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Wednesday, September 17, 2014

Same Disease, Different Day

Many people think that being a vet is exciting.  You're constantly seeing new patients, doing surgery, running tests, diagnosing diseases, and saving lives.  You never know what's going to come through the door next!  At any  moment that emergency could burst in and you'll have to drop everything to handle it while your adrenalin surges!  While those moments do sometimes happen, they are not as frequent in general practice as you might think.  Most of the cases we see in a day are almost identical to cases we saw the day before or even earlier that day.  Here's a brief list of cases I see the most.
  • Colitis--This is typically diarrhea in an otherwise normal dog, sometimes with blood.  Most of the time we don't figure out an exact cause and treat symptomatically. Almost every day I'll see one of these.
  • Ear infections--While most common in the warm, humid months I can see these just about any time of the year.  It's not uncommon to have 4-5 ear infection cases in a day.
  • Itchy skin--This is often seasonal and even regional, depending on the prevalence of fleas and other allergens.  Most of the time it's something other than fleas, though in the summer months that becomes more likely.
  • Vomiting--This is something that comes in daily.  And it's only because just about every kind of illness has the potential to make a pet vomit.  Sometimes these require a lot of thinking and workup, but it still gets tiring to have go into a room that's the fourth nauseous pet of the day.
  • Lethargy--In the US, especially the South, we call this "ADR", or "Ain't Doin' Right".  "Well, doc, I'm not quite sure what's goin' on, but he just ain't doin' right."  This is about as vague as they come because litterally any disease or disorder can cause this as a symptom.  Sometimes we get a clue on the exam, but often it requires a lot of testing to nail down the problem.
 
On an average day the above cases account for probably around 60-70% of my cases when you also throw in routine checkups and vaccinations.  In a way it becomes rather routine and boring.  "Oh, no, not another ear problem!  I've already seen five of those today!"  At the same time, if you are careful as a doctor you can get very good at diagnosing and treating these problems, especially if they go from routine to complicated.
 
The danger is becoming complacent.  "This is the sixth itchy dog I've seen today.  It's probably just fleas or a grass allergy."  Each case still needs to be completely worked up because there are cases that simply aren't what you may initially think.  If you just threw steroids or antibiotics at everything you may be missing other problems that need different treatment.
 
I'm sure that my human colleagues have similar disorders they see daily.  When I've taken my kids in for strep throat I've sometimes wondered how many other cases of that particular infection the pediatrician has seen that day.  It probably gets routine and boring for them as well.
 
This monotomy is often why veterinary staff get so excited to see something different.  "Oh, wow, there's a foxtail in that ear!"  "Hey, look, it's positive for Giardia!"  "Cool, it's a wolf bot!!!"  We don't want a pet to have something bad, but there are some things that are so uncommon that we can't help but get energetic that our routine has been broken. 

When you're a new graduate just about everything is exciting because you get to see and put into practice the things that had previously just been theory taught in classes and clinics.  But after a few years you start dreading that next ear infection because it's the 20th you've seen this week.  It's all just part of being a vet, and one of the parts that most people never consider.

Saturday, September 13, 2014

Superhero Cosplay, 1940s Style

Time to move away from veterinary medicine for a little while and share a bit of the non-vet side of my life.  Long-time readers will be familiar with my forays into "cons", the popular name for sci-fi/comic/fantasy conventions.  Every year for the last 10 years my family has attended Dragon*Con in Atlanta, Georgia, one of the largest such cons in the US.  Every labor day weekend it takes over downtown Atlanta with events in at least five hotels.  We've been big into "cosplay", the common term for costuming at such events, and have had some pretty spectacular ones.

Five years ago my wife was invited to be a calendar girl in a then fledgeling product called "Girls of the Con".  It was a great experience and showcased women in various kinds of costumes.  What impressed me (and continues to do so over the years) was that it wasn't just skinny, buxom women in skimpy clothing.  My wife wore a Victorian outfit with little skin showing and there were women of all body types.  She got to know the producer of the calendar over the years and when they decided to make a 5th Anniversary calendar my wife was again invited. 

The calendar release party is always during Dragon*Con, and this year was at the Hard Rock Cafe in Atlanta.  Since she was going to be attending as one of the calendar girls and signing autographs she wanted to look good.  We debated which costume for her to wear and eventually settled on the DC Bombshells version of Black Canary.  For those who aren't as familiar with comic books, this is a line of statues, and now comic covers, featuring various DC Comics superheroines and villains designed in the style of 1940s pinup girls.  Because Green Arrow is one of my favorite superheroes of all time she and I have costumed as him and his lady-love, Black Canary, so this was a natural costume for us to consider.  Plus, the costume was fairly simple and sexy without being too revealing.

