Compendium | June 2009 by davidpsu

VOLUME 31 NUMBER 6 JUNE 2009

Compendium CompendiumVet.com | Peer Reviewed | Listed in MEDLINE

3 CE Contact Hours

Vol 31(6) June 2009

CONTI N U I NG EDUCATION FOR VETERI NARIANS ®

FREE

Feline Obesity Clinical Recognition and Management

COMPENDIUM CONTINUING EDUCATION FOR VETERINARIANS® SERIES

A AAFP Retrovirus Guidelines

PAGES 249–296

Understanding Behavior Adding B Addi Behavior h i Services S i

Surgical Views Laparoscopic Cryptorchidectomy

fo te C rS d m # om al 1 lA i pe ni n m O nd al v Ve e ium te ra rin l ar l Q yJ u ou a rn lit al y s! *

Refereed Peer Review

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CaliciVax 1. 2006 American Association of Feline Practitioners Feline Vaccine Advisory Panel Report. JAVMA, Vol. 229, No. 9, Nov. 1, 2006. 2. Data on file, Fort Dodge Animal Health. Comparison among Fort Dodge vaccines. ©2009 Fort Dodge Animal Health, a division of Wyeth.

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June 2009 Vol 31(6) CompendiumVet.com | Peer Reviewed | Listed in MEDLINE

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June 2009 Vol 31(6) CompendiumVet.com | Peer Reviewed | Listed in MEDLINE

EDITORIAL BOARD Anesthesia Nora S. Matthews, DVM, DACVA Texas A&M University

Internal Medicine Dana G. Allen, DVM, MSc, DACVIM Ontario Veterinary College

Cardiology Bruce Keene, DVM, MSc, DACVIM North Carolina State University

Internal Medicine and Emergency/ Critical Care Alison R. Gaynor, DVM, DACVIM (Internal Medicine), DACVECC North Grafton, Massachusetts

Clinical Chemistry, Hematology, and Urinalysis Betsy Welles, DVM, PhD, DACVP Auburn University

EDITOR IN CHIEF Douglass K. Macintire, DVM, MS, DACVIM, DACVECC

Department of Clinical Sciences College of Veterinary Medicine Auburn University, AL 36849

Dentistry Gary B. Beard, DVM, DAVDC Auburn University R. Michael Peak, DVM, DAVDC The Pet Dentist—Tampa Bay Veterinary Dentistry Largo, Florida Emergency/Critical Care and Respiratory Medicine Lesley King, MVB, MRCVS, DACVECC, DACVIM University of Pennsylvania Endocrinology and Metabolic Disorders Marie E. Kerl, DVM, ACVIM, ACVECC University of Missouri-Columbia

EXECUTIVE ADVISORY BOARD MEMBERS Behavior Sharon L. Crowell-Davis, DVM, PhD, DACVB The University of Georgia Dermatology Craig E. Grifﬁn, DVM, DACVD Animal Dermatology Clinic San Diego, California Wayne S. Rosenkrantz, DVM, DACVD Animal Dermatology Clinic Tustin, California Nutrition Kathryn E. Michel, DVM, MS, DACVN University of Pennsylvania Surgery Elizabeth M. Hardie, DVM, PhD, DACVS North Carolina State University

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CompendiumVet.com

Epidemiology Philip H. Kass, DVM, MPVM, MS, PhD, DACVPM University of California, Davis Exotics Avian Thomas N. Tully, Jr, DVM, MS, DABVP (Avian), ECAMS Louisiana State University Reptiles Douglas R. Mader, MS, DVM, DABVP (DC) Marathon Veterinary Hospital Marathon, Florida Small Mammals Karen Rosenthal, DVM, MS, DABVP (Avian) University of Pennsylvania Feline Medicine Michael R. Lappin, DVM, PhD, DACVIM (Internal Medicine) Colorado State University Margie Scherk, DVM, DABVP (Feline Medicine) Cats Only Veterinary Clinic Vancouver, British Columbia Gastroenterology Debra L. Zoran, DVM, MS, PhD, DACVIM (Internal Medicine) Texas A&M University Infectious Disease Derek P. Burney, PhD, DVM Gulf Coast Veterinary Specialists Houston, Texas

Nephrology Catherine E. Langston, DVM, ACVIM Animal Medical Center New York, New York Neurology Curtis W. Dewey, DVM, MS, DACVIM (Neurology), DACVS Cornell University Hospital for Animals Oncology Ann E. Hohenhaus, DVM, DACVIM (Oncology and Internal Medicine) Animal Medical Center New York, New York Gregory K. Ogilvie, DVM, DACVIM (Internal Medicine, Oncology), DECVIM-CA (Oncology) CVS Angel Care Cancer Center and Special Care Foundation for Companion Animals Carlsbad, California Ophthalmology David A. Wilkie, DVM, MS, DACVO The Ohio State University Parasitology Byron L. Blagburn, MS, PhD Auburn University David S. Lindsay, PhD Virginia Polytechnic Institute and State University Pharmacology Katrina L. Mealey, DVM, PhD, DACVIM, DACVCP Washington State University Rehabilitation and Physical Therapy Darryl Millis, MS, DVM, DACVS University of Tennessee Surgery Philipp Mayhew, BVM&S, MRCVS, DACVS Columbia River Veterinary Specialists Vancouver, Washington C. Thomas Nelson, DVM Animal Medical Center Anniston, Alabama Toxicology Tina Wismer, DVM, DABVT, DABT ASPCA National Animal Poison Control Center Urbana, Illinois

AMERICAN BOARD OF VETERINARY PRACTITIONERS (ABVP) REVIEW BOARD Kurt Blaicher, DVM, DABVP (Canine/Feline) Plainﬁeld Animal Hospital Plainﬁeld, New Jersey Canine and Feline Medicine Eric Chafetz, DVM, DABVP (Canine/Feline) Vienna Animal Hospital Vienna, Virginia Canine and Feline Medicine Henry E. Childers, DVM, DABVP (Canine/Feline) Cranston Animal Hospital Cranston, Rhode Island Canine and Feline Medicine David E. Harling, DVM, DABVP (Canine/Feline), DACVO Reidsville Veterinary Hospital Reidsville, North Carolina Canine and Feline Medicine, Ophthalmology Jeffrey Katuna, DVM, DABVP Wellesley-Natick Veterinary Hospital Natick, Massachusetts Canine and Feline Medicine Robert J. Neunzig, DVM, DABVP (Canine/Feline) The Pet Hospital Bessemer City, North Carolina Canine and Feline Medicine

Compendium is a refereed journal. Articles published herein have been reviewed by at least two academic experts on the respective topic and by an ABVP practitioner. Any statements, claims, or product endorsements made in Compendium are solely the opinions of our authors and advertisers and do not necessarily reﬂect the views of the Publisher or Editorial Board.

Canadian News

Coming Events July 16 Ontario Veterinary Medical Association: Career Planning for Associate Veterinarians & Potential Practice Owners Ontario Veterinary Medical Association Milton, Ontario This course will present the benefits and downsides of owning a practice as well as the practical aspects of practice ownership. Web www.ovma.info/Meetings/ August 8–13 World Association for the Advancement of Veterinary Parasitology: 22nd International Conference Calgary, Alberta This conference will discuss current issues in parasitology. Web waavp.org September 9 Calgary Academy of Veterinary Medicine: Ophthalmology Clara Christie Theatre, Health Sciences University of Calgary, Alberta This seminar will offer 1.5 hours of scientific CE and will be presented by Dr. Cheryl Cullen. Phone 403-863-7160 E-mail info@cavm.ab.ca Web cavm.ab.ca/ce_calendar.html September 15 Toronto Academy of Veterinary Medicine: Update on Clinical Gastroenterology Dave and Buster’s Toronto, Ontario This seminar will provide an update on gastrointestinal disorders of cats and dogs, with an emphasis on diagnosis and treatment. It will offer 5.5 CE credits. Phone 800-670-1702 Web tavm.org October 13 Toronto Academy of Veterinary Medicine: Early Resuscitation and Stabilization of the Emergency Patient Dave and Buster’s Toronto, Ontario This seminar will focus on practical emergency management using case examples. It will offer 5.5 CE credits. Phone 800-670-1702 Web tavm.org October 18 Calgary Academy of Veterinary Medicine: Hematology Clara Christie Theatre, Health Sciences University of Calgary, Alberta This seminar will offer 6 hours of scientific CE and be presented by Dr. Marjorie Brooks. Phone 403-863-7160 E-mail info@cavm.ab.ca Web cavm.ab.ca/ce_calendar.html

Canadian Government Invests in Western College of Veterinary Medicine

he government of Canada is investing $2.7 million in the infrastructure of the University of Saskatchewan’s Western College of Veterinary Medicine (WCVM). The funding, coming from the Canadian Western Economic Diversiﬁcation program, will be used on upgrades to the large animal clinic and the diagnostics laboratory at the college. The upgraded facilities will make the college, province, and country more competitive, according to Minister of State Lynne Yelich. “Investments such as these will lead to new diagnostic tests that will protect Canada’s livestock industry and the health and safety of Canadians, their families, and communities.”

The construction of a two-story addition and basement will add 3000 m2 of additional space to the diagnostics facility. Once completed, the centre will be a major western Canadian hub for veterinary diagnostics services, animal health research, and specialized training in diagnostic pathology, virology, bacteriology, immunology, and a range of biomedical sciences. “The expansion of the college’s diagnostics area and the renovation of our large animal clinical services will provide our staff and students with specialized, biosecure facilities where they’ll have access to a full range of new technologies,” says WCVM Dean Dr. Charles Rhodes.

Animal Health Network Announced

he Canadian Food Inspection Agency and the Atlantic Veterinary College (AVC) at the University of Prince Edward Island have joined together in a $1.2-million partnership to create the Canadian Regulatory Veterinary Epidemiology Network. This network will link the ﬁve Canadian veterinary colleges and enhance animal health expertise by contributing to research and training programs. In addition to strengthening Canada’s animal disease prevention and control efforts, the program will also help meet national and international demands for animal and veterinary health experts. The initial phase of the project will establish a research chair in regulatory veterinary epidemiology at the AVC as well as related graduate positions. The network will be led by the Centre for Veterinary Epidemiological Research at the AVC, which is considered one of the leading centres for animal health epidemiologic research in the world. “This network will further strengthen

our ability to understand and respond to animal health and zoonotic disease challenges in a world of ever-changing risks,” said Dr. Brian Evans, chief veterinary ofﬁcer of Canada.

