Stevie was diagnosed with diabetes almost five months ago. He lives with Ms. W and her elderly daughter (who has health problems of her own), and they are treating him with daily insulin injections.

When Ms. W’s daughter was admitted into a hospital for several days, she instructed her mother to board Stevie at our clinic until she was able to return home and help care for their pet. When Ms. W dropped off Stevie, she told us he was not eating and felt he was having a hard time getting around. Over the next 24 hours, we administered his insulin and arthritis medication and fed him. He ate without hesitation, ran around the clinic and seemed to sleep comfortably with normal eliminations.

The next day, Ms. W was confused about why Stevie was at our clinic and came to pick him up. I informed her specifically when he had his insulin and when to give it again that evening. Within one hour of her leaving, she called back to ask if he had been given his insulin. When she called an hour later with the same question, we asked her to bring Stevie back and offered to board him at no cost until her daughter returned.

These incidents have brought up many concerns that I foresee we will need to address in the near future:

• When and how do I step in and express the concern that Ms. W may not be able to take care of Stevie the way he needs, especially if she is left alone with him?
• How do I discuss my apprehension with her family about allowing her to drive; should social services be contacted at some point?
• I know that the human-pet bond provides many real and measurable health benefits for people and would not want to limit her from this, but at the same time I have a responsibility to my patient. There is always the fear that she may forget to give insulin or give too much/too often, she may forget to feed him or give him an overdose of the arthritis medication.
• Is part of the reason we are having difficulty regulating the diabetes due to the effects of the Alzheimer’s and her ability to care for him?
• Is she legally able to make any medical decisions for her pet anymore?
• What if her family refuses to help care for Stevie?

More and more of us have family or friends who have been touched by Alzheimer’s and other health problems that cause very real concerns in terms of these pet owners’ ability to care for themselves and their pets properly. You want what is best for your patient, but do you tackle the invisible legal/ethical/moral boundaries to address those uncertainties and, if so, when and how?

The only answer I have is that every situation is unique, requiring the utmost compassion, communication and documentation.

For more information on Alzheimer’s:  http://www.alz.org/

Could some of these data be correlated with the rise in popularity of certain breeds (doesn’t everyone just have to have a Yorkie these days)? Are there more parasites nowadays because of increased population density or because of the climate? Are our pets getting heavier because of all the unhealthy cheap pet food out there? Are our clients less educated? Is the economy affecting the quality of medical care? Whatever the reasons, Dr. Klausner makes the point that there is a recent decline in the frequency and number of veterinary visits. And this is coming at a time when pet ownership is on the rise and pets are more popular than ever.

Is any of this within our control? What can we do, as veterinarians, to combat these dangerous trends? Perhaps these data suggest that doctors are becoming more vigilant in recognizing certain diseases. If this is the case, it’s the clinicians on the “front lines” in our hospitals who are blessed with the know-how and the strategy to fight the battle every day.

Take diabetes for example. Dr. Miguel Navarro, at Banfield Pet Hospital #1396 in San Antonio, Texas, regularly asks his clients about their dog’s treats. “I think there may be a correlation between increased dog treats on the market and diabetes mellitus,” say Dr. Navarro. “Treats make clients susceptible to overfeeding.” Knowing what treats a client gives their pet, how much, and how often, can spell the difference between illness and wellness. Even having a list of favorite “go to” healthy treats for clients can help them manage their pets’ intake.

Dr. Yvonne Woltz, Chief-of-Staff at the same hospital, has diagnosed an unusually high number of diabetic dogs lately. She explained that of the five patients she has diagnosed in the last few months, two of their owners came to her for help at the first sign of increased thirst, and two others were diagnosed with routine pre-anesthetic bloodwork – before they had begun to show clinical signs. Because of the trust that Dr. Woltz’s clients have in her, and because of the convenience and affordability of the Basic Plus Optimum Wellness Plan, she was able to preserve the quality of life of four out of five of these patients. And that is a much more positive statistic!

