Oh, No! Heartworm Preventatives Aren't Perfect Anymore

Year Round Heartworm Prevention is Important                  by Dr. Michael Fagan

For twenty-plus years, we've enjoyed the privilege of telling our clients that our heartworm preventative medications were 100% effective in preventing heartworm disease if given monthly throughout the entire mosquito season.  Now we have to settle for telling you that they are Very Effective. 

Very Effective is still a good thing, but some aspects of our overall prevention strategy have become even more important.  Over the past several years, there have emerged a few strains of heartworms that are resistant to the entire class of drugs used as heartworm preventatives (known as macrocyclic lactones, or ML).  So far, it appears that none of the available products (Heartgard, Iverhart, Revolution, Interceptor, Advantage Multi), are superior to any other:  while every product is still very effective, each has been documented to be less than 100%. 

What this means for our patients:

• It is very important to give monthly heartworm preventive year-round.
• Annual heartworm testing is essential to identify any dog that have acquired a resistant heartworm infection. 

One of our patients, a year
after heartworm treatment

Dogs that do become infected with ML-resistant heartworms tend to be infected with lower numbers of worms than dogs that are not on preventatives at all.  They still need to be treated with injections of melarsomine to eliminate the adult heartworms for their own health, but also to eliminate the source of resistant worms that could be transmitted to other dogs.

Treating dogs that are infected is expensive and painful. The drug (melarsomine) is currently only available on a case-by-case basis from European production facilities. Melarsomine is injected deep into the muscle along the spine and it hurts! Dogs must be kept quiet for two months during treatment which means no running or playing. We are currently treating a really sweet black lab who moved here from the Southern U.S. where resistant heartworms have been identified.

 

Should a Pet With Cancer Get Chemotherapy?

by Michael Fagan, DVM

“Cancer” is a word that can induce fear and other emotions.  Many people have personal experiences with cancer and chemotherapy that they don’t wish to impose on their pets.  To be sure, cancer and the many treatment options we can offer are not to be taken lightly.  However, we do have many patients that have received treatments for cancer with favorable outcomes, from cures or long term remission to improved quality of life for many months to years.

The most important factor in determining treatment options and recommendations is what type of cancer the pet has developed.  “Cancer” is a very broad term, with many different types and variable response to different kinds of treatment.  Each patient with cancer is unique.  We offer options based on the type of cancer, symptoms or lack thereof, the pet’s overall health, and owner preferences.  Some cancers are best treated by surgical removal.  Others respond best with radiation, chemotherapy, or immunotherapy.  Some have a poor prognosis regardless of treatment, and control of pain or other symptoms takes priority before opting for euthanasia. We will often consult with a veterinary oncologist as we explore the options available.

The goals of treatment are also unique to each patient, but as a general rule, we aim for a cure only if we can preserve good quality of life throughout the process.  More often, we are trying for a long term remission or control of tumor growth for many months to a few years.  The most common treatment for cancers that are not curable with surgery is chemotherapy of one form or another.

Herein lies a vital difference between veterinary and human medicine:  in human medicine, the treatment goal is often to eliminate the cancer and then recover the patient; in veterinary medicine, we want to preserve good quality of life while limiting the cancer.  In other words, we use drugs, doses, and treatment schedules that minimize side effects while still providing the benefit of remission or delayed growth of the cancer cells. 

With chemotherapy, we have had lymphoma patients live longer than two years; bladder cancer patients, one to two years; dogs with nasal tumors, over a year; most with minimal side effects from the chemotherapy and reduction or elimination of symptoms caused by their cancer.  Unfortunately, not all patients respond, and not all tolerate the chemotherapy equally.  Each patient needs to have its treatment protocol customized. 

One relatively new approach to chemotherapy is using small daily doses instead of higher intermittent doses.  This tends to reduce toxicity and has a different effect on tumor growth.  Rather than actively killing tumor cells directly, low-dose daily therapy (called metronomic therapy) may work by reducing the blood supply to the tumor and by allowing the immune system to respond more aggressively. 

The bottom line is that we have many options for treating the many kinds of cancer that we diagnose in pets, including surgery, radiation (by referral to a veterinary oncologist), traditional or metronomic chemotherapy, immunotherapy (there is a vaccine for melanoma!), and/or palliative care (control of pain and other symptoms caused by the cancer). In animals we also have the option of euthanasia when appropriate but that is a subject for another blog. 

"Is Your Veterinarian Being Honest With You?"

