F V M A ADVOCATE ISSUE 2 | 2021
THE YELLOW CAT
ALL ABOUT JAUNDICE/ICTERUS Stuart Walton, BVSc (Hons), BScAgr (Hons), MANZCVS (SAIM), DACVIM | Pg. 8
EAR INFLAMMATION AND INFECTION Amelia G. White, DVM, MS, DACVD | Pg. 12
MENTAL MOP UP
SPRING CLEANING FOR YOUR MIND Katie Pearce, Content & Engagement Specialist | Pg. 22
FVMA ANNUAL CONFERENCE JULY 8-11, 2021 | Pg. 16
President's Message Hello again, I guess is the appropriate way to start. As I begin my year as president of the FVMA, I would like to both look back and look forward. I have previously served on the leadership of my local veterinary society as well as serving many years as the District 2 representative of the FVMA. My previous time on the board culminated with the privilege to serve as FVMA president in 2016. During those years, I not only provided leadership, but I personally benefited from the vast amount of information and knowledge I gained from fellow board members and my dear friend, Phil Hinkle.
7207 Monetary Drive Orlando, Florida 32809 Phone – 407.851.3862 Toll-free – 800.992.3862 Fax – 407.240.3710 firstname.lastname@example.org | www.fvma.org
Dr. Richard Sutliff President Dr. Marta P. Lista President-elect Dr. Donald H. Morgan Treasurer Dr. Mary Smart Past President
DISTRICT REPRESENTATIVES Dr. Scott Richardson District 1–Big Bend Dr. Thomas E. Hester District 2–Northeast Dr. Todd Fulton District 3–Central Dr. Donald S. Howell District 4–Tampa Bay Dr. Susan M. Carastro District 5–Treasure Coast Dr. Robert L. Swinger District 6–South Florida Dr. Barbara Lewis District 7–Southwest Dr. John R. Wight District 8–Northwest Dr. Christine M. Storts District 9–Space Coast Dr. Ernest C. Godfrey AVMA Delegate Dr. Richard B. Williams AVMA Alternate Delegate Dr. Jacqueline S. Shellow FAEP Representative to the FVMA Executive Board
Last fall, during one of the most difficult times our association and profession has faced, your current board of directors reached out to me hoping I could help. The concern at the time was multifold but could be focused on two issues. The first was they were beginning the difficult task of searching for a new executive director to lead our association’s mission. The second was to slow the turnover of board leadership and potential loss of the experienced individuals needed as we emerge from COVID-19. This would provide education, guidance and insight for the new director during his or her first years on the job. In order to retain the experience on the board, since most officers term off after serving in upper leadership, there was a thought that inserting a previous president for this one year could retain those postured to move up for an additional year. This provides leaders for those important tasks ahead and provides the consistency needed in the years before us. I discussed this recommitment with my loving wife, Kay, and it was decided that there was no greater honor than to again serve the profession that is dear to my heart. Looking forward, as we emerge from a year of trials, the FVMA is postured to continue serving as a bright light on the hill for the entire country. As one of the largest and most proactive associations in organized veterinary medicine, how we support our members and defend their right to provide proper health for the animals and humans that our vocation touches, we must shoulder our pain and previous loss in order to surge forward towards new challenges. Often, we do not have a second chance to do most things in life. This is my second chance to hopefully make a positive impact on veterinary medicine in Florida. Along with second chances comes “hindsight”—what is important that may not have been addressed well the first time. I have been asking myself what is truly important for our members. Why would veterinarians want to be a member of our association? Besides all the excellent advocacy and educational opportunities we offer, I need your help to better focus on how the FVMA can help you. We will shortly be unveiling a members wellness program that I believe will fill a great need. This is going to be a member benefit for everyone! We want to know what else the FVMA can do to make your life better, and make you proud to say “I'm a member!” How can we work together to address the true needs of our fellow members? What is of value to a practice owner and provides support for their business, cannot always bring value to an associate. What brings value to the associate veterinarian or the industry veterinarian? We all have different needs and ideas. As we rebrand ourselves, bring in our new executive director, and slow the turnover of the dedicated leadership we have on our board, I am opening the door and asking for you to step in with ideas and bring up needs that we can work together to meet. This is your association. Take advantage of what we can do, and help us see the needs of our individually unique veterinarians and veterinary team members.
Dr. Dana Nicole Zimmel Dean, Ex Officio
Richard Sutliff, DVM FVMA President
TO ADVANCE THE VETERINARY MEDICAL PROFESSION, PROMOTE ANIMAL HEALTH AND WELL-BEING, AND PROTECT PUBLIC HEALTH.
Opinions and statements expressed in The Advocate reflect the views of the contributors and do not represent the official policy of the Florida Veterinary Medical Association, unless so stated. Placement of an advertisement does not represent the FVMA’s endorsement of the product or service.
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HB911 & SB1370 UPDATE HB911 and SB1370 did not pass the legislature this year, and the session officially ended in Tallahassee on April 30. These bills began their legislative journeys as identical twins with what appeared to be a fast trajectory to the governor's desk. The FVMA’s grassroots efforts spearheaded by a call to action and members contacting their legislators' offices led to some logical discussions with the Senate bill sponsor. Her willingness to consider and promote an amendment to SB1370 slowed the rocket trajectory and illuminated more of the bill’s issues to other decision makers. The amended Senate bill was far from perfect, but it provided us the most precious commodity we needed…TIME! We must thank those who were so vital in providing us the opportunity to advocate for our patients and owners with the sole goal of ensuring proper care for animals. Thank you to the AVMA; thank you to Dr. Yoho; thank you to the FVMA staff, legislative committee members (Drs. Rick Williams and Christy Layton), and to our governmental adviser, Paul Lowell, and his colleagues of the Converge Team.
In This Issue 3 | 4 | 5 | 6 | 8 |
HB911 & SB1370 Update Obituaries FVMA Regionals: Save the Date FVMA New Executive Director The Yellow Cat - All About Jaundice/Icterus
Most of all, thank you-the members of the FVMA who stood up and sat down! You stood up to represent what we know is the proper quality of care for animals-the quality of care we've been trained to deliver-and you sat down to communicate that passion and insight to your legislators in a way only a lifetime of dedication could guide. Your continued support is what drives our ability to maintain legislature that uplifts veterinary medicine. To continue supporting us, we ask that you donate to the FVMA PAC, which allows us to keep fighting for your right to practice in the way that best benefits you. PAC was essential to our ability to work against HB911 and SB1370. The financial health of our PAC will be instrumental in our ability to continue that fight when the time calls again. To learn more, visit https://fvma.org/advocacy/ professional-advocacy-committee/ or scan the QR code below.
12 | Canine Otitis - Ear Inflammation and Infection 16 | 92nd FVMA Annual Conference 22 | Mental Mop Up: Spring Cleaning for Your Mind 26 | Practice Pulse 28 | Classified Advertisements
In Remembrance Dr. Robert Michael Purvis, MS, DVM Dr. Robert Purvis, 66, passed away on April 2, 2021, in Tallahassee, Florida. Born in 1954 in Madison, Florida, he attended Leon High School and received his BS in animal science from the University of Florida with high honors. He then attended Auburn University, where he received his masters and doctorate in veterinary medicine. Dr. Purvis owned and operated his own clinic in Monticello, Florida, before joining the staff of Florida A&M University (FAMU) as an extension veterinarian in the College of Agriculture Veterinary Technology Program. He was the first veterinarian in Florida to diagnose West Nile Virus in the state and coordinated the use of new and alternative treatments to increase infectedequine survival rates. A community man and leader, he served in several roles at Auburn during his time there and later in his local community.
He produced an educational video used by several surrounding states, reviewed state and federal laws for the Florida Department of Agriculture and Consumer services and the USDA and served as head veterinarian of regulatory operations at the Jefferson County Kennel Club. He wrote newspaper articles and columns as well as spoke at public meetings. He was a member of the emergency management team of Jefferson County and the advisory board of Farmers and Merchants Bank He was a lifelong lover of music and signing, Dr. Purvis was most well-known for leading the Encore Band (also known as the Purvis Brothers) and Willie Nelson Tributes. Through the years, Encore helped raise over one million dollars for various charities. Dr. Purvis played six musical instruments and was often asked to be a substitute player for many bands in the Southeast. Dr. Purvis was preceded in death by his father, George “Shorty” Purvis, and his mother, Fannie Mae “Mutt” Bass. He is survived by his sons, Michael Purvis and Tommy Wallace; two brothers, Wendell Purvis (Carol) and Franklin “Frank” Purvis (Nancy); two sisters, Joan Rhodes (Aubrey) and Diane Lee (Ken); his granddaughter, Madison Wallace; and six nephews and two nieces.
Dr. Terry Lynn Garner, DVM Dr. Terry Garner of Venice Animal Clinic passed away March 20, 2021. Dr. Garner was born August 15, 1946, in Miami, Florida. Dr. Garner attended Southwest High School before going to the University of Florida for his undergraduate studies. He later received his DVM from Auburn University. Dr. Garner—known as “Doc”—was a fifth-generation Floridian and a Venice, Florida, resident for the past 45 years. In 1974, he opened Venice Animal Clinic.
