-care/poison-control/people-foods.aspx.
CHoColAte
While the word has been out for a while that chocolate can be toxic to pets, it is still the number one
human food that pets ingest. The APCC received 8575
calls about chocolate in 2012, about 23.5 a day.1 The darker
the chocolate, the higher the methylxanthine content and
higher the risk of toxicity.3
Because cats do not have the same sweet taste buds as
dogs and humans, dogs are the most likely species to be
poisoned by chocolate. Signs of chocolate toxicosis include
vomiting, diarrhea, agitation, high heart rate, tremors, seizures, and death.
PlAntS
About 4% of APCC phone calls were about animals

that had consumed plants.1 This is another category
in which cats are over-represented. Houseplants, especially
ones containing insoluble calcium oxalates (eg, Dieffenbachia, Philodendron) are the most common type ingested.
Fortunately, most cases of plant ingestion cause nonlifethreatening illness and minimal clinical signs (ie, drooling,
vomiting). Lilies and sago palms are probably the most
dangerous to cats and dogs, respectively. The APCC offers
a list17 Poisonous Plantsat aspca.org/pet-care/poison-control/17-common-poisonous-plants.aspx.
rodentiCideS
Rodenticides are designed to kill rodents, but they can

be deadly for other mammals and birds. The APCC
handled approximately 6965 cases of rodenticide ingestion in 2012.1 Anticoagulants are still the primary type of
rodenticide used, but bromethalin and cholecalciferol are
gaining market share.
Veterinarians should counsel owners to:
Be very careful when setting out rodent baitthe
resourcefulness of pets, especially dogs that are attracted to grain-based baits, should never be underestimated.
Keep all rodenticide labels because many baits look
identical but cause very different clinical signs
10
lAWn & GArden ProduCtS
Many Americans are obsessed with creating the

perfect lawn and, likewise, the APCC received
almost 3500 calls about noninsecticidal lawn and garden
items in 2012.1
Lawn products can range from tasty fertilizers (bone
meal and blood meal) and herbicides that are only expected
69
Toxicoses in Dogs & Cats
ToP Ten |
| ToP Ten
ToP 10 Toxicoses in dogs & caTs in 2012

rAnK CAllS PotentiAl toxin
exAMPleS
25,200 Human prescription medications
Cardiac, antidepressant, thyroid, ADHD medications
20,400 insecticides
Insecticide granules, yard sprays, preventives for pets
18,400
10,700 veterinary products
nSAIDs, phenylpropanolamine, joint products, heartworm medications
10,000 Household items
Paint, cleaning products, laundry detergent
over-the-counter human
medications
Acetaminophen, ibuprofen, vitamin D
9400
Human food (other than

chocolate)
Xylitol, grapes, raisins, onions, garlic, avocados
8575
Chocolate
Chocolate candy, baked goods
7100
Plants
Lilies, sago palms, house plants
6965
rodenticides
Anticoagulants, bromethalin, cholecalciferol
10
3500
lawn & garden products
Fertilizers, herbicides, snail/slug bait
to cause gastrointestinal signs, to more toxic products,

such as the snail and slug bait metaldehyde, which can be
deadly.7
Veterinarians should encourage pet owners to read and follow label directions, which greatly minimizes the risk to pets.
Learn more about rodenticide poisoning by

reading rodenticide Poisoning: What to
do After exposure (March/April 2012), available at
todaysveterinarypractice.com.
exPoSure vAriAntS
Fortunately, most animal exposures to toxic agents result
in no or mild clinical signs.8 This may be due to a small
exposure dose of the toxicant or decontamination by the
owner and/or veterinarian.
Exposure to toxicants can vary depending on the:
Pets environment
Time of year
Geographical location.
For example, the APCC sees an increase in rodenticide
poisoning in the northern U.S. in the fall (crop harvesting
and cold weather drives rodents inside).1
References
1. data from the asPca aPcc regarding animal poisonings in 2012.
2. richardson Ja. Permethrin spot-on toxicoses in cats. J Vet Emerg Crit
Care 2000; 10:103-106.
3. gwaltney-Brant s. chocolate intoxication. Vet Med 2001; 96:108-111.
4. dunayer eK. Hypoglycemia following canine ingestion of xylitol containing
gum. Vet Human Toxicol 2004; 46(2):87-88.
5. asPca animal Poison control center. People foods to avoid feeding your
pets. aspca.org/pet-care/poison-control/people-foods.aspx.
6. schell MM. Tremorgenic mycotoxin intoxication. Vet Med 2000;
95(4):283-286.
7. dolder LK. Metaldehyde toxicosis. Vet Med 2003; 98:213-215.
8. Forrester MB, stanley sK. Patterns of animal poisonings reported to
the Texas Poison center network: 1998-2002. Vet Hum Toxicol 2004;
46(2):96-99.
Client eduCAtion
Educating the public about potential toxins lurking in the
house and yard is a very important part of veterinary care.
It is much easier to prevent poisonings than to attempt to
treat them.
Placing information in puppy/kitten packs, on your website, and in other communication with clients is a good
way to start educating owners.
Seasonal topics, such as Easter lilies and chocolate, can
be included in newsletters and on websites, Facebook,
and other social media outlets.
Provide the APCCs website link, aspca.org/home/petcare/poison-control, to clients, which allows them to
access additional information on pets and poison prevention concerns.n
70
Tina Wismer, DVM,