Dr. John Hallett

Sometimes, my dad would lecture me and my brother about something my brother did wrong, and I would interrupt to say, "But dad, I didn't do it." Dad didn't like interruptions, especially when he was on a roll sharing his life lessons with his captive audience. Dad would scowl at me and say, "Son, if the shoe fits, wear it!" I was insulted that I had to sit through a lecture when my brother was the one who left the dirty dishes in the sink or tracked mud in the house. Dad was trying to say, "if this doesn't apply to you, then just listen anyway."

Last week, there was a 20/20 episode on ABC asking "Is Your Veterinarian Being Honest With You?" Many veterinarians are insulted by the episode and are angry that our profession is being accused of cheating pet owners.  I, however, have decided to take my dad's advice because "the shoe doesn't fit."

I realize that a small number of veterinarians do things that are dishonest or unethical or just outdated. I agree with 20/20 that pet owners should be educated and involved in their pet's care, and they should ask questions.  The veterinary community is not highly regulated, and there is wide variation in the level of care offered in different facilities. 

Let's look at some of the points made in the 20/20 piece.

Recommending services to boost the clinic's income:

I believe that a veterinarian can and should make a profit by practicing good medicine, educating pet owners, involving owners in the decision making process, and by charging appropriately for what is done. Veterinarians do not have to resort to selling unnecessary vaccines or procedures just to make money.  Not every client is going to follow every recommendation, but when they leave my office, they will be educated and involved.

Two areas cited by 20/20 are dentistry and lumps:

Dentistry:

I do my best to do a complete oral exam on awake dogs and cats. It is hard. They move, they lick me, some try to bite, and none will tell me that a particular tooth aches. I try to predict when a pet needs a dental cleaning under anesthesia based on what I see in the exam room. The problem is that I often miss problems that only become apparent once the pet is anesthetized because that allows me to probe the gum line and look closely at all the teeth. We are constantly reminded that 60% of the tooth is hidden below the gum line and only becomes visible when dental radiographs (X-rays) are done. Dental radiographs can't be done without general anesthesia in pets. We also have to balance the cost of labwork, monitoring, and safe anesthesia with the need for dental work. I wouldn't cut corners to save a few dollars with my own pet, and I won't with my patients either.  I do my best to recommend dental cleaning and evaluation under anesthesia before teeth need to be extracted, but I can't always do that based on my oral exam in an awake patient. I rarely recommend annual dental cleaning and never based on age alone, but if I see gingivitis, a crevice between calculus buildup and the gum, a gingival mass, or if I smell bad breath, then I will recommend a procedure. For more information on veterinary dentistry, watch this 3 minute video from our practice.

It is interesting to note that one of the dogs that 20/20 argued did not need dental cleaning did have an oral mass clearly visible next to the upper left premolar. That mass should be removed under general anesthesia and submitted for biopsy. Hopefully, it is benign, but some oral masses can destroy bone in the jaw (or worse).

That brings me to lumps and tumors: 

My oncology professor taught us that you can't tell what a mass is just by feeling it. Masses on the skin and under the skin are easily assessed with a fine needle aspirate using the same size needle we use for vaccines.  If I see fat cells under the microscope, then it is most likely a benign lipoma. Without the needle aspirate, I'm just guessing. Anybody can guess. People pay me for my educated opinion and expect me to make recommendations based on my 23 years of practice experience and the most current information available in the veterinary literature. They pay me to look in the microscope, not to guess.

If an owner tells me that a mass has been there for years and hasn't grown or changed, then I am less likely to suggest an aspirate. I educate the owner, tell them the cost, and let them decide. If the owner chooses to wait and monitor the mass, then that is their educated decision, and I tell them to return if the mass grows rapidly, bleeds, or becomes painful. Sometimes, I see things in the microscope that are clearly cancer or are worrisome, and I recommend removing the mass and sending the tissue in to a pathologist for review. Of course, we discuss cost, risks, and potential benefits with the owners.

I love helping animals, but I do not work for free. I do have staff to pay, expensive equipment, overhead, and personal bills, but those bills do not drive my decisions. Providing excellent care for my patients is always my goal.  I treat all my patients the same way I treat my own pets. Yes, keeping pets healthy can be expensive, but consider that veterinary care is far less expensive than human medical care, even with the Affordable Care Act on the way. I believe the majority of veterinarians are honest, but there are unethical or lazy people in all professions including veterinary medicine.