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A born leader, he was a member of various organizations, like Kiwanis, Big Brothers Big Sisters, Boys and Girls Club, Venice YMCA, the Masonic Lodge, Boy Scout Troop 1001, Sahib Temple, and Oak Park School. Dr. Garner was dedicated to his family, profession and community. His kindness and compassion for others defined his character. He was a humble man with an infectious laugh and will be missed by many. Dr. Garner was preceded in death by his father, Harvey Hainesworth Garner; his mother, Elva Robinson Garner; and brother, Timmy Lane Garner. He is survived by his wife, Kathy Kelley Garner; sons, Kelley R. Garner, DVM (Amber), and Justin D. Garner, PSM (Margaret); daughter, Jessica L. Heiny, PE (Matthew); and grandchildren, Riley, Scarlett, Finn, Sawyer, Lane, Jackson, Keagan, and Grayson.
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SPOTlight: RENÉ PLASENCIA
THE FVMA'S NEW EXECUTIVE DIRECTOR Perhaps it was the moment when a younger René Plasencia was driving to graduate school in Arizona on a last-minute decision— with nothing but his dog and a backpack of clothes—that served as a lifetime of catalysts leading him to becoming the Florida Veterinary Medical Association’s (FVMA) newest executive director. But it is tough to pinpoint an exact moment of inspiration for this self-described hippie, whose mantra centers on finding happiness in a career dedicated to serving others. 6 6 || FVMA FVMA ADVOCATE ADVOCATE
In Plasencia’s first month at the FVMA, “life is too short not to be happy” is the phrase his staff has heard the most, as it is the one that guides many of his ideas and principles as he seeks to propel veterinary medicine in Florida into the future. “Happiness is a state of mind,” Plasencia says. “Things can happen around you, but how it affects you is always under your control.” Plasencia joins the FVMA just before it hosts its first in-person conference since the onset of the COVID-19 pandemic in the
United States in 2020. The rest of his first year will be filled with similar firsts, as he is the FVMA’s only new executive director in the last thirteen years. “I like to learn a lot before I do anything,” Plasencia says. “Things have been going very well, but you see how you can do things a little bit differently, and you bring your own experience into every situation.” Plasencia’s experiences are highlighted by a 17-year career in teaching social studies and coaching cross country and track and field at Colonial High School in Orlando, Florida, serving as the district regional manager and executive director for Florida Virtual School, and as a member of the Florida House of Representatives. “I have a lot of experience in education and the growth of organizations,” Plasencia says. “I’m trying to see what we’ve done well and how we can build on that and create an environment in which everyone is happy.” Plasencia says he wants to do that by listening to members and working with additional partners who can help the FVMA realize solutions to members’ needs. Such a willingness to listen comes after years of saying “yes” when afforded unique opportunities. “I don’t like walls,” Plasencia says. “I don’t like when people pin you into categories.” Such statements are a callback to Plasencia’s college days, where fond memories as a cross country and track and field athlete as well as a passion for learning at the University of Central Florida (UCF) led Plasencia to graduate school. But even when Plasencia has a plan, like attending Louisiana’s Northwestern State University, he never seems to say no to other ideas. “I already filled out the paperwork, I had a job,” Plasencia says of his plan to attend Northwestern. Then he got a phone call from UCF’s former associate athletic director, who offered him a graduate assistant position at Northern Arizona State University. With only a moment’s notice, Plasencia changed his mind and chose the opportunity that would provide him with greater fulfillment. His creativity and willingness to listen underlies almost every statement and decision he makes; he says he wants to implement that same philosophy when working with the FVMA’s staff. “You are only as good as your staff,” Plasencia says. “To be able to come into an association and have a successful staff in place is a huge benefit to anyone who is taking over an organization. I think members should know the FVMA has an awesome
staff.” He says he intends to operate the FVMA by working closely with its staff and placing an emphasis on the wellness of those the association serves. “Even when I was in elementary school, middle school—I always just wanted to help people. No matter what your occupation is, you can have a profound impact on someone’s life,” Plasencia says. When he is not working, Plasencia enjoys spending time with his wife, daughters and rescued dogs. From pulling over a van of kids on the way to soccer practice to save a stray, to adopting a college friend’s dalmatian not allowed to live in the original owner’s dorm, Plasencia’s dedication to animals mirrors the same philosophies he applies with people. His intense dedication to animal care, which is central to veterinary professionals, serves to further drive the FVMA’s mission of advancing the veterinary medical profession, promoting animal health and well-being, and protecting public health. “My life would have been different had it not been for dedicated veterinarians who sincerely cared about myself and my dogs,” Plasencia says. “I see the FVMA as an extension of whatever role we can play in supporting the practice of veterinary medicine and the veterinary professionals who make it possible for us to spend the most amount of time with the four-legged family members we love.”
all aboutjaundice/icterus Dr. Stuart Walton, BVSc (Hons), BScAgr (Hons), MANZCVS (SAIM), DACVIM Jaundice/Icterus is a yellow discoloration of the skin, mucous membranes, sclera, and bodily fluids (plasma and urine) secondary to an increased concentration of bilirubin in serum and tissues. It poses a diagnostic challenge to the veterinary practitioner because it has several vastly different etiologies. In most instances, serum bilirubin > 1 mg/dl is considered abnormal with clinically detectable icterus occurring when the bilirubin is > 2 mg/dl (35 μmol/L) or greater than 5 – 10-fold above normal. It occurs either when the rate of bilirubin production exceeds the rate of bilirubin uptake by the hepatocytes (i.e., prehepatic e.g., hemolysis), when bilirubin cannot be handled by the liver (i.e., hepatic e.g., hepatic insufficiency), or bilirubin cannot be excreted by the biliary tract (i.e., post-hepatic e.g., biliary tract disease). Each designation may have a different or combined etiopathogenesis. Approximately 80% of bilirubin is formed after red blood cells are recycled. Approximately 20% of bilirubin is formed from the breakdown of myoglobin, cytochromes and other hemecontaining proteins within the liver. Within macrophages of the liver and spleen, heme from phagocytized senescent erythrocytes is cleaved by the enzyme, heme oxygenase, to form biliverdin, a green pigment. Biliverdin is reduced to bilirubin by biliverdin reductase. Unconjugated bilirubin (free or direct), a yellow orange pigment, is then released into the circulation and is bound to albumin. Plasma bilirubin (unconjugated) is removed from the circulation by the liver (uptake) and converted to conjugated bilirubin by hepatocytes. From here, it is secreted from hepatocytes into the biliary system, and then excreted into the intestines with bile. Most conjugated bilirubin can be deconjugated in the duodenum by gut bacteria into urobilins (e.g., urobilinogen). A small amount of this is oxidized to form stercobilin, while the rest is reabsorbed via enterohepatic circulation and then re-excreted by the liver. A small portion of urobilins are excreted into the
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urine by the kidneys. Bilirubin is not detectable in normal feline urine. In cats, the presence of bilirubin in the urine is indicative of conjugated hyperbilirubinemia. The differentials for hyperbilirubinemia and jaundice should be organized by location; 1. Prehepatic – Increased bilirubin production from destruction of erythrocytes (hemolysis) 2. Hepatic – Decreased hepatocyte uptake, conjugation and secretion of bilirubin 3. Post-hepatic - Impaired biliary excretion The first step toward an effective and efficient diagnostic workup of icteric cats is to determine whether jaundice falls into the category of prehepatic, hepatic or post-hepatic disease. Essential to a diagnosis is a thorough history and detailed physical examination which incorporates the cat's signalment. History taking should question whether there are other cats in the household and whether they are clinically well. Indoor/Outdoor status should also be ascertained. A thorough medical and dietary history should be elucidated as well as parasitic prophylaxis. The diagnostic workup should also be able to address and answer the following questions: 1. Is the source of the jaundice prehepatic, hepatic or posthepatic? Differentiating prehepatic disease from hepatic and post-hepatic disease is relatively simple and involves obtaining a small sample of blood to measure the packed cell volume (PCV) and total solids. Typical manifestations of anemia include: pale mucus membranes, lethargy, weakness/
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the yellow cat
CAUSE Cytauxzoon felis FeLV FIV Hemotropic Mycoplasma spp. Heinz body anemia Medications variety (cephalosporins, penicillins, potentiated sulfonamides) Hypophosphatemia FIP FeLV FIV Histoplasma capsulatum Toxoplasma Cytauxzooan Hyperthyroidism Medications variety (acetaminophen/paracetamol, diazepam, ketoconazole, itraconazole, methimazole) End-stage chronic liver disease Hepatic lipidosis Hepatitis/cholangiohepatitis Neoplasia (carcinoma, lymphoma) Sepsis Liver flukes Platynosomum liver fluke Cholecystitis Cholelithiasis Gallbladder rupture Neoplasia (biliary adenocarcinoma) Pancreatitis
Table 1: Differentials for prehepatic, hepatic and post-hepatic disease in cats. collapse, tachypnea, tachycardia, physiologic cardiac murmur and hepatosplenomegaly. If an anemia is identified, clinicians should then determine if there is any evidence of RBC regeneration, and examine serum and a blood smear for evidence of hemolysis, Heinz bodies and red blood cell parasites. 2. Is there associated encephalopathy? This has a complex pathogenesis with an increase in blood ammonia concentration playing a significant role. Clinical signs are variable ranging from minor change in mentation/motor activity to depressed neurologic function (mental dullness/ coma). 3. Is there an associated coagulopathy? Liver disease is associated with coagulation abnormalities (82–98% of all cases) and can result in an increased risk of bleeding. Coagulation abnormalities may include thrombocytopenia (due to decreased hepatic production of thrombopoietin or increased platelet consumption), alterations in prothrombin time/activated partial thromboplastic time (due to factor deficiencies) and increased D-dimer concentrations. Cats without anemia should be evaluated for primary hepatobiliary disease or post-hepatic disease. Important diagnostics include a complete blood count, assessment for infectious diseases
