Body

VetInfo Digest June 2004

Learning to think like your vet.
Help your vet by supplying the information you know that he or she might not
New products and information

This Month's Note:
Veterinary practice necessarily involves taking risks with another being's health on a daily basis. I prescribe medications that might have unexpected side effects every day. I do surgery that can have a bad outcome with a minor slip of the hand. I use anesthetic agents with the express purpose of bringing a patient very close to death so that I can perform procedures that conscious patients simply couldn't tolerate.
It is easy to get used to the risk and to learn to live with them, much like everyone does when they decide to get in the car and drive to work each day -- there are risks that are simply necessary. We learn to think that we can control them if we are just careful, even though we are really aware of the fact that we really aren't in total control. It just feels better to think that we are.
Veterinarians sometimes forget that veterinary clients don't see the risks the same way they do. Clients are more like the passenger in our car that is heading off to work -- they might know that the driver has to take some risks but they sure look scarier from the passenger seat where there is so much less control of the situation. Everyone is familiar with the increase in difficulty in driving when someone in the passenger seat is trying too hard to help. On the other hand, we all know that there are situations when calmly pointing out that an accident is about to occur can also be very helpful. Being a veterinary client is a lot like being a passenger in a car -- you want to pick a good driver and give the driver leeway to get to your destination safely. However, there are times when you have to help the driver out. If you pick those times carefully everyone will be safer. I hope that this month's article will help you choose the times to help your veterinarian for the best effect.

Learning to Think Like Your Vet
Last month I tried to cover the very basics of thinking like a veterinarian, covering a little bit about evaluating scientific journals and general philosophies of practice. This issue I would like to cover some of the process of decision making in veterinary medicine and to how this decision making is influenced by the veterinarian's practice philosophy.
I didn't cover one aspect of veterinary medicine that definitely plays a role in decision making, which is that veterinary medicine is a business. In order to keep providing care for pets, a veterinarian has to generate enough money to pay for the medications, the necessary equipment, the building and the staff help necessary to keep the practice running. The need to make a profit does impact on decision making in veterinary medicine and as we go along evaluating some of the examples of practice decision making in this issue I will try to show where and how business decisions can play a role in the medical decision making process.
As noted previously, it is entirely possible for a veterinary client to learn a great deal about a particular disease or disorder in a relatively short period of time, often even more than the veterinarian can recall about that disorder without referring to reference materials. If clients can do this, why shouldn't they just take care of their own pets and not worry about using veterinarians?
Veterinarians have certain advantages over veterinary clients when it comes to the diagnostic process, the most important of these being:
1) Veterinarians see about 15 to 20 pets a day so they have a really good idea of what is normal for pets and also for a normal progression of most illnesses. This also gives a veterinarian a perspective that helps in sorting out spurious claims of treatment successes. I once had someone write and tell me they had found a cure for parvovirus and it had worked in over 500 dogs. Since I'm not sure that I've seen 500 dogs with parvovirus in my entire career and I was around when the first major parvovirus outbreak occurred, this information was immediately suspect in my mind. When you talk to a dog breeder or a groomer and get medical information try to keep in mind a rough comparison between the breeder's potential medical experience with a particular problem and the veterinarian's likely experience.
2) Veterinarians have a broader background in medicine in general, making it easier for them to interpret lab test results and to evaluate the meaning of clinical symptoms that appear. The strongest portion of this background relates to determining the variations of "normal" that occur. Vets worry less about some symptoms than others because they have experience sorting out which ones really matter.
3) Veterinarians have experience with the diagnosis and treatment of various illnesses so they have a better idea of how pets should respond to therapy. In addition, veterinarians usually have a fairly organized approach to diagnosis.
4) Everyone wants there to be a single cause for all the symptoms present. Veterinarians are just like clients in this regard. However, it is possible to document concurrent illnesses in many patients and having two illnesses at the same time can really alter the appearance of either illness. Veterinarians are a little more used to considering the possibility of multiple illnesses and at dealing with the interactions of these illnesses and the interactions of medications used to treat these illnesses than clients are. It can be so confusing when multiple illnesses are present that it really does take a medical professional with some experience to have a reasonable chance of making the compromises necessary to deal with all illnesses present successfully.
5) Like many professions, veterinarians have developed a language that inhibits outsiders from fully understanding the profession's writings and even its spoken word. This code is breakable but it is best to purchase a medical dictionary if you really want to understand articles written by veterinarians for veterinarians.
These factors are very important but they are balanced by advantages that the client has over the veterinarian, which are also very important:
1) The client knows the individual pet's normal behavior and lifestyle better than the veterinarian does.
2) The client has more time to devote to research about an individual pet's problems than the veterinarian does. This might sound strange at first, but veterinarians see many pets during the course of a day and often the day is fully scheduled, leaving very little time for research into unusual problems. Many vets do take their texts home, use online services, or stay after work to try to figure out the most difficult cases but there are many times when other concerns outside of work simply make research time hard to find. The client, on the other hand, is highly motivated to find information relating to their pet's specific problem and information is widely available on many diseases and disorders that affect pets.
3) The client has a much better idea of how far they wish to go in making a diagnostic effort, how cautious they wish to be about medications and how aggressively they wish to pursue therapy than the vet does. Most vets practice within their own comfort zone instead of the client's comfort zone -- if you don't mind paying for specialized testing or pursuing expensive treatment options you may have to actually convince your vet that it is really what you want to do. Most vets will believe you readily if you indicate that you don't want to pay for diagnostic procedures or consider expensive therapies because that is the more common mindset in veterinary clients.

