VetInfo Digest                    April 1998

This issue

Lessons Learned Online and in Veterinary Practice
New Flea Treatments
Veterinary Emergencies
Why won't your vet see you in an emergency?
Trust Your Instincts
You're Supposed to Warm the Water for a Leboyer Birth
 
 

Lessons Learned Online and in Veterinary Practice

I have been answering questions online for approximately 6 years now. The experience has been a real eye-opener for me and I would like to share some of what I have learned with you. Even though I was technically the "expert" in most of the exchanges I think that I probably have learned as much or more during this time as the people I was trying to help. Currently most of the questions I receive come by e-mail. I was the Coordinator of the Pet Care Forum on America Online for a couple of years and answered questions in the Questions for Vets section there for several years prior to that. Bulletin board messages were more common on AOL. People tended to use the bulletin boards a little more like personal soapboxes and the exchanges were often openly hostile, often due to misinterpretations of previous messages. Answering questions in that format was difficult, but it taught me a lot about communications and people.

Perhaps the most important lesson I have learned is that people do not necessarily read a message in the manner I intended when I wrote it. Sometimes this is my fault and sometimes it is the fault of the reader. Other times, I really think it just has more to do with differences in perspective and background that just aren't easy to resolve. After reading the messages about conversations with other vets, I am firmly convinced that people do not always hear messages as they were intended, either. It is a good idea to make a quick summary of what you thought you heard at the end of the office visit with your vet. If your vet agrees that your summary is an accurate representation of what he or she wanted to you to know then at least both of you were in some agreement when you left the office. Taking a minute or two to do this can save a lot of worry and a few outright mistakes. While that works for the real world it may just incite anger on a bulletin board. If you participate on e-mail lists or bulletin boards, don't reply hastily. Just because you can jot off a ten second flaming message and post it instantly doesn't mean you should. A few hours of thought or reflection may enable you to post a much more effective reply that educates instead of inflames the reader.

The second lesson I have learned by reading people's descriptions of their visits to veterinarians is that many vets shorten their explanation of illnesses by using the name of a similar and well known human disease. If your vet says your dog has diabetes this is very similar to the same disease in humans. If your vet says your dog has a cold he is being inaccurate, although often with the best intentions. Dogs do not get colds. They do not usually have heart attacks. Strokes are not a common event. Despite this I hear of these terms being used often to describe an illness in a pet fairly frequently. I think that vets sometimes just use familiar terms to make explanations easier. This can lead to confusion, though. I wish it didn't happen.

I have also come to the conclusion that most people do not have a firm grasp of scientific principles. The press has pointed out the shortcomings of the American educational system when it comes to teaching science. I see the results of this every day. One glaring example of "in your face" rejection of science is the way the new Excedrin (tm) commercials are worded. "I don't care about clinical studies....." I have a really hard time understanding why a pharmaceutical company would want to run an ad that says that. The only way to be sure that medications really work is to subject them to rigorous scientific study, preferably "double blind" studies in which neither the veterinarian nor the client is aware of whether their patient is getting the real medication or a placebo. Recently, when Rimadyl (Rx) was being tested, approximately 25 percent of the veterinarians in the study thought that their patients were improved on the placebo used in the study. Clients were fooled an even higher percentage of the time. If your vet wants to believe in the medication being used so strongly that one-fourth of the time he or she is fooled by placebos, it is easy to see why non-effective medications often get endorsements from vets, especially when they are new. Don't accept an endorsement or a testimonial as "proof" that a medication works. Look for something more substantial to base an opinion on, if possible.

Often, people are disappointed with the lack of medications for a problem. There are times when it is hard to stick to medicine that has been proven to work in good scientific studies. This is especially true for situations in which there really isn't a good medication or in circumstances that seem hopeless. Your vet will probably resist helping with alternative medications that are unproven. This may irritate you but if your vet is sticking to a strong belief in scientifically validated medicine it is not reasonable to expect her to abandon her convictions. If you feel you have to seek alternative medications or therapies you may need to find a veterinarian comfortable with this approach. I know that there is a strong interest in alternative medicine right now. I am convinced that some of these medications will help to control diseases or disorders in dogs. I have a much harder time deciding which ones are reasonable choices, though. It is very hard to tell, based on the currently available information. On the other hand, I know that many veterinarians dispense medications that have been shown to be ineffective in clinical trials, just because it says on the label they will work and there are no better alternatives. To me, this is no less scientific than using an unproven alternative therapy. It is easier to give a client a medication to use than to explain that there isn't one. People just don't accept that there isn't a medication that will cure whatever condition their pet is suffering from..