(e.g., FeLV antigen, FIV antibody) and serum biochemistry. Urinalysis, liver function tests (e.g. ammonia) and coagulation profiles are also important in the initial assessment as they provide essential information as to whether further diagnostic testing can and should be performed without complication. Hepatobiliary enzyme abnormalities should suggest certain diagnostic possibilities and be a guide for further investigation. It is important for clinicians to realize that the magnitude and duration of increase of hepatobiliary enzymes is dependent on the type, severity and duration of stimulus. It does not prognosticate the irreversibility of liver disease. With hepatocellular injury, increased transaminase activity is expected with jaundice (i.e., ALT and AST). There is also expected to be some degree of cholestasis (i.e., increases in ALKP and GGT) due to cellular swelling and canaliculi occlusion. In general, there is usually a two to three time increase of primary hepatocellular enzymes (ALT, AST) above the reference range compared to cholestatic enzymes (ALP, GGT). In cats with biliary or post-hepatic disease, increases in liver enzymes usually reflect a decrease in bile canaliculi flow and regurgitation of conjugated bilirubin into plasma. Causes include intrahepatic biliary compression due to infection, inflammation or neoplasia (Table 1), and extrahepatic obstruction. Cats with cholestatic disease
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are expected to have comparable levels of increased ALKP and GGT (i.e., ALKP = GGT). When there is discordance between ALKP and GGT (i.e., ALKP > GGT) hepatic lipidosis should be suspected. Hepatic lipidosis will occur as either a primary idiopathic disease or secondary due to other diseases like pancreatitis, inflammatory bowel disease, diabetes mellitus, etc. Abdominal radiography and/or ultrasound examination are diagnostics that are routinely performed in the workup for hepatic and post-hepatic jaundice. Radiographs are important in the assessment of liver size, whereas abdominal ultrasound is useful in differentiating hepatic and extrahepatic disease. Abdominal ultrasound is a sensitive tool for evaluating the hepatic parenchyma, biliary system and hepatic vasculature. It is important to assess the cystic and bile ducts. Clinicians should be also aware that gallbladder wall thickening or the presence of echogenic material within the gallbladder is not normal and indicates inflammatory biliary disease (e.g., cholecystitis). Other readily detectable luminal abnormalities include nonmineralized and mineralized choleliths, an extrahepatic bile duct obstruction from pancreatitis (i.e., inflammation and edema surrounding the bile duct), duodenal strictures at major duodenal papilla, or biliary tumor. Causes of hepatic disease are further decoded by fine needle aspirate and liver biopsy. Cytology is a useful diagnostic tool for hepatic lipidosis and infiltrative neoplasms. It is not useful in the diagnosis of inflammatory, dysplastic or hyperplastic changes to the liver. Complications are rare with bleeding being the most significant. Prior to performing cytology, it is important that clinicians warn owners of this potential complication. As part of any diagnostic workup, cholecystocentesis should be considered. This has now become part of a routine diagnostic workup for hepatic disease. Cytology of bile should always be
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paired with culture. The procedure is considered safe with only a small number of complications being reported. Complications can include bile peritonitis, bleeding/hemorrhage, bacteremia/ sepsis and dissemination of neoplastic disease as well as others. Biopsy should be considered if cytology is non-diagnostic, and cats have failed empiric medical therapy. Biopsy samples should be obtained for histopathology, aerobic and anaerobic culture, and heavy metal analysis. As well as biopsies of the liver, samples of bile should be collected for cytology and aerobic/anaerobic bacterial culture.
Dr. Stuart Walton, BVSc (Hons), BScAgr (Hons), MANZCVS (SAIM), DACVIM Stuart Walton is a clinical assistant in small animal internal medicine at University of Florida Small Animal Hospital. He graduated from the University of Queensland in 1999 and gained experience in small animal practice, greyhound practice, and emergency medicine and critical care before undertaking advanced training in small animal internal medicine, initially in Australia and then at LSU. He was employed at University of Florida in 2016 at the completion of his residency. Dr. Walton has an interest in immune-mediated disease, infectious disease, toxicology and respiratory medicine. In his downtime, he enjoys photography, travelling and live music.
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EAR Inflammation and infection Amelia G. White, DVM, MS, DACVD
PATHOGENESIS OF OTITIS
Otitis is the inflammation and/or infection of the ear. Otitis is further characterized by the extent of disease present, and is generally categorized as pinnal dermatitis, otitis externa, otitis media and otitis interna. Distinguishing between these types requires a working knowledge of basic ear anatomy. Pinnal dermatitis refers to inflammation/infection of the concave or convex aspects of the pinna (ear flap). Otitis externa refers to disease affecting the external ear canal, which begins at the tympanic membrane (ear drum) and extends out the horizontal and vertical canals to the opening of the ear canal. Otitis media refers to disease affecting the middle ear compartment or tympanic bulla. Otitis interna refers to disease affecting the inner ear, which includes the cochlea and semicircular canals. Understanding which part(s) of the ear is affected is important when implementing treatment plans that will be effective. Tackling a case of otitis externa can seem daunting at first, so following a schematic approach will be useful when obtaining success with even the most complicated cases of otitis.
Otitis externa is a common disease and represents the most common insurance claim presented to pet insurance companies for dogs. When making the diagnosis of otitis externa, it is important to remember that it is always a secondary disease. This is a very important concept because failure to identify and treat the primary disease will result in chronic recurrent otitis. This leads to frustration for pet owners and veterinarians as the pet continues to suffer long term with painful ear inflammation and infections. After repeated exposure to antimicrobials, resistance to these medications may occur and the pet may become refractory to treatment. Additionally, chronic changes in the ear canal may eventually lead to permanent mineralization. Neurological abnormalities may manifest as the disease spreads into the middle and inner ear compartments. Because the ear apparatus is an extension of the skin, it is very common for dogs and cats to show signs of dermatitis concurrently with otitis.
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Remember to look for the primary disease along the way!
History Physical Examination Otoscopy
Otitis Media –TM
Anti-inflammatory Recheck 10-14 d
Treat accordingly Recheck 10-14 days
+/- CT +/- VO +/- TECA +/- VBO
The factors and causes of otitis are commonly divided into several categories: 1) predisposing factors, 2) primary causes, 3) secondary causes and 4) perpetuating factors.
Predisposing Factors Predisposing factors are components of the disease process or pet that contribute to or promote otitis but are not able to cause otitis alone. Examples include conformation (narrow/stenotic ear canals, excessive hair in the ear canal, pendulous pinnae), lifestyles/ behaviors (swimming, bathing, grooming with frequency), obstructive disease (feline ceruminous cystomatosis, neoplasia, polyps), primary otitis media, systemic disease, and treatment effects (disturbance of normal flora, trauma from cleaning ears).
+/- culture +/- histopath
Figure 1: Otitis Decision Tree. Following a stepwise approach starting with history and working through physical exam findings, cytology, and remembering the primary disease along the way will be helpful when designing successful treatment plans for canine otitis externa.
Perpetuating Factors These factors develop in response to the existing predisposing, primary and secondary factors. Perpetuating factors compound the inflammation occurring in the ear canal and inhibit resolution of the otitis externa through promoting additional infections and inflammation. Perpetuating factors must be addressed in order to completely resolve the otitis. Examples of perpetuating factors include changes in epithelial migration and cerumen production; hyperplasia, edema, or stenosis of the ear canal; damage to the tympanic membrane; hyperplasia or altered function of the glandular tissue; calcification of the ear canal; otitis media; and osteomyelitis.
IMPORTANCE OF THOROUGH HISTORY
Causes: Primary and Secondary
Primary causes are considered those things that directly cause otitis externa. This includes allergic skin diseases (e.g. food allergy, atopic dermatitis, contact allergy, or flea allergy), autoimmune diseases (e.g. pemphigus complex, lupus erythematosus, adverse drug reactions, or vasculitis), endocrinopathies (e.g. hypothyroidism, hyperadrenocorticism, or sex hormone abnormalities), epithelialization disorders (e.g. zinc-responsive dermatosis, vitamin A-responsive dermatosis, or sebaceous adenitis), foreign bodies (e.g. hair, grass awn, or insects), glandular disorders (e.g. sebaceous gland disease), microorganisms (e.g. dermatophytosis), parasites (e.g. Otodectes sp. or Sarcoptes sp.), viral diseases (e.g. canine distemper), or miscellaneous diseases (e.g. feline proliferative and necrotizing otitis externa). Primary causes must be identified and treated in order to control the otitis long-term. Secondary causes directly induce otitis in ear canals that are already abnormal by causing additional inflammation resulting in changes in the ear canal. Examples of this are a bacterial or Malassezia sp. infection within the ear canal of an atopic dog, and topical acquired irritant reactions from ear cleaners or treatments. Secondary causes of otitis are generally easier to treat and may even self-resolve if the primary or perpetuating factors are addressed.