Diplomate ABVT & ABT,
is the senior director of
veterinary educational
outreach at the ASPCA
Animal Poison Control
Center in Urbana, Illinois.
She is also an adjunct
instructor at the University of
Illinois and a consultant for the Veterinary Information
Network. Dr. Wismer received her DVM from Purdue
University. Prior to her current position, she worked
in small animal practice in Michigan and emergency
practice in Indiana.
Peer reviewed
Todays Technician
Assisting the surgeon
Practical
strategies for
Preventing
nosocomiAl
infections
Noah Jones, RVT
osocomial infections increase morbidity and

mortality in patients as well as cost to clients.
Antimicrobial resistance further complicates
nosocomial infections by increasing morbidity, mortality, and cost.
RISK FACTORS
Postoperative patients are among those at highest risk
for nosocomial infection because these patients:1
Are frequently fasted
Have ongoing disease processes
Undergo procedures in which multiple medical
devices are inserted into the body
Receive drugs that alter the normal physiology of
the patient.
All of these factors can modulate a patients immune
system. Veterinary health care teams must take precautions to minimize the risk of transferring pathogens between patients and maximize their ability to
fight infection.
SIGNS OF INFECTION
Patients at risk for nosocomial infections (see Potential Risk Factors for Nosocomial Infection) should
be monitored closely for signs of infection, such as:
Increasing lethargy
Edema, redness, pain, and/or heat (or fever)
Discharge from wounds or surgical sites.
72
POTENTIAl RISK FACTORS FOR

NOSOCOMIAl INFECTION1
Patient Condition
immune deficiency (ie, neutropenia, diabetes
mellitus, immunosuppresive drugs)
Malnutrition
open wounds
Patient Environment
Prolonged hospitalization,
surgical preparation, or
surgery/anesthesia time
Medical Procedures
Blood product administration
central venous
catheterization
concurrent antibiotic therapy
Frequent bandage changes
Prolonged catheterization (of any type)
Inappropriate Care
improper aseptic/sterile technique, care of
catheters, and/or tissue handling
inexperienced surgeon
NOSOCOMIAL OR RESISTANT?
Nosocomial Infections
A nosocomial infection is defined as an infection that
is acquired or occurs in a hospital.1
Extensive research has been performed in the
human medical field due to the frequency of occurrence, increased costs, and large number of deaths
associated with nosocomial infections:
In the U.S., annual costs related to nosocomial
infections in human medicine are reported to be
over $4 billion.1
Over 2 million patients (5% to 10% of the total
patient population) are affected, causing over
80,000 deaths each year.2
Due to lack of uniform reporting and surveillance,
veterinary nosocomial infection rates are unknown,
though it has been found to be a common problem
encountered in veterinary teaching hospitals.3 Additional research is needed to determine the frequency
of nosocomial infections in private veterinary practice
as this data does not exist at this time.
Antimicrobial Resistance
Antimicrobial resistance (AMR) occurs when a pathogen develops resistance to 1 or more agents to which
the pathogen was previously sensitive.1 AMR is a
growing problem in both human and veterinary medicine.1 AMR has become more common in nosocomial
infections, although the 2 are not synonymous.
AMR often occurs due to inappropriate antimicrobial administration, causing selection for resistant
organisms, but can also occur in the face of appropriate antibiotic administration.1 In the latter case, the
gastrointestinal tract is a reservoir for resistant organisms, which can then be transferred from patient to
patient.
The rate of AMR in veterinary medicine is largely
unknown. In a recent study of 10 private veterinary
hospitals,3 Enterococcus contamination was found at
all 10 hospitals, with approximately 20% of the isolates
having AMR. Of the AMR isolates:
About 30% were found on stethoscopes, with 50%
of personnel reporting that they almost never
cleaned their stethoscopes.
6% were found on thermometers, with 30% of
hospitals reporting that thermometers were not
cleaned between patients.
60% were found on cage doors, with 30% of hospitals reporting that cage doors were not disinfected
between patients.
Another study showed that 44% of dogs with pyoderma were infected with resistant isolates, mostly
Staphylococcus pseudintermedius, which is the most
frequently isolated Staphylococcus species in canine
and feline patients.4
HAND HYGIENE
Pathogen transmission in hospitals occurs most
often via contaminated hands of health care workers.2 Although our patients are handled differently than human patients, it is likely that pathogen
transmission still occurs frequently via contaminated hands. Therefore, hand hygiene should be a high
priority in any health care setting.
Proper hand hygiene consists of hand disinfection:
Before
Direct contact with a patient or its environment
Placement of any type of catheter
Movement from a contaminated to a clean site
on a patient
After
Direct contact with a patient or its environment
Contact with patient bodily fluids
Removal of gloves.2
Disinfection
Disinfection for visibly soiled hands is
achieved by (Figure 1):2
1. Washing hands
in running warm
water, with sufficient volume
of antimicrobiFigure 1. Proper hand
al soap to cover
hygiene is critical for prevenall surfaces of
tion of nosocomial infection.
hands/fingers in
lather.
2. Rubbing for at least 15 seconds before rinsing.
3. Using paper towels or single-use cloth towels to
dry hands.
4. Turning the faucet off using the towel.
Alcohol-based sanitizers are the preferred method
of hand hygiene in human medicine and have shown
better bactericidal activity than that of soap and
water.2 Hands that require disinfection but are not
visibly soiled can be effectively disinfected by:2
1. Using a sufficient volume of alcohol-based hand
sanitizer to cover all surfaces of hands/fingers.
2. Rubbing for at least 15 seconds before hands are
dry.
Gloves
Gloves can be used to prevent gross contamination of the hands, but are not an alternative to
proper hand disinfection. Gloves should be worn
while handling every patient and hand disinfection should be performed after carefully removing contaminated gloves. Even though clean gloves
are used with each patient, hands can become contaminated during glove removal and hand disinfection prevents any transfer of pathogens from one
patient to another.
73
Practical Strategies for Preventing Nosocomial Infections
TodayS TechNIcIaN |
| Todays Technician
Education
Despite health care workers acknowledging the
importance of hand hygiene, compliance rates are
very low.2,5,6
Recent veterinary studies report hand hygiene compliance to be between 20% to 40%, with 85% of
workers feeling they should be washing their hands
more frequently.5
One veterinary study showed that implementing a
comprehensive education program could increase
compliance, which is consistent with human data on
the same subject.6
The Institute for Healthcare Improvement (IHI) recommends implementing an intervention package consisting of 4 items to increase hand hygiene compliance:
1. Educate staff on the
importance of proper hand hygiene: Staff
should understand why
hand hygiene is important and the implications
of poor hand hygiene. Inservice educational programs, posters, and other
literature can be useful as
educational tools.
2. Verify appropriate hand
hygiene technique: Proper technique should be
Figure 2. Various methods,
demonstrated to all staff
such as posting reminders
members. Reminders of
in patient care areas, are
proper technique may be
useful in promoting proper
posted at sinks and other
hand hygiene.
hand hygiene stations
(Figure 2).
3. Ensure hand hygiene is available at point of
care: Ideally, someone is assigned the task of refilling dispensers and ensuring availability of adequate
supplies. Checklists may be especially useful for this
purpose.
4. Continually monitor compliance while providing feedback: Staff should be regularly evaluated
on proper technique to ensure ongoing patient safety. Written examinations and direct observation are
useful in monitoring compliance.
SURFACE DISINFECTION
Additional routes of transmission include contaminated environmental surfaces and equipment.3 Proper environmental disinfection is challenging for veterinary teams as patients are not usually confined to
a hospital bed.
The appropriate disinfectant is dependent on the
surface or device. Disinfectants are divided into 3
categories:
1. Low level
2. Intermediate level
3. High level or sterilization.
74
Many disinfectants become unstable after