SPREAD YOUR GOOD NEWS Have any interesting news to share? Send it in! We would like to provide more recognition of veterinarians doing great things in their professional or personal lives. If you have news about yourself or a colleague or about some other newsworthy topic that would be of interest to others in the profession, send it (along with a picture if you have one) to: Canadian News c/o Veterinary Learning Systems 780 Township Line Road Yardley, PA 19067, USA E-MAIL editor@CompendiumVet.com FAX 800-556-3288 WEB CompendiumVet.com

CompendiumVet.com | June 2009 | Compendium: Continuing Education for Veterinarians®

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June 2009 Vol 31(6)

CompendiumVet.com | Peer Reviewed | Listed in MEDLINE

284

Feline Obesity: Clinical Recognition and Managementt

FREE

❯❯ Debra L. Zoran Obesity is a common problem in cats that is compounded by most cats’ sedentary lifestyles and many owners’ feeding techniques. Recognition of the risk factors for obesity and early education of owners to prevent excessive weight gain are crucial to feline health. Further information on feline obesity is available on CompendiumVet.com.

EEach CE article is accredited for 3 contact hours by Auburn University College of Veterinary Medicine. A

Features 258 Understanding Behavior Incorporating Behavioral Medicine Into General Practice ❯❯ Lisa Radosta Learn how—and why—to include basic behavioral medicine into your dayto-day practice.

264 Feline Focus

NEW

2008 Feline Retroviruss Management Guidelines

SERIES

In the debut of this quarterly series devoted to feline medicine, the American Association of Feline Practitioners shares an abridged version of its most recent guidelines.

274 Surgical Views Laparoscopic and Laparoscopic-Assisted Cryptorchidectomy in Dogs and Cats ❯❯ Philipp Mayhew Surgical removal is the standard of care for cryptorchid testicles. Laparoscopy can help reduce incision sizes and postoperative pain in these patients. Watch videos of some aspects of these procedures on CompendiumVet.com.

On the Cover This radiograph, obtained by Carol Adams, DVM, of Lone Oak Veterinary Clinic in Visalia, California, is from an 8-year-old cat that weighed 19 lb. The excessive weight placed undue stress on the cat’s skeleton. *2009 PERQ/HCI FOCUS® Veterinary Study of Total Companion

Animal Veterinarians, in comparison to ratings for each publication, by that publication’s readers.

252

Compendium: Continuing Education for Veterinarians®

Departments 254 Letters

295 Index to Advertisers

256 CompendiumVet.com

295 Market Showcase

257 Editorial: Feline Focus ❯❯ Margie Scherk

295 Classiﬁed Advertising

294 Product Forum

296 In Memory: Anna Worth

Gentle on his ears

The Latest Generation in Otitis Externa Treatment. Mometasone furoate UÊ,>« ` ÞÊV ÌÀ ÃÊ yÊ> >Ì ÊÌ ÊÀi`ÕViÊÀi >Ìi`Ê«> Ê> `Ê ÀÀ Ì>Ì UÊ iÜÊÃÌÕ`ÞÊÀi« ÀÌÃÊ Ê>`Ài V ÀÌ V> ÊÃÕ««ÀiÃÃ ÊÜ Ì ÊÌ « V> Ê>` ÃÌÀ>Ì

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Mometamax Ê"Ì VÊ-ÕÃ«i Ã Ê ÃÊ ` V>Ìi`Êv ÀÊÌ iÊÌÀi>Ì i ÌÊ vÊ Ì Ì ÃÊiÝÌiÀ >Ê Ê` }ÃÊV>ÕÃi`ÊLÞÊÃÕÃVi«Ì L iÊÃÌÀ> ÃÊ vÊÞi>ÃÌÊMalassezia pachydermatis) > `Ê L>VÌiÀ >Ê PseudomonasÊ Ã««°Ê Q V Õ` }Ê P. aeruginosaR]Ê V >}Õ >Ãi « Ã Ì ÛiÊ ÃÌ>« Þ V VV ]Ê Enterococcus faecalis, Proteus mirabilis]Ê > `Ê LiÌ> i ÞÌ VÊÃÌÀi«Ì V VV ®°Ê « i ÌÃÊ >ÞÊV>ÕÃiÊ V> Ê Þ«iÀÃi Ã Ì Û ÌÞÊ ÀÊ Ì Ì Ý V ÌÞ°Ê ÀÊÃ `iÊivviVÌÃÊ> `ÊÜ>À }Ã]Ê« i>ÃiÊÃiiÊ>VV «> Þ }ÊLÀ ivÊ ÃÕ >ÀÞÊ vÊ*À `ÕVÌÊ v À >Ì ° See Page 254 for Product Information Summary

1. Reeder CJ, Grifﬁn CE, Polissar NL, et al. Comparative adrenocortical suppression in dogs with otitis externa following topical otic administration of four different glucocorticoid-containing medications. Vet Therap. 2008;9:111-121. 2. Rubin J, Walker RD, Blickenstaff K, Bodies-Jones S, Zhao S., Antimicrobial resistance and genetic characterization of ﬂuoroquinolone resistance of Pseudomonas aeruginosa isolated from canine infections., Vet microbiol. 2008 Mar 4; [Epub ahead of print] SPAH-MO-96

Letters I read with interest the March 2009 Understanding Behavior article on feline hyperesthesia syndrome (FHS), a poorly understood clinical entity. To me, it is plausible that some cats with clinical signs compatible with FHS may truly experience bouts of breakthrough neuropathic pain leading to allodynia (sensation of pain resulting from non-noxious stimuli, such as a light touch), regardless of whether higher brain functions are involved (e.g., displacement behavior). If this is the case, it could partly explain why some cats appear to improve with certain centrally acting therapies, such as the anticonvulsant gabapentin. This drug binds to a subunit of the voltage-gated calcium channels in the dorsal horn and is commonly used for conditions associated with neuropathic pain or with chronic pain when central sensitization is suspected, even though clinical studies are lacking in veterinary medicine.1 As such, a clinical response to gabapentin should not necessarily lead the practitioner to conclude that the patient was experiencing seizures, as is suggested in this article (p.118), but may instead be the result of a true neuropathic pain syndrome responding to an adjuvant analgesic drug. The same reasoning could apply to other drugs, such as tricyclic antidepressants and selective serotonin reuptake inhibitors, often considered as ﬁrst-line therapies in people with neuropathic pain.2 Louis-Philippe de Lorimier, DVM, DACVIM (Oncology) Hôpital Vétérinaire Rive-Sud Brossard, Québec Canada References 1. Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebocontrolled clinical trials. Clin Ther 2003;25:81-104. 2. Verdu B, Decosterd I, Buclin T, et al. Antidepressants for the treatment of chronic pain. Drugs 2008;68:26112632.

Understanding

Behavior

Feline Hyperesthesia Syndrome*

About This Column

❯❯ John Ciribassi, DVM, DACVB

Behavior problems are a signiﬁcant cause of death (euthanasia) in companion animals. While most veterinary practices are necessarily geared toward the medical aspect of care, there are many opportunities to bring behavior awareness into the clinic for the beneﬁt of the pet, the owner, and ourselves. This column acknowledges the importance of behavior as part of veterinary medicine and speaks practically about using it effectively in daily practice.

Chicagoland Veterinary Behavior Consultants Carol Stream, Illinois

eline hyperesthesia syndrome (FHS) is known by several names, including rolling skin disease, neurodermatitis, neuritis, psychomotor epilepsy, and pruritic dermatitis of Siamese.1,2 As evidenced by these names and by the use of the term syndrome, FHS is not characterized as having a single etiology. In fact, it is often a diagnosis of exclusion. The differential diagnosis for FHS includes diseases related to the ﬁelds of dermatology, neurology, and behavior. Only after conditions relating to skin and the nervous system have been ruled out can this condition be labeled a behavior disorder.

Signalment FHS can occur in cats of any age, but it is commonly seen in cats aged 1 to 5 years. Males and females are equally affected. While all breeds can be affected, Siamese, Burmese, Persian, and Abyssinian cats are more commonly afﬂicted.3

Clinical Signs

QuickNotes FHS can occur in cats of any age, but it is commonly seen in cats aged 1 to 5 years.

As indicated by the name rolling skin disease, affected cats often show rippling or rolling skin along the lumbar spine. Palpation of the lumbar musculature may elicit signs of pain. Mydriasis is common during bouts of FHS. Affected cats commonly stare at their tail, then attack the tail and/or ﬂanks. Biting of the tail base, forelegs, and paws is common. These cats often run wildly around the home, vocalizing at the same time. Normally calm cats may display aggression toward people or other cats in the household, while aggressive cats may display increased affection. The behavior may be induced by petting or stroking the cat’s fur and most commonly occurs in the morning or later in the evening.2

Diagnosis *Adapted with permission from John Ciribassi, DVM, and the Veterinary Information Network (VIN).

116

The differential diagnosis for FHS can be categorized by the type of clinical signs displayed:

CompendiumVet.com | March 2009

Feline Hyperesthesia Syndrome

to neuropathic pain. As indicated in my article, some believe that myopathic disorders can result in the clinical signs seen with FHS. An underlying neuropathy may certainly account for these signs. Gabapentin, while often used in treating seizure disorders, is also well known for its use in human and veterinary medicine for treating neuropathic pain.1,2 As a result, it can be difﬁcult to distinguish, in patients responding to treatment with gabapentin for FHS, whether the response is managing a seizure disorder centrally or is exerting peripheral neuropathic effects. The advantage of initially using phenobarbital in managing cases in which seizures are suspected as the etiology is that phenobarbital would not be expected to act peripherally. As a result, improvement with phenobarbital would provide a presumptive diagnosis of seizure. If phenobarbital proves to be ineffective, turning to gabapentin can help distinguish seizure from neuropathy. This being said, diagnosis by drug trial does not truly provide a secure diagnosis. Instead, it merely gives circumstantial evidence of an etiology based on the assumption of a known and speciﬁc mode of action of the drug that is providing relief of the signs. Dr. John Ciribassi Chicagoland Veterinary Behavior Consultants Carol Stream, Illinois References

The Author’s Reply Thank you for your comments regarding my article on FHS. It is plausible that at least some cases of FHS are related

254

1. Kumar B, Kalita J, Kumar G, Misra UK. Central poststroke pain: a review of pathophysiology and treatment. Anesth Analg 2009;108(5):1645-1657. 2. Clivatti J, Sakata RK, Issy AM. Review of the use of gabapentin in the control of postoperative pain. Rev Bras Anestesiol 2009;59(1):92-8, 87-92.

