Today's Veterinary Technician, September 2016

SHELTER MEDICINE WHAT EVERY SHELTER TECHNICIAN SHOULD KNOW

CAREER CHALLENGES GETTING YOUR LIFE UNSTUCK

NUTRITION HOW AND WHY TO FEED PARVOVIRUS PATIENTS

CLINICAL PATHOLOGY “SMALL STUFF” THAT INFLUENCES RESULTS

FELINE MEDICINE THE VALUE OF BEING CAT FRIENDLY

TODAY’SVETERINARYTECHNICIAN | An Official Journal of the NAVC | todaysveterinarytechnician.com | Volume 1, Number 5 | September/October 2016 |

Veterinary Technology A CAREER FOR ALL AGES

FRIENDS

LIFE

Protect all that matters with the ONLY 6-IN-1 PARASITE PROTECTION POWERED BY LUFENURON. Help preserve their special connection with parasite protection that can’t be imitated. SENTINEL® SPECTRUM® (milbemycin oxime/lufenuron/praziquantel) covers 6 different parasites and is the only heartworm preventive that uses the power of lufenuron to stop flea infestations before they start.

To order, contact your Virbac representative or call 1-844-4-VIRBAC (1-844-484-7222).

Dogs should be tested for heartworm prior to use. Mild hypersensitivity reactions have been noted in some dogs carrying a high number of circulating microfilariae. Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention. Please see full product label for more information, or visit www.virbacvet.com.

© 2016 Virbac Corporation. All Rights Reserved. SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation. 6/16 16643

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TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

SEPTEMBER/OCTOBER 2016

VOLUME 1, NUMBER 5

Today’s Veterinary Technician is proudly published by the NAVC

Chief Executive Officer Thomas M. Bohn, MBA, CAE

Editor in Chief Lynne Johnson-Harris, LVT, RVT LJohnson@NAVC.com

Senior Vice President of Sales and Publishing Laura C.S. Walker LWalker@NAVC.com Publisher Nick Paolo, MS, MBA NPaolo@NAVC.com Executive Editor Robin Henry RHenry@NAVC.com

Editorial Advisory Board Brenda K. Feller, LVT, CVT, VTS (Anesthesia) Animal Specialty Hospital of Florida, Naples, Florida Rosemary Lombardi, CVT, VTS (Emergency and Critical Care) Director of Nursing, University of Pennsylvania Matthew J. Ryan Veterinary Hospital Jeanne R. Perrone, CVT, VTS (Dentistry) VT Dental Training, Plant City, Florida Heidi Reuss-Lamky, LVT, VTS (Anesthesia and Analgesia, Surgery) Oakland Veterinary Referral Services, Bloomfield Hills, Michigan Kathi L. Smith, RVT, VTS (Oncology) Portland Veterinary Specialists Portland, Maine Deborah A. Stone, MBA, PhD, CVPM StoneVPM Austin, Texas Daniel J. Walsh, MPS, RVT, LVT, VTS (Clinical Pathology) Purdue University (Retired)

Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition) 4 Cats Consulting Belleville, Michigan

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Directors Paige Allen, MS, RVT Harold Davis, Jr, BA, RVT, VTS (Emergency and Critical Care, Anesthesia and Analgesia) Cheryl Good, DVM Sally Haddock, DVM Bob Lester, DVM

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

SEPTEMBEROCTOBER2016

Volume 1, Number 5

PEER-REVIEWED CE How and Why to Feed Canine Parvovirus Patients Right Away KENICHIRO YAGI, BS, RVT, VTS (ECC, SAIM)

Canine parvovirus is a longstanding nemesis of veterinary professionals. Learn why enteral feeding benefits patients with this common disease and how to measure, place, and use nasoesophageal and nasogastric tubes.

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FEATURES 15 Years: A Brief History of Shelter Medicine MICHAEL BANNASCH, BS, RVT

The field of shelter medicine has made enormous strides since the first shelter medicine residency was established at UC Davis in 2000.

Get an inside look at the people who started the program and how they did it.

35

The Non-pathologic, Non-collection, and Non-sample Preanalytical Small “Stuff” That Influences Reliable Laboratory Results DANIEL J. WALSH, MPS, LVT, RVT, VTS (CLINICAL PATHOLOGY)

Laboratory tests are invaluable medical tools…if the results are reliable. Aside from sample collection and handling, many other factors can affect test outcomes, from patient stress to client misunderstanding. This article addresses the seemingly unimportant details that can have significant effects.

44

How Being Cat Friendly Has Made a Difference in Our Practice SARAH DAWSON, RVN

This article from the British journal Feline Focus describes one clinic’s experience in—and benefits from—making the effort to become “feline friendly.”

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Contents

TODAY’S VETERINARY TECHNICIAN

Caution Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.

An Official Journal of the NAVC

Indications SENTINEL® SPECTRUM® (milbemycin oxime/lufenuron/praziquantel) is indicated for the prevention of heartworm disease caused by Dirofilaria immitis; for the prevention and control of flea populations (Ctenocephalides felis); and for the treatment and control of adult roundworm (Toxocara canis, Toxascaris leonina), adult hookworm (Ancylostoma caninum), adult whipworm (Trichuris vulpis), and adult tapeworm (Taenia pisiformis, Echinococcus multilocularis and Echinococcus granulosus) infections in dogs and puppies two pounds of body weight or greater and six weeks of age and older.

SEPTEMBEROCTOBER2016 COLUMNS Editor’s Letter | The Definition of “Home” LYNNE JOHNSON-HARRIS, LVT, RVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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In Memoriam | Earl Rippie, Jr, DVM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 What Moves You? | Family Ties LEONARD MARINO, MD, LVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ideas Into Practice | Becoming a “Cat-Friendly” Practice ESTHER KLOK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Career Challenges | Getting Your Life Unstuck DEBORAH A. STONE, MBA, PHD, CVPM.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Toxicology Talk | Top 10 Toxins That Are Rarely Serious JENNIFER A. SCHUETT, CVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Final Thoughts | The Golden Ticket to Feeling Better JULIE SQUIRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24 28 52 56 66

Careers | Career Opportunities............................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Advertiser Index. . ............................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Dosage and Administration SENTINEL SPECTRUM should be administered orally, once every month, at the minimum dosage of 0.23 mg/lb (0.5 mg/kg) milbemycin oxime, 4.55 mg/lb (10 mg/kg) lufenuron, and 2.28 mg/lb (5 mg/kg) praziquantel. For heartworm prevention, give once monthly for at least 6 months after exposure to mosquitoes.

Dosage Schedule Praziquantel per Number of chewable chewables

Milbemycin Oxime per chewable

Lufenuron per chewable

2 to 8 lbs.

2.3 mg

46 mg

22.8 mg

One

8.1 to 25 lbs.

5.75 mg

115 mg

57 mg

One

25.1 to 50 lbs.

11.5 mg

230 mg

114 mg

One

50.1 to 100 lbs.

23.0 mg

460 mg

228 mg

One

Body Weight

Over 100 lbs.

Administer the appropriate combination of chewables

To ensure adequate absorption, always administer SENTINEL SPECTRUM to dogs immediately after or in conjunction with a normal meal.

SENTINEL SPECTRUM may be offered to the dog by hand or added to a small amount of dog food. The chewables should be administered in a manner that encourages the dog to chew, rather than to swallow without chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole. Care should be taken that the dog consumes the complete dose, and treated animals should be observed a few minutes after administration to ensure that no part of the dose is lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended.

Contraindications There are no known contraindications to the use of SENTINEL SPECTRUM. Warnings Not for use in humans. Keep this and all drugs out of the reach of children.

Precautions Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention.

Prior to administration of SENTINEL SPECTRUM, dogs should be tested for existing heartworm infections. At the discretion of the veterinarian, infected dogs should be treated to remove adult heartworms. SENTINEL SPECTRUM is not effective against adult D. immitis.

ON THE COVER Leonard Marino, MD, LVT, assists his son, Dominic J. Marino, DVM, DACVS, DACCT, CCRP, during surgery. Cover image by Peter Olson

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Mild, transient hypersensitivity reactions, such as labored breathing, vomiting, hypersalivation, and lethargy, have been noted in some dogs treated with milbemycin oxime carrying a high number of circulating microfilariae. These reactions are presumably caused by release of protein from dead or dying microfilariae.

Do not use in puppies less than six weeks of age.

Do not use in dogs or puppies less than two pounds of body weight.

The safety of SENTINEL SPECTRUM has not been evaluated in dogs used for breeding or in lactating females. Studies have been performed with milbemycin oxime and lufenuron alone.

Adverse Reactions The following adverse reactions have been reported in dogs after administration of milbemycin oxime, lufenuron, or praziquantel: vomiting, depression/lethargy, pruritus, urticaria, diarrhea, anorexia, skin congestion, ataxia, convulsions, salivation, and weakness.

To report suspected adverse drug events, contact Virbac at 1-800-338-3659 or the FDA at 1-888-FDA-VETS.

Today’s Veterinary Technician (ISSN 2472-209X print and ISSN 2472-2103 online) does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products and claims contained therein. The publisher, Eastern States Veterinary Association, Inc (NAVC), disclaims any liability for any damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective authors and do not necessarily represent the opinions of the NAVC nor its Editorial Advisory Board. NAVC does not guarantee nor make any other representation that the material contained in articles herein is valid, reliable, or accurate; nor does the NAVC assume any responsibility for injury or death arising from any use, or misuse, of same. There is no implication that the material published herein represents the best or only procedure for a particular condition. It is the responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly available. Today’s Veterinary Technician is published Jan/Feb, Mar/Apr, May/June, Jul/Aug, Sep/Oct, Nov/Dec (6x per year) by NAVC. Postmaster: address corrections to CDS/Today’s Veterinary Technician, 440 Quadrangle Drive, Ste E, Bolingbrook, IL 60440.

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Information for Owner or Person Treating Animal Echinococcus multilocularis and Echinococcus granulosus are tapeworms found in wild canids and domestic dogs. E. multilocularis and E. granulosus can infect humans and cause serious disease (alveolar hydatid disease and hydatid disease, respectively).

Owners of dogs living in areas where E. multilocularis or E. granulosus are endemic should be instructed on how to minimize their risk of exposure to these parasites, as well as their dog’s risk of exposure. Although SENTINEL SPECTRUM was 100% effective in laboratory studies in dogs against E. multilocularis and E. granulosus, no studies have been conducted to show that the use of this product will decrease the incidence of alveolar hydatid disease or hydatid disease in humans. Because the prepatent period for E. multilocularis may be as short as 26 days, dogs treated at the labeled monthly intervals may become reinfected and shed eggs between treatments.

Manufactured for: Virbac AH, Inc. P.O. Box 162059, Ft. Worth, TX 76161 NADA #141-333, Approved by FDA © 2015 Virbac Corporation. All Rights Reserved.

SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation.

02/15

Editor’s Letter The Definition of “Home” Lynne Johnson-Harris, LVT, RVT | Editor in Chief

“B

e it ever so humble, it’s more than just a place. It’s an idea—one where the heart is.

It’s a way of organizing space in our minds. Home is home, and everything else is not-home. That’s the way the world is constructed.” 1 Home is more than concrete and wood. Home is a feeling. It may be a feeling that you associate with where you grew up, or where your children grew up. It may be a friend’s house, or a favorite vacation spot. If you are lucky, it’s where you are right now. For those that are “homeless,” home might be where they are treated with dignity and respect, such as a shelter (read Michael Bannasch’s article starting on page 35 for more about how today’s animal shelters have evolved).

Home is where I spend my days and nights with my husband and furry family members, whether we are in our Ohio house or our Maine retreat. When I pull up to my physical home, I get that emotional feeling of being home.

Home is that all-comforting feeling of being safe, secure, needed, and loved.

WELCOME TO OUR NEW NAVC HOME “Home: A place where something is discovered, founded, developed or promoted; a source.” 4 In February 2017, the NAVC moves to its new home, the Orange County Convention Center (OCCC), where you will learn, explore, discover, and connect. We are excited to open our doors to a new experience: the OCCC is an all-inclusive venue, with all the NAVC excitement under one roof. For those of you who have attended before, your homecoming will be in a new location; however, you will still have the feeling of being home at the NAVC. For those of you joining us for the first time…welcome home!

Home is a feeling. 

Photo by www.ianjphoto.com

COMPLEX, YET BASIC “The meaning of home is complex, interpretational, and unique. It is also subject to our aspirations, beliefs, and historical experiences. Whatever it is, the meaning of home is a way of organizing and understanding the space within ourselves and the way the world is constructed around us.” 2 With so many recent tragic world events, many people question home. Buildings can be destroyed by floods and tornadoes; by tsunamis and hurricanes; by deliberate explosions and industrial accidents. Yet even for those affected by such disasters, the tie to the feeling of home remains intact. Home is linked to the most basic things around us. Smells, pictures, memories, and songs all remind us of home.

LYNNE WITH HER SISTER, Mairi Marker (left), and niece, Marlie Johnson-Wyatt, DVM, at Marlie’s wedding in Montana. No matter where you are, when family is there, you are home.

MY DEFINITION OF HOME CHANGES DAILY “There’s no place like home… There’s no place like home…” 3 For Dorothy in The Wizard of Oz, home was Kansas.

That was her country. Home is your country. I recently traveled to Montana for my niece’s wedding. I had never been out West before, and I was overwhelmed by the beauty of it. Being surrounded by family and friends, gathered at this spectacular location, I felt at home.

References 1. Klinkenborg V. The definition of home. Smithsonian.com. May 2012. smithsonianmag. com/science-nature/the-definition-of-home-60692392/?no-ist. Accessed July 2016.

2. Bennett L. What is the meaning of home? Architizer.com. October 3, 2014. architizer. com/blog/what-is-the-meaning-of-home/. Accessed July 2016.

3. Langley N, Ryerson F, Woolf EA. The Wizard of Oz. Metro-Goldwyn-Mayer. 1939.

4. American Heritage Dictionary. ahdictionary.com/word/search.html?q=homes.

Accessed July 2016.

Do you have a story you’d like to share? Write me at ljohnson@navc.com.

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In Memoriam Earl Rippie, Jr, DVM Dr. Earl Rippie, Jr, age 74, passed away on June 24, 2016.

A native of Bell Buckle, Tennessee, and a resident of Mt. Laurel, New Jersey, Dr. Rippie served as the President of the NAVC from 1999 to 2000. Dr. Rippie graduated from Tennessee State University in 1963 and the Tuskegee School of Veterinary Medicine in 1967. He worked as a small animal practitioner and was the owner/director of the Pennsauken Animal Hospital in Pennsauken, New Jersey.

Today’s Veterinary Technician sat down with Editor in Chief Lynne Johnson-Harris, LVT, RVT, to talk about Dr. Rippie’s impact not only on veterinary medicine, but on the role of veterinary technicians in particular.

Earl Rippie, Jr, DVM Owner/Director Pennsauken Animal Hospital Pennsauken, New Jersey

What is your best memory of Dr. Rippie?

One of my favorite memories of Earl is from an NAVC Board of Directors Spring Meeting. The meeting was at Earl’s favorite destination, St. Maarten. He was so proud to show off the area, and he was so loved there that the locals referred to him as “The Mayor.” He shared his island and his friends with the Board and made our meeting one of my favorites.

Dr. Rippie served as president of the New Jersey Veterinary Medical Association and represented New Jersey for 9 years in the House of Delegates of the American Veterinary Medical Association (AVMA). He was a member of many veterinary organizations, including the AVMA, American Animal Hospital Association, American Association of Feline Practitioners, Veterinary Dental Society, Emergency and Critical Care Society, and American Society of Association Executives.

In what way did Dr. Rippie influence the world of veterinary medicine, particularly for you as a veterinary technician?

Earl influenced veterinary medicine in many ways; however, my experience with Earl was as a colleague and mentor on the NAVC Board. I was the first veterinary technician invited onto the Board, and he valued veterinary technicians in realizing and promoting what our community offers to the health and well-being of animals. He took me under his wing and shared processes and procedures of the Board and NAVC that made me a more productive Board member.

Why is Dr. Rippie special to NAVC in particular?

Earl served not only as an NAVC President but also as the Secretary– Treasurer of NAVC from 2007 to 2014. The financial health of NAVC was extremely important to Earl.

An avid traveler, Dr. Rippie traveled to over 30 countries in his lifetime. He was also an enthusiastic Philadelphia Eagles fan. A celebration of his life was held on July 16, 2016.

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Why is Dr. Rippie’s passing a loss to the veterinary community?

Earl’s care and compassion for the profession was always foremost on his mind. He will be missed in more ways than can be described. Personally, I will miss his amazing smile and bear hugs. 

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ARTICLE 1 CR E DIT

How and Why to Feed Canine Parvovirus Patients Right Away

C

anine parvovirus is a longstanding nemesis of veterinary professionals. It is a very common disease leading to a mortality rate of approximately 90% in untreated animals.1,2 Even with aggressive treatment involving hospitalization, intravenous fluid replacement, antibiotics, antiemetics, gastroprotectants, and antiviral agents, the observed mortality rate is as high as 10%1 to 36%.2 OVERVIEW OF CANINE PARVOVIRUS Parvoviruses are nonenveloped, singlestranded DNA viruses. Canine parvovirus commonly infects young dogs 6 weeks to 6 months of age and unvaccinated adults.

It is transmitted through the fecal–oral or oronasal route by exposure to fecal material, vomitus, or fomites. In exposed animals, the virus has an incubation period (time between first exposure and appearance of clinical signs) of 3 to 14 days, and it is shed for as long as 3 to 4 weeks after onset of clinical disease.2 The hallmark clinical signs of parvoviral enteritis are vomiting and diarrhea resulting from enterocyte destruction, which is caused by the virus taking advantage of the high mitotic rate of intestinal crypt cells to replicate.

The virus also localizes in the tongue, oral cavity, esophagus, bone marrow, thymus, and lymph nodes. Key signs of lethargy, inappetence, abdominal pain, and subsequent dehydration and hypovolemia are related to breakdown 8

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Kenichiro Yagi, BS, RVT, VTS (ECC, SAIM) Adobe Animal Hospital Los Altos, California

Ken practices at Adobe Animal Hospital as an ICU and Blood Bank Manager. He is an active educator, lecturing internationally, providing practical instruction, and authoring texts, chapters, and articles on transfusion medicine, respiratory care, and critical care nursing.

He serves on the boards of the Veterinary Emergency and Critical Care Society and the Academy of Veterinary Emergency and Critical Care Technicians, on the Veterinary Innovation Council, and as the NAVTA State Representative Chairperson. He is a graduate student in veterinary medicine and surgery through the University of Missouri. Ken invites all veterinary technicians to ask “Why?” to understand the “What” and “How” of our field and to constantly pursue new goals as veterinary professionals.

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of the gastrointestinal mucosa and increased intestinal permeability; neutropenia can result from bone marrow involvement. Intestinal damage can lead to secondary bacterial infection, bacterial translocation, bacteremia, and sepsis. Sepsis can then lead to systemic inflammatory response syndrome and shock. Patients in shock may exhibit tachycardia or bradycardia, obtunded mentation, and poor pulse quality, and death may result.1,2 The mainstream treatment plan for canine parvoviral enteritis includes fluid therapy to replace deficits and keep up with ongoing losses, antimicrobial therapy against secondary bacterial infection, and isolation of the patient to prevent exposure of other animals.

Electrolyte and dextrose supplementation through intravenous fluids should be adjusted according to regularly monitored blood glucose and electrolyte levels. Common electrolyte abnormalities include hyponatremia, hypochloremia, and hypokalemia. Antiemetics such as metoclopramide, ondansetron, dolasetron, or maropitant are provided to control vomiting and nausea.

Traditionally, synthetic colloids (e.g., hydroxyethyl starch) have been used to augment colloid osmotic pressure, which is decreased when the protein-losing nature of the enteritis leads to hypoalbuminemia. Their use is now debated because of the potential for acute kidney injury, which seems greatest when they are administered as

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TE C HP O I N T 

CE Article | How and Why to Feed Canine Parvovirus Patients Right Away

A fasted animal experiences reduced secretion of digestive enzymes. Lower levels of digestive enzymes impair an animal’s ability to digest food, leading to less efficient use of nutrients when food is reintroduced.

thought to serve as nutrition for bacteria, leading to further proliferation of detrimental microbes.

4. T he presence of food in the gastrointestinal lumen can draw exudate into the lumen through osmosis and exacerbate diarrhea.

5. O ffering food to a patient that is nauseated and feeling ill can lead to food aversion, delaying the return of appetite when the patient is ready to eat.

While these reasons seem sound, evidence points toward various benefits of feeding and supports arguments against an NPO strategy.5–7,9,10 REASONS TO FEED Fasting Causes Contractions and Pain While the common belief is that fasting allows the bowel to rest, it seems to increase the degree of intestinal contractions instead. The lack of nutrients in the gastrointestinal lumen leads to vigorous contractions from the pylorus to the ileum, causing sensations described as “hunger pains.”5 These contractions are observed to be inhibited by the presence of food.9 The presence of luminal nutrients also seems to promote contractions of normal intensity sooner, preventing the persistence of ileus related to gastroenteritis. Introducing food early thus prevents pain, promotes normal contractions, and shortens recovery time from impaired gastrointestinal motility.5

a constant-rate infusion (CRI).3 Recombinant feline interferon omega has shown some beneficial effects in reducing mortality from canine parvovirus.4 Other, less commonly used treatment options, such as human recombinant factors, equine lipopolysaccharide antitoxin, oseltamivir, and antibody-rich plasma, have not shown beneficial effects.2 THE TRADITIONAL NUTRITIONAL APPROACH: NPO Traditionally, interventions used in parvoviral enteritis patients include the practice of placing the patient on NPO, or nil per os (“nothing by mouth”), treatment for 24 to 72 hours, preventing any food from entering the gastrointestinal tract.5 While the application of NPO treatment is common, growing evidence indicates that early implementation of enteral nutrition is beneficial for patients with a variety of gastrointestinal diseases, including canine parvoviral enteritis.6–8 A number of longstanding reasons advocate for an NPO strategy in a patient that is exhibiting gastroenteritis with signs of vomiting and diarrhea: 1. It has been thought that the presence of food in the gastrointestinal tract can delay recovery by stimulating intestinal contractions and increasing frequency of defecation, thereby increasing patient discomfort, and that fasting allows the bowel to rest.

2. The introduction of food is thought to stimulate further vomiting in animals with gastroenteritis, which can lead to higher chances of aspiration.

3. Undigested food in the gastrointestinal lumen is TODAY’SVETERINARYTECHNICIAN

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Feeding Shortens Duration of Nausea Feeding animals with gastroenteritis is thought to stimulate vomiting. One study that evaluated the effect of early enteral nutrition on patients with hemorrhagic gastroenteritis observed that the chances of vomiting did increase, although the frequency subsided starting on the second day.6 Similarly, another study evaluating dogs with parvoviral enteritis observed a shorter time to vomiting cessation in the group that was fed starting 12 hours after admission compared with the group that was fasted.7 The presence of luminal nutrition is thought to help maintain the integrity of the gastrointestinal mucosa and promote healthier motility, leading to less vomiting.

However, food containing high amounts of fat or poorly digestible starches causes maldigestion and gastrointestinal distention and promotes vomiting through afferent stimulation of the vomiting center in the medulla oblongata. When feeding is instituted, small, frequent meals of highly digestible foods are recommended to prevent excessive secretion of gastric acids and minimize gastric distention, which can stimulate emesis.5 |

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NOT ALL FLEA AND TICK CHEWS ARE CREATED EQUAL

Flea and tick protection that goes on and

IMPORTANT SAFETY INFORMATION: Simparica is for use only in dogs, 6 months of age and older. Simparica may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures. Simparica has not been evaluated in dogs that are pregnant, breeding or lactating. Simparica has been safely used in dogs treated with commonly prescribed vaccines, parasiticides and other medications. The most frequently reported adverse reactions were vomiting and diarrhea. See full Prescribing Information on the back of the next page and at www.zoetisUS.com/SimparicaPI. *Studies show Simparica starts killing ticks in 8 hours and is ≥96.9% effective for 35 days against weekly reinfestations of Amblyomma americanum, Amblyomma maculatum, Dermacentor variabilis, and Rhipicephalus sanguineus.1-6 References: 1. SIMPARICA (sarolaner) [package insert]. Kalamazoo, MI: Zoetis, Inc; 2015. 2. Zoetis. Dose Confirmation of Sarolaner Administered Orally Against Induced Infestations of Amblyomma maculatum on Dogs (A166C-US-12-128, 2014; A166C-US-12-129, 2014). 3. Zoetis. Dose Confirmation of Sarolaner Administered Orally Against Induced Infestations of Amblyomma americanum on Dogs (A166C-US-12-130, 2014; A166C-US-12-131, 2014).