Perhaps the hardest thing to explain is the uncertainty inherent in medicine. A common estimate of the state of veterinary medicine is that at any given time twenty-five percent of the currently accepted information is incorrect. This may sound pretty outlandish since veterinary medicine has made great strides in establishing scientific testing and journals with review panels comprised of veterinary experts in various fields (called refereed journals) but it always seems to be true. Many of the papers published, some of which seem to make perfect sense, can not be verified in later testing. Several times studies have been widely reported before they were proven to be wrong. It is very hard to retract the information in these cases. After nineteen years in practice I still find myself uncovering false information I really believed to be true. I don't anticipate that will change anytime soon. It never hurts to check several sources before assuming something is true. This also means that your vet can be wrong about one thing, or even a few things, without being incompetent. During the time I have been in practice I have seen digitalis type medications go from "good for any heart condition" to "worthless" to "good for some heart conditions" to "worthless" at least two full cycles. There are many other medications, diets and therapies that fall in and out of favor over the years. I just have to admit that I have no real idea who is right in these debates. I use digoxin when I think I need to and hope I'm not hurting my patients. I base some decisions on personal experience, which can be very misleading. For now, it is the best I can do.

Lastly, don't forget that veterinarians are people, too. Mistakes are going to happen even when people are working as hard as they can to avoid them. All of us make them and it really doesn't matter how important the job is or how much we would like to believe they are avoidable. In stressful situations they are even more likely. One of my best friends is a physician. He recently had surgery that resulted in partial paralysis of one hand. It was uncertain whether this would be permanent. It was obviously a difficult time for him. I asked him how he felt about the outcome. He told me that he had no regrets. He trusted the surgeon and knew that he was the best person he could find for the job. If he had to have surgery again tomorrow he would choose the same surgeon. He knew he cared and that he would do his best to avoid complications. Overall, he was the most likely surgeon to successfully manage his case. The outcome had just been bad luck. Good doctors make mistakes, they just make fewer of them. Pick your veterinarian carefully but don't expect perfection. You're sure to be disappointed.
 

New Flea Treatments

There is a lot of confusion about when and how to use the new flea treatments that are being advertised right now. All of the companies want you to believe that their product is best. This is a quick summary of the best of the new products and their advantages and disadvantages. All three of these products are considered to be very safe at this time.

Lufenuron (Program Rx, Sentinel Rx)

    Oral dosing on a once a month basis. This is easier for some pet owners.

    Best for pets that are confined to a specific area, such as housecats or dogs with access to a fenced yard or who are leash walked. Can be used as sole product for these pets.

    Prevents growth of fleas only. This means that it takes several months to provide effective    flea control when used alone, if fleas are already present.

    Isn't washed off with bathing or exposure to water.

    Does not control ticks.

    Combined with milbemycin (Interceptor Rx) it is sold as Sentinel (Rx) and provides heartworm, whipworm, roundworm and hookworm prevention. There isn't much of a price break in giving Sentinel over combining Interceptor and Program, though.

 

Imidacloprid (Advantage Rx)

    Topical dosing formula. Applied once a month.

    Washes off easier than fipronil but should hold up to one or two baths during the month.

    Does not kill ticks.

    Causes itchiness at the site of application in a small number of cases.

    Effectively kills adult fleas, making it a better choice for flea allergic dogs than lufenuron, especially when adult fleas are already present.

 

Fipronil (Frontline Rx, Frontline Topspot Rx)

    Topical dosing formula applied once a month for cats, once a month for dogs that require tick control and every one to three months as necessary in other dogs.

    Will kill ticks but effectiveness is moderate, based on our clinical experience.

    Is not affected much by bathing as long as it isn't done within 48 hours of application. Is a better choice than imidacloprid for dogs that spend a lot of time in the water.

    Is a better choice than lufenuron for dogs and cats that have flea allergy dermatitis since it effectively kills adult fleas.
 