dilution, and must be changed daily, while
others may be stable for months.7,8 consultation
with your disinfectant manufacturer for stabilityin-solution information is recommended.
low-level Disinfectants
Low-level disinfectants are used for noncritical surfaces that touch intact skin or do not come in
contact with the patient, such as floors, tables, food
bowls, cages, and stethoscopes.7 Examples include:
70% isopropyl alcohol
Quaternary ammonium compounds
Peroxygen compounds
0.05% chlorhexidine
Sodium hypochlorite (1:100).
While very popular in the veterinary industry, quaternary ammonium compounds have been shown to
have poor virucidal and sporucidal activity (despite
label claims) and are not recommended for disinfection of contaminated or potentially contaminated surfaces, such as floors.7,8 Additionally these compounds
are bacteriostatic and can cause pathogens to become
disinfectant-resistant.7
Intermediate-level Disinfectants
Intermediate-level disinfectants are used for semicritical surfaces that will contact mucous membranes
or intact skin, such as laryngoscopes, thermometers,
and endotracheal tubes.7 Examples include:
70% ethanol
Peroxygen compounds
0.5% chlorhexidine
Sodium hypochlorite (1:10; contact time will be longer compared to low-level use7).
High-level Disinfectants
High-level disinfectants or sterilizers are used for critical surfaces that enter the bloodstream or a body
cavity, such as intravenous catheters, surgical instruments, and laparoscopes.7 Examples include:
Ethylene oxide gas
Hydrogen peroxide gas (low-temperature plasma)
2% activated glutaraldehyde
Steam (121F).
The Centers for Disease Control and Prevention have published guidelines outlining methods of disinfection and sterilization, available
agents, concentrations, contact times, and special considerations. These guidelines are available at cdc.gov/hicpac/pdf/guidelines/Dis
infection_Nov_2008.pdf.
Two percent activated glutaraldehyde is often adequate for critical items that cannot be sterilized.7
Step-by-Step Disinfection
Surface disinfection should be a 2-step process consisting of:
1. Organic debris removal
2. Disinfection using appropriate contact time.
However, consideration of proper disinfectants, dilution, and contact times are not sufficient.
Prepared scrub gauze and items from cold sterile trays should be removed by tongs. Weekly sterilization of these items
is necessary to prevent multidrug-resistant colonization.7
Mop heads and
solutions (Figure 3) should
be changed at
least twice daily,
preferably at the
beginning of the
day and before
Figure 3. Effective disinfection
is ensured by proper disinfecfinal
mopping
tion protocols and care of disat closing time;
infection equipment.
sooner if visible
soil is present.7
A separate mop bucket/head should be used for
the surgical suite to minimize potential for cross
contamination.
Periodic scrubbing with an intermediate-level disinfectant should be performed on all mop buckets and handles.
Floor drains should be disinfected weekly with a
1:50 bleach solution.7
High-touch surfaces, such as computers, handsets,
mobile phones, door handles, and cage handles,
should receive low- or intermediate-level disinfection.
Stethoscopes, pulse oximetry probes, Doppler probes, blood pressure cuffs, and other
monitoring equipment must be cleaned between
patients and at least once daily. Isopropyl alcohol
(70%) is reportedly most effective when proper contact times are observed.3,7
Laundry should be collected in leak-proof containers and washed in hot water (> 160F) for at least
25 minutes.7 A 1% bleach solution should be used for
laundry disinfection, although polyester fabric may
be resistant to this form of disinfection, with further
disinfection necessary.7
SURGICAL SUITE
Special precautions must be made in the surgical suite
as these patients may be at high risk for nosocomial
infection due to anesthetic-related immune suppression and exposure of tissues (Figure 4). The anes-
thesia work area can become contaminated, causing spread of resistant bacterial organisms between
patients.9
Area Designation
A clean area should be used to store new items and
drugs; a dirty area should be used to store items
specific to the current patient, such as monitoring
equipment and predrawn drugs.
A plastic bag or tub works well as a dirty area to isolate patient-specific items while maintaining portability throughout the hospital.
All surfaces and equipment should be disinfected
between patients using an appropriate disinfectant
and contact time.
Personnel
Surgical personnel should practice barrier precautions, such as gowns, gloves, masks, and face shields
specific to that patient, when a known or suspected
infectious patient, such as one with a positive culture or zoonotic disease, is in the surgical suite.
Street clothes should never be worn in the operating theatre. Research has shown that, when
compared to street clothes, scrubs reduced airborne S aureus levels by 75%.10 Therefore, scrubs
should not be worn outside the hospital and surgical personnel should change into clean scrubs
before entering the surgical suite.
The addition of masks and gowns only improved
the reduction of S aureus levels to 82%, which
emphasizes the importance of wearing clean scrubs
in the surgical suite.10
Modifiable Risk Factors
Perioperative hypothermia has been shown to suppress immune function and should, therefore, be
avoided in patients.11
Figure 4. Patients under anesthesia for surgical procedures are at higher risk for nosocomial infection.
75
Practical Strategies for Preventing Nosocomial Infections
TodayS TechNIcIaN |
| TodayS TechNIcIaN
Using forced-air blankets, heating pads, heatmoisture exchangers, low-flow oxygen, and minimizing surgical preparation time can all reduce the
likelihood and severity of perioperative hypothermia.
Use of forced air blankets, however, should be
delayed until final sterile draping of the patient
to minimize the likelihood of foreign material or
pathogens being blown into the surgical field.
Impaired tissue oxygenation has been shown to
delay wound healing and increase infection rates; supplemental oxygen should be provided to all anesthetized patients.11
Shaving patients with a razor has been shown to
increase infection rates; patients should be clipped
with clippers in the immediate preoperative period if
hair removal is necessary.11
Protocols
Prophylactic antibiotics must be present in sufficient concentration in the tissues at time of contamination in order to effectively prevent nosocomial
infection.12 The American Society of Health System
Pharmacists recommends administration of cefazolin,
20 to 30 mg/kg IV, at induction of anesthesia for most
surgical procedures; however, specific veterinary data
on the appropriate dosage and frequency of perioperative antibiotics is lacking.12,13
Aseptic technique is essential, and any breach of
the sterile field should be immediately brought to the
surgeons attention.
Surgical instruments should be immediately processed after the procedure, including:14
Manual scrubbing to remove gross contamination
Ultrasonic cleaning
Lubrication, if necessary
Appropriate sterilization
Careful inspection to ensure proper function and
decontamination.
Minimizing anesthesia and surgery time is
likely the most important intervention in preventing nosocomial infections.15
IN SUMMARY
Nosocomial infections and AMR are life-threatening problems for veterinary patients, especially surgical patients. Proper hand hygiene, surface disinfection, and surgical etiquette are essential in minimizing risk and obtaining positive outcomes in veterinary
patients. Further research is necessary to determine
the rate of nosocomial infection, organisms responsible, risk factors, and recommended interventions for
patients at risk. n
aMR = antimicrobial resistance;
IhI = Institute for healthcare Improvement
76
References
1. Ogeer-Gyles JS, Mathews KA, Boerlin P. Nosocomial
infections and antimicrobial resistance in critical care
medicine. J Vet Emerg Crit Care 2006; 16(1):1-18.
2. Institute for Healthcare Improvement. How-To Guide:
Improving Hand Hygiene. Available at shea-online.org/
assets/files/IHI_hand_hygiene.pdf, assessed June 16,
2012.
3. KuKanich KS, Ghosh A, Skarbek JV, et al. Surveillance of
bacterial contamination in small animal veterinary hospitals
with special focus on antimicrobial resistance and virulence
traits of enterococci. JAVMA 2012; 240(4):437-445.
4. Eckholm NG, Outerbridge CA, White SD, Sykes JE.
Prevalence of and risk factors for isolation of methicillinresistant Staphylococcus spp. from dogs with pyoderma in
northern California, USA. Vet Derm 2013; 24(1):154-234.
5. Nakamura RK, Tompkins E, Braasch EL, et al. Hand
hygiene practices of veterinary support staff in small animal
private practice. J Small Anim Pract 2012; 53(3):155-160.
6. Shea A, Shaw S. Evaluation of an educational campaign to
increase hand hygiene at a small animal veterinary teaching
hospital. JAVMA 2012; 240(1):61-64.
7. Portner JA, Johnson JA. Guidelines for reducing pathogens
in veterinary hospitals: Disinfectant selection, cleaning
protocols, and hand hygiene. Compend Contin Educ Vet
2010; 53(3):E1-E12.
8. Eleraky NZ, Potgieter LN, Kennedy MA. Virucidal efficacy of
four new disinfectants. JAAHA 2002; 38(3):231-234.
9. Loftus RW, Koff MD, Burchman CC, et al. Transmission
of pathogenic bacterial organisms in the anesthesia work
area. Anesthesiol 2008; 109:399-407.
10. Bischoff WE, Tucker BK, Wallis ML, et al. Preventing
airborne spread of Staphylococcus aureus by persons with
the common cold: Effects of surgical scrubs, gowns, and
masks. Infect Control Hosp Epidemiol 2007; 28(10):11481154.
11. Sessler DI. Non-pharmacological prevention of surgical
wound infection. Anesthesiol Clin 2006; 24(2):279-297.
12. American Society of Health System Pharmacists. ASHP
Therapeutic Guidelines on Antimicrobial Prophylaxis in
Surgery. Available at ashp.org/s_ashp/docs/files/BP07/TG_
surgical.pdf, assessed January 31, 2013.
13. Knights CB, Mateus A, Baines SJ. Current British veterinary
attitudes to the use of perioperative antimicrobials in small
animal surgery. Vet Rec 2012; 170(25):646.
14. Crow S. Protecting patients, personnel, instruments in the
OR. J AORN 1993; 58(4):771-774.
15. Nicholson M, Beal M, Shofer F, Brown DC. Epidemiology
evaluation of postoperative wound infection in cleancontaminated wounds: A retrospective study of 239 dogs
and cats. Vet Surg 2012; 31:577-581.
Noah Jones, RVT,