Otitis externa is a multifactorial disease with a complicated pathogenesis. Obtaining a thorough and detailed history will be imperative when working through the differential diagnoses that may be contributing to the otitis. Primary and secondary causes must be identified and treated in order to treat and prevent relapses of the otitis. Predisposing and perpetuating factors must be considered in order to resolve the active inflammation and infection of the ear canal. Important history questions may include age of onset of disease, level of pruritus, distribution of pruritus, seasonal trends in disease occurrence, dietary history, current medications and response to previous therapies. General demeanor, activity level, appetite, thirst level, urinary/defecation habits, body weight fluctuations and changes in neurological status may all be necessary to understand the severity of disease and consider non-allergic causes of otitis such as endocrinopathies.
CLINICAL SIGNS The clinical signs of otitis externa can vary widely based on the type of infection present, the primary cause and the severity of infection. Some of the most common signs of acute otitis externa
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include erythema of the pinna and/or ear canals, otic debris, malodor, alopecia, excoriations, scaling, crusting, broken hairs, decreased pliability of ear canals, head shaking, head shyness, scratching the ears, facial rubbing, aural hematoma, acute moist dermatitis near/around the ear base or neck, change in ear carriage, and intermittent head tilt. Dermatological lesions may involve the ear canal, pinna and/or periaural skin. Clinical signs that are more suggestive of otitis media +/- interna would include facial paralysis, Horner’s syndrome, head tilt, ataxia, nystagmus, change in ear carriage, difficulty opening the mouth completely and nausea. Palpation of the ear canals is an important tool capable of indicating the severity of ear disease. Normal, non-inflamed ear canals are pliable and small on palpation. Ear canals with severe, chronic inflammation are large and firm on palpation with decreased pliability. Those ear canals that palpate similar to a hard rock are most suggestive of mineralization which is considered end-stage ear disease. Once mineralization occurs, medical therapy becomes challenging. Patients experience moderate to severe levels of pain, and infections become trapped within the ear epithelium and mineralized canal. This acts as a source of recurrent infection of the ear canals, and may require surgical intervention to resolve. The most common surgical treatment is a total ear canal ablation with or without a bulla osteotomy. Lateral ear resections are not generally recommended because the tympanic bulla is commonly mineralized as well.
BASIC OTOSCOPIC EXAMINATION TIPS When examining the ear canal, there are a few tips that can be utilized to improve the likelihood of a thorough evaluation.
Animal Restraint The most important aspect of a good ear exam is excellent, safe and fear-free animal restraint. It is critical that the animal is properly restrained in order to prevent unintended harm to the examiner, holder and patient. Restraint should be performed in a fear-free fashion to improve the comfort level of the patient and minimize patient anxiety. Additionally, proper restraint decreases the possibility of discomfort from the otoscopic examination and decreases the likelihood of further damage to the fragile ear canal. When examining a small dog, place the dog on a nonslip tabletop. The holder will snuggle the patient into their upper body by placing their arm over the lateral aspect of the patient while using their hand to hold the shoulder and lateral cervical region. The opposite hand should be used to gently hold the patient’s muzzle with the hand over the dorsal muzzle and the fingers clasping in the intramandibular space (Figure 2A). If a patient is known to bite, a muzzle can be used to improve safety. This hold allows the examiner to easily access the ear canal and prevents occlusion of the canal by the holder’s hand. Large dogs are restrained in a similar fashion while standing on the floor. Instead of snuggling the dog into the holder’s torso, the dog can be snuggled into the knee/leg of the holder (Figure 2A). An additional holder may be required to prevent the animal from backing away from the holder. Cats can be examined on a nonslip tabletop or within the carrier once the top has been removed. Feliaway® or similar feline pheromones may aid in reducing patient anxiety. Cats are generally restrained in the same fashion as a small dog with a few exceptions. The holder should attempt to hold the front legs between their fingers to avoid unintended scratching. The holder should attempt to cover the cat’s eyes when restraining the head (Figure 2B). Towels can be used to create a “kitty burrito” for cats that are known to scratch. For all animals, it is important to remember that otitis generally hurts! If your patient is not being compliant for the exam, do not force them into a wrestling match. This is unsafe for the people and patient, and creates unnecessary stress to the pet. Chemical restraint should be utilized whenever necessary and safe for the patient.
Figure 2: Proper Restraint. (A) Small dogs can be restrained on a nonslip table by placing one hand on the lateral shoulder or cervical region, and the other hand dorsally over the muzzle. Larger dogs can be restrained while standing on the floor in a similar fashion. Image courtesy of Dr. Amelia White.
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Figure 2: Proper Restraint. (B) Cats can be restrained on a nonslip table or within their carriers by placing one hand on the lateral shoulder while holding the front legs, and the other hand dorsally over the head. Image courtesy of Dr. Amelia White.
Getting Into the Ear To access the ear canal with ease, first locate the tragus. This is the plateau-like outermost piece of cartilage at the ear canal opening. Find the intertragic incisure just caudal to the tragus, and gently insert the otoscope cone into this slit with the otoscope cone pointed ventral and slightly rostral while gently lifting the ear pinna dorsally. Maneuvering the ear pinna will help to straighten out the vertical ear canal. Once you have reached the floor of the ear canal, turn the otoscope cone medially while maneuvering the ear pinna out and down towards your body. This will allow you to access the horizontal ear canal. While evaluating the ear canal, observe for changes in wall thickness, erosions/ulcerations, masses, foreign body, otic debris, hair and the tympanic membrane. Be mindful of the patient’s comfort level during this process. The tympanic membrane should be assessed for normal structures and position. Changes in architecture or presence of fluid/masses behind the tympanic membrane may cause bulging or rupture. Sometimes a tear or complete loss of the tympanic membrane is present. If the ear
canal has a bumpy appearance similar to that of a cobble-stoned road, then this is indicative of hyperplasia of the ceruminous (waxproducing) glands of the ear canal and suggests a more chronic case of otitis (Figure 3).
DIAGNOSIS Making the clinical diagnosis of otitis externa is easily accomplished with a thorough history and physical examination. Understanding the primary/secondary cause of otitis is more challenging especially in chronic cases where more than one cause may be present. Diagnosing the cause and factors contributing to otitis will be important for understanding the long-term prognosis and developing a treatment plan. History, physical examination, otoscopic examination, cytologic examination, histopathology, myringotomy, culture and susceptibility testing, and advanced imaging may all be required to make an accurate diagnosis.
Figure 3: Chronic otitis externa. Images are from a six-year-old male castrated cocker spaniel dog with chronic atopy. (A) There is moderate pinnal erythema, yellow ceruminous otic debris and lichenification. (B) Marked ceruminous gland hyperplasia giving the appearance of a cobblestoned road within vertical and horizontal ear canals confirms chronic otitis externa. The ear canal also has moderate erythema and mild ceruminous otic debris.
Image courtesy of Dr. Amelia White.
Continued on Page 20 WWW.FVMA.ORG |
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Continued from Page 15 Cytological examination of otic debris does not provide a definitive diagnosis, but it does give the veterinarian an understanding of secondary causes contributing to otitis. Cytologic samples are obtained from both the affected and unaffected ear using cottontipped applicators to swab the external ear canal. Samples are rolled onto a glass slide, heat fixed, and then stained using Diff-Quik® and/ or gram stains when evaluating for bacteria, yeast, inflammatory cells and neoplastic cells. The light source should be bright and the oil objective (100X) is used to evaluate these samples. The most common bacteria present in the canine ear include Staphylococcus pseudintermedius, Streptococcus canis, Pseudomonas sp., Proteus sp., and E. coli. The most common yeast present in the canine ear is Malassezia spp. Samples can be evaluated for parasites by placing the otic debris into mineral oil on a glass slide and covering with a glass cover slip. The microscope light source (condenser) is dropped low, and the light power turned down when evaluating for parasites with the less powerful objectives (4X or 10X). Mites and other parasites are much larger than bacteria and yeast, so less power is required. Also, these organisms may be very translucent, so use of less light power enhances visualization of these parasites. Myringotomy is used to collect a sample of fluid from the tympanic cavity when the tympanic membrane is still intact. Visualization of fluid in the tympanic cavity may be achieved on otoscopic examination or via advanced imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) studies. During otoscopic examination, seeing a bulging tympanic membrane or visualizing a fluid line may indicate that something is in the tympanic bulla. Remember that besides fluid, a mass or excessive air may also be the cause of a bulging tympanic membrane. Myringotomy can be especially helpful for cytological evaluation and culture and susceptibility testing of middle ear fluid prior to selecting antibiotic therapy for otitis media. Most of the time, the middle ear fluid is infectious. Occasionally, sterile otitis media may be the cause of the otitis, and antimicrobial therapy is not warranted in these cases. One dog breed especially predisposed to sterile otitis media is the Cavalier King Charles spaniel.
