Wendy Blount, DVM

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Wendy Blount, DVM
Things We Dont Do that we Should Things We
Do that we Shouldnt
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Wendy Blount, DVM

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

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Wendy Blount, DVM

• drblount_at_vonallmen.net
• www.wendyblount.com

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Upper Respiratory Infections - Cats

• How do many of us treat feline URI?
• Penicillins (Amoxidrops, Clavamox)
• Eye ointment (triple antibiotic)
• Supportive
• antihistamines
• Fluids if needed

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Upper Respiratory Infections - Cats

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

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Upper Respiratory Infections - Cats

• How primary organisms treated?
• Feline calicivirus
• supportive
• Feline herpesvirus
• Lysine
• Vaccination if naive
• Anti-herpetics (acyclovir) dont work well
• FIP
• (pentoxyphylline, prednisone)
• Chlamydia psittaci, Mycoplasma spp.
• Tetracyclines, quinolones

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Upper Respiratory Infections - Cats

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

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Upper Respiratory Infections - Cats

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

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Identifying Skin Masses

• Can we tell whether a skin mass should be
  removed, just by looking at it?
• Sebaceous gland adenoma - 98 benign
• Differential diagnoses for hairless skin masses

• Histiocytoma - benign
• Plasmacytoma malignant or benign
• Mast cell tumor - malignant
• Melanosarcoma - malignant

• Fibroma - benign
• Follicular tumor - benign
• SGA - benign
• Perianal gland tumor benign or malignant

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Identifying Skin Masses

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

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Identifying Skin Masses

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

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Cytology

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

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Cytology

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

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Cytology

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

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Cytology

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

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Cytology

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

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Cytology

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

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Cytology

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

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Spot Checking Diabetics

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

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Spot Checking Diabetics

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

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Spot Checking Diabetics

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

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Spot Checking Diabetics

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

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Spot Checking Diabetics

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

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Spot Checking Diabetics

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

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Spot Checking Diabetics

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

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Spot Checking Diabetics

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

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Surgery Without IV Catheterization

• 12 of 58 (20) of systemically healthy dogs
  undergoing anesthesia for orthopedic surgery
  experienced clinically significant hypotension
  (prior to surgery
• Use of ephedrine and dopamine in dogs for the
  management of hypotension in routine clinical
  cases under isoflurane anesthesia
• Vet Anaesth Analg. September 200734(5)301-11.Hu
  i C Chen1, Melissa D Sinclair, Doris H Dyson

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Surgery Without IV Catheterization

• MP could result in renal failure in dogs with
• subclinical upper urinary tract infection
• subclinical renal disease
• Rx ACE-inhibitor, diuretics, NSAIDs
• Dehydration (NPO overnight??)
• We get away with it on a regular basis
• Would our A clients appreciate it, if the knew?

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Surgery Without IV Catheterization

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

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Surgery Without IV Catheterization

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

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Perioperative NSAIDs

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

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Perioperative NSAIDs

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

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Perioperative NSAIDs

• Deramaxx Package Insert
• Appropriate monitoring procedures should be
  employed during all surgical procedures

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Deworm Vomiting Dogs Cats

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

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Nutrition for Diabetic Cats

• For many years, we fed diabetic cats high fiber,
  low fat diets, just like dogs people
• 2000 - Randomized, controlled crossover study
• Improved glycemic control when fed 12 insoluble
  fiber
• Both diets high in carbs (35)
• J Am Vet Med Assoc. 2000 Apr 1216(7)1082-8.
  Effect of dietary insoluble fiber on control of
  glycemia in cats with naturally acquired diabetes
  mellitus. Nelson RW, Scott-Moncrieff JC, Feldman
  EC, DeVries-Concannon SE, Kass PH, Davenport DJ,
  Kiernan CT, Neal LA.

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Nutrition for Diabetic Cats

• 2001 ACVIM Abstract
• Low carb-low fiber diet (canned Hills Feline
  Growth) compared to high carb-high fiber diet
  (canned W/D)
• 31 fed LC diet were able to d/c insulin, and an
  additional 46 decreased insulin dose
• None of the HC cats were able to reduce or
  discontinue insulin
• Comparison of a low carbohydrate versus high
  fiber diet in cats with diabetes mellitus.
  Bennet N, Greco DS. ACVIM 2001. 13 cats.
• J Feline Med Surg. April 20068(2)73-84. 63 cats.

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Nutrition for Diabetic Cats

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

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Nutrition for Diabetic Cats

• Use of a High-Protein Diet in the Management of
  Feline Diabetes Mellitus. Vet Ther 23238-246
  Summer'01 Clinical Study 14 Refs. G Frank W
  Anderson H Pazak E Hodgkins J Ballam D
  Laflamme.
• The Effect Of High Protein, High Fat Or High
  Carbohydrate Diets On Postprandial Glucose And
  Insulin Concentrations In Normal Cats. ACVIM
  2002. H A Farrow, J S Rand, G D Sunvold.
• Use of glargine and lente insulins in cats with
  diabetes mellitus. J Vet Intern Med. 2006
  Mar-Apr20(2)234-8. KE Weaver, EA Rozanski, OM
  Mahony, DL Chan, LM Freeman.

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Nutrition for Diabetic Cats

• Ideal diet for diabetic cats
• 40 protein and
• A little different from DM basis (fat is 2x as
  calorie dense as protein carbohydrate)
• Only one dry diet on the market that fits the
  bill
• Innova EVO (California Naturals - Natura)
• Purina DM and Hills R Diet M/D dry - 15 carbs,
  protein OK
• Many commercial canned diets fit the bill
• Handout

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Nutrition for Diabetic Cats

• Myth 1 Diabetic cats should be meal fed if
  they are to be well regulated
• Fresh food BID allowed to eat ad lib
• Multiple small meals eaten throughout the day and
  night
• 24 hour glucose curve done (q2h)
• no correlation between blood glucose and the
  amount of food consumed over the previous 2-h
• overnight fast did not significantly alter
  morning blood glucose
• J Feline Med Surg. 1999 Dec1(4)241-51. Food
  intake and blood glucose in normal and diabetic
  cats fed ad libitum. Martin GJ, Rand JS.