Veterinary Emergencies

It can be very hard to determine if a health problem is an emergency or if a definite diagnosis and treatment can be put off for a day or so. These are the conditions that I think are serious enough to warrant a trip to the emergency veterinary hospital or an after-hours visit to your regular vet, if that is an option. Of course, you should know in advance where you have to take your pet after hours. No one can work 24 hours a day, 365 days a year, for a lifetime. Knowing where to go when the day comes that your vet is not available might save your pet's life. Just call your veterinary clinic and as the receptionist what you should do in an emergency. Write down any phone numbers or addresses you will need. Put this information somewhere you can find it quickly.

Severe bleeding is an emergency. Even a small bleeder like an ear artery can lead to severe blood loss if the bleeding does not stop. Bleeding that can be controlled by direct pressure or that has already stopped but appears to have been significant is more of a judgment call. Many people panic before they need to when bleeding occurs. A dog is about 8% blood, which means that a 50 lb. dog has about 4 lbs. of blood or about 4 pints. Blood loss does not normally cause severe problems until about 25% of blood is lost, which is about 1 pint. This much blood can make a room look like a mob hit occurred in it! About 8 to 10% of a cat's weight is made up of blood but they do have less room for blood loss, since their overall blood volume is closer to one pint. Go to the emergency hospital if you think there has been major blood loss, even if the bleeding has stopped. Go to the emergency hospital if you can not stop any bleeding that appears minor within 10 minutes by using direct pressure, pressure points or bandaging.

Virtually all eye injuries should be treated as emergencies. There is only a 4 hour time period in which an eye can be repaired if leakage of ocular contents with collapse of the eye has occurred. A corneal ulcer can easily perforate an eye in 12 to 24 hours if it gets infected and is not treated. In most cases a pet will hold the eyelids partially shut if there is damage to the cornea, but not always. Don't take a chance with a suspected eye injury. This is a time to find emergency assistance.

Bloat is a term that is used to describe accumulation of gas in the stomach, which leads to abdominal distension. When bloat occurs it is not unusual for the abdomen to be noticeably larger than the circumference of the rib cage. Often, a pet is attempting to vomit unsuccessfully. There may be obvious pain. If there is an obvious accumulation of gas in the abdomen, it is a critical emergency. Severe circulatory problems, shock and death can occur in less than two hours after abdominal distension occurs. Do not try to wait for your regular vet to see your dog if you suspect bloat is possible. Be cautious and find emergency help. Bloat is very unusual in cats. Abdominal distension is usually due to fluid accumulation in cats and tends to come on a little slower, giving you time to seek assistance at your regular vet, most of the time.

Breeding dogs and cats can lead to emergency visits to the vet. Some guidelines might help in determining when these are necessary. A bitch in labor should produce a puppy within 4 hours of the onset of visible regular contractions. She should have puppies within 1 hour of each other and no longer than 2 hours in-between. Cats should produce kittens within a couple of hours of obvious labor and the interval between kittens is more variable than in dogs. Some cats have delays of several hours between kittens but any obvious distress should prompt consultation with a vet. An individual puppy or kitten should be born within a few minutes of any part being visible. If delivery does not occur you should assist or take the mother to the emergency vet. It is OK to gently assist a puppy or kitten being born but remember to be fairly gentle. Newborn pets are easily damaged. If you are queasy or just don't feel comfortable helping out with delivery, this is another time to get in the car and go to the vet.

You should always have your cat or dog checked for injuries if he or she is hit by a car or other vehicle, even if there appears to be no damage. It may be OK to wait a few hours for your regular vet if you keep a close eye on the pet for signs of breathing difficulty, pale gums and bleeding. Do not delay at all in having your pet checked if there is any visible difficulty with breathing. In many instances there are obvious broken bones. If a pet is comfortable there is usually no problem with waiting a few hours to have these examined. Many clients call us when pets appear to be severely injured because they are unwilling to move them. It is necessary to be very careful when moving a pet that is traumatized because pain makes a pet more likely to bite. Making an effort to move a pet without causing movement of broken bones or touching injured areas will reduce the likelihood of causing pain or getting bitten. Many people have enough knowledge of human first aid to be aware of the need to immobilize a trauma victim in order to reduce the risk of paralysis or aggravating internal injuries. While this is a good goal and some effort should be made to achieve it, there is a practical side to this in veterinary medicine. A person with severe spinal injuries may survive and have a good quality of life despite significant disabilities. Most people are not able to provide the level of care necessary for this to be true for a pet. In almost all instances, carefully moving a pet to the vet's is better than calling the vet and trying to arrange transportation, since ambulance services are rare in veterinary medicine. Muzzling a pet or at least ensuring that you wil not be bitten or scratched may make it safer for both of you.