4. Zoetis. Dose Confirmation of Sarolaner Administered Orally Against Induced Infestations of Dermacentor variabilis on Dogs (A166C-US-12-132, 2014; A166C-US-12-133, 2014). 5. Zoetis. Dose Confirmation of Sarolaner Administered Orally Against Induced Infestations of Rhipicephalus sanguineus on Dogs (A166C-US-12-135, 2014; A166C-IE-13-160, 2014; A166C-US-13-303, 2014; A166C-AU-14-419, 2014). 6. Zoetis. Knock-down and Speed of Kill of Sarolaner Administered Orally Against Induced Infestations of Amblyomma maculatum on Dogs (A166C-US-13-318, 2014).

on and on...all month long.

Introducing Simparica Monthly chewables for dogs that offer persistent protection from fleas and ticks.1 Simparica acts fast—it starts killing fleas within 3 hours and ticks within 8 hours*—and keeps going strong for 35 days* without losing effectiveness at the end of the month.1

Fetch more information about Simparica from Zoetis Customer Service at 1-888-ZOETIS-1 or 1-888-963-8471.

All trademarks are the property of Zoetis, Inc., its affiliates and/or licensors. © 2016 Zoetis Inc. All rights reserved. March 2016. SMP-00094

TM

(sarolaner) Chewables FOR ORAL USE IN DOGS ONLY CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.

Description: SIMPARICA is a flavored, chewable tablet for administration to dogs over 6 months of age according to their weight. Each tablet is formulated to provide a minimum sarolaner dosage of 0.91 mg/lb (2 mg/kg) body weight.

Sarolaner is a member of the isoxazoline class of parasiticides and the chemical name is 1-(5’-((5S)-5-(3,5-Dichloro-4-fluorophenyl)-5-(trifluoromethyl)-4,5-dihydroisoxazol-3-yl)3’-H-spiro(azetidine-3,1’-(2)benzofuran)-1-yl)-2-(methylsulfonyl)ethanone. SIMPARICA contains the S-enantiomer of sarolaner.

The chemical structure of the S-enantiomer of sarolaner is: Indications: SIMPARICA kills adult fleas, and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of tick infestations [Amblyomma americanum (Lone Star tick), Amblyomma maculatum (Gulf Coast tick), Dermacentor variabilis (American dog tick), and Rhipicephalus sanguineus (brown dog tick)] for one month in dogs 6 months of age or older and weighing 2.8 pounds or more.

Dosage and Administration: SIMPARICA is given orally once a month at the recommended minimum dosage of 0.91 mg/lb (2 mg/kg).

Dosage Schedule: F

F

F

O

N

O

CI

F

CI

N

O

O

S

O

Body Weight 2.8 to 5.5 lbs 5.6 to 11.0 lbs 11.1 to 22.0 lbs 22.1 to 44.0 lbs 44.1 to 88.0 lbs 88.1 to 132.0 lbs >132.1 lbs

SAROLANER per Tablet (mg) Number of Tablets Administered 5 One 10 One 20 One 40 One 80 One 120 One Administer the appropriate combination of tablets

SIMPARICA can be offered by hand, in the food, or administered like other tablet medications.

Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused.

If a dose is missed, administer SIMPARICA and resume a monthly dosing schedule.

SIMPARICA should be administered at monthly intervals.

Flea Treatment and Prevention: Treatment with SIMPARICA may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with SIMPARICA can continue the entire year without interruption.

To minimize the likelihood of flea re-infestation, it is important to treat all dogs and cats within a household with an approved flea control product.

Tick Treatment and Control: Treatment with SIMPARICA can begin at any time of the year (see Effectiveness).

Contraindications: There are no known contraindications for the use of SIMPARICA. Warnings: Not for use in humans. Keep this and all drugs out of reach of children and pets. For use in dogs only. Do not use SIMPARICA in cats.

SIMPARICA should not be used in dogs less than 6 months of age (see Animal Safety).

Precautions: SIMPARICA may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures (see Animal Safety).

The safe use of SIMPARICA has not been evaluated in breeding, pregnant, or lactating dogs.

Adverse Reactions: SIMPARICA was administered in a well-controlled US field study, which included a total of 479 dogs (315 dogs treated with SIMPARICA and 164 dogs treated with active control once monthly for three treatments).

Over the 90-day study period, all observations of potential adverse reactions were recorded.

Table 1. Dogs with adverse reactions Adverse reaction

sarolaner N

Vomiting Diarrhea Lethargy Inappetence

3 2 1 0

sarolaner % (n = 315) 0.95% 0.63% 0.32% 0%

active control N 9 2 2 3

active control % (n =164) 5.50% 1.20% 1.20% 1.80%

Additionally, one female dog aged 8.6 years exhibited lethargy, ataxia while posturing to eliminate, elevated third eyelids, and inappetence one day after receiving SIMPARICA concurrently with a heartworm preventative (ivermectin/pyrantel pamoate). The signs resolved one day later. After the day 14 visit, the owner elected to withdraw the dog from the study.

For a copy of the Safety Data Sheet (SDS) or to report adverse reactions call Zoetis Inc. at 1-888-963-8471. Additional information can be found at www.SIMPARICA.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or http://www.fda.gov/AnimalVeterinary/SafetyHealth.

Clinical Pharmacology: Sarolaner is rapidly and well absorbed following oral administration of SIMPARICA. In a study of 12 Beagle dogs the mean maximum plasma concentration (Cmax) was 1100 ng/mL and the mean time to maximum concentration (Tmax) occurred at 3 hours following a single oral dose of 2 mg/kg to fasted animals. The mean oral bioavailability was 86% and 107% in fasted and fed dogs, respectively. The mean oral T1/2 values for fasted and fed animals was 10 and 12 days respectively.

Sarolaner is distributed widely; the mean volume of distribution (Vdss) was 2.81 L/kg bodyweight following a 2 mg/kg intravenous dose of sarolaner. Sarolaner is highly bound (≥99.9%) to plasma proteins. The metabolism of sarolaner appears to be minimal in the dog. The primary route of sarolaner elimination from dogs is biliary excretion with elimination via the feces.

Following repeat administration of SIMPARICA once every 28 days for 10 doses to Beagle dogs at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, steady-state plasma concentrations were reached after the 6th dose. Following treatment at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, sarolaner systemic exposure was dose proportional over the range 1X to 5X. Mode of Action: The active substance of SIMPARICA, sarolaner, is an acaricide and insecticide belonging to the isoxazoline group. Sarolaner inhibits the function of the neurotransmitter gamma aminobutyric acid (GABA) receptor and glutamate receptor, and works at the neuromuscular junction in insects. This results in uncontrolled neuromuscular activity leading to death in insects or acarines.

Effectiveness: In a well-controlled laboratory study, SIMPARICA began to kill fleas 3 hours after initial administration and reduced the number of live fleas by ≥96.2% within 8 hours after flea infestation through Day 35.

In a separate well-controlled laboratory study, SIMPARICA demonstrated 100% effectiveness against adult fleas within 24 hours following treatment and maintained 100% effectiveness against weekly re-infestations for 35 days.

In a study to explore flea egg production and viability, SIMPARICA killed fleas before they could lay eggs for 35 days. In a study to simulate a flea-infested home environment, with flea infestations established prior to the start of treatment and re-infestations on Days 7, 37 and 67, SIMPARICA administered monthly for three months demonstrated >95.6% reduction in adult fleas within 14 days after treatment and reached 100% on Day 60.

In well-controlled laboratory studies, SIMPARICA demonstrated ≥99% effectiveness against an initial infestation of Amblyomma americanum, Amblyomma maculatum, Dermacentor variabilis, and Rhipicephalus sanguineus 48 hours post-administration and maintained >96% effectiveness 48 hours post re-infestation for 30 days.

In a well-controlled 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of SIMPARICA against fleas on Day 30, 60 and 90 visits compared to baseline was 99.4%, 99.8%, and 100%, respectively. Dogs with signs of flea allergy dermatitis showed improvement in erythema, papules, scaling, alopecia, dermatitis/pyodermatitis and pruritus as a direct result of eliminating fleas.

Animal Safety: In a margin of safety study, SIMPARICA was administered orally to 8-week-old Beagle puppies at doses of 0, 1X, 3X, and 5X the maximum recommended dose (4 mg/kg) at 28-day intervals for 10 doses (8 dogs per group). The control group received placebo tablets. No neurologic signs were observed in the 1X group. In the 3X group, one male dog exhibited tremors and ataxia post-dose on Day 0; one female dog exhibited tremors on Days 1, 2, 3, and 5; and one female dog exhibited tremors on Day 1. In the 5X group, one female dog had a seizure on Day 61 (5 days after third dose); one female dog had tremors post-dose on Day 0 and abnormal head coordination after dosing on Day 140; and one female dog exhibited seizures associated with the second and fourth doses and tremors associated with the second and third doses. All dogs recovered without treatment. Except for the observation of abnormal head coordination in one dog in the 5X group two hours after dosing on Day 140 (dose 6). There were no treatment-related neurological signs observed once the dogs reached the age of 6 months.

In a separate exploratory pharmacokinetic study, one female dog dosed at 12 mg/kg (3X the maximum recommended dose) exhibited lethargy, anorexia, and multiple neurological signs including ataxia, tremors, disorientation, hypersalivation, diminished proprioception, and absent menace, approximately 2 days after a third monthly dose. The dog was not treated, and was ultimately euthanized. The first two doses resulted in plasma concentrations that were consistent with those of the other dogs in the treatment group. Starting at 7 hours after the third dose, there was a rapid 2.5 fold increase in plasma concentrations within 41 hours, resulting in a Cmax more than 7-fold higher than the mean Cmax at the maximum recommended use dose. No cause for the sudden increase in sarolaner plasma concentrations was identified.

Storage Information: Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F).

How Supplied: SIMPARICA (sarolaner) Chewables are available in six flavored tablet sizes: 5, 10, 20, 40, 80, and 120 mg. Each tablet size is available in color-coded packages of one, three, or six tablets.

NADA #141-452, Approved by FDA

Distributed by: Zoetis Inc. Kalamazoo, MI 49007 Made in Switzerland December 2015

30491300A&P

CE Article

Enteral Nutrition Literally Feeds the Gut Normally, enterocytes of the small intestine are passively exposed to nutrients in ingested material and use them to their benefit. Glutamine, an amino acid derived in the intestinal lumen, serves as an antioxidant as well as the carbon skeleton and amino acid for DNA synthesis during enterocyte turnover.5 Mucosal cells normally expire every few days; therefore, healthy mucosal turnover is vital to maintaining a functional gastrointestinal barrier. Deficiency in other nutrients, such as essential fatty acids, folate, zinc, vitamin A, and vitamin B12, decreases mucosal turnover.

The presence of nutrients in the intestinal lumen allows enterocytes to directly acquire these nutrients.

Feeding Maintains Digestive Function and Structure Changes are seen in the gastrointestinal system when an animal is fasted, even when the animal is healthy. First, fasting promotes negative changes in the intestinal mucosa, such as decreased villus height and crypt depth, decreased antioxidants within enterocytes, and increased enterocyte apoptosis. These changes lead to increased permeability of the mucosal barrier and higher chances of bacterial translocation. Negative changes such as small intestinal villous atrophy and infiltration of the lamina propria with white blood cells have been observed even in animals that were provided parenteral nutrition in the absence of oral nutrition, indicating that the presence of food in the gastrointestinal tract has beneficial effects beyond nutritional content in the blood.5 Second, a fasted animal experiences reduced secretion of digestive enzymes. Lower levels of digestive enzymes impair an animal’s ability to digest food, leading to less efficient use of nutrients when food is reintroduced. Basal and histamine-stimulated gastric acid levels and secretion of pancreatic exocrine enzymes (lipase, trypsin, and amylase) decrease when an animal is fasted, potentially contributing to diarrhea.5 The presence of food is therefore important to both structural and functional soundness of the gastrointestinal tract.

Summary of Benefits Providing enteral nutrition early in the course of parvovirus treatment instead of applying an NPO strategy has significant benefits, including the following: ÆÆ Alleviating pain through promotion of normal peristaltic activities ÆÆ Shortening the duration of the vomiting period and limiting aspiration ÆÆ Thwarting microbial proliferation and reducing bacterial translocation ÆÆ Promoting the return to healthy enterocyte and mucosal turnover ÆÆ Limiting inflammation and improving immune function For these reasons, providing enteral nutrition as soon as fluid deficits are replenished and adequate perfusion of the gastrointestinal tract is reestablished is recommended.8 Adequate perfusion is indicated when mentation, heart rate, pulse quality, mucous membrane color, capillary refill time, and core-to-extremity temperature gradient return to normal. Many negative effects of feeding can be alleviated through providing smaller amounts (25% of resting energy requirement, or RER) of a highly digestible, low-fat diet, preferably consisting of a novel protein source.5

Feeding Reduces Inflammation The number of neutrophils primed for activation through the expression of adhesion molecules increases when an animal is fasted. The adhesion molecules enable neutrophil sequestration in the microvasculature of the intestinal tract, where the neutrophils cause oxidative and enzymatic damage upon activation and degranulation. Fasting also leads to impairment in the interaction of T and B lymphocytes and, subsequently, reduced production of immunoglobulin A and cytokines, which are important in |

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How and Why to Feed Canine Parvovirus Patients Right Away

immunologic function and regulation of inflammation.5 This dysfunction is seen even when total parenteral nutrition is provided,5 further supporting the importance of enteral nutrition.

Feeding Reduces Bacterial Proliferation and Translocation While the presence of undigested food might lead to the proliferation of some species of microbes, the presence and production of volatile fatty acids such as proprionic acid and butyric acid acidify the environment and suppress pH-sensitive pathogens such as Campylobacter and Clostridium spp.10 In addition, fasting seems to increase the chances of bacterial translocation and bacterial adherence, as seen in several experimental studies,5 leading to worse consequences such as bacteremia and sepsis. Providing nutrition leads to a healthier mucosal barrier.5

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METHODS OF FEEDING Methods of providing enteral nutrition include voluntary eating, hand or syringe feeding, and feeding through orogastric, nasoenteric, esophagostomy, gastrostomy, or jejunostomy tubes. In parvoviral enteritis and other gastroenteritis patients, less invasive methods of feeding |

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that are appropriate to short-term hospitalization are desirable. The best method is for the patient to eat voluntarily, indicating the limited presence of nausea. Hand or syringe feeding an inappetent patient can lead to food aversion caused by the patient’s association of food with nausea and procedures performed during hospitalization.

A reasonable in-hospital method of enteral feeding is through a nasoenteric tube, alleviating this effect.

Nasoesophageal Versus Nasogastric Tubes Nasoenteric tubes are tubes inserted through the nasal passage into the oral cavity and then advanced through the oropharynx to end in the esophagus or stomach (FIGURE 1).

Tubes that end in the esophagus are called nasoesophageal tubes; tubes that end in the stomach are called nasogastric tubes. Nasoenteric tubes are useful in hospitalized patients for short-term (days to a couple of weeks) enteral feeding with a liquid diet. Unlike esophagostomy, gastrostomy, or jejunostomy tubes, they often do not require sedation or anesthesia during placement.11 The determination of whether to terminate the tube at the esophagus or the stomach depends on the purpose of the tube and the potential complications. Epistaxis, rhinitis, clogging of the tube, and early removal can be associated with both nasogastric and nasoesophageal tubes.

Nasogastric tubes, which are placed through the lower esophageal sphincter, are thought to increase the chance of gastroesophageal reflux leading to esophagitis or strictures; nasoesophageal tubes are not. Advantages of nasogastric tubes are the lower risk for malpositioning after placement and the ability to perform gastric decompression and monitor gastric motility. Gastric decompression is beneficial because it can decrease nausea by removing stagnant gastric fluid.11

FIGURE 1. A patient in isolation for parvovirus infection with a nasogastric tube in place.

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A study evaluating the complication rates associated with nasoesophageal and nasogastric tubes saw no difference in the occurrence of vomiting, regurgitation, diarrhea, epistaxis, tube clogging, early tube displacement or removal, aspiration pneumonia, or hyperglycemia.11 In this study, the presence of esophagitis was not evaluated, thus leaving open the possibility of gastroesophageal reflux, although its presence would be subclinical. Given the lack of difference in complication rates, nasogastric tubes are more commonly used because they allow for serial aspiration of gastric contents to monitor gastric motility (FIGURE 2).

Tube Placement Nasoenteric tubes can be placed with ease by trained veterinary technicians. The process starts by gathering the supplies and tools needed for the procedure (BOX 1) and

FIGURE 2. Gastric contents can be aspirated through a nasogastric tube to quantify the gastric residual volume and assess gastric motility.

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TE C HP O I N T 

The single most important step in the placement process is the confirmation of proper location; specifically, avoiding endotracheal intubation.

from the nares to the 10th intercostal space to the last rib is appropriate for nasogastric tubes (FIGURE 3).

Confirming Tube Location The single most important step in the placement process is the confirmation of proper location; specifically, avoiding endotracheal intubation. Accidental infusion of liquid diets into the airway leads to impaired gas exchange and inflammation of pulmonary tissues and promotes bacterial proliferation and infection of the pulmonary parenchyma (pneumonia). Diligence in confirming proper tube placement is of utmost importance to prevent causing additional harm to a patient.

forming a plan for sedation, if necessary. Tubes made of polyurethane and silicone, with or without guide wires, are available. Polyurethane tubes have been observed to be more tension-rupture resistant than silicone, although no difference in bacterial adhesion was seen in one study.12 Placement of the tube requires at least two individuals.

One technique involves one person placing the tube while the second restrains and positions the head; how the steps are shared may vary. Practices should have an established protocol for tube placement to ensure consistency in training and placement procedures among team members (BOX 2).

The major difference between nasoesophageal and nasogastric tube placement lies in the landmark used to measure the length of the tube to be inserted. Measurement from the nares to the sixth to eighth intercostal space is appropriate for nasoesophageal tubes, while the distance

Common Methods Methods commonly used to determine tube placement include the presence or absence of coughing during intubation or upon saline infusion, aspiration of air or gastric contents, and radiography. Visual confirmation through the oropharynx is also possible in animals that are heavily sedated or placed under anesthesia. No one method is completely reliable, and a combination of methods, including radiography, should be used to confirm proper placement. Insufflation of air while auscultating the stomach, although sometimes used for nasogastric tubes, is not thought to be a reliable confirmation method in humans.13 Coughing. The absence of coughing upon placement of the tube or infusion of saline should not be considered

BOX 1 Supplies Required for Nasoenteric Tube Placement  Nasoenteric tube

 Cats and small dogs: 5–8 Fr, 40–60 cm

 Larger dogs: 8–12 Fr, 60–90 cm

 Analgesic drops (proparacaine, lidocaine)  Lidocaine gel  Suture or skin stapler  Tape  Marker  Elizabethan collar  Mild sedative of choice, if required (maintain patient’s ability to swallow)  3–6 mL syringe (for confirmation tests)  10–60 mL syringe (if performing gastric decompression)

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BOX 2 Sample Protocol for Nasoenteric Tube Placement Preparation 1. Select the appropriate-size tube.

2. Place 1 or 2 drops of proparacaine in each naris.

This can be done before gathering the necessary equipment, but usually only takes 1 or 2 minutes to take effect.

3. Measure the tube according to intended placement:

a. Nasogastric: From the nares to between the 10th intercostal space and last rib

b. Nasoenteric: From the nares to the sixth to eighth intercostal space

c. Place tape or mark tube at appropriate length if no measurement marks are available.

4. Consult veterinarian for feeding plan.

5. If appropriate, obtain sedation protocol from veterinarian and ready needed items for swift administration.

Procedure 1. Wash hands.

2. Coat tubing with a thin layer of lidocaine gel/lubricant, at least up to ½ inch before measurement mark.

3. Elevate the nose without extending the neck. Slight flexion of the neck can facilitate intubation of the esophagus rather than the trachea.

4. Direct the tube ventromedially into the nostril, past the ventral meatus. Do not force the tube. It should slide in fairly easily, frequently with visible swallowing.

5. Swiftly advance the tube to the premeasured mark.

A

6. Place a skin staple over the tube as close to the nares as possible (not on the nose itself) and an additional staple midway on muzzle or cheek. These staples are to hold the tube in place until correct location has been confirmed with radiography.

7. Aspirate the tube with an empty 3- to 6-mL syringe, based on patient size. Negative pressure should be achieved if the tube is in the esophagus, and gastric contents if in the stomach.

8. Take placement/confirmation radiograph(s). Have the veterinarian confirm placement. The tube may need to be adjusted in or out for proper positioning.

Additional views may need to be taken until placement is confirmed.

9. Once placement is confirmed, mark the tube at nares entrance. If a tube with a guide wire was used, remove the guide wire gently from the tube. If removing the guide wire is difficult, the initial staples may need to be removed and the tube straightened.

Be cautious of the tube moving from its original placement.

10. Secure the tube at the side of the nares and one more location approximately caudal to the zygomatic arch. Skin staples and tape or a finger-trap suture pattern may be used.

11. Place and secure an Elizabethan collar on the patient.

If a significant portion of the tube remains hanging, it may be anchored to the tie of the collar.

12. Document tube size and intended length of insertion on the patient record sheet.

13. Begin feeding based on nutritional plan.

B

FIGURE 3. Measurement of a nasogastric tube. The tube can be measured (A) externally to between the 10th intercostal space (ICS) and the last rib, which (B) is used as a landmark for the tube to terminate at the stomach, as confirmed in this radiograph.

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a certain sign of placement into the gastrointestinal tract, as debilitated patients often exhibit a lack of normal reflexes and saline infusion into the lower airway does not always lead to coughing.

Aspiration. If the tube is placed in the flaccid esophagus, aspiration results in negative pressure; if the tube is in the stomach, gastric contents will be aspirated. Placement of the tube in the trachea often results in a continuous supply of air because the cartilaginous rings prevent collapse of the tissues around the opening of the tube, although it can be possible to achieve negative pressure.

Carbon dioxide (CO2) measurement. Use of a colorimetric CO2 sensor has been evaluated to confirm tube placement with 86.7% sensitivity and 99.8% specificity in human patients.14 Use of sidestream capnometry is reasonable for additional support for proper placement, with measurement of any CO2 indicating improper placement of the tube in the airway.

Radiography. The 3 basic points evaluated on radiographs for confirmation of placement are the tube’s entry point into the oropharynx, a lack of overlap with the trachea, and the terminating location. The oropharynx can be evaluated by including the cervical region in the radiograph.

A properly placed tube should be seen to divert away from entering the trachea; this often serves as a reliable sign of its avoidance of the airway. A lack of overlap of the tube with the trachea as it travels distally toward the target area is also a good indication of proper placement. The correct terminating location of the tube depends on whether a nasoesophageal or nasogastric tube is intended, with proper termination in the stomach (i.e., abdominal cavity) being much more obvious than in the esophagus (FIGURE 4).

A lateral view can be initially obtained for evaluation, with the option of obtaining a perpendicular view for further confirmation if any of the 3 points are uncertain.

Alternatively, practice protocols may call for a standard of 2 views as a part of the due diligence in placement confirmation.

Tube Anchoring Once placement is confirmed, the tube is anchored to the patient with skin staples, tape, or sutures in a finger-trap pattern placed along the side of the face, along the cheek, or up the forehead between the eyes. An Elizabethan collar should be used to prevent dislodgment by the patient.

Once stabilized, the tube can be used immediately in nonsedated patients that do not have a risk for aspiration.

FIGURE 4. The 3 points to evaluate on a radiograph to confirm tube placement are the oropharynx (red circle), trachea (blue oval), and terminating location (yellow circle). This radiograph shows the tube avoiding the airway opening (red), overlapping with most of the trachea (blue), and terminating in the stomach (yellow), making 2 of 3 points favorable to proper placement. Other information that would support proper placement would include the ability to see the tube separately from the trachea in a perpendicular radiographic view or aspiration of gastric contents through the tube.