So how do you learn to think about a medical case like your veterinarian thinks about it?
The first step is understand the concept of a differential diagnosis. It is extremely unusual for a symptom, or even a combination of symptoms, to point to a single disease with no chance that another disease is present. When a symptom does exist that only occurs when a particular disease or disorder is present it is referred to as a pathognomonic symptom -- it's presence tells you what disease is present. One example of this is chorea, the "chewing gum" motion that dogs who have survived distemper virus sometimes develop. Distemper is the only known cause of chorea, so this symptom is "pathognomonic". Except for a few rare situations, there isn't a single symptom that gives a disease away. So veterinarians develop lists of possible diseases based on the clinical symptoms present. This list is referred to as the "differential list".
It is truly critical that you understand that all clinicians, both human and veterinary, are wrong at least a third of the time and closer to half the time on their number one guess about what is causing a particular pet's illness. If you can accept this concept then you can see just how important it really is that your veterinarian have a list that includes as many of the other possible illnesses that could cause the symptoms present as exist -- or as close to a complete list as it is possible to compile.
The best way to build a differential list when first starting out is to write down all the symptoms that are present in a patient and then make a list of all the illnesses than can cause those symptoms. Then compare the lists and see which diseases or disorders show up on multiple lists -- these are the ones that are most likely to be present. In many instances it is also necessary to consider the possibility of multiple illnesses which can result in a differential list that includes most of the diseases that occur on any of the symptom lists.
Having the list is not enough. Once you have a list of the possible differential diagnoses, it is necessary to decide which one is the most likely problem. The usual way to do this is to pick the one that matches most closely with the whole list of symptoms. Sometimes this choice just doesn't work out, though. There is no reason to diagnose parvovirus in an adult dog except in rare instances, for example --- even if it does match the list of symptoms perfectly it just isn't very likely because it is primarily a disease of dogs less than a year of age. In addition, making sure that a disease occurs in your area is also an important step in determining if a disease should be the number one differential. Heartworm disease isn't very likely as a cause of coughing or retching in a cat that lives in the mountains of Colorado, for instance.
Eventually you have to pick the most likely diagnosis and begin treatment. Careful consideration of how the treatment of the initial guess will effect the other possible illnesses is very important, though. In many situations veterinarians are faced with choosing a second or third choice of medical therapy for their prime suspect simply because using the best treatment for the most likely illness could result in a dead patient if the initial guess is wrong and "illness number two" is actually present. An example of this is a dog who is suspected of having allergic skin disease but who may have primary bacterial pyoderma (skin infection).
Using a corticosteroid initially for the allergy wouldn't be a good idea in this case, as the corticosteroid could allow the bacterial infection to become much worse very rapidly. In this case, even though allergic skin disease might seem most likely, it is necessary to treat for the second possibility first. It is just safer to use an antibiotic that is likely to eliminate skin infection first and then to come back and use the corticosteroid later, if it is necessary to do so.
Choosing not to pursue the optimum treatment for the most likely disease on your differential list can also be important in patients with multiple illnesses. There are lots of times in older dogs when we have to make choices between doing what is best for a patient's kidney failure and what is best for their heart failure since both are present in the same pet. Often, this involves altering both treatment protocols or using dosages of medications that ordinarily would be too low or too high when treating a single illness using optimal dosing. Sometimes we are just stuck with treating the most pressing illness aggressively and hoping that we don't cause too much problem with the secondary condition.
Drawing up differential lists wouldn't be nearly as important if there weren't so many possible causes of most symptoms. There are many symptoms for which twenty or more diseases are possibilities. Most differential lists for increased drinking and urinating (polyuria and polydypsia or PU/PD) include twenty-two to twenty-five possible causes. This seems overwhelming when first using differential lists but over time it becomes possible for most veterinarians to divide these lists into two categories --- likely and not very likely. A ten year old dog with PU/PD is more likely to have diabetes or hyperadrenocorticism than a one year old dog with these symptoms, for instance. A male dog won't have a uterine infection. These types of obvious choices can cut the initial working lists down considerably. If the "likely" group is totally ruled out eventually through testing, then the "unlikely" group can be considered again.