TREATMENT AND LONG-TERM MANAGEMENT Treatment of otitis involves identifying and treating the causes of otitis while also resolving factors contributing to otitis. If both of these are not addressed, then the otitis will not resolve completely. Long-term management of the ears may not be required if the cause is able to be well-controlled. Otherwise, frequent use of ear cleansing agents likely will be required to help reduce the build-up of otic debris and reduce normal flora overgrowth within the ear canal. Frequent follow-up visits and owner compliance are critical for treatment success.
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Acute Otitis Externa In cases of uncomplicated otitis externa, a short 10-14 day course of anti-inflammatory +/- antimicrobial therapy and ear cleansing agents will resolve the inflammation/infection completely. The cause of the otitis may be transient or mild in these cases; however, if it continues to go untreated then disease can progress. General cleansing ear flushes may include Otirinse®, EpiKlean™, pHnotix™, DouxoMicellar®, EpiOtic/EpiOtic Advanced®, and Malacetic/Ultra™. Ceruminolytic cleansers that help to break down severe buildup of waxy debris include Cerumene®, KlearOtic™, pHnotix™, and Douxomicellar®. Pyoclean® Oto may also be helpful to breakdown debris especially biofilms. Cleaners containing TrizEDTA® such as TrizEDTAUltra™+/- Keto or T8Keto® are very effective against gram-negative organisms like Pseudomonas sp. When selecting an antimicrobial agent, it is recommended to select a first-line antimicrobial in cases of uncomplicated acute otitis (Figure 4A). Most commercially available products contain a combination of an antibiotic, antifungal, and anti-inflammatory (steroid) agent. Common first-line antimicrobials used in these cases include florfenicol (e.g. Claro® and Osurnia®) effective against gram-positive organisms only, or gentamicin and neomycin effective against gram-positive and -negative organisms (e.g. Otomax®, Mometamax®, Tresaderm®, Animax®, Easotic®). Firstline antibiotics are used first and in acute, uncomplicated cases of otitis. Long-term management of mild, recurrent otitis externa involves treating the primary disease and using topical ear therapies to maintain a healthy ear canal. This includes routine ear cleaning (once every one-two weeks) to prevent excessive build-up of cerumen within the ear canal. Topical glucocorticoids can be used to control inflammation locally without the need for systemic therapies (e.g. CortAstrin®, Synotic®, MalaceticUltra®, and ZymoxHC®). Remember to consider the potency of the steroid within the product to decide how often to apply the product. Overuse of topical glucocorticoids can have local and systemic side effects.
Chronic otitis usually requires treatment with antimicrobials within the second-line of treatments (Figure 4B). Second-line antimicrobials are those used after first-line drugs fail, or in cases that are recurrent or more complicated. All second-line antibiotics are effective against both gram-positive and -negative organisms. This includes fluoroquinolones (e.g. Baytril Otic®, Posatex®, Aurizon®), polymixin B (e.g. Surolan®), and sulfonamides (e.g. silver sulfaidiazine 1% cream). These cases also usually require the use of systemic glucocorticoids to help manage the moderate the severe inflammation within the epithelium of the ear canals. Prednisone at a dose of 1 mg/kg every 12-24 hours for seven days or longer followed by a tapering schedule can be useful to assess the responsiveness of the ear canal to medical therapy. If the ear canal fails to improve by 50% within the first two to three weeks of
Figure 4: (A) First-line antibiotics are used in cases of acute, mild otitis externa. Therapy should be selected based on cytological findings and continued for 10-14 days, or until the otitis is resolved completely. (B) Second-line antibiotics have broad-spectrum coverage against grampositive and gram-negative organisms. These antibiotics should be used in more severe cases of otitis externa, based on cytological findings, and when first-line antibiotics are not helpful. (C) Third-line antibiotics are reserved for complicated, chronic cases of otitis externa +/- media for which first-and second-line antibiotics have failed to improve the infection.
SUMMARY Otitis is a multifactorial disease influenced by causes and factors that need to be addressed in order to achieve treatment success. While acute otitis cases are relatively easy to treat, chronic cases of otitis can be complicated and challenging to maintain long-term success.
Amelia White, DVM, MS, DACVD
aggressive anti-inflammatory and antimicrobial therapy, then endstage ear disease is likely present and referral to a dermatologist or surgeon is recommended. Third-line antimicrobials are reserved for treatment of the more severe and refractory cases of otitis (Figure 4C). These cases require veterinary compounding to create broad-spectrum antimicrobial approaches utilizing drugs such as amikacin or piperacillin. These cases usually require aggressive treatment approaches with repeated deep ear flushes and long-term care. These represent cases where specialty referral is warranted.
Dr. Amelia White received her DVM from the University of Georgia College of Veterinary Medicine in 2010 followed by a one-year internship in small animal medicine and surgery at Auburn University. She was accepted to a dermatology residency at the University of Illinois at ChampaignUrbana the following year, where she completed three years of specialty training and a master’s degree in 2014. Dr. White completed her board certification exam in veterinary dermatology in fall 2014 and became a Diplomate of the American College of Veterinary Dermatology. She currently is an associate clinical professor of dermatology at Auburn University College of Veterinary Medicine. She has authored or contributed to various abstracts, case reports, primary research and book chapters. Dr. White has been a consultant for the Veterinary Information Network (VIN) since 2015. She teaches the communications skills course at Auburn University and enjoys opportunities to provide continuing education seminars to veterinary professionals. Her research interests include allergic skin and ear diseases, infectious diseases, and student mental health and well-being.
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Mental Mop Up Katie Pearce, Content & Engagement Specialist The last year was full of new stressors, scares and improvisations. We recently passed the one-year anniversary of shutdowns due to the COVID-19 pandemic, and we now hope to spring past the restrictions of the pandemic. Spring cleaning is a hallmark of the season—and it’s not just for your home. Mental wellness and well-being in the veterinary profession is particularly important. Take a moment to look at your mental well-being and do some metaphorical, and even physical, cleaning up.
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MENTAL CLUTTER Mental “clutter” can be stress, anxiety, racing thoughts or negativity we might be holding on to. This mental clutter holds us back from embracing the best parts of life. While tough experiences are a part of life, there are mental negatives that we can control. These negatives eat away at our health, and though they may be hard to untangle ourselves from, when we free ourselves from this mental clutter, we experience greater peace and health.
Toxic Relationships and Drama
It is never a good time to hold onto relationships with people who seem to constantly drag you down and create unwarranted stress in your life. Though we may think we’re not affected, other people’s negativity and drama only results in our own emotional reservoirs becoming easily exhausted. Whether friends, significant others, or even employers, staff, or clients, it is always okay to end any relationship that is harming or burdening your mental and physical health. Sometimes it is enough to have a forthright conversation laying down new rules—and in other instances, the best option may be to walk away entirely.
and resources we spend unhappily taking care of it. Our free time becomes consumed with taking care of ‘things’ and ‘stuff ’ rather than relaxing and enjoying our time. Sometimes there’s so much we become burnt out by our chores and can no longer easily or properly care for our things—this leads to further frustration due an accumulation of work needing to be done. Decluttering a space (home, office or yard) can reduce stress and help those that use the space avoid injuries. Cleaning and organizing the space you spend most of your time in can also keep your immune system strong, boost your mood, and offer a task that promotes focus and reflection during a trying time. Furthermore, cleaning things you touch a lot—or several people use often—can help you avoid illness and minimize the spread of viruses and bacteria.
Whether minor or major, bad habits are important to recognize and address. Overwork, substance abuse, poor diet and exercise, ignoring your emotions/self-truths, or even social media addiction—are common and often overlooked habits. Bad habits are not easy to break, but they are important to work on. Focus on one bad habit; take your time, reach out to those around you for support and encouragement, and consider professional help.
Negative talk is greatly influenced by who we surround ourselves with. It can be directed at those around us and at our life circumstances, or it may be directed towards yourself (a constant focus on your flaws). Gossiping or constantly complaining can lead to a worsening outlook on life. Occasional venting can be good for getting rid of stress, but constant complaining and verbalizing old hurts only allows those feelings to fester and further harm our mental health. Always wallowing in the negative brings ourselves and those around us, like fellow staff, down.
Often linked to negative talk, self-deprecating thoughts and selfdoubt are often rampant in the veterinary profession. This may even manifest as imposter syndrome. Often times, our very own potential for greatness and possibility for achievement is ruined by our own thoughts. We don’t express confidence in our abilities, and tell ourselves, “I can’t,” or “I’m not good enough.” Even when we accomplish great things, we feed this negative thought process by thinking things like: “I don’t deserve this,” or “They made a mistake.” Negative thoughts get in the way of our dreams and stymies the enjoyment of our achievements.