Here is what the statue and comic cover look like:



And here is my wife's interpretation, with her costume hand-made.  She's naturally a brunette, so this is a blonde wig:




Since we were going to the party together, we wanted to match.  We started wondering how we might do Green Arrow in a similar style, and a zoot suit quickly came to mind.  She made this as well, and we added an arrow on the fedora and a bow-and-arrow tie tack.




Here we are together:




We both love the clothing and music of the 1940s, so this was a fun costume set for us to do.  It's also one that we plan on wearing again.

Wednesday, September 10, 2014

"Vaccines Are A Money-Making Scam!"

Vaccines are often a controversial issue in veterinary medicine and can stir up a lot of heated discussion (something from which I've never shied away).  You will have some people who are decidedly anti-vaccines, some who think they should only be given every 7-10 years, some who think that Leptospirosis is a highly reactive vaccine, and so on.  Even the veterinary community is often split, with some vets still advocating annual vaccination for all diseases and others saying that we should perform titers in place of vaccination.  I tend to fall in the middle and have changed my outlook over my career.  Medicine is constantly changing as new treatments are developed and our understanding of physiology improves.  As responsible medical professionals we in the veterinary field should be willing to adapt to these changes.
Because even vets differ in their opinions regarding vaccinations it can be confusing to owners.  You'll also get some very strong opinions about vaccines online, especially against them.  One of the things that I hear from time to time is that vets are recommending more vaccines than necessary and at closer intervals than necessary, all simply to make more money.  In the minds of people making those statements the vaccine protocols of the vets are nothing more than a way to scam money from hard-working people.

Unfortunately it's not that simple.  Anyone who thinks that the book is closed on vaccine immunology is deluded.  I've even seen specialists who disagree on the right interval between vaccines.  Our understanding of the immune systems and cell functions of animals is still developing and there is no way that we can say that we understand it all.  At the same time our technology is improving so that we can make vaccines that last longer and cause fewer reactions.  Someone condoning the same vaccine protocols as were done 20 years ago is just as wrong as someone who believes with certainty that they know what we'll be doing with vaccines 10 years from now.  This is an ever-changing field and we need to both pull people from the past into the current understanding as well as keep people from dismissing the past and forging ahead without proper evidence.

In my practice we have embraced the research that says that some of our vaccines will last for at least three years.  There is possible evidence that these vaccines may last seven years or more, but there are also limited studies and only slight evidence in support of this.  Most veterinarians are doing the best that they can while acting on sometimes contradictory information. Most vets practicing now saw the writing on the wall many years ago and have been moving away from vaccines as a big income-generator.  These vets are giving vaccinations based on their best understanding of currently accepted immunology and not just as a way to make money.  While some may disagree with their stance on vaccine intervals, most vets really are simply trying to do the best preventative care and make the best recommendations based on a combination of experience and current science.  Yes, vaccines earn them money, but they're looking at it from a medical standpoint rather than financial.

Unfortunately there are some vets out there who seem to be in it more for the money than anything else and they often have questionable practices in regards to vaccines.  Recently one of my associate doctors brought in a flyer for a mobile vaccine clinic that was going to be setting up at a local Walgreens pharmacy. That by itself wasn't too surprising, even though I'm not a fan of in-and-out shot clinics due to the lack of a good physical exam (I ranted about that recently).  What bothered me was their pricing structure, which was printed directly on the flyer.

"$10 1-Rear Rabies          $25 3-Year Rabies
$25 DA2PP/Cvk              $49 3-Year DAP"

The prices themselves aren't my issue.  It's the fact that they are being somewhat deceptive in their practic, as well as not following current vaccine recommendations.  First of all, the accepted duration of the rabies vaccine is one year if it is the first time being given and three years after that.  Some states and counties may require stricter booster durations, such as mandating annual boosters, but medically there is no reason for doing so annually.  What's deceptive?  Most of the time it's the same vaccine!  There are some rabies vaccines that only have a duration of immunity of a year, but most of them carry a three-year label.  So if this clinic is using one of these vaccines, they are charging more for a three year duration than for a one year duration, even though it's the same vaccine and costs them the same to administer!  It's also the same dosage!  So a three-year duration doesn't require a triple dose.  My clinic charges $19 for a rabies vaccine regardless of the duration since it costs us the same to administer either way.

