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Thursday, July 31, 2014

Trifexis Safety Concerns: Poor Reporting And Media Hype

Anyone want to take bets on how long it takes for someone to make a disparaging or hateful comment on today's blog post?  Or how quickly someone accuses me of being stupid, uninformed, or a shill for Elanco?  I'm expecting it because I know that there are some people who are pretty heated about this topic.  Well, so am I, so prepare for my rant.

Last November WSB TV in Atlanta, Georgia "broke" a story about possible dog deaths related to the owners having given them Trifexis, a common and popular oral preventative for fleas, heartworms, and several intestinal parasites.  Living in the metro area near Atlanta and carrying Trifexis, I was of course interested in the story and even a little concerned.  Then I watched it and had to shake my head in amazement at the hack job that was done.  I have always liked WSB and watch them in the morning when I'm getting ready for work.  But the reporter, Jim Strickland, did such a horrible job of presenting the facts that I can no longer fully trust their news department and when I see his reports I wonder what he's leaving out.

Here's a link to the original story, including a video of the broadcast segment.  I encourage you to watch it, as I'll be discussing specifics about it.

It seems pretty damning, right?  But let's analyze how the story was presented.  You get a mention that a University of Georgia pathologist concluded that the hearts of these puppies were inflamed, consistent with a bacterial infection and that there were no signs consistent with a drug toxicity.  Okay, seems like the toxicity has been ruled out.  Nope!  Just a little after that we see a huge "31 DEATHS" fill the screen, even though these were not confirmed to be related to Trifexis.  Which part do you think people will remember?  Does anyone really think that the reporter was trying to present a fair and balanced representation of the facts?

A couple of weeks later a follow-up story was broadcast.  This one proudly proclaimed "Owners blame 700 dog deaths on Trifexis"!  And during the lead-in to the story Strickland says "Since the pill was launched on the market on average every 36 hours a pet owner reports that Trifexis killed a dog."  Shortly after that you see a big yellow "700 DEATHS" fill the screen.  The story goes on and a couple of times the reporter mentions that these are reports made by owners and not confirmed deaths.  He admits that there is no proof of the connection.  Hmmmm....How different would people have taken the story if they mentioned 700 deaths reported but then flashed a big yellow "NO PROOF" on the screen?  Manipulation, folks.  And many people bought into it.

There was also a whooooole lot that was left out and that is pertinent to interpreting the case.
  • Trifexis is made of spinosad and milbemycin oxime, neither of which are new compounds.
  • Milbemycin is the same antiparasitic used in Interceptor and Sentinel.  It has been on the market since the 1990s and has been used consistently since then with no significant adverse effects reported, especially deaths.
  • Spinosad is the same compound used in Comfortis.  It has been on the market and used extensively since 2006.  The only significant side-effect reported is vomiting.
  • Trifexis has been on the market since 2011 and tens of millions of doses have been sold in 15,000 veterinary clinics across the US.  The only thing "new" about Trifexis is that it is the first time that two already existing chemicals were combined into one product.
  • There is extensive testing before any pharmaceutical makes it to market.  While this certainly does not eliminate all possible reactions or problems, it rules out many of the common ones.
  • The reporter never looked into whether or not any of these dogs had any underlying health conditions or were on other medications.  Some investigation!  He never even seemed to consider the possibility of other causes of death or illness.  I'm sure he never bothered to look at the medical records of these dogs to see whether or not the people's thoughts were supported by science and diagnostics.  Investigative reporter my lily white toches!!!  It's obvious that Strickland was more interested in emotions than facts.
Stop and think about this for a moment.  If either spinosad or milbemycin was a dangerous chemical, why are there no reported deaths with the products prior to this news report?  And why are we not getting reports about deaths with Interceptor, Sentinel, or Comfortis?  I think that knowing the history behind the chemicals puts good perspective on how not dangerous they really are.

Speaking of perspective, let's delve into how the Food and Drug Administration handles reporting.  If a client contacts them and says "Product X killed my dog!", they have to put down that Product X is a potential cause of the death.  The "700 deaths" reported are simply the owner claiming that it happened and is prior to any investigation of the facts and other details of the cases.  I'm not knocking the clients as they likely legitimately feel that Product X was the cause.  But when someone like one of the clients in the Trifexis story are convinced that the product killed her dog, then an independent pathologist reports heart disease unrelated to toxicity, which one is a fact and which is an opinion?  And even if the conclusion is that the dog's death was unrelated to Product X, the FDA report will still list it as a "possible" death.  The big yellow "700 DEATHS" is owner-reported and isn't necessarily connected to the truth at all.  And there is no way to remove cases that are confirmed to be unrelated.  So even cases confirmed to be unrelated stay in these preliminary reports.  People don't seem to understand that a report of death doesn't mean that it's confirmed.

In the time that I've been in and around veterinary medicine I've seen similar hype that turned out to be simply hot air.  When I first started practicing in the late 1990s Rimadyl (carprofen) had recently come onto the market as a pain medication for dogs.  It was great and helped a lot of pets, especially with chronic arthritis.  But then all of the message boards (remember, we're pre-Facebook and pre-Twitter here) started blowing up over "Rimadyl killed my dog!"  There were "thousands" of dogs who had died from it, or at least that's what the internet was claiming.  The manufacturer and FDA investigated and found that there was no connection.  In fact, some of the details were pretty ridiculous once you looked into them.  I remember one dog died from lymphoma, yet it had been originally reported with Rimadyl being a possible cause of death.  Some of the deaths happened months after being given Rimadyl.  This is why the "700 deaths" above really doesn't mean anything without more details.  What happened to Rimadyl?  Well, almost 20 years later it is now the single most common pain medication used for dogs in veterinary medicine.  It is trusted and used by tens of thousands of vets in millions of dogs world-wide and we haven't seen wide-spread problems since that initial set of reports (and those were not really "wide-spread problems").

Back in the early 2000s a heartworm preventative called ProHeart6 came onto the US market.  It's an injection that lasts for six months, keeping people from having to remember a pill every month and possibly missing doses.  After a couple of years of use there was an internet blow-up about dogs dying from ProHeart6 injections.  This spread like wildfire as people talked about it via email and forums.  It reached the FDA as people wanted it pulled from the market because of its extreme danger.  Around 2006 the manufacturer volutarily pulled it from the market to conduct further research on safety.  The worked with a well-know epidemiology specialist and compared reaction rates of all heartworm preventatives in the US market.  The study (peer-reviewed and published) showed that reaction rates were statistically the same across all types of heartworm prevention.  There was no difference in illnesses or death regardless of whether the pet took Heartgard, Interceptor, or ProHeart6.  In 2008 it was brought back on the US market with significant restrictions, which were then mostly lifted in 2010.  Over the last six years it has been very closely tracked and monitored, and there haven't been the wide-spread deaths that people seemed to claim.  You know what else?  During all of this investigation it was available outside of the US at a much higher dose that gave a full 12 months of protection, all without the reports of deaths that were seen in the US.

Okay, so the Trifexis report was last November, why bring it up now?  Because apparently WSB and Jim Strickland believe that there is still a story there, and on July 30th broadcast an update.  What was the new, breaking information that caused them to visit it?  There wasn't any.  Seriously.  There really wasn't anything new.  There apparently have been more reports to the FDA of adverse reactions, but once again these are concerns that clients had, and not illnesses or deaths directly related to Trifexis.  So far, every case has shown other causes related to the illnesses or deaths. Thankfully, he was more obvious about stating that these cases were not proven to be related to Trifexis.  But if they weren't proven, where is the story?  What is it other than speculation and emotions?

Here's something else frustrating about these news reports....there is more information on the TV station's website that isn't mentioned in the broadcasts.  So to get more details you have to be willing to go to their site and click on links other than the video.  For example, here is part of a statement from the FDA that you can find on the WSB site:

FDA is aware of adverse event reports in connection with Trifexis and continues to closely monitor them. It is very important to realize that reports of adverse events do not necessarily mean that the product caused the event. Other factors, such as existing disease, exposure to chemicals or contaminants, foods, or other medications may have triggered or contributed to the cause of the event.

I also bet you don't remember Strickland saying anything like the following in his reports: 

For any given ADE report, there is no certainty that the reported drug caused the adverse event. The adverse event may have been related to an underlying disease, using other drugs at the same time, or other non-drug related causes.  And, this listing does not include information about underlying diseases, other drugs used at the same time, other non-drug related causes, or the final outcome of the reaction.