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CE Article | How and Why to Feed Canine Parvovirus Patients Right Away

It is a veterinary technician’s role to be a patient advocate for and to help reinforce the notion, “While patients do eat when they feel better, they also feel better when they eat.”

hydrochloric acid. Hydrochloric acid helps limit bacterial overgrowth in the intestine, and discarding of residual volume has been linked to increased intestinal inflammation.

A portion or the entire volume of the gastric contents can be refed to the patient, although evidence regarding the benefits of this practice is mixed.15,16 Liquid diets for enteral nutrition should be handled with caution to prevent bacterial contamination. Handwashing and donning clean examination gloves before handling the solution and lines are required. The length of time a liquid diet can be left at room temperature or refrigerated is variable, typically ranging from 2 to 6 hours and approximately 24 hours, respectively, and practices should follow manufacturer recommendations for storage. When a syringe or volumetric pump is used for CRI, the volume of liquid diet it contains should be no more than the amount that can be infused in the time the diet is allowed to stay at room temperature. The entire line setup is generally recommended to be changed every 24 hours, although protocols calling for shorter hang times exist.17,18

INTRODUCTION OF FOOD Food should be introduced cautiously in a critical care patient while the patient is monitored for tolerance. Feeding 25% of RER is a common initial approach, with the amount gradually increased over a course of 2 to 3 days. This approach is well aligned with the strategy of providing small amounts of highly digestible, low-fat food. Because patients with parvoviral enteritis are often young and generally have a higher energy requirement, consideration should be made to meet energy demands for the specific age sooner, as long as the increase is tolerated by the patient.

RER is estimated using an allometric formula intended to scale properly with changing body sizes. An extrapolated linear equation is often used for simpler calculation and yields similar results within the range of 2 to 20 kg body weight (BOX 3). Either formula can be used in parvovirus patients to provide enough food for a beneficial effect.

Typical canned food, even when blended, can clog the largest-diameter nasoenteric tubes, limiting delivery of nutrition provided this way to liquid diets. Commercial liquid diets differ in composition and caloric density. The caloric density of the diet being provided must be known because the delivery is based on the patient’s caloric needs. The use of a liquid diet makes CRI of enteral nutrition easily possible through the use of syringe pumps (BOX 4). Bolus feeding is also possible, but to prevent stimulation of vomiting, the portions must be small and frequent, resulting in at least 3 feedings per day. In terms of achieving target caloric intake, there is no clear evidence of either CRI or bolus feeding having an advantage. Gastric residual volume, or the volume of food and gastric secretions remaining in the stomach, can be measured periodically to evaluate gastric motility.

Aspiration of gastric contents can lead to electrolyte and metabolic disturbances, especially through the removal of TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

CONCLUSION Early implementation of enteral nutrition is a key element in reducing morbidity and shortening recovery time in patients with parvoviral enteritis. The provision of a liquid diet helps

BOX 3 Comparison of Two Resting Energy Requirement Formulas

Allometric RER formula (orange line): RER(kcal per day) = 70 × BW(kg)0.75 Linear RER formula (blue line): RER(kcal per day) = 30 × BW(kg) + 70 Note: RER calculations with both formulas are within small percentage differences in patients weighing between 2 to 20 kg. Larger differences are seen with much smaller and much larger patients.

BW(kg) = body weight in kilograms.

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Peer-Reviewed

directly replace fluid lost through the gastrointestinal tract and reduces the ongoing loss by reducing the chance of vomiting, reducing intestinal mucosal permeability, and alleviating diarrhea. The positive effects on the mucosal barrier reduce

BOX 4 Initial Nutritional Calculation in a Parvoviral Enteritis Patient The patient: A 2-month-old, 2.3-kg, mixed-breed dog presenting with vomiting and diarrhea, with diagnosed canine parvovirus infection.

The plan: The veterinarian orders for a highly digestible liquid diet of 1.0 kcal/mL caloric density to be fed through a nasogastric tube at 25% RER for the first 24 hours.

Step 1: 25% RER Calculation RER(kcal/day) = 70 × BW(kg)0.75

= 70 × 2.30.75

= 130.7 kcal/day

25% RER = 32.7 kcal/day

Step 2 (Option 1): Liquid Diet Constant Rate Infusion Calculation

25% RER = 32.7 kcal/day ÷ 24 h/day

= 1.4 kcal/h ÷ 1.0 kcal/mL

= 1.4 mL/h

If this option is used, the patient will be placed on a constant rate infusion via a syringe pump at 1.4 mL/h.

Step 2 (Option 2): Liquid Diet Bolus Feeding (4 times a day)

25% RER = 32.7 kcal/day ÷ 4 feedings/day

= 8.2 kcal/feeding ÷ 1.0 kcal/mL

= 8.2 mL/feeding

I f this option is used, the patient will receive 8.2 mL per feeding every 6 hours (4 times a day).

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the rate of bacterial translocation, the chances of bacteremia and subsequent sepsis, and the further consequences of systemic inflammation that can lead to patient death.

Implementation of enteral nutrition as soon as vomiting is no longer intractable and initial fluid deficits are replaced is a powerful form of intervention, leading to better outcomes.

“Patients eat when they feel better.” It has been a longstanding notion that animals will regain an appetite and start eating when they feel well. While this is true, we must recognize the critical role nutrition plays in recovery, greatly aiding the patient in its path to feeling well enough to eat voluntarily. It is a veterinary technician’s role to be a patient advocate for and to help overturn this archaic notion, amending it to “While patients do eat when they feel better, they also feel better when they eat.”  References 1. Sykes JE. Canine parvovirus infections and other viral enteritides. In: Sykes JE, ed.

Canine and Feline Infectious Diseases. St. Louis, MO: Elsevier; 2014:141-151.

2. Goddard A, Leisewitz AL. Canine parvovirus. Vet Clin North Am Small Anim Pract 2010;40(6):1041-1053.

3. Hayes G, Benedicenti L, Mathews K. Retrospective cohort study on the incidence of acute kidney injury and death following hydroxyethyl starch (HES 10% 250/0.5/5:1) administration in dogs (2007–2010). J Vet Emerg Crit Care 2016;26(1):35-40.

4. Mari K, Maynard L, Eun HM, et al. Treatment of canine parvoviral enteritis with interferon-omega in a placebo-controlled field trial. Vet Rec 2003;152(4):105-108.

5. Cave N. Nutritional management of gastrointestinal diseases. In: Fascetti AJ, Delaney SJ, eds. Applied Veterinary Clinical Nutrition. Ames, IA: Wiley-Blackwell; 2012:175-219.

6. Mohr AJ, Leisewitz AL, Jacobson LS, et al. Effect of early enteral nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis. J Vet Intern Med 2003;17:791-798.

7. Will K, Nolte I, Zentek J. Early enteral nutrition in young dogs suffering from haemorrhagic gastroenteritis. J Vet Med Series A 2005;52(7):371-376.

8. Liu DT, Brown DC, Silverstein DC. Early nutritional support is associated with decreased length of hospitalization in dogs with septic peritonitis: a retrospective study of 45 cases (2000–2009). J Vet Emerg Crit Care 2012;22(4):453-459.

9. Defilippi C. Canine small bowel motor activity in response to intraduodenal infusion of nutrient mixtures of increasing caloric load in dogs. Dig Dis Sci 2003;48(8):1482-1486.

10. Cummings JH, Macfarlane GT, Englyst HN. Prebiotic digestion and fermentation.

Am J Clin Nutr 2001;73(2 Suppl):415S-420S. 11. Yu MK, Freeman LM, Heinze CR. Comparison of complication rates in dogs with nasoesophageal versus nasogastric feeding tubes. J Vet Emerg Crit Care 2013;23(3):300-304.

12. Lima JC, Andrade NJ, Soares NF, et al. The hydrophobicity and roughness of a nasoenteral tube surface influences the adhesion of a multi-drug resistant strain of Staphylococcus aureus. Braz J Microbiol 2011;42(2):489-498.

13. Metheny N. Verification of feeding tube placement. AACN Practice Alert Dec 2009.

Available at: aacn.org/wd/practice/docs/practicealerts/verification-feeding-tubeplacement.pdf. Accessed July 2016.

14. Munera-Seeley V, Ochoa JB, Brown N, et al. Use of a colorimetric carbon dioxide sensor for nasoenteric feeding tube placement in critical care patients compared with clinical methods and radiography. Nutr Clin Pract 2008;23:318-321.

15. Davinder K, Meenakshi A, Sukhpal K, et al. Effect of reintroduction of aspirated gastric content on serum electrolytes levels of patients receiving nasogastric/orogastric feed admitted in intensive care units. Nurs Midwifery Res J 2012;9(2):162-168.

16. Parker L, Torrazza RM, Li Y, et al. Aspiration and evaluation of gastric residuals in the NICU: state of the science. J Perinat Neonatal Nurs 2015;29(1):51-59.

17. Perez SK, Brandt K. Enteral feeding contamination: comparison of diluents and feeding bag usage. J Parenter Enteral Nutr 1989;13(3):306-308.

18. Neely AN, Mayes T, Gardner J, et al. A microbiologic study of enteral feeding hang time in a burn hospital: can feeding costs be reduced without compromising patient safety? Nutr Clin Pract 2006;21(6):610-616.

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Buster’s playmates miss him.

It won’t be for long, because you prescribe PREVICOX.® Who isn’t sad when a dog is in too much osteoarthritis pain to play?

So trust PREVICOX as your go-to NSAID because PREVICOX: • Provides efficacy both pet owners and veterinarians notice In a field study, after 30 days of use: – 96% of pet owners saw improvement in their dogs1 – Veterinarians saw improvement in 93% of dogs1 • Is rapidly absorbed—detected in plasma levels within 30 minutes2 • Is convenient with once-daily dosing

PUT RELIEF IN MOTION

Important Safety Information As a class, cyclooxygenase inhibitory NSAIDs may be associated with gastrointestinal, kidney or liver side effects. These are usually mild, but may be serious. Pet owners should discontinue therapy and contact their veterinarian immediately if side effects occur. Evaluation for pre-existing conditions and regular monitoring are recommended for pets on any medication, including PREVICOX. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided. Refer to the Prescribing Information for complete details.

REFERENCES: 1. Pollmeier M, Toulemonde C, Fleishman C, Hanson PD. Clinical evaluation of firocoxib and carprofen for the treatment of dogs with osteoarthritis. Vet Rec. 2006;159(17):547-551. 2. Data on file at Merial. ®PREVICOX is a registered trademark of Merial. ©2014 Merial, Inc. Duluth, GA. All rights reserved. PVX15TRADEADA-R (08/16).

CHEWABLE TABLETS Brief Summary: Before using PREVICOX, please consult the product insert, a summary of which follows: Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian.

Indications: PREVICOX (firocoxib) Chewable Tablets are indicated for the control of pain and inflammation associated with osteoarthritis and for the control of postoperative pain and inflammation associated with soft-tissue and orthopedic surgery in dogs.

Contraindications: Dogs with known hypersensitivity to firocoxib should not receive PREVICOX. Warnings: Not for use in humans. Keep this and all medications out of the reach of children. Consult a physician in case of accidental ingestion by humans.

For oral use in dogs only. Use of this product at doses above the recommended 2.27 mg/lb (5.0 mg/kg) in puppies less than seven months of age has been associated with serious adverse reactions, including death (see Animal Safety). Due to tablet sizes and scoring, dogs weighing less than 12.5 lb (5.7 kg) cannot be accurately dosed.

All dogs should undergo a thorough history and physical examination before the initiation of NSAID therapy.

Appropriate laboratory testing to establish hematological and serum baseline data is recommended prior to and periodically during administration of any NSAID. Owners should be advised to observe for signs of potential drug toxicity (see Adverse Reactions and Animal Safety) and be given a Client Information Sheet about PREVICOX Chewable Tablets.

For technical assistance or to report suspected adverse events, call 1-877-217-3543.

Precautions: This product cannot be accurately dosed in dogs less than 12.5 pounds in body weight.

Consider appropriate washout times when switching from one NSAID to another or when switching from corticosteroid use to NSAID use.

As a class, cyclooxygenase inhibitory NSAIDs may be associated with renal, gastrointestinal and hepatic toxicity.

Sensitivity to drug-associated adverse events varies with the individual patient. Dogs that have experienced adverse reactions from one NSAID may experience adverse reactions from another NSAID. Patients at greatest risk for adverse events are those that are dehydrated, on concomitant diuretic therapy, or those with existing renal, cardiovascular, and/ or hepatic dysfunction. Concurrent administration of potentially nephrotoxic drugs should be carefully approached and monitored. NSAIDs may inhibit the prostaglandins that maintain normal homeostatic function. Such anti-prostaglandin effects may result in clinically significant disease in patients with underlying or pre-existing disease that has not been previously diagnosed. Since NSAIDs possess the potential to produce gastrointestinal ulceration and/or gastrointestinal perforation, concomitant use of PREVICOX Chewable Tablets with other anti-inflammatory drugs, such as NSAIDs or corticosteroids, should be avoided. The concomitant use of protein-bound drugs with PREVICOX Chewable Tablets has not been studied in dogs. Commonly used protein-bound drugs include cardiac, anticonvulsant, and behavioral medications.

The influence of concomitant drugs that may inhibit the metabolism of PREVICOX Chewable Tablets has not been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy. If additional pain medication is needed after the daily dose of PREVICOX, a non-NSAID class of analgesic may be necessary. Appropriate monitoring procedures should be employed during all surgical procedures. Anesthetic drugs may affect renal perfusion, approach concomitant use of anesthetics and NSAIDs cautiously. The use of parenteral fluids during surgery should be considered to decrease potential renal complications when using NSAIDs perioperatively. The safe use of PREVICOX Chewable Tablets in pregnant, lactating or breeding dogs has not been evaluated.

Adverse Reactions: Osteoarthritis: In controlled field studies, 128 dogs (ages 11 months to 15 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27mg/lb (5.0 mg/kg) orally once daily for 30 days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed adverse reactions during the study.

Adverse Reactions Seen in U. S. Field Studies Adverse Reactions Vomiting Diarrhea Decreased Appetite or Anorexia Lethargy Pain Somnolence Hyperactivity

PREVICOX (n=128) 5 1 3 1 2 1 1

Active Control (n=121) 8 10 3 3 1 1 0

PREVICOX (firocoxib) Chewable Tablets were safely used during field studies concomitantly with other therapies, including vaccines, anthelmintics, and antibiotics.

Soft-tissue Surgery: In controlled field studies evaluating soft-tissue postoperative pain and inflammation, 258 dogs (ages 10.5 weeks to 16 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27 mg/ lb (5.0 mg/kg) orally approximately 2 hours prior to surgery and once daily thereafter for up to two days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study.

Adverse Reactions Seen in the Soft-tissue Surgery Postoperative Pain Field Studies Adverse Reactions Vomiting Diarrhea Bruising at Surgery Site Respiratory Arrest SQ Crepitus in Rear Leg and Flank Swollen Paw

Firocoxib Group (n=127) 5 1 1 1 1 1

Control Group* (n=131) 6 1 1 0 0 0

*Sham-dosed (pilled) Orthopedic Surgery: In a controlled field study evaluating orthopedic postoperative pain and inflammation, 226 dogs of various breeds, ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group were evaluated for safety. Of the 226 dogs, 118 were given PREVICOX Chewable Tablets at a dose of 2.27 mg/lb (5.0 mg/kg) orally approximately 2 hours prior to surgery and once daily thereafter for a total of three days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study.

Adverse Reactions Seen in the Orthopedic Surgery Postoperative Pain Field Study Adverse Reactions Vomiting Diarrhea Bruising at Surgery Site Inappetence/ Decreased Appetite Pyrexia Incision Swelling, Redness Oozing Incision

Firocoxib Group (n=118) 1 2** 2 1 0 9 2

A case may be represented in more than one category. *Sham-dosed (pilled). **One dog had hemorrhagic gastroenteritis.

Control Group* (n=108) 0 1 3 2 1 5 0

Post-Approval Experience (Rev. 2009): The following adverse reactions are based on post-approval adverse drug event reporting. The categories are listed in decreasing order of frequency by body system: Gastrointestinal: Vomiting, anorexia, diarrhea, melena, gastrointestinal perforation, hematemesis, hematachezia, weight loss, gastrointestinal ulceration, peritonitis, abdominal pain, hypersalivation, nausea Urinary: Elevated BUN, elevated creatinine, polydypsia, polyuria, hematuria, urinary incontinence, proteinuria, kidney failure, azotemia, urinary tract infection Neurological/Behavioral/Special Sense: Depression/lethargy, ataxia, seizures, nervousness, confusion, weakness, hyperactivity, tremor, paresis, head tilt, nystagmus, mydriasis, aggression, uveitis Hepatic: Elevated ALP, elevated ALT, elevated bilirubin, decreased albumin, elevated AST, icterus, decreased or increased total protein and globulin, pancreatitis, ascites, liver failure, decreased BUN Hematological: Anemia, neutrophilia, thrombocytopenia, neutropenia Cardiovascular/Respiratory: Tachypnea, dyspnea, tachycardia Dermatologic/Immunologic: Pruritis, fever, alopecia, moist dermatitis, autoimmune hemolytic anemia, facial/muzzle edema, urticaria In some situations, death has been reported as an outcome of the adverse events listed above.

For a complete listing of adverse reactions for firocoxib reported to the CVM see: http://www.fda.gov/AnimalVeterinary/SafetyHealth/ProductSafetyInformation/ucm055394.htm Information For Dog Owners: PREVICOX, like other drugs of its class, is not free from adverse reactions. Owners should be advised of the potential for adverse reactions and be informed of the clinical signs associated with drug intolerance. Adverse reactions may include vomiting, diarrhea, decreased appetite, dark or tarry stools, increased water consumption, increased urination, pale gums due to anemia, yellowing of gums, skin or white of the eye due to jaundice, lethargy, incoordination, seizure, or behavioral changes. Serious adverse reactions associated with this drug class can occur without warning and in rare situations result in death (see Adverse Reactions).

Owners should be advised to discontinue PREVICOX therapy and contact their veterinarian immediately if signs of intolerance are observed. The vast majority of patients with drug-related adverse reactions have recovered when the signs are recognized, the drug is withdrawn, and veterinary care, if appropriate, is initiated.

Owners should be advised of the importance of periodic follow up for all dogs during administration of any NSAID. Effectiveness: Two hundred and forty-nine dogs of various breeds, ranging in age from 11 months to 20 years, and weighing 13 to 175 lbs, were randomly administered PREVICOX or an active control drug in two field studies. Dogs were assessed for lameness, pain on manipulation, range of motion, joint swelling, and overall improvement in a non-inferiority evaluation of PREVICOX compared with the active control. At the study’s end, 87% of the owners rated PREVICOX-treated dogs as improved. Eighty-eight percent of dogs treated with PREVICOX were also judged improved by the veterinarians. Dogs treated with PREVICOX showed a level of improvement in veterinarian-assessed lameness, pain on palpation, range of motion, and owner-assessed improvement that was comparable to the active control. The level of improvement in PREVICOX-treated dogs in limb weight bearing on the force plate gait analysis assessment was comparable to the active control. In a separate field study, two hundred fifty-eight client-owned dogs of various breeds, ranging in age from 10.5 weeks to 16 years and weighing from 7 to 168 lbs, were randomly administered PREVICOX or a control (sham-dosed-pilled) for the control of postoperative pain and inflammation associated with soft-tissue surgical procedures such as abdominal surgery (e.g., ovariohysterectomy, abdominal cryptorchidectomy, splenectomy, cystotomy) or major external surgeries (e.g., mastectomy, skin tumor removal ≤8 cm). The study demonstrated that PREVICOXtreated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with soft-surgery. A multi-center field study with 226 client-owned dogs of various breeds, and ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group was conducted. Dogs were randomly assigned to either the PREVICOX or the control (sham-dosedpilled) group for the control of postoperative pain and inflammation associated with orthopedic surgery. Surgery to repair a ruptured cruciate ligament included the following stabilization procedures: fabellar suture and/or imbrication, fibular head transposition, tibial plateau leveling osteotomy (TPLO), and ‘over the top’ technique. The study (n = 220 for effectiveness) demonstrated that PREVICOX-treated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with orthopedic surgery.

Animal Safety: In a targeted animal safety study, firocoxib was administered orally to healthy adult Beagle dogs (eight dogs per group) at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated dose of 5 mg/kg, there were no treatment-related adverse events. Decreased appetite, vomiting, and diarrhea were seen in dogs in all dose groups, including unmedicated controls, although vomiting and diarrhea were seen more often in dogs in the 5X dose group. One dog in the 3X dose group was diagnosed with juvenile polyarteritis of unknown etiology after exhibiting recurrent episodes of vomiting and diarrhea, lethargy, pain, anorexia, ataxia, proprioceptive deficits, decreased albumin levels, decreased and then elevated platelet counts, increased bleeding times, and elevated liver enzymes. On histopathologic examination, a mild ileal ulcer was found in one 5X dog. This dog also had a decreased serum albumin which returned to normal by study completion. One control and three 5X dogs had focal areas of inflammation in the pylorus or small intestine. Vacuolization without inflammatory cell infiltrates was noted in the thalamic region of the brain in three control, one 3X, and three 5X dogs. Mean ALP was within the normal range for all groups but was greater in the 3X and 5X dose groups than in the control group. Transient decreases in serum albumin were seen in multiple animals in the 3X and 5X dose groups, and in one control animal. In a separate safety study, firocoxib was administered orally to healthy juvenile (10-13 weeks of age) Beagle dogs at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated (1X) dose of 5 mg/kg, on histopathologic examination, three out of six dogs had minimal periportal hepatic fatty change. On histopathologic examination, one control, one 1X, and two 5X dogs had diffuse slight hepatic fatty change. These animals showed no clinical signs and had no liver enzyme elevations. In the 3X dose group, one dog was euthanized because of poor clinical condition (Day 63). This dog also had a mildly decreased serum albumin. At study completion, out of five surviving and clinically normal 3X dogs, three had minimal periportal hepatic fatty change. Of twelve dogs in the 5X dose group, one died (Day 82) and three moribund dogs were euthanized (Days 38, 78, and 79) because of anorexia, poor weight gain, depression, and in one dog, vomiting. One of the euthanized dogs had ingested a rope toy. Two of these 5X dogs had mildly elevated liver enzymes. At necropsy all five of the dogs that died or were euthanized had moderate periportal or severe panzonal hepatic fatty change; two had duodenal ulceration; and two had pancreatic edema. Of two other clinically normal 5X dogs (out of four euthanized as comparators to the clinically affected dogs), one had slight and one had moderate periportal hepatic fatty change. Drug treatment was discontinued for four dogs in the 5X group. These dogs survived the remaining 14 weeks of the study. On average, the dogs in the 3X and 5X dose groups did not gain as much weight as control dogs. Rate of weight gain was measured (instead of weight loss) because these were young growing dogs. Thalamic vacuolation was seen in three of six dogs in the 3X dose group, five of twelve dogs in the 5X dose group, and to a lesser degree in two unmedicated controls. Diarrhea was seen in all dose groups, including unmedicated controls. In a separate dose tolerance safety study involving a total of six dogs (two control dogs and four treated dogs), firocoxib was administered to four healthy adult Beagle dogs at 50 mg/kg (ten times the recommended daily dose) for twenty-two days. All dogs survived to the end of the study. Three of the four treated dogs developed small intestinal erosion or ulceration. Treated dogs that developed small intestinal erosion or ulceration had a higher incidence of vomiting, diarrhea, and decreased food consumption than control dogs. One of these dogs had severe duodenal ulceration, with hepatic fatty change and associated vomiting, diarrhea, anorexia, weight loss, ketonuria, and mild elevations in AST and ALT. All four treated dogs exhibited progressively decreasing serum albumin that, with the exception of one dog that developed hypoalbuminemia, remained within normal range.

Mild weight loss also occurred in the treated group. One of the two control dogs and three of the four treated dogs exhibited transient increases in ALP that remained within normal range.

Made in France Marketed by: Merial Limited, Duluth, GA 30096-4640, U.S.A. 1-877-217-3543 NADA 141-230, Approved by FDA Rev. 07-2012 ®PREVICOX is a registered trademark of Merial. ©2016 Merial Inc., Duluth, GA. All rights reserved.

CE Article

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How and Why to Feed Canine Parvovirus Patients Right Away

CE Test How and Why to Feed Canine Parvovirus Patients Right Away The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com/tvt.aspx. A $5 fee applies. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

1. Which of the following best describes the pathogenesis of canine parvovirus?

a. The virus crosses the blood–brain barrier and overstimulates the emetic center.

b. The virus infiltrates the intestinal mucosa, paralyzing peristaltic actions.

c. The virus causes intestinal enterocyte destruction, increasing mucosal permeability.

d. The virus enters the bloodstream, causing systemic inflammation and sepsis.