Have you ever noticed it’s harder to be productive in a messy room or house? Physical objects and tasks take up mental space. Too much ‘junk’ in our lives leads us to constantly have to figure out how to take care of it (storing, cleaning, repairing). The more ‘junk’ we have that doesn’t bring us enjoyment, the more time
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CHANGING YOUR MINDSET As you declutter your mental and physical space, you’ll be able to focus on healthier habits—and may consider filling the gap of a bad habit with a good one.
Your Physical Health
Physical health, eating healthier, drinking plenty of water, healthy sleeping patterns, and, of course, physical activity. These days we’re all tired of hearing “diet and exercise” and many struggle to ‘stay on top of ’ their physical health. Physical health is often tied to mental and emotional well-being, but rather than looking down on your current self, it may be helpful to simply look forward to a fun activity that just so happens to get you moving. Walking while shopping, exploring a new town or swimming at the beach all require physical activity—you don’t have to begin a daunting exercise regime to simply get moving. Small actions, such as taking a walk on a sunny day, drinking more water, or eating less sugary foods and drinks, all add up to a healthier overall lifestyle.
Reflecting and being aware of our thoughts and feelings allows us to be better prepared to handle stress and be more in-tune with ourselves and those around us. It also helps us to see the ‘big picture’ so that our thoughts are less likely to snowball into ‘worst case scenarios.’
CONCLUSION Mental wellness is key to a fulfilling life and career. In support of our members health, the FVMA will be expanding our wellness and well-being initiatives this year. We look forward to sharing more information with you soon!
Focusing on what you're grateful for will help pull your mind away from the negatives that can sometimes feel overwhelming. From your favorite smelling candle and a shower at the end of the day to family and pets, there’s so many things to focus on and be grateful for.
Creative projects are a wonderful way to learn something new while also changing your focus. Whether learning a musical instrument, drawing or painting, it’s not about being perfect or immediately excelling, it’s a way to let your creativity out and improve your well-being.
Friends that encourage you and make you laugh are worth holding on to. Positive friendships can change our outlook and leave us feeling loved and fulfilled. If you’ve let friends fall to the bottom of your priority list, now is always the right time to take the time to revitalize your friendships.
If you or a loved one is experiencing suicidal thoughts or actions, help is available. Call the National Suicide Prevention Lifeline: 800-273-8255
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Practice Pulse QUESTION: We recently had a client who brought their pet in for a wound, which received treatment and a drain. At the time of one of the most recent visits, the client became agitated and verbally abusive (including threats and racial slurs) to staff and surrounding clients. Two of our clients refuse to return to our practice after witnessing this behavior. The client had a second appointment this past Saturday to remove the drain and the pet appears to be healing, but in instances like this—what responsibility do we have to complete medical treatment or continue medical treatment if we choose to discharge this client? Any information you can provide would be of great help. A: You should write a letter to the client that says something similar to the following: Dear Client: The veterinarian-client-patient relationship is based on mutual trust and understanding. Your recent behavior at our clinic was unacceptable and shows a lack of regard for said relationship. Therefore, we have no other option than to discharge you as a client of our clinic. Below is a list of other veterinary clinics in the area. We will forward any records we have to any subsequent treating veterinarian that you designate. [Insert list of other veterinarians in the area.] Sincerely,
QUESTION: What needs to be done in the event that a practice closes - not a sale, but a closure. Are there some notifications that need to go out or some notice in the papers? A: 61G18-18.0015 Medical Records; Relocating or Terminating Practice; Retention and Disposition. (1) Every veterinarian or entity licensed pursuant to Chapter 474, Florida Statutes, who terminates practice or relocates practice and is no longer available to patients or clients, shall retain medical records pertaining to patients for at least a period of 3 years after the date of last entry. (2) No later than one month after the veterinarian or entity terminates practice or relocates practice and is no longer available to patients or clients, the veterinarian or entity shall cause to be published in the newspaper of greatest general circulation in the county where the veterinarian or entity resided or practiced, a notice indicating to the owners of the patients of said veterinarian
26 | FVMA ADVOCATE
or entity that the medical records are available to the owners of the patients or their duly constituted representative from a specific person at a specific location. (3) At the conclusion of a 3 year period of time from the date that the veterinarian or entity terminated practice or relocated practice and was no longer available to patients or clients, the veterinarian or entity shall cause to be published once during each week for 4 consecutive weeks, in the newspaper of greatest general circulation in the county where the veterinarian resided or practiced, a notice indicating to the owners of the patients of the veterinarian or entity that the medical records may be disposed of or destroyed one month or later from the last day of the 4th week of publication of notice. However, nothing herein shall be construed to require that a veterinarian or entity ever destroy the medical records; it permits destruction of records after 3 years and requires notification to clients that the records can be destroyed. We would also recommend an email or letter to the active clients of three years or less. Records of patients not seen in three years can be destroyed.
QUESTION: We have a client that is requesting we change their pet's breed description from a German Shepard mix to a hound mix. This pet was established with us as a puppy in 2015 and was recorded as a German Shepard mix. This was not an issue prior to today, until the owner requested a copy of her dog's vaccine reports. What is our obligation on record keeping for changing the identification for a mixed breed dog? A: Our thoughts are that if the veterinarian assigned German Shepherd in the beginning based on the best available information and description, and if the dog looks more like that than a hound, then the original description should be maintained. On the other hand, if it looks more like a hound as an adult then changing the description would be OK. The client must be informed that a dog’s description is based on sound veterinary medicine factors (because some breeds have propensities for certain conditions), and that it is not simply a matter of client preference. Changing a dog’s description in established medical records that go back five years for no legitimate reason could be considered altering a medical record.
GOT A QUESTION? THE FVMA CAN HELP.
One of the benefits of an FVMA membership is our helpline (800.992.3862), which is available to members Monday through Friday from 8 a.m.-5 p.m. Our helpline also provides insight to the FVMA staff of the challenges and concerns of our members. In this feature, we will highlight topics from the questions we received in preceding weeks as a part of an effort to keep our members up to date on current concerns, as well as regulatory and legislative changes.
QUESTION: I have a client that would like us to give half dose vaccines to her two–three pound dogs. She is quoting a doctor at a university for the half-dose protocol. I know the rabies is nonnegotiable and needs to be given as the full 1cc. The question is regarding the distemper/parvo/adenovirus vaccine. My concern is that giving half the dose will result in a reduced immune response and inadequate protection. I'm also concerned that if one of her dogs later gets one of the three infections in the vaccine that we will be held accountable. One of my associates would like to go ahead with it, having the owner sign a waiver that removed the clinic of responsibility if any of the half-vaccinated dogs became ill. Is that adequate? Or should we just not touch it with a barge pole? I had even said let them get their DAP vaccine online or at Tractor Supply and give it however they want...My associate's comment was the owners are probably concerned those vaccines are not as efficacious. My response was I don't think a half dose is as efficacious. Can you give me some guidance on how to proceed?
A: We would strongly suggest that you not give half-dose vaccines. The VCPR is based on mutual trust and understanding. The definition of VCPR in the statute is 'veterinarian/client/ patient relationship' means a relationship where the veterinarian has assumed the responsibility for making medical judgments regarding the health of the animal and its need for medical treatment.” It is the job of the veterinarian to make the medical judgments regarding the health of the animal and its need for medical treatment, not the client’s job. If the client wants to have half-dose vaccines given to their dogs, and you have concerns about its efficacy, we advise that you decline. We would also not recommend that you refer the client to anyone else, as that veterinarian would be in violation of the VCPR if they accepted the client’s recommendation. Finally, a waiver removing the clinic of responsibility if any of the half-vaccinated dogs become ill is ill-advised. If the dogs get ill, the client can easily file a complaint with DBPR, stating that while they signed the waiver, you should not have only given half a vaccine in the first place. Such a waiver opens you up to too much liability.
QUESTION: My husband and I (he is also a vet) are retiring soon and plan to close our clinic as opposed to selling it. We do have another local veterinarian who will be taking over our client records, but this business entity will no longer exist. We know the rules about providing records for three years and about giving notice in the local paper where those records can be obtained, but we're unclear about other potential issues we need to address. One is whether my DEA license remains in effect if I no longer work in a clinic location but only take care of my own pets, those of my grown children, other close family members, and perhaps an occasional neighbor’s pet (all without any financial gain). For instance, would I be able to call in a script for phenobarbital for my daughter’s epileptic dog? Can I prescribe other medications to local or online pharmacies for these family-owned pets as well as my own? Can we still order from veterinary suppliers to have medications sent to our home when we no longer have a clinic business? Any other insights or resources you can provide as we make this major life change is much appreciated.
A: A DEA registration is personal to the practitioner and not the clinic. What you need to do is to change the address with the DEA to your home address. You will now become a "house-call practice” and will not need a premise permit. You must create and maintain all appropriate patient records as well as drug records. Suppliers can sell and deliver to the residence address of a house-call practice veterinarian. The statute of reference is below. 61G18-15.006 Minimum Standards for House-Call Practices. Veterinarians practicing on a house-call basis and who practice where the animal is kept must meet the requirements of rule 61G18-15.002 or 61G18-15.0035, F.A.C., except that no premises permit is required.