Yet that statement is on the WSB website from last November, specifically attributed to him.  Knowing other underlying conditions and treatments is extremely important in fully evaluating adverse events like the ones currently in question.  I think it's worthwhile to point out a few of those cases so that the average person can see just how much is left out of these stories and how biased the media is in presenting the case.
  • The case that started these reports was related to three Viszla puppies who died after receiving Trifexis.  All three puppies had necropsies preformed by an independent pathologist and reviewed by another pathologist.  In all three puppies there were no signs related to the Trifexis and all three had changes in the heart consistent with a bacterial infection.  Elanco has provided a copy of this report to vets, which I've read, and it is very clear that the pathologists who were not paid by Elanco concluded that the deaths were unrelated to Trifexis.  How much of that made it into the news reports?
  • A Scottish terrier was reported to have had a reaction after a single dose of Trifexis in 2013, having vomiting, lethargy, and ataxia lasting a few minutes, but the recovered.  Okay, that sounds like a problem, right?  And this may be the same dog in the most recent broadcast story, though Elanco's case report doesn't list the client's name.  That same dog had been reported to have vomiting and lethargy after Comfortis in 2012 (remember, same flea ingredient).  The dog also had been diagnosed with cerebellar atrophy in 2004-2005, though that wasn't initially disclosed by the client.  In 2010 there was an elevation in one of the liver values.  Prior to taking Trifexis the dog had other health problems, including hypothyroidism, and was on various homeopathic nutritional supplements.  A liver biopsy after the Trifexis dose showed long-term cirrhosis of the liver.  You see on the news report "my dog took Trifexis, did poorly, and died."  You don't get the full story of the multiple factors and problems involved.  You aren't told that the dog had previous history of liver and neurological problems.  With all of these underlying issues there were multiple potential causes of the dog's illness.  It may also have reacted poorly to the Trifexis due to pre-existing liver problems.  Did these already existing problems make it on the news report?  Only a brief mention, which isn't as impactful as the owner getting emotional.
  • Watch the bulldog case on the same video.  The dog suffered seizures "after her third Trifexis dose".  And her other dogs continued to take it without any problems.  But the woman breaks down crying over this tragic death.  When you read the full report of the case you see that the dog had Trifexis for over six months, with a seizure starting in October 2013.  The vet she saw at that time concluded that the seizures happened unrelated to the Trifexis.  Seizures continued off and on for a month, but seemed to resolve from November until January 2014.  They became worse and by March the dog was euthanized due to seizures being uncontrolled.  The timing and likelihood of underlying problems weren't reported on the news.
The news reports the upset, crying owners, which pulls at the hearstrings.  I completely understand that these owners honestly believe that Trifexis was responsible for their dogs' death and illness.  Their grief is real and in their minds they know the answer.  I'm not belittling their feelings and genuinely wish this hadn't happened to them.  But when you get past emotions and look at ALL of the details objectively, a different picture comes to mind of other health problems.

Could Trifexis be a problem?  Possibly.  I'm open to that possibility, especially if further objective investigation leans in that direction.  But so far I've seen nothing that convinces me that this is a general problem of the medication's safety.  I still consider it safe for the majority of dogs and continue to recommend it to my clients.  If information comes out that confirms deaths and other serious adverse reactions, I'm willing to change my opinion.

Could an individual dog have a sensitivity to the ingredients in Trifexis and have serious health concerns?  Absolutely.  In fact, that may be what has happened in some cases.  However, unexpected or rare reactions are unpredictable and don't indicate a pervasive problem with the product.  We can never tell when a pet is going to have an unexpected reaction.  But the same thing happens in people.  I think most people consider aspirin to be safe, and never think to look at the warnings on the label.  Well, I did, and here are some of the possible side effects listed
Body as a Whole: Fever, hypothermia, thirst.
Cardiovascular: Dysrhythmias, hypotension, tachycardia.
Central Nervous System: Agitation, cerebral edema, coma, confusion, dizziness, headache, subdural or intracranial hemorrhage, lethargy, seizures.
Fluid and Electrolyte: Dehydration, hyperkalemia, metabolic acidosis, respiratory alkalosis.
Gastrointestinal: Dyspepsia, GI bleeding, ulceration and perforation, nausea, vomiting, transient elevations of hepatic enzymes, hepatitis, Reye's Syndrome, pancreatitis.
Hematologic: Prolongation of the prothrombin time, disseminated intravascular coagulation, coagulopathy, thrombocytopenia.
Hypersensitivity: Acute anaphylaxis, angioedema, asthma, bronchospasm, laryngeal edema, urticaria.
Musculoskeletal: Rhabdomyolysis.
Metabolism: Hypoglycemia (in children), hyperglycemia.
Reproductive: Prolonged pregnancy and labor, stillbirths, lower birth weight infants, antepartum and postpartum bleeding.
Respiratory: Hyperpnea, pulmonary edema, tachypnea.
Special Senses: Hearing loss, tinnitus. Patients with high frequency hearing loss may have difficulty perceiving tinnitus. In these patients, tinnitus cannot be used as a clinical indicator of salicylism.
Urogenital: Interstitial nephritis, papillary necrosis, proteinuria, renal insufficiency and failure.
Holy, freakin' heck!  If you take an aspirin it might kill you!!!!

EVERY medication carries potential side effects, some of them potentially serious.  There are no medicines on the market, even natural supplements, that have a completely 0 risk of adverse effects.  It simply doesn't happen!  Seriously, the next time you buy any over-the-counter medication, take a look at the product labeling and worry about the problems you might have.  Could Trifexis have caused some side-effects?  Yes.  But there is no evidence that it is a "dangerous" medication.

If anyone doesn't believe in media manipulation of facts, they need to seriously analyze these stories by Jim Strickland and WSB.  This is pure and simple one-sided fear-mongering and manipulation of emotions.  This is not real reporting, as a true investigation would easily bring up the facts that I've written here.  But that would not make good ratings, and that's all this story is about.  It's designed to make people watch because they fear for their pets.  It's not presenting all of the facts.

Now I know that there are plenty of web sites and reports from people who are convinced that Product X is deadly and should be removed from the market.  I've visited many of them in relation to Trifexis, Rimadyl, and ProHeart6.  I know that there is a good likelihood of someone making a comment, screaming at me for my ignorance, willingness to ignore "facts", and being a "Big Pharma sheep".  In fact, I'm expecting it.  But let's get beyond emotions and look at facts.  Let's look at the full details on cases, not just the emotional people that make it on the news, or the 10 second snippet from pet owner.  And let's put everything in the same font and style, rather than filling the screen with "935 DEATHS". 

With both Rimadyl and ProHeart6 there was a hue and cry about dogs getting sick and dying left and right.  When it was fully investigated it was learned that there was no basis to wide-spread problems and subsequent use over years and years proved the fears to be unfounded.  I fully expect the same thing to happen with Trifexis.

The question I then frequently get is "What do you use with your own dogs?"  I use ProHeart6 for heartworms and Comfortis for fleas.  If ProHeart6 wasn't available, I would use Trifexis.  Yes, even after all of these recent reports.   

Tuesday, July 29, 2014

Whelping/Queening At Home

Recently I was asked whether or not it was safe to allow pet dogs and cats to give birth at home (called whelping with dogs and queening with cats).  After all, humans in Western countries typically give birth in hospitals due to the risks to the baby and mother.  Is it the same with animals?
Definitely not.  It has been years since anyone brought a pet to me during the birthing process, and then only because there were problems with the mother being able to give birth.  Animals run much more on instinct than do humans and the process typically goes much smoother.  Often a dog or cat will give birth when the owner isn't around, so the person happens to go to their bed and find puppies or kittens wriggling around after everything is finished.  In the huge majority of cases the birth will happen safely and without the need for human intervention.

However, problems do occur and may require veterinary intervention.  Babies can be too big to pass through the birth canal or become stuck partway through.  If this happens get your pet to a vet immediately and do not try to pull the baby out yourself.  These cases may require a c-section and you could do more harm than good by simply pulling.  A good rule of thumb is that if the mother is having obvious labor (active abdominal contractions) for 45-60 minutes without a baby coming out, or that long between babies, contact a vet right away.  Some of these cases may simply require an injection of oxytocin or similar care, but there is always the risk of a stuck baby.