specializes in emergency
and critical care
practice. He has worked
in private emergency/
referral practice as well
as in academia at the
University of California
Davis Veterinary Medical
Teaching Hospital. Mr. Jones has a strong
interest in infectious disease prevention and
critical care nursing of infectious patients.
Journal Club
FOCUS ON DIABETES MELLITUS
iabetes mellitus is a common condition in both dogs and cats, and small animal practitioners need to feel comfortable with the long-term management of these patients. The following 4 abstracts highlight articles that provide useful insight into the management of both
feline and canine diabetics.
The study by Hafner and colleagues looked at placement sites for continuous glucose monitoring systems (CGMS) in cats. CGMS are routinely used in human diabetics and are now appearing in veterinary referral centers and emergency clinics. Successful sensor placement can be
problematic, but this study shows that the dorsal neck region is both a reliable and comfortable
site for feline patients.
borin-Crivellenti and colleagues evaluated the carpal pad as a potential site for blood glucose
testing in dogs. as home monitoring becomes a routine part of diabetic management for dogs
and cats, information such as thissample collection techniquesis timely and relevant.
Samples were reliably obtained from this site and patient discomfort was minimal. blood
glucose measurements were comparable to those obtained from the ear vein in both diabetic
and healthy dogs.
The study by niessen and colleagues provides useful insight into the concerns of owners with
diabetic dogs. as clinicians, we tend to focus on the pets immediate health needs, and may fail
to consider the owners worries and perceptions. This report describes owner responses to a
series of questions regarding quality of life issues and provides a reliable tool for future clinical
studies.
In the study by Hofer-Inteeworn and colleagues, the impact of hypothyroidism on glucose
homeostasis was investigated using dogs with experimentally induced thyroid deficiency.
although hypothyroidism is routinely listed as a cause of insulin resistance, this paper provides
the first clear evidence of this association and demonstrates the mechanism. Diabetic dogs
with insulin resistance should be screened for hypothyroidism, particularly if weight gain is
noted despite persistent hyperglycemia.
Effective care for diabetic patients requires partnership between the owner and the veterinary
team. These recent studies improve our ability to manage these patients and provide optimal
service to our clients.Audrey K. Cook, BVM&S, MRCVS, Diplomate ACVIM (Small Animal Internal
Medicine) & ECVIM (Companion Animal), Texas A&M College of Veterinary Medicine and Biomedical
Sciences
77
Journal Club