It's a similar situation with the other vaccine.  There are more than one distemper-parvo combination vaccines (DAP) that are valid for three years after the initial puppy series.  And the adult booster is the same vaccine as the one used in the puppy series.  "DAP" and "DA2P" are really the same vaccine components.  The second "P" is for an upper respiratory disease, parainfluenza, which is covered in most kennel cough vaccines.  The Cvk is corona virus, which most immunologists and internal medicine specialists now recognize as an insignificant disease that doesn't need to be vaccinated against.  There is also doubt about just how effective the vaccine really is, so I don't even carry it or recommend it anymore.  Once again this practice seems to be worrying more about the money than the pet's health.  At my clinic a DAP vaccine is $32, regardless of whether  it is used in a puppy series or as an adult 3-year booster.  And that's because, as before, it costs us the same no matter what we make the duration. 

Vaccines are absolutely necessary to protect the health of humans and animals.  Such immunizations have saved literally countless lives and have protected human and animal health for well over 100 years.  Please don't misunderstand me and use this blog as an excuse to avoid vaccinating your pets.  However, feel free to ask your vet questions about the vaccines, how long the duration is, and whether they are necessary for your pet's lifestyle.  Most vets are simply trying to make ends meet and support their business, and aren't trying to gouge you when doing vaccines.  But there are bad apples in any profession, including veterinarians, and you need to be well informed and ask questions.

Sunday, September 7, 2014

Is Brushing Teeth REALLY Necessary?

I recently was asked an interesting question.
 
Do dogs really need their teeth brushed or is it just a money grab by companies?
 
It may seem like this is a valid concern, at least on the surface.  If you go back 20 years or more nobody was really talking about tooth brushing.  The further back you go the less you will see even dental cleanings by vets.  Older dogs and cats just lost teeth and that was due to aging.  A real interest in veterinary dentistry didn't come about until the late 1980s.  It was in 1988 that the American Veterinary Dental College became a board-certified specialty recognized by the AVMA in the same way that surgical, opthalmology, and dermatology specialists are recognized.  Over the last 25-30 years we as a profession have put more and more emphasis on preventative dental care rather than just dealing with teeth that are litterally rotting out of the mouth.  A joke in the profession is that about 25 years ago we discovered that dogs have teeth, and about 15 years ago we discovered the same thing in cats.  This change in thinking is one of the reasons you will see so many vets talking about dental care and why there are so many products on the market.
 
The consequences of dental tartar and periodontal disease are very, very real.  Dental infections can lead to seeding of bacteria into the blood stream, causing infections in the kidneys, liver, and heart.  Periodontal disease can be very painful, and the odor coming from an infected mouth harms the bond people have with their pets.  There is even an increased risk of diabetes assocaited with periodontal disease.  Dogs and cats live shorter, less comfortable lives when they are allowed to develop advanced dental problems.  Obviously none of us want this to happen, so the question then becomes "how do we prevent it?"
 
The "gold standard" of dental care is teeth brushing.  More specifically it's brushing the teeth at least five days per week. Whenever a new product is examined to determine efficacy it is compared to brushing this often.  When you think about it, this makes sense.  Why do we brush our own teeth?  To remove food particles, bacteria, and the debris that builds up on teeth.  Those factors lead to hard calculus and gum infection.  Removing these things helps keep dental disease from developing.  Since it works so well in humans, it shouldn't be hard for us to realize the benefits in dogs and cats.  Yes, there are products on the market that take the place of tooth brushing, such as chew treats, foods, dental sprays, and so on.  But none are more effective than brushing, even if they may be as effective.
 
I've personally seen the difference brushing makes.  I only have a few clients who brush their dogs' teeth daily, but I can absolutely see a difference.  Their pets' teeth are the only ones where I don't have to talk about putting them under anesthesia for a professional dental cleaning.  Besides clean teeth that habit will pay dividends in improved health and reduced veterinary bills.
 
No scam or money grab here.  Teeth brushing really does make a big difference and really is important.

Thursday, September 4, 2014

Extra Toes

Often I will have people ask me about a pet's dewclaws or extra toes.  Why does this happen?  Where do they come from?  Do we need to take them off?
 
Bone development, including toes, is determined genetically.  Genes within a breed and individual will cause cells to develop a certain way and guide how many limbs an animal has, how long and thick the bones develop, where the limbs are placed, and so on.  Pretty much everything to do with an animal's physical appearance and function is governed by genes.  We haven't reached the point where it is easy to manipulate genes and significantly affect how physical development takes place.  But we have been able to achieve a similar result by carefully breeding individuals that look the way we want them to.  Over generations we can cause the face to be shorter, the leg bones to develop curved, and toes not to develop at all.  Once those characteristics are common within a breed or bloodline they are maintained through continued selective breeding.
 