Some dogs and cats want to give birth right next to you, so don't be surprised if they pick a spot on your bed or under your kitchen table.  Others want the birth to happen in a quiet, secluded area, including the back of a closet or an unused room.  Let the pet pick their own location as that will be less stressful for them.  Provide a queening/whelping box (just do an internet search for those terms and you'll find links on how to make one) and keep an eye on things, but for the most part you simply let nature take its course.

Sunday, July 27, 2014

Does Trap-Neuter-Release Help Feral Cat Populations?

TNR programs (Trap-Neuter-Release) are common in many Western countries as a way to control feral cat populations.  The idea is that when there is a community of wild, unowned domesticated cats we can help reduce and eliminate this population by capturing them, testing for certain diseases, vaccinating, spaying and neutering them, then returning them to the wild.  Advocates of this policy believe that simply capturing and euthanizing these cats provides a vaccuum in the population which allows new cats to enter and continue the process.  They also believe that this is the most human method of handling feral cats.  But does this really work?
Unfortunately a growing number of studies is casting considerable doubt on the efficacy of such programs.  The stated goals of reducing the number of feral cats is rarely reduced unless there is considerable effort made.  In fact, studies have shown that in these cases populations tend to remain stable rather than decreasing.  The more that researchers have looked at the issue, the less support there is for the idea that TNR programs reduce feral populations.
Yet you'll find that most humane societies, animal control departments, and rescue groups support this idea, and even promote the position that it really does work.  If you simply look at the logic of procedure it really should work since you're removing breeding cats from a population yet keeping them there to compete for resources.  Unfortunately the reality of the situation doesn't tend to support this, and many of the studies quoted by such groups really don't provide data as the grops think they do.
Does that mean that TNR shouldn't be done?  Honestly, I'm on the fence about it.  You'd be hard-pressed to find anywhere in the world where an average TNR program has eliminated a population of feral cats.  By this evidence it really is a waste of money.  At the same time, we must be affecting populations by spaying and neutering, and hopefully reducing cats with FIV or feline leukemia by testing for and euthanizing those who are positive.  Maybe it's my heart rather than my mind that wants to believe in continuing them.  I still wonder if there are better ways to spend limited resources.
For more information here are a few links.  Read through them, compare the data, and make your conclusions.

Thursday, July 24, 2014

Dogs And Sunscreen

Most people don't think about it but animals actually can get sunburned.  It's not as common as in humans because their fur is typically so dense that direct sunlight doesn't make it to the skin.  They can still become overheated but true sunburn is uncommon.
That doesn't mean that it can't happen.  Breeds that are hairless are absolutely at risk for getting burned.  The same is true with a dog that has a thin coat where skin is exposed through the hair, or one that has a localized patch of hair loss due to another disorder.  Geography can also increase the risk, due to an area having a lot of direct sunlight or at higher elevations where the atmosphere is thinner and allows more ultraviolet rays. 
Excessive sunlight can carry the same risks as it does with humans.  You can have physical burns that can be painful or become infected.  You can increase the risks of certain kinds of cancer, especially squamous cell carninoma on the face and head of primarily white animals (dogs, cats, and horses).  Obviously these are things that we want to avoid.  The reason that pigs wallow in mud is to coat their skin and help block sunlight. 
Thankfully there are ways to help.  First, don't shave your dogs too short for the Summer.  The longer hair coat actually helps prevent sunlight from directly hitting the skin, so if the coat is too short you can increase the risks of burns.  As with humans, provide plenty of shaded areas for your dogs and try to avoid them staying in the direct sun for prolonged periods.  There are sunscreens specifically designed and approved for dogs, but in a pinch you can use plain zinc oxide sunblocks.  However, be careful not to let the dog lick at this kind of sunscreen as zinc can be toxic in high enough doses.  The key is to not ignore the potential for problems and burns.
Summer sun and heat can carry as much risk for our pets as it does for us.  Don't forget about them!

Monday, July 21, 2014

Dental Floss Doesn't Remove Skin Tags, But Thanks For Trying

After over 17 years in practice it gets difficult to surprise me or for me to see things I haven't seen before.  But today it happened.  It caused more of a sigh and face-palm than a true surprise, but it was still a variation that was new to me.
One of my other doctors saw a dog that has been a regular at our clinic for years.  He is an older beagle and generally in pretty good health.  He has had a rather large and long, but otherwise benign, skin tag for a long time.  We have talked to them about removing it while he was under anesthesia for a routine dental cleaning, but they had always declined.  It seems as if they had an inkling to try it themselves.
Today they brought him in to remove the dental floss they had placed around it. Yes, you read that correctly.  Dental floss.  About a month ago they had tied it tightly around the base of the skin tag, hoping that it would cut off blood supply and cause the tag to fall off without surgery.  The floss dug into the skin and tag, but didn't actually result in enough blood occlusion to cause the tissue to die and slough off.  But it did dig in enoug that they couldn't remove it themselves.  So our doctor had to use some suture scissors to get underneath it, cut it loose, and then clean the infected tissue around it.  All while the skin tag flapped around like it always had.

While this may be the first time I've seen dental floss used, this is an old (and rather bad) way to try and remove masses or even castrate an animal.  Usually rubber bands are used tightly around the offending growth or testicles, constricting the blood supply and eventually causing the tissue to fall off because the cells have died.  For some reason some people think that this is a perfectly acceptable substitution for surgery.

Using floss, string, or rubber bands in this way is one of the worst things you can do.  If the tissue is large enough, such as the scrotum and testicles, there will be pain and discomfort.  Would any man feel fine with having his family jewels tied off and left to rot for a month or two?  If the procedure actually does work, it's doing so because the tissues are dying from lack of blood supply.  It is literally dying and rotting off the body.  Who thinks this is a good thing?  There is a big risk of infection or having more tissue than desired be affected.  In the case of a mass or polyp you leave the base in the skin so it has a chance of regrowing.  In order to completely resolve the problem you have to cut away the attached skin, not just remove the dangling part.

Thankfully this was a relatively minor irritation and the dog is going to be fine.  And he's coming in later this week to have the skin tag properly removed.

Sunday, July 20, 2014

Questioning A Veterinary Career Choice

Here's a question from Ingelin.  Though she's in Norway (I love having an international readership!), her frustrations and concerns are universal and really shows some of the challenges for veterinarians world-wide.  I could take out the country references and completely believe that she is here in the US.
I am a Norwegian veterinary student, studying in Budapest, starting on my 5th year this fall.
I am currently - and have been for the last year or so, afraid that I have chosen the wrong profession.
Ever since I was a little girl (yep, as "all the others" also say..), I have imagined that nothing in the entire world would be better than doing veterinary medicine. My love for animals hasn't changed at all - I would almost say it has become stronger by seeing all the cruel things going on in research, labs and especially in the farm industry. Though, i sit here - closer to the goal than ever, feeling nothing but sad and frustrated.
This summer I am doing my practice in, so to say, the only horse clinic in Norway. The past months i have spoken to every vet i could, asking them about their working life and what they have to say about it. As I really really want to do horses, as this is where I feel most confident, I know the horse sport and I have been a horse owner myself for many years, and I feel like this is where I could do best - I have mostly spoken to horse practitioners. In general, most of them tell me: Life is tough. They spend hours and hours working their a**** off, earning nothing compared to what they do. They walk around in horse s*** all day long, one got his arm broken by a horse and a year later his mandibula. Another got her collar bone broken by a horse and actually, just after recovery - her knee got crushed by a horse. One got back problems after just working a year and is now in a lab.
Working 70-80 hours a week, one of them were in a period of 7 years in three car accidents due to driving from farm to farm - being so tired and falling asleep behind the wheel. They tell me that driving around day in and day out all alone without a supporting team around you is very hard. The physical work is tough, the organization of equipment that you need is both expensive and lots of work, all the billing/invoice work is time consuming and you would optimally need some knowledge in economics to do it well, it's hard with customers/owners not being willing to pay, or arguing with you that the treatment is too expensive, and especially as a woman you will meet many tough physical challenges and farmers can be very "oh jesus are YOU gonna do that - I could do it better". Ok, I think you got my point.
Some veterinarians tell me: do an internship straight after graduating, choose exactly what field you want to specialize in and stick to that. (For example not just equine surgery, but equine orthopedics). Others tell me that doing internships is "lethal": the salary is very little, you get to do very little "hands on" if you are at a big clinic with lots of specialists ect, maybe you wont get work in that field when you finish.. Do a mixed practice and learn a bit of everything so you can fall back on things if you have a hard time to get a job. Oh everyone is giving me different advises.

