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Sunday, April 12, 2015

Questions From A Prospective Vet Student, Part 4

New readers may be a bit confused at the title of this post.  About four years ago I answered a series of questions from someone wanting to enter vet school (Here, here, and here).  I recently received some questions from a different person, but thought it could actually fit with the previous discussions.
 
I am allergic to cats and am very interested in veterinary school and working with dogs. I am open to allergy shots, but do most veterinary schools mind this?
 
A vet school isn't going to care that you're taking allergy shots as long as it doesn't interfere with your studies and clinical duties. This is something that should be discussed with your own physician or allergist, as it may be a big issue of your allergy is severe.
 
I went to a very good University for undergraduate studies, however my GPA was around a 3.0. It is difficult to gauge which schools, if any, I should consider applying to. If I do not get in the first time, is it easier to get in if I receive a masters or vet technician certification first? What about working in a clinic for a year?
 
To be perfectly honest, a 3.0 isn't competitive. Most vet schools accept 80-100 students per year, and there are typically 300-500 applicants for those positions. Competition is pretty fierce, and GPA is a quick and easy way for the admissions department to weed people out. I'm not saying to avoid applying, but be aware that there is a good chance of getting denied. Working for a vet won't overcome a comparatively low GPA. A Master's might! However, I absolutely would not recommend getting another degree unless you really wanted it and would consider using it instead. Getting a Master's Degree simply to get into vet school will possibly be a waste of time and money.
 
I do not have all of the required courses needed for most veterinary schools, as I am missing a biotechnology course. Can I take this course during the DVM program or do I need to complete it before, and where can I take those courses once I have already graduated undergrad?
 
You're going to have to get all required courses before applying.  I can't rule out the possibility that a school might make an exception, but you'll have to check with each individual admissions department to see if this is the case.  I really would expect that a school simply would pass you by, especially with a 3.0 GPA.  There are much more competitive students who would have completed their requirements and it is simpler for them to consider those candidates rather than make an exception.
 
I actually had a similar situation!  While my undergraduate GPA was 3.495 and therefore very competitive, I wasn't able to get my last organic chemistry course before the registration deadline.  I was faced with either taking a year out of school and working, or getting a Master's Degree.  At the time I was strongly interested in animal behavior (and still am), so I decided to pursue a MS in Ethology with the thought that I might actually go on to a PhD.  While in the program I decided that I didn't want to do research and ended up going to vet school.  But I was considering not being a vet so the Master's program wasn't a place-holder decision for me.  I also took my last organic chemistry class while getting the MS and was able to qualify for vet school.
 
Best of luck!

Thursday, April 9, 2015

Sinuses Or Esophagus? What To Do Next?

Here is a recent question from Joanne....
 
My husband is a cardiac surgeon and I am a PA. We therefore tend to have differential dx in our head when there is a problem with our canine kids.
 
We have a now 5 yo neutered yellow lab named Oliver.
In July 2014 Oliver started to reverse sneeze on a daily basis approx 2-4 times a day. He had bilateral clear nasal discharge and started swallowing at night when he slept. He sounded as if he had a cold when breathing.
We took him to the University of FL to be seen by IM. Bloods and urine WNL. They took him in the back for an exam. The resident dx Oliver with allergies. No meds were given.
 
There was no reverse sneezing Aug, Sept or Oct. it started again in Nov and lasted 3 weeks.
I began to notice that Oliver sounded as if he refluxed at night (GERD) and again sounded like he has a cold when he breathes.
March 1st at 3 a.m. And 5 a.m. He vomited clear thick mucous. At 6 a.m. He vomited mucous streaked with blood. His stool also had some blood in it.
 
At that point we brought him to a specialty hospital to be seen by critical care. During all of this he was acting normal and wanted to eat and drink. Bloods, urine, fecal were normal as was an abdominal ultrasound.
Dx was reflux and he was placed on sucralfate 1 g po bid ac and pepcid 20 mg qhs for 2 weeks. Reverse sneezing stopped as did night time reflux. Fifteen days after the tx ended his sx's began again.
I questioned why an eval of his esophagus wasn't done either via barium swallow or upper endoscopy and was told that we usually don't do that since vomiting blood doesn't have the same implications as it does in a human. I'm not a vet but I don't buy that reasoning. Please explain if you could.
 