6. A study comparing the complication rates of nasoesophageal and nasogastric tubes found that

a. the use of nasogastric tubes caused gastroesophageal reflux.

b. there was no difference in the complication rates for the two types of tubes.

c. the use of nasoesophageal tubes led to higher chances of aspiration.

d. esophagostomy tubes were preferable to nasoenteric tubes.

2. The most common therapies for parvoviral enteritis include _______________.

a. feline interferon omega

b. fluid therapy and antibiotics

c. human recombinant factors

d. plasma transfusions

7. The length of tube required for a nasogastric tube is the distance from the nares to the

a. thoracic inlet.

b. sixth to eighth intercostal space.

c. 10th intercostal space to the last rib.

d. point where resistance is felt during insertion.

3. Which of the following nutritional approaches to treatment of parvoviral gastroenteritis promotes healthy turnover of enterocytes, leads to swifter cessation of vomiting, and helps maintain normal gastric function?

a. Place a central line to provide parenteral nutrition.

b. Offer food in a bowl and wait for appetite to return.

c. Provide early enteral nutrition through a nasoenteric tube.

d. Withhold food for 24 to 72 hours, then reintroduce food.

8. Proper placement of a nasoenteric tube is best ascertained by

a. aspiration of the tube lumen with an empty syringe.

b. radiography to view the location of the end of the tube.

c. experience.

d. using a combination of methods.

9. Which statement is true with regard to providing early nutrition to parvoviral enteritis patients?

a. The patient should be fed small amounts of highly digestible, low-fat food.

b. The patient should be fed enough food to meet its full resting energy requirement.

c. The patient should be fed a large amount of high caloric density food.

d. The patient should not be fed until it is ready to eat on its own.

4. Fasting leads to which of the following gastrointestinal changes?

a. Pancreatic and digestive secretions are primed and ready to express adequate enzymes when food enters the gastrointestinal tract.

b. Enterocyte villus height and crypt depth are reduced, and mucosal permeability is increased.

c. Intestinal contractions become less vigorous.

d. Bacterial proliferation increases.

5. A key benefit of early implementation of enteral nutrition in gastroenteritis patients is

a. immediate reduction in vomiting frequency.

b. support for healthier enterocyte turnover and stronger mucosal barrier.

c. increased activation of neutrophils through stimulation of adhesion molecule expression.

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d. prevention of diarrhea by providing osmotic material in the intestinal lumen.

10. To receive 25% of RER, a 5 kg patient on a liquid diet CRI should be fed approximately ________.

a. 2.44 kcal/h

b. 9.75 kcal/h

c. 15.8 kcal/h

d. 81 kcal/h

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What Moves You?

Family Ties

shutterstock.com/Rita Kochmarjova

In May 2016, Leonard Marino received an associate’s degree in veterinary science technology from Suffolk County Community College on Long Island. This qualified him to work as a veterinary technician and as the editor of the hospital’s newsletter at Long Island Veterinary Specialists (LIVS) in Plainview, New York. Marino’s story, however has a unique twist. He is not only a retired pediatrician but is as industrious and persistent as ever at the age of 84. Here he shares why a new career late in life was exactly what he wanted.

For its 2016 Conference, the NAVC asked veterinary professionals to share their stories: What drives you?

What inspires you?

What moves you?

Throughout the year, Today’s Veterinary Technician will be publishing veterinary technicians’ answers to these questions.

What inspired you to make the transition from human to animal medicine?

As a pediatrician, I enjoyed the “hands-on” parts of pediatrics—suturing, spinal taps, cutdowns, starting IVs, and so forth. Activities such as being present at emergency C-sections and performing intubations—as well as exchange transfusions, when indicated—were also exciting parts of my former profession. After I “slowed down” owing to my wife’s stroke, my son asked if I would assist him in unique surgical procedures at the animal hospital where he worked, especially performing total hip replacements on dogs. I said yes!

Two pair of hands are useful in draping, opening instrument packs, holding retractors, mixing cement, etc, during surgery. In human medicine, a surgeon has a circulating or surgical nurse to help prepare the incision site and hand over instruments, among other things. I wanted to help my son because I love this part of medicine, and that’s when I decided I wanted to have the education to be even better at it.

What moves you?

Do you have a story you’d like to share? Send it to us at TVTech_submissions@NAVC.com.

Submissions should be approximately 500 words or less and may be posted on our website or edited for publication in the journal.

Tell us your story!

Peter Olson

“I had to learn how to insert an IV through furry skin, which I never had to do for infants or children!”

—Leonard Marino LEONARD MARINO at work as the newsletter editor at the Long Island Veterinary Specialists animal hospital in Plainview, New York.

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September/October 2016

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www.todaysveterinarytechnician.com

What Moves You?

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Family Ties

Peter Olson

At age 84, Leonard Marino received an associate’s degree in veterinary science technology from Suffolk County Community College.

In your opinion, what are the major differences between human and animal medicine, especially in regard to being a veterinary technician?

There are so many things that are different between human and animal medicine. In human medicine, you’re covering, well, humans! In veterinary medicine, you’re covering a variety of different species. At LIVS, in addition to dogs and cats, we’ve treated turtles, goats, birds, potbelly pigs, snakes, and even a kangaroo! And the differences aren’t just in anatomy. For instance, medications that work for dogs don’t always work the same for cats, and vice versa.

My ideas about veterinary medicine have changed noticeably, especially about the veterinary technician profession. You would think a vet tech is akin to a registered nurse, but human nurses generally don’t do radiography and ultrasonography. They also don’t regularly perform electrocardiography or monitor anesthesia without special training, and human nurses never perform dental prophylaxis.

That’s handled by another profession altogether, but veterinary technicians often do all of that and much more.

TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

Did you learn any skills as a veterinary technician that you didn’t already have as a pediatrician?

Well, my experience in pediatrics is of another era—I retired in the 1990s, and lots of techniques that are standard now were unknown then. However, I had to learn how to insert an IV through furry skin, which I never had to do for infants or children! I also learned to use sonography to find organs for specimen collection (urinary bladder) and Doppler to get systolic blood pressure readings. The process of anesthetizing an animal for any procedure is entirely new to me.

Did the “youngsters” in the college program embrace you?

I was older than many of my fellow classmates’ grandparents, but that meant I could tell them about early antibiotics— that’s just penicillin, sulfa, and streptomycin—as well as stories about my college president, Dwight Eisenhower, who then became the President of the United States. The other students loved my tales! |

September/October 2016

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What Moves You?

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

Family Ties

What’s the reward for you?

The major perk is that I get to talk to my son during his busy day (see Like Father, Like Son). The practice where we work is a referral hospital, and in addition to performing a variety of special procedures, the staff teaches classes for the care of traumatic injuries to dogs belonging to the Department of Defense, Homeland Security, and other K-9 units. It’s an incredible place to work. Also, I edit the “LIVS in Plain View” veterinary newsletter, which covers a variety of subjects, including pain management, diagnostics, behavior therapy, rehabilitation, oncology, ophthalmology, and much more.

My veterinary education only enhances this role.

Speaking of family connections, are there any notable differences between “pet parents” and human parents?

There is considerable overlap in concern for 2- and 4-legged “children.” The main difference I have seen is that pet owners have the heart-rending choice of compassionate euthanasia. Of note is that the term often used is “humane euthanasia“ when applied to animals!

Another difference is in office communication. In my pediatrics experience, phone calls from and to parents often exceeded 100 per day, whereas pet owners are asked to call in at specified times to speak to veterinarians about admitted pets. Of course, emergency messages are always accepted at all hours.

T ECHPO INT 

A more informed public means more pets get to the veterinary clinic, and more vet techs will be needed.

Where do you see the veterinary technician profession going?

A more informed public means more pets get to the veterinary clinic because owners seek better care. This leads to more preventive medicine such as heartworm prevention and vaccines for diseases like canine distemper, parvovirus, hepatitis, rabies, feline panleukopenia, and rhinotracheitis.

The bottom line is that more vet techs will be needed.

What would you say to people considering a career in animal medicine, especially those who already have worked in another career field?

Go for it, as long as you love animals and have little fear of fractious cats and hard-to-manage exotics! Or maybe you want to work outdoors in a large animal practice. There are so many opportunities in this field. 

Like Father, Like Son We asked Dr. Marino’s son to weigh in on what his father’s career change meant to him. Dominic J. Marino, DVM, DACVS, DACCT, CCRP, is chief of staff at Long Island Veterinary Specialists, where his father now works alongside him.

What is it like to work alongside him?

My dad has always been a teacher. Every “home project” we did together when I was a kid was an adventure in learning, and the same is true now.

He loves to problem solve and so do I. I’m the luckiest guy in the world to be able to work with my pop, teach him a few things, and still be able to learn from him!

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An Official Journal of the NAVC

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Peter Olson

What was your reaction to your father making this switch of fields?

I wasn’t surprised. He had been working at our specialty center for years helping with various research and administrative projects and always said, “I could be of more help if I understood the veterinary portion better.” Well, that was the start of his pursuit to learn more. At 80 years old and working full time with me, he enrolled in night school, and 4 years later, he got his degree in veterinary technology. He is now an MD and an LVT.

“I’m the luckiest guy in the world to be able to work with my pop, teach him a few things, and still be able to learn from him!”

September/October 2016

—Dominic J. Marino

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Ideas Into Practice

Becoming a “Cat-Friendly” Practice

E

ven though I am a dog and horse lover, I admit that becoming a cat-friendly practice is one of the best changes my clinic has made in the 22 years I have worked there.

I will also say this: in the first few years of my career, I really did not like cats. But that changed after I learned about cats at the NAVC Conference, about their behavior, and about how you should treat cats and their owners. So I hope that, especially for the “non” cat lovers, reading this article will help you work with cats better.

Esther Klok Dierenkliniek Winsum The Netherlands Esther Klok, a veterinary technician at Dierenkliniek Winsum in the Netherlands, has described her passion to bring new ideas from the NAVC Conference to her clinic in “What Moves You? From Holland: Looking Back on a GREAT Adventure” (Today’s Veterinary Technician May/June 2016) and “Ideas Into Practice: Starting Veterinary Technician Appointments” (Today’s Veterinary Technician July/ August 2016). In this article, she discusses her inspiration for creating a cat-friendly practice, as well as how she introduced and implemented her plan.

ALL MIXED UP When I started working as a veterinary technician 22 years ago, our clinic was a mixed one. We treated livestock, horses, and small animals. I worked in all three areas, as did the veterinarians. I can tell you that it was not easy. I needed to have knowledge about so many different animals and to develop the skills to treat them.

For instance, imagine that one Monday, you are out in the fields assisting with a caesarian section on a sheep. Next, you must address a cow with milk fever. You finish your morning with a horse that has colic and an upset owner. Then you eat your lunch, grab yourself a clean shirt and pants, and go back to the veterinary clinic to start office hours for the small animals. Your first client is a cat lover holding a carrier with a longhaired cat in one hand and an article from the internet in the other.

Those of you with many years in this profession may recognize this situation. For the rest of you, believe me, it was a big headache. We had vastly different animals and different owners, and we had to help them all equally, to do the best for every animal and owner.

For me, the cats caused the most headaches. They were opinionated and difficult to handle. And when my colleagues and I talked afterward about appointments, our opinion was always that the cat owners had exactly the same characteristics as their cats.

Our practice finally split a few years ago into 3 sections: small animals, livestock, and horses. That was the first step toward improving our care for all our patients. Our second step was to become cat friendly.

“For me, the cats caused the most headaches. They were opinionated and difficult to handle.”

— Esther Klok

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PLANT AN IDEA AND IT WILL GROW In January 2014, I attended the NAVC Conference in Orlando. On the second day, my colleague and I went to an early morning breakfast lecture. I left the room hungry because the topic was so interesting that I took notes throughout and had no time to eat anything.

An Official Journal of the NAVC

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September/October 2016

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TE C HP O I N T 

Ideas Into Practice

I learned to stop fighting my feline patients and start thinking. When you try to eliminate stress for cats, it is much easier to treat them.

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Becoming a “Cat-Friendly” Practice

this kind of course should be mandatory for every vet and vet tech all over the world. I learned to stop fighting my feline patients and start thinking. When you try to eliminate stress for cats, it is much easier to treat them.

WOMAN ON A (CAT) MISSION On my way back to Holland, I started to make a plan for our practice. When I explained it to my colleagues, they were all enthusiastic. Of all the employees, only one vet was a cat lover, and we knew we had to do something because when you do not love cats, you will not get good results or attract many cat owners as clients. So everyone agreed that we had to take a chance. The whole staff was on board to become approved by the American Association of Feline Practitioners (AAFP) as a Cat Friendly Practice. (I will add that I was lucky that the cat lover in our practice was one of my two bosses!)

Our plan included these steps: ÆÆ Every team member had to read and learn the information book we made about cats and their handling. ÆÆ Some physical parts of the practice had to become more cat friendly. ÆÆ The handling of cats had to be addressed. ÆÆ Our information for cat owners “on paper and in words” would be updated.

The subject? A cat-friendly practice.

After that lecture, I took my personal schedule of lectures—which I start making up about 3 weeks before the conference—and threw it all away. Instead, I looked for everything about cat-friendly practices and procedures, cat behavior, and any other subject with the word “cat” in it. That was a big change because, normally, I went to lectures with subjects I love, like anesthesia, dog behavior, public relations/marketing, and horse topics, and as I mentioned, I really did not like cats. I thought they were difficult, incomprehensible, and could hurt you too much!

Lucky for me, the first lecture was one of the best I ever heard. It was about cat behavior, and the presenters had several great video clips with good examples that showed problems between cats, problems between owners and cats, and situations in the living area of cats that caused problems for them. This lecture was an eye opener for me. Afterward, I understood a little bit more about cats and a little bit more why cats and our practice were not always a good match.

For the rest of the conference, I soaked up lots of information, and I closed it with a hands-on lab about stress-free handling of dogs and cats. I LOVED it! I think

The plan became a team effort and team building experience. After the practice closed each day, we started to renovate, paint, and spruce up our 2 buildings. It’s an amazing feeling to be standing on a table, painting the walls (with more paint in your hair and on your face than what’s on the wall), and to look around and see your colleagues making jokes to each other as they work toward a common goal!

That’s the spirit of a vet clinic.

FIGURE 1. (A) A converted isolation cage with hiding places and toys for cats. (B) The mesh roof of the cage.

TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

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September/October 2016

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Ideas Into Practice

Daily Nutrition Matters ®

Clients are asking tough questions about nutrition.

Are you ready? Daily Nutrition Matters is a free, comprehensive education program brought to you by nutrition experts.

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Becoming a “Cat-Friendly” Practice

So what did we change?

In the building itself, we did the following: ÆÆ We converted a quarantine cage for dogs into a space for cats. These cages are huge—150 cm (about 5 feet) on a side. So we put a roof on one to use it for cats that had to stay more than one day. We created hiding places inside the cage with a big cat carrier and a cardboard box. A tunnel is also fun for cats to explore, and we added a big covered litterbox and a large, soft bed. Before putting a cat in, we use Feliway to keep it from soiling outside the litterbox. So we created an environment with as little stress as possible and made it interesting and fun for cats. For most feline patients that are not very sick, it’s perfect (FIGURE 1). ÆÆ We put double doors on our cat cages so that we can approach the cats through 2 doors and not have to be right in front of their noses. Also, we covered one door of each cage so that cats can hide behind it (FIGURE 2). I’d say that 95% of our feline patients make use of this feature. Cats that stay a while in a practice may feel less stress when they can hide. When you give them sedation, they can hide and relax, and your anesthetic will work quicker and more effectively. ÆÆ We put locks on the consulting rooms because we were always trying to keep the cats on the exam table. But why? The examination takes only about 40% of the visit, and for the rest of the time, you are talking with the owner or typing on the patient’s chart. As for the cat, it’s so stressful for it to stay on the table and be held by the owner, vet, or vet tech. When we lock the door, we can let the cat walk freely in the examination room. This works extremely well. ÆÆ We placed a big table in the waiting room so clients can put their cat carriers on it.

Dogs cannot approach it, and the cats cannot see other animals in front of their carrier door. Adding a “Cat Parking Sign” on the table is ideal (FIGURE 3).

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FIGURE 2. Cat cages with double doors. When the doors are closed, cats can hide behind the solid door to feel safe.

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September/October 2016

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Ideas Into Practice

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

Becoming a “Cat-Friendly” Practice

Less stressed cats are happier and more relaxed, which makes them much easier to treat.

ÆÆ We bought a wireless doorbell that runs on

batteries (FIGURE 4). We give the bell to the owner and keep the button. When it’s time to come into the examination room, we push the button and the owner gets a bell signaling to come in and go straight into the examination room, allowing the owner and cat to skip the waiting room with its noises and smells. The doorbell is also handy for situations like euthanasia.

When the animal passes away, we bring the clients something to drink, and they can stay as long as they want in the room and say goodbye to their friend. In this instance, we give them the button and keep the bell ourselves. When clients want to leave or have a question, they can push the button, and we hear the bell and come to them.

The physical premises and procedures were not the only things we changed. A few examples of other items include: ÆÆ We now use an insulin syringe for intramuscular injections for sedation. While the vet tech is petting the cat, the vet can give the injection very slowly. In our experience, about 90% of cats do not react to the injection. ÆÆ When a cat is afraid to have blood taken from its neck, we wrap it in a towel and take the blood from the inside of a hind leg. In the past, we sedated many cats to take blood, but now it’s almost never necessary. ÆÆ To take blood pressure, we put the little machine inside the cat’s cage. I’ve seen this greatly reduce a cat’s stress. I can tell the machine to measure again and again so we have a good average. On the other hand, for cats that are really relaxed with their owners, we can measure blood pressure on the owner’s lap. ÆÆ We made a flyer that explains how to transport cats.

FIGURE 3. “Cat parking” sign at Dierenkliniek Winsum.

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TECHPOINT 

At our practice, we also sell “cat-friendly transport boxes.” I think owners do not always realize they are already making their cat anxious at home. They take the cat carrier out and grab the cat, and then they put their pet in a strange-smelling, dark cage and close the door. I ask them, “Can you imagine yourself grabbing your child by the neck and putting him or her in a laundry basket? Would you put a cover on the basket even while your child is screaming and struggling, then put the basket with the screaming child in your car to drive to the doctor?” I know that at least 99% of children treated like that would be completely stressed out when they arrived at the doctor’s office, and when they were let out, if anybody tried to touch them, they would kick, bite, and fight back. Then, in the future, when they saw the basket, they would run away or start kicking and fighting immediately when approached.

So...cats are not that strange! Our job is to explain to owners how they can teach their cats that the transportation box is okay and how they can get their cat accustomed to going somewhere in the car. ÆÆ Finally, we sell cat toys and explain how important it is that owners enrich the lives of their cats.

FIGURE 4. Wireless doorbell for client signaling.

An Official Journal of the NAVC

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September/October 2016

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FLEA AND TICK control dogs run to, not from…

NexGard® (afoxolaner) for dogs is: POWERFUL so it keeps killing fleas and ticks all month long EASY to give because it’s soft and beef-flavored

Dogs love it!

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1

Data on file at Merial.

®NexGard is a registered trademark, and FRONTLINE VET LABS is a trademark of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved.

NEX16TRADEAD (01/16).

IMPORTANT SAFETY INFORMATION: NexGard is for use in dogs only. The most frequently reported adverse reactions included vomiting, dry/flaky skin, diarrhea, lethargy, and lack of appetite. The safe use of NexGard in pregnant, breeding, or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures. For more information, see full prescribing information or visit www.NexGardForDogs.com.



T EC HP O I N T 

When you implement new things in your practice, you are developing the practice, the team, and all the individual team members.

MISSION COMPLETE? When our practice looked back after a few years as a cat-friendly practice, what were our benefits? Well, they were too many to count, but here are a few: ÆÆ Less stressed cats are happier and more relaxed, which makes them much easier to treat. ÆÆ Less stress for the cat is also less stress for the owner. The result? Clients come more readily to the clinic, because they are not scared about their cat being completely stressed out. They are also happy and satisfied after the visit. ÆÆ Less stress for the veterinary team means less “fighting” with a cat. Now, everything that is happening with the cat is super relaxed. The result is that we have all started to love cats more and more! ÆÆ We gained new clients because they heard from friends or saw on the internet or in the newspapers that we are cat friendly. ÆÆ We’ve had really great press because newspapers loved the story of a cat-friendly practice. ÆÆ Most importantly, we now know more about cats and their behavior.

I advise every clinic to try this concept. I must be honest and say that while we will stay cat friendly, we are not AAFP approved and might not become so. We love how the AAFP helped us, but because all the patient information, flyers, and posters are in English, we cannot really use them in the Netherlands. But we will follow the AAFP guidelines as much as we can.

I will also say that the hardest part is to change yourself.

I think it’s very important to explain to the team that they really should try to adopt the “new” approach, but it works best when they see the results of it for themselves.

As for you? Just TRY it!

At my practice, we now love cats instead of seeing them as a “problem.” Funny, because the cats didn’t change. Only we did!  34

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TODAY’SVETERINARYTECHNICIAN

CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.

Description: NexGard® (afoxolaner) is available in four sizes of beef-flavored, soft chewables for oral administration to dogs and puppies according to their weight. Each chewable is formulated to provide a minimum afoxolaner dosage of 1.14 mg/lb (2.5 mg/ kg). Afoxolaner has the chemical composition 1-Naphthalenecarboxamide, 4-[5- [3-chloro-5-(trifluoromethyl)-phenyl]-4, 5-dihydro-5-(trifluoromethyl)-3-isoxazolyl]-N-[2-oxo-2-[(2,2,2-trifluoroethyl)amino]ethyl.

Indications: NexGard kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of Black-legged tick (Ixodes scapularis), American Dog tick (Dermacentor variabilis), Lone Star tick (Amblyomma americanum), and Brown dog tick (Rhipicephalus sanguineus) infestations in dogs and puppies 8 weeks of age and older, weighing 4 pounds of body weight or greater, for one month.

Dosage and Administration: NexGard is given orally once a month, at the minimum dosage of 1.14 mg/lb (2.5 mg/kg).

Dosing Schedule: Body Weight 4.0 to 10.0 lbs.

10.1 to 24.0 lbs.

24.1 to 60.0 lbs.

60.1 to 121.0 lbs.

Over 121.0 lbs.

Afoxolaner Per Chewables Chewable (mg) Administered 11.3 One 28.3 One 68 One 136 One Administer the appropriate combination of chewables

NexGard can be administered with or without food. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused. If it is suspected that any of the dose has been lost or if vomiting occurs within two hours of administration, redose with another full dose. If a dose is missed, administer NexGard and resume a monthly dosing schedule.

Flea Treatment and Prevention: Treatment with NexGard may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with NexGard should continue the entire year without interruption.

To minimize the likelihood of flea reinfestation, it is important to treat all animals within a household with an approved flea control product.

Tick Treatment and Control: Treatment with NexGard may begin at any time of the year (see Effectiveness).

Contraindications: There are no known contraindications for the use of NexGard.

Warnings: Not for use in humans. Keep this and all drugs out of the reach of children. In case of accidental ingestion, contact a physician immediately.

Precautions: The safe use of NexGard in breeding, pregnant or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures (see Adverse Reactions).

Adverse Reactions: In a well-controlled US field study, which included a total of 333 households and 615 treated dogs (415 administered afoxolaner; 200 administered active control), no serious adverse reactions were observed with NexGard.

Over the 90-day study period, all observations of potential adverse reactions were recorded. The most frequent reactions reported at an incidence of > 1% within any of the three months of observations are presented in the following table. The most frequently reported adverse reaction was vomiting. The occurrence of vomiting was generally self-limiting and of short duration and tended to decrease with subsequent doses in both groups. Five treated dogs experienced anorexia during the study, and two of those dogs experienced anorexia with the first dose but not subsequent doses.

Table 1: Dogs With Adverse Reactions.