I feel really lost and I would almost say depressed. I have worked so hard to get where I am now and I want to feel nothing but proud and happy. I spoke to my supervisor at the horse clinic today which is on of the only horse surgeons in Norway. I have thought about doing and externship, and then hopefully get an internship, at the horse clinic in Kentucky, which my surgeon professors at my university has recommended me to do. Today my supervisor told me that the need for horse surgeons in Norway are very very limited, and if I want to work in Norway, DON'T do it. He recommended me small animals - but in Norway, believe it or not, the salary for a small animal practitioner is worse than working on the supermarket. Although there are opportunities to start your own clinic, get a good job if you do specialization first etc - so well, there are always options.
So to my conclusion: I have strongly considered changing to human medicine. In one way it makes me feel as an egoistic and cynical person - I always lived for the animals. They give us so much and I want to give back to them. But I see all the advantages as a human doctor compared to a veterinarian. You have a huge support team and always someone to ask, you never have limitations in treatments (so to say), I would have the chance to specialize in Norway and not having to do many more years abroad, you don't have to deal with everything on the economic aspect but can rather focus on your own profession, and you actually get paid for the hard work you do, which I think is important to a certain point for quality of life. To a human at least they can understand why you are doing what you are. To an animal however, I get a feeling of hopelessness. I know I am helping of course, but it's like: "hey this is gonna hurt like hell but don't worry it's to help you". They get angry, afraid, frustrated and aggressive, and I have never seen so many unhappy and suffering animals and I never thought it would be this tough. (Not that seeing severely ill people is easy..)

Ok i'm gonna put the finish line here. Sorry for all my thoughts and the very long email, but I would really really appreciate an answer! Maybe you have some encouraging thoughts to share.
Thank you very much in advance.
I thought it was worth printing all of Ingelin's email, as her thoughts, feelings, and experiences are actually pretty common.  I think that any veterinarian or vet student reading this will be nodding their heads in agreement, having run through the same scenarios in their mind.  I also think this is very important for pet owners to understand, as vets aren't sitting on their duffs just counting their wads of cash.  This is a hard, often thankless profession for which we are significantly underpaid for our level of skill and knowledge.
I'm a small animal veterinarian and haven't worked with horses in about 18 years.  I've never practiced on them and have never considered a career in large animal medicine.  But I'm at least basically familiar with that part of the profession and know that Ingelin's experiences are shared here in the US also.  I do think that the typical 70-80 hour work week is gradually going away as we graduate new vets who realize that they can't be everything to everyone, and are trying to have a decent work-life balance.  But it's still long hours.  You often find yourself in creeks in the dead of winter and in shadeless fields in blazing summers.  While most horse vets I've known manage to get away with few major injuries, it is still a much higher risk than with small animals.  There is absolutely the risk of serious injury and broken bones when dealing with animals this large and strong.  It is definitely a physically demanding profession and not one for the faint-hearted.
The business aspect depends on where you work.  Many vets, especially younger ones, are learning the benefits of hiring an office manager to handle the financial side of things.  A solo equine practitioner is in for an incredible amount of work if they do everything by themselves.  But if you get into a practice with a physical location and hire a good staff, you can get an office manager to handle payroll, billing, ordering, invoices, and so on.
Customers not wanting to pay?  Welcome to veterinary medicine!  Certainly you can get a bias against females among some farmers, as well as sometimes an attitude that they know more than you do because they're older and the farm has been in their family for generations.  You won't find as much of that in small animal medicine.  But if you are seeing client-owned animals you will quickly become frustrated with people who can't or won't pay for needed care.  The species of the patient is irrelevant.  I deal with at least a few clients like this every single day that I work, and have for my whole career.  Because pretty much all of animal health care comes straight from the owner's pocket you see them holding tighter to their purse strings than when it comes to their own medical expenses that are generally covered by insurance. 
Animals suffering breaking your heart?  Having a hard time dealing with animals in pain when you can't explain things to them?  Again, welcome to the profession.  It takes a special kind of person to be objective and distant enough to handle sick and injured animals while still maintaining compassion and empathy.  Working in any medical field can be emotionally draining and requires some good mental resilience. 
Internships and residencies are indeed brutal.  If you don't really, truly want to specialize I don't think I'd recommend it.  You make less than half of what you would make being in practice and the hours are much longer.  Should you consider going into a specialized field?  Only if you really have a super-strong interest in that area.  When I was in vet school I spent a few weeks working side-by-side with a board-certified surgical specialist.  He told me that he did make more than a general practitioner, but it took him about six years after vet school doing internships and residencies to reach that point.  For those six years he made about 1/3 of what his classmates made.  His lifetime earnings were going to be no different than a general practitioner due to the significant delay in finally practicing his speciality.
From what I understand in the US, your prospects of finding a good job in equine medicine may be better than in Norway.  It would certainly depend on where you wanted to live and work, as some areas are more under-served than others.  The areas with fewer vets working with horses and other large animals unfortunately tend to be areas where the salaries would be lower and you'd be working hard due to a lack of qualified vets.  But you may not want to leave your home country, especially for an entire career, so this is something you'd have to think hard about.
Personally I could never work in human medicine.  Humans gross me out and I can't handle that sort of thing.  I get feces and urine on me every single day and it's not a big deal.  But the idea of getting human feces on me makes my stomach churn.  Yes, the pay is higher, you have much more support staff, and you get to do more things without worrying about money.  But I'm not willing to make that trade because I can't handle seeing human illness and injuries.  It digusts me and makes me uncomfortable.  That may seem strange to some people, but it's actually a common thing among those in veterinary medicine.
Ingelin, I had to be a downer but you have actually expressed the same frustrations shared by the majority of the profession.  You have expertly described the daily problems we have and why this is not the best profession in the world.  I actually agree with everything you said, as it's true here in the US as well as other countries.  That is the depressing nature and harsh reality of veterinary medicine.
So why do it?
There are moments of greatness every day.  You will meet wonderful clients who think the world of you and will follow your every instruction.  Today we had a client bring us fresh, homemade eggrolls, still warm when she brought them in.  I got to work with some incredible cute and sweet puppies.  I was able to tell an owner that her cat didn't have a blocked bladder and had a treatable infeciton.  I helped comfort a client by easing the passage of their terminal cat.  I got to teach an eager veterinary student.  I can walk out of my clinic today proud of the fact that I helped to change and improve lives. 
It isn't an easy job and I frequently question my career choice.  But I've also reach the point in my life where I can see the joy in the day and be able to smile when I've helped someone.  Would I do it all over again if I had the chance to go back and make changes?  Probably not, except for the fact that I love my wife, family, and faith, and I wouldn't have those if it wasn't for my choices in and after vet school.  I would definitely pick a completely different career.  But I also don't hate my job (most days) and am very content where life has taken me.  It's a good job and I've been successful at it.
This probably doesn't help, and if you go back through the archives of my blog you'll find that I think this is a bad time to try and get into veterinary medicine.  Should you change your career, Ingelin?  It depends on how much passion you feel about veterinary medicine, how desperately you want to work with animals, and how well you can deal with the long hours and low pay.  That's certainly not a simple, easy choice and I don't have an easy answer.

