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Wendy Blount, DVM

Things We Don’t Do that we Should Things We Do that we Shouldn’t. Wendy Blount, DVM. Wendy Blount, DVM. DVM TAMU 1992 Private Practice Houston 2 years Westbury Animal Hospital Small Animal Internal Medicine Residency TAMU 1994-1997 Private Practice 1997-present

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Wendy Blount, DVM

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  1. Things We Don’t Do that we Should Things We Do that we Shouldn’t Wendy Blount, DVM

  2. Wendy Blount, DVM • DVM TAMU 1992 • Private Practice Houston 2 years • Westbury Animal Hospital • Small Animal Internal Medicine Residency • TAMU 1994-1997 • Private Practice 1997-present • Nacogdoches and Lufkin, TX • See appointments at 3 practices • CE for groups and in-house

  3. Wendy Blount, DVM drblount@vonallmen.net www.wendyblount.com

  4. Upper Respiratory Infections - Cats • How do many of us treat feline URI? • Penicillins (Amoxidrops, Clavamox) • Eye ointment (triple antibiotic) • Supportive • antihistamines • Fluids if needed

  5. Upper Respiratory Infections - Cats • What causes feline URI? • Feline calicivirus • Feline herpesvirus (FHV-1) • Feline Infectious Peritonitis (FIP) coronavirus • Chlamydia psittaci var. felis • Mycoplasma spp. • (Maybe Bordetella bronchiseptica) • Other bacteria can be secondary invaders

  6. Upper Respiratory Infections - Cats • How primary organisms treated? • Feline calicivirus • supportive • Feline herpesvirus • Lysine • Vaccination if naive • Anti-herpetics (acyclovir) – don’t work well • FIP • (pentoxyphylline, prednisone) • Chlamydia psittaci, Mycoplasma spp. • Tetracyclines, quinolones

  7. Upper Respiratory Infections - Cats • So how can we tell the cause? • Conjunctivitis • NOT Mycoplasma or Bordetella • Oral ulcers • FHV-1, FCV • Keratitis • FHV-1 • Coughing • FHV-1, Mycoplasma, Bordetella • More commonly lower respiratory disease • Lameness • FCV, (Chlamydia)

  8. Upper Respiratory Infections - Cats • So how should we treat? • Supportive • Fluids, decongestants, mucolytics • Antivirals? • You can try them if FHV-1 is suspected • Recurring disease, oral ulceration, conjunctivitis, keratitis • Lysine? • If FHV-1 is suspected • Antibiotics and eye ointment? • PO - Tetracyclines or quinolones • OU – tetracyclines, chloramphenicol

  9. Identifying Skin Masses • Can we tell whether a skin mass should be removed, just by looking at it? • Sebaceous gland adenoma - 98% benign • Differential diagnoses for hairless skin masses • Histiocytoma - benign • Plasmacytoma – malignant or benign • Mast cell tumor - malignant • Melanosarcoma - malignant • Fibroma - benign • Follicular tumor - benign • SGA - benign • Perianal gland tumor – benign or malignant

  10. Identifying Skin Masses • So what should we do to decide whether a skin mass should be removed? • Cytology • Inflammatory, or non-inflammatory? • What is the cell type? • Characteristics of malignancy or not? • If malignant, is it a tumor that metastasizes? • If so, do met check prior to removing skin mass • Draining lymph nodes • Chest x-rays, abdominal US

  11. Identifying Skin Masses • Differential diagnosis for a fully haired dermal mass • Epidermal inclusion cyst - benign • Mast cell tumor – malignant (grade III metastasizes) • Fibrosarcoma – malignant (locally invasive) • Hemangiopericytoma – malignant (locally invasive) • Hemangiosarcoma – malignant (metastasizes) • Lipoma – benign • Malignant histiocytosis – malignant (metastasizes)

  12. Cytology • Inflammatory or Non-inflammatory? • Are inflammatory cells present? • Neutrophils • Macrophages • Lymphoid/plasma cells • Eosinophils

  13. Cytology • Cell Type? • Epithelial cells • Round to oval in shape • Distinct cytoplasmic borders • Lines of cell-to-cell adherance (clumps of cells) • Round cells • Round in shape • Distinct cytoplasmic borders • Cells are single • Mesenchymal cells • oval to cigar shaped nuclei • Diffuse-fading cytoplasmic borders • Cells are single