My advice to pet owners: 

• Ask your veterinarian questions
• Discuss options and potential outcomes
• Ask for articles from reputable sources if you want to learn more
• Get a second opinion from a board certified specialist if needed
• Ask your veterinarian what continuing education they attend or how they stay current

My advice to veterinarians: 

• If the shoe fits, wear it! Otherwise, stop complaining about a TV show and use it to educate your clients.

If you would like to watch the 20/20 episode, click here.

Grain-Free Diets for Dogs???

News flash!  Dogs are descendants of the Grey Wolf.

by Dr. John Hallett

photo by Thomas Calvy

Everyone knows that dogs and wolves are related but recent research shows that a dog's dietary needs are very different from wolves. A few months ago I heard a fascinating story on NPR about this research and how it applies to my canine patients. 

Apparently dogs have genes that allow them to digest carbohydrates, wolves don't have those genes so they eat almost exclusively meat. It seems that this was important in the domestication process because the dogs that survived best around people were those that could digest carbs in human food scraps.

I get daily questions from dog owners about what to feed their dogs. Many of them proudly tell me that they feed "grain-free" dog food. They read on the internet that this was important because wolves don't eat grain and dogs are like wolves. This implies that a lack of grain in the dog's diet will make them healthier so it is worth the extra money to buy the expensive "grain-free" diet.   

So, what do animal nutritionists tell us about dog nutrition? First, dogs are omnivores, meaning that they need a variety including both meat and grains and fiber. Second, corn (one of the most common grains in dog food) rarely causes food allergy or skin problems in dogs. A grain-free diet is not the answer to all your dog's health problems.

What should you feed your dog? Before you pay extra for a grain-free diet, ask your veterinarian for suggestions. Our hospital staff are very knowledgeable on nutrition topics. Kelly Neu, one of our certified veterinary technicians, has a special interest in nutrition and has put together a notebook with nutritional information on many brands of pet food. Dr. Heidi Hallett has also done a tremendous amount of reading on nutrition topics and is available to answer questions. 

The big news today is that dogs are different from wolves. Thank goodness!
Here are links to the NPR story  to the original research article in Nature. 

Cats are an entirely different topic that we will cover later. Cats are obligate carnivores, meaning they must have meat.

So You Want to be a Veterinary Technician?

by Kelly Lemke, CVT

Kelly Lemke, CVT

It took me awhile to figure out what I wanted to "be" when I grew up.  I was never one of those kids who knew what they wanted to do by the time they were 10 years old.  After I graduated from high school, I went to UW-Milwaukee for a few years taking pre-vet classes with the plan of going on to veterinary school.  Then life got in the way.  I got married, bought a house, and realized that I didn't want to be in school for 4-5 more years, or spend a few hundred thousand dollars more on my education.  The only thing I still knew was that I still wanted to work in veterinary medicine.  Becoming a veterinary technician was the perfect option, and looking back, I'm so happy I never made it to veterinary school. 

To become a veterinary technician, a person must graduate from an AVMA accredited school and pass the Veterinary Technician National Exam.  Thirteen years ago when I started school, the only AVMA accredited school in Wisconsin was Madison Area Technical College.  The Veterinary Technician program is two years, plus a summer internship.  I spent hours taking notes in lectures (with an actual pen and notebook), staring into microscopes in clinical pathology labs, prepping and monitoring surgery patients in surgical nursing classes, and learning how to examine, draw blood, and give injections to mice, cows, goats, horses, dogs, and cats.  I carried on average 16 credits a semester, which cost me roughly $2000/semester.  On top of that, I had to buy books, a stethoscope, scrubs, coveralls, and boots to wear in the barn.  These additional supplies were about $500 a semester.  The summer internship was considered “summer school” so I had to pay to do that as well.  I spent 320 hours working here in a small animal hospital and at Jefferson Veterinary Clinic working with large animals.  I was fortunate to be paid minimum wage during my internship, but many of my classmates were not paid at all, which isn’t unusual for an internship.  All told, my education cost me around $11000, plus the money I spent on gas driving to Madison five days a week for two years.  In 2011, the average starting salary for a Certified Veterinary Technician was $20000-$23000, which in the “real world” isn’t a lot of money.  In fact, low salary was the number-one cited reason for veterinary technicians leaving the field in a 2007 survey by the National Association of Veterinary Technicians.