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

What do dogs who take e VETORYL (trilostane) have in common? ®

Results like these.

Prior to VETO RYL treatment

Effective treatment for Cushing’s syndrome is now FDA approved. You now have easy access to the most powerful weapon in the fight against canine Cushing’s syndrome. VETORYL Capsules are the only licensed treatment available for both pituitary-dependent and adrenal-dependent hyperadrenocorticism.

treatment Following 3 months of with VETORYL

VETORYL Capsules contain the active ingredient trilostane, which blocks the excessive production of cortisol. Daily administration of VETORYL can greatly reduce the clinical signs associated with Cushing’s syndrome, enhancing the quality of life for both dog and owner. For more information, visit www.VETORYL.com. Contact your local veterinary distributor to order VETORYL Capsules today!

Following 9 months of treatment with VETO RYL

(trilostane)

Photographs courtesy of Carlos Melian, DVM, PhD

VETORYL is a trademark of Dechra Ltd. ©2009, Dechra Ltd. NADA 141-291, Approved by FDA As with all drugs, side effects may occur. In field studies, the most common side effects reported were poor/reduced appetite, vomiting, lethargy, diarrhea, and weakness. Occasionally, more serious side effects, including severe depression, hemorrhagic diarrhea, collapse, hypoadrenocortical crisis, or adrenal necrosis/rupture may occur, and may result in death. VETORYL Capsules are not for use in dogs with primary hepatic or renal disease, or in pregnant dogs. Refer to the prescribing information for complete details or visit www.VETORYL.com. VTYL0209-01-47122-CPD

See Page 256 for Product Information Summary

WEB EXCLUSIVES

June 2009

VETORYL Capsules (trilostane)

Vol 31(6)

30 mg and 60 mg strengths Adrenocortical suppressant for oral use in dogs only

BRIEF SUMMARY (For Full Prescribing Information, see package insert.) CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: VETORYL is an orally active synthetic steroid analogue that blocks production of hormones produced in the adrenal cortex of dogs. INDICATIONS: VETORYL Capsules are indicated or the treatment of pituitary-dependent hyperadrenocorticism in dogs. VETORYL Capsules are indicated for the treatment of hyperadrenocorticism due to adrenocortical tumor in dogs. CONTRAINDICATIONS: The use of VETORYL Capsules is contraindicated in dogs that have demonstrated hypersensitivity to trilostane. Do not use VETORYL Capsules in animals with primary hepatic disease or renal insufficiency. Do not use in pregnant dogs. Studies conducted with trilostane in laboratory animals have shown teratogenic effects and early pregnancy loss. WARNINGS: In case of overdosage, symptomatic treatment of hypoadrenocorticism with corticosteroids, mineralocorticoids and intravenous fluids may be required. Angiotensin-converting enzyme (ACE) inhibitors should be used with caution with VETORYL Capsules, as both drugs have aldosterone-lowering effects which may be additive, impairing the patient’s ability to maintain normal electrolytes, blood volume and renal perfusion. Potassium-sparing diuretics (e.g., spironolactone) should not be used with VETORYL Capsules as both drugs have the potential to inhibit aldosterone, increasing the likelihood of hyperkalemia. HUMAN WARNINGS: Keep out of reach of children. Not for human use. Wash hands after use. Do not empty capsule contents and do not attempt to divide the capsules. Do not handle the capsules if pregnant or if trying to conceive. Trilostane is associated with teratogenic effects and early pregnancy loss in laboratory animals. In the event of accidental ingestion/overdose, seek medical advice immediately and take the labeled container with you. PRECAUTIONS: Hypoadrenocorticism can develop at any dose of VETORYL Capsules. A small percentage of dogs may develop corticosteroid withdrawal syndrome within 10 days of starting treatment. Mitotane (o,p’-DDD) treatment will reduce adrenal function. Experience in foreign markets suggests that when mitotane therapy is stopped, an interval of at least one month should elapse before the introduction of VETORYL Capsules. The use of VETORYL Capsules will not affect the adrenal tumor itself. Adrenalectomy should be considered as an option for cases that are good surgical candidates.

CE ARTICLES

❯❯ Renal Secondary Hyperparathyroidism ❯❯ Jenefer R. Stillion and Michelle G. Ritt The parathyroid glands secrete parathyroid hormone (PTH), which is important for maintaining calcium homeostasis. Parathyroid gland hyperplasia and subsequent hyperparathyroidism can occur secondary to chronic renal failure in dogs, resulting in signiﬁcant alterations in calcium metabolism. Renal secondary hyperparathyroidism is a complex, multifactorial syndrome that involves changes in circulating levels of calcium, PTH, phosphorus, and 1,25-dihydroxycholecalciferol (calcitriol). WEB-EXCLUSIVE VIDEOS

❯❯ Laparoscopic and LaparoscopicAssisted Cryptorchidectomy Videos The June 2009 Surgical Views column, “Laparoscopic and Laporoscopic-Assisted Cryptorchidectomy in Dogs and Cats,” by Dr. Philipp Mayhew, discusses the advantages and disadvantages of these techniques. Three videos, contributed by Dr. Mayhew, demonstrate some of the techniques discussed in this column. VIDEO 1 demonstrates the manipulation of the

normal testicle in a unilaterally cryptorchid dog. By pushing the normal testicle in a cranial direction, it is possible to see whether the

ADVERSE REACTIONS: The most common adverse reactions reported are poor/reduced appetite, vomiting, lethargy/dullness, diarrhea, and weakness. Occasionally, more serious reactions including severe depression, hemorrhagic diarrhea, collapse, hypoadrenocortical crisis, or adrenal necrosis/rupture may occur, and may result in death.

normal testicle is located on the right or the left side (in this case the normal testicle is the right testicle). The cryptorchid ❯❯ Cryptorchidectomy Video 1 testicle should be located on the contralateral side. VIDEO 2

demonstrates use of the vessel-sealing device to seal and section the gubernaculum, spermatic cord, ❯❯ Cryptorchidectomy Video 2 and, ﬁnally, the vascular pedicle of an abdominally cryptorchid testicle. If a totally laparoscopic cryptorchidectomy is performed (VIDEO 3), the testicle can be removed through the ❯❯ Cryptorchidectomy Video 3 subumbilical port. This way, enlargement of the port can be performed through the linea alba rather than the muscular body wall where the instrument ports are located. E-NEWSLETTER ❯❯ COMPENDIUM EXTRA, a monthly e-newsletter, provides Web-exclusive articles and news as well as a preview of this month’s journal. Sign up at CompendiumVet.com.

(trilostane) Distributed by: Dechra Veterinary Products 7015 College Boulevard, Suite 525 Overland Park, KS 66211 www.VETORYL.com 866-933-2472

❯❯ E-mail your questions, suggestions, corrections, or letters to the editor: editor@CompendiumVet.com

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Compendium

Editorial Contributed by:

AMERICAN ASSOCIATION OF FELINE PRACTITIONERS

About AAFP

2008 Feline Retrovirus Management Guidelines* Members of the Advisory Panel ❯❯ Julie Levy, DVM, PhD, DACVIM, Chair ❯❯ Cynda Crawford, DVM, PhD University of Florida

❯❯ Katrin Hartmann, Dr. Med. Vet., Dr. Habil., DECVIN-CA Ludwig Maximilian University Munich | Munich, Germany

❯❯ Susan Little, DVM, DABVP (feline practice)

Winn Feline Foundation | Manasquan, New Jersey

❯❯ Eliza Sundahl, DVM, DABVP (Feline Practice)

eLV and FIV are among the most common infectious diseases of cats. Risk factors for infection include male gender, adulthood, and outdoor access, whereas indoor lifestyle and sterilization are associated with reduced infection rates.1–5 The retroviral status of all cats should be known. Cats may require retrovirus testing at different times in their lives. Here are some general principles for retrovirus testing:

A cat with a confi rmed-positive test result should be diagnosed as having a retroviral infection—not clinical disease. Diseases in cats infected with FeLV or FIV may not necessarily be the result of the retrovirus infection. Cats infected with FeLV or FIV may live for many years. A decision for euthanasia should never be made solely on the basis of whether the cat is infected. No test is 100% accurate at all times under all conditions. All test results should be interpreted along with the patient’s health and prior likelihood of infection. All positive results should be conﬁrmed by another test method. While FeLV and FIV can be life-threatening viruses, proper management can give infected cats longer, healthier lives. The following article reﬂects the recommendations of the AAFP on managing these infections.

Purrfect Practice | Lebanon, Oregon

❯❯ Regina Hoffmann-Lehmann, Dr. Med. Vet.,Dr. Habil, FVH University of Zurich | Zurich, Switzerland

Page XXX

Limiting Transmission in the Veterinary Practice Page XXX

Diagnosing FeLV and FIV Page XXX

Managing Positive Cats Page XXX

*This is an abridged version of the full guidelines (Levy JC, Crawford C, Hartmann K, et al. 2008 American Association of Feline Practitioners’ feline retrovirus management guidelines. J Feline Med Surg 2008;10[3]:300-316), available at Catvets.com from the American Association of Feline Practitioners (AAFP). Adapted with permission of AAFP.

472

Factor Study site

This report is an abridged version of the Retrovirus Guidelines of the American Association of Feline Practitioners (AAFP) to guide veterinary practitioners who want to optimize the care and management of feline patients. It represents a consensus of current information compiled by the researchers and practitioners on the panel. The guidelines in this report are based on the best research data, clinical experience and technical judgments available at the time of preparation. While the guidelines are as accurate and comprehensive as possible, they are subject to change should new insights become available from additional research or technological updates. The AAFP is a professional organization of practitioners and board-certiﬁed specialists who seek to raise the standards of feline medicine and surgery among practitioners.