CONTINUOUS GLUCOSE MONITORING IN CATS
Continuous glucose monitoring systems (CGMS) can be used to measure glucose concentrations
in interstitial fluid every 5 minutes for up to 72 hours. In humans, the monitors are often placed in
the abdominal para-umbilical region, however, glucose levels from this placement are 20% lower
than reference glucose concentrations or readings from sensors placed in the forearm. There are
no specific recommendations for sensor placement in cats at this time.
This study evaluated 3 sites for placement of a Guardian real-Time CGMS (medtronic.com) in
18 client-owned diabetic cats. Monitors were placed in (1) subcutaneous tissue of the lateral chest
wall in all cats, (2) subcutaneous tissue of the knee fold in 10 cats, and (3) dorsal neck area in 10
cats. Two cats had all 3 sensors in place at the same time.
The first calibration was evaluated 2 hours after the initialization period per the manufacturers
instructions. after that, calibrations were conducted after 6 hours; then every 10 hours. The
alphaTrak portable blood glucose meter (abbottanimalhealth.com) was used to evaluate glucose
concentrations from the capillary blood of the inner pinna, which were used as reference
calibrations.
Successful calibrations were achieved in:
15/20 (75%) of the sensors placed in the lateral chest wall
9/10 (90%) of the sensors placed in the neck region
3/10 (30%) sensors in the lower knee region.
uninterrupted glucose concentration recordings over a 48-hour period occurred in 17/20 (85%)
of the sensors placed in the lateral chest wall and in 7/10 (70%) of the sensors placed in alternate
locations. one sensor in the lateral chest wall and 1 sensor in the lower knee region were never
successfully calibrated; however, sensors were well tolerated in all 3 locations.
overall, the results of this study indicated that placement of the CGMS in the dorsal neck region
was superior to the other sites tested; however, further investigation is needed.
Hafner M, Lutz, Reusch CE, Zini E. Evaluation of sensor sites for continuous glucose monitoring in cats with
diabetes mellitus. J Fel Med Surg 15:117, 2013; DOI: 10.1177/1098612X12463925.
COLLECTING BLOOD FROM CARPAL PADS

a study was conducted to investigate the feasibility and validity of using the carpal pad in dogs to
collect blood for glucose monitoring. Sixty client-owned dogs were used in the study, including 30
healthy dogs and 30 dogs with diabetes mellitus. The metacarpal pad was cleaned with alcohol
and a blood sample was obtained with a 25 0.77 mm hypodermic needle; an ear vein nick
sample was obtained at the same time. The dogs were minimally restrained during sampling.
Glucose was measured with a glucometer that had previously been validated for use in dogs.
Glucose values were not significantly different between sampling sites and the dogs tolerated
both collected methods.
Twitching was observed in 10% of the dogs during ear sampling and 6.7% during carpal pad
sampling. Growling was observed in 2 dogs from both groups (3.3%).
The results of this study indicate that the carpal pad provides a good alternative sampling site for
monitoring of blood glucose in diabetic dogs.
Borin-Crivellenti S, Crivellenti Z, Tinucci-Costa M. The carpal pad as an alternative sampling site for blood
glucose testing in dogs. J Small Anim Pract 53:684-686, 2012.
78