If you suspect that your pet has ingested a poison it is important to do several things. First, before anything else, locate the container or package the poison came in if at all possible. Knowing what the poison is helps at every step of the treatment process. Keep syrup of ipecac or hydrogen peroxide on hand at home to induce vomiting. Hydrogen peroxide will eventually cause vomiting if you keep giving a teaspoonful at a time until vomiting occurs. Syrup of ipecac can be used according to package directions to induce vomiting. Your vet will have additional ways to induce vomiting if necessary. MAKE SURE THE PACKAGE SAYS TO INDUCE VOMITING BEFORE DOING SO. Some toxins damage the oral and esophageal tissues and will cause twice the damage if the pet is made to vomit after ingesting them. Other products are highly likely to cause aspiration pneumonia and vomiting should be avoided with them, as well. If there is any chance that your pet ingested antifreeze you should immediately proceed to your vet or to the emergency veterinary hospital. It is imperative to treat antifreeze poisoning as quickly as possible. Don't forget that acetaminophen (Tylenol (TM) and others) is toxic to cats.

A number of clients have called to report that their male cat is constipated. Fortunately, many people consider this to be very important and will call on an emergency basis. While we don't usually consider constipation an emergency this worry has saved a lot of male cats. When cats are trying to urinate they often appear to be straining to have a bowel movement. A male cat who can not urinate is in danger of dying rapidly. Other owners are able to distinguish between the attempt to urinate and the attempt to defecate but may not know it is important to treat urinary blockage immediately. If your cat is trying to urinate and can not, this is an emergency. This is true for dogs, too, but is less commonly a problem -- with the possible exception of male dalmatians.

Some breeds of dogs are prone to herniation of intervertebral discs. This can cause sudden paralysis. If you own a dachshund or a poodle it is a good idea to decide in advance if you are financially able and willing to have spinal surgery done if your dog becomes suddenly paralyzed. Surgery for pressure on the spine from a herniated disc works much better if it is done within 24 hours of the onset of paralysis. It becomes less and less likely to help with every hour that passes. Surgery may cost as much as $2000 to $3000. This is an emergency that you really do have to be prepared for. It is hard to face a decision of this magnitude without a plan.

Diarrhea and vomiting are rarely emergencies. The exception to this would be diarrhea in young puppies or kittens. It is easy for young animals to become dehydrated and these are symptoms of parvovirus in puppies, which is best treated quickly. If diarrhea and vomiting are accompanied by depression the situation may be more serious. In a dog less than 6 months of age, it is best to consider vomiting and diarrhea as emergencies. For cats the situation is less clear. You may have to make a judgment call based on your ability to tell how sick your pet is.

Respiratory difficulties in cats should be treated as an emergency. This is true for dogs, too, but cats seem to have more problems with sudden onset of breathing difficulties. A cat that is panting, breathing openmouthed or obviously working hard to inhale or exhale should be seen immediately by a veterinarian. Cats have a tendency to develop fluid accumulation in their chest due to several illnesses and will die without prompt treatment. I have had these cats arrive in my office so stressed that the most prudent thing to do seemed to be to put them somewhere quiet for a few minutes to allow them to calm down enough to work on. Sometimes a few minutes of patience, despite the severe problems, can be the difference between living through treatment and dying during attempts to relieve the fluid burden. At least treatment is available immediately if this approach doesn't result in an improvement in clinical signs.