Every doctor has a story like this and a strategy to share. What is your story? What is your strategy?

As veterinarians we need to take the time to educate our clients on a few facts:

1. Currently there is no risk of radiation toxicity to pets in the United States
2. Potassium Iodide has side effects, and
3. Potassium Iodide exists in limited quantities and perhaps it should be provided to humans before it is provided to pets. 

We can also empathize with the pet owners—as we are all pet owners as well.  If we’re feeling helpless, there are things we can do to help the Japanese people by sending aid. There are also things we can do to help our pets by making sure we do everything we can to keep them healthy by keeping all of their preventive care up to date.

Assessing the Current Risk

Currently, the radioactive fallout heading towards the west coast is not supposed to cause any medical issues for people or for their pets.  According to the article on VIN, the U.S. Food and Drug Administration says that there is currently no medical reason for people in the United States to be taking potassium iodide because of the ongoing situation in Japan.  The current levels of radiation are just not high enough to cause a risk within the United States.  Currently, no risk to humans should mean no risk to pets.

Proper use of Potassium Iodide for Pets

Potassium iodide (abbreviated KI) is used to treat certain medical conditions in animals (primarily actinobacillosis and actinomycosis in ruminants and sporotrichosis in horses, dogs, and cats).  Plumb’s Veterinary Drug Handbook does not provide any information about using it to treat radiation exposure in pets.  In the article, VIN interviewed Donald Plumb, the author of the reference book, who said that he felt the risk is low enough that pets do not need to be taking the medication and if the levels were high enough, the medication is in short supply and would be needed for people first.

Further, studies using KI for radiation exposure have been done in humans and not in animals.  Also, in humans, the medication does not protect against radiation exposure “in general,” it only protects against radiation-induced thyroid cancer.  No one knows what reasonable doses for treatment of pets would be anyway.  Using the wrong dose could result in toxic levels of the medication.  KI is not a benign medication.  According to the article, side effects include: “excessive tearing, vomiting, anorexia, nasal discharge, muscle twitching, cardiomyopathy” and others.

So, it seems that there is currently no risk to pets in the United States, so as care givers, we need to resist the urge to give in to the pet owner’s demands and try to get them medication that they do not need and medication that might actually be harmful.  We also need to consider whether or not a medication that exists in limited quantities should be given to pets or if it should be saved for human use in case the tragedy does worsen.

If you’re a veterinarian who has had to deal with this issue with your own clients, please post a comment so that you can share how you dealt with the situation.  This is obviously an evolving situation so we all need to stay up to date on the current risk level and any new information that becomes available.

There is nothing quite like the jolt I feel when my CSC (receptionist) comes back to tell me that an emergency is on its way in, and that is especially true with rattlesnake bites being that they are so variable.  There are so many factors – known ones such as the size of the dog and location of the bite; possibly known ones such as the type of snake and time elapsed since the bite; and the unknown factors such as the amount of envenomation and the make-up of the venom. (Fortunately we only have one venomous snake in the Folsom area, but sometimes there is confusion with non-venomous bites).

One of the most important things we can do for our patients is educating their owners on the dangers of snake bites and what to do and even more importantly, what NOT to do.  First off, the timeliness of treatment is critical so it is crucial for the client to get to a hospital as soon as possible, and preferably one that has antivenin available if it ends up being needed.  Other than keeping the patient as quiet and calm as possible and (if applicable) keeping the bite site lower than heart level, they should not provide any first-aid.  They should not apply hot or cold compresses and absolutely not make any cuts, try to suck out the venom or place a tourniquet.

Antivenin is the only treatment that will slow, halt or reverse the effects of the venom.  Other than that we can provide supportive care to reduce the risk of shock with IV fluids and limit pain and the chance of infection.