QUALITY OF LIFE: DIABETIC PETS & OWNERS
Evaluating quality of life (Qol) in companion animals is important, especially when the animal is
suffering from a chronic condition, such as diabetes mellitus (DM). There is a perceived lack of
attention by veterinary clinicians and researchers regarding the psychological and social impact of
DM on both the animal and the owner.
The authors of this study designed a diabetic pet- and owner-centered, individualized measure
of the impact of DM on Qol of diabetic dogs and their owners (DIa-Qol-pet), and had previously
validated its use for a diabetic cat population. This study evaluated 101 insulin-treated diabetic dogs
and their owners, and included 29 specific DM-associated Qol questions.
Various methods were used to evaluate the survey, which identified specific areas that most
negatively impacted dogs and their owners Qol, including worries/concern about:
Medical issues, such as diabetes, potential vision problems due to cataracts, and development of
hypoglycemia
leaving the dog with friends or family or at a kennel
The negative impact the care associated with a pets DM will have on the owners life
Cost of care and whether the owner will be able to take care of the pet in the future.
Concerns listed in the free comments section included:
lack of support from the veterinary team
Difficulties involved with the monitoring and stabilization process
Concurrent diseases affecting the dog.
These issues should be considered for future questionnaires. However, many owners felt they had a
special bond with their dogs and that living with a pet with DM was a positive experience.
Niessen SJM, Powney S, Guitian J, et al. Evaluation of a quality-of-life tool for dogs with diabetes mellitus. J Vet
Intern Med 26:953-961, 2012.
CONCURRENT DIABETES MELLITUS & HYPOTHYROIDISM

Dogs are frequently diagnosed with concurrent diabetes mellitus and hypothyroidism. Hypothyroidism
has been associated with poor glycemic control in diabetic dogs, but it has been suggested that it is
not a common cause of insulin resistance. a study was conducted to:
Evaluate whether hypothyroidism caused insulin resistance
Determine the overall effect of hypothyroidism on glucose tolerance in dogs
Characterize the secretion profiles of hormones that are counter-regulatory to insulin.
Sixteen anestrous mixed-breed bitches were used in the study. Hypothyroidism was chemically
induced in 8 of the dogs, with the remaining dogs acting as euthyroid controls.
an insulin-modified, frequently sampled IV glucose tolerance test (FSIGT) and minimal model
analysis determined basal plasma insulin and glucose concentrations, insulin sensitivity, glucose
effectiveness, and disposition index
Stimulation and suppression tests assessed growth hormone response
Dual energy x-ray absorptiometry evaluated body composition
Basal serum growth hormone (GH) and insulin-like growth factor-1 (IGF-1) concentrations and
urine cortisol-to-creatinine concentration ratios were also measured.
This study suggested that dogs with hypothyroidism had substantial insulin resistance. Hypothyroid
dogs were able to maintain glucose tolerance by a compensatory increase in insulin secretion. They
also had an increase in abdominal fat and high serum GH and IGF-1 concentrations, which may
have affected insulin sensitivity. In dogs with impaired insulin secretion, such as those with diabetes
mellitus, concurrent hypothyroidism can have important clinical implications.
Hofer-Inteeworn N, Panciera DL, Monroe WE, et al. Effect of hypothyroidism on insulin sensitivity and glucose
tolerance in dogs. Am J Vet Res 73:529-538, 2012.
79
Focus on Diabetes Melitis
Journal Club |
The Back Page: VeTerinary ViewPoinTs
The Future of Veterinary Medicine Makes Headlines

A RESPONSE FROM OUR EDITORIAL TEAM
Travis Meredith, DVM, MBa, Diplomate acT
It was the 1950 movie Born Yesterday that

made famous the quote, Never do nothing you
wouldnt want printed on the front page of The
New York Times. While it wasnt the front page,
veterinary medicine found itself in the Business
Section of that very publication just a few short
weeks ago.
On February 23, David Segals article,
High Debt and Falling Demand Trap New
Vets, brought public attention to some of the
challenges facing veterinarians and the industry
as a whole. In short, the article:
Outlined the trials and tribulations of a typical
new graduate during her first year of clinical
practice
Cited industry experts and quoted
employment and industry data about falling
demand for veterinary care
Painted a gloomy picture for the future of
veterinary medicine and those choosing to
pursue it as a career.
80
Did the Veterinary Community Respond?