So now we are on sucralfate 1 g po bid ac and pepcid 20 mg po q12h for 3 weeks. Then d/c the sucralfate and continue peocid for 2 weeks then d/c all meds.
 
Today Oliver was having a Beams dehydrated fish skin treat which is about 5 inches long and an inch wide and rigid. He put the entire piece in his mouth and he usually chews it. This time he attempted to swallow it and started rapidly swallowing to no avail. The treat was not visible in his mouth but luckily I was able to put my fingers down his throat to grab it and pull it out.
 
When I did there were a few specs of blood on it with clear thick mucous. I am assuming that just like a person, with his repeated swallowing, the treat could have scratched the mucosal surface causing it to bleed. Can that assumption hold true for dogs?
 
Oliver seems to produce a large amount of clear thick mucous which he is always swallowing and again sounds as if he has a cold since last July when all of this started. I am at a loss since a university dismisses it as allergic rhinitis and a specialty hospital critical care vet does only an abdominal ultrasound without evaluating the esophagus.
Local vets do not have the capability to scope. How useful is a barium swallow in dogs? I am assuming it would delineate a mass if present as it does in people by indicating what we refer to as an "apple core" appearance. Wouldn't this also tell us about his esophageal motility as well as stomach emptying?
 
Are these symptoms due to diet? I asked my local vet who admitted she hasn't a clue about nutrition. Right now I am at a loss.
 
 
Interesting case, Joanne. And I don't think you're off base with your concerns and thoughts. While there are significant differences in anatomy and physiology of dogs and humans, there are also a lot of similarities.
 
I would start by investigating the cause of the reverse sneezing. There isn't anything about reflux that would affect the sinus passages. However, problems in the sinus passage could drain down into the throat and esophagus. Reverse sneezing is typically due to minor sinus irritation and isn't harmful by itself. Usually over-the-counter antihistamines are sufficient to help the symptoms. But this sounds like there is something else to the case. And I could see a situation where the persistent nasal drainage is leading to reflux and esophagitis.
 
Based on your descriptions, if this was my patient here's how I would proceed.
1. Sedate/immobolize and do radiographs of his skull and sinuses. Any good general practitioner should be able to do this. While it won't typically give you a specific answer, you can see destruction of the nasal turbinates and possibly an increased radiopacity in one area to indicate a mass effect. This may help you localize if there is a lesion in the sinuses.
2. If that doesn't give a clear answer, refer to a facility with a small, flexible endoscope. This is commonly used to go into the pharynx and then retrograde above the soft palate to visualize the caudal nasal sinuses. At the same time the endoscope could be used to evaluate the esophagus and stomach.
3. A barium swallow is really most effective when done with fluoroscopy, which not even many referral practices have. You may have to end up at a veterinary college for that. It's the only way to actually see the true motility of the esophagus. And upper GI barium series could determine gastric emptying time and could potentially outline an esophageal mass, but could also miss a small mass. I'd rule out the sinus problems before focusing on the esophagus, as it seems like it all started there.
4. If none of the above gives answers, then a CT or MRI would be indicated to get better imaging of the inside of the sinuses and look for subtle changes.
 
As medical professionals you and your husband know that some cases aren't exactly straightforward. The patient and the clinician must both be politely persistent in pursuing the diagnosis. I certainly think that empiric treatment has it's place, and that's what's being tried. But when that doesn't work you go to the next step. If you strongly requested any of the above diagnostics, I'd be surprised if any vet would refuse to do any of it. Other than minor risks inherent to sedation or anesthesia all of these procedures are safe and minimally invasive to non-invasive. I would agree with the other vets that upper GI studies aren't first on our list and we don't jump at these diagnostics for a potential case of reflux. However, if the symptoms persist we have to re-consider doing them.
 