In addition to educating clients about what happens AFTER a snake bite, we should be doing what we can to prevent things from getting to that point.  As the old adage goes, “An ounce of prevention”… yada yada yada.  There are more and more companies offering snake avoidance training.  We have hosted a “Rattlesnake Avoidance Training” day the past two years and our clients have greatly appreciated it and we’ve had more than a couple account of how their dogs responded (appropriately) even possibly preventing their “parents” from getting bitten. 

Well, I’m not quite sure what to expect for the rest of this season, but I do know that anytime we get a rattlesnake bite victim, I won’t need a Starbucks fix!

1. Introduce yourself with confidence with a warm, friendly smile and always use soft, calm speech.  If you approach a client with overpowering, firm speech then they will tend to back off and not trust you. Trust is the key to keeping a client’s nerves at ease.
2. Talk to your nervous client like you would talk to a good friend. Make them feel at ease and allow them to approach you with what is really making them nervous. If they don’t tell you, then ask them directly what is making them most concerned about the situation. I would stay away from mentioning “being nervous” because nobody really wants to be called nervous, use the words concerned or worried.
3. Address the issue that concerns them most first. A nervous client wants to know or wants an answer right away. If this isn’t possible then explain why it is not, and what you will do to find that answer as quickly as possible.
4. Assure them that their Pet is in good hands.  It’s amazing what these words will do.
5. Assure them that they aren’t the only one to go through this. Tell them it’s ok to be concerned, for this is a sign of a good Pet parent. I sometimes tell them a story about myself going through a similar situation and how I felt.
6. Make sure that you keep them super- informed of what is going on with their Pet.  A couple of hours can feel like 24 to a nervous client.
7. Nervous clients can quickly escalate to irate clients if they aren’t getting the outcome that they expected. Always explain all possible outcomes before they occur to avoid this.  Don’t sugar coat things just because the client is nervous – be honest and direct with the client’s concerns.  The worst possible scenario CAN happen.
8. And most importantly – do NOT get nervous yourself – this will make clients even more uneasy. I would be wide-eyed nervous if I had a fidgety, squirrely doctor talking to me about my precious little Pet.

Over the next few months, the BARK team will focus on the on the topic of Pet overweight and obesity.  They will be conducting additional research on this health topic by evaluating trends and identifying risk factors associated with Pet obesity.  Their aim is to use the findings to better equip doctors with concise, succinct reports that enhance risk communication with their clients.  Since the goal of evidence-based medicine is to enhance clinical expertise in concert with consideration of patient needs and client circumstances, the BARK team will develop evidence-based tools to provide to Banfield hospital associates. For instance, client talking points will be written to incorporate evidence that PetNurses can use to educate clients on the dangers of having an overweight Pet. To integrate with the rest of the veterinary community, this research initiative will also include publishing a Critically Appraised Topic (CAT) report, an exhaustive literature review (quarterly white paper) and results from these studies will appear in future blog postings on this site.

As a veterinarian, how are you addressing this epidemic in your clinic and how do you think we can address the under-diagnosis of overweight and obesity?  What questions do you have and want to see answered regarding this health topic?  How do you educate clients on the prevention of overweight/obesity in their Pets?  Post your inquiries here and we may pick yours to answer by leveraging our nationwide medical e-record database.

If you’d like to subscribe to the Banfield Applied Research and Knowledge (BARK) quarterly white paper, email us at bark@banfield.net and include SUBSCRIBE in the subject line.