Some dogs are born without dewclaws.  Some are born with double dewclaws.  In most cases this is based on our particular idea of how a given breed should look.  While hind limb dewclaws are undesireable on a Labrador retriever and have generally been bread out of them, two dewclaws per hind foot are breed standard for the Great Pyrenees.  Because humans decided that the breed should look a certain way they breed to have fewer or more toes than the wild anscestors.
 
Sometimes this happens naturally.  Even with careful breeding we can't make 100% guarantees for how genes will combine or activate.  Sometimes you'll get a dog develop dewclaws even if other members of the breed don't have them.  Some cats have an extra dewclaw (called polydactyly), and the tendency for this trait can be passed to offspring.  These happen when specific genes are activated that would normally remain dormant, and the same thing can happen in humans.
 
In the large majority of pets nothing needs to be done about these extra toes.  I'm not an advocate of routinely removing them and I challenge the old notion that they are more likely to be torn off.  I've tracked broken or torn toenails at my own clinic and haven't seen the dewclaws any more affected than any other toe.  So I typically tell clients to leave them and not worry about it unless specific problems develop.

Monday, September 1, 2014

Does Homeopathic Therapy Work?

A reader recently asked me my thoughts about "quack" treatments (their words) such as homeopathy, accupuncture, and so on.  This is another very polarizing subject, but as long-time readers know by now (and new readers find out quickly) that doesn't make me be quiet.  Polite discourse and debate is good for the mind!
As should be pretty clear, I am a trained in and practice traditional Western medicine.  I fully support traditional methods of diagnosis and treatment, using them myself on a daily basis.  For example, I would much rather use antibiotics than colloidal silver to treat an infection.  I also only have limited knowledge of many homeopathic/holistic treatments as that was never part of my education and I tend to think that there isn't a lot of evidence for many treatments.  That being said, I don't think that all homeopathy is "quack" medicine.
The hallmark of Western science is scentific study and peer reviews.  If we say that a prevention, test, or treatment is effective, we had better be able to support that with properly conducted scientific studies.  No, not all of them are 100% accurate and over time opinions can change.  But those opinions often change based on new evidence and data or new studies.  The duration of immunity ascribed to certain vaccines has increased over the years based on trials rather than merely thought and anecdote.  From what I've seen there is a lack of rigorous, independent, double-blind studies with many homeopathic treatments.  And really, that's the biggest complaint that most scientists and vets have about these therapies.  Show us the studies!  Show us the proof!  Don't say "well, it's worked well for me"!
Let me give a recent example that I came across.  I had a client tell me that she had started using black walnut extract to prevent heartworm disease based on things she had seen on the internet.  I had never heard of this so I started looking into it.  I found many websites, blogs, and articles from naturopaths on the benefits of black walnut, on how toxic traditional heartworm preventions are, and how safe and effective this extract was.  Do you know what I didn't find?  Proof.  Studies.  Sure, plenty of proponents of this method of prevention talked about what the mechanism of action should be, and I read a website from a vet about how he only recommended it and had never seen a case of heartworm disease in a dog using black walnut.  But all of these were opinions.  There wasn't a single scientific study, or even a report by parasitologists, immunologists, or toxicologists.  Some of the articles were by vets but most were by laypeople or people with an interest in homeopathy rather than a degree in a related field.  I even found articles and opinion pieces written by advocates of homeopathic therapy who had looked for direct proof or studies and found none.  Those same people were very honest in cautioning people about quickly jumping on black walnut extract because it really hadn't been appropriately studied for safety and efficacy.
"But it works!  And I know it does because I haven't seen a case of it!"  Really?  Okay, by the same logic when I see a dog who has never been on heartworm prevention and they test negative, it means that it's okay to not give preventative to that dog.  Right?  And in the same vein if I run back and forth across the interstate and never get hit by a car it must mean that doing so is safe.  Right? 
Not seeing a case does not constitute proof.  There is a difference between correlation and causation.  For example, I can see a graph that shows as temperature goes up the number of pirates also increases (yes, this is from the Wikipedia article I linked above).  Does this mean that an increase in temperature causes pirates to multiply?  That would be causation.  And that's the same kind of thinking that we often see with people advocating homeopathic treatment.  "I give A and I haven't seen a problem with B, so A must be working."  "My dog had X so I gave it Y and X went away.  Therefore Y works."  This is directly attributing causation when you may actually have correlation.  Using this method of determining efficacy contains a huge logical fallacy.  Scientific analysis and study through hypothesis testing and experimentation is supposed to differentiate between correlation and causation, allowing us to make a proper conclusion.  That has historically been missing in homeopathy.
I know that anyone reading this who is very much into holistic or homeopathic medicine is likely becoming very red-faced about now. But bear with me, as I'm not done. Because using the same logic we must keep in mind that just because there are no studies doesn't mean that a given treatment won't work.  If we say "Medicine P probably doesn't work because there haven't been rigid studies" we make the same mistakes of logic and once again place causation as a direct result when it may not be.  I do think that there are several homeopathic treatments that do work.