Friday, July 18, 2014

Being A Better Customer

As the lead doctor and a manager in my practice I have to deal with a lot of odd or cranky clients.  Over the years I've had this blog I've talked about many of them.  I also am a fan of the website Not Always Right ( because of the plethora of stories about strange, unruly, and unreasonable customers.  It's kind of therapeutic for me to read about other people's encounters with the bad customers and clients, as I see similar situations almost daily.  As in any profession we often have to handle clients who are impatient, make unreasonable demands, have a short temper, seem determined to blame us for their negligence, or simply have an inability to understand very simple things.
Over the years I've gotten better at handling these situations.  They don't bother me and sometimes I'm downright amused rather than upset by the client.  I've learned a lot of ways to talk to people, help them understand, and overall calm them down.
But one of the best things about being a manager and working with the public is that it has made me a better customer and consumer.  When I talk to my team about excellent client service I make people give examples from their own lives of experiences where they were blown away by service and ones where they were so poorly treated that they would never go back again.  I have my own stories, especially of stellar service.  While I use this to teach my staff how to treat our clients, it also helps me understand how to be a consumer myself.
I try to smile at cashiers and acknowledge their greeting.  I try not to be upset at someone who merely works at a the desk or answer the phone, realizing that they were not involved in a mistake that was made.  When there is a problem I try to be patient and see how it is handled and rectified rather than jumping straight into yelling.  I try to remember that everyone is human and makes mistakes, so it's more important to see what happens after the mistake rather than being upset just at the mistake.  I try to give businesses time to look into a problem and try to fix it.  When someone gives me exceptional service I always try to remember to thank them, and then find a manager to acknowledge that service.  When I go to a doctor's office I bring a book or something to work on as I know that delays can happen and are often beyond the doctor's control.
I'm not perfect and I get as frustrated as the next person.  The difference is that I and my staff have been on the receiving end of bad clients many times, and I don't want to be that kind of client.  I try to remember how those situations made me feel and why I thought the client was unreasonable, and then avoid acting the same way.  I'm in a service industry and have sympathy for others who deal with customers, especially the cranky ones. 
I just wish everyone could learn the same lessons.

Wednesday, July 16, 2014

TPLO For A Dog's Knee

One of the most common orthopedic injuries in dogs is a rupture of the cranial cruciate ligament (CCL).  In humans this is the anterior cruciate ligament, or ACL, and is a very common sports injuries.  Just about everyone I've met has known someone who ruptured their ACL or did so themselves.  Dogs and cats can also cause damage to this structure, especially certain breeds such as Labrador retrievers.  When we see a dog come in with acute single hind limb lameness this is the first injury that we consider.

The main function of this ligament is to give the knee joint stability in a forward-to-backward motion.  The knee should have minimal movement in this direction and if the ligament is torn you have sudden instability.  You also get significant inflammation due to the damaged tissues.  In really bad cases the meniscus (cushioning pad in the joint) can also be torn, further heightening the damage.  This kind of injury typically occurs suddenly and after activity such as running or jumping.  The patient is painful, the joint becomes swollen, and there is usually noticeable movement of the joint (something called "drawer motion").  The combination of these symptoms results in the pet not wanting to put any weight down on that leg.  The nature of the damage also means that this does not get better in a day or two.

As with humans this virtually always needs surgery to correct.  Cats actually may not need surgery due to their size, less stress on the joints, and some minor differences in the flexibility of their joints.  If a dog doesn't have surgery they are looking at months of slow, gradual recovery and a joint that will always be unstable and possibly always be painful.  I have seen dogs go on to be normal after a CCL injury without surgery, but the it too a long time and the joints always developed arthritis earlier than would otherwise have happened.

There are two common ways to fix this injury and several less common ones.  The most tried-and-true is what we call an "extra-capsular" repair.  In this case the surgeon goes into the knee, removes any damaged tissue, drills a hole in the tibial crest, and places high-test nylon wire or suture in a pattern around the knee joint.  Removing the tissue debris allows the inflammation to resolve.  The nylon provides stability to the joint and once healed allows normal movement and weight-bearing.  This is a surgery that can easily be performed by a skilled general practitioner and there is rarely a need to have a specialist surgeon involved.  But not all vets are comfortable doing this procedure.  I'm one of them!  I can take out a spleen or kidney, remove bladder stones, repair a ruptured diaphragm, and similar soft tissue surgeries, but I just do not like orthopedic surgeries and don't do them.  While possible for a non-specialist to perform, and while being the least expensive of the CCL repair surgeries, this technique does carry the highest risk of complications.  The nylon suture can rupture at some point and therefore would need to be taken out and replaced.  You can also have more likelihood of arthritis in the joint compared to other procedures, but not as likely as if surgery was not done.  This is still a viable option if you cannot afford a more complex procedure.

The other common technique, and one most recommended by surgical specialists, is "tibial-plateau leveling osteotomy", or simply TPLO.  This is a much more complicated surgery as it requires the bone of the tibia to be cut, rotated, and held in place with plates and screws.  The goal is to change the angle of the "plateau" of the tibia (the part at the joint with the femur), preventing the femur from sliding along an angle when weight is placed on the leg.  This change in angle provides more stability and less slipping stress than other procedures.  The long-term outcome tends to be much better than with an extra-capsular repair and recovery is much faster.  The down side is that it can cost around  twice as much and often requires going to a specialty facility.

Such a procedure needs to be done by someone highly trained in the technique and with good experience.  Definitely not something the average veterinarian will do!  Typically this is done by a board-certified surgical specialist, though in some areas your vet may know someone who is highly trained as a surgeon but isn't actually certified.  I use that kind of doctor in my area because he will come to my clinic, and he's an awesome surgeon.  

Besides education, why bring this up now?  One of my staff recently had this done.  What's interesting is that her dog had an extra-capsular repair on his left knee several years ago by a general practitioner.  Recently he tore the CCL in his right knee and needed another surgery.  The staff member is considering going to vet school in a few years and is well-versed in the field.  She did a lot of research and decided that she wanted a TPLO done on the newly injured knee.

The surgery went well and his recovery was fast.  I saw him around a week after the surgery and he was starting to bear weight on the leg.  Much faster than I've seen with techniques other than a TPLO!

A week or so after that he jumped up and down when someone came to their house, and then became lame again.  One of the most important parts of recovery for this surgery is keeping activity minimal until full healing has occurred.  We were worried that his jumping had torn apart the surgery and he'd have to go through it again.  Here are his x-rays, clearly showing the technique of the surgery (which is a main reason for the post....x-rays are cool!).  Please pardon any blurriness, as these were taken with my phone pointed at the computer screen.

Thankfully everything looked good.  We put him on pain medications and anti-inflammatories, then went back to earlier rest and physical therapy.  Within a couple of days he was feeling better.  His owner was very happy that nothing had moved and he wasn't going to have to have another surgery.

Personally I think the TPLO procedure is better than extra-capsular, especially in large breed dogs.  But many people can't afford the $2000-$3000 price tag (depending on regional variation in prices), in which cases the extra-capsular surgery is still acceptable.  

This is yet another reason why having pet insurance and setting money aside for pet emergencies is such a good idea!

Monday, July 14, 2014

Cheap Food Vs. Expensive

This email hit my inbox recently and brings up a great question....

Hi, your blog is great. Anyways, as someone who knows quite a bit about the beauty industry I know the cheaper products usually work better than more expensive bc the big brands like P&G and Loreal have more money for R&D and formulations between the cheaper and more expensive brands they own are almost identical. An Olay anti wrinkle cream is likely to work better than a cream that costs hundreds of dollars. Is it the same for pet food? What's the relationship between food price and quality?

In general I do believe that you get what you pay for.  More expensive products often are that way for a reason related to the quality of ingredients or manufacturing.  For example, there is a big difference in the cost and features of a Hyundai versus a Lexus.  A Mont Blanc pen is going to last longer and have better quality than a Bic.  But does that extend to pet foods?

All pet foods in America are required by law to meet certain nutritional standards.  But some of them do it better than others.  And just because a food meets a minimum standard doesn't mean that it meets the best standard.  There really is a difference in the quality of the different foods, though it's not easy to tell which is better.  Certainly you can't rely on the commercials and other advertisements, as those are written by marketing experts to deliberately convince you to buy the product.  Not all of them are deceitful but all are by their very nature manipulative.

You also have to be careful about the representatives you meet in pet stores.  Like advertisements these people are trained to make you think their company's food is the best thing ever and all other foods are no better than eating from a trash can.  They are taught all of the right talking points and how to win you over to their point of view.  Some of them even give misinformation, either deliberately or through poor training by the company.

There are definitely differences, though. Just looking at the ingredient list you can usually tell a difference between "good" and "bad" foods.  However, there is certainly both an art and science to reading labels so this isn't always the best determining factor.  As a few examples, by-products aren't bad, "fillers" really aren't used in pet foods, and the first ingredient may not be the ingredient with the highest percentage of nutritients in the food.  Even I have sometimes gotten confused as to which is a high quality brand and which isn't.

In my experience and based on my discussions with nutritional specialists the cheapest foods are lower in quality.  But the most expensive foods may not always be the best ones.  And regardless of the price of the food your pet can certainly survive.  The question is, will it thrive.  Eating a cheap food is similar to a human subsisting on pizza, hamburgers, and an occasional salad or carrots.  Can you live and survive on that diet?  Sure.  But you won't be doing the best thing for your body.