Treatment Group Afoxolaner

Vomiting (with and without blood) Dry/Flaky Skin Diarrhea (with and without blood) Lethargy Anorexia

N1 17 13 13 7 5

% (n=415) 4.1 3.1 3.1 1.7 1.2

Oral active control

N2 25 2 7 4 9

% (n=200) 12.5 1.0 3.5 2.0 4.5

1 Number of dogs in the afoxolaner treatment group with the identified abnormality.

2 Number of dogs in the control group with the identified abnormality.

In the US field study, one dog with a history of seizures experienced a seizure on the same day after receiving the first dose and on the same day after receiving the second dose of NexGard. This dog experienced a third seizure one week after receiving the third dose. The dog remained enrolled and completed the study. Another dog with a history of seizures had a seizure 19 days after the third dose of NexGard. The dog remained enrolled and completed the study. A third dog with a history of seizures received NexGard and experienced no seizures throughout the study.

To report suspected adverse events, for technical assistance or to obtain a copy of the MSDS, contact Merial at 1-888-6374251 or www.merial.com/NexGard. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth.

Mode of Action: Afoxolaner is a member of the isoxazoline family, shown to bind at a binding site to inhibit insect and acarine ligand-gated chloride channels, in particular those gated by the neurotransmitter gamma-aminobutyric acid (GABA), thereby blocking preand post-synaptic transfer of chloride ions across cell membranes. Prolonged afoxolaner-induced hyperexcitation results in uncontrolled activity of the central nervous system and death of insects and acarines. The selective toxicity of afoxolaner between insects and acarines and mammals may be inferred by the differential sensitivity of the insects and acarines’ GABA receptors versus mammalian GABA receptors.

Effectiveness: In a well-controlled laboratory study, NexGard began to kill fleas four hours after initial administration and demonstrated >99% effectiveness at eight hours. In a separate well-controlled laboratory study, NexGard demonstrated 100% effectiveness against adult fleas 24 hours post-infestation for 35 days, and was ≥ 93% effective at 12 hours post-infestation through Day 21, and on Day 35. On Day 28, NexGard was 81.1% effective 12 hours post-infestation. Dogs in both the treated and control groups that were infested with fleas on Day -1 generated flea eggs at 12- and 24-hours post-treatment (0-11 eggs and 1-17 eggs in the NexGard treated dogs, and 4-90 eggs and 0-118 eggs in the control dogs, at 12- and 24-hours, respectively). At subsequent evaluations post-infestation, fleas from dogs in the treated group were essentially unable to produce any eggs (0-1 eggs) while fleas from dogs in the control group continued to produce eggs (1-141 eggs).

In a 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of NexGard against fleas on the Day 30, 60 and 90 visits compared with baseline was 98.0%, 99.7%, and 99.9%, respectively.

Collectively, the data from the three studies (two laboratory and one field) demonstrate that NexGard kills fleas before they can lay eggs, thus preventing subsequent flea infestations after the start of treatment of existing flea infestations.

In well-controlled laboratory studies, NexGard demonstrated >97% effectiveness against Dermacentor variabilis, >94% effectiveness against Ixodes scapularis, and >93% effectiveness against Rhipicephalus sanguineus, 48 hours post-infestation for 30 days. At 72 hours post-infestation, NexGard demonstrated >97% effectiveness against Amblyomma americanum for 30 days.

Animal Safety: In a margin of safety study, NexGard was administered orally to 8 to 9-week-old Beagle puppies at 1, 3, and 5 times the maximum exposure dose (6.3 mg/kg) for three treatments every 28 days, followed by three treatments every 14 days, for a total of six treatments. Dogs in the control group were sham-dosed. There were no clinically-relevant effects related to treatment on physical examination, body weight, food consumption, clinical pathology (hematology, clinical chemistries, or coagulation tests), gross pathology, histopathology or organ weights. Vomiting occurred throughout the study, with a similar incidence in the treated and control groups, including one dog in the 5x group that vomited four hours after treatment.

In a well-controlled field study, NexGard was used concomitantly with other medications, such as vaccines, anthelmintics, antibiotics (including topicals), steroids, NSAIDS, anesthetics, and antihistamines. No adverse reactions were observed from the concomitant use of NexGard with other medications.

Storage Information: Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F).

How Supplied: NexGard is available in four sizes of beef-flavored soft chewables: 11.3, 28.3, 68 or 136 mg afoxolaner. Each chewable size is available in color-coded packages of 1, 3 or 6 beef-flavored chewables.

NADA 141-406, Approved by FDA Marketed by: Frontline Vet Labs™, a Division of Merial, Inc. Duluth, GA 30096-4640 USA Made in Brazil. ®NexGard is a registered trademark, and TMFRONTLINE VET LABS is a trademark, of Merial. ©2015 Merial. All rights reserved.

1050-4493-03 Rev. 1/2015

15 Years: A Brief History of Shelter Medicine

I

n November 2015, nearly a dozen shelter veterinarians convened at the American Board of Veterinary Practitioners Symposium in New Orleans to sit for the first certification examination for the newly approved Shelter Medicine Practice specialty. Most of the candidates were faculty and graduates from formal university residency training programs at veterinary schools across the nation— programs that generally had not existed a mere decade before. This watershed moment came nearly 15 years to the day that Drs. Niels Pedersen and Janet Foley launched the world’s first residency training program at the UC Davis School of Veterinary Medicine in the previously unheard-of field of shelter medicine.

FOUNDING AN ACADEMIC FIELD The program at UC Davis was born out of Dr. Pedersen’s long recognition that veterinary professionals responsible for the medical management of intensively housed companion animals were in desperate need of an evidence-based approach to providing for the mental and physical well-being of this vulnerable population. A truly legendary veterinarian, scientist, humanitarian, and visionary, Dr. Pedersen has been a leading researcher in the field of feline retroviruses since the mid 1960s. In this role, he was placed in charge of the UC Davis research cat colony in the early 1970s. Dr. Pedersen had noticed that his colony cats, which he allowed to roam

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Michael Bannasch, BS, RVT UC Davis School of Veterinary Medicine

free in purposely designed housing arrangements, remained relatively disease free, while other campus colonies of animals obtained from shelters and housed in “traditional” stainless steel cages were continually battling infectious disease. Dr. Pedersen’s observation and practices are detailed in his highly regarded book Feline Husbandry and Diseases and Management in the Multiple-Cat Environment, published in 1991.

In 2000, Dr. Pedersen was leading the UC Davis Center for Companion Animal Health when he learned about Maddie’s Fund, the largest individually funded companion animal welfare foundation in the world. David Duffield, co-founder and former chairman of PeopleSoft, had endowed the fund in 1999 in the name of his beloved miniature schnauzer, who had died of cancer 2 years previously. Duffield also lured Richard Avenzino away from his position as president of the San Francisco SPCA to run the fund. Considered by many to be the father of the “no kill” movement, Avenzino had championed the San Francisco shelter’s effort to create the world’s first “no kill city.” One of Avenzino’s first proclamations as president of Maddie’s Fund was that within 10 years, no animal would be euthanized unless it was irremediably suffering or could not be rehabilitated because of a behavior issue. To achieve this objective, Avenzino knew he would have to infiltrate, influence, and coerce

Michael began his career in high school working as an animal care attendant, groomer, and veterinary assistant at a family-owned veterinary practice in the suburbs of Detroit, Michigan. He spent nearly a decade working at the Virginia–Maryland Veterinary Emergency Service and over a year at the National Institutes of Health National Heart, Lung, and Blood Institute. In 1998, Michael moved to California to accept a position in UC Davis’s Small Animal Intensive Care Unit.

He joined Dr. Niels Pedersen’s lab 2 years later, and shortly after that he became program coordinator of the first shelter medicine veterinary training program in the world. After 15 years in that position, Michael joined the UC Davis Veterinary Center for Clinical Trials.

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veterinary academia to address the medical needs of intensively housed animals.

After some negotiation, Maddie’s Fund promised to grant the UC Davis School of Veterinary Medicine $1.5 million over 5 years to (1) start a resident training program, (2) conduct noninvasive research of benefit to shelter animals, and (3) provide outreach and support to animal sheltering organizations, as long as at least 60% of the shelters helped were self-described as no kill facilities. And with that agreement, shelter medicine as an academic field was born.

Dr. Pedersen’s first task was to hire a director to lead the program. He immediately identified his former graduate student, Janet Foley, DVM, PhD, as the right person for the job. Dr. Foley, a free-spirited, confident, bold personality, had the scientific curiosity and know-how necessary to not only lead this pioneering program but also maintain and defend its academic freedom and integrity while working in the often volatile and polarizing field of companion animal welfare.

With her on board, a program coordinator was needed to run day-to-day operations and to field cries for help from every type of animal shelter from around the world.

That’s where I entered the field of shelter medicine.

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HAPPY TO HELP are Barbie Laderman-Jones (left) and Tess Kommedal (right), who perform examinations on and report findings in shelter cats at the Sacramento SPCA. A Technician’s Perspective When Dr. Foley approached me to see if I was interested in the program coordinator position, I was working as postgraduate researcher on a project to identify the origins of the domestic dog through Y chromosome haplotype analysis.

Before that, I had enjoyed a 12-year career as a companion animal emergency and critical care technician, the last 2 years of which I had worked in the UC Davis Small Animal Intensive Care Unit. I had also spent a year as a certified laboratory animal technician at the National Institutes of Health National Heart, Lung, and Blood Institute.

While many folks working in the field of animal welfare view working with homeless animals as a calling, I admit I was drawn by the opportunities for basic research that could immediately improve management practices and enhance infectious disease prevention. I have to also confess that my wife, a veterinary geneticist, was in line for a faculty position at UC Davis where she would take charge of the canine

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genetic research that I was a part of, which I thought might lead to some complications at home. So I was in need of a new career path, and when I heard about the plans for the shelter medicine program, my interest was piqued.

Granted, my experience with animal shelters to that point was limited to having adopted 2 dogs. Both came with the array of shelter diseases usual at that time; one also came with a lesson in defying poor customer service. In addition, like any emergency and critical care technician worth his or her salt, I could amaze pet owners with my ability to guess the origin of their recently acquired pet as being an animal shelter, and I could identify the time since adoption and the animal’s most likely medical condition based on the owner’s description of the telltale signs of advanced upper respiratory disease, parvovirus, panleukopenia, ringworm, etc.

The Final Pieces Fortunately for Dr. Pedersen, Dr. Foley, and myself, our first resident, Dr. Kate Hurley, had vastly more shelter experience than any of us. A 1999 UC Davis School of Veterinary Medicine graduate, Dr. Hurley started her path into shelter medicine in earnest while working in the trenches as an animal control officer in Santa Cruz, California, in 1989. After graduating from UC Davis, she worked as a shelter veterinarian in California and Wisconsin. Frustrated by the lack of resources available to assist veterinary professionals merge the needs of population and individual health management in the challenging environments where homeless companion animals are housed, she sought out advanced shelter medicine training. Soon after, Dr. Sheila Segurson-D’Arpino joined the program, becoming the first resident to undertake a postgraduate behavior specialty training program that focused on shelter animals and shelter behavior programs.

CREATING A NEW DIALOGUE As pioneers in a field yet to be defined, our little group found the early years of the shelter medicine program challenging.

There were very few resources available. A quick search of scholarly publications using the search term “animal shelter” yields a total of 150 papers published between 1970 and 2001, when the program began. Outside of and in spite of these scant research efforts, many shelters had operated for decades through the vertical transfer of knowledge perpetuated by personal experience and by perception.

Approaches to preventive measures as simple as vaccination varied widely between—and, in many cases, within—shelters, depending on who was tasked with intake of animals on a particular day. Animals were housed in inadequate caging without a clear plan or path out, often for weeks, months, years, or, alternatively, for not enough time to allow a 38

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SHELTER MEDICINE includes many veterinarians and veterinary technicians who passionately care for this incredibly vulnerable population of dogs and cats. desperate owner to navigate obstacles in time to prevent the unthinkable. Newspaper articles, TV reports, and the newly emerging blogosphere were replete with horror stories about conditions at shelters and gut-wrenching testimonials from bereaved pet owners whose animal had died in a shelter because of unchecked disease or clerical error.

As such, from the outset, we had to be creative when researching and seeking support material for recommendations to improve conditions at shelters. For help with sanitation and disinfection recommendations, we turned to human hospital, industrial, and even restaurant and hospitality disinfection journals for information about products and techniques. For help with vaccination and disease prevention questions, we looked to herd health publications. However, when speaking in public or writing recommendations, we made an effort to avoid “hot-button” terms such as “herd” or “research,” which could result in immediate dismissal of and negative feedback about the information we provided. We visited small groups at shelters and spoke at conferences, and because immediate feedback and amplification outlets such as Facebook and Twitter didn’t yet exist, some of our more progressive suggestions and recommendations were able to take root before being subjected to “conventional wisdom.”

Gradually, we learned what worked and what didn’t, as much through research as through visiting shelters, both large and small, municipal and private, open admission and no kill. We gathered, compiled, and published our findings on our website, sheltermedicine.com, updating information and deleting outdated recommendations as our understanding of shelter medicine expanded. We reached out to researchers at veterinary schools across the country to share what we had learned and to learn from the experts at these institutions. As we soon discovered, there were, in fact,

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experts who had long been working diligently to improve the mental and physical well-being of shelter animals through their research efforts: Dr. Jan Scarlett at Cornell, Dr. Gary Patronek at Tufts, Dr. Ron Shultz at Wisconsin, Drs. Julie Levy and Cynda Crawford at Florida, Dr. Phill Kass at UC Davis, and many more. In addition to the academics, there were plenty of devoted shelter experts working tirelessly in and around animal shelters across the county and in our Northern California backyard, such as Dr. Wes Jones, Dr. Richard Bachman, Dr. Cynthia D. Delany, and Dr. Bonnie Yoffe-Sharp.

Ultimately, the program survived and even thrived by reaching out to everyone with a unique perspective on or a novel approach to improving the care of shelter animals.

We embraced the open-source approach to acquiring, evaluating, and disseminating information of import to the field of shelter medicine. One of my proudest achievements was the creation of our shelter medicine class, which ran for 11 years and was open to not only veterinary students but also to any shelter professional or interested community member. We took advantage of cutting-edge (at the time) software that allowed us to live stream and archive each shelter lecture on our website, which quickly became the go-to resource for evidence-based shelter medicine. Our lecture series featured guests from around the country who we considered to be experts on particular facets of animal welfare. Topics ran the gamut from behavior to neonatal care to vaccination to legislation. Today, you can find their technological descendants, webcasts, on pretty much every shelter topic out there, and nearly every shelter advocacy group hosts them, including the Humane Society of the United States, PetSmart Charities, and Maddie’s Institute.

growing, and incredibly rewarding specialty field of veterinary medicine. As of this writing, the same journal search for “animal shelter” that yields a mere 150 publications before 2001 brings back over 800 citations from between 2001 and today on topics ranging from disease recognition and testing to enrichment techniques for alleviating stress in shelter animals. Countless webinars on every imaginable shelter topic are accessible at the click of a button. Shelter medicine programs are expanding at veterinary schools across the United States and around the world! Progressive programs in shelter medicine like the University of Florida’s online master’s degree and innovative leaders like Dr. Brittany Watson at the University of Pennsylvania School of Veterinary Medicine (BOX 1) are expanding the reach and redefining the meaning of shelter medicine by bringing students into communities to provide medical care and education to at-risk animals and their owners in an effort to further increase companion animal and decrease relinquishment.

LOOKING BACK During my time as the UC Davis’ shelter medicine program coordinator, I saw the good, the bad, and the ugly of traditional, private, municipal, no kill, rescue, sanctuary, and the occasional plain old “too many animals to properly care for” shelter organizations. Along the way, I met many incredible veterinarians and veterinary technicians who headed the call to care for this incredibly vulnerable population. Many dedicated and talented people blazed this trail. All are worthy of the term hero, but none is more worthy than Dr. Niels Pedersen, scientist, humanitarian, and father of shelter medicine. 

BOX 1 Pursing the Future of Shelter Medicine

GROWING ACROSS THE WORLD Together, we built the path forward. In 2004, the first textbook on the topic of shelter medicine, Shelter Medicine for Veterinarians and Staff, was published. In 2005, the recently formed Association of Shelter Veterinarians began to discuss shelter medicine becoming a board specialty. In 2008, residency standards were developed, and in 2010, Guidelines for the Standards of Care in Animal Shelters was published.

Chaired by Dr. Sandra Newbury, and coauthored by many of the aforementioned shelter experts from across the nation, the Standards is the seminal document in the field of shelter medicine. Based on the Five Freedoms, which were created in 1965 in the United Kingdom and are broadly accepted as the guidelines of welfare for all animals, the Standards have allowed shelters around the world to examine their lifesaving ability and to identify and prioritize areas and practices within their operational model that need improvement.

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Today, nearly every veterinary school in North America and a handful of veterinary schools around the world offer some form of shelter medicine training. In addition to learning opportunities open to veterinary students, the University of Florida shelter medicine program has created a specialized online training program open to all sheltering professionals.

For more information, visit onlinesheltermedicine. vetmed.ufl.edu.

At the same time, progressive programs like Penn Vet’s shelter animal medicine program, led by Dr. Brittany Watson, continue to expand the definition of shelter medicine and the role that veterinarians and veterinary technicians play in reducing relinquishment and euthanasia of healthy, adoptable animals. For information, visit vet.upenn. edu/research/centers-initiatives/shelter-medicine.

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the TOP 1O things Every Shelter Technician Should Know and Do

➊

Know your organization’s capacity for care.

This magic number depends on several factors, including the organization’s mission, available resources, and number of qualified and trained staff. The good news is that you can figure it out before a heinous outbreak.

A number of resources exist to help your organization determine its unique capacity for care. Once established, there are many tips and tricks that you can learn to increase it in a healthy and productive way. Visit the Maddie’s Fund website for more information: maddiesfund.org/capacity-for-care-learning-track.htm

➋

Obtain at least a basic understanding of immunology and of infectious disease control.

Which animals should receive a vaccination? When should an animal be vaccinated? What measures should be taken in the face of an outbreak, or better still, what measures should be implemented to prevent an outbreak? Most animals entering a shelter or rescue come with questionable backgrounds and histories. Intensively housed shelter animals make up a “herd of companion animals,” where each individual animal is as vulnerable to disease as it is a potential hazard to the herd. Fortunately for today’s shelter technicians, many advancements have been made in companion animal herd management tools and techniques over the past decade. A few good resources and references to help shelter technicians in this area are:  ASPCA Pro Shelter Management website: aspcapro. org/shelter-management  Greene C. Infectious Diseases of the Dog and Cat. 4th ed. Saunders; 2012.  Miller L, Hurley K. Infectious Disease Management in Animal Shelters. Wiley-Blackwell; 2009.  Miller L, Zawistowski S, eds. Shelter Medicine for Veterinarians and Staff. 2nd ed. Wiley-Blackwell; 2013.

➌

Look around and outside your organization and understand the difference between what your shelter is doing and what other successful shelters are doing.

Throughout my time in shelter medicine, when working with a shelter struggling with significant disease, I often heard the staff proclaim, “We didn’t realize things were that bad,” or “We thought all shelters were like ours.”

Find out what is going on in your sheltering community and beyond. Listen, borrow from, and support your fellow

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animal welfare organizations. Today, numerous online communities and local, regional, and national continuing education opportunities exist for shelter technicians.  animalsheltering.org/expo  navc.com  pro.petfinder.com/calendar

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Take advantage of online training opportunities in the field of shelter medicine.

In addition to the many regional and national meetings with shelter medicine tracks, there are many online educational resources for shelter technicians to obtain the latest information on sheltering issues. Webinars are a free, easy, fun way to learn from and interact with fellow sheltering professionals. If you are truly inspired, look into obtaining an online master’s degree in animal welfare through the University of Florida. Below are just a few websites offering free shelter medicine training opportunities.  aspcapro.org/recorded-webinars.php  petsmartcharities.org/pro/learn  sheltermedicine.vetmed.ufl.edu/education/courses/

➎

You don’t have to be a shelter technician to help shelter animals.

More and more people are realizing that animal homelessness and pet overpopulation are not shelter problems; they are community problems. If you are a private practice technician with a client who recently adopted an animal from a local shelter and you identify a health issue of concern, don’t badmouth the shelter or dismiss it as a place for your clients to avoid when looking for their next companion. Instead, reach out to the shelter, let them know what you are seeing, and ask if there are ways that your practice can help. Not only is it the right thing to do for your community, but it will likely boost your practice’s clientele. Visit The Humane Society’s Pets for Life website for more information and ideas on how you can help! humanesociety.org/about/departments/pets-for-life

➏

Remember that customer service saves lives.

Some technicians elect to work in a shelter because they do not enjoy working with clients; however, the best thing a shelter technician can do for animals is to get them out of the shelter and into a forever home.

Customer service is an important component of making that happen. Nothing frustrated me more during my time in shelter medicine than watching a family wandering around a shelter, clearly in search of a pet, without

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As part of a UC Davis study of upper respiratory infections, Tess Kommedal and Michael Bannasch swab a cat at the Marin Humane Society in California.

15 Years: A Brief History of Shelter Medicine

➑

Know and support your foster homes to achieve success together.

Shelters are constantly seeking alternatives to intake to alleviate the numbers of in-shelter animals that must be cared for at any given time. One popular method to achieve this goal is the use of foster homes, especially in the case of neonates; however, to be successful, a foster program must provide extensive training for foster families and offer continual oversight of their activities. An in-foster outbreak of parvovirus, panleukopenia, or ringworm often results in significant emotional trauma that leads to the loss of the affected foster home and may also severely affect the shelter’s ability to recruit future foster homes because of negative reviews shared on social media. A good shelter technician possesses the expertise needed to support the physical and emotional well-being of the animals in foster care while at the same time supporting the emotional and physical well-being of their fostering families. The ASPCA Pro website offers a comprehensive listing of training opportunities on managing a foster home network: aspcapro.org/search/index/foster

➒ anyone offering them assistance. Smile, be helpful, and be honest.  shelterskills.com  maddiesfund.org/when-adopters-show-up.htm

➐

Take time out for yourself.

Compassion fatigue is a very real and a very serious issue among all shelter professionals. I can unequivocally report that during my 15 years of visiting shelters and speaking with technicians and doctors, the most welladjusted, productive, and truly happy shelter professionals were those with an interest outside of shelter medicine.

Being “the only one” who is capable of saving the lives of the animals in your shelter is a definite red flag and speaks to the shelter’s capacity for care and/or your own need to take the time to work on your work–life balance. There are many resources for shelter employees faced with compassion fatigue, and many of those resources have been compiled at compassionfatigue.org.

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Know the guidelines for standards of care in animal shelters, and make sure your organization is living up to them.

Published in 2010, the Association of Shelter Veterinarians’ Guidelines for Standards of Care in Animal Shelters provides sheltering professionals with research-based guidelines to help them meet the physical, medical, and behavioral needs of the animals under their care. Used in concert with the handy shelter standards checklist offered by the ASPCA, these guidelines can help shelter technicians evaluate a shelter’s capacity for care and set a course toward improvement.  The Standards: sheltervet.org/assets/docs/shelterstandards-oct2011-wforward.pdf  The ASPCA checklist: aspcapro.org/checklist

➓

Be a positive, effective communicator.

Thankfully, due in large part to the advent of evidence-based shelter medicine research and practices, shelters no longer have to rely on word-of-mouth transfer of “traditional shelter practice.” A large library of shelter practice resources now exists and grows every day.

However, there are still those—shelter directors, managers, and medical staff, as well as city managers and/ or board members—to whom these resources are new.

Educate yourself and be a positive voice for change.

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Peer-Reviewed

The Non-pathologic, Non-collection, and Non-sample

Preanalytical Small “Stuff” That Influences Reliable Laboratory Results Daniel J. Walsh, MPS, LVT, RVT, VTS (Clinical Pathology) Academy of Veterinary Clinical Pathology Technicians West Lafayette, Indiana

“It’s a patient, not just a sample.”

The Hippocratic Oath

Author unknown In veterinary medicine, as in human medicine, doctors have become more dependent on laboratory results. Lisa Sanders, MD, of the Yale School of Medicine, quipped that medical doctors look at laboratory values as “coming straight from god.”1 Although this statement is an exaggeration, it does suggest the degree of importance placed on laboratory data. It also emphasizes the level of responsibility placed on medical laboratory professionals in human medicine and, by extension, on the veterinary healthcare team (VHCT) and their clients in veterinary medicine to obtain reliable results.

But not only the sample collection and handling portions of the preanalytical process influence laboratory results. Everything from client education and VHCT preparedness to patient “state of mind” to clinical facilities and beyond may also affect the reliability of results. This article addresses the latter factors.