Categories Animal shelter Veterinary clinic

Epidemiology

West

Age

Health status

Number of Cats with Positive Results for FeLV(%)

American Association of Feline Practitioners 203 Towne Centre Drive Hillsborough, NJ 08844-4693 phone: 800-874-0498 phone: 908-359-9351 fax: 908-292-1188

8068 9970 3737

124 (1.5) 285 (2.9) 39 (1.0)

141 (17) 305 (3.1) 72 (1.9)

325

8 (2.5)

10 (3.1)

6359

144 (2.3)

183 (2.9)

Northeast

3747

107 (2.9)

79 (2.1)

Midwest

3870

111 (2.9)

102 (2.6)

Clinic (indoors only)

3613

53 (1.5)

32 (0.9)

6357

232 (3.6)

273 (4.3)

Shelter (relinquished pet)

2809

41 (1.5)

38 (1.4)

Shelter (stray)

4550

71 (1.6)

75 (1.6)

Shelter (feral)

709

12 (1.7)

28 (3.9)

Juvenile

9556

131 (1.4)

8482

278 (3.3)

100 (1.0) 346 (4.1)

Spayed female

2611

45 (1.7)

82 (1.2)

Neutered male

2984

88 (2.9)

127 (4.3)

Sexually intact female

6588

128 (1.9)

44 (1.7)

Sexually intact male

5855

148 (2.5)

193 (3.3)

Healthy Sick

Media contact: Valerie Creighton, DVM, ABVP

Number of Cats with Positive Results for FIV (%)

Canada

Adult Sex

Number of Cats Tested

South

Clinic (outdoors access)

About These Guidelines

Page XXX

Preventing FeLV and FIV Infection

e-mail: info@catvets.com

TABLE 1

Source

Epidemiology

All kittens because the lifestyles of kittens frequently change after acquisition and they may subsequently be at risk for FeLV exposure Cats that go outdoors Cats that have direct contact with cats of unknown status or in high-turnover situations

Risk Factors for FeLV and FIV Seropositivity in 18,038 Cats Tested at Veterinary Clinics and Animal Shelters in North America1

At a Glance

FeLV Vaccination The decision to vaccinate an individual cat against FeLV should be based on the cat’s risk of exposure. Cats that live in a FeLV-negative, indoor environment are at minimal risk. FeLV vaccination is recommended for:

Preventing FeLV and FIV Infection Vaccines are available for both retroviruses. Both FeLV and FIV vaccines are non-core. Risk assessment of the individual animal should dictate their use. No vaccine is 100% effective, and repeat testing should be performed as warranted.

Region

KC Cat Clinic | Kansas City, Missouri

❯❯ Vicki Thayer, DVM, DABVP (Feline Practice)

In a study of more than 18,000 cats tested in 2004, 2.3% were positive for FeLV and 2.5% were positive for FIV.1 Infection rates for FeLV and FIV (TABLE 1) varied among subpopulations and sources of cats.

15,312

238 (1.6)

280 (1.8)

2726

171 (6.3)

166 (6.1)

Disclaimer These guidelines are not exclusive. Other techniques and procedures may be available. The AAFP expressly disclaim any warranties or guarantees, express or implied, and shall not be liable for any damages of any kind in connection with the material, information, techniques, or procedures set forth in these guidelines.

CompendiumVet.com | June 2009 | Compendium: Continuing Education for Veterinarians®

Compendium | June 2009 | CompendiumVet.com

❯❯ Margie Scherk, DVM, DABVP (Feline Medicine)

473

Vancouver, British Columbia

The new Feline Focus series begins on page 264.

Feline Focus

y now, you know that Compendium is launching several new series this year, and excitement is building! So what’s new in the journal for you and your feline patients? The American Association of Feline Practitioners (AAFP) is partnering with Compendium to shine the spotlight on cats on a quarterly basis in Feline Focus! This series will provide you with pertinent and timely updates in feline medicine, covering a myriad of useful and useable facts to help you help cats in your practice. It will include brief abstracts and conference pearls; how-to articles about approaching speciﬁc problems in cats, as well as handling and working more peacefully and effectively with the more difﬁcult members of this species; and summaries of AAFP guidelines.

While FIV and FeLV vaccines are not considered core for adult cats, FeLV is a core vaccine for cats younger than 1 year. Every column will be peer-reviewed by a diplomate specialist and approved by a representative of the AAFP. Together, Compendium and the AAFP want to provide more access to information about feline medicine, brought to you by sources you know you can trust. In this premiere offering of Feline Focus, we are pleased to share with you the 2008 AAFP Feline Retrovirus Management Guidelines. Not excited yet? Let me whet your appetite. For example, did you know that testing, not vaccination, is

the cornerstone to management and prevention of the spread of FeLV and FIV and that all cats should be tested, especially when they are ill? Vaccination should be considered only in adult cats that are deemed to live in an at-risk environment (i.e., FeLV and FIV vaccines are not core for adult cats). However, FeLV vaccination is now recommended as core for cats younger than 1 year. Do you know what the risk for FeLV or FIV is in your region? In addition to providing recommendations on preventing retrovirus infections, the guidelines are an excellent source of information about caring for retrovirus-positive cats—not only pet cats but also those in cattery, shelter, and rescue situations. Do clients ask you whether fencing is adequate for isolation of retrovirus-positive cats from uninfected cats, or what kinds of disinfectant they need to use? Do you know how often a cat with FeLV should be examined and which tests should be conducted at each visit, or what drugs have been shown to be effective in the treatment of FeLV or FIV? If the answers to any of these questions intrigue you, the practical, scientiﬁcally solid article in this issue should be a useful clinic resource. Welcome to Feline Focus! We look forward to growing a relationship with you based on solid, practical feline facts. Cheers! Margie

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Understanding

Behavior About This Series Behavior problems are a signiﬁcant cause of death (euthanasia) in companion animals. While most veterinary practices are necessarily geared toward the medical aspect of care, there are many opportunities to bring behavior awareness into the clinic for the beneﬁt of the pet, the owner, and ourselves. This series acknowledges the importance of behavior as part of veterinary medicine and speaks practically about using it effectively in daily practice. SERIES EDITOR Sharon CrowellDavis, DVM, PhD, DACVB The University of Georgia

QuickNotes Providing basic behavioral services can help increase revenue and improve patient health.

a Dr. Radosta discloses that she has received ﬁnancial support from Eli Lilly and Company and Virbac Animal Health.

258

CompendiumVet.com | June 2009

Incorporating Behavioral Medicine Into General Practice ❯❯ Lisa Radosta, DVM, DACVBa

Florida Veterinary Behavior Service | Royal Palm Beach, Florida

ehavior issues affect almost every aspect of veterinary medicine (BOX 1). The most obvious, such as aggression, fears, and phobias, may be serious enough to prompt consultation with a behavior specialist. Others, however, may simply be considered “normal,” such as stress during ofﬁce visits or avoidance of a carrier. Although they may not be dramatic, these behaviors can cause clients to limit the number of nonemergency veterinary visits they make, ultimately affecting a practice’s bottom line. Therefore, providing basic behavioral services, such as socialization or habituation, can not only help increase revenue in general practices but also improve patient health.

Why Provide Behavioral Services? Many general practices do not offer behavioral services for several reasons. The appointments are assumed to be too time-consuming to be profitable (1½ to 3 hours), and add-on services and products are not obvious to practices. In addition, many veterinarians are not comfortable with treating behavior problems. However, many behavior services can be provided within a 20- to 30-minute appointment, and although adding a new profit center and retraining employees is a large investment, the return on investing in behavioral services is sizable. Adding these services can not only increase client compliance (e.g., medication administration, scheduling recheck appointments), retention, and satisfaction but also BOX 1 improve your patients’ quality of Common Circumstances life and decrease the likelihood of in Which Behavioral Issues relinquishment. Clients are often Affect General Practice embarrassed to share their pet’s behavior problems or their decision Avoidance of cat carrier to relinquish their pet with their veterinarian. You may not know how Stress during veterinary visit many patients you lose to behavior Difficult handling during veterinary visit problems each year, but behavior Intolerance of regular injections/ problems are the leading cause of medication relinquishment and euthanasia of Anxiety during boarding dogs and cats.1–3 Offering behavAggression in the waiting room ioral services is, therefore, a great way to attract and retain clients, Lack of compliance with postoperative rest recommendations reduce stress and euthanasia in your practice, and even make a profit. By Resistance to nail trimming improving a pet’s behavior, you ultiRelinquishment of pets for treatable mately help the pet, the client, and problems the practice.

Cat owners listen to their cats. Listen to your cat owners. Cats and their owners agree: a topical dewormer beats a pill any day. In fact, nearly 90% of cat owners prefer topical drops to pills or tablets.* So listen to your cat owners. Choose the only feline dewormer that treats and controls roundworms, hookworms and tapeworms with the ease and convenience of a topical application: ProfenderÂŽ Topical Solution. *From a survey of 736 cat owners. Data on file.

Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. Children should not contact application site for twenty-four (24) hours. See Page 260 for Product Information Summary

P08711n

Understanding

Behavior Where to Begin Planning for New Services First, decide which levels of care your practice can provide. Examples include prepurchase counseling, doggie day care, preventive medicine, behavior modiﬁcation for simple or major problems, basic obedience classes, behavioral consultation for major problems, and referral to a behavior specialist. Next, decide how you will delegate the responsibilities to your team. Your role as the veterinarian is to diagnose the problem and write a treatment plan. Just as you would not ask a technician to make the treatment plan for a dog with acute pancreatitis, you should not turn the responsibility to diagnose and treat behavior problems over to a technician. So, what will the technician’s role be? Will he or she implement the treatment plan for you or be responsible for phone follow-up and follow-up appointments? What will the receptionist’s role be? All members of the practice should be on board with the plan for it to be effective. Next, think about how you will train your staff. Some resources for education are textbooks, continuing education courses, and professional organizations (BOX 2). Contact your nearest board-certiﬁed veterinary behaviorist and ask which textbooks and conferences he or she recommends or whether he or she would be willing to talk to your staff to get the ball rolling. Finally, consider how to make behavioral services simple and accessible for clients. Easy-to-understand client handouts explaining the diagnosis and treatment should be used to help keep appointments to a reasonable length of time. Handouts can be written by staff and edited by the veterinarian, or prewritten handouts can be found in a number of textbooks (BOX 2). Handouts can also be inte-

260

Compendium

Understanding

Behavior grated into a computer-generated discharge sheet so that all client instructions are in the same place. The number of handouts and the topics to be covered will depend on the services offered at the practice. Also, decide which behaviorrelated products the practice will carry, as this will be an important part of completely integrating behavior services.