I don't see that the reverse sneezing would be in any way related to diet. While I'm no expert, I do find pet nutrition interesting and can't think of any dietary disorder that would lead to sinus inflammation. Reflux could be related to it, but I don't know that this is the primary problem.
It's always hard (if not impossible) to make a diagnosis based merely on a written description. But I can certainly see a situation where there is a mass or foreign body in the nasal passages that are causing drainage into the esophagus. In fact, that makes the most sense to me based on the description. My thoughts might change after looking at Oliver myself, so I'll hedge my bets a bit.
 
In the end, a lot of this depends on how much you are able and willing to do. All of these diagnostics aren't cheap, but they are absolutely possible in veterinary medicine. You might want to respectfully and politely push for more advanced diagnostics. But keep in mind how you or your husband would feel if a client pushed you in this way. There is an appropriate way to do it.
 
I hope some of this helps, and I hope you can get Oliver's problem figured out!
 
 

Tuesday, March 31, 2015

Horse Manure Toxicity

Stefanie emailed me with the following....
 
I ran across a couple of warnings on line about the dangers of dogs eating horse poop because of the potential of horse wormer being present. This is one of the sites: http://beingstray.com/dogs/eating-horse-manure-dangerous-to-dog/.
I'd like to know if you've ever experienced anything like this first hand or heard of it? My dog loves horse poop - and given all the hiking we regularly do, we run into it pretty regularly, so it is an on-going training process in getting her to leave it alone. Or maybe I am being overly cautious and should just let her have her dog fun?
 
 
I'll admit that this was the first time that I've heard of this particular problem.  However, I've always practiced in suburban areas with few livestock around so it's never really been a concern.  With that in mind, I read the blog post above with interest and did some digging on my own.  And I do think that there is a cause for concern.
 
Intestinal parasites are common in horses and can really affect their health.  Because of this risk horse owners commonly use over-the-counter dewormers as a routine treatment or even in the feed.  Most of these dewormers contain ivermectin or moxidectin, as these products are very effective against a broad spectrum of parasites.  They are also considered very safe to horses and have been used extensively for decades.
 
Some of the dewormer can be excreted in the feces, though it's less than they ingest.  The problem isn't that the chemicals are inherently toxic.  Ivermectin is found in the majority of heartworm preventatives on the market and moxidectin is found in ProHeart (an injectable heartworm preventative for dogs).  At appropriate doses these compounds are very safe, even for collie breeds that contain a mutation making them more sensitive to side effects of this category of drugs.  However, the horse products are far more concentrated and contain a far higher dose than is used in dogs.  Remember, virtually all dogs are going to weigh less than 100lbs (45kg) and horses can easily get over 1000lbs (450kg).  It's this higher concentration that is the concern, and can be found in potentially dangerous amounts in horse feces.  Side-effects of ivermectin or moxidectin are typically neurological and if treated appropriately most dogs can make it through if the symptoms aren't too severe.
 
So yes, there can be concern from eating not only horse manure, but the feces of any livestock.  Cases have been documented by vets, and the amount of ivermectin found in manure has actually been studied.  It's a pretty low concentration, so a dog has to eat a fair amount to become toxic, but it can happen.  The half-life of ivermectin in horse and cow feces has been measured at as low as 11 hours and as long as 9 days.  That means that it can take up to 9 days for half of the ivermectin to become inactivated, then up to another 9 days for half of the remaining amount, and so on.  Realistically you can have measurable ivermectin in the manure for 1-2 weeks.
 
Stefanie, I think that answers your question!  Don't let your dog eat livestock manure. 

Wednesday, March 25, 2015

What Defines Dog Size?

Here's a question from a reader.....
Why does the canine world categorise dog breed size using its weight?
Why don't they use height instead?

Pet food company sell food meant for large, medium, small, toy breed by categorizing them through weight. What about the dogs on the cusp? For example, a female Belgian Shepherd could be 25kg, the male Belgian Shepherd would be well over 30kg. Does that mean a certain breed needs different sized pet food for differrent gender?

I understand pet food are formulated taking into account of kcal, minerals ratio for a certain size, however, a tall dog can often be thin, think greyhounds etc. Does that turn them into a medium breed?

What do you think of the categorisation? How did it came to be in the first place? Who placed the call to set the figures as such initally? I think this should be very interesting.


