VetInfo Digest   February 2001

This Month:

Who Are We and Why Do We Do This?

What Would You Do, Doc?

New Medications:

Baytril OticÒ

AcarexxÒ

Monthly Note:

I am hoping that our subscribers who like to read in-depth reviews of a particular disease or disorder will forgive me for being self-indulgent this month.

What Would YOU Do, Doc?

Several subscribers have asked me questions in the last two months prefaced with "I would like to know what you would do in this circumstance.."

I think that is a legitimate question and that it deserves some attention in the VetInfo Digest. To know the answer, it helps a little to know why I write this newsletter and why Michal and I put together the information on the web site.

This also ties in with Michal's request that I provide some biographical information and an explanation of why we provide the vetinfo.com web site and what we hoped to accomplish with the subscriber area and the VetInfo Digest as time goes on.

We haven't really stuck to a writing trend long term yet, and this won't be any exception. Next month we'll do something different!

Who Are We and Why Do We Do This

I grew up in Bel Air, Maryland and Sparta, New Jersey, living near Army bases where my father worked. Fortunately, he was transferred to Rock Island Arsenal during my senior year in high school, making me an Iowa resident and allowing me the opportunity to be an "in-state" student at Iowa State University. I got into veterinary school after two years of pre-veterinary studies. I graduated from veterinary school in 1979 when I was 24 years old. I wanted to work on the East Coast so I took the first job opening that I could find, which was in Virginia. I worked for my new employers for about 10 months prior to being fired from the job for insubordination. Since I told one of the two partners I worked for that I thought he was incompetent, it was hard to argue the charge. Being young and pretty rash and recognizing that I had no talent for subordinating myself, I took my entire $600 life savings and moved to Mathews County with my pregnant wife and went into business working on farm animals from my pickup truck. I supplemented this income with a contract to spay and neuter dogs and cats for a local humane organization. It took five years for me to decide that this was not in the best interests of the pets, their owners, or veterinarians, because it encouraged people who could not care for pets to adopt them and because I was often operating on pets whose medical histories were largely a mystery to me. By then, though, I owned a small animal clinic and was running a "mixed" practice, seeing large animals in the mornings and pets in the evenings. In 1988, a cow ran over me and produced enough spinal damage to make it impossible for me to work on large animals for about eighteen months. I decided that anyone who hadn't found a large animal vet in that length of time probably wasn't a good client, anyway, and so the timing seemed good for becoming a small animal only veterinarian. From 1989 until the present, I have spent my time working almost exclusively on dogs and cats. I own and operate Mathews Veterinary Services, Inc., in partnership with my wife, who is a 1989 graduate of the Virginia-Maryland Regional College of Veterinary Medicine. We practice in a small rural county in Virginia and the rural location allows us to run the practice with just one part-time employee at the present time.

What are the highlights of my life? I was New Jersey Group II State Champion in Cross Country and second in the mile run in 1971 (cross country) and 1973 (mile). I worked at the Henry Doorley Zoo in Omaha for ten weeks doing an externship in veterinary school and got to experience something special there. I have a pilot's license and I can still run faster than all but one of my daughters' present and past boyfriends and row faster than most of them, too! I was lucky enough to marry a special person and together we have fought for new schools for our county and a great youth center. I served for five years as chairman of the board of that center, until it was completely paid for and well established. I resigned as chairman this month, hoping to have a little more time to devote to the web site. My wife is chairman of the School Board and has helped oversee the construction or renovation of three schools. Our daughters are both in college and so far, they still talk to me. I'll be president of my Rotary Club for another six months. I am not the best qualified veterinarian online but I was among the first and I am proud to have helped establish the Internet as a source of information for the general public on at least one topic. I'd add that I was humble, but I think I have blown my chance.

Michal Justis, who designs our web site, organizes all the information and addresses the mail sent to vetinfo@vetinfo.com, is an accomplished artist, was once our receptionist, worked for a large accounting firm and held several other jobs over the years. At present she is retired and living in Fredricksburg, Virginia. She has worked on an entirely volunteer basis on our site since its inception. I'm pretty sure she's one of the elite few Metallica fans of her generation who the band can recognize on sight. Michal is a huge movie buff, especially movies featuring Toshiro Mifune. In case all this has made you wonder, Michal is a native of Virginia and not some more progressive Northern state.