SAM-e has been studied quite a bit as a supplement to help liver function in animals, and has been attributed to improvement in osteoarthritis and even Alzheimer's in humans.  Glucosamine, chondroitin, and green-lipped mussel are all well known to help reduce joint pain and improve arthritis.  Omega fatty acids and fish oils have considerable benefit in certain kinds of skin and joint disorders.  All of these were at one point (and to many still are) considered "alternative" or "natural" therapies.  But because of scientific studies and considerable use we have been able to document true effects instead of simply anecdotes and personal reports.  Because of the scientific analysis they have become accepted by maintream medicine.

There is a form of "Western" accupuncture that seems to also have a legitimate basis in physiology.  I knew a vet in my area, a colleague whom I knew well and trusted, who had been trained in this form of accupuncture.  She said that it worked with known nerves and nerve clusters, stimulating them with the puncture of the needle.  It had also been studied and accepted at several veterinary colleges.  This particular method of accupuncture is different from the Eastern philosophies which tend to lean more towards energy clusters and similar mechanisms of action (as I understand them). 

There is much of homeopathic medicine and therapy that I do think is entering the realm of "quackery" and for which you won't find true scientific support.  However, I don't think that we should throw the baby out with the bath water and automatically eliminate all natural or holistic therapy.  More and more we are seeing proper studies done on these methods, many of which are showing real results and supporting the idea of a given treatment as being effective and safe.  As these studies build in number and are more widely known I would not be surprised to start seeing other formerly homeopathic-only treatments become commonly accepted in traditional Western medicine.  It's certainly happened before.

If you are interested in finding a vet who practices these methods of pet care, here are a few links.  And for now I'll continue to support my own methods and practice as I was taught in school.

American Holistic Veterinary Medical Association
Academy of Veterinary Homeopathy
British Association of Homeopathic Veterinary Surgeons

Wednesday, August 27, 2014

Even Furry Pets Get Mosquito Bites

I received this comment on a recent post about mosquito-borne diseases.  It was from a spammer, so I didn't publish it, but it brings up a very important point that is worth discussing.
 
My dog is a Pomeranian and he (like most dogs) is covered in a thick coat of fur. He always looks healthy and this fur is probably one of the reasons. Mosquitoes cannot penetrate the thick fur to get to his skin, if we were covered in hair I think it would be the same situation.
 
Unfortunately this is a misconception that many people have.  They assume that because their pet's body is covered in dense, thick fur a mosquito can't bite them.  And if a mosquito can't bite them, it can't transmit disease such as heartworms.  Sounds like it makes sense, right? 

This idea is absolutely, 100% false!  There is no such thing as fur too dense or skin too thick for a mosquito to get through.  These insects are quite persistent, and will find any area of exposed skin.  If the body fur is extremely dense, they will be happy to go for the face and ears where fur is naturally thinner and the skin more easily reached.  No matter how thick the rest of the coat, it is always at least a little thinner around the muzzle and eyes, regardless of the breed.  It's also not impossible for mosquitoes to burrow through a thick area of the coat.

It really comes down to this....If you live in an area that has mosquitoes your pet can and probably will get bitten.  You need to care for your pet accordingly with good preventative medicine.  First and foremost this is proper and consistent use of heartworm preventative in all dogs, cats, and ferrets (yes, all of these species can be infected), no matter where you live or the condition of their coat.  Since there are a few other diseases besides heartworms that can be carried by these insects, I recommend using a topical flea/tick preventative that also repels mosquitoes (you'll see that on the package label), especially if you live in a high risk area.

Whether your pet is an Alaskan Malamute or a Mexican hairless, they ARE at risk for mosquito bites.  Don't fall into a false sense of security that might result in your pet contracting a serious or fatal disease.