Integrating New Services Into the Practice For any service to be a successful practice builder, it must be integrated into the practice, from the receptionist to the veterinarian. From the moment that clients enter the waiting room, they should be aware that you provide behavioral services. Signs unique to the practice or supplied by toy manufacturers or pharmaceutical companies are one way of achieving this goal. The receptionist should mention the addition of behavioral services to the practice when clients book appointments and should give each arriving client a short behavior checklist (BOX 3) to be ﬁlled out while waiting. The client can then give the completed form to the technician at the beginning of the visit. Using a form is the most efﬁcient way of collecting information about a pet’s

behavior at each appointment. By incorporating behavioral issues into routine wellness visits, you foster the idea that behavior is just another aspect of the patient to be examined. Similarly, the practice should support the message that behavioral problems should be treated as promptly as medical illnesses. For example, when you write a medical treatment plan, the practice pharmacy dispenses the necessary medications (e.g., an antibiotic for superficial pyoderma). Although other pharmacies may dispense the same medication at a lower price, dispensing from the practice pharmacy allows clients to begin treatment immediately and conveniently. Behavior cases are no different. Behavioral supplies (e.g., food toys, collars, clickers) should be displayed prominently in the lobby. Although clients can purchase these products elsewhere at QuickNotes a later time, they are more likely to Behavioral medicine initially purchase them from the vetcan be a profit cenerinarian at the time of the appointment because the product is unique ter for primary care to the veterinarian’s office (e.g., Blue practices. Kong) or was “prescribed” as part of the treatment plan.

What to Offer Prepurchase Counseling

BOX 2

Resources Textbooks Horwitz D, Mills D, Heath S, eds. BSAVA Manual of Canine and Feline Behavioural Medicine. Gloucester, England: BSAVA; 2002. Landsberg G, Ackerman L, Hunthausen W. Handbook of Behavior Problems of the Dog and Cat. Philadelphia: Elsevier; 2003. Organizations American College of Veterinary Behaviorists: www.dacvb.org American Veterinary Society of Animal Behavior: www.avsabonline.org Society of Veterinary Behavior Technicians: www.svbt.org

Prepurchase counseling helps owners avoid problems of incompatibility by suggesting a pet that matches their lifestyle. These appointments typically take 20 to 30 minutes and can be conducted by a veterinary technician. Technicians can educate themselves by using Internet resources (e.g., akc. org, iams.com, purina.com), attending continuing education classes, and familiarizing themselves with breed handbooks. Before the appointment, the owner ﬁlls out a 1- to 2-page questionnaire listing his or her expectations for a pet (e.g., grooming, exercise, energy level). The technician should consider the owner’s ability to exercise the pet, the amount of time available for training, the presence of children in the household, grooming requirements, and the owner’s travel/work schedule. The client should be sent home with a summary of recommendations, which can be as simple as a list of breeds with the suitable candidates checked off.

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Understanding

Behavior Doggie Day Care In today’s busy society, many owners do not have the time to adequately exercise their dogs, which can contribute to several behavior problems. By instituting a doggie day care program, your practice can offer your clients several benefits. To clients who pick up their dog after a long day of work, the most obvious benefit will be the dog’s reduced need for activity. This aspect of the service will build client loyalty and encourage clients to continue to use the day care. Another benefit of a good doggie day care program is screening for common infectious diseases and aggression (via a questionnaire), which should be required for all dogs before they are permitted to participate. Doggie day care requires a significant commitment of space and dedicated staff. A medium-tolarge room or yard is necessary. Outdoor yards should have secured fencing of adequate height to contain large dogs. Agility equipment, beds, crates, and toys can also be provided. Ideally, there should be at least three separate areas for small dogs, large dogs, and older dogs. Dogs should be rotated between rest and play in QuickNotes appropriate groups, depending on Behavioral issues their play style. All interactions should affect almost every be supervised by at least one person for every four or five dogs. Upgrades aspect of veterinary such as baths and viewing by webcam medicine. can also be offered.

Preventive Medicine Veterinarians practice preventive medicine every day, but behavioral advice is frequently left out. Puppies and kittens have sensitive periods for socialization in which a relatively small amount of effort can have a very large effect. Unfortunately, if their experiences during these periods are stressful, or if they are not exposed to new people and situations during this time, they often become fearful or anxious. Fears and anxieties are the most common causes of behavior problems, including aggression, in animals. Therefore, each new puppy or kitten appointment should include counseling about socialization and habituation. In addition, the practice can offer inhouse socialization/habituation services, kitten and puppy classes, obedience classes, and counseling services for life/schedule changes. In-house socialization/habituation services for puppies and kittens reduce clients’ time commitment to this type of training. Instead, clients bring their pets to the clinic, where habituation to startling noises (e.g., thunderstorms, ﬁreworks), house-

262

training, crate training, and socialization to people and other animals can be conducted. While this may seem like a large task, it requires little more time and commitment than boarding patients. Crate training and housetraining of dogs include walking them on a schedule and teaching them that the crate is a fun place to be. Socialization to people takes roughly 5 to 10 minutes, three times a day. Clients who are in your clinic waiting for their own pets can help by playing with puppies and kittens in a clean, safe area, adding to socialization without placing a drain on the practice. However, these services require a separate puppy/kitten area that is kept clean and free of any pets with infectious diseases, and owners of pets with infectious diseases should not participate. Clients may want to complete the socialization of their pet themselves but not know how to do so. In these cases, the veterinarian can customize a plan, based on the pet’s strengths and weaknesses, for the client to implement at home. Appointments generally last 20 to 30 minutes. The client should leave the appointment with a summary and a handout on which the appropriate recommendations are checked off. Puppy and kitten socialization classes are vitally important in preventing behavioral disorders.4 Because the classes should be limited in size and the patients are small, there is no need for a large space. During these classes, pets are socialized to people and other pets, habituated to sounds and handling, and taught to tolerate nail trims and tooth brushing. Finally, they are taught basic obedience behaviors. These positive-reinforcement classes can be taught by a veterinarian or a member of the staff. Puppies and kittens should be enrolled when they are as close to 8 weeks of age as possible to offer the greatest beneﬁt to the pet and client. BOX 3

Waiting-Room Behavior Checklist Have your pet’s elimination habits changed since his/her last appointment? Has your pet growled at or bitten someone since his/her last appointment? Has your pet had an increase in anxiety or fear since his/her last appointment? Has your pet’s personality changed since his/her last appointment? Are any of your pet’s behaviors of concern to you?

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

Understanding

Behavior a standard part of treating a medical disorder. Some examples are muzzle training for veterinarian-aggressive dogs, behavior modiﬁcation for cats that will not enter their carriers, and counterconditioning for pets that do not tolerate medication administration. When topical, oral, or injectable medications are prescribed, the client should be asked if he or she will be able to administer the medication for the duration of the treatment plan. If the answer is “no,” a behavior modiﬁcation appointment should be recommended.

Problem Behavior Referrals Appointments for problem behaviors typically last 1½ to 3 hours. Most general practices choose not to offer these appointments because of their length and profitability compared with other services. If this is the case in your practice, you can offer an initial 30-minute consult preceding a referral to a boardcertified veterinary behaviorist. These visits include a physical examination, screening laboratory tests (e.g., complete blood count, serum chemistry profile, thyroxine, urinalysis), and a short list of five to Obedience classes can be offered at the clinic. 10 safety recommendations specific to the case (e.g., A member of the staff can teach the class, or the avoidance of provocative situations, discontinuation clinic can partner with a dog trainer. Such classes of physical corrections or confrontational interaccan be a good way to supplement income, increase tions). By offering this service, you ensure that the employee job satisfaction and retention, and intro- patient has had a recent medical workup before it duce new clients to your practice. However, these goes to the behavior specialist and that this income classes should be undertaken with care because the stays in your practice. In addition, screening tests practice may be legally responsible for the advice may help identify, and allow you to start treatment given. Regardless of who you employ to teach obe- for, an underlying medical disorder that may be condience or puppy classes, observe them teaching first. tributing to the behavior problem. Ask them what methods they use and how much experience they have. Lay down guidelines for pos- Conclusion itive-reinforcement training in writing so that there There are many ways to integrate behavioral medicine into the general veterinary practice. Change is is no confusion about what is permitted. Counseling services can help clients transition their never easy or comfortable, but by adding behavpets in circumstances such as moving, marriage, loss ioral services to your practice, you can improve your of a family member (animal or human), or arrival of patients’ quality of life; increase patient, client, and a baby. Even the best pet can become agitated by employee retention; and positively affect your pracmajor life changes. Appointments generally last 20 to tice’s bottom line. 30 minutes. As with a medical appointment, the technician takes the history and presents the case to the References Patronek FJ, Glickman LT, Beck AM, et al. Risk veterinarian. The veterinarian examines the pet and 1. factors for relinquishment of dogs to an animal makes an assessment and a treatment plan. After pre- shelter. JAVMA 1996;209:572-581. senting the plan to the client, the technician teaches 2. Patronek GJ, Glickman LT, Beck AM, et al. TO LEARN Risk factors for relinquishment of cats to an anithe client how to implement it and sends him or her mal shelter. JAVMA 1996;209:582-598. MORE 3. Salman MD, Hutchinson J, Ruch-Gallie R, et al. home with an appropriate handout.

Basic Behavior Modification Basic behavior modiﬁcation appointments last 20 to 30 minutes and are conducted either by the technician after the veterinarian has examined the pet or as

Behavioral reasons for relinquishment of dogs and cats to 12 shelters. J Appl Anim Welf Sci 2000;3(2): 93-106. 4. Duxbury MM, Jackson JA, Line SW, Anderson RK. Evaluation of association between retention in the home and attendance at puppy socialization classes. JAVMA 2003;223:62-66.

For a sample waiting room questionnaire, please visit flvetbehavior.com.