With the patient as the primary focus, the laboratory process has been divided into 3 related stages: preanalytical, analytical, and postanalytical (BOX 1).

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“…do no harm…”

Dan’s veterinary career began when he worked in a small animal practice during college.

Upon graduation, he served in the Army as a Veterinary Care Specialist and had the privilege of caring for the Army mascot mules for a time.

After discharge, he worked in mixed animal practice.

Dan subsequently taught in the veterinary technology programs at SUNY Delhi for 28 years and Purdue University for over 11 years.

Dan holds an associate degree in veterinary technology; associate, bachelor’s, and master’s degrees in animal science; and a graduate certificate in veterinary homeland security. He is a member of several associations, including NAVTA and the Uniformed Veterinary Medical Association.

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In multiple studies in human medicine,3,4 and in anecdotal information and one study found in veterinary medicine,5 most challenges to reliable results were traced to the preanalytical phase.

Although this is the most common phase for challenges, it is frequently where they are simplest to control.6,7 In human medicine studies, the results varied. The total error in the human regulated laboratory process was approximately 0.1% to 9.3% in one study4 and 0.1% to 3% in another.3 The effects of these errors ranged from inconsequential to life-threatening. Approximately 31% to 75% of the errors were traced to the preanalytical phase of the laboratory process.3,8 One recent study in human medicine suggests the distribution of errors among the phases may be changing, based on its finding that an increasing number of errors in the analysis phase are due to operator error.9 With rare exceptions (e.g., equine infectious anemia testing),10 there is no government-required external oversight system for the veterinary point-of-care (POC) laboratory. The amount of error in the veterinary POC laboratory is unknown, but it is predicted to be similar to that in

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Preanalytical Small “Stuff” That Influences Reliable Laboratory Results

shutterstock.com/nimon

Inaccurate results are worse than no results!

human medicine.11,12 Although the overall percentage of errors seems low, for an affected patient and client, any error is still important.

precise. In this context, accurate means that they are truly representative of the patient’s values, whereas precise means that they are repeatable.7,13 Reliable results aid the entire VHCT in delivering the best possible: ÆÆ Routine health screenings (e.g., geriatric, presurgical, initial, and annual visits) ÆÆ Diagnoses ÆÆ Prognoses ÆÆ Treatments ÆÆ Patient monitoring ÆÆ Development and maintenance of patient-specific baselines ÆÆ Development and maintenance of practice-specific reference intervals ÆÆ Forensic evidence

THE NEED FOR RELIABLE RESULTS The goal of every laboratory, whether POC or off-site, is to provide reliable results and excellence in patient care.

Reliable results, by definition, are both accurate and

BOX 1 Phases of the Laboratory Process2 Preanalytical  Client request for in-clinic or ambulatory services  Client education  Patient identification, preparation, transport, history, and physical examination

STEPS TOWARD RELIABLE RESULTS: QUALITY ASSURANCE, QUALITY CONTROL, AND STANDARD OPERATING PROCEDURES To ensure reliable results, it is necessary to have a quality assurance (QA) program that sets the planning, implementation, education, monitoring, and assessment parameters for the entire process—preanalysis through analysis to postanalysis. This is commonly accomplished through the development and use of protocols and standard operating procedures (SOPs). Integral to the analysis phase of QA are quality control (QC) procedures that commonly use a commercially available substance, or “control,” of known value that is similar to and treated in the same manner as the patient sample. It is assumed that,

 Sample collection, labeling, handling, and preparation for test Analytical  Performance of tests Postanalytical  Reporting of results  Review of values and possible anomalies  Diagnosis  Client education  Process review

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barring unforeseen circumstances, if the control results provided by the manufacturer are achieved, the patient results will also be correct for the specific test.12,14,15 To minimize the effects of personal differences on reliability of results, standardization of procedures is necessary. Written SOPs provide a foundation for communication and control of the entire process. For SOPs to be effective, all members of the VHCT must buy into them. To minimize drift, all members of the VHCT must be initially and periodically educated, updated, observed, and evaluated in the use of the SOPs. The SOPs must provide the who, what, when, where, and why in addition to the how of each procedure performed in the process. SOPs must be periodically reviewed, with adjustments made only when a valid need arises.12,14 Veterinary practice and consumer protection regulations, standards of practice, and/or professional ethics may state or imply the need for quality in all aspects of practice. To this end, throughout the laboratory process, regardless of whether tests are performed in a POC or off-site laboratory, the primary responsibility lies with the VHCT to prevent or catch potential issues that may cause errors. Inaccurate results are worse than no results!16 SMALL STUFF MATTERS In his book An Astronaut’s Guide to Life on Earth: What Going to Space Taught Me About Ingenuity, Determination, and Being Prepared for Anything, Canadian astronaut Col. Chris Hadfield acknowledges that not only large, obvious issues but also small, seemingly unimportant, and easily overlooked matters can be detrimental to a mission.17 This lesson can be applied to the “mission” of veterinary medicine as well. Just as in a space mission, recognizing and avoiding pitfalls in clinical pathology and associated laboratory processes can go a long way toward ensuring reliable results and preventing potential harm to the patient.

Many challenging factors in clinical pathology can negatively influence the validity of results. Some are external to the patient; others are patient-specific but may or may not be related to the patient’s particular medical condition or health screening. They can mistakenly cause: ÆÆ Test results that should be negative to be positive, or results that should be positive to be negative ÆÆ Values that should be low to be high, or those that should be high to be low ÆÆ Values that should be outside of the reference interval or baseline for the patient to be within the reference interval or baseline, or values that should be within the interval or baseline to be outside it 46

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TECHPOINT 

Clients must be educated at the point of first contact, thus initiating an ongoing process of communication.

Another confounding element is when, based on the control, patient results are assumed reliable for the specific sample obtained and tests conducted but do not meet expectations. These results warrant additional investigation and should not be automatically assumed to be errors.

Some common sources for these apparent contradictions are listed in BOX 2.

BOX 2 Common Reasons for Unexpected Laboratory Results6,9,12,18  “Snapshot-in-time” phenomenon: results are representative of the patient at the time of collection, but have been skewed by an influencing factor (e.g., excitement, sedation) with a very short-term effect  Lack of characteristic signs of a medical condition  Presence of disease that is new to the geographic area  Individual physical, physiologic, and/or psychologic factors that are not characteristic of the patient’s species, breed, or strain  Insufficient patient history  Lack of DVM order for and/or performance of a relevant test  Test methodologies that lack specificity and/or sensitivity  Differences in reporting methods  Human (client/VHCT) factors  Environmental influences  Expectation that all values within the reference interval for the patient’s reference group are “normal” and those that are outside are “abnormal,” or vice versa  Patient or sample mix-up  Unknown, forgotten, or perceived “unimportant” details

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An additional challenge is the apparent lack of availability of practical QA and QC information and of initial and continuing education for POC QA and QC. Much of the available information has been developed for veterinary reference and commercial laboratories, extrapolated from the regulated human medical field, passed on by word of mouth, or gleaned from commercial marketing rather than technical materials. Caution must be used with these sources of information, which may not be complete or specific for a particular POC situation.8,11,12

turn, are influenced by pathologic and/or nonpathologic variables. The scope of this phase is likely one of the major reasons the preanalytical clinical pathology phase is considered to have the greatest number of influences on the reliability of results.

THE GOAL: PATIENT-CENTERED CARE Patient-centered care is a team-based approach that includes the patient, client, and all members of the VHCT. The goal of patient-centered care is to foster a communicative, sharing, and collaborative relationship to specifically meet the patient’s needs. The clinical pathology part of this approach is to provide the “right test, to the right patient, at the right time,” culminating in reliable results and excellence in patient care.2,20 By initially addressing the patient, client, environmental, and nonpathologic biologic variables, we set the stage to be better prepared for the actual collection and sample handling procedures. Ensuring that the client is on board, gathering the appropriate information about the patient, and having the necessary materials and VHCT members available help to expedite the process.

PEOPLE ARE IMPORTANT “High-tech,” “new and improved,” and “quick and easy” are not synonymous with reliability. Nor can technology use suboptimal samples to achieve reliable results.

The human elements of experience, knowledge, observation, ability, integrity, intuition, communication skills; recognition of strengths and limitations; and empathy for the patient and client are necessary to achieve the desired outcome.19 Most VHCT members would probably agree that there are areas in our professional and home lives in which we feel more comfortable, based on our level of knowledge and abilities. Most likely, we also recognize the information explosion that surrounds us in both settings and the need to keep up with the times to the best of our abilities in as many areas as possible. To this end, we find ourselves attaining different levels of expertise based on the needs and demands of these two “lives”: ÆÆ User: obtains reliable results when performing a procedure ÆÆ Operator: user + “understands” the basic principles of the procedure ÆÆ Specialist: operator + evaluates reliability of results, process, and user/operator; makes appropriate changes, “repairs,” and corrections with minimal, if any, assistance17

COMMUNICATION IS KEY

“I know that you believe that you understood what you think I said, but I am not sure you realize that what you heard is not what I meant.”

Attributed to Robert J. McCloskey, Spokesman, US State Department, at a Vietnam War press update

EVERYTHING INFLUENCES SOMETHING The factors that influence the preanalytical phase can be divided into 6 categories: ÆÆ VHCT ÆÆ Client ÆÆ Patient ÆÆ Environment ÆÆ Sample collection ÆÆ Sample handling and processing

As people, we are all different because of our varied experiences, education, knowledge, interpersonal interactions, and capabilities. These differences, more often than not, are a great benefit. To ensure they will be an advantage lies in our ability to communicate and have a mutual understanding.19 Within the Veterinary Healthcare Team The information veterinary technicians attempt to gain from or share with clients or other members of the VHCT depends on several communication influences:

This categorization demonstrates the range of the preanalytical phase. All the parts are interrelated and, in TODAY’SVETERINARYTECHNICIAN

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To ensure reliable results, it is necessary to have a quality assurance program that sets the planning, implementation, education, monitoring, and assessment parameters for the entire process.

ÆÆ What is said and not said: Reading between the lines ÆÆ How it is said: Interpreting the attitude of the

interaction/transmission of information (e.g., perceived level of interest, facial expression, eye movement/ contact, voice inflection/tone/volume, vocabulary/ grammar, professionalism of appearance and behavior) ÆÆ Means of transmission: Oral (e.g., instruction, question, conversation), written, visual, audiovisual, demonstration, telephone, text, e-mail ÆÆ Individual state of mind during and between transmission and use of information ÆÆ Level of comprehension ÆÆ How, when, and from whom the information was obtained ÆÆ Other variables (e.g., ability to hear, regional accent, speech impediment, distractions)21–23 With the Client The veterinary–client–patient relationship assists the client in being an “active” partner in all processes with the VHCT. In turn, it helps the client to make informed decisions based on the recommendations of the VHCT. For the client to be informed sufficiently to make these decisions and the VHCT to be prepared for the patient, clients must be educated at the point of first contact, thus initiating an ongoing process of communication.24 Client knowledge and compliance are related to an understanding of the patient’s needs and the abovementioned communication influences. BOX 3 describes a recommended approach to obtaining information from clients; BOX 4 lists the basic information that VHCT members should provide in turn.

“I hear and I forget.

I see and I remember.

I do and I understand.”

Paraphrase, attributed to Confucius To reinforce and supplement verbal communication and help improve client compliance, VHCT members can use practice-prepared written/visual materials, practice-reviewed and approved outside/commercial information, and/or practical demonstration. If it will be necessary for the client to perform a procedure in the home environment, it may be prudent to observe the client’s ability to do so. In addition to on-site and telephone communication, it may be appropriate to use texting, e-mail, and websites with practice-prepared and/or practice-reviewed and approved information.21–23

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THE TOTAL PATIENT Behavioral Factors A knowledge of the patient’s innate and learned behaviors, likes and dislikes, and types of responses to different stimuli can assist veterinary technicians in providing the

BOX 3 Suggested Approach to Acquiring Client Information21–23  Know what information must be obtained from or transmitted to the client before the conversation (who, what, where, when, why, how)  Identify the services the client perceives to be necessary for the patient (e.g., presenting complaint, preventive care)  Use open-ended questions to stimulate the client to consider the issue and subsequently answer in a more complete manner, providing facts, not opinion or interpretation  Use follow-up questions to clarify information; these questions may be short-answer (e.g., yes or no) questions  Avoid interrupting the client unless time is critical and/or they have veered off topic  Provide the opportunity for the client to ask questions and to add free-form pertinent information  Document what information has been requested and received

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best possible experience and the least amount of discomfort, stress, and excitement for the patient, client, and VHCT alike.

Regardless of patient size or species, negative and positive sensory (e.g., sight, smell, taste, sound, touch, pain, temperature, balance) experiences form a basis for the patient’s memory of people, places, and things.6,25 These experiences can be associated with transport, a new environment or the presence of other patients, a procedure, or even a hearty welcome from a VHCT member, and any of these events may initiate a patient response.

Whether immediate or long-term, patient stimuli can result in stress, causing the release of glucocorticoids, and/ or excitement, resulting in the release of epinephrine.

Even though the initiator of the stress and/or excitement is not necessarily bad, the influences on laboratory values may be confounding, resulting in alterations such as hyperglycemia, glycosuria, leukocytosis, and neutrophilia.6,9,25–28

Environmental Factors Environmental factors such as a cold table, slippery surfaces, the noise of a fluorescent light, the bang of a gate or cage door, and differing amounts or varying patterns of light can be confusing and physiologically and psychologically stimulating to some patients. Other environmental factors can be of a geographic nature. Patients living in areas of higher altitude or poorer air quality may have higher packed cell volume and hemoglobin levels. Patients in transient situations may have a greater chance of exposure to diseases not native to their home environment.

Like us, our patients acclimate physically, physiologically, and psychologically to circumstances, tend to have a long memory, and are more likely to respond positively to quiet handling and consistent, low-key, complementary environments.6,7,11,22–24,26 Regardless of the term used to describe it—patientcentered, low-stress, humane, Fear Freesm, genuine care and concern for the individual, kinder–gentler—minimizing patient stress and excitement and that of the associated humans can lead to more reliable results and excellence in patient care.6,7,11,22–24,26

BOX 4 Common Information to Provide to Clients

Physical Factors BOX 5 lists nonpathologic physical characteristics that should be observed for every patient.

Acquired identification characteristics and signalment assist in the positive identification of the patient and sample and the retrieval and update of patient and client records. The signalment may also help support or eliminate conditions associated with a particular species, breed/strain, age, gender, genotype, or other inherited/ congenital characteristics. These characteristics also may help to determine what methods may be used in patient care (e.g., handling, restraint, sample collection).

In addition to contact information, client qualifiers may assist in identifying issues related to the patient’s medical condition. For example, the location may assist in detecting disease associated with a specific geographic area.

Having multiple members of the VHCT examine and observe the patient not only allows for efficient gathering of information but also minimizes the chance of missing a patient characteristic. The typical observation points may provide a link to confounding influences such as a possible medical condition, iatrogenic characteristics, or ”whitecoat syndrome” factors (e.g., stress. excitement).6,8,27

The order of information to be disseminated may vary with the circumstance.  The client’s expected role, including unique situations (e.g., need to collect samples or administer sedatives at home)  Special patient care required before sample collection (e.g., fasting, special diet, minimizing excitement)  Additional information the client will need to provide at the clinic or ambulatory visit (e.g., history, presenting complaint)  After the veterinarian evaluates the patient and orders the tests to be performed:

 Types of samples required

 What procedures will be performed during sample collection (e.g., clipping an area for a venipuncture)

 Why the tests are being performed

 How the information obtained from the test will help the veterinarian to help the patient

 When results will be available

The Other Somethings Patient identifiers, demographics, and other influences such as those listed in BOX 6, as well as how much, when,

 Costs involved

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and how a patient has been exposed to each, may affect the patient and, subsequently, its laboratory results.

Regardless of whether there is a noticeable effect on the patient, the test results still may be affected. Even circumstances that are perceived as “typical” or “good” for the patient may influence test results.

The effect of these in vitro and/or in vivo influences on laboratory values may result in relative or absolute increases or decreases in the amount of an analyte and/or chemical or physical changes that interfere with the test procedure. The effects may be due to acute or chronic influences, and there is no accurate way of determining in all situations how values may be altered. Patients are individuals, and their responses may be different.2–5,8,27

BOX 5 Nonpathologic Physiologic Patient Identifiers6 Acquired Identification

TECHPOINT 

Most challenges to reliable results were traced to the preanalytical phase.

CONCLUSION This is only the beginning of the preanalysis phase. It continues through a multiplicity of procedures involving the patient, as well as sample collection and handling.

As much as possible, communicate, standardize through SOPs, and use QA programs and QC procedures to monitor the entire process.2–5,8,27 

BOX 6 Examples of Demographic and Patient Factors That Can Influence Laboratory Results6,9,29

 Name, number  Tag, collar, brand, implant, tattoo, notching

 Client (e.g., initial information provided)

 Acquired characteristics (e.g., dehorning, docked tail, ear cropping, scars)

 Preventive care (e.g., vaccines, parasiticides, physical examination)

 Associated client information Signalment  Species

 Environment (e.g., geographic location, season, diurnal variations, travel, weather, air quality, biohazards, biosecurity, biocontainment practices, toxin exposure)

 Breed/strain  Age/date of birth  Gender, including neuter status, intersex  Color (e.g., coat color, eye color)

 Bowel movements and urination (e.g., frequency, volume, changes, description)

 Inherited and congenital characteristics; genotypes (e.g., identity/disease susceptibility)

 Association with other animals (e.g., domestic, wild, vermin) or insects; health status of other animals; new arrivals

Physical Examination Findings and Observations

 Emesis, drooling, discharge (e.g., frequency, amount, contents, color, transparency, consistency)

 Veterinary technician observations (at minimum)

 Types of samples required

 Association with people and their health status, travel history, association with animals

 Mucous membrane color, moistness, capillary refill time

 Medication history (e.g., prescription, over the counter, compounded, supplements, vitamins, minerals, anthelmintics, alternative, source, brand, dose, dosage regimen, means of administration, responses)

 Weight, body condition score

 Temperament, behavior, typical versus atypical

 Temperament

 Overall appearance, posture

 “Lifestyle” or function (e.g., pet, production animal), amount and type of activity (e.g., exercise, “work,” pregnancy)

 Veterinarian examination

 Medical/surgical history

 Temperature, pulse, respiration, skin turgor

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 Diet, feeding/watering regimen (e.g., changes, amount, communal or individual, free choice or intermittent, source, brand), changes in appetite, treats or snacks, fasted

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Preanalytical Small “Stuff” That Influences Reliable Laboratory Results References 1. Fisher M. What to do when your doctor doesn’t know. AARP The Magazine July/ August 2011. pubs.arp.org/aarptm/20110208_PR?=54. Accessed October 2015.

2. Vap LM, Lab errors: if you can’t catch them, avoid them. Proc CVC 2010. veterinarycalendar.dvm360.com/lab-errors-if-you-cant-catch-them-avoid-themproceedings. Accessed March 2016.

3. Hammerling JA. A review of medical errors in laboratory diagnostics and where we are today. Lab Med 2012;43(2):41-44.

4. Kakra J. Medical errors: impact on clinical laboratories and other critical areas. Clin Biochem 2004;37(12):1052-1062.

5. Hooijberg E, Leidinger E, Freeman KP. An error management system in veterinary clinical laboratories. J Vet Diagn Investig 2012;24(3):458-468.

6. Latimer KS. Duncan and Prasse’s Veterinary Laboratory Medicine: Clinical Pathology.

5th ed. Ames, IA: Wiley-Blackwell; 2011:366.

7. Cornell University College of Veterinary Medicine. eClinPath.com. Accessed March 2016.

8. Braun JP, Bourgès-Abella N, Geffré A, et al. The pre-analytic phase in veterinary clinical pathology. Vet Clin Pathol 2015;44:8-25.

9. Barger AM, Macneill AL. Clinical Pathology and Laboratory Techniques for Veterinary Technicians. Ames, IA: Wiley-Blackwell; 2015:232.

10. United States Department of Agriculture. APHIS-Approved Laboratories. Equine infectious anemia. aphis.usda.gov/aphis/ourfocus/animalhealth/lab-info-services/ sa_approved_labs/ct_approved_labs. Accessed July 2016.

11. Weiser MG, Thrall MA. Quality control recommendations and procedure for in-clinic laboratories. Vet Clin North Am Small Anim Pract 2007;37:237-244.

12. American Society for Veterinary Clinical Pathology. Principles of quality assurance and standards for point-of-care testing in veterinary medicine. Section 1: 2-6; Section 2: 7-8,10-11,29-32. asvcp.org/pubs/qas/index.cfm. Accessed March 2016.

13. Sirois M. Laboratory Procedures for Veterinary Technicians. 6th ed. St. Louis, MO: Mosby; 2015:28.

14. Sirois M. Clinical pathology close-up: developing a standard operating procedures manual. Vet Tech 2013;34(3). vetfolio.com/veterinary-practice-issues/clinical-pathologyclose-up-developing-a-standard-operating-procedures-manual. Accessed July 2016.

15. Epperley LA. Quality control counts with in-clinic veterinary labs, Heska and Abaxis say. Vet Pract News. September 24, 2012. veterinarypracticenews.com/ September-2012/Quality-Control-Counts-With-In-clinic-Veterinary-Labs-Heska-And-

Abaxis-Say/. Accessed July 2013.

16. Meinkoth JH, Allison RW. Sample collection and handling: getting accurate results.

Vet Clin North Am Small Anim Pract 2007;37:203-219.

17. Hadfield C. An Astronaut’s Guide to Life on Earth: What Going to Space Taught Me About Ingenuity, Determination, and Being Prepared for Anything. Boston, MA: Little, Brown & Co; 2013.

18. Gilor S, Gilor C. Common laboratory artifacts caused by inappropriate sample collection and transport: how to get the most out of sample. Top Companion Anim Med 2011;26(2):109-118.

19. Gray M. Let computers help you, not break you. Online J Nurs Informatics 2009;13(1). ojni.org/13_1/Gray.htm. Accessed March 2016.

20. Adams C. In pursuit of patient-centered care. Med Lab Observ 2016;48(4):8. mloonline.com/pursuit-patient-centered-care. Accessed July 2016.

21. Ishmael W. How to avoid conflict and be a better listener on your ranch. Beef Magazine Spring 2015:23-28. beefmagazine.com/beef-vet/how-avoid-conflict-bebetter-listener-your-ranch. Accessed July 2016.

22. Kleen JL, Atkinson O, Noordhuizen JPTM. Communication in production animal medicine: modeling a complex interaction with the example of dairy herd health medicine. Irish Vet J 2011;64:8. irishvetjournal.biomedcentral.com/ articles/10.1186/2046-0481-64-8. Accessed March 2016.

23. Shadle CC. Why listening is an important skill. Vet Pract News April 5, 2016. veterinarypracticenews.com/why-listening-is-an-important-skill/. Accessed April 2016.

24. American Veterinary Medical Association. Veterinarian-client-patient relationship (VCPR) FAQ. avma.org/public/PetCare/Pages/VCPR-FAQs.aspx. Accessed March 2016.

25. Grandin T, Deesing M. Humane Livestock Handling. Adams, MA: Story Publishing; 2008:4-30.

26. Cowell RL. Veterinary Clinical Pathology Secrets. St. Louis, MO: Elsevier Mosby; 2004:39-40.

27. Siska W, Provencher A. Avoiding the pitfalls of pre-analytical variables in animal health studies. Int Anim Health J 2015;12(4):54-57. www.animal healthmedia.com.

Accessed March 2016.

28. Manning S. Don’t fret, pet. Journal & Courier Lafayette, IN. January 15, 2016:D1, D6. newspapers.com/newspage/148154562/. Accessed July 2016.

29. Forman DT, Young DS, Drug interference in laboratory testing. Ann Clin Lab Sci 1976;6(3):263-271.

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Career Challenges

Getting Your Life Unstuck

S

tuck. Many of us can relate to feeling stuck when we continuously repeat old processes, live in unhappy relationships, or work in unhealthy environments. We may know that we are unhappy but often stay the course because we don’t know how to make successful change happen. We become comfortable with the familiar misery.

This article discusses the steps necessary to get unstuck and realize forward momentum by making successful change happen. This topic was introduced at the 2016 NAVC Conference and will continue at the 2017 Conference.

Deborah A. Stone, MBA, PhD, CVPM StoneVPM | Austin, Texas Deborah has been involved with the veterinary profession for nearly 30 years and has experience in specialty, emergency, and general practice management.