  14. Cytology • Characteristics of Malignancy? • Variation in the size and shape of nuclei • Multinucleation and indentation of nuclei as a result of abnormal mitosis (especially odd numbers) • Increase in the number and size of nucleoli • Abnormal (asymmetrical) or frequent mitosis • Increase in the nucleus-to-cytoplasm ratio (nucleus too big) • Increased basophilia of the cytoplasm (cytoplasm too purple)

  15. Cytology • Examples • Subcutaneous mass mammary area 10 yr female poodle • Moderately inflammatory, epithelial tumor with characteristics of malignancy • Suspect mammary carcinoma • Aspirate local lymph nodes, take chest x-rays • Then excise • Raised, hairless pink skin mass 1 cm diameter • Non-inflammatory epithelial tumor with no characteristics of malignancy • Suspect basal cell or other adnexal tumor

  16. Cytology • Examples • Raised, hairless pink skin mass 1 cm diameter on lip • Non-inflammatory, round cell tumor with characteristics of malignancy • Aspirate local lymph nodes • Then excise • Raised, hairless pink skin mass 1 cm diameter • Inflammatory (eosinophils) round cell tumor with no characteristics of malignancy • Suspect agranular mast cell tumor • Aspirate local lymph nodes, then excise

  17. Cytology • Examples • Raised, hairless pink skin mass 1 cm diameter • Mildly inflammatory, mesenchymal cell tumor with characteristics of malignancy • Suspect sarcoma • Aspirate local lymph nodes, do chest x-rays • Then excise • Hairless pink skin mass 1 cm diameter, 1 week after vaccination • Pyogranulomatous inflammation, with no organisms • Suspect vaccination granuloma • Observe, excise if gets bigger or not resolved in 3-4 weeks

  18. Cytology • Examples • Hairless pink skin mass 1 cm diameter, 1 week after vaccination • Non-inflammatory mesenchymal tumor with strong characteristics of malignancy • Suspect vaccine associated sarcoma • Excise immediately, with wide borders

  19. Spot Checking Diabetics Quiz – Spot glucose checks at insulin time What Would you do? • 250, 260 • 350, 335 • 245, 265 • 200,200

  20. Spot Checking Diabetics • Which values in a glucose curve are used to determine dose? • Nadir (lowest glucose values - insulin peak) • Lowest glucose value should be around 100 • Which values on a glucose curve are used to determine interval and insulin type? • Peak glucose values (insulin nadir) • If glucose nadir is ideal, and glucose peaks are too high, then you need to give insulin more often, or you need a longer acting insulin • Ideally, a majority of the time, glucose should be between 100 and 200 • Never go lower than 80-90

  21. Spot Checking Diabetics Doing glucose curves • If patient doing well, do fructosamine first. If normal, no need to do a glucose curve • Begin when insulin given and fed • Every 2 hours until 2 values in a row with a significant uptrend • Every hour when glucose <80 • If your curve is not finished at the end of the business day, it must be finished in order to know how to give insulin properly • Have owners finish at home, with their own glucometer • Transfer to emergency clinic if you have one available

  22. Spot Checking Diabetics Interpreting glucose curves • Duration of curve – • If your curve is 10 hours or less, you need to give insulin BID, not SID • Glucose range • If all values are 100-200, leave it alone • Consider the same if 100-250, if clinical signs are controlled

  23. Spot Checking Diabetics Interpreting glucose curves 3. Glucose nadir • If < 90-100, reduce the insulin dose • If >100-150 and glucose peak too high, increase insulin dose 4. Glucose peak • If nadir OK and peak too high, change to longer duration insulin • NPH – shortest • Then Vetsulin (Lente) • Then PZI • Lantus longest (not for most dogs)

  24. Spot Checking Diabetics Interpreting glucose curves 3. Glucose nadir • If < 90-100, reduce the insulin dose • If >100-150 and glucose peak too high, increase insulin dose 4. Glucose peak • If nadir OK and peak too high, change to longer duration insulin • NPH – shortest • Then Vetsulin (Lente) • Then PZI • Lantus longest (not for most dogs)

  25. Spot Checking Diabetics If you were only allowed two glucose checks in every 24 hour period, when would you want to take them? At Insulin Time? 5-7 hours after insulin? One of each?