I'll start with the last questions.  I honestly don't know how categorizing dogs into "small", "medium" and "large" came to be, and I don't think it can be traced to a single person or moment in time.  This has kind of developed and become accepted without there being hard and fast rules.  Some of the breed clubs do have rules as to what weight a dog of a given breed should be, but that doesn't translate across all breeds.
In general we consider dogs to be "toy" if they are under 10lbs, small if they are under around 20-25lbs, medium from around 30 to 50lbs, and large if they are over 50lbs.  However these are not hard, set rules, and there can be variation around the borders of the categories.  It also depends on what that dog's normal weight should be.  If a dog who should weigh 8lbs actually weighs 13, we'd still consider it a toy breed because of the normal weight range.
Height is irrelevant in determining general size for food, as the calories and nutrient requirements are based off average basal metabolic rate, which is closely tied to weight. Two 60 pound dogs (assuming both are of the same body condition, i.e. neither is over- or underweight) would burn a similar amount of calories even if one was short and stocky and the other was tall and lean.  The height of a dog is determined by bones and the genetics of their development rather than the soft tissue structures.  A basset hound is short because of their leg structure, but they are rather stout dogs.  If their genetics caused them to have longer legs, they would still be of the same body size.

We also don't "split hairs" (no pun intended) when it comes to gender.  In the reader's example of a 25kg female and 30kg male, those 5kg really don't make a big difference.  The average of the breed determines whether it is small, medium, and large, not the individuals within the breed.  Also, the actual amount fed is determined by the individual dog's weight.  Labrador retrievers are considered a large breed, but I've seen normal weight vary from 60lbs to 90+lbs.  We obviously wouldn't feed individuals on either end of the range the same amount of food.  The smaller lab would need far fewer calories than the larger one.

Really, we don't need to over-think this.  Sometimes the only difference in the foods is the size of the kibble and not the nutrient content.  If you have questions about which food to feed your own dog, ask your vet.

Sunday, March 22, 2015

Monster Lipomas!

Lipomas are a common occurence in dogs, especially those that are overweight and at least middle-aged.  We typically consider these benign growths and rarely do we talk about surgically removing them.  Once a dog starts to develop one lipoma the chances of developing more of them increases.  It is also common to leave some cells behind, potentially resulting in regrowth at that location.  If we remove one or two of them there is no guarantee that more won't form.

When we do remove them it is usually because either they are rapidly growing and thus have a higher likelihood of malignancy, or because they are affecting the dog's mobility.  The latter was the case with a dog we recently saw, who we'll call Lumpy.

Lumpy is a sweet older chocolate lab who had had multiple lipomas for several years.  A few of them had been growing, and one on his left front leg was starting to interfere with normal movement due to its size.  After discussion with the owner it was decided to remove that lipoma as well as two larger ones elsewhere on his body.

The surgery was a long one but went smoothly.  I was able to get all three large lipomas out, as well as some smaller ones that were right next to them.  The challenge came in closing up all of the open space (what we call "dead space") that used to be taken up by the mass.

Here's what Lumpy looked like before going home.  I kicked myself for not taking pre-surgical pictures!  But you can get an idea of the locations.





Here is a great photo of the lipomas together.  That's my hand to give you a sense of scale.  The largest one (top right) was the one around the left elbow and shoulder.  As you can see, they are huge!



Believe it or not, these aren't the largest I've seen on dogs.  I had one patient that had a lipoma covering the entire side of its chest.  And we didn't even come close to removing all of the lipomas on Lumpy.  He still has at least a good half-dozen small ones scattered over his body.  But he's doing well and the owners are glad that he can move a little easier now.

Thursday, March 19, 2015

Bored In Veterinary Medicine?

Here's a question from Genesis..........

Hi, my name is Genesis, I'm currently studying biology and have been interested in veterinary medicine since I started my bachelor. The problem is, I'm very concerned about the debts, about the fact of me getting tired of the job and the probabilities of finding a job once I finish vet school. This is why I've been thinking about going into med school or the possibility of finishing vet school, and then specializing in surgery.
I actually don't see myself working all day with people doing the same thing over and over again. I love to do different things and to have a change once in a while, but I'm not sure if Veterinary medicine is the same.