So how do you tell the difference between foods?  Which ones are best?  And what determines that?

Every few years I contact the board-certified veterinary nutritional specialist at the closest vet school and ask them about these issues (most recently in December 2013).  I want to hear from the ones teaching the classes and doing the research, and want to keep up with current information.  Every time I talk to a specialist I end up with the same recommended food list.  And their recommendations are consistently based on things that you can't find on the food label or on the food company's website.  Heck, even I can't get the best information without contacting a specialist!

For the nutritional specialists there are a few very important things they consider besides simply the ingredients.  One factor is whether or not the company is actively engaging in current research on veterinary nutrition.  These companies have a long history of spending money into research on nutrition in animals, both for well pets and to help treat diseases with the right nutrient balance.  They are the ones who help build the current knowledge we have of how nutrition relates to health and physiology in pets. 

The other factor, which in many ways is even more important, is the amount and type of quality control the company has over the manufacturing process.  The best companies test batches daily to ensure consistent nutritional quality and seek out the best quality ingredients.  Some food companies simply can't test their food this rigorously because they don't own the manufacturing plant.  Yes, there are plants that exist and will make a pet food based on the recipe they are given.  But since the company providing the recipe doesn't own the plant, that company can't check the food as well or as consistently.  And then there are those who simply don't bother checking the foods often enough.

So what foods?  What brands?  According to the specialists I've spoken to personally, the following companies' foods are the ones they recommend the most and which they feed their own pets.

Royal Canin

Personally I do think there are different "tiers" of foods within such companies, especially Purina. Of their foods I only typically recommend Pro Plan or Purina ONE as being better than their cheaper ones such as Dog Chow and Cat Chow. 

So I would never go with the cheapest foods, but you don't have to use the most expensive ones to still provide a great quality nutrition.  Hope that helps answer the question!

Here are links to some of my previous posts on nutritional issues with pets.

The Tricky Fine Print On Pet Food
The First Ingredient....It May Not Be The Most!
Corn In Food...No, It's Not Bad
The Great Veterinary Food Conspiracy?

 And inevitably a discussion on nutrition brings out people who are adamantly against manufactured foods, who think that I and other vets are buying into a bunch of hogwash promoted by the food companies merely to sell food, and who think that only their little community of friends and nutritionists know the "truth".  No problem.  I've handled those discussions before, so go ahead.

"Let food be your medicine and medicine be your food."

Saturday, July 12, 2014

War Of Words: Purina Vs. Blue Buffalo

There is a battle brewing between two major food companies, and it's not pretty.  Blue Buffalo and Nestle Purina PetCare are going to blows in the legal system in the US and the war of words is becoming ugly.
It started back in May when Purina sued Blue Buffalo over what Purina saw as misleading claims on Blue Buffalo packaging and in advertisements.  Purina had some of Blue Buffalo's foods put through independent analysis of the contents, and found evidence of ingredients that Blue Buffalo explicitly states are not in their foods.  According to an article in Veterinary Practice News:
Nestlé Purina reported that independent laboratory tests found "significant percentages” of poultry byproduct meal in several Blue Buffalo Life Protection recipes and discovered both poultry byproduct meal and corn in LifeSource Bits, a mixed-in blend of vitamins, minerals and antioxidants.

Levels of poultry byproduct meal ranged from 25 percent in one sample of Indoor Health Chicken and Brown Rice Recipe for cats to 22 percent in a sample of Chicken and Brown Rice Recipe for adult dogs, according to the Nestlé Purina lawsuit.

"In addition, several Blue Buffalo products promoted as ‘grain-free’ actually contain rice hulls despite Blue Buffalo stating on its website that its
grain-free products will ‘free your pet from the grains and glutens that cause allergic reactions in some dogs,’” Nestlé Purina reported in a separate statement.
Blue Buffalo is obviously aggressively denying these claims and even calling Purina's analysis "voodoo science".  And if one lawsuit isn't enough, Blue Buffalo countersued for defamation, unfair competition, and false advertising.

"In response to Nestle Purina’s malicious attacks against us, we have initiated a lawsuit against them demanding that Nestlé Purina and the individuals working in concert with them be held accountable for their false accusations about Blue Buffalo and that their carefully orchestrated smear campaign against the Blue brand cease,” company founder Bill Bishop said.

Purina slammed the new allegations.

"Blue Buffalo’s lawsuit today is exactly what we expected: a distraction from the real issues in the case and an attempt to stop Purina from being honest with the

This isn't actually the first time Blue Buffalo has found itself in trouble for potentially misleading statements about their foods compared to competitors'.  Back in March the National Advertising Division (NAD) ruled against Blue Buffalo when Hill's claimed its commercials and websites were manipulative, misleading, and untrue.

"The challenger argued that all of the challenged advertising conveys the same falsely disparaging and inflammatory message: that ‘big name’ pet food manufacturers, including Hill’s, are actively [trying] to conceal the fact that they include chicken byproduct meal, instead of meat, as the first ingredient,” NAD stated.

The agency determined that the advertisements "reasonably conveyed that leading pet food makers are misleading consumers by actively concealing the content of their products and by positioning their products as high quality when they are not and that consumers should switch to Blue.”
And we can go back to 2008 for a similar complaint against Blue Buffalo (as stated in this 2009 article from Pet Product News).

The National Advertising Division of the Council of Better Business Bureaus (NAD) claims the Wilton, Conn.-based manufacturer has declined to modify or discontinue its “no animal by-products” advertising claims. Blue Buffalo maintains that it has altered its advertising, but not its packaging, which the company claims NAD does not have authority over.

NAD reviewed advertising for the Blue line of pet food in July 2008 following a challenge by competing pet-food manufacturer Hill’s Pet Nutrition. NAD recommended that Blue Buffalo discontinue its “no animal by-products” claims when made in reference to pet foods containing fish meal, lamb meal and/or liver.

NAD noted that Blue Buffalo pet foods are made with liver, fish meal and lamb meal. Although Blue Buffalo did not disclose the composition of its fish and lamb meal, “the relevant regulatory guidelines make clear that these meals can include kidneys, intestines, eyeballs, brains and other viscera,” according to NAD. NAD found consumers would “expect that a food with ‘no animal by-products’ [would] not contain such ingredients.”

And while the company did handle the issue, there was a recall of some Blue Buffalo foods in 2010 for excessive vitamin D, leading to possible toxicities. 

Want one more opinion?  This past December I had conversations with Dr. Sherry Sanderson, a nutritionist and professor at the University of Georgia College of Veterinary Medicine, about various pet foods.  I was surprised at how strongly she was against Blue Buffalo foods.  Her opinion is based on the vitamin D toxicity issue I mentioned above, as well as dishonesty from the company about their foods and their competitors'.  She is a university professor and doesn't work for a food company, so I think she's about as objective as you can get.  This summer I have a veterinary student from that college working for us, and she confirmed that Dr. Sanderson is recommending people against Blue Buffalo.

Now some may say that Purina is just trying to destroy a competitor by making slanderous statements, and thus trying to protect their own market share.  Certainly it does have a very "David versus Goliath" feel to it considering that Purina is the largest pet food manufacturer in the US.  But when taking all of the information together, I really have to start thinking that there really are issues with Blue Buffalo.  We have not only Purina's recent lawsuit, but two different decisions by the NAD against Blue Buffalo, a recall of their food, and a nutritional specialist against the company.  I have also never seen Hill's, Purina, or any other pet food company attack a competitor in this way.  Sure, each company says why their product is better than anyone else's, but in 17 years in practice I've never seen any company so consistently blasted for misleading or inaccurate statements.   Hills', Purina, Iams, Royal Canin, and others have never gone this far when trying to convince people that their food is best, and Purina has had opportunities to "crush" other up-and-coming companies. At some point where there is smoke there is probably fire. 

Needless to say, at this point I don't recommend that my clients use Blue Buffalo foods.  I'm also very curious as to what will come out in the lawsuit since Purina claims they have definitive proof of the ingredient analysis. 

Friday, July 11, 2014

Confused About Flea Control

Anne has a question to which I'm sure many other people can relate.

Hopefully you can help me since after reading your blog it is clear you have a more accurate opinion than mine ….I currently own 2 short leg jack russell, 1 jack russell and a Basenji.