  26. Spot Checking Diabetics Correct Your Quiz • 250, 260 • Need to decrease insulin • 350, 335 • Increasing insulin would probably make this dog or cat hypoglycemic • Need to change insulins instead • 245, 265 • Need to increase insulin • 200,200 • Insulin should not be changed

  27. Surgery Without IV Catheterization 12 of 58 (20%) of systemically healthy dogs undergoing anesthesia for orthopedic surgery experienced clinically significant hypotension (<60 mm Hg MP) during the short anesthetic period prior to surgery Use of ephedrine and dopamine in dogs for the management of hypotension in routine clinical cases under isoflurane anesthesia Vet Anaesth Analg. September 2007;34(5):301-11.Hui C Chen1, Melissa D Sinclair, Doris H Dyson

  28. Surgery Without IV Catheterization • MP < 60 mm HG compromises renal perfusion, and could result in renal failure in dogs with • subclinical upper urinary tract infection • subclinical renal disease • Rx ACE-inhibitor, diuretics, NSAIDs • Dehydration (NPO overnight??) • We get away with it on a regular basis • Would our A+ clients appreciate it, if the knew?

  29. Surgery Without IV Catheterization • The cost of an IV catheter and IV fluids is minimal • IV catheter can be put in in minutes • Doing surgery on systemically ill animals without IV fluid support is probably outside protection by standard of care

  30. Surgery Without IV Catheterization • Using pre-operative NSAIDs without IV fluid support is probably outside protection by standard of care • Owners who “shop” elective surgeries can accept lack of IV support/access at their own risk, if you wish to allow that

  31. Perioperative NSAIDs Deramaxx and Rimadyl Package Inserts: • Laboratory tests to establish …baseline data prior to, and periodically during, administration of any NSAID should be considered • Owners should be advised of the potential for adverse reactions and be informed of the clinical signs associated with drug intolerance • The use of parenteral fluids during surgery should be considered to reduce the potential risk of renal complications when using NSAIDs perioperatively

  32. Perioperative NSAIDs Rimadyl Package Insert: • Always provide Client Information Sheet with prescription • For control of postoperative pain, administer approximately 2 hours before the procedure

  33. Perioperative NSAIDs Deramaxx Package Insert: • Appropriate monitoring procedures should be employed during all surgical procedures

  34. Deworm Vomiting Dogs & Cats Why should we deworm vomiting dogs and cats? • Worms can make dogs and cats vomit • Physaloptera spp. • Obscure? • Found on endoscopy in dogs and cats referred for chronic vomiting • Easily treated with pyrental pamoate

  35. Nutrition for Diabetic Cats For many years, we fed diabetic cats high fiber, low fat diets, just like dogs & people • 2000 - Randomized, controlled crossover study • Improved glycemic control when fed 12% insoluble fiber • Both diets high in carbs (~35%) J Am Vet Med Assoc. 2000 Apr 1;216(7):1082-8. Effect of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. Nelson RW, Scott-Moncrieff JC, Feldman EC, DeVries-Concannon SE, Kass PH, Davenport DJ, Kiernan CT, Neal LA.

  36. Nutrition for Diabetic Cats 2001 – ACVIM Abstract • Low carb-low fiber diet (canned Hill’s Feline Growth) compared to high carb-high fiber diet (canned W/D) • 31% fed LC diet were able to d/c insulin, and an additional 46% decreased insulin dose • None of the HC cats were able to reduce or discontinue insulin Comparison of a low carbohydrate versus high fiber diet in cats with diabetes mellitus. Bennet N, Greco DS. ACVIM 2001. 13 cats. J Feline Med Surg. April 2006;8(2):73-84. 63 cats.

  37. Nutrition for Diabetic Cats Since 2001 • Goal of treatment is remission rather than merely good control • Achieved by using low carb-high protein diets with long acting insulin (glargine - Lantus) • 1998 ACVIM article - median survival 2 years • Some papers have reported remission rate as high as 68% • Chances of remission increases four-fold by feeding low carb-high protein diet

  38. Nutrition for Diabetic Cats Use of a High-Protein Diet in the Management of Feline Diabetes Mellitus. Vet Ther 2[3]:238-246 Summer'01 Clinical Study 14 Refs.G Frank; W Anderson; H Pazak; E Hodgkins; J Ballam; D Laflamme. The Effect Of High Protein, High Fat Or High Carbohydrate Diets On Postprandial Glucose And Insulin Concentrations In Normal Cats. ACVIM 2002. H A Farrow, J S Rand, G D Sunvold. Use of glargine and lente insulins in cats with diabetes mellitus. J Vet Intern Med. 2006 Mar-Apr;20(2):234-8. KE Weaver, EA Rozanski, OM Mahony, DL Chan, LM Freeman.