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2008 Feline Retrovirus Management Guidelines* Members of the Advisory Panel ❯❯ Julie Levy, DVM, PhD, DACVIM, Chair ❯❯ Cynda Crawford, DVM, PhD University of Florida

❯❯ Katrin Hartmann, Dr. Med. Vet., Dr. Habil., DECVIN-CA Ludwig Maximilian University Munich | Munich, Germany

A cat with a conﬁ rmed-positive test result should be diagnosed as having a retroviral infection—not clinical disease. Diseases in cats infected with FeLV or FIV may not necessarily be the result of the retrovirus infection. Cats infected with FeLV or FIV may live for many years. A decision for euthanasia should never be made solely on the basis of whether the cat is infected. No test is 100% accurate at all times under all conditions. All test results should be interpreted along with the patient’s health and prior likelihood of infection. All positive results should be conﬁrmed by another test method.

❯❯ Regina Hoffmann-Lehmann, Dr. Med. Vet., Dr. Habil, FVH University of Zurich | Zurich, Switzerland

❯❯ Susan Little, DVM, DABVP (Feline Practice)

Winn Feline Foundation | Manasquan, New Jersey

❯❯ Eliza Sundahl, DVM, DABVP (Feline Practice)

While FeLV and FIV can be life-threatening viruses, proper management can give infected cats longer, healthier lives. The following article reﬂects the recommendations of the AAFP on managing these infections.

KC Cat Clinic | Kansas City, Missouri

❯❯ Vicki Thayer, DVM, DABVP (Feline Practice) Purrfect Practice | Lebanon, Oregon

At a Glance Epidemiology Page 265

Preventing FeLV and FIV Infection Page 265

Limiting Transmission in the Veterinary Practice Page 268

Diagnosing FeLV and FIV Page 269

About These Guidelines This report represents a consensus of current information compiled by the researchers and practitioners on the panel. These guidelines are based on the best research data, clinical experience and technical judgments available at the time of preparation. While the guidelines are as accurate and comprehensive as possible, they are subject to change should new insights become available from additional research or technological updates. The American Association of Feline Practitioners is a professional organization of practitioners and board-certiﬁed specialists who seek to raise the standards of feline medicine and surgery among practitioners.

Managing Positive Cats Page 270

* This is an abridged version of the full guidelines (Levy JC, Crawford C, Hartmann K, et al. 2008 American Association of Feline Practitioners’ feline retrovirus management guidelines. J Feline Med Surg 2008;10[3]:300-316) available at catvets.com from the American Association of Feline Practitioners (AAFP). Adapted with permission from AAFP.

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Compendium | June 2009 | CompendiumVet.com

Categories

Study site

Region

Source

Age

Sex

Canada

325

8 (2.5)

10 (3.1)

South

6359

144 (2.3)

183 (2.9)

Northeast

3747

107 (2.9)

79 (2.1)

Midwest

3870

111 (2.9)

102 (2.6)

Clinic (indoors only)

3613

53 (1.5)

32 (0.9)

Clinic (outdoors access)

6357

232 (3.6)

273 (4.3)

Shelter (relinquished pet)

2809

41 (1.5)

38 (1.4)

Shelter (stray)

4550

71 (1.6)

75 (1.6)

Shelter (feral)

709

12 (1.7)

28 (3.9)

Juvenile

9556

131 (1.4)

100 (1.0)

Adult

8482

278 (3.3)

346 (4.1)

Spayed female

2611

45 (1.7)

44 (1.7)

Neutered male

2984

88 (2.9)

127 (4.3)

Sexually intact female

6588

128 (1.9)

82 (1.2)

Sexually intact male Health status

Healthy Sick

5855

148 (2.5)

193 (3.3)

15,312

238 (1.6)

280 (1.8)

2726

171 (6.3)

166 (6.1)

Disclaimer These guidelines are not exclusive. Other techniques and procedures may be available. The AAFP expressly disclaims any warranties or guarantees, express or implied, and shall not be liable for any damages of any kind in connection with the material, information, techniques, or procedures set forth in these guidelines.

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QuickNotes The retroviral status of all cats should be known because the serious health consequences of infection inﬂuence patient management both in illness and wellness care.

addition, cats should be tested for FeLV infection before initial vaccination and whenever the possibility exists that they have been exposed to FeLV since they were last tested. Administering FeLV vaccines to cats conﬁrmed to be FeLV infected is of no value.

FIV Vaccination The decision to vaccinate a cat for FIV is complicated. FIV vaccines may be considered for cats with lifestyles that put them at high risk for infection, such as outdoor cats that ﬁght or cats living with FIV-infected cats. Because FIV infection is more often spread by unfriendly exchanges (usually biting), cats in households with a stable social structure are at lower risk for acquiring FIV infection.

Current FIV antibody tests cannot distinguish vaccinated cats from infected cats. Clients should be informed that vaccinated cats will have positive FIV test results, and the decision to vaccinate should be reached only after careful consideration of this implication. If the decision falls in favor of vaccination, cats should test negative immediately before vaccination. A permanently placed identiﬁcation microchip and collar are recommended for all cats to increase the chance of returning lost cats to their owners. Microchip databases can also record FIV vaccination histories. This information can be used by animal shelters to help assess the significance of positive FIV test results when screening cats before adoption.

General Recommendations for Testing for and Controlling Transmission of FeLV and FIV in Shelters and Breeding Catteries Testing As for pet cats, it is ideal for all cats in shelters and catteries to be tested for FeLV and FIV.* Testing at admission is optional for singly housed cats. Testing is highly recommended for group-housed cats. If not performed before adoption, testing should be recommended to the new owner before exposure to other cats. Testing should be repeated 60 days after the initial test and annually for cats kept in long-term group housing. Each cat should be individually tested. Testing representative kittens in a litter or colony and extrapolating results to other cats in the group is unreliable. Procedures such as pooling mul-

tiple samples for use in a single test reduce test sensitivity and should not be performed. Foster families and adopters should have their own resident cats tested before fostering or adopting a new cat. Testing is optional in feral cat trap– neuter–return programs. Controlling Transmission FeLV vaccination is optional for singly housed cats. FeLV vaccination is highly recommended for all cats housed in groups and for foster cats and permanent residents in foster homes. Cats should test negative before vaccination. In catteries that follow testing guidelines and maintain retrovirus-negative

BOX 1

status, vaccination against FeLV and FIV is not necessary. Vaccination is not 100% effective and should never be used in place of a test-and-segregate program. In contrast to feline panleukopenia, herpesvirus, and calicivirus vaccines, the value of a single FeLV vaccine for feral cats has not been determined. Therefore, FeLV vaccination is not recommended for feral cat trap–neuter– return programs if program resources are needed for higher priorities. FIV vaccination is not recommended for use in shelters or feral cats. Strict adherence to universal precautions is required to prevent iatrogenic transmission of retroviruses in the shelter environment via contaminated equipment and secretions.

*Currently, no test can distinguish FIV antibodies induced by infection from those induced by vaccination. Therefore, shelters have the difﬁcult task of determining the true infection status of stray cats that are admitted without medical histories and that test positive for FIV antibodies. If the cat is microchipped, the history of FIV vaccination may be recorded in an accessible database. However, even if cats are known to have been vaccinated against FIV, determining whether they are also infected is not usually possible. This is a challenge for shelters for which no solution currently exists.

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Limiting Transmission in the Veterinary Practice

FeLV and FIV Diseases

Retroviruses are unstable outside their host animals and can be quickly inactivated by detergents and routine disinfectants.7–11 Simple precautions and routine cleaning procedures prevent transmission of these agents in veterinary hospitals. As a guide:

QuickNotes Retroviruses can be quickly inactivated by detergents and routine disinfectants.

Although many FeLV-/FIV-infected cats experience prolonged survival, retroviral infections can be associated with: Anemia Secondary and opportunistic infections Neoplasia Chronic inﬂammatory conditions Ocular disorders Hematologic disorders

All infected patients should be housed in individual cages when hospitalized and not in isolation/contagious wards where they may be exposed to infectious agents. Hospital staff should wash their hands between patients and after cleaning cages. Because FeLV and FIV can be transmitted in blood transfusions, donors should be tested before donating. A real-time polymerase chain reaction (PCR) test for FeLV is recommended for blood donors because proviral elements in seronegative cats with regressive FeLV infection may cause infection in transfusion recipients. FIGURE 1 2

BOX 2

Speciﬁc diseases associated with very high rate of infection: Cutaneous abscesses (FeLV: 8.8%, FIV: 12.7%)12 Oral inﬂammation (FeLV: 7.3%, FIV: 7.9%)a a

Bellows J, Lachtara JL. Feline retroviruses and oral disease [unpublished]. Reported in: Veterinary Medicine, “Spotlight on Research”; 2006.

FeLV Antigen test

FeLV antigen positive

FeLV antigen negative

All positive results should be conﬁrmed.

Negative screening test results are highly reliable. However, if results are negative but recent infection cannot be ruled out, testing should be repeated a minimum of 30 days after the last potential exposure.

Retest immediately with IFA.

IFA test

FeLV IFA negative

FeLV IFA positive Consider FeLV infected and start appropriate management program.

Discordant results may be due to the stage of infection, the variability of host responses, or technical problems with testing. It is not usually possible to determine the true FeLV infection status of cats with persistently discordant test results. If resolving is desired, retest in 60 days using antigen and IFA.

FeLV test interpretation algorithm—all cats. IFA = immunofluorescence assay

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Dental and surgical instruments, endotracheal tubes, and other items potentially contaminated with body ﬂuids should be thoroughly cleaned and sterilized between uses. Fluid lines, multidose medication containers, and food can become contaminated with body ﬂuids (especially blood or saliva) and should not be shared among patients. Recommendations on testing for and controlling transmission of FeLV and FIV in shelters and catteries are listed in BOX 1.

Diagnosing FeLV and FIV The retroviral status of all cats should be known because the serious health consequences of infection inﬂuence patient management both in illness and wellness care. Failure to identify infected cats may lead to inadvertent exposure and transmission to uninfected cats. Misdiagnosis of infection in uninfected cats may lead to inappropriate changes in lifestyle or even euthanasia. FIGURE 2

Cats should be tested when they are: Sick, regardless of age, despite previous negative test results or previous vaccination. FeLV and FIV are associated with a wide variety of health disorders4,5 (BOX 2). Identiﬁcation of retroviral infection as a complicating factor can assist in the development of optimal management plans. About to be adopted or brought into a new household, regardless of age. Even if no other cats are present in the household, testing will protect future cats that may join the family as well as neighborhood cats, should the pet escape or be allowed outside. At risk of exposure, even if their most recent test was negative. As an example, a 2008 study12 showed that more than 19% of cats with cutaneous abscesses were FIV or FeLV positive at the time of presentation. Because of delay in seroconversion after initial infection, these cats should also be retested (a

FIV Antibody test

FIV antibody positive

Negative screening test results are highly reliable. However, if results are negative but recent infection cannot be ruled out, testing should be repeated a minimum of 60 days after the last potential exposure.