One thing that pet owners and dog breeders are sometimes better about than veterinarians about is keeping track of which illnesses are likely in a particular breed of dog or cat. Breed enthusiasts are sometimes aware of illnesses within a breed that have not made it into publications or are just more likely to have read about the particular disorders affecting their favorite breed than their vet --- especially when the breed is not especially common in an area. Some of the breeding organizations disseminate information that doesn't hold up to scrutiny about breed sensitivities, though. Almost all breeds are susceptible to anesthetic complications if you read enough about them -- but the truth here is that anesthetic complications occur in pets of all breeds and are really noticeably greater in just a handful of breeds, mostly the sight hounds and mostly just to barbituate anesthetic agents. I have kind of a long running discourse with members of the collie breeding organizations because they believe that ivermectin even at the very low doses in heartworm prevention medications can cause severe problems in collies, despite a total lack of case reports of problems at these dosages. Ivermectin does cause problems in collies at higher doses and it has to be used carefully or avoided entirely when illnesses are present that require higher dosing. At the heartworm dosage there are no confirmed cases of serious reactions that I am aware of, though. Even with these types of problems in mind it still makes sense to check with breed organizations about the potential for increased risk of particular illnesses in your pet's breed if there is a need to do so.
Even after considering where diseases occur, how they are transmitted and whether a particular age, sex or breed of dog or cat may be more susceptible it is still likely that you will have more than one possible illness on your list of differentials. At this point, it is necessary to have a plan for moving from the lists of illnesses to a relatively firm diagnosis of one illness. I think that one of the major differences between pet owners and veterinarians at this point is that veterinarians have an organized plan for ruling in or ruling out various diseases and disorders. I have noticed that a lot of pet owners latch onto a particular disease and try to prove that it is present, rather than looking at the whole list of possibilities and trying to narrow it down. Veterinarians sometimes get caught up in this type of behavior, as well. It is sometimes difficult to admit that a first guess is simply wrong and move on. Being able to do this is one of the most important aspects of becoming a good diagnostician, though.
The most concise lists of differential diagnoses in veterinary textbooks that I have found is in the "Handbook of Small Animal Practice" by Rhea V. Morgan. This is an expensive text if it won't be used regularly but it is very useful if you have a strong interest in following along when your vet is trying to diagnose a problem. The book does not go into much depth as it is written in outline form.
Another choice if you want more detail is "Sauners Manual of Small Animal Practice" by Scherding. If you feel the need to know more about different diseases than these texts provide the best in-depth book on internal veterinary medicine is probably "Small Animal Internal Medicine" by Stephen Ettinger and the best book on surgery is probably "Small Animal Surgery" by Slatter.
Veterinarians take different approaches to the problem of coming up with an organized diagnostic plan. I like the use of algorithms. An algorithm is a step -by-step process for moving from a list of differentials to a most likely diagnosis. These can be formed in several ways but I find it easiest to use algorithms that are drawn up as a list of "if this, then that" statements. Many people like to make charts that look like organizational charts for a big company. Most algorithms start with a particular symptom and follow a path determined by the historical statements (is diarrhea present?) or by a series of clinical tests (are worm eggs found on fecal examination). The response to each question or test result determines the next step in the process. Algorithms are not available for every symptom or every set of diseases with similar symptoms but there are many published algorithms that can be used as guidelines. A very good collection of these is in the textbook: "Common Small Animal Diagnoses" by Linda Shell and Charlotte Davies, which can be purchased from www.us.elsevierhealth.com. An example of an algorithm can also be found in the subscriber area in the October 2001 VetInfo Digest: http://www.vetinfo.com/subscriber/1001digest.html
There is a very strong temptation to skip the process of forming a differential list and going through an algorithm to find a diagnosis after a veterinarian gains experience. It is often quite obvious what the most likely diagnosis is when a pet comes into the examination room. It isn't even unusual to know from the initial phone conversation what a pet most likely is suffering from. This isn't necessarily a bad thing, since it often saves the client money and spares the patient from unnecessary lab work or unnecessary office visits. However, when the initial treatment plan doesn't seem to be working it is usually better to go to a real diagnostic process rather than simply making a second guess and treating for it. After a while the guessing game can severely compromise the ability to make a diagnosis by minimizing some clinical signs and often the original disease process can become much worse while a trial and error approach to diagnosis is being made. If your vet doesn't appear to have a pretty good plan for sorting through the most likely differential diagnoses after making one or two stabs at guessing the diagnosis it may be best to ask for referral to a specialist or to seek another opinion about your pet's case locally.