Rural veterinary practitioners were at a huge disadvantage in obtaining information until the early 1990s. It was hard to close up the practice and attend continuing education seminars, where the current information was traded. I subscribe to eleven professional journals, but the information in them is often as much as two years old at the time of publication. Obtaining current information on treatment techniques, surgical procedures, new medications and similar practice necessities was difficult, prior to 1992.

I hired new graduates several times when my wife was in veterinary school and then got a lot of updates from her education, but it was never really possible to feel fully "up to date". This all changed in 1992 when I discovered the Veterinary Information NetworkÔ (VIN), which was on America OnlineÔ at the time. I spent hundreds of dollars on long distance telephone charges over the course of a year or so connecting to AOL back then. For the first time, I could find information that was current at the time I was reading it, directly from many of the veterinarians who were producing the research.

As the availability of information on the Internet expanded, I learned to find it, gradually becoming very good at it. In turn, I was answering questions for members in the "Veterinary Hospital" section of the PetCare Forum and was asked to be the director of the PetCare Forum in 1994 and kept this position until 1996. At that time, I realized that I was spending more time settling conflicts between members than providing useful information and so I left that position to found the vetinfo.com web site. I was happy doing that and didn't mind doing it at my cost for a year or so, but then the costs started to mount and we established the VetInfo Digest and the vetinfo.com subscriber area as a method of providing some income for the site. Michal and I were determined not to go the typical "dot.com" route and borrow more money than it was conceivable for us to generate. We pledged to buy equipment, work with virtual server space, all on a "pay as you go" philosophy.

So far, we have not managed to make enough money to actually pay salaries for either Michal or myself, but we do own good computing equipment and the expenses of hosting a web site and publishing a newsletter have been covered by the subscription fees. Since we were paying for all that stuff ourselves for several years, we are pretty happy with this much success and look forward to the time when the newsletter and web site actually make money. In the meantime, I will continue to practice veterinary medicine full time and provide this service in the time available outside of practice. I still have to pay attention to both the practice and the business of veterinary medicine, and for now, my "real life" practice must come first in my priorities. This does give me a little better insight into client needs and the difficulties facing general practice veterinarians than many people writing on the subject of veterinary medicine, though.

I cannot say with certainty why Michal puts the time she does into the web site. She calls it her "Mother Teresa" project. I write the web site because I think it is important that veterinary clients who really want to know all that can be done for a pet have access to that information and because I think that pet owners should be able to find current diagnostic and treatment information for disorders their pets have. I feel that distribution of this sort of information helps to fulfill the potential of the Internet and I am truly hoping that it turns out to be one of the most enlightening tools that mankind will ever have.

I know that in my own practice, I do not always remember to tell clients all the possibilities, or just run out of time to do so. I also know that sometimes I am judgmental and decide that a certain client won't pay for advanced procedures, which is not really good medical practice. It is sometimes a practical way to get through a difficult day with a minimum of angry remarks by clients who think that a cat's health care should never cost more than $25, though. In a few instances, I make the mistake of thinking a procedure is just generally too costly and that no pet owner would be interested. My two biggest mistakes in this regard were the cat patient who had a $10,000 kidney transplant and the dog patient who was flown to the Netherlands for a second opinion on pituitary gland surgery because I couldn't find a specialist doing the surgery in the United States. I began to realize that some clients really do mean it when they say they will spend what it takes to make their pet well. These clients deserve to know all the options that are available. All pet owners deserve to be able to double check dosages for medications their pets are receiving, to understand the meaning of lab tests and the limitations of lab tests and to have information on the differential diagnoses for conditions that have been diagnosed in their pets. Our site is just one of many resources for finding this information but we hope to make it a good one.

We were disappointed to see pets.com go under last year, because we were proud of pointing out that our profit was 18 million dollars higher than theirs in 1999 and we had hoped to do even better in 2000.

(note: pets.com lost 18.2 million dollars in 1999, in case you missed that one!)

What Would YOU do, Doc?