Retest with another antibody test.

> 6 Months of age

Retest at 60-day intervals FIV antibody positive If positive after kitten reaches 6 months of age, consider FIV infected.

ELISA and other immunochromatographic tests are the preferred screening tests for FeLV and FIV.

FIV antibody negative

All positive results should be conﬁrmed. Cats vaccinated with a whole-virus vaccine will test antibody positive.

< 6 Months of age

QuickNotes

Retest immediately with different test

FIV antibody negative If negative at any interval, consider free of infection and begin a wellness program.

FIV antibody positive

FIV antibody negative

Consider FIV infected and continue appropriate management program.

Consider free of infection and begin a wellness program.

Note: False-positive results will exist in vaccinated cats.

FIV test interpretation algorithm—all cats. CompendiumVet.com | June 2009 | Compendium: Continuing Education for Veterinarians®

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minimum of 30 days after the last potential FeLV exposure and 60 days after potential FIV exposure). Of “unknown” viral status. Infected cats can remain asymptomatic for years, during which time they may serve as hidden sources of infection to other cats in the household. About to be vaccinated against FeLV or FIV. These vaccines should not be administered to cats that are already infected. Vaccination does not affect the carrier state, the capacity to infect other cats, or the development of disease in cats with preexisting infection.

from a different manufacturer.18,19 Western blot tests have been the recommended conﬁrmation tests in the past, but they were found to be less sensitive and speciﬁc than in-clinic screening tests in one study.17 Vaccination of cats against FIV induces antiFIV antibodies that cannot be distinguished from natural infection. These antibodies persist for at least 1 year and can be transferred in colostrum to kittens. While PCR assays may help distinguish cats infected with FIV from cats vaccinated against FIV, one study found marked variability in diagnostic accuracy among commercial laboratories.20

Diagnosis of FeLV

QuickNotes Both FeLV-infected and FIV-infected cats can live for many years.

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*** Soluble-antigen tests are preferred for initial screening (FIGURE 1). These include ELISA and Negative results for either FeLV or FIV other immunochromatographic tests. are much more reliable than positive results While screening tests detect the presence of because of the low prevalence of infecfree antigen in the circulating blood, the immu- tion in most cat populations. Positive test nofluorescence assay (IFA) tests for the presence results should be confirmed, especially in of antigen within infected white blood cells and asymptomatic and low-risk cats. No test is platelets. Positive results from tests that detect 100% accurate all the time, under all confree antigen may be reflective of the transient ditions. In cat populations with a low period of antigenemia associated with regres- prevalence (e.g., <1%), more than half of the sive infections. Positive results from tests that cats that test positive are likely to be uninfected.21 Kittens may be tested for FeLV and FIV at detect cell-associated antigen, such as the IFA, are likely to be reflective of progressive infec- any age. Most kittens test negative, indicattions. Tests that use saliva and tears yield an ing no infection. Antibody tests for FIV can unacceptably high percentage of inaccurate detect antibodies passed in colostrum from an infected or vaccinated mother, which can results, and their use is not recommended.13 Although there are no published assessments be mistaken for infection in the kitten. Kittens of diagnostic accuracy of PCR testing for FeLV, that test positive for FIV antibodies should the test is offered by a number of commercial be retested every 60 days up to 6 months laboratories. Recent studies14,15 using real-time of age. If the kitten becomes seronegative, it PCR have shown that 5% to 10% of cats with most likely is not infected. If results of tests negative results on soluble antigen tests were performed after 6 months of age are still conpositive for FeLV provirus by PCR (regressive firmed positive, these kittens should be coninfection). sidered infected. FeLV vaccinations will not induce positive Diagnosis of FIV test results. FIV produces a persistent, lifelong infection, FIV vaccinations will induce positive test so detection of antibodies in peripheral blood results. has been judged sufficient for routine diagnostic screening if the cat has not been previously Managing Positive Cats vaccinated against FIV and has not acquired Both FeLV-infected and FIV-infected cats can live for many years and may succumb at older FIV antibodies in colostrum16,17 (FIGURE 2). ELISA and other immunochromatographic ages to causes unrelated to their retrovirus tests are the preferred screening tests. Confir- infections. In recent studies,22 the median surmation of positive screening tests should include vival after diagnosis of FeLV-infected cats was a different method or at least an antibody test 2.4 years; for FIV-infected cats, it was 4.9 years.

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

September 9-13, 2009

IVECCS 2009 FIFTEENTH INTERNATIONAL VETERINARY EMERGENCY & CRITICAL CARE SYMPOSIUM

Hyatt Regency • Chicago, Illinois

• Basic to specialist level sessions • 14 continuous daily tracks of instruction • Small Animal, Large Animal and Exotics programs • Features over 125 of the profession’s top speakers from the clinical disciplines • Specialist-level information on surgery, internal medicine, anesthesia and nursing, as well as emergency medicine • Over 40 labs and workshops to choose from to focus your educational experience • Over 40 CE credits available

Registration Available Online at www.veccs.org. Offering over 40 hours of comprehensive, progressive and innovative CE that saves Lives! Call 800-948-3227 or logon to the IVECCS website at http://2009.iveccs. org for complete details.

• Research abstracts, case reports, interactive sessions • Outstanding Technician program - 4 1/2 days and 3 continuous tracks • ACVA program to be held at IVECCS • IVECCS Job Fair Wednesday, September 9 • Expanded exhibit hall – over 145 exhibits • Lunch coupons, receptions, exhibit hall happy hour

Thus, a decision for treatment or for euthanasia should never be based solely on the presence of a retrovirus infection.

Infected queens should not be bred and should be spayed if their condition is sufficiently stable to permit them to undergo surgery.

Managing Healthy Positive Cats Examinations should be performed at least twice a year. At each visit: Update medical history. Monitor for any signs of weight loss. Perform a thorough physical examination; pay close attention to the lymph nodes, eyes, and oral cavity. Conduct a complete blood count, biochemical analysis, urinalysis, and fecal examination at least once a year. FeLV-positive cats may need a complete blood count twice a year. Spay or neuter intact cats. Control internal and external parasites. Vaccinate as lifestyle indicates. Most retrovirusinfected cats mount adequate immune responses when vaccinated, and there is no need to modify standard vaccination intervals.23 There is controversy about the use of inactivated versus modiﬁed-live vaccines. Current recommendations are to use inactivated vaccine products due to the theoretical risk of a modiﬁed-live product regaining its pathogenicity in cats with compromised immune systems.

Managing Clinically Ill Positive Cats Prompt and accurate diagnosis is essential to allow early therapeutic intervention and a successful treatment outcome. Therefore, intensive diagnostic testing should proceed early in the course of illness for infected cats. Many cats infected with FeLV or FIV respond as well as their uninfected counterparts to appropriate medications and treatment strategies, although a longer or more aggressive course of treatment may be needed. Few attempts have been made to evaluate antiviral drugs, immunomodulators, or alternative therapies in large controlled studies of naturally infected cats. To date, no treatment has been shown to reverse well-established retrovirus infection in cats. Clients with a healthy or ill retroviruspositive cat may be frightened by the initial diagnosis. It is important to alleviate these fears when appropriate and offer encouraging advice on the proper care and management of the cat (BOX 3). BOX 3

Advice for Owners of Infected Cats Limiting Transmission at Home Confine—Infected cats should be confined indoors so they do not pose a risk of infection to other cats and so they are protected against infectious hazards in the environment. Isolate—The best method of preventing spread to other cats in the household is to isolate the infected cat from interacting with its housemates. Isolation in a separate room is recommended, but a simple screen or chain-link barrier is adequate. Generally, FeLV transmission is low in households with stable social structures where housemates do not fight, but FeLV can still be transmitted via friendly interactions.

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Don’t Introduce—If separation is not possible, no new cats should be introduced in the household to reduce the risk of territorial aggression. If owners choose not to separate retrovirusinfected housemates from their other cats, the uninfected cats should be considered for vaccination. Vaccinated cats should be isolated from infected cats for at least 2 months after the vaccine series. Managing Positive Cats Watch closely for behavioral changes in the cat. Feed a nutritionally balanced diet. Avoid raw diets because of the risk of food-borne bacterial and parasitic infections.

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

References 1. Levy JK, Scott HM, Lachtara JL, Crawford PC. Seroprevalence of feline leukemia virus and feline immunodeﬁciency virus infection among cats in North America and risk factors for seropositivity. JAVMA 2006;228:371376. 2. O’Connor TP Jr, Tonelli QJ, Scarlett JM. Report of the National FeLV/FIV Awareness Project. JAVMA 1991;199:1348-1353. 3. Levy JK, Crawford PC. Feline leukemia virus. In: Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine. 6th ed. Philadelphia: WB Saunders; 2005:653-659. 4. Hoover EA, Mullins JI. Feline leukemia virus infection and diseases. JAVMA 1991;199:1287-1297. 5. Levy JK. Feline immunodeficiency virus update. In: Bonagura J, ed. Current Veterinary Therapy XIII. Philadelphia: WB Saunders; 2000:284-288. 6. Moore GE, Ward MP, Dhariwal J, Al E. Use of a primary care veterinary medical database for surveillance of syndromes and diseases in dogs and cats. J Vet Intern Med 2004;18:386. 7. Francis DP, Essex M, Gayzagian D. Feline leukemia virus: survival under home and laboratory conditions. J Clin Microbiol 1979;9:154-156. 8. van Engelenburg FA, Terpstra FG, Schuitemaker H, Moorer WR. The virucidal spectrum of a high concentration alcohol mixture. J Hosp Infect 2002;51:121-125. 9. Moorer WR. Antiviral activity of alcohol for surface disinfection. Int J Dent Hyg 2003;1:138-142. 10. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006;6:130. 11. Terpstra FG, Van Den Blink AE, Bos LM, et al. Resistance of surface-dried virus to common disinfection procedures. J Hosp Infect 2007;66:332-338. 12. Goldkamp CE, Levy JK, Edinboro CH, Lachtara JL. Seroprevalences of feline leukemia virus and feline immunodeﬁciency virus in cats with abscesses or bite wounds and rate of veterinarian compliance with current guidelines for retrovi-