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Nutrition for Diabetic Cats

• Myth 2 You shouldnt give insulin to pets who
  arent eating
• If glucose 300 for any period of time, insulin
  needs to be given to prevent diabetic
  ketoacidosis
• Dogs and cats with DKA will remain acidotic until
  they get insulin
• If you are chicken, give small amounts only as
  needed
• A small amount of insulin can do a great deal of
  good in a DKA patient

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Nutrition for Diabetic Cats

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

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Annual Vaccination

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

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Annual Vaccination

• In 1978, University of WI-Madison recommended
  ideal MLV protocol
• Puppy/kitten series, boost a 1 year of age
• Then every 3 years
• No one is recommending that we dont vaccinate
• puppy/kitten vaccines, and boosters at 1 year are
  crucial
• We shouldnt overvaccinate adult pets

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Annual Vaccination

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

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Annual Vaccination

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

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Annual Vaccination

• Duration of Immunity (DOI)
• Distemper
• Vaccinated or not, it is exceedingly rare for
  adult dogs to get this disease
• Dont confuse old dog distemper with active
  disease
• 1999 RD Schulz DOI Study
• single distemper vaccine given to puppy
• no boosters
• 95 protection by challenge at 5-7 years
• 95 protection by titers at 9-15 years

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Annual Vaccination

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

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Annual Vaccination

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

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Annual Vaccination

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

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Annual Vaccination

• Duration of Immunity (DOI)
• Feline Calicivirus (FCV)
• Considerable genetic variation results in
  resistant strains
• Multivalent vaccines may be more effective
• Vaccine does not prevent infection, just
  minimizes clinical signs
• Does not eliminate the carrier state
• 1999 Scott Geissinger DOI Study
• SPF cats vaccinated at 8 12 weeks
• no boosters
• Titers begin falling after 3-4 years
• 63 protection by challenge at 7.5 years

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Annual Vaccination

• Duration of Immunity (DOI)
• Feline Herpesvirus (FHV-1)
• Vaccine does not prevent infection, just
  minimizes clinical signs
• Does not eliminate the carrier state, though
  period of shedding is shortened
• 1999 Scott Geissinger DOI Study
• SPF cats vaccinated at 8 12 weeks
• no boosters
• Titers begin falling after 3-4 years
• 52 protection by challenge at 7.5 years

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Annual Vaccination

• Adverse Reactions to vaccines
• Attention began in 1990s with the first articles
  associating vaccines with IMHA and VAS
• 1999 DOI studies published
• Vaccinating older dogs and cats
• Adverse reactions to vaccines may be
  significantly more likely than getting the
  disease
• FPV, CPV, CDV, ICH

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Annual Vaccination

• Adverse Reactions to vaccines
• Life threatening
• acute anaphylaxis
• vaccine associated sarcomas
• 22,000 cases per year
• Risk is 1 in 10,000
• post vaccinal encephalitis
• CDV and CAV
• especially MLV in pups
• IMHA

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Annual Vaccination

• Adverse Reactions to vaccines
• Life threatening
• post-vaccinal infection
• Increased virulence of vaccine
• Patient immunosuppression
• Greyhounds - hot CDV vaccine
• Snyder Hill CDV on exotic animals
• fetal malformation/abortion
• hypertrophic osteodystophy
• especially Weimeraners

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Annual Vaccination

• Adverse Reactions to vaccines
• Potentially serious
• local allergic reaction
• Swelling of face, paws, hives
• Panniculitis - rabies
• Puppy strangles
• Vaccine contamination
• No preservatives in MLV
• Mycoplasma has been found in vaccines
• CAV has been isolated from feline vaccines
• Canine parvo conspiracy theory

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Annual Vaccination

• Adverse Reactions to vaccines
• Potentially serious
• multifocal ischemic dermatopathy - rabies
• hypothyroidism
• Facial/nasal dermatitis, stomatitis - IN
• Polyarthritis
• Vaccines given by wrong route
• IN vaccines given SC
• Inflammatory disease
• Liver failure and occasionally death
• SC vaccines given IN
• Severe necrosing facial/nasal dermatitis

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Annual Vaccination

• Adverse Reactions to vaccines
• Usually self-limiting
• Itching, redness, sneezing
• Pain, soreness, lethargy fever
• Local reaction
• Swelling
• Ulceration, irritation, Hair loss
• Thrombocytopenia
• CDV MLV
• Behavior changes

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Annual Vaccination

• Vaccination protocols
• Titers validated for all but rabies
• Vaccine manufacturers guarantee MLV vaccines for
  3 years
• Including FeLV
• All vet schools in US for 10 yrs
• triennial vaccination for MLV vaccines
• AAFP, AAHA, ACVIM, AVMA and TVMA reports
  extended vaccine intervals
• AAFP Report AAHA Report

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Annual Vaccination

• Vaccination protocols
• Nov 2005 - TSBVME Policy on Vaccination an
  Informed Consent
• Followed Feb 2003 open letter and Nov 2004
  Reminder to review vaccine protocols
• Reminds DVMs to stay informed
• DVMs must communicate possible adverse vaccine
  reactions and get informed consent
• Must be documented in the record
• Specifically recommends against CCV

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• It takes less time to do things right than to
  explain why you did it wrong.
• --Henry Wadsworth Longfellow