I have been providing information online to pet owners for a long time now. I think I can say with certainty that the practice of "theoretical" medicine online is easier than the practice of "real" medicine in my clinic. The differences are sometimes illuminating.

With that in mind, I think it is fair to address the questions about what I would do, or what I actually do, in various practice situations.

Vaccinations

We vaccinate kittens in individual homes starting at about eight weeks of age. We vaccinate routinely for panleukopenia (feline distemper), rhinotracheitis, calicivirus at eight weeks of age and repeat vaccination with these viruses, plus rabies, at twelve weeks of age. We vaccinate kittens for feline leukemia virus if there is risk of exposure to other cats and we do this at the same time as their other vaccinations, when we feel it is necessary. We follow the kitten vaccinations with booster vaccinations at one year of age. After that time, we vaccinate every three years.

At the present time, we do not use the PureVaxÔ rabies vaccination. This vaccine does not contain adjuvents, the irritating substances that seem to be the cause of cancer at some vaccination sites in cats. If this theory is correct, there should not be vaccine related sarcomas in cats vaccinated with this product. Unfortunately, it is only approved for one year duration of action and it is significantly more expensive for veterinarians to purchase than the standard rabies vaccine. We feel that it is more acceptable to the majority of our clients to use a three year duration vaccine, especially those that are cost sensitive. However, if Merial does get three year approval for this vaccine line and if the theory that it will cause less vaccine related sarcoma formation appears to be true in practice after it has been used a while, we will probably switch to this vaccine at some time in the future.

For puppies, we recommend vaccination for distemper, parvovirus, Adenovirus TypeII (protects against hepatitis and upper respiratory infection from adenovirus), parinfluenza (DA2PP combination) and rabies on a routine basis. We do not use leptospirosis or coronavirus vaccines in our practice because leptospirosis is rare in our practice area and because I am still not completely convinced that coronavirus is a clinically significant infection. We start vaccinations in puppies at six weeks of age and we vaccinate every three to four weeks until a DA2PP vaccine is given at twelve weeks of age or older. We use MerialÔ vaccines (currently these have been voluntarily recalled by the manufacturer) and ScheringÔ vaccines. If we were using the Fort DodgeÔ vaccine line, or one of the other older vaccine lines, we would vaccinate until puppies reached sixteen weeks of age, as these vaccines are not quite as good at breaking through the maternal antibody protection from parvovirus, making the extra vaccination necessary. We booster these vaccinations at one year of age and have just switched to an every three year vaccination schedule for dogs in our practice for dogs over one year of age.

Other routine procedures

We think that kittens and puppies should be dewormed, starting at two weeks of age for puppies and six weeks of age for kittens. Deworming should be continued every two weeks for at least three dewormings and then on a monthly basis until puppies and kittens are four to six months old.

In our area, it is necessary for all dogs to be on heartworm prevention medications. We strongly favor the once a month preventatives because their track record in our practice is better than the daily medications. To give you some idea of how much more effective, we used to find between five and twenty dogs each year who had positive heartworm tests despite their owner's belief that they had given the pills each day. We have found less than ten dogs, total, who have heartworms who have been on the monthly pills when owners felt they had given the medication properly, in the entire time these pills have been available.

For cats, the heartworm situation is a little more complex. Cats get heartworms much less frequently than dogs, even in areas in which heartworms are very common. However, heartworm infection is a more difficult problem in a cat because there is not an good way to treat cats. It is estimated that approximately 50% of cats will die from the infection if heartworms manage to reach adult size. Many more cats are exposed but the worms die, or are killed by the cat's immune system prior to the time they become adults. This is an important point, because the common heartworm tests for cats test for antibodies and these are produced by exposure to heartworms, which may not indicate a current infection with adult heartworms. Many of our cat owning clients have cats because they are less expensive to care for than dogs and many are very cost sensitive. If we advocate heartworm prevention, the money spent on this is often subtracted from the money available for other care, not looked at as an "add on". In this situation, I view flea control, teeth cleaning and other procedures as more beneficial for more cats, than heartworm prevention. For the cat owner who really wants to take advantage of all the reasonable health prevention measures, heartworm prevention makes good sense, though. We try to educate clients about the availability of this medication and let them make the decision about whether to use it or not.