We all live in Guatemala City and I give them their anti-flea (Frontline or “Pulga Kill) and when ever I can find Heatgard for heartworm. The flea prevention available is not the best and the heatgard is not always available so I decided to buy it from the US (Im thinking 1800petmeds) a year supply of heatgard and advantix…..

I started looking into triflexis and sentinel and the many other pills available that can replace the advantix and heatgard.

*There is one that we have to keep in mind, here there are fleas everywhere so i need a flea prevention method that repels fleas and would prevent any larva to develop.
I am just very very confused, i don’t know if I should use them or stick with what i know and do already? I have been reading online and the more I read the more options/reviews and it gets very confusing.
Any comments or suggestions to see would be very appreciated.

I haven't blogged about flea control in a few years, so I thought it was about time.  Before anyone really delves into today's post (especially to criticize any information) I would recommend going to the search box at the top of the page and put "fleas" or "flea control" as the subject.  Even though it has been several years since I've discussed this in detail the information I shared previously really hasn't changed.  You'll also get a lot of answers to your questions in some of my older posts.

There are a few key points to keep in mind.

1.  If you don't have good environmental control you won't keep the fleas in check.  Besides treating the dog you also need to treat the house and yard, as this is where the eggs and larvae are.  If there are stray dogs and cats or wild animals in the area they can be a constant source of new fleas.  If you have a lot of these animals around your home it will be virtually impossible to have complete flea control.

2.  Any topical medication can be washed off with frequent bathing.  Most of them are waterproof or water resistant, but none of them are shampoo-proof.  If you bathe more than 1-2 times per month you are significantly decreasing the effectiveness of any topical flea preventative.

3.  You want to look for products containing an IGR ("Insect Growth Regulator").  These products will help control eggs and larvae, keeping them from developing into adults.  If the package does not specifically state that it controls eggs and larvae it will only kill the adults and you will have a harder time fixing the problem.

4.  Personally my favorite products are Vectra ( also sold as First Shield in Banfield Pet Hospitals in the US), Advantage/Advantix, Comfortis, and Trifexis.  My opinion is based on research and discussions from two top parasitology specialists, Dr. Mike Dryden and Dr. Byron Blagburn, both of whom are recognized world-wide for their expertise.  Comfortis and Trifexis actually kill fleas faster than any other product, but won't treat anything in the environment or kill stages other than adults.  However, they kill adults so fast that those fleas don't have time to lay eggs after feeding.

5.  Opinions are like ***holes...everyone has one.  I know it can be confusing on the internet, but you will eventually have to make up your own mind.  For any product you consider you can find people who whole-heartedly support them and others who think they are evil incarnate.  Take various opinions with a grain of salt, including my own.  Also keep in mind that someone's opinion is generally worth what you pay for it, once again including mine. At some point you're going to have to decide who and want to believe, as you're not going to find 100% consensus on anything.

Personally I don't like Sentinel for flea control as it doesn't actually kill fleas.  Did you know that?  The main ingredient, lufenuron, prevents the flea larvae from hatching, thus helping to control the population in an area.  But the adult flea lives out its normal life span and will continue to bite on your dog.  If there are warm-blooded animals in the area which can provide a food source for the flea, you will continue to have problems.  This product is only good if you have a family with only dogs and the environment is easy to control.  Even so, if you do end up with fleas and the dog is allergic this is not a good product.

I hope that gives a little bit of help for Anne and everyone else struggling with fleas.

Thursday, July 10, 2014

Puppy's Receeded Vulva

Debby sends this to me....

I have spent hours scouring the Internet for information about chronic eColi bladder infections in young dogs.
My Havanese Gracie has had them since 8 weeks of age. I take her to my trusted vet immediately when she shows symptoms and she has been on numerous rounds of antibiotics. She has a "tucked" vulva and may need surgery to correct. Very disappointing since I went to a reputable breeder with champion dogs who has been breeding for over 13 years.

Now my dear friend Kimberly has a 10 week old yellow lab with an inverted or tucked vulva. Her vet said he has never seen such a severe case.

1) is this a defect that our breeders should have disclosed?

2) Does surgery always correct chronic UTIs?

We want to find a veterinary surgeon with expertise in this condition. Can you tell us where to go? Is UGA the best option? I have searched the web for "canine vulvoplasty specialist in GA" and all I find are owner blog posts.

Any help you can give us will be greatly appreciated.

An inverted vulva is an uncommon problem and can happen in any dog.  For those who are not aware of this condition, the outer vulvar lips become depressed within a fold of the skin in the genital area.  This is a problem that can be genetic with an abnormal development of the tissues, but it can also be secondary to obesity or inflamed skin.    Obviously in a case like this it is likely genetic.  And it can predispose a dog for both urinary tract infections and localized skin infections as superficial bacteria are more likely to ascend into the vagina and bladder, and urine can pool in the folds causing irritation.

Debby, first I want to say that this doesn't mean that the breeder did something wrong or was careless.  Breeding good quality is all about genetics, and there is no way to 100% control those factors.  A great breeder can choose dogs carefully and thus improve the odds of high quality puppies, but nobody can completely control how the genes will combine and how those genes are expressed in an individual.  Due to the nature of gene replication and combination there is always a chance that two champion dogs with no defects of their own can produce a puppy with some problems.  Picking a great breeder only lessens your odds of a puppy with abnormalities; it doesn't eliminate them.  Genetics is a bit of a crap shoot and while you can changes the odds a bit you can't fix them to always be in your favor.

Should your breeder have disclosed this?  Honestly, they may not have noticed it.  This is an uncommon problem and not something for which we routinely check unless it's glaringly obvious or there seems to be a health concern.  Most breeders and owners don't routinely make a careful exam of their dogs' genitalia.  And since it's uncommon they may not have seen it before or been aware of it as a legitimate concern.  So this is a quesition for them.

The way to fix the problem is with a vulvoplasty, as you mentioned.  Essentially this surgery results in removing the deep fold by removing the skin in that area, then suturing the outside of the vulva to the skin.  If done properly you end up with a normal looking genital area and no increased risks of urinary problems.  Since there is a genetic component to this problem I would also strongly recommend spaying her if you weren't already planning to.  If the chronic infections were due to the receeded vulva then surgery should correct that tendency.  However, there is a small chance that it won't and in this case there may be other issues that need to be addressed.  Since you now exactly what the bacteria is I assume that your vet has performed a urine culture and sensitivity.  If not, then this should be an immediate step in order to rule out resistance to common antibiotics.

There is no such things as a "vulvoplasty specialist".  In veterinary medicine we simply don't see enough of a certain case to become specialized in one single form of surgery.  A very skilled general practitioner can do this surgery.  I've done this before and truthfully it's not a complicated procedure.  I wouldn't want a new graduate to do it without supervision, but a specialist is not required.  Your vet may not feel comfortable with it and may recommend a specialist, which is perfectly normal.  There are plenty of surgeries that I won't do but other vets will (such as cruciate repair).

If you really do want to go to a specialist you would need to look for a board-certified veterinary surgeon.  I actually practice in northern Georgia, so I'm familiar with the ones in this area.  If you're close to Athens then the University of Georgia veterinary school is your best option.  If you're closer to Atlanta I would recommend either Georgia Veterinary Specialists or Veterinary Referral Surgical Practice. South of Atlanta I'm not familiar with who might be an option.  But really you should ask your own vet who they recommend and with whom they typically work.

With a good surgeon there should be no reason why this puppy couldn't go on to lead a normal life.

Tuesday, July 8, 2014

Dog Punishing A Cat

Here's a rather unique and interesting situation from Autumn.

I adopted my dog from a shelter about 7 years ago when she was about 1 year old. She is a crossbreed, but definitely has strong herding instincts. She is generally sweet and calm around my cat, except for when the cat gets in trouble. If I raise my voice at the cat when he is chewing on the afghan, the dog runs over and smacks him. The cat is old now and I’m afraid he will get hurt. The cat hasn’t been hurt so far and the dog hasn’t escalated the discipline, but I would like to stop her from doing this. Any suggestions?

I would absolutely love to see a video of this!  Yes, part of the reason is that it would allow me to have a better idea of exactly what is going on.  But to be completely truthful, I think this would be one of those videos on YouTube that goes viral!