Once a veterinarian has examined a pet and come up with an initial diagnosis, thought about the most likely alternative, or differential diagnosis, and then formulated a plan to determine what disease is present, it is time to actually do the diagnostic work up. In veterinary medicine this process is often hampered by the fact that some of the recommended testing requires specialized skill or specialized equipment that may not be available at the local veterinary clinic or hospital. At this point, a decision has to be made. Is this a case in which it is important to work through every aspect of the diagnostic process or is it safe to skip some steps ? If steps are skipped it is important that it be possible to go back and redo the diagnostic process, if necessary. There are times when a treatment may preclude going back and starting fresh. Some examples include using prednisone therapy to treat a pet when lymphoma is suspected. This is commonly done and can provide relief from some symptoms of the cancer but it also makes it hard to go back and do chemotherapy later. Dogs who have been treated with prednisone prior to chemotherapy for lymphosarcoma do not do as well clinical as dogs who have not had this medication. Your vet should be cautious about taking diagnostic or treatment steps that close the door on a more complete diagnostic process or on treatment options. This is something that is hard for pet owners to understand sometimes. If you know that you and your vet are cutting some corners while trying to treat your pet make an effort to ensure that the medications and diagnostic steps chosen are broad spectrum enough to allow for course changes if they become necessary.
It might seem hard to have to think of all these things yourself when your pet has a serious illness. Many people simply leave the diagnostic process up to the veterinarian and often don't even take part in treatment decisions. This is OK as long as you are capable of following directions and of giving medications that must be administered. Remember that your vet may not know the limitations on pill giving ability that you have or that you can't be home to give medications three times a day. Pay attention to any directions given by your vet and be sure that you can follow them.
It is disheartening how often I have failed to impress on a client the extreme importance of giving medications as directed. If you can't give pills, can't be home on a regular schedule or something else interferes with your ability to help your pet through an illness make sure that your vet is aware of the limitation. Veterinarians don't want to dispense medications that won' t be used. In addition, if treatment is not done properly it can make it quite difficult to figure out the diagnosis as it interferes with the logical thought process when a treatment which should be effective isn't working.
Perhaps the most important thing to examine when trying to become familiar with how veterinarians think is to look at what the veterinarian is thinking when things aren't going well. There are going to be times when every step is taken in the proper order and when treatment decisions are made appropriately and the pet doesn't respond to the treatment as expected, anyway. There are also going to be times when the initial diagnosis is wrong or when a lab value is in error and leads down a false pathway in the diagnostic process. Sometimes the diagnostic process is perfect but the treatment choice is less than ideal or the pet has an inapparent complicating factor that prevents treatment from working. These situations are not uncommon. It is estimated that at least a third of veterinary diagnoses are not supported by post-mortem examination findings when post-mortem examination is done. Recent medical studies suggest that this error rate is similar to that found in human medicine, even at very good human hospitals.
All veterinarians and all veterinary clients must keep in mind the possibility that diagnostic decisions and treatment decisions may be incorrect. Failing to accept this might be the single biggest weakness among veterinarians. Being too suspicious about the diagnostic and treatment process and consequently failing to allow the veterinarian to work through a proper diagnostic process may be the single biggest weakness among veterinary clients. There has to be a balance between these two extremes.
No veterinarian I know is really comfortable with the fact that there are a huge number of possibilities whenever a pet is ill and that it is entirely possible that an initial diagnosis is wrong. Veterinarians worry that clients will perceive them as weak diagnosticians or perhaps even as incompetent veterinarians if they admit that they were wrong after making a declaration about what is wrong with a pet. In addition, veterinarians worry that clients will feel like their money was not spent wisely if the initial diagnostic process doesn't provide a direct path to appropriate treatment and full recovery by the pet. Telling a client that you spent $500 of their money to follow a blind pathway isn't fun but it must be done. If your vet isn't willing to do this or can't admit that a diagnosis might be wrong, then you have to be able to figure it out on your own. Ultimately the responsibility for caring for your pet does fall back to you and you must be an advocate for your pet at times. Ask your vet what other disorders could be causing your pet's symptoms or if a trip to a specialist would be worthwhile when treatments aren't working properly.
Many veterinary clients really want instant success in treating their pets. There are lots of times when you must wait patiently and do your part to provide the treatment you vet prescribes while a diagnostic process is ongoing. This is especially true for conditions in which the initial diagnostic steps must be done in an appropriate order for the diagnostic process to work. Skin disease and disorders involving vomiting and/or diarrhea are probably the two most common initial complaints in which patience can be extremely important to the diagnostic process. There are just too many treatments that can alter the disease process for these conditions, so it is often better to take a step by step approach to the diagnostic process for these types of disorders, even though doing so may delay effective treatment for several days or several weeks. This is hard for clients to accept since they sincerely want their pet's condition to improve quickly, but being patient and working with your vet often results in much better long term results.