The article created a stir both within and outside
veterinary circles. Dr. Deborah Kochevar, Dean of
Tufts Universitys Cummings School of Veterinary
Medicine and President of the Association of
American Veterinary Medical Colleges (AAVMC)
responded to the article with an open letter to the
veterinary medical community, acknowledging
some of the issues raised but also countering
other conclusions, citing data from an AAVMC
survey of recent graduates.
Was The New York Times Article Right?
Its not our job to determine that answer. As
with many commentaries written by those with a
limited understanding of an industry, the article
based many of its conclusions on inaccurate
or skewed perspectives. In fact, several
inaccuracies were corrected in a later issue of the
newspaper.
However, the article does identify several, very
real challenges that exist in our vital branch of
health care. The article, Dr. Kochevars response,
and ensuing dialogue in many circles effectively
raises awareness of several issues that are front
and center to veterinarians across this industry.
What Challenges Will Define Our Future?
Todays challenges and issues will have a longlasting effect on the industry, including:
Is truly objective data available about the
economic climate of veterinary medicine?
For todays veterinary students, are the costs of
veterinary education out of control?
The Back Page |
Are increased class sizes and the emergence of

new schools really dictated by market demand or,
instead, attempts to increase tuition revenues in
times of budgetary contraction?
Is there an over or under supply of veterinarians in
the market?
Does the growth of foreign training institutions
truly influence the supply of veterinarians in the
U.S.? Does that negatively impact todays market?
How do we, as an industry, bring veterinary
medicine to underserved areas of this country?
What is the impact of the increasing percentage of
female veterinarians in the workplace?
How do our responses to these issues impact
consumers views of our industry?
Can My Voice Be Heard?
The Todays Veterinary Practice team would like
to explore these questions and, therefore, we are
planning to bring together individuals from all walks
of veterinary medicineprivate practice, academia,
industry, government, practice development/
financefor our first Challenges & Opportunities
in Veterinary Medicine roundtable.
We want you, the reader and todays practitioner,
to have a voice in this session: Please send
your comments and questions to tmeredith@
todaysveterinarypractice.com or editorinchief@
todaysveterinarypractice.com, which will allow our
roundtable participants to address the issues most
important to you.
We look forward to bringing you a comprehensive
overview of this roundtable event in a future issue of
Todays Veterinary Practice! n
READ ALL ABOUT IT

High Debt and Falling Demand Trap New
Vets, The New York Times, February
23: nytimes.com/2013/02/24/business/
high-debt-and-falling-demand-trap-newveterinarians.html?pagewanted=all&_r=0
Dr. Deborah Kochevars response to the
article: aavmc.org/events/?id=52
Survey of Recent DVM Graduates
of Schools and Colleges of
Veterinary Medicine in the United
States: aavmc.org/data/images/
research/aavmc%20data%20reports/
aavmcsurveyofrecentdvmgraduates.pdf
Corrections, The New York Times,
March 3: nytimes.com/2013/03/03/
pageoneplus/corrections-march-3-2013.
html?pagewanted=all
CHEWABLES
CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian.
INDICATIONS: For use in dogs to prevent canine heartworm disease by eliminating the tissue stage of heartworm
larvae (Dirofilaria immitis) for a month (30 days) after infection and for the treatment and control of ascarids (Toxocara
canis, Toxascaris leonina) and hookworms (Ancylostoma caninum, Uncinaria stenocephala, Ancylostoma braziliense).
DOSAGE: HEARTGARD Plus (ivermectin/pyrantel) should be administered orally at monthly intervals at the
recommended minimum dose level of 6 mcg of ivermectin per kilogram (2.72 mcg/lb) and 5 mg of pyrantel (as pamoate
salt) per kg (2.27 mg/lb) of body weight. The recommended dosing schedule for prevention of canine heartworm
disease and for the treatment and control of ascarids and hookworms is as follows:
Dog
Weight
Chewables
Per Month
Ivermectin
Content
Pyrantel
Content
Color Coding 0n
Foil Backing
and Carton
Up to 25 lb
26 to 50 lb
51 to 100 lb
1
1
1
68 mcg
136 mcg
272 mcg
57 mg
114 mg
227 mg
Blue
Green
Brown
HEARTGARD Plus is recommended for dogs 6 weeks of age and older.