Veterinary Technicians don’t spend as much on their educations as veterinarians do and oftentimes don’t have huge amounts of debt coming out of school.  Yes, we don’t earn a lot of money, but there are other rewards.  If a person is unable to afford veterinary school, becoming a veterinary technician is an affordable option.  If you are trying to decide what you want to “be” when you grow up, give us a call and arrange a day to job-shadow a technician.  We’d be happy to show you what we do!

 

So You Want to be a Vet?

by Dr. Michael Fagan

Michael Fagan, DVM

This post is geared toward high school or college students who might be considering veterinary medicine.  I don’t want to discourage anyone who is certain that they want to become a veterinarian, but I do want to help set up realistic expectations. 

I love my job as a veterinarian.  I get to work with other like-minded people.  I get to play with puppies and kittens.  I very often make patients’ lives better, and every now and then literally save a life.  Biology and medicine are interesting and challenging.  Surgery can be exciting and rewarding.  There’s no other job I would prefer to do. 

But, like any other good thing, there are not-so-good things that tag along.  Sometimes we can’t save a patient’s life, or even make it feel much better.  Euthanasia is always sad, even when it is the best and right option.  People sometimes get angry with us.  Sometimes they cannot afford a treatment we know would help.  Surprisingly, some dogs and cats don’t like us!  Bites are rare but can happen at any time.

Then there are the financial issues facing new or prospective veterinarians.  A recent article in the NY Times revealed the median cost of veterinary school (including living expenses) to be nearly $250,000 in 2011.  This does not include the cost of three to five years of undergraduate study.  Meanwhile, the median salary of new veterinarians that year was only $45,500. 

It is nearly impossible to repay a $250,000 loan on such a salary.  It would require over $2500 a month, on a salary less than $4,000 a month.  And not all graduates are finding jobs lately.  Last year, about one third of veterinary graduates were without an offer for a full time job.

There are some loan forgiveness programs, such as 501(c)3 charitable or military service, or Income Based Repayment or Pay As You Earn programs which keep payments lower but come with a potentially hefty tax burden at the end. 

So!  If science and math and problem solving and communication and a love of living things are your strong suits, by all means consider becoming a veterinarian.  But do so with eyes wide open to the cost of getting there and the challenge of repaying loans after graduation.  It is possible, but requires planning, discipline, commitment and endurance, and sometimes help from families or spouses. 

And finally, if you are still interested, contact us to arrange a day of job-shadowing so you can see what a small animal veterinarian does in real life!

Kelly's Cat "Sixxy"

by Kelly Lemke, CVT

Sixxy

I’ve been a Certified Veterinary Technician for 11 years.  I understand and believe in the importance of annual physical exams for all cats.  I’m also the owner of a big, black cat named Sixxy.    He’s a good cat, he goes in his crate willingly, and is cooperative during his physical exam.  Just like many cat owners, I hate bringing him to the hospital.  It’s stressful for me; listening to him cry all the way to the hospital in the car, holding him for his exam, and watching him get his vaccines.  The visit is also stressful for Sixxy; having his mouth examined, getting on the scale, and, of course, getting his vaccines.  Sixx is lucky (I’m sure he’d argue otherwise) because I still bring him in at least once a year for a doctor to do a physical exam and make sure he is still doing well.  We can catch problems early and begin treatment if something is found.  Many other cats are not so lucky and we see them only when something is very wrong.    Because we know how stressful it is to bring cats to the doctor, we decided to do something about it.  Hallett Veterinary Hospital was recently recognized as a Cat Friendly Practice by the American Association of Feline Practitioners.  We have voluntarily evaluated our practice to meet the standards set by the AAFP to become cat friendly.

So how will this help cats? As a Cat Friendly Practice, we are committed to learning ways to make visits more pleasant for cats and to help owners learn ways they can also contribute.  Our cat only exam room is an environment that is less threatening for cats.  We have a Feliway (pheromone) diffuser plugged in all the time.  The exam room is situated away from the busy area of the hospital.  We even have a windowsill where cats can look outside.  Our staff has been trained on how to interact with and handle cats to make their experience more pleasant and less stressful. 

            As the Cat Advocate for Hallett Veterinary Hospital, I am dedicated to making sure the cat friendly standards are adhered to.  I am happy to answer any questions on what we are doing to remain Cat Friendly and how to make your cat’s visit easier on you and your cat. 

            As for Sixxy, he’ll be here in July for his annual exam and vaccines, hopefully leaving with a clean bill of health and a lot less stress!