Veterinary clients are often subjected to widely differing opinions when researching information on an illness affecting their pets. Deciding who to believe can be difficult. This is an other area in which veterinarians have some advantage over their clients. Veterinarians who take the time to go to continuing education seminars, who consult on-line veterinary reference services and who read some of the popular literature, such as "Dog Fancy", "Cat Fancy" or "Dog World" can often tell you which veterinary authors or researchers are producing the best quality information or giving the best quality advice. I know that I have strong biases for and against the information that comes from particular veterinarians. This is something else that veterinary clients sometimes have a hard time discerning. There are a few things that you can do to help sort through these information sources, though.
I have seen several veterinarians who make claims about being specialists in articles in magazines or online who are not board certified in any field. In veterinary medicine the use of the term "specialist" is usually restricted to veterinarians who have met board certification standards in a recognized specialty. A subscriber once told me her veterinarian was a specialist in eight fields. I can tell you with certainty that this is simply not true. There are a few veterinarians who have specialty status in two fields, such as internal medicine and pharmacology or surgery and internal medicine. There are a much small number of veterinarians who are board certified in three specialties and I am not aware of any veterinarians who have board certification in more than three fields of study. Some of these "specialists" claimed specialties that don't even officially exist, such as a specialty in geriatric medicine, Lyme disease or in the treatment and care of particular breeds. It is acceptable to point out that a practice is restricted to treatment of a particular condition or even a particular breed (although I'm not aware of any veterinary hospitals that treat a particular breed only) but it is not acceptable to claim to be a specialist in these areas of practice.
There are veterinarians who claim to have treated "ten thousand or more" cases of a particular illness or syndrome. I find this these claims to be extremely difficult to accept in most cases, since most veterinarians treat two to four thousand patients a year and presumably these patients are likely to have a variety of ailments, making it difficult to see one particular ailment more than a few hundred times in a career in most cases.
A few veterinarians have stopped trying to produce scientifically valid information and have built large followings by ignoring science and making claims that the general veterinary community is overlooking some important issue or treatment. Some of these people are scary and some are sincere in their worries about particular aspects of veterinary care but still lack scientific data to support their claims. Your veterinarian may be extremely reluctant to discuss information that comes from particular veterinarians. If this reluctance is based on reviewing the literature produced by the veterinarian in the past it is best to consider your veterinarian's point of view when choosing whether to accept or reject the information.
Veterinary research can be tainted in many ways. In some cases it is obvious that a company paid for a study and that the study is set up in such a way that it favors the company's product. Sometimes it is much harder to tell when research is tainted but your vet may be able to tell you if he or she pays a great deal of attention to the literature. Some researchers really seem easy to sway with a grant and others are not as easily influenced.
There are veterinary researchers who put the need to publish above the need to publish truly meaningful information. They may draw conclusions that don't match the statistics in their papers. They may design studies that simply don't meet good scientific standards. Over time, your veterinarian is going to recognize which veterinary authors can generally be trusted and which ones can't be. This information is valuable to you and if your veterinarian openly discounts the value of a particular veterinarian's research articles it is best to find out why. If you disagree with the logic you can form your own opinion. If the logic rings true you may have saved yourself some time and energy by checking with your vet before discovering that the information was tainted on your own.
It isn't possible for most veterinary clients to substitute an intense search through available texts and online information for a veterinary education. It is also difficult for the great majority of veterinary clients to acquire experience with common diseases that comes close to the experience a veterinarian has after two or three years in practice. It is entirely possible for veterinary clients to work with their veterinarians to ensure that the diagnostic process includes a good review of possible causes of the symptoms seen and to ensure that these alternative diagnoses are kept in mind if treatment doesn't work as well as the veterinarian expects. It is also possible for veterinary clients to research specific conditions that affect their pet and to ask about differences between recommended diagnostic procedures and recommended treatments and those found online, in magazine articles or in books. Your vet should be willing to explain why he or she feels that a particular diagnosis is correct and to explain why an alternative treatment has been selected for a particular pet. In some cases your veterinarian should also be willing to admit that the additional information really is helpful and contributes to the quality of care. If this never happens it should probably worry you some. Everybody can benefit from a little help sometimes.