END NOTE: The ultimate responsibility
in the practice of veterinary medicine lies with the licensed veterinarian. Professional discretion must always be exercised. WWW.FVMA.ORG |
@THEFVMA | 27
CLASSIFIED ADVERTISEMENTS VETERINARIANS WANTED
VETERINARIAN WANTED – TAMPA BAY, FL: The Humane Society of Tampa Bay is seeking a full time veterinarian for our shelter , as well as, a full-time veterinarian for our animal hospital . This position will perform high volume sterilizations, diagnostics and treatments for the over 11,000 shelter animals we care for each year. The Humane Society of Tampa Bay is a cutting edge animal shelter which maintains a save rate of over 90%. We have built a new state of the art shelter which opened September 2020. GREAT benefits package which includes medical/dental/vision, life insurance, disability and paid time off, 401 K plan and more !!! Includes a VERY Generous Sign on Bonus!!! If you want to make a difference in animal welfare, please apply today!!! MUST HAVE A Florida Veterinarian License. To apply please send your resume to Colleen Tessmer at ColleenT@humanesocietytampa.org. (2/21 ID#49259)
PART-TIME VETERINARIAN WANTED – DUNEDIN, FL: We are in need of a P/T Veterinarian for a day, or two, or three a week to replace our 5-year P/T vet, full time mom, who has bought her own practice. We are a small 1 1/2 Vet, 5 employees, client focused personalized practice with the usual bells and whistles. We are very flexible, and amenable to whatever will work for you. It is a nice place to hang your hat! For more information please visit us at dunedinveterinarian.com. (2/21 ID#10891) VETERINARIAN WANTED – JUPITER, FL: The Opportunity in
Paradise… Jupiter. Jupiter Pet Emergency and Specialty Center is seeking an emergency veterinarian to join our 24-hour emergency/specialty practice. This is an exciting opportunity for a highly motivated individual to join a great long standing practice with a team of like-minded doctors committed to delivering progressive veterinary care. Competitive salary and generous benefits package. To learn more about the position, please send your resume to email@example.com. (2/21 ID#3758)
VETERINARIAN RESIDENT WANTED – CLEARWATER AND WESLEY CHAPEL, FL: The Pet Dentist at Tampa Bay—Clearwater
and Wesley Chapel, FL: The Pet Dentist at Tampa Bay is seeking a full time resident for its AVDC approved residency program, beginning in 2022. With two locations in the Tampa Bay area, our practice offers mentorship from two board-certified veterinary dentists. Our practice on the west coast of Florida continues to grow thanks to over 20 years of relationships with local general practitioners and specialists. Our offices have great support staff including certified veterinary technicians and receptionists. The caseload is diverse and includes all aspects of veterinary dentistry and oral surgery. Practice locations are recently renovated and offer state of the art equipment. Applicants are required to have completed a one-year internship or equivalent experience in private small animal practice. We offer a competitive salary and benefits package and a 5-day work week. A letter of intent, curriculum vitae, and three references should be sent via email to firstname.lastname@example.org. For more information about the program, contact Dr. Chris Smithson or Dr. Michael Peak, phone: 813-406-4800. (2/21 ID#592)
VETERINARIAN WANTED – OLDSMAR, FL: Woodlands Animal
Hospital is seeking a full or part-time Associate Veterinarian to join our rapidly growing small animal practice. We are located in Oldsmar, Florida with close access to Honeymoon Island, Clearwater Beach, Tampa, and St. Petersburg. Oldsmar provides a great sense of family and adventure with its many parks, biking and walking trails, kayaking and paddleboarding access points, and community events. Our mission and philosophy here is to provide high-quality and compassionate veterinary care with excellent customer service. We are looking for a like-minded, dedicated, and motivated doctor to join our team. The salary and benefits package being offered are generous and negotiable, depending on your priorities and goals within the profession. We welcome applicants in any phase of their veterinary career, including new graduates who would like mentorship. Future partnership opportunities are an option for the right individual.
28 | FVMA ADVOCATE
If you would like to apply, or are interested in further details, please contact us at email@example.com. (2/21 ID#37183)
VETERINARIAN WANTED – WINTER PARK, FL: What if you could enjoy coming to work every day to reasonable hours with great support staff and clients? Garden Veterinary Clinic is looking to add a veterinarian to our rapidly growing, family-style, small animal exclusive practice. An interest in surgery and dentistry a plus! Knowledge or an interest in holistic medicine and acupuncture also welcome. A friendly, non-judgmental personality a must! For more information, please contact Dr. Erin Lindblad at firstname.lastname@example.org. (2/21 ID#5679) VETERINARIAN WANTED – RIVERVIEW, FL: Very progressive, integrative and client centered practice in need of a full time experienced (3+ years) veterinarian to help be a part of a successful, busy, growing practice in Riverview, FL. Four Paws Veterinary Hospital is committed to providing the community with the highest level of professional veterinary care, client education and support, and preventative medicine available. Focused on continuous staff improvement and ongoing quality control, our staff is committed to providing outstanding customer service, encouraging individual and team development, and maintaining an upbeat clinic where tails wag, and clients and staff find reasons to smile.
Skills need to include excellent surgical experience, excellent diagnostic skills, an open mind and excellent client and staff relationship skills, must be a team player. Salary plus bonus commensurate with experience, plus IRA plan, vacation 3 weeks paid and other benefits. Practice hours would be Monday-Thursday 8:00-5:30 pm and every other Saturday 8-12 pm. Send Resume’s to email@example.com (2/21 ID#25922)
VETERINARIAN WANTED – WEST PALM BEACH, FL: Enjoy practicing quality medicine in beautiful suburban West Palm Beach. Full Time Small Animal Associate Veterinarian position available in 3 DVM, AAHA Certified Hospital. Consideration given to enthusiastic individuals who practice qulaity veterinary medicine and surgery, provide compassionate care and possess excellent client communication skills. Mentoring by Diplmate ABVP for new associates. State-of-theart equipment: Digital Radiology and Ultrasound, Luxar CO2 Surgical Laser, In-house lab, Endoscopy, Digital Dental Radiology. *Enjoy your time off - *4 day work week - *5 days off every 3 weeks *CE Allowance *Paid Time off *Paid Professional Association dues *401k *Competitive Salary based on experience *DVM/VMD *Licensed in Florida. E-mail resume to firstname.lastname@example.org (2/21 ID#10351)
VETERINARIAN WANTED – FORT LAUDERDALE, FL:
Independent multi-doctor animal hospital in the Fort Lauderdale area is looking for a full-time veterinarian to join our team! As seen in our reviews, Nova Animal Hospital is a great work place featuring- wonderful clients - excellent support staff - a modern facility - friendly and collaborative clinic culture - mentoring for new and recent graduates Our compensation package is competitive and features:
--paid vacation and holidays
Contact practice owner Dr. Meg Formoso at email@example.com (2/21 ID#7744)
VETERINARIAN WANTED $200,000/YR. – ZEPHYRHILLS, FL:
Please contact Dr. Larry Adkins at (407) 529-5651 for more information. (Issue 2/21 ID#28095)
VETERINARIAN WANTED $200,000/YR. – ST. CLOUD, FL:
Please contact Dr. Larry Adkins at (407) 529-5651 for more information. (Issue 2/21 ID#28095)
VETERINARY WANTED – SUN CITY, FL: Seeking Associate
Veterinarians – TAKE IT PERSONALLY
Fox and Friends, located in beautiful Sun City, FL is a fast-paced, boutique small animal practice that has been serving our community for over 20 years. We enjoy a great internal collaborative culture and have a loyal client base that trusts us with their loving pets. Our team loves what they do – creating Happy Vets & Healthy Pets. Being an AmeriVet Partners Practice, we also practice the core behavior, TAKE IT PERSONALLY! You might be asking, what does that actually mean?! We are accountable for our actions. When there is a problem or a challenge, take it personally and put brainpower to work. Look for the “how” rather than the “can't”. Be confident that you can effect positive change. Show initiative, be resourceful – the obstacle is the way. Located near some of the most beautiful beaches in Florida and all the outdoor recreation you could want!