1. Burkholder, W.J. and P.W. Toll, Obesity, in Small Animal Clinical Nutrition,4th edition, M.S. Hand, C.D. Thatcher, R.L. Reimillard, P. Roudebush, M.L. Morris, and B.J. Novotny, Editors. 2000, Mark Morris Institute: Topeka, KS. p. 401–430.
2. Hill, R.C., Conference on “Multidisciplinary approaches to nutritional problems”. Symposium on “Nutrition and health”. Nutritional therapies to improve health: lessons from companion animals. Proceedings of the Nutrition Society, 2009. 68(1): p. 98-102.
3. McGreevy, P.D., et al., Prevalence of obesity in dogs examined by Australian veterinary practices and the risk factors involved. Veterinary Record, 2005. 156(22): p. 695-702.
4. Lund, E., et al., Prevalence and risk factors for obesity in adult dogs from private US veterinary practices. International Journal of Applied Research in Veterinary Medicine, 2006. 4(2): p. 177-186.
5. Lund, E., et al., Prevalence and risk factors for obesity in adult cats from private US veterinary practices. International Journal of Applied Research in Veterinary Medicine, 2005. 3(2): p. 88-96.
6. German, A.J., The growing problem of obesity in dogs and cats. Journal of Nutrition, 2006. 136(7 Suppl): p. 1940S-1946S.

No other Iams foods are affected, and this recall is limited to Iams canned cat food in North America. The Procter & Gamble Company is recalling these specific lots because the product may contain insufficient levels of thiamine (Vitamin B1), an essential nutrient for cats.   Thiamine deficiency in cats can manifest with clinical symptoms including loss of appetite, salivation, generalized weakness, vomiting, weight loss, ventroflexion of the neck, ataxia, tremors, falling, circling and seizures. 

Diagnosis is made by history, physical examination, and response to thiamine supplementation.  Thiamine concentrations can be measured in whole blood (the sample must be frozen and protected from light during collection, storage, and shipment), or in food.   

Treatment requires thiamine, given either by injection or by mouth.  Recommended doses are 100 to 250 mg SC q 12 hrs or 2-4 mg/kg PO q 24 hrs.  Note that injections may sting, and rapid intravenous administration has been associated with anaphylaxis.     

Concerned pet owners who have purchased Iams ProActive Health canned cat and kitten foods with these codes should discard the product – please make sure the contents of the can are destroyed in such a way that no other pets can inadvertently eat the food. For further information veterinarians should call P&G at 800-535-8387.  Clients/Pet owners can call P&G at 877-340-8826.

We found that the prevalence of tapeworms in cats is greater than the prevalence of fleas. This seems counterintuitive since tapeworms are transmitted when cats ingest fleas. This probably means two things – first, that cats probably remove most of their visible flea burden when they’re grooming (which makes it more difficult to diagnose flea infestation) and second, that flea control in cats is probably lower on most people’s list of priorities than ideal.

This is potentially important, as tapeworms are zoonotic. It’s no cause for alarm, as the prevalence of all the internal parasites (tapeworms, hookworms, whipworms and roundworms) is low, but it reinforces the point that year round flea, tick and worm prevention is extremely important.  It also should remind us of our responsibility as health professionals to discuss zoonotic diseases and how prevention can eliminate disease transmission with our clients.

Have you found the same thing out in practice and how do you approach the subject of regular parasite control? We’d love to get your feedback.

If you’d like to subscribe to the Banfield Applied Research and Knowledge (BARK) quarterly white paper, email us at bark@banfield.net and include SUBSCRIBE in the subject line.

People and their Pets share close living (and sleeping!) spaces. The recent 2009 H1N1 flu outbreak with reports of the virus found in people, dogs and cats demonstrates this closeness. Did you know that over three quarters of the emerging infectious diseases are zoonotic? ⁽¹⁾ However, as a recent survey revealed, most veterinarians in the United States aren’t encouraging client practices that could help to reduce zoonotic disease transmission. ⁽¹⁾ The survey also revealed that veterinarians consider it important to educate clients on zoonotic disease prevention, but only a small percentage initiate the discussion. The Centers for Disease Control and Prevention (CDC) provide on their “Healthy Pets Healthy People” website talking points, called Pet-Scriptions, to help veterinarians communicate strategies for zoonotic disease prevention with clients. Understanding whether there are young children or immunocompromised individuals in the family help veterinarians integrate zoonotic disease risk into their medical decision-making and client recommendations. In your own hospital setting, you can encourage frequent hand-washing and wearing gloves to handle feces and other biologic samples.