New Products and Information
Proof of three year duration of immunity for at least one vaccine:
Ft. Dodge Laboratories has introduced a three year duration distemper, adenovirus and parvovirus vaccine. The duration of immunity for this vaccine was proven in challenge studies, which are generally thought to be the most conclusive tests of a vaccine's efficacy. While I think that most of the currently available vaccines produce at least three years of immunity having proof that at least one vaccine meets the standard established by a challenge study should allow the majority of veterinarians to offer a vaccine schedule with a three year interval between vaccinations.
Avoid pop top cat food cans?
A study in the March 15, 2004 AVMA Journal (Edinboro, et al.) pointed out a correlation between the use of pop-top cat food cans and the subsequent development of hyperthyroidism in cats. This study merely points out a statistical correlation and doesn't prove that this relationship is certain but if you wish to be cautious about the possibility there is no harm in switching to cans that have to be opened with a can opener. Most cat foods are available in both types of cans, although it may be necessary to buy bigger can sizes to avoid the pop-tops.
New tests
Idexx has introduced a screening test for giardia infection in dogs and cats that is likely to be more accurate than fecal examination through more traditional means. If your pets or premises have had problems with this parasite in the past it might be worth screening for it using the new Snap Giardia (tm) test.
Idexx also has a Snap (tm) test for detecting heartworm disease and detecting antibodies to Lyme disease and Ehlichia. It is very important to recognize that Lyme disease and ehrlichiosis portions of this test are for antibody production and only indicate exposure to the disease organisms. The test is not conclusive for active disease and it is not appropriate to treat all pets who test positive for antibodies against either of these organisms.
Mitaban Dip is back on the market
Mitaban Dip (tm) , which is the brand name for amitraz, is back on the market. This dip is used to treat demodectic mange. It has been off the market for quite some time. The availability of this dip gives veterinarians another option for treating demodecosis. This is particularly important for ivermectin sensitive dogs and dog breeds.
Sterilization by vaccination?
The University of Florida is testing sterilization vaccines for male and female cats. Dr. Julie Levy is the main researcher in this effort and has good success experimentally with the male cat vaccine. It may take some time to be certain this approach works and to get vaccines to the market but this may be a very important breakthrough in controlling feral cat overpopulation, which is a major problem in some areas of the U.S. and the world.

Thanks for Your Support!

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 2004, TierCom, Inc.
This page was last edited 06/17/04
Subscriber homepage |Backissues | Breed index |digestindex |
Vetinfo | vetinfo4cats| vetinfo4dogs

| Canine Encyclopedia | Feline Encyclopedia| VetInfo Digest |Links |Zoonotic info

Please do not send anything in attachment form. We will not be able to open it due to security risks.

This page is authored by
Dr Michael Richards, DVM
and produced by TierCom, Inc.
Opinions expressed are those of Dr. Richards.
Designed and edited by Michal Justis
copyright �1996,1997,1998,1999,2000,2001,2002,2003,2004 TierCom, Inc