STUCK: WHAT DOES IT MEAN? Everyone gets stuck at some point in life, whether on a personal or professional level or a blend of both. Being stuck is also known as being in a rut, frozen, trapped, or getting the same unwanted results over and over (FIGURE 1).

She earned an MBA with a concentration in business management and completed her PhD in Organizational Leadership. Deborah is a Certified Veterinary Practice Manager, accredited from the Veterinary Hospital Managers Association. She devotes much of her time to community service activities and holds memberships with several veterinary-related associations and organizations.

Deborah is a national speaker, founder of Austin City Unlimited Veterinary Management Symposium, and published author of practice management/professional development articles. She enjoys spending time with her family as well as performing with her bands, the LaxaTones and the No-Lo Prophets.

FIGURE 1. Other terms for being “stuck.”

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Career Challenges

Can you think of a time when you were stuck?

If so, how did you deal with it?

Familiar Misery “Familiar misery” is the state of not necessarily being happy with an aspect of our life, but knowing what we have and choosing to stay in that state (FIGURE 2). It is often rooted in fear, specifically fear of the unknown. As a result, we may miss opportunities. A couple examples of familiar misery are: “I love caring for patients but dread going to work. At least it’s better than the unknown and starting all over.”

“I’m not in a healthy personal relationship, but at least I’m with somebody and I know what I have. It beats being alone.”

When we live in a state of familiar misery, we become comfortable with what we know and remain content with the status quo. According to Achor, “When our brains get stuck in a pattern that focuses on stress, negativity, and failure, we set ourselves up to fail.”1 Our Brains: Friend or Foe? Our brains, as magnificent as they are, sometimes prevent us from making quick and easy changes. We can become rooted in our habits and routines, which in turn make pathways in our brain. On a daily basis, we often travel the same route to our jobs, order the same coffee drink, and make other similar regular decisions. What happens when we have to go outside of our daily routine or comfort zone?

Neuroscience continues to discover new information concerning the health, elasticity, and functionality of the brain. Research shows3 that we can actually make new pathways that help us respond to and process situations differently. This is encouraging, especially concerning the process of making change happen and getting different results. As Achor indicates, “cultivating positive brains makes us more motivated, efficient, resilient, creative, and productive, which drives performance upward.”1 Our brains are also exposed to extreme amounts of data every day, in and outside of the veterinary practice. Achor notes that, “Scientists estimate that we remember only one of every 100 pieces of information we receive; the rest gets filtered out, dumped into the brain’s spam file.”1

WHAT GETS IN OUR WAY? Although we may believe somewhere deep down inside that we would benefit from change, there are many things that can get in the way. Some reasons may be clear to us,

MAKING CHANGE STICK Many programs developed to help manage change initiatives are available. Philosophies differ concerning the amount of time needed to realize effective change. Does it take 30 days, 60 days, 90 days, or even longer?

FIGURE 2. Familiar misery and missed opportunities. |

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but more often, self-reflection is needed to understand what is keeping us stuck.

One indicator of being stuck may be one’s happiness level. Sometimes we may not be happy and we don’t know why. Other times, we may know why we are not happy but don’t know where to begin to make change happen. There may be still other times when we know we aren’t happy but just can’t “go there” or can’t imagine doing all the work that it takes to realize better results.

The science of happiness has been studied for more than 2 decades. Researchers continue to explore why some people seem happier than others, why it matters, and how it affects the change process. According to positive psychology expert Shawn Achor, “Happiness is not the belief that we don’t need to change; it is the realization that we can.”1 Correlations can be seen between our level of happiness and ability to realize positive life outcomes.

According to happiness expert Sonja Lyubomirsky, “Genuinely happy people do not just sit around being content. They make things happen.”2

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The answer is, it depends. Many variables must be considered when launching a change initiative, such as: What do we want to change? How long have we been doing it this way? Does it involve professional or personal change? Is it group change or individual change? Is it turning off a light switch when leaving the practice or moving from paper files to electronic medical records?

How and where do we start? Who is part of the process?

How do we make long-lasting change? These are just a few items to consider when developing effective change that sticks.

One example of a well-known change program was developed by change expert John Kotter.4 One of the first comprehensive change management programs, this

Take the Change Challenge Are you stuck with something in your life? Remember the 4 steps to getting unstuck and start the change process.

SELF-REFLECTION 

What are some of the barriers that have kept you from getting unstuck or making change happen?

8-step program is especially useful when trying to make group change.

1. Create a sense of urgency.

2. Pull together the guiding team.

3. Develop the change vision and strategy.

4. Communicate for understanding and buy-in.

5. Empower others to act.

6. Produce short-term wins.

7. Don’t let up.

8. Create a new culture.

1. Pause Find a quiet space where you can just stop, someplace where you aren’t pulled in several directions. This is difficult, but it is the necessary first step in learning about yourself and what movement you’d like to make.

2. Breathe Once you’ve found your space, breathe deeply, then exhale. This works like a reset button and helps you become more present and ready to hear and acknowledge what you are thinking and feeling.

3. Listen (heart and head) We have goals and dreams of the ideal scenarios.

These come from our heart, or feeling. Then we have the plans, pathways, and how-to’s. These come from our head, or thinking. Listening to both the heart and head helps avoid short-changing possibilities and missing opportunities. Write out your reflections and ideas and share them with those you trust and who are open.

4. Move Take action on your change initiative. There will be many lessons throughout this process, and they may require you to tweak some of the plans and pathways to realize your goals and dreams. Keep the forward momentum by evaluating the results frequently.

Write down both the process and the results you have achieved. Give yourself some kind words and thoughts. Credit yourself for all that you have done and all that you will do in the future.

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Kotter’s steps are a result of decades of research, and the key to this methodology is that every step must be addressed.

Shortcuts often leave critical items unaddressed, resulting in gaps in achieving change success. Sometimes it is necessary to revisit a previous step and make adjustments to realize change that sticks.

Other examples of change systems can be seen in weight-management programs and fitness clubs. Each has a strategy concerning how to make change happen and achieve long-lasting results.

FOUR STEPS TO GETTING UNSTUCK Although everyone has different stories, interests, and experiences, there are 4 common steps to explore to start getting our lives unstuck.

1. Pause This is a difficult first step. In our profession, we are known to be helpers and givers to many, often at our own expense. Stopping to take time for ourselves is frequently difficult because we usually are very busy, even working after hours or bringing work home with us.

Taking the time to stop or pause is the first critical step.

2. Breathe The next necessary but difficult step is to take a deep breath, exhale, and get ready to really listen to what it is that you want to change.

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Career Challenges

Have you realized success in making change stick?

What was the key to your success?

SUMMARY Is getting unstuck easy? No. Can it be done? Absolutely.

It’s truly your choice if you want to be part of changing outcomes in your life.

Whether your story of being stuck is personal, professional, or both, if you want to achieve better results, you must do the difficult work. It’s also important to note that we don’t get stuck and unstuck just once in our lives.

The more we develop our self-awareness and understanding of why we’re stuck, the better we’ll get at making change happen—perhaps even becoming happier along the way. 

4. Move This is the step where you take action and apply the strategies you developed in the listening step. This should help create new pathways and movement toward realizing new outcomes.

GETTING UNSTUCK: ONE CASE STUDY Scenario Although our life experiences vary, we often have many of the same feelings and fears when making changes. Here is an actual account of a veterinary professional making change happen and getting unstuck from both a personal and professional perspective.

Jerry, a veterinary technician in a general practice, was married with children. The marriage was becoming increasingly unhealthy. Jerry and his wife seemed to be growing apart and no longer demonstrated the kindness and generosity they had earlier in their relationship. Jerry also had musical talent that he felt was going nowhere.

As a result, Jerry was becoming more and more depressed. He became short-tempered at work, and his absenteeism increased. Jerry was just shuffling through his days and eventually realized that his job was in jeopardy.

He was stuck.

References 1. Achor S. The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work. NY: Crown Publishing Group; 2010.

2. Buettner D. Thrive: Finding Happiness the Blue Zones Way. Washington, DC: National Geographic Society; 2010.

3. Goleman D. The Brain and Emotional Intelligence: New Insights. Northampton, MA: More Than Sound LLC; 2011.

4. Kotter JP. Leading Change. Boston, MA: Harvard Business Review Press; 2012.

Call to Action: Do you have a story about being stuck? How did you deal with it? Visit our Facebook page (facebook.com/todaysveterinarytechnician/) and share it with us and your colleagues!

Solution Jerry realized he had to step out of his comfort zone to understand why he felt so stuck and how the disastrous ripple effect influenced the rest of his life. He realized he |

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Getting Your Life Unstuck

had to, as they say in the airline safety demonstration, put his oxygen mask on first before helping anyone else, specifically his wife and family.

He realized the best way he could listen to himself and communicate with others was through the power of music, which was another casualty as he became stuck. He wrote and recorded a song called “In This Together” and shared it with his wife. They began having open discussions about how both would contribute to the health of the relationship. He decided to leave the general practice and accepted a position with a veterinary radiology group that was closer to home and provided better opportunities for career growth. In his downtime, he built a home recording studio so he could reconnect with his joy of music while still enjoying quality family time.

This story of change took a significant amount of time and required going to uncomfortable places, but the payoff for Jerry was tremendously positive, both personally and professionally.

3. Listen Honestly listening to your heart and head will help you understand what is truly holding you back from moving forward with your goals. In this step, you will identify the results you are getting now and what different outcomes you would like to realize. By listening to your heart and your head, you’ll explore your dreams and goals and start to identify the steps necessary to make them happen.

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Toxicology Talk

Top 10 Toxins That Are Rarely Serious

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ach day, the ASPCA Animal Poison Control Center (APCC) receives calls from panicked pet owners asking what they should do after their pets have ingested a potentially dangerous substance. The following are some very common exposures that may sound serious but rarely cause any significant clinical signs. Some recommendations for treatment—if needed—are included.

Jennifer A. Schuett, CVT ASPCA Animal Poison Control Center, Urbana, Illinois

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Jennifer worked in a small animal practice for 6 years before considering toxicology.

She went to Joliet Junior College for her associate’s degree in veterinary medical technology, graduated in May 2010, and became a certified veterinary technician by August 2010.

She has been with the ASPCA Animal Poison Control Center for a little over 5 years. Jennifer has written several protocols for her workplace and articles for an online veterinary magazine, as well as being an active board moderator on the Veterinary Support Personnel Network (VSPN).

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In her spare time, Jennifer likes to garden, craft, and spend time with friends and family. When Halloween season comes around, she is also an actor/makeup artist for a local haunted house.

Jennifer and her husband Tom celebrated their first wedding anniversary in June 2016.

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ANT AND ROACH BAIT TRAPS Exposures to bait traps are reported frequently in dogs and occasionally in cats. The baits contain peanut butter, breadcrumbs, sugar, and other sweeteners that act as attractants for roaches and ants. Dogs, cats, ferrets, house rabbits, and pet pigs may also be attracted to the baits. Some common insecticides used in these traps include boric acid, chlorpyrifos, fipronil, indoxacarb, abamectin, and hydramethylnon.1–3 Bait traps have very low concentrations of insecticides and have a wide margin of safety in dog and cat exposures. Bait traps usually weigh around 0.06 oz, which is less than the weight of a penny.

Gastrointestinal (GI) upset is the most common clinical sign seen when these baits are ingested. Life-threatening clinical signs are not expected; however, some dogs may eat the plastic or metal bait casing, which could lead to a foreign body obstruction.

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GLOW STICKS AND JEWELRY Glow sticks, bracelets, and necklaces are very popular. Cats are especially attracted to glow jewelry, and children may use the jewelry as a toy when playing with their cats. Many pet owners get concerned when their pets bite the jewelry because the liquid that makes it glow, dibutyl phthalate, is very bitter. It can cause an intense taste reaction, and since pets cannot spit, they drool and foam at the mouth. Some animals display erratic behavior while trying to run away from the taste. In reality, dibutyl phthalate is safer than many common household cleaners. If the pet has been brought to the clinic, the mouth should be gently flushed and the pet given something to eat to mask the bitter taste.

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Toxicology Talk

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Glow sticks contain dibutyl phthalate, which is very bitter and can cause an intense taste reaction.

Since pets cannot spit, they drool and foam at the mouth. However, dibutyl phthalate is safer than many common household cleaners.

shutterstock.com/Karen Walker

Owners can be instructed to treat the pet at home by providing something tasty to eat or drink. Some animals can also develop GI upset when the liquid is ingested. To be sure a pet is not reexposed through grooming (at home or in the clinic), the animal can be placed in a dark room to detect any glowing liquid on the coat. If present, the liquid should be wiped off with a damp cloth or the pet can be bathed. Additionally, if plastic was ingested, the pet should be monitored for foreign body obstruction.

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POINSETTIA (EUPHORBIA PULCHERRIMA) This plant is commonly used as a decoration around the winter holidays, and many people falsely believe it is deadly. The myth of the “deadly” nature of poinsettia evolved from a single case report in the medical literature from 1919. The article suggested that a toddler died after eating a couple poinsettia leaves, when in fact the child had eaten many other plants as well.

When cats and dogs ingest poinsettia, it can irritate their oral mucous membranes. Drooling and GI upset are common clinical signs in dogs and cats. Treatment includes managing vomiting and diarrhea, and all signs are expected to resolve within 24 hours (assuming no repeated exposures). Most pet owners can manage poinsettia ingestions at home.

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SILICA GEL Silica gel packets typically are labeled “do not eat” because silica gel is not a food source; however, ingestion is not expected to cause serious clinical signs. Silica gel packets are found in items such as shoes, purses, and medication bottles. They vary in size and usually contain gel beads. Silica gel is designed to absorb moisture and keep products from developing mold or mildew. When ingested, silica gel is poorly absorbed by the GI tract. These beads can draw moisture into the GI tract, causing some vomiting and/ or diarrhea. If the entire packet was ingested, it could cause the same clinical signs as well as foreign body obstruction.

DEOXIDIZERS While many people think deoxidizers are the same as silica gel packets, they contain different materials. Deoxidizers are placed in packaged food products such as beef jerky and semi-moist dog and cat treats. They can also be found in

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If an animal drinks treated toilet water, colloquially known as toilet bowl cocktail, mild GI upset can develop. If the animal ingested the actual toilet tablet or undiluted liquid, more significant signs, such as oral ulcers, may develop.

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loosen the trap, and then the animal can be bathed with liquid hand dishwashing soap to remove the oil. Solvents should not be used to dissolve the glue because they are significantly more toxic than the glue.

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GLUE TRAPS Glue traps are made to trap small rodents, insects, and other small pests. The glue traps themselves contain no poison, but some owners may add a rodenticide to the trap, which is a separate concern. If traps are chewed or ingested, they can cause some mild GI upset and possible foreign body obstruction.

If the trap gets stuck to an animal’s fur, using scissors or clippers to remove longer fur also removes the trap.

Care must be taken to avoid cutting the pet’s skin. An oily substance (e.g., olive oil, mineral oil) can be used to 58

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TOILET WATER Treated toilet water can upset an animal’s stomach when ingested.

Tablets, clings, and liquids are some products that can be placed into the toilet bowl or tank to treat the water. Some common ingredients found in these products are calcium hypochlorite, sodium hypochlorite, and anionic and nonionic surfactants. The volume of water in the toilet dilutes the product.

If an animal drinks treated toilet water, colloquially known as toilet bowl cocktail, mild GI upset can develop. However, if the animal ingested the actual toilet tablet or undiluted liquid, more significant signs, such as oral ulcers, may develop.

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other items, such as medication bottles. They are used to remove oxygen from the surrounding area to prevent mold, mildew, rust, color change, and staleness.

Deoxidizer packets usually contain iron in addition to activated charcoal and carbon. When the packets are exposed to room air, oxygen oxidizes the iron. Iron oxide is inert, and significant toxicity is not expected.4 Mild, self-limiting GI signs may develop after ingestion. The animal’s stool may be darker in color from the iron and activated charcoal. Ingestion of packaging can potentially cause foreign body obstruction.

WOODEN PENCILS Number 2 pencils, commonly used in elementary school, are what most people associate with the term pencil. Despite what most people think, wooden pencils contain graphite, not lead.

During the 20th century, paint used for the outer coating on the pencil contained high amounts of lead. Today, there is no lead in pencils.

GI upset is commonly seen with these exposures. If pieces of wood or the metal ferrule that attaches the eraser were ingested, foreign body obstruction may be a concern as well.

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BIRTH CONTROL PRODUCTS Exposure to birth control products is very common and rarely results in significant clinical signs.

Birth control comes in different forms. Pills are most common; a vaginal ring is also available. |

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1 in flea and heartworm protection*

5 in 1

parasite protection Fleas Heartworms Roundworms Hookworms Ear Mites Adds up to unlimited purrs.

REVOLUTION® (selamectin) effectively kills fleas and prevents flea eggs from hatching, while providing broad-spectrum parasite control. Unlike some parasiticides, it’s safe for breeding and nursing cats and doesn’t require separation from family or other pets after application.

revolution4catsdvm.com IMPORTANT SAFETY INFORMATION: Do not use REVOLUTION on sick, weak, or underweight cats. Use only on cats 8 weeks and older. Side effects may include digestive upset and temporary hair loss at application site with possible inflammation. In people, REVOLUTION may be irritating to skin and eyes. Wash hands after use. See Brief Summary of full Prescribing Information on page XX. *VetInsite™ Analytics January 2016. Zoetis data on file.

All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted. ©2016 Zoetis Services LLC. All rights reserved. REV-00283A

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(selamectin)

Topical Parasiticide For Dogs and Cats

Distributed by: Zoetis Inc. Kalamazoo, MI 49007

www.revolutionpet.com

These products contain estrogens, which dogs actually tolerate very well. Doses less than 1 mg/kg are unlikely to cause significant signs,* but GI upset is possible.

If plastic was ingested, foreign body obstruction is a concern.

Birth control pills contain a low enough concentration of estrogen that they usually do not pose a risk of toxicity; however, the risk depends on the number of pills ingested. Clinicians and technicians should be aware that medications used to treat postmenopausal symptoms and other clinical conditions (e.g., patches, creams) may contain higher concentrations of estrogen. If an animal ingests one of these products, veterinary staff should obtain the estrogen concentration because estrogen doses >1 mg/kg may result in bone marrow suppression.5,6

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BRIEF SUMMARY: See package insert for full Prescribing Information.

CAUTION: US Federal law restricts this drug to use by or on the order of a licensed veterinarian.

INDICATIONS: Revolution is recommended for use in dogs six weeks of age or older and cats eight weeks of age and older for the following parasites and indications: Dogs: Revolution kills adult fleas and prevents flea eggs from hatching for one month and is indicated for the prevention and control of flea infestations (Ctenocephalides felis), prevention of heartworm disease caused by Dirofilaria immitis, and the treatment and control of ear mite (Otodectes cynotis) infestations. Revolution also is indicated for the treatment and control of sarcoptic mange (Sarcoptes scabiei) and for the control of tick infestations due to Dermacentor variabilis.

Cats: Revolution kills adult fleas and prevents flea eggs from hatching for one month and is indicated for the prevention and control of flea infestations (Ctenocephalides felis), prevention of heartworm disease caused by Dirofilaria immitis, and the treatment and control of ear mite (Otodectes cynotis) infestations.

Revolution is also indicated for the treatment and control of roundworm (Toxocara cati) and intestinal hookworm (Ancylostoma tubaeforme) infections in cats.

WARNINGS: Not for human use. Keep out of the reach of children.

In humans, Revolution may be irritating to skin and eyes. Reactions such as hives, itching and skin redness have been reported in humans in rare instances.

Individuals with known hypersensitivity to Revolution should use the product with caution or consult a health care professional. Revolution contains isopropyl alcohol and the preservative butylated hydroxytoluene (BHT). Wash hands after use and wash off any product in contact with the skin immediately with soap and water. If contact with eyes occurs, then flush eyes copiously with water. In case of ingestion by a human, contact a physician immediately. The material safety data sheet (MSDS) provides more detailed occupational safety information. For a copy of the MSDS or to report adverse reactions attributable to exposure to this product, call 1-888-963-8471.

Flammable - Keep away from heat, sparks, open flames or other sources of ignition.

Do not use in sick, debilitated or underweight animals (see SAFETY).

PRECAUTIONS: Prior to administration of Revolution, dogs should be tested for existing heartworm infections. At the discretion of the veterinarian, infected dogs should be treated to remove adult heartworms. Revolution is not effective against adult D. immitis and, while the number of circulating microfilariae may decrease following treatment, Revolution is not effective for microfilariae clearance.

Hypersensitivity reactions have not been observed in dogs with patent heartworm infections administered three times the recommended dose of Revolution.

Higher doses were not tested.

ADVERSE REACTIONS: Pre-approval clinical trials: Following treatment with Revolution, transient localized alopecia with or without inflammation at or near the site of application was observed in approximately 1% of 691 treated cats. Other signs observed rarely (≤0.5% of 1743 treated cats and dogs) included vomiting, loose stool or diarrhea with or without blood, anorexia, lethargy, salivation, tachypnea, and muscle tremors.

Post-approval experience: In addition to the aforementioned clinical signs that were reported in preapproval clinical trials, there have been reports of pruritus, urticaria, erythema, ataxia, fever, and rare reports of death. There have also been rare reports of seizures in dogs (see WARNINGS).

SAFETY: Revolution has been tested safe in over 100 different pure and mixed breeds of healthy dogs and over 15 different pure and mixed breeds of healthy cats, including pregnant and lactating females, breeding males and females, puppies six weeks of age and older, kittens eight weeks of age and older, and avermectinsensitive collies. A kitten, estimated to be 5–6 weeks old (0.3 kg), died 8 1⁄2 hours after receiving a single treatment of Revolution at the recommended dosage.

The kitten displayed clinical signs which included muscle spasms, salivation and neurological signs. The kitten was a stray with an unknown history and was malnourished and underweight (see WARNINGS).

DOGS: In safety studies, Revolution was administered at 1, 3, 5, and 10 times the recommended dose to six-week-old puppies, and no adverse reactions were observed. The safety of Revolution administered orally also was tested in case of accidental oral ingestion. Oral administration of Revolution at the recommended topical dose in 5- to 8-month-old beagles did not cause any adverse reactions. In a pre-clinical study selamectin was dosed orally to ivermectin-sensitive collies.

Oral administration of 2.5, 10, and 15 mg/kg in this dose escalating study did not cause any adverse reactions; however, eight hours after receiving 5 mg/kg orally, one avermectin-sensitive collie became ataxic for several hours, but did not show any other adverse reactions after receiving subsequent doses of 10 and 15 mg/kg orally. In a topical safety study conducted with avermectin-sensitive collies at 1, 3 and 5 times the recommended dose of Revolution, salivation was observed in all treatment groups, including the vehicle control. Revolution also was administered at 3 times the recommended dose to heartworm infected dogs, and no adverse effects were observed.

CATS: In safety studies, Revolution was applied at 1, 3, 5, and 10 times the recommended dose to six-week-old kittens. No adverse reactions were observed. The safety of Revolution administered orally also was tested in case of accidental oral ingestion. Oral administration of the recommended topical dose of Revolution to cats caused salivation and intermittent vomiting. Revolution also was applied at 4 times the recommended dose to patent heartworm infected cats, and no adverse reactions were observed.

In well-controlled clinical studies, Revolution was used safely in animals receiving other frequently used veterinary products such as vaccines, anthelmintics, antiparasitics, antibiotics, steroids, collars, shampoos and dips.

STORAGE CONDITIONS: Store below 30°C (86°F).

HOW SUPPLIED: Available in eight separate dose strengths for dogs and cats of different weights (see DOSAGE). Revolution for puppies and kittens is available in cartons containing 3 single dose tubes. Revolution for cats and dogs is available in cartons containing 3 or 6 single dose tubes.

NADA 141-152, Approved by FDA

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LATEX PAINT In most cases, ingestion of latex paint is not expected to cause significant clinical signs. GI upset is the most common sign. Animals may ingest paint by drinking from the paint tray or chewing on the paintbrush. Pet owners may read the label, note that the paint contains ethylene glycol, and call with concerns. Usually, such paint contains <10% ethylene glycol to prevent it from freezing, and animals do not ingest enough to cause a significant problem. Before 1972, lead was used in paint; thus ingestion of old paint chips can lead to lead intoxication.