Dogs don't mimic human disciplinary actions the way that our children or even apes might.  Dogs also don't associate cause-and-effect in the same way that we do.  So it is unlikely that the dog is consciously seeing herself as a "disciplinarian" or somehow punishing the cat for you.  That is especially true if you have never struck the cat yourself (based on your concern I assume you haven't).

What is more likely is that your raised voice is triggering excitement in your dog, and that is leading to the behavior.  She hears your own anxiety or excitement and sees your body language.  When you raise your voice it triggers even more of a heightened excitement state in her and is the trigger.  If you've been around herding dogs you probably know that they can become worked up quite easily and have a low threshhold for such triggers unless they are specifically trained otherwise.  The cat is likely just the outlet for this behavior and it could be directed towards any nearby pet if you had others.

There are a few things you can do.  First, change your own behavior.  Instead of yelling at the cat make different noizes.  Air horns can work well, though they are particularly loud.  You can also put coins or small rocks in a used metal can and shake it vigorously.  Any sudden, loud noise is generally sufficient to startle a cat out of its behavior.  And such noises don't come from a human so your dog may not react the same way.  An alternate is to have water guns placed around the house and whenever you see the cat doing this simply give him a good squirt.  This has no noise and is a highly effective training tool.

You can also work with your dog regarding those vocal tones.  Use methods similar to what hunters do to desensitize a dog to gunshots.  Start with her in a quiet place and give her a command to sit, lie down, or stay.  Then make a soft yell or shout.  If she gets up, make her go back into a stay or hold position and reward her.  If she doesn't get out of that position, give her a bigger reward.  Do that for several minutes every day, and after a few days raise the volume and urgency of the shout.  Only reward the good behavior of being calm and still, and don't get mad if she gets up or runs around.  At those times just make her go back to the beginning.  The idea is to reward the desired behavior and gradually raise the intensity of the stimulus.  When she starts to learn that a raised voice means she should be still you can start trying it around your cat.

Best of luck!

Monday, July 7, 2014

Product Review: Firefly Wireless Video Otoscope

A few weeks ago I received an email asking if I would be willing to review a wireless video otoscope.  I've always wanted to use one so of course I said yes.  Currently my practice uses the Welch Allyn line of equipment so this was a bit of a departure for me.  I eagerly awaited the package and once it came I started taking it to work to get a feel for things.

Initial impressions:  Dang, this thing is small!  All of the video otoscopes I had previously seen at conferences were at least as large as my Welch Allyn unit, if not slightly larger.  The Firefly DE551* fits in one hand very comfortably.

The silver focus dial sits right at the index finger, making it easy to change the dept of focus during the exam.  At the top of the unit is a single button that allows you to take pictures of the image, saving them for later use.  One drawback that I found is that this picture button is a little awkward as you have to use your other hand to push it.  I tried various positions and this was the easiest.  If you're the only one handling the pet this can be tricky to do without losing a good image.  But with an assistant this is a minor concern.

On the side is a dial that controls the brightness of the light.  Most of the time I left it at the brightest setting, though this may vary based on your individual preferences.

The unit comes with a set of disposable plastic otoscope cones.  It's pretty obvious that these are designed for humans, as they are very short and really don't go deeper than the vertical canal in a dog or cat.  Thankfully Firefly makes a set of metal veterinary cones.  These are much longer and work as well as a typical cone.  

Here are some comparison pictures. The top image is the largest ones and the bottom is the smallest ones.  On the left is the Welch Allyn cones we use.  On the right are the two firefly cones.  

You can see how much smaller the plastic Firefly cones are.  I found the plastic cones that came with the unit to be pretty much useless for average veterinary use.  But the metal ones worked very well.  And I really liked the fact that they are metal rather than plastic!  In human medicine the cones are discarded after each patient, but in a vet's office we clean and disinfect them, then reuse them.  The metal cones will last much longer and stand up to rough use better.  I also like the fact that the standard set comes with cones that have open channels, which makes it easier to insert probes.

Here's a quick tip for any new users.  Make sure the cone is pushed all of the way into the unit.  I found that if it was partially seated it would feel stable but would have the potential to shift easily if the patient moved their head during the exam.  Pushing it firmly and deeply into place made this much less likely.

One of the things I like most about the Firefly otoscope is that it is wireless.  I don't have to worry about wires running around the room or getting myself, clients, or patients tangled in the otoscope cord.  The unit comes with a wireless receiver that fits into any USB port.  Since I only have one (so far) I chose to use my laptop on a Mayo stand, making it quite portable.  

So that's the setup.  What about the image quality?  How well does it actually work?  

Pretty good, actually.  I'm still getting used to it, so I'm sure that with more practice I'll be able to take better pictures.  There is a bit of a learning curve to getting the right position, focus, and lighting,  The images aren't quite as sharp as what you will see with specialists and in the text books, but I think this is an acceptable trade-off for the cost and portability.  Here are some pictures that I took during actual use.

A nice feature is that the camera automatically stamps the time and date, making it easy to find the right image.  The images with the larger opening have the shorter cone and the smaller openings are the longer cones.  While I'd prefer to have the canal take up more of the screen, this is a factor of the cone itself, and is necessary to reach down in the long ears of dogs and cats.  I do like the magnification and the amount of magnification.

Another great feature?  Video!  You can actually record video of the exam.  I was going to show you two videos I recorded, but for some reason Blogger won't load them properly and gives me an error message.  So you'll have to trust me that the video option is one of the best things about the Firefly.  It allows you to record a full exam rather than just snippets.  The down side is that you have to start the recording from the software screen on the computer rather than the hand unit.  But once you hit the record button you can just use it like normal until you are finished.

Okay, so all of this is well and good, but why buy one of these instead of a traditional otoscope?  In my opinion there are three reasons.

1.  You can save the pictures and videos on the clinic computer or even the patient file (if your software allows this).  When you are doing follow-up exams you don't have to try and remember what the ear looked like.  And if you're doing a follow-up on another doctor's patient you don't have to try and figure out what the ear looked like from the written notes.

2.  This is an incredible teaching tool.  I mentor a lot of veterinary students and new doctors and it has always been a challenge for me to show them the inside of an ear canal.  Up until now I would have to get the otoscope in the right position, then bend out of the way so they could look, all without moving the scope.  Now I can show them on the screen at the same time I'm looking at it.  I can also record images and videos to show people in the future.

3.  This is probably the biggest one....client compliance!  I've never been able to show a client what their dog's ear canal looks like.  It can impress some people when I show them a cotton swab with the goo from their pet's ear.  But it makes an even bigger impression to show them what it looks like down in the ear canal.  The goo, wax, narrowing, inflammation...everything.  This brings the exam and client education to a completely new level.  But does it make a difference?  Yes.  During my trial period I had two clients who purchased ear cleaner when I showed them the wax plugs in their dog's ears.  A few other clients were visibly disgusted when I showed them what an ear with infection looks like and they truly saw what was going on in their own dog's ears.  Sometimes a picture really is worth a thousand words, and a single image can carry far more weight than anything I describe.  I have already seen better compliance with ear care and infection treatment when I use the Firefly compared to when I don't.

This particular Firefly unit has a MSRP of $399.  In the USA it is sold through Henry Schein Vet.  For customers outside of the US they recommend contacting them to find your local distributor.

So what's the final verdict?

Pros:  Incredibly small and fits easily in the hand.  Ability to record and save images and videos.  Metal cones are very durable and easy to clean.  Great teaching tool.  Very convincing to clients and increases their acceptance of treatment plans.

Cons:  Image quality is good but not exceptional.  Standard otoscope cones are too short, necessitating having to purchase an additional set of cones.  Camera button isn't easy to use with one hand.

Overall I think that the cost is minimal when you keep in mind the ability to keep better medical records and increase the compliance of clients.  In just a couple of weeks I generated nearly $100 in revenue that I might not have otherwise.  The price of the Firefly makes it very economical and easy to recoup the cost.  Any of my concerns are minor and far outweighed by the benefit of having it.  I really think that the more I use it the more I'll like it.  And I would definitely recommend it to anyone else.

Rating:  4/5

Firefly Global website

*  The geek in me absolutely loves having a Firefly.  I have always been a huge fan of the short-lived TV show Firefly and smile every time I think "I have a Firefly".  Yes, this has nothing to do with the review and didn't influence my opinion.  Just one of the personal things that makes me happy!