Hospitalization vs. Home Care for Patients

In general, we try very hard not to hospitalize patients. I used to live on the same property as my clinic and when we were right there, even though we went to the neighboring house to sleep, I felt more comfortable with hospitalization. At this time, if we hospitalize a patient, the cat or dog is generally alone most of the night, since I live several miles from the clinic. With this in mind, the only real justification for hospitalization that I can see is convenience for the pet owner. Pet owners often prefer hospitalization for pets who need care for several days in a row or who have diarrhea, vomiting, bleeding or other "messy" illnesses. Veterinarians may keep such patients in order to prevent late night and early morning phone calls to their home from concerned owners who may think that a small amount of bleeding is a crisis or who become resistant to caring for pets with diarrhea or vomiting. These are not really medically justifiable reasons for hospitalization, though. When we have a patient who really needs monitoring, who needs continuous fluid therapy, oxygen therapy or other continuous care or patients who need medications on a very frequent basis, we refer patients to the local emergency clinic for overnight observation or we teach the clients to administer the medications themselves. In most cases, our clients have proven to be quite adept at administering fluid therapy and at monitoring patients who need to be watched carefully, such as diabetics being introduced to insulin or pets with seizures. We have always sent our surgery patients home on the day of surgery, except in rare instances when we felt that the car trip would be too much for a patient. I think that we would have a very different attitude about hospitalization if we had twenty-four hour a day staffing. This is a rarity in veterinary medicine, though. If it has never occurred to you to ask if someone stays with your pets all night when they are the veterinarian's this might be something to think about in the future. If not, it makes sense to me that they are better off at home, where someone is watching out for them and can communicate with the veterinarian on their behalf or take them to the emergency clinic, if that is required. This is sometimes a little tough on my clients, but most of them seem happy to have their pets at home and are able to provide the care that is necessary.

Declawing Cats

I get a lot of questions from non-subscribers about declawing cats. Most of these come from people who are against declawing cats under any circumstances and who feel that my stated positions on the web site are immoral, or even criminal.

I don't like to declaw cats. After just about every declaw procedure, my wife and I look at each other and say "we should just quit doing this procedure." Our motives are only partly ethical. The declaw procedure itself is relatively easy, once learned, and does not take a lot of surgery time. The aftercare for the patients involves bandaging the front paws, which presents the possibility of injury from the bandaging and does not always prevent postoperative bleeding, since cats are pretty good at removing the bandages.

This is a surgery that does produce pain and the pain can last as long as two to three weeks in some cats, although most are comfortable within five to seven days. We use pain relievers and we hospitalize these patients overnight in order to prevent problems with bleeding at home, although we will let them go home with owners who are willing to deal with any bleeding that occurs.

We do have some ethical concerns about declawing, as well. It is a procedure that changes the natural state of a patient and there are some risks associated with it due to anesthesia, bandaging and postoperative infections. It is painful and most veterinarians would like to avoid inflicting pain. So why do we do it? The primary reason is that we have seen many cats lose their homes and end up in animal shelters or suffer simple abandonment, over their furniture or carpet scratching habits. In some situations, the anger generated by damaged household items leads to near abuse or to real abuse of the pet. It is easy to say these people shouldn't own cats but they already do --- and the cat has very little chance of finding a new home, at least in a rural area like ours. So we declaw cats when it seems necessary. It can make the cat's life much more pleasant by reducing the anger and stress in the household, as well as saving its life. Hopefully, someday we will find a better alternative than surgery.

I would like very much to purchase a laser for declawing procedures, as long as we are going to continue to do them. The reports on declawing procedures done by laser really seem impressive. Right now, the lasers are around $20,000 and we do about twenty declaw procedures a year, so I am not seeing the economics of this as promising. I would recommend this surgical technique if it is available, though.