For dogs over 100 lb use the appropriate combination of these chewables.
ADMINISTRATION: Remove only one chewable at a time from the foil-backed blister card. Return the card with the
remaining chewables to its box to protect the product from light. Because most dogs find HEARTGARD Plus palatable,
the product can be offered to the dog by hand. Alternatively, it may be added intact to a small amount of dog food.The
chewable should be administered in a manner that encourages the dog to chew, rather than to swallow without
chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole.
Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few
minutes after administration to ensure that part of the dose is not lost or rejected. If it is suspected that any of the
dose has been lost, redosing is recommended.
HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors),
potentially carrying infective heartworm larvae, are active. The initial dose must be given within a month (30 days)
after the dogs first exposure to mosquitoes. The final dose must be given within a month (30 days) after the dogs last
exposure to mosquitoes.
When replacing another heartworm preventive product in a heartworm disease preventive program, the first dose of
HEARTGARD Plus must be given within a month (30 days) of the last dose of the former medication.
If the interval between doses exceeds a month (30 days), the efficacy of ivermectin can be reduced. Therefore, for
optimal performance, the chewable must be given once a month on or about the same day of the month. If treatment is
delayed, whether by a few days or many, immediate treatment with HEARTGARD Plus and resumption of the
recommended dosing regimen will minimize the opportunity for the development of adult heartworms.
Monthly treatment with HEARTGARD Plus also provides effective treatment and control of ascarids (T. canis, T. leonina)
and hookworms (A. caninum, U. stenocephala, A. braziliense). Clients should be advised of measures to be taken to
prevent reinfection with intestinal parasites.
EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against
the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development of
the adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) and
hookworms (A. caninum, U. stenocephala, A. braziliense).
ACCEPTABILITY: In acceptability and field trials, HEARTGARD Plus was shown to be an acceptable oral dosage form
that was consumed at first offering by the majority of dogs.
PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with
HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult
heartworms and microfilariae before initiating a program with HEARTGARD Plus.
While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level,
HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due to
dead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials with
ivermectin alone after treatment of some dogs that have circulating microfilariae.
Keep this and all drugs out of the reach of children.
In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a
Poison Control Center for advice concerning cases of ingestion by humans.
Store between 68F - 77F (20C - 25C). Excursions between 59F - 86F (15C - 30C) are permitted. Protect
product from light.
ADVERSE REACTIONS: In clinical field trials with HEARTGARD Plus, vomiting or diarrhea within 24 hours of
dosing was rarely observed (1.1% of administered doses). The following adverse reactions have been reported
following the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering,
convulsions and hypersalivation.
SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability of
ivermectin. The dose regimens of HEARTGARD Plus and HEARTGARD are the same with regard to ivermectin (6
mcg/kg). Studies with ivermectin indicate that certain dogs of the Collie breed are more sensitive to the effects of
ivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds.
At elevated doses, sensitive dogs showed adverse reactions which included mydriasis, depression, ataxia, tremors,
drooling, paresis, recumbency, excitability, stupor, coma and death. HEARTGARD demonstrated no signs of toxicity at
10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies,
support the safety of HEARTGARD products in dogs, including Collies, when used as recommended.
HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant or
breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea collars,
dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with
HEARTGARD Plus in a heartworm disease prevention program.
In one trial, where some pups had parvovirus, there was a marginal reduction in efficacy against intestinal nematodes,
possibly due to a change in intestinal transit time.
HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (See DOSAGE section) for dogs of different
weights. Each strength comes in convenient cartons of 6 and 12 chewables.
For customer service, please contact Merial at 1-888-637-4251.
HEARTGARD and the Dog & Hand logo are registered trademarks of Merial.
2013 Merial Limited, Duluth, GA. All rights reserved. HGD13TRMARCHAD (02/13).
Clients prefer
HEARTGARD Plus
(ivermectin/pyrantel):
Dogs love to take the only preventive
that comes in a Real-Beef Chewable.2
#1 most requested heartworm
preventive owners prefer to give
their pets HEARTGARD Plus.1
Backed by the Plus Customer
Satisfaction Guarantee.3
Easy to give. Protection to live.
1 Opinion Research Corporation, Heartworm Prevention Medication Study, 2012. Data on le at Merial.
2 Of dogs showing a preference in three studies, dogs preferred HEARTGARD Chewables over
INTERCEPTOR (milbemycin oxime) Flavor Tabs by a margin of 37 to 1; data on le at Merial.
3 Ask your Merial Sales Representative for full guarantee details.
HEARTGARD and the Dog & Hand logo are registered trademarks of Merial.
INTERCEPTOR is a registered trademark of Novartis Corporation. FLAVOR TABS
is a registered trademark of Novartis AG. 2013 Merial Limited, Duluth, GA. All rights
reserved. HGD13TRMARCHAD (02/13).
IMPORTANT SAFETY INFORMATION: HEARTGARD (ivermectin) is

well tolerated. All dogs should be tested for heartworm infection before
starting a preventive program. Following the use of HEARTGARD,
digestive and neurological side effects have rarely been reported. For
more information, please visit www.HEARTGARD.com.

Today Veterinary Magazine March 2013

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Today Veterinary Magazine March 2013

Hochgeladen von

Copyright:

Verfügbare Formate

A Peer-Reviewed Journal

The Vomiting Patient

March/April 2013 Volume 3, Issue 2

Subscribe FREE at tvpjournal.com/subscribe

Get tough on Lyme disease

To see Nobivac Lyme

Reference: 1. LaFleur RL, Dant JC, Wasmoen TL, et al. Bacterin

saLes & marKetinG

eDitoriaL aDVisorY BoarD

mark Cofone, VMD,

sheila Grosdidier, RVT, PHR

rosemary Lombardi, CVT,

Garret Pachtinger, VMD,

michael schaer, DVM,

eDitoriaL Peer reVieW BoarD

March/April 2013 Todays Veterinary Practice

March/April 2013 Vol 3, No 2

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

HOW TO AVOID THE FIVE MOST COMMON MISTAKES IN VETERINARY DERMATOLOGY

Discover the five pitfalls most commonly encountered by practitioners when

THE NEUROLOGIC EXAMINATION IN COMPANION ANIMALS

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

Todays Veterinary Practice March/April 2013

THE PERFORMANCE YOU EXPECT FROM

Bayers sustained release technology combines two eective

March/April 2013 Vol 3, No 2

57 VITAL VACCINATION SERIES

Dr. Ford presents nine key questions that

61 CONSIDER THIS CASE

This table is the third in our

Erin O. Dresner, DVM, MS, and Gary D.

An aging spayed female cat is presented

65 NEW DENTAL DIAGNOSIS

Brook A. Niemiec, DVM, FAVD,

Todays Veterinary Practice interviewed

A picture is worth 1000 words, and the

Tina Wismer, DVM, Diplomate ABVT & ABT

The American Heartworm Society

In honor of Poison Prevention Week, Dr.

Wallace Graham, DVM

April is National Heartworm Awareness

Noah Jones, RVT

Postoperative patients are among those

Small Animal Spinal Radiography

Proper technique for routine lateral

80 THE BACK PAGE

A Response From Our Editorial Team

Todays Veterinary Practice March/April 2013

Dogs Can Get

Lesley G. King, MVB, Diplomate ACVECC, ACVIM (Small Animal Internal

Todays Veterinary Practice March/April 2013

Uniting Medical Professionals

Merck Animal Health, 27

Todays Veterinary Practice

LeTTers To The ediTors

Internal Medicine Pearls Rocked

When to Give Bordetella Boosters

In addition, while both parenteral and IN vaccines

Todays Veterinary Practice March/April 2013

tica) is significantly reduced (or

You make a difference for your patients every day

Enter for your chance to win:

Ask your Merial Representative or visit