For most veterinarians, deciding if a client's pet has a real emergency, over the phone, is very difficult. If it was possible to provide 24 hour a day emergency care and still have a life, most vets would probably do it. It is easier to let the client decide if the situation is an emergency. We usually do this by charging an emergency fee that is sufficient to be slightly discouraging and seeing a pet if it is possible and the owner is willing to pay the fee. I don't know of a better way to handle this situation. It isn't perfect, though. I remember two phone calls about ten minutes apart on a Sunday morning. The first owner was frantic and insisted that I see her pet immediately because he had a cut that was bleeding profusely. She stopped just short of threatening to sue me if I wasn't at the clinic in ten minutes. Just as I hung up, I got a second call. "My dog has a cut. It isn't bleeding. I won't pay an emergency fee but if you're going to be at the office this morning and will see her anyway, I'll bring her in," the voice on the other end said. Since I was going in anyway and didn't have time to argue, I said I'd waive the emergency fee. The first dog had a cut so small it took the owner five minutes to find it to show me. It was no longer bleeding and required no treatment other than a good cleansing. The second dog had a laceration that started between the toes of the left leg and extended straight up the leg to the shoulder blade. I could easily see the major veins, many muscles and even a little bit of bone. Surprisingly, there wasn't much bleeding. I couldn't even figure out how this injury could have occurred. I spent an hour or so repairing the leg and was glad I wasn't doing it the next day after infection or swelling made it more difficult. Why the phone calls weren't reversed still eludes me. As a veterinary friend of mine says, "If the client thinks its an emergency, it is an emergency. If not, it isn't."
 
 

Why won't your vet see you in an emergency?

We refer our patients to an emergency veterinary clinic (EVC) at night. I treated emergencies by myself at night for a number of years because the emergency clinic is about 25 miles from our clinic and I thought I could do a better job treating my patients than a stranger could. Over time, I came to realize that I was wrong. At night I have no staff support. I am often the anesthetist, surgeon, surgical assistant and receptionist. It is impossible to properly monitor the pet and do a cesarean section at the same time. It is extremely difficult to try to hold organs out of the way and repair other injured organs at the same time. I have worked all day already and am tired. I can not stay with the pet all night after surgery or to administer medications because I have to work the next day. This is a dangerous situation for the pet, for the pet owner and for myself. Despite this, many of my clients are upset when they find that we expect them to take their pet to the EVC at night or on weekends. The advantages of having a full staff, being equipped specifically for emergency treatment and availability of round-the-clock care do not seem as important as the disadvantage of dealing with a vet they do not know. In most instances there is little question that the EVC is better, at least objectively, though. If your vet does not provide 24 hour emergency services you can prepare for an emergency by driving to the emergency hospital and familiarizing yourself with it in advance. If the EVC is having a quiet night you might even be able to talk the staff into giving you a tour or introducing you to the veterinarian on duty. The EVC is there to make sure your pet has access to emergency care when it becomes necessary. They might be your pet's best friends one night.
 

Trust Your Instincts

If you believe your pet is very ill, find assistance, even if your vet encourages you to wait until tomorrow. I know I have been guilty of assuming that the symptoms reported were not severe enough to warrant coming out in the middle of the night and been wrong. Trust your instincts in these cases. Your vet may be trying to save you time or money, in good faith. But it is your time and your money and you should decide the importance of spending it. Be reasonable if your vet indicates that he or she can not see you. Ask your vet to suggest another veterinarian who can and who will do a good job.
 

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This is an area on our corporation's web site, so it does not show up in web searches conducted in the VetInfo web site. We hope to continue to develop a subscriber's area, adding additional information over time.
 
 