Seizure therapy
 

I do not like anti-seizure medications for the most part. So I try not to use them until it seems really necessary to do so. I am not sure that this is the best approach, because there does seem to be some evidence that early use of seizure medications may suppress seizures to the point that they stop occurring in patients who might have had them lifelong, otherwise. However, the side effects of phenobarbital can be pretty severe and we are not yet convinced that potassium bromide works as well for most patients, as a sole therapeutic agent. So our policy is to use seizure control medications when patients seem debilitated by the seizures, when they occur with such frequency they interfere significantly with the quality of a pet's life, when they occur in clusters or last for more than five minutes and when clients feel strongly that the seizures must be controlled, even if we don't always agree.

When we do treat for seizures we usually start with phenobarbital. We measure the levels of the phenobarbital in the serum after one month (earlier if we suspect an overdosage) and then on a regular basis, to determine if we are using appropriate dosages. I really believe that this is the only way to really be sure that the medication is justified and that the dosage achieves therapeutic levels. We use potassium bromide in combination with phenobarbital in most patients with difficult to control seizures. So far, this combination has been effective enough that we haven't had to look for alternatives. In patients with cluster seizures, we dispense diazepam (Valium Rx) to be mixed with a water-based lubricant (K-Y JellyÔ) and administered rectally at home by the owner, to try to prevent the clusters of seizures after the first one occurs. Diazepam is not stable in plastic syringes, so we do dispense it in the bottles it comes in, which some veterinarians are reluctant to do, fearing that the drug may be diverted to human use. We feel that the patient's needs outweigh this concern and so far have no reason to be suspicious that any of the diazepam we have dispensed has been misused. The diazepam appears to sting or burn when it is administered in this manner, so use lots of lubricant to mix the diazepam with. This method of seizure control seems to work really well to stop the clusters of seizures based on our experiences so far (three patients). I feel very strongly that primidone (Neurosyn Rx) use should be avoided in veterinary medicine -- or at least used a a last resort only. It works primarily by being transformed into phenobarbital by the liver and it damages the liver more often than phenobarbital does, so there is not any significant advantage and more risk associated with it. The sole reason that it continues to be used, in my opinion, is that it does not require as much controlled substance paperwork as phenobarbital.

Lab testing

When to run lab tests, which lab tests to run and how to interpret the results of the tests are all important considerations in veterinary medicine. I think that there is more room for legitimate disagreement over these issues than just about anything else in veterinary medicine.

The most common routine lab tests in dogs are heartworm examinations and fecal examinations. In cats, feline leukemia and feline immunodeficiency virus testing are probably the most commonly run "routine" lab tests, although fecal examinations are also frequently performed in cats.

We heartworm check dogs at the time of their first year booster vaccinations and then every two years. From the standpoint of an individual patient, it would be easy to justify a longer interval but from the standpoint of dog health in general, it is pretty important to recognize resistance problems to heartworm medications early, if they ever occur, so routine testing of large portions of the population is justified. Think of it as pitching in and doing your part to keep all dogs healthy.

We usually only check fecal samples in puppies and dogs with diarrhea, other digestive tract disease, unexplained weight loss and coughing (there are lungworms whose eggs show up in the stool), if heartworm preventative containing an intestinal deworming medication is being used. Since this is almost all of our canine patients, we don't do very many "routine" fecal samples. In cats, only roundworm and hookworms can usually be identified by fecal sample and these are easy to kill. So we usually do routine deworming on examinations for outside cats and check fecal samples for the same reasons we check them in dogs. Tapeworms do not show up very often in fecal samples, so we deworm for these when clients see the telltale egg sacs (small flat "worms" around the rectum or in the stool). We do not test all cats routinely for feline leukemia and feline immunodeficiency virus but we are very quick to test for these diseases when cats are ill.

One of the biggest problems in veterinary medicine is the reluctance to run laboratory tests more than one time. It is frightening to me how often major treatment decisions, often with lifelong consequences, are made based on one lab sample or on test procedures that are less accurate but also less expensive. This is especially true when the particular lab test is frequently faulty or based on the lab technician's interpretation. We try to do the most accurate testing, or not to test at all. It is much better to base the decision to use thyroid medication on a free T4 test run by equilibrium dialysis than a total T4 test done in on an "in-house" lab analyzer, for instance. Calcium tests are often inaccurate and are influenced a great deal by the albumin levels in the serum. Platelet numbers vary widely over the course of a day or so and platelets are prone to clumping together and seeming to be low when they are not. Single urine specific gravity tests are almost completely without value in judging kidney function but multiple tests for urine specific gravity done over the course of a day or so can be very valuable. It may be hard to charge clients for the same lab test several days in a row, but it is money well spent.