VETERINARY TECHNICIANS WANTED – GAINESVILLE AND OCALA, FL: The UF Veterinary Hospitals are hiring for our small
and large animal hospitals in Gainesville and Ocala. Unbelievable benefits, opportunities for advancement, and the best co-workers you'll ever know. Visit tinyurl.com//UFjobs to see our current openings. (2/21; ID #9162)
RELIEF VETERINARIAN: "Got to get away? "VetRxRelief , 37 years
experience small animal Veterinarian. Please call (321) 508-3879 or Vetgator@gmail.com. (2/21; ID #2187)
VETERINARY RELIEF SERVICES AVAILABLE – NAPLES, FL:
Veterinary relief services available for the Naples area. 20 year’s experience with extensive training and experience in veterinary dentistry. Contact: Dr. Altman at firstname.lastname@example.org (2/21; ID #36551)
Our Doctors enjoy:
PRACTICE FOR SALE/LEASE
• Competitive Salary
PRACTICE FOR SALE – FT. MYERS, FL: Veterinarian retiring in
SW Florida ( Ft. Myers ), small animal clinic in affluent area. Established over 30 years ago. Grossing over $340,000.00 working only 20 hours a week. Profitable with great potential and low overhead, low stress and great clients. Listed Contact Email: email@example.com (2/21 ID#10682)
• Growth Opportunities Available • Health Benefits • 401K with Match • CE • and more... CHECK US OUT HERE. We can't wait to meet YOU! Apply Here: https://www.click2apply.net/ljQ4MySKPNJouQGwIJM8R PI127908858 (2/21 ID#49734)
PRACTICE FOR SALE – MELBOURNE, FL: Turn Key, fully equipped hospital , Space Coast, close to beach, marina, and shopping. Equipment also for sale separately. Call (321) 508-3879 or VetGator@gmail.com. (2/21; ID#2187)
VETERINARIAN WANTED – SARASOTA, FL: Medical Director/
Clinic near Sarasota, FL seeks Veterinarian for Medical Director. Generous compensation package with vesting equity. Immediate equity and partnership interest with investment. Send CV to: William@Hi-GearBusinessBrokers.com. (2/21 ID#49950)
VETERINARIAN WANTED – ST. PETERSBURG, FL: We are hiring a full-time veterinarian for our low-cost, full-service clinic. We have digital x-ray and digital dental x-ray equipment. Each client room has it’s own computer so you may look at client records and show client’s x-rays. We have one full-time vet and two part-time vets. We would like to add an additional vet so that we may increase the number of patients seen and surgeries performed.
EQUIPMENT FOR SALE/LEASE
X-RAY SYSTEMS FOR SALE - FLORIDA:
DIGITAL AND STANDARD X-RAY SYSTEMS, FLORIDA X-RAY SALES, FOR MORE INFORMATION, PLEASE CONTACT FRANK BYKOWSKI AT (941) 637-0614.(2/21 ID#26934)
You must be licensed in the state of Florida. Must have or be able to obtain DEA license. Our address is 1900 34th St S, St Petersburg FL 33711. Our hours are 8-5, Monday thru Friday. We are open ½ day on Saturdays, but you will not be expected to work Saturday unless filling in for our Saturday vet for vacation. New graduates are welcome to apply. We have PTO, paid CE, paid health insurance, and we pay for your license renewal. For more information, please contact Scott Daly at (727) 385-8025 or by email at firstname.lastname@example.org.(2/21 ID#50474)
VETERINARY TECHNICIANS WANTED
VETERINARY TECHNICIAN WANTED – OCALA, FL: Looking
for a certified and/or experienced veterinary technician for a busy, fast-paced small animal general practice in Ocala, FL. Great benefits. Please email resume to email@example.com. (2/21; ID #37347)
VETERINARY TECHNICIANS WANTED – FT. LAUDERDALE, FL: Animal Cancer Care Clinic, Florida’s Leading Oncology Practice,
with eight locations, is looking for certified and/or experienced veterinary technicians to join our clinic and contribute to our culture, our team and the Optimal OUTCOMES of our Clients and Animal Patients. Our practice concept is unique and is devoted to caring for all aspects of the cancer patient and their families. Compensation is based on experience and we offer a comprehensive benefits package and opportunities for advancement. For more information please email firstname.lastname@example.org. (2/21; ID #639)
@THEFVMA | 29
PET LOSS SUPPORT YOUR CUSTOMERS DESERVE
FLORIDA’S LEADING ONCOLOGY PRACTICE HOPE, CARE, AND OPTIMAL OUTCOMES
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OUR LOCATIONS: Wellington Orlando Melbourne Stuart West Palm Beach Deerfield Beach Fort Lauderdale South Miami
954.527.3111 www.animalcancercareclinic.com 30 | FVMA ADVOCATE
Your clients depend on you to help guide them throughout their pet’s lives – as well as at the end of it. As a Paws & Remember provider, you benefit from our specialized staff training, quality education material, dignified cremation services, and memorial items that are tailored to the needs of the pet owner and their pet. These resources will help your clients cope with their loss and remember their beloved companions in a way that is meaningful to them. Contact us for more information about how we can help you create a more personal memory for your clients.
171 Hood Ave. #4 | Tavernier, FL | 305-699-9576
Practices for Sale UNDER CONTRACT NEGOTIATIONS - FL, Central: SA Solo Dr Prx. 20 mi NW Orlando. >$1.1M+ gross & growing. Well-equipped. 2 buildings at 7,534SF on 6.32 acres. Prx & RE (FL12A) AAHA Listing - NC, Piedmont/Triad/Growing Area: SA Solo Dr. Prx., Approx 3000SF spacious facility. Well Equipped. PRX & RE $625K. Personal income to new owner $165K+! (NC15B) NC, Northeast, near VA: $1.1M+ gross, 2 dr., SA w/ LA capability. Immaculate, well-equipped facility. Ample room for growth. Established staff. Owner willing to stay 1 year. (NC66G) GA, South Atlanta: Solo SA Prx w/ RE, Approx. 2,217SF spacious facility. Open 4.5 days a week + 1/2 day Saturday. Well Equipped. Gross $680K+. Prx & RE. (GA48C) GA, South Central: Grossing >$1.1M+ & growing, 2 Dr practice. Attractive facility kept in immaculate condition with 5 acres and modern equipment. Well-established staff. (GA14F) GA, Savannah-Coastal: AAHA Listing – SA solo Dr. Prx. w/RE incl 2 acres, Approx 6,184SF spacious facility. 30 years same location, no emergency, 5 days/wk. Updated Equipment. Gross $657K. (GA20S) SOLD - FL, Clearwater: SA Solo Dr Prx., well equipped, and growing. PRX + RE (FL007A)
Practices for Sale North Central FL – 1+ Dr. 2020 gross ~$800k, free standing clinic w/ 2 exam rooms, in-house lb, digital x-ray, great staff. Primary vet in this practice is willing to stay on. Eastern Panhandle – 1 DR. w/ 2020 gross of $690K, 3200 sq. ft. clinic, 2 exam rooms, in-house lab, digital x-ray. Great small town atmosphere, only an hour from the Gulf beaches. Equine Practice – Brevard Co.- Rare opportunity to buy a turnkey Equine practice on the central east coast. 1 to 1.5 Dr. 2020 gross $678K. Barn, stalls, treatment area, paddocks, office. Motivated owner...any offer will be considered. New-S.E. Florida-Solo Dr. Prx with huge growth in 2020... $657K..Lease space in high growth area west of the Turnpike. 2 exam rooms, digital x-ray, in-house lab, great clientele. Owner is ready to retire. New-Treasure Coast- Solo Dr. grossing $332K with just 20-24 hrs./week. Nice lease space, 2 exam rooms, digital x-ray, treatment laser & more. Close to the beach with affluent clientele. New-Coastal Panhandle- Solo Dr. grossing $1.1M, 2200 sq. ft., 2 exam rooms, tenured staff, after debt income ~$190K. Just minutes to the beach.
1610 Frederica Road, Saint Simons Island, GA 31522 Toll Free: (800) 333-1984 | www.simmonsinc.com Email: email@example.com Licensed in Florida, Georgia, North Carolina, South Carolina and South Carolina Real Estate Broker
Veterinary Practice Sales, Acquisitions & Valuations
When Selling or Buying a Veterinary Practice... Call on
LEON COUNTY: Long-established practice! $750K gross and $127K after-debt income. Real estate included. Seller financing available! Reasonable growth potential. (FL97) BROWARD COUNTY: Profitable practice! Over $1.2M gross and $235K after-debt income. Leased facility. Heavy traffic area. Excellent growth! (FL100) BREVARD COUNTY: Double-digit growth! Over $1.5M gross and $239K after-debt income. Real estate Included. Great location! (FL104) MIAMI-DADE COUNTY: Prime location! Leased facility + mobile unit. Option to buy real estate available. (FL105) NAPLES: Great location! Asking Price is $125K. Urgent sale! All offers welcome! Leased facility. (FL106) PALM BEACH COUNTY: Prime location on ocean with dock! $618K gross and $120K after-debt income. Real estate included. Huge growth potential! (FL107) psbroker.com | 800.636.4740 | firstname.lastname@example.org
Practice Sales Buyer Representation Associate Buy-Ins Exit Strategies Appraisals Richard Alker, DVM Florida Representative
e-mail: Richard@TPSGSales.com www.TotalPracticeSolutionsGroup.com
The only Veterinary Practice Broker
Solely Focused on Florida! Showcase Properties of Central Florida Inc.
Florida Veterinary Medical Association 7207 Monetary Drive Orlando, FL 32809
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YOU’LL NEVER BE THE LEAD DOG WORKING FOR SOMEONE ELSE. Being an owner will help you retire debt faster while creating the practice of your dreams. You can establish the quality of care and service, choose your schedule, and achieve significant financial success.
Is it time for you to break from the pack? Since 1977, the experts at Simmons have helped veterinarians buy their own practice – even those burdened with student debt. Trust Simmons to guide you through the buying process.
Call us today at 800.333.1984 for a complimentary and confidential conversation.
simmonsinc.com It’s your future - Own it.