You're Supposed to Warm the Water for a Leboyer Birth

I hate chain saws. The sound they make sets my teeth on edge and they scare me. I wasn't thrilled to hear the unmistakable roar of a chain saw revving up behind me.
    "Doc, you think you could quit moving around so much?"
    I looked back to see Johnny Harcum standing on the creek bank with a large chain saw and an earnest expression.
    "I think I can cut that foot clear if you stay out of the way a few minutes."
    I was kneeling in the middle of a small creek in the middle of February with both arms inside an Angus heifer who had decided to meander into the creek prior to giving birth. She had slipped on the way down the bank and pushed one leg up through a hole between two large roots, from the bottom. Al Harcum, who everyone called "Cap'n" was holding her head up while I worked to deliver the calf that was trying unsuccessfully to be born in the first LaBoyer calf birthing I had ever attempted. It seemed logical to me that if humans can be delivered underwater, calves wouldn't be too much different. Of course, I would have preferred the nice body temperature water Dr. Leboyer advocated!
    I gave Johnny my best glaring look. I was using the root as a brace for one foot. The creek was part of the Dragon Run. In the Southeast, the word "run" seems to be a colonial euphemism for swamp. The bottom was mostly clay which was pretty good because I wasn't sinking too much. But it was slippery and I needed the brace.
    "You're going to have to wait to get her out. The calf has one leg back but his nose is out. If he gets his head out, he may want to breathe. Let me finish here and then you can cut her free."
    "Whatever you say, Doc."
    He looked a little hurt. His finger kept brushing the trigger, revving up the saw and sending chills down my spine. I was careful to check over my shoulder as often as I could.
    With one foot braced solidly, I could get enough leverage to push the calf back into its reluctant mother almost enough to reach in with the other hand and grab the leg that was folded back, keeping the calf from being born. Then my foot would slip and the weight of the cow's abdominal organs would push the whole calf up hard against her pelvis. I was getting tired. I looked back over my shoulder and Johnny was gone.
    "I think he went to get the big Deere, Doc."
    I looked at Captain Harcum and knew that I had better deliver this calf before a bout of All-American ingenuity ruined the situation. He was smiling. He knew exactly what I was thinking.
    Giving up all pretense of staying dry, I began a desperate attempt to deliver the calf as the slow putta putta sound of a John Deere tractor started up in the distance. I leaned way over and cold water started to rush down over the top zipper of my insulated overalls and into my underwear. With a short burst of adrenaline, I was able to get the calf far enough back to grasp the misplaced hoof. Miraculously, the loop in the calving chain slipped over the foot and I had it. A flood of relief made me forget about the cold water for a couple of minutes. I braced a foot against her prominent pelvic bones and began to pull the calf out . I got the head and chest without too much trouble. Suddenly, the heifer regained her interest in escape and made a desperate lunge to free her foot. It didn't work, but it did cause the calf to become locked into its mother again as her pelvis and his hips met.
    I must have looked pretty miserable at that point because I heard Captain Harcum say "Its OK, Doc, Johnny 's back with the tractor". I hadn't even heard it get up close.
    "Johnny, go ahead and cut her foot free, I can keep the calf's head out of the water." I figured that letting him use the chain saw might prevent an argument over using the tractor to pull the calf. Besides, I really wanted to get out of that creek. I had enough of the calf to keep its head out of the water. I was finally desperate enough to let him saw away right behind me.
    "WAIT!" In a sudden inspiration, it had occurred to me that we didn't have a halter on the heifer. We fashioned one out of a throwing rope and Cap'n Harcum tied one end to the tractor. We were ready.
    Johnny carefully cut through the root in two places. It only took the heifer a few seconds to realize she was free. Her foot moved slightly and then there was an explosion of activity. She took off up the riverbank, slipping and sliding while I tried to keep up with her and hold the calf up at the same time. Cap'n Harcum and been knocked over in the stream as the suddenly taut lead rope hit him mid-chest. Johnny had dropped the chain saw in the water where it was still sputtering. It was one of those slow motion moments when life is unfolding with incredible speed but your mind just takes in the details and all the movement seems so slow. I remember the look on Cap'n Harcums's face as the rope slackened up again when the knot he tied unraveled . That was going to be hard to live down, if anyone remembered it later.
    I was still keeping up with the heifer when she seemed to hit the end of the rope. Confused, I looked back to see that Johnny had abandoned the chain saw and actually had the end of the rope wrapped around a small tree and was holding fast. I grabbed her tail as she spun around to face him and she stopped, feeling trapped between me and the rope.
    It only took a moment to deliver the calf at this point. Johnny released the rope and mom and baby collapsed together in the grass. Despite all the excitement, she immediately began licking her newborn calf. For a moment, it was a warm enough sight that I forgot I was really cold. It didn't take too long for the pins and needles feelings in my feet to make me head for the farmhouse and the dry clothes in my truck.
    Mrs. Harcum had hot chocolate going in the kitchen and I changed into a dry set of coveralls for the ride home. I sat at the table just long enough to warm up a little and finish a cup of the hot chocolate. As I was leaving, I could hear Johnny say to his father, "Was that a bowline or a clove-hitch you had that heifer tied to the tractor with?"
    It was nice that the mistake wasn't mine. Those kind tend to stick around for every return farm call or office visit. This time I'd have a story to tell on someone else!

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The opinions expressed in this newsletter are solely those of the author, Michael Richards, DVM, unless otherwise noted in the text. Michal Justis is our web designer and graphic artist.