We try very hard to convince our clients to pay for repeat lab testing when a value doesn't fit the rest of the clinical picture, when we are making life and death decisions and when we are considering a lifelong course of treatment. There are times when waiting for a second lab sample is not possible, such as a patient suspected of having acute renal failure, severe Addison's disease (hypoadrenocorticism) or immune mediated hemolytic anemia. At these times, treatment can be initiated and the crisis dealt with prior to trying to do follow-up lab work to see if the situation really requires life long therapy.

Biopsy samples are the other lab procedure that frequently must be repeated to find the proper diagnosis. There are lots of times when the pathologist is certain of a diagnosis or when the diagnosis fits the clinical signs so well that repeating biopsies is really unnecessary. However, due to the need to sample an area of tissue that contains enough information for the pathologist to make a diagnosis and difficulty doing this in inflamed skin or digestive mucosa, there is often a need for second, or even third, biopsy attempts prior to getting a diagnosis for many skin and digestive tract disorders.

Organ biopsies also have these problems and repeat biopsies are especially likely to be necessary for needle biopsies, even when imaging techniques such as ultrasound guided biopsy are used to try to obtain good samples. It is really frustrating to put a pet through two or three anesthetic procedures and surgical procedures to try to obtain diagnostic information but in chronic illnesses getting a good diagnosis can be the difference between a lifetime of comfort or discomfort and sometimes even between life and death.

Do not hesitate to offer to pay for repeat lab testing or additional lab testing, if your vet seems to be confused by lab results, if no diagnosis is possible from lab results or when the results seem to conflict with the clinical signs or when therapy for the diagnosed condition is not working. I try to be honest with my clients about what lab work can and cannot help with and to encourage clients to redo lab work when it is really necessary.

I Think I Lied.... (there is more to cover than I can in one month)

I do want to cover a few more topics before giving up this theme. Next month, I'll try to cover what we do in cases of trauma, diabetes, inflammatory bowel disease, chronic bronchitis/asthma, anesthetic monitoring, antibiotic use and dental care.

New Medications

There are two new medications that I think will be helpful to some of our clients and subscribers.

Baytril OticÒ, is new ear medication that has just started being advertised, so it should be available soon. It is a combination of enrofloxacin and silver sulfadiazine, both of which have been advocated for use against Pseudomonas infection, which is a very common cause of bacterial infections of the ears in dogs. While I have not seen any information on the efficacy of this particular combination, yet, I suspect that it will be helpful for many dogs who have chronic Pseudomonas infections that are not responding to the currently available topical ear medications.

AcarexxÔ is a new medication for ear mites. It is a 0.01% ivermectin formulation that is supposed to have a base that protects the active ingredient, allowing it to work for longer periods of time. Using ivermectin for ear mites is not a new approach but there have been problems with using the injectable forms of the medications topically in some cat's ears. This formulation is reported to have a low incidence of side effects. It is a one-time application to kill ear mites, which would be really great for multiple cat households with problems getting rid of ear mite infections except that Acarexx is fairly expensive and will probably be sold for about $15 per treatment at most veterinary hospitals.

Denosyl SD4ä ( S-adenosylmethionine), which is not a new medication but which many of our subscriber's veterinarians have had a hard time finding, has just launched a national ad campaign and produced new, more convenient packaging for patients with liver disease. If your pet has chronic liver disease this is a medication that may be helpful.

Thanks for Your Support!

If you send us e-mail, remember that Michal Justis answers the e-mail at vetinfo@vetinfo.com. E-mail sent to mervet@inna.net is answered by Dr. Michael Richards.

The VetInfo Digest is published by TierCom, Inc., P.O. Box 476, Cobbs Creek, VA 23035. The opinions expressed in this newsletter are those of Michael Richards, DVM., author.

Copyright 2001, TierCom, Inc.

This page was last edited  06/15/04

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