To help formalize the concepts into practice, the American Veterinary Medical Association launched the One Health initiative, which strives for an “establishment of closer professional interactions, collaborations, and educational opportunities across the health sciences professions, together with their related disciplines, to improve the health of people, animals, and our environment.” The most effective strategies for infectious disease prevention integrate the systems of medicine, veterinary medicine, and public health.

Veterinarians are essential partners in making One Health a reality. Did you know that it was a veterinary pathologist who linked a mysterious disease outbreak between humans and animals, which was later discovered to be West Nile virus ⁽²⁾! We want our clients and their pets to have long, happy lives together. When we talk about zoonotic disease, we are demonstrating our responsibility as health professionals and building trust with our clients. Sharing this information can strengthen both the client-veterinarian bond and the Pet-family bond!

What are the challenges for veterinarians in taking a bigger role in One Health? What are the opportunities? Please let us know what you think.

Further Reading:

• Childs, J.E. & Gordon, E.R. (2009). Surveillance and control of zoonotic agents prior to disease detection in humans. Mount Sinai Journal of Medicine, 76, 421-428.
• Kuehn, B.M. (2010). Human, animal, ecosystems health all key to curbing emerging infectious diseases. Journal of American Medical Association, 303(2), 117-124.

References:

1. Chomel, B.B. & Marano, N. (2009). Essential veterinary education in emerging infections, modes of introduction of exotic animals, zoonotic diseases, bioterrorism, implications for human and animal health and disease manifestation. Scientific and Technical Review, 28(2), 559-565.
2. Kahn, L.H. (2006). Confronting zoonoses, linking human and veterinary medicine. Emerging Infectious Diseases, 12(4), 556-561.

Feel free to copy the tips below and distribute to clients:

Contented Confinement: I suggest that every dog should be trained to accept confinement in a portable kennel as early in life as possible. (Prepare her now for boarding or hospitalization later.) For “gone to work” confinement, the ideal setup is a portable kennel connected to, or inside an indoor “exercise pen” with newspaper or fake grass as a toilet. This setup is safe for 8-10 hours at a time and limits the puppy’s access to everything it might do wrong. The best way to introduce the closed kennel is to pair every entry into the kennel with a toy containing a fresh dab of peanut butter. If the puppy cries later, first do a “Needs Analysis” and if elimination, exercise and other needs have been met, it will be necessary to let the pup learn that tantrums don’t work.

Chew Training: A few chew toys inside the kennel during confinement teach the puppy that these are his items to chew. Other times the owner should actively put these chew toys in the puppy’s mouth and praise any chewing. Start with very easily chewed toys such as Greenies and work up to compressed rawhide that has one end soaked in water to soften it up. Booby trap unacceptable targets with mouth wash or underarm anti-perspirant.

Reward Based Elimination Training: Punishing house soiling teaches, “Don’t eliminate when he’s watching!” This approach makes proper training more difficult because the goal is to BE THERE outside to praise correct elimination. When home, begin with confinement in a closed kennel which inhibits elimination. Take the pup out every few hours when awake, and no food or water inside the kennel overnight. If the puppy does not eliminate, just put her back into the kennel and try later. She will learn the way to get freedom, play and other rewards is to eliminate in the right place. Make her urine or feces so valuable she won’t want to waste it indoors. When she routinely asks to go out, she has earned her indoor freedom.

Leash Training: After successful elimination, suggest the owner take the puppy for a walk as reward. This habit of rewarding elimination on the owner’s property reduces the future need to bring baggies on walks. If an outdoor walk isn’t possible, suggest an “indoor walk” i.e. hold the leash INSIDE the house during post elimination play periods. This is a positive leash association, and makes it easy to catch the pup if mouthing something inappropriate, or if about to eliminate again. In the evenings, use the leash to tether the pup next to people to bond, and to prevent sneaking away to trouble.

Following these simple steps will go a long way in making the “Holiday Puppy” a permanent member of the family.