  39. Nutrition for Diabetic Cats Ideal diet for diabetic cats • >40% protein and <8% carbs, as % of calories • A little different from DM basis (fat is 2x as calorie dense as protein & carbohydrate) • Only one dry diet on the market that fits the bill • Innova EVO (California Naturals - Natura) • Purina DM and Hill’s R Diet M/D dry - 15% carbs, protein OK • Many commercial canned diets fit the bill • Handout

  40. Nutrition for Diabetic Cats Myth #1: Diabetic cats should be meal fed if they are to be well regulated • Fresh food BID – allowed to eat ad lib • Multiple small meals eaten throughout the day and night • 24 hour glucose curve done (q2h) • no correlation between blood glucose and the amount of food consumed over the previous 2-h • overnight fast did not significantly alter morning blood glucose J Feline Med Surg. 1999 Dec;1(4):241-51. Food intake and blood glucose in normal and diabetic cats fed ad libitum. Martin GJ, Rand JS.

  41. Nutrition for Diabetic Cats Myth #2: You shouldn’t give insulin to pets who aren’t eating • If glucose >300 for any period of time, insulin needs to be given to prevent diabetic ketoacidosis • Dogs and cats with DKA will remain acidotic until they get insulin • If you are chicken, give small amounts only as needed • A small amount of insulin can do a great deal of good in a DKA patient

  42. Nutrition for Diabetic Cats Flop • Day 0 • not feeling well, abscess on toe, Tx clindamycin PO BID • Day 3 • still not feeling well, not eating • UA shows ketones and glucose, blood glucose 298 • Treated with IV fluids and IV antibiotics • No insulin given because not eating • Day 6 • Very weak, vomiting blood • BUN 41, glucose 290, venous pH 7.035, K+ <2.0, Phos 1.6 • Diabetic ketoacidosis with pancreatitis

  43. Annual Vaccination Appropriate for bacterins • Leptospirosis • Bordetella • Lyme Disease (in endemic areas) Reasonable for Feline Leukemia • No published studies investigating duration of immunity beyond 1 year

  44. Annual Vaccination In 1978, University of WI-Madison recommended ideal MLV protocol • Puppy/kitten series, boost a 1 year of age • Then every 3 years No one is recommending that we don’t vaccinate • puppy/kitten vaccines, and boosters at 1 year are crucial • We shouldn’t overvaccinate adult pets

  45. Annual Vaccination Duration of Immunity (DOI) • Rabies • Vaccine manufacturers have known for decades that rabies vaccines protect very well for at least 3 years • They are under no obligation to share any data they may have that shows longer DOI • Only 5 states have ever required use of rabies vaccine more often than on the label • The rest of the world has used rabies vaccines according to the label for more than 50 years with exceedingly rare vaccine failure

  46. Annual Vaccination Duration of Immunity (DOI) • Rabies • No person has ever contracted rabies from any domestic animal that has ever received a rabies vaccine • 1-year and 3-year vaccines are in almost all cases the same vaccine • 1999 – RD Schulz DOI Study • single rabies vaccine given to puppy • no booster at 1 year of age • 95%+ protection by challenge at 3 years • 95%+ protection by titers at 7 years

  47. Annual Vaccination Duration of Immunity (DOI) • Distemper • Vaccinated or not, it is exceedingly rare for adult dogs to get this disease • Don’t confuse “old dog distemper” with active disease • 1999 – RD Schulz DOI Study • single distemper vaccine given to puppy • no boosters • 95%+ protection by challenge at 5-7 years • 95%+ protection by titers at 9-15 years

  48. Annual Vaccination Duration of Immunity (DOI) • Parvovirus • Vaccinated or not, it is exceedingly rare for adult dogs to get this disease • 1999 – RD Schulz DOI Study • single parvo vaccine given to puppy • no boosters • 95%+ protection by challenge at 7 years • Giving parvo boosters every 6 months • started in the 70’s when panleukopenia vaccines were given to dogs • Not based on any study - empirical

  49. Annual Vaccination Duration of Immunity (DOI) • Canine Infectious Hepatitis • 1999 – RD Schulz DOI Study • single CAV-1 vaccine given to puppy • no boosters • protection by challenge at 7 years • Protection by titers at 9 years

  50. Annual Vaccination Duration of Immunity (DOI) • Feline Parvovirus (panleukopenia) • Vaccinated or not, it is exceedingly rare for adult cats to get this disease • 1999 –Scott & Geissinger DOI Study • SPF cats vaccinated at 8 & 12 weeks • no boosters • 95%+ protection by challenge at 7.5 years • Protection also evaluated by titers

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