Some modern artist oil paints and agricultural-use paints may still contain lead. If lead is present, it should be listed on the label. Artist paints that have the AP seal are considered nontoxic. Paints with a CL seal can contain metals like cadmium, which can cause toxicity.  References 1. Budavari S, ed. The Merck Index. 12th ed. Whitehouse Station, NJ: Merck and Co; 1996.

2. Micromedex, Inc. Tomes CPS™ System. Vol. 44 exp. April 30, 2000. Borates. Meditext® - Medical Management.

3. Extoxnet, Extension Toxicology Network. Pesticide Information Profiles. Chlorpyrifos (revised June 1996). extoxnet.orst. edu/pips/chlorpyr.htm.

4. Iron (toxicologic management). In: Rumack BH, Hess AJ, Gelman CR, eds. POISINDEX® System. MICROMEDEX, Inc, Englewood, CO. (Edition expires 3/2000).

5. Oral contraceptives (toxicologic management). In: Rumack BH, Hess AJ, Gelman CR, eds. POISINDEX® System.

MICROMEDEX, Inc, Englewood, CO. (Edition expires 3/2000).

6. Progestins (toxicologic management). In: Rumack BH, Hess AJ, Gelman CR, eds. POISINDEX® System. MICROMEDEX, Inc, Englewood, CO. (Edition expires 3/2000). *This dose has been established based on APCC experience. No specific publications reference this dose.

Toxicology Talk is written and reviewed by members of the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center (APCC). The mission of the APCC is to help animals exposed to potentially hazardous substances, which it does by providing 24-hour veterinary and diagnostic treatment recommendations from specially trained veterinary toxicologists. It also protects and improves animal lives by providing clinical toxicology training to veterinary toxicology residents, consulting services, and case data review.

The ASPCA APCC includes a full staff of veterinarians, including board-certified toxicologists, certified veterinary technicians, and veterinary assistants, and its state-of-the-art emergency call center routinely fields requests for help from all over the world, including South America, Europe, Asia, and the Pacific Islands.

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How Being Cat Friendly Has Made a Difference in Our Practice Sarah Dawson, RVN Walton Vale Vets4Pets, Liverpool, UK

O

pening a new clinic provides on their trip to the vet has been a great opportunity to make increasingly brought to light by facilities cat friendly. A cat-only organizations such as the waiting room, consulting room, and International Society for Feline ward were created at the authorâ&#x20AC;&#x2122;s Medicine. In response, many clinic in Liverpool, UK. The waiting veterinary practices are stepping room provides opportunities to cover up and creating a welcoming cat baskets and place them in an cat-friendly environment to help elevated position, and the consulting tackle this issue. room contains a high-sided basket in Sarah Dawson started work which to examine and treat nervous OUR CLINIC in veterinary practice in 2005 cats. Hospitalized cats stay in the Walton Vale Vets4Pets opened in and at present is the Head cat-only ward, and inpatients are November 2013 in a busy suburb Nurse and Cat Advocate given opportunities to hide in of Liverpool, UK. The practice was for Walton Vale Vets4Pets in disposable boxes. Staff and owners designed to create a welcoming catLiverpool, UK. She recently have noticed great differences, with friendly environment for cat owners completed the ISFM previously aggressive cats now and hopefully make trips to the vet Certificate in Feline Friendly handleable and clients more willing more enjoyable for them. Being cat Nursing with Distinction. Sarah to bring their cats for examination, lovers and taking a huge interest in was integral in implementing encouraging preventive healthcare feline welfare and behavior over the the Cat Friendly Clinic and early diagnosis of disease. Being past few years, my colleagues and I scheme in her practice, which cat friendly has definitely benefited set about creating a carefully was awarded silver, and cats and clients visiting this practice, planned cat section of the practice. she is working hard to as well as the staff caring for stressSince doing so, we have noticed a change this to gold. free feline patients. great difference in the behavior of The stress of the journey in the even our most nervous patients car, the noisy waiting area, topped visiting the practice. off with the struggle of luring our frightened friends out of the pet carrier are enough to CAT-FRIENDLY FACILITIES discourage any cat owner from making regular trips to the Our cat-only consulting room is located adjacent to the cat vet. In the past few years, the stress many cats go through waiting area, which leads onto the cat hospital ward. Making

This article was originally published in the October 2015 issue of Feline Focus and is reprinted with permission from International Cat Care. Feline Focus is the online veterinary nursing journal of the International Society of Feline Medicine. Subscription is free for all veterinary technicians. Find out more at icatcare.org/nurses/membership.

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Small changes can make a big difference to cats.

For example, covering cat baskets and placing them in an elevated position in the waiting room can reduce stress.

these in proximity and keeping these sections of the practice specifically for cats have allowed us to reduce the sights, smells, and sounds cats are exposed to on their visits.

Waiting Room The cat waiting area (FIGURE 1) has towels available for owners to cover their pet carriers, restricting what their pets can see while waiting. Owners are also encouraged to use our cat tree, where they can place their cats on an elevated surface to hopefully decrease stress levels (on the right in FIGURE 1). These small differences have helped reduce stress levels for many cats before they enter the consulting room for examination. Client information is displayed in the waiting area, encouraging clients to take advantage of these extra features and explaining why they reduce stress levels. Educating clients is one of the most important things a nurse, veterinarian, or receptionist can do in practice regarding feline stress and welfare. We also offer information leaflets for clients to take away and read at home regarding trips to the vet and reinforcing what is

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discussed in the consultation, which is very popular and helps ensure everything discussed is not forgotten when the client leaves.

Consulting Room The cat-only examination room has been kept exclusively for cats visiting the practice. An examination table

FIGURE 1. The cat-only waiting room, complete with a “tree” to ensure baskets are elevated off the floor (right) and leaflets on cat topics for owners to read or take home.

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A high-sided basket in the consulting room may allow examination and treatment of nervous cats.

FIGURE 2. Happy kittens in the cat-only consultation room.

(FIGURE 2) covered with a blanket to create a warm surface, cat scales, and a high-sided basket for more nervous cats to hide inside if they choose to leave the safety of the pet carrier are all featured in this room.

Separate equipment is kept in this room to reduce smells cats will be exposed to, along with toys to encourage play

or distract nervous animals. We encourage owners to keep their pets in carriers until we have discussed what the visit is about to reduce handling time and reduce stress.

Where possible, we like to allow the cats to remain in their pet carriers and remove the lids for examination; this allows them to remain in the safety of the carriers with their own comforts, such as blankets and toys with familiar smells. We also have the option of a high-sided basket lined with a blanket (FIGURE 3), which has proved very popular with more nervous cats that choose to venture out of the carrier. This simple feature has made a noticeable difference in patient compliance when being

FIGURE 3. A cat having its nails clipped in the high-sided basket available in the consulting room. This cat previously had to be sedated to clip its nails but now happily sits in the basket for the procedure.

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Cats are taken to the veterinary clinic less frequently than dogs, but being cat friendly can encourage regular checkups to detect disease early and encourage preventive healthcare. handled by staff. The basket has been used for nail clips and routine examination and is sprayed with Feliway spray (Ceva; feliway.com) every few hours.

The Cat Ward The cat hospital ward had been diverged in the same way.

This ward is exclusively for cats, keeping cat-only blankets, boxes, and equipment separated from those used for other species (FIGURE 4). Disposable hiding spots made from cardboard boxes are used and discarded after use. A pheromone diffuser is permanently switched on, and kennels are lined along one wall to avoid cats being able to see each other (FIGURE 5). The kennels of other cats are covered to avoid direct eye contact if a cat needs to be removed from a cage.

THE DIFFERENCE BEING CAT FRIENDLY MAKES Since introducing cat-only facilities, my colleagues and I have noticed an unbelievable difference in even the most

How Being Cat Friendly Has Made a Difference in Our Practice

FIGURE 6. Being cat friendly benefits cats, clients, and staff. anxious of cats. Cats that have previously been known for displaying aggressive or frustrated behavior have been handled and examined without any issues. Patient compliance for nail clips and blood sampling has improved massively, and this has also been noticed by owners. Cats previously sedated for basic procedures such as nail clips have been handled without a problem. Seeing these changes in our feline patients is something we are all extremely proud of. Being more feline focused has made such a difference to us, our patients, and owners. A positive stress-free trip to the vet is a key feature when encouraging clients to return for more frequent checkups (FIGURE 6).

With statistics showing our dog owners bring their pets to the vet much more than our cat owners, it is our duty to try and resolve this and gives owners an experience that will encourage them to come back. Frequent checkups allow us to detect health problems earlier, issue regular parasite control, monitor weight, and provide annual vaccinations, which overall are in the best interest of the animal. 

Cat Friendly Clinic The Cat Friendly Clinic program is run by the International Society of Feline Medicine, in collaboration with several different partners across the world. In the United States, it is known as the Cat Friendly Practice program, run by the American Association of Feline Practitioners. The program is designed to help create more cat-friendly veterinary clinics, reducing stress for the cat as well as both the owner and veterinary staff treating the cat.

For more information, go to catfriendlyclinic.org or catvets.com.

FIGURE 5. The cat ward.

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Careers Career Opportunities for Veterinary Technicians SOUTH CAROLINA — Licensed Veterinary Technician needed for full/part-time position at AAHA accredited hospital to assist 5-doctor practice. Emphasis on technical skills in surgery/anesthesia, client/patient care, education, and creating positive relationships with clients and co-workers. Benefits include health insurance, 401K, continuing education, vacations, uniforms, pet care discount. Seeking employees who strive for excellence and demonstrate reliability, flexibility, strong communication and organizational skills. Some weekends required. Non-smoking and drug-free workplace.

IOWA

Looking for big city capabilities with small town hospitality?

Veterinary Associates of Manning, Iowa, is seeking a Veterinary Technician (preferably Registered) to work at their progressive, mixed animal practice. Veterinary Associates offers in-house blood work as well as surgery and therapy lasers, digital radiography, stem cell regenerative therapy, ultrasonic dental capability and a full pharmacy. For this reason, the applicant must be proficient in restraint, phlebotomy, laboratory work and analysis as well as surgical assistance, dental prophylaxis and the ability to figure medication dosages.

Email resumes to Angela at blufftonvet@gmail.com.

The willingness to learn, work as a team as well as individually, and to multi-task is a must.

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Join Our Family!

Veterinary Associates is nestled in a small town of 1,500 people and services clients from 4 county seat towns of 10,000+ within a 30 minute radius. Manning is a progressive and forward-thinking town with many conveniences. If you’re looking for a place to feel like part of the community & actually know your neighbors, Manning is the place for you!

At BluePearl Veterinary Partners, we’re always looking for passionate veterinary assistants and technicians to join our national network of specialty and emergency hospitals. Learn more at bluepearlvet.com/careers and apply today! Please follow us on FaceBook at: facebook.com/BluePearlJobs

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American Society for the Prevention of Cruelty to Animals Animal Poison Control Center aspca.org 51 BluePearl Veterinary Partners Career opportunities bluepearlvet.com/careers 65 Bluffton Veterinary Hospital Career opportunities 65

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Please submit resume and brief biography to: Veterinary Associates of Manning 1603 Enterprise Street Manning, IA 51455 or email to manningvets@gmail.com

IDEXX SNAP Test idexx.com/idexxsnap2 3

NAVC 2017 Conference navc.com 42, 43

PNC Bank Financial Services pnc.com 17

Virbac Sentinel Spectrum virbacvet.com Inside front cover, 4

Merial Frontline Gold frontline.com 7

2017 Institute navc.com/institute 27

Veterinary Associates of Manning Career opportunities manningvet.vetstreet.com 65

Zoetis Feline Revolution revolution4catsdvm.com 59, 60

VetFolio VetFolio vetfolio.com Inside back cover

Simparica zoetisus.com 10–12

Heartgard Plus heartgard.com Back cover, 68 NexGard nexgardfordogs.com 33, 34 Previcox previcox.com 21, 22

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Nestlé Purina EN Gastroenteric Low Fat Dry Canine Formula purinaproplanvets.com 30, 31 Penn Foster Diploma programs pennfoster.edu 57

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September/October 2016

VetMedTeam Online CE vetmedteam.com 37

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Final Thoughts

The Golden Ticket to Feeling Better Recently, I worked with a practice where a client’s dog had presented in very poor condition after being hit by a car.

The client was difficult from the outset, refusing to fill out paperwork because he “knew” he was already in the computer, stating the practice had “killed his other dogs.”

When it was determined that he was unable to financially provide care, he opted for euthanasia and spat “I hope the building burns down and you’re all in it!” on his way out the door.

Julie Squires Rekindle, LLC Julie is a compassion fatigue specialist who brings a unique perspective and approach to support the sustained energy and passion of animal workers.

Her company, Rekindle LLC, offers on-site compassion fatigue training to veterinary hospitals, animal shelters, and other animal organizations.

Whoa.

What fascinated me was hearing all the different reactions his words provoked from the staff. Some team members were really ticked off, some found it funny, and others felt empathy for the man. How could this be? How could the same comment elicit such a range of feelings?

The answer lies in the fact that circumstances do not create our feelings. This client’s comment did not cause the myriad feelings I was told about. Our thoughts are what cause our feelings—more specifically, our thoughts about things that happen. That is how one incident can lead to such a variety of feelings and reactions: everyone had different thoughts about it.

shutterstock.com/wavebreakmedia

Julie has more than 20 years of experience within the veterinary field and with leading organizations. She has developed and executed training, workshops, and 1:1 coaching for major companies in the animal health industry. She obtained her certification as a compassion fatigue specialist through the Green Cross Academy of Traumatology and has also completed training from The Figley Institute and Traumatology Institute. Julie’s clients also gain from her experience as a certified health and wellness coach and corporate wellness specialist.

WHEN YOU BELIEVE that the circumstances in your life cause your feelings, you are left feeling powerless. Becoming aware of your thoughts is the first step.

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Final Thoughts

Some of the staff thought, What an ungrateful jerk.

Here we bent over backwards for his dog, and he didn’t deserve the dog anyway. Loser. The dog is better off now, and he just doesn’t want to pay his bill because it died.

Others thought, Wow, what a sorry excuse for a human being. He probably has a miserable life and just wants to make ours miserable too.

Or, Really, dude? You’re angry at us? Give me a break; we did our job.

And still other staff thought, Oh boy, who knows what his life is like. Maybe the guy is down on his luck and this dog was all he had. Anyone who could say such an awful thing must be in a pretty low place in his life.

Because they all had different thoughts about his comment, they all had different feelings about it—and him. Some were still seething about it, although it had happened a long time ago. Others were over it the second after he left the building.

Which would you rather be?

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An Official Journal of the NAVC

The Golden Ticket to Feeling Better

can’t change how people behave. We can’t change the fact that cancer exists. We can’t change the fact that some pet owners have no idea how to care for animals.

I see many people who push against and resist all these facts. When you resist reality, the only one you harm is yourself. What you are in control of is…everything else. That’s right. We have much more power than we think and the ability to influence our lives in more ways than most of us ever realize.

Become the Watcher Your power lies in your awareness of what you are thinking about all of these things: the clients, the work, the patients, the organization, the co-workers, the leadership, the researchers, the public. Becoming aware of your thoughts is the first step.

How you do that? Get quiet with yourself. Journaling is a great tool to empty your mind. Set a 10-minute timer and just start writing. If journaling isn’t your thing, find what is: take a walk, go for a run, create something artistic, meditate, do yoga, or do anything that allows you to disconnect from your thinking mind and connect to the you that “watches” your mind.

Spiritual author and teacher Eckhart Tolle says it this way: Be present as the watcher of your mind—of your thoughts and emotions as well as your reactions in various situations. Be at least as interested in your reactions as in the situation or person that causes you to react. […] Don’t make a personal problem out of them. You will then feel something more powerful than any of those things that you observe: the still, observing presence itself behind the content of your mind, the silent watcher.1

Find the Golden Ticket I can remember the exact day I learned that my thoughts create my feelings. It was like finding a Golden Ticket in a Wonka bar. Finally, I felt empowered.

When you believe that the circumstances in your life cause your feelings, you are left feeling powerless. Some people react by trying to manipulate everyone and everything around them in an attempt to feel better. Good luck with that. We can’t control others. Clients are going to behave badly, coworkers will aggravate us some days, we may have supervisors who have no business leading, and other people in our lives will continue to do things that aggravate and inconvenience us. But we get to decide what to think about all of those situations. And in turn, we get to decide how we are going to feel.

If you don’t like the way you feel, look at how you think.

Pay attention to the thoughts that come up repeatedly, and you will see why you feel the way you do. Everything in your life is determined by your thoughts. Your thoughts determine your feelings. Your feelings drive your actions (or inaction, like shutting down or withdrawing). And your actions create results in your life. Compassion fatigue is such a result.

As a compassion fatigue specialist, I’ve witnessed the suffering of many veterinary technicians. Not many people talk about the toll that veterinary medicine takes on technicians. I do. I do because you tell me, and also because I’ve experienced it myself.

What I have come to believe is that, to a large extent, compassion fatigue is a thought problem, whether with our thoughts and expectations of ourselves or of our clients, colleagues, bosses, researchers, the general public, etc. We TODAY’SVETERINARYTECHNICIAN

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Your thoughts are a choice. Once you are aware of what you are thinking, you have the ability to change it to something else. This is how you can change your life. This is how you can feel empowered rather than defeated. Ask yourself: Do you want to continue thinking the way you’ve been thinking? Maybe so, if your thoughts are uplifting, motivating, and supportive and are serving you well. By contrast, if you are struggling with your work or an area of your life, check in with your thoughts and how they make you feel. Your feelings will tell you everything you need to know about how you are thinking.

I’ll say it again: your thoughts are a choice. For example, an HBC stray cat ends up being euthanized because no one claimed ownership and offered to pay for surgery to fix his broken legs. Do you think, This totally stinks. Why couldn’t the shelter take him and pay for this? Why couldn’t we do it pro bono and find a home for him? Or do you think, I wish |

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Final Thoughts

chewables

CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian.

INDICATIONS: For use in dogs to prevent canine heartworm disease by eliminating the tissue stage of heartworm larvae (Dirofilaria immitis) for a month (30 days) after infection and for the treatment and control of ascarids (Toxocara canis, Toxascaris leonina) and hookworms (Ancylostoma caninum, Uncinaria stenocephala, Ancylostoma braziliense).

DOSAGE: HEARTGARD® Plus (ivermectin/pyrantel) should be administered orally at monthly intervals at the recommended minimum dose level of 6 mcg of ivermectin per kilogram (2.72 mcg/lb) and 5 mg of pyrantel (as pamoate salt) per kg (2.27 mg/lb) of body weight. The recommended dosing schedule for prevention of canine heartworm disease and for the treatment and control of ascarids and hookworms is as follows: Dog Weight

Chewables Per Month

Ivermectin Content

Pyrantel Content

Color Coding 0n Foil Backing and Carton

Up to 25 lb 26 to 50 lb 51 to 100 lb

1 1 1

68 mcg 136 mcg 272 mcg

57 mg 114 mg 227 mg

Blue Green Brown

HEARTGARD Plus is recommended for dogs 6 weeks of age and older.

For dogs over 100 lb use the appropriate combination of these chewables.

ADMINISTRATION: Remove only one chewable at a time from the foil-backed blister card. Return the card with the remaining chewables to its box to protect the product from light. Because most dogs find HEARTGARD Plus palatable, the product can be offered to the dog by hand. Alternatively, it may be added intact to a small amount of dog food.

The chewable should be administered in a manner that encourages the dog to chew, rather than to swallow without chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole.

Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes after administration to ensure that part of the dose is not lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended.

HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors), potentially carrying infective heartworm larvae, are active. The initial dose must be given within a month (30 days) after the dog’s first exposure to mosquitoes. The final dose must be given within a month (30 days) after the dog’s last exposure to mosquitoes.

When replacing another heartworm preventive product in a heartworm disease preventive program, the first dose of HEARTGARD Plus must be given within a month (30 days) of the last dose of the former medication.

If the interval between doses exceeds a month (30 days), the efficacy of ivermectin can be reduced. Therefore, for optimal performance, the chewable must be given once a month on or about the same day of the month. If treatment is delayed, whether by a few days or many, immediate treatment with HEARTGARD Plus and resumption of the recommended dosing regimen will minimize the opportunity for the development of adult heartworms.

Monthly treatment with HEARTGARD Plus also provides effective treatment and control of ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). Clients should be advised of measures to be taken to prevent reinfection with intestinal parasites.

EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development of the adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense).

ACCEPTABILITY: In acceptability and field trials, HEARTGARD Plus was shown to be an acceptable oral dosage form that was consumed at first offering by the majority of dogs.

PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult heartworms and microfilariae before initiating a program with HEARTGARD Plus.

While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level, HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due to dead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials with ivermectin alone after treatment of some dogs that have circulating microfilariae.

Keep this and all drugs out of the reach of children.

In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans.

Store between 68°F - 77°F (20°C - 25°C). Excursions between 59°F - 86°F (15°C - 30°C) are permitted. Protect product from light.

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The Golden Ticket to Feeling Better

we could’ve helped him, but at least he died being held and loved by me. I did what I could. I imagine the first thought will result in you feeling angry or frustrated or cynical or grief-stricken. The second, I imagine, would result in feelings of sadness but also contentment, peace, or reverence. Can you see how our thoughts create our feelings, and therefore shape our experience?

Which do you think is more likely, over time, to fuel compassion fatigue?

Do you want to continue to think thoughts that don’t make you feel good?

Appreciate the Gift When you truly realize that you can influence your thoughts and, therefore, how you feel, you will be able to use this skill in all areas of your life. It really is an immense gift. We are not taught how to make ourselves feel better, which is why we live in a culture of addiction and hyperactivity. People try to numb their uncomfortable feelings with too much alcohol, food, technology, and other distractions, when what we really need is just to realize we have the power to make ourselves feel better—and we always have.

Be gentle and compassionate with yourself, not judgmental. As you begin to recognize your thoughts, you will also begin to realize that many are simply not true. Don’t criticize your thoughts, just notice them, and be curious about them. Ask yourself, Is this true? We are never motivated to change anything when we come from a place of self-criticism, so stay open, loving, and compassionate towards yourself.

And remember: I want you to know you are more powerful than you think, more amazing than you know, and capable of feeling much better than you do now.  Reference 1. Tolle E. The Power of Now: A Guide to Spiritual Enlightenment. Namaste Publishing; 2004.

ADVERSE REACTIONS: In clinical field trials with HEARTGARD Plus, vomiting or diarrhea within 24 hours of dosing was rarely observed (1.1% of administered doses). The following adverse reactions have been reported following the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions and hypersalivation.

SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability of ivermectin. The dose regimens of HEARTGARD Plus and HEARTGARD are the same with regard to ivermectin (6 mcg/kg). Studies with ivermectin indicate that certain dogs of the Collie breed are more sensitive to the effects of ivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds.

At elevated doses, sensitive dogs showed adverse reactions which included mydriasis, depression, ataxia, tremors, drooling, paresis, recumbency, excitability, stupor, coma and death. HEARTGARD demonstrated no signs of toxicity at 10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies, support the safety of HEARTGARD products in dogs, including Collies, when used as recommended.

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HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant or breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea collars, dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with HEARTGARD Plus in a heartworm disease prevention program.

In one trial, where some pups had parvovirus, there was a marginal reduction in efficacy against intestinal nematodes, possibly due to a change in intestinal transit time.

HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (See DOSAGE section) for dogs of different weights. Each strength comes in convenient cartons of 6 and 12 chewables.

For customer service, please contact Merial at 1-888-637-4251.

®HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved. HGD15PRETESTTRADEADS (01/16).

JOURNALING is a great tool to empty your mind. Set a 10-minute timer and just start writing.

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Data on file at Merial.

®HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved.

HGD15PRETESTTRADEADS (01/16).

IMPORTANT RISK INFORMATION: HEARTGARD® Plus (ivermectin/pyrantel) is well tolerated. All dogs should be tested for heartworm infection before starting a preventive program. Following the use of HEARTGARD Plus, digestive and neurological side effects have rarely been reported. For more information, please visit www.HEARTGARD.com.

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PREVENTS HEARTWORM DISEASE

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TREATS AND CONTROLS 3 SPECIES OF HOOKWORMS

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TREATS AND CONTROLS 2 SPECIES OF ROUNDWORMS

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#1 RECOMMENDED HEARTWORM DISEASE PREVENTIVE 1

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SAFE FOR PUPPIES AT 6 WEEKS