Let me start with the first concerns.  Debt load is a huge concern for newly graduated vets.  In fact, many people (myself included) would consider this at crisis levels and the single biggest concern in the profession right now.  So anyone wanting to enter the field needs to do some serious financial planning before ever entering vet school.  I posted recently that while veterinary job prospects may have been slightly lower recently, overall it's very possible to get a job.  While it make take more effort than when I graduated, as a whole it's a profession with extremely low unemployment.  Do a search of my blog and you'll find several posts on these subjects.

Now let's tackle the bigger concern....boredom.

In any job you'll reach a point where you'll see numerous routine cases.  Human doctors see the same problems in patients again and again, and give the same advice over and over.  If you look at general practice veterinary medicine it may superficially seem like just about all you're doing is vaccines, spays and neuters, and skin problems.  Even veterinary surgeons tend to do a lot of the same procedures, with routine things like ACL and broken bone repair happening more often than you may think.  So the first thing I'd recommend is to realize that no matter what job you have there will periods where you do repetitive work and tasks that you do daily.  

Correct me if I'm wrong but I would suspect that you haven't spent a lot of time in a veterinary practice.  Yes, we do a lot of basic preventative care every day.  Yes, there are some disorders that we see almost every day (ear infections, diarrhea, itchy skin all jump to my mind first).  And yes, we're continually giving the same kinds of advice to people daily.  But I would never say that the job is boring.  

Every day brings surprises.  Often I'll expect one thing in a room and end up finding something different.  Just a couple of weeks ago I had to cancel my afternoon appointments so I could do an emergency c-section on a cat.  I commonly have to make challenging diagnoses, some that really test my knowledge.  Even routine cases will have variety.  Not every ear infection is exactly the same, and can vary in the infectious organisms, degree of infection, secondary changes, and so on.  Also, each day is far from the same.  Some days will be virtually nothing but sick or injured pets, leaving me wishing for a simple preventative care case.  Sometimes we'll get a run of a particular case; recently one of my associate doctors kept diagnosing pancreatitis, making her almost develop a complex about the next vomiting dog.We do see some cases commonly,  but the mixture of cases is different every day.

Genesis, I'd first ask why you think being a general practitioner is boring, and how you would specifically define "doing the same thing over and over again".  Knowing the specifics of your fear of boredom might help determine if this is a realistic apprehension.  If you're looking for a job with absolutely no repetition or routine, you won't find that in any sort of medicine.  If you haven't spend a lot of time in or around veterinary medicine I'd strongly recommend getting a job in a practice, even a part-time one.  That may change your impression about what we do.

Because the job certainly isn't boring.

Monday, March 16, 2015

Is It Okay To Cut A Dog's Whiskers?

I haven't had questions from readers in a while, and now I have several of them to answer.  Here's one from Crystal.

I am a fairly new subscriber to your blog.  I have a 4 month old Yorki Poo.  I was wondering if it is ok to cut her whiskers when grooming her face.  I've read different opinions online some saying to never cut the whiskers as they are needed and the dog's behavior can change if they are cut.
I'd love your opinion.

I answered a similar question about cat whiskers several years ago.  The same principle applies here.  A dog's whiskers aren't quite as important as a cat's whiskers, especially in captivity.  There is absolutely nothing wrong with trimming the whiskers along with the rest of the facial hair.  In fact, there's no way to trim the hair close without cutting the whiskers as well.  Grooming the facial hair happens routinely at grooming salons, and I have clients come in all of the time with small, fuzzy dogs who have had this part of the coat shortened, including the whiskers.  In 18 years of practice and 31 years in the profession, I have never seen a dog have any sort of problems after cutting whiskers.  Does it change the way they sense and feel things around their face?  Sure.  Because of the functionality of the structures it has to.  But this doesn't seem to cause any change in behavior or how they react to their environment.  Through selective breeding we have already significantly changed the structure and behavior of dogs from their wild ancestors.  We're not going to alter that significantly with a haircut. If it was my dog I wouldn't have any worries about doing this.