rus testing. JAVMA 2008;232:1152-1158. 13. Panel report on the colloquium on feline leukemia virus/feline immunodeficiency virus: tests and vaccination. JAVMA 1991;199:1273-1277. 14. Hofmann-Lehmann R, Huder JB, Gruber S, et al. Feline leukemia provirus load during the course of experimental infection and in naturally infected cats. J Gen Virol 2001;82:1589-1596. 15. Gomes-Keller MA, Go¨nczi E, Tandon R, et al. Detection of feline leukemia virus RNA in saliva from naturally infected cats and correlation of PCR results with those of current diagnostic methods. J Clin Microbiol 2006;44:916-922. 16. Hartmann K. Feline immunodeficiency virus infection: an overview. Vet J 1998;155:123-137. 17. Levy JK, Crawford PC, Slater MR. Effect of vaccination against feline immunodeficiency virus on results of serologic testing in cats. JAVMA 2004;225:1558-1561. 18. Barr MC. FIV, FeLV, and FIPV: interpretation and misinterpretation of serological test results. Semin Vet Med Surg Small Anim 1996;11:144-153. 19. Hartmann K, Werner RM, Egberink H, Jarrett O. Comparison of six inhouse tests for the rapid diagnosis of feline immunodeficiency and feline leukemia virus infections. Vet Rec 2001;149:317-320. 20. Bienzle D, Reggeti F, Wen X, et al. The variability of serological and molecular diagnosis of feline immunodeficiency virus infection. Can Vet J 2004;45:753-757. 21. Jacobson RH. How well do serodiagnostic tests predict the infection or disease status of cats? JAVMA 1991;199:1343-1347. 22. Levy JK, Lorentzen L, Shields J, Lewis H. Long-term outcome of cats with natural FeLV and FIV infection. In: 8th Int Feline Retrovirus Res Symp 2006. 23. Richards JR, Elston TH, Ford RB, et al. The 2006 American Association of Feline Practitioners Feline Vaccine Advisory Panel Report. JAVMA 2006;229:1405-1441.

OCTOBER 12–15, 2009 Atlantic City Convention Center

Atlantic Coast Veterinary Conference Offering the best value in veterinary continuing education — plus the excitement of Atlantic City! Check out everything that's included in your registration fee: • WORLD CLASS CE in a relaxed, smoke-free environment, featuring more than 40 of the foremost veterinary speakers across the United States • Breakfast and lunch included Tuesday, Wednesday & Thursday • “Ask The Professor” Lunch Sessions • Proceedings on-line (pre-conference) and provided on CD-ROM (also available in printed version) • Access to over 200 of the leading suppliers of veterinary goods and services will be exhibited

• We provide over 330 hours of stimulating education in an environment that emphasizes the entire veterinary team • 23 RACE approved Continuing Education credits • Wet labs for veterinarians: Ultrasound, Rigid Endoscopy, Ear Therapeutics, Stifle Procedures, Tibial Tuberosity Advancement, and more! • Wet labs for technicians: Animal Behavior, Canine CPR, Dental Radiography, Clinical Chemistry, Instrument Care, and more! Wet Lab Space is Limited! Be sure to register early!

www.acvc.org 390 Amwell Road, Suite 403, Hillsborough, NJ 08844 p 908.359.1184 | f 908.450.1340 | CompendiumVet.com e info@acvc.org | June 2009 | Compendium: Continuing Education for Veterinarians®

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In collaboration with the American College of Veterinary Surgeons

Laparoscopic and Laparoscopic-Assisted Cryptorchidectomy in Dogs and Cats ❯❯ Philipp Mayhew, BVM&S, MRCVS, DACVS Columbia River Veterinary Specialists Vancouver, Washington

Abstract: There are many applications for laparoscopy in small animal surgery. A relatively simple one is abdominal cryptorchid castration. Laparoscopic examination of the peritoneal cavity can both aid in the diagnosis of abdominal cryptorchidism and allow treatment using either a totally laparoscopic or a laparoscopic-assisted technique. Minimally invasive cryptorchid castration obviates the need for “open” celiotomy and may thereby reduce postoperative discomfort and wound-related complications in these patients.

At a Glance Advantages Page 275

Disadvantages Page 275

Preoperative Assessment Page 275

Instrumentation Page 276

Surgical Techniques Page 278

TO LEARN MORE

For a description of conventional surgical approaches to cryptorchid testes, see the June 2008 article “Cryptorchidism,” available at

CompendiumVet.com.

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uring embryonic development in male dogs and cats, contraction of the gubernaculum causes progressive migration of the testes from a location just caudal to the kidney to their normal position in the scrotum.1 This migration is typically complete by 2 months of age but can take place as late as 6 months of age in some breeds.1 The cause of cryptorchidism has not been completely elucidated but is likely multifactorial.1 Migration of the testis can cease at any time, with the result that one or both testes can remain in the peritoneal cavity, within the inguinal rings, or in the inguinal area cranial to the scrotum. Owners should be advised that there are several important reasons to castrate a cryptorchid pet. First, cryptorchidism is thought to be a sex-linked autosomal recessive trait in dogs. Further breeding could lead to propagation of this undesirable trait. Second, cryptorchid testes are prone to several pathologic states. CE Article #1

Cryptorchidism Stephen J. Birchard, DVM, MS, DACVS Michael Nappier, DVM The Ohio State University

ABSTRACT: Cryptorchidism is a common clinical problem in dogs and cats. Retained testes can

be unilateral or bilateral, are usually small and atrophied, and vary in location.These factors make

diagnosis and surgical removal challenging in some animals. Diagnosis is confirmed using a variety of

modalities, including diagnostic imaging in difficult cases. Surgical removal of the affected and normal

testes is the treatment of choice.The surgical approach and technique used depend on the location of the retained testis.

ryptorchidism is one of the most common congenital defects seen in small animal practice. In dogs, the reported prevalence of cryptorchidism ranges from 0.8% to 10%.1 The defect is a sex-linked autosomal recessive trait that is common in certain breeds,2 such as Chihuahuas, miniature schnauzers, Pomeranians, poodles, Shetland sheepdogs, and Yorkshire terriers. Smaller breeds are 2.7 times more likely to be cryptorchid than larger breeds.3 In cats, one study found Persians to be predisposed to cryptorchidism.4 Due to the thermal suppression of sperm production, bilaterally cryptorchid animals are sterile, while unilaterally cryptorchid animals are usually fertile.5 Undescended testes are 13.6 times more likely to develop neoplasia (Figure 1) than normal testes and are at increased risk of torsion.6,7 Undescended testes vary in their anatomic position. They may be located in the prescrotal area, inguinal region, or abdominal cavity. In a study of 240 cryptorchid dogs and 50 cryptorchid cats, retained testes were most commonly found in the right inguinal region in • Take CE tests dogs and in the left or right • See full-text articles inguinal region in cats.8 LocatCompendiumVet.com ing an ectopic testis can be dif-

June 2008

325

ficult in some animals. A thorough and systematic approach to patient evaluation is necessary to efficiently find and remove the abnormal testis. Although surgery for removal of cryptorchid testes is well described in the veterinary literature, approaches to diagnosis and localization of ectopic testes have not been extensively described. This lack, coupled with the increasing number of animals that present with an unknown neutering history (e.g., rescue animals), emphasizes the need for a discussion of a thorough clinical approach to cryptorchidism. This article describes a systematic approach to the diagnosis and surgical treatment of cryptorchidism in dogs and cats, including the integration of the history; physical examination; blood tests, including hormone assays; and diagnostic imaging to make a definitive anatomic diagnosis. Various options for surgical removal of the retained testis are also described.

DIAGNOSIS History Most authors agree that if one or both testes are not present in the scrotum by 2 months of age, the animal is cryptorchid. 2 It is highly unlikely that the testes will descend into the scrotum after this age. The clinical signs of COMPENDIUM

Testicular tumors develop much more frequently in cryptorchid testes than in scrotal testes. In one study, the risk of tumor development in cryptorchid testes was 13.6 times the risk in scrotal testes.2 Inguinally retained testes appear to be at even higher risk of developing neoplasia than abdominally retained testes.3 The risk of testicular torsion is also increased for cryptorchid testes, with torsed testes often being neoplastic.4 If, on physical examination, one or both testes are not present inguinally or scrotally, the missing testis is most likely within the peritoneal cavity. Palpation should be performed carefully because cryptorchid testes are often smaller than descended testes and can be difﬁcult to ﬁnd. Traditionally, abdominal testes have been removed through either a ventral midline celiotomy or a parapreputial laparotomy.5 Totally laparoscopic or laparoscopic-assisted techniques now exist, allowing removal of intraabdominal testes through much smaller incisions. Neoplastic cryptorchid testes can also be removed laparoscopically, although if the tumor is very large, open surgery may remain more practical.

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

Advantages A minimally invasive approach to abdomi-nal cryptorchid testis removal reduces tissue trauma and is likely to reduce postoperative pain and wound healing complications com-pared with open laparotomy. If localization of a cryptorchid testis is challenging, laparo-scopic examination of the caudal peritoneal cavity and the entrance to the inguinal rings provides excellent visualization and can help to rule out the diagnosis of abdominal cryptorchid-ism. This may help to minimize iatrogenic dam-age to surrounding structures, which has been attributed in some cases to inadequate visual-ization when small paramedian laparotomies are performed. Such damage includes inad-vertent prostatectomy and ureteral or urethral trauma.6–8

Disadvantages The principal disadvantage of laparoscopy is the need for specialized equipment and the associ-y ated costs. Adequate training is also necessary to perform laparoscopic procedures and to use the equipment appropriately. Although surgi-cal time can initially be longer than that for an open procedure, with experience, laparoscopic cryptorchidectomy is likely to become as efﬁcient, if not faster than, its open counterpart.

Preoperative Assessment A careful history should be taken for any male cat or dog in which two testes cannot be palpated in the inguinal area to ensure that one or both testes have not been removed previously. Generally, a male dog or cat in which one or both testes are absent from the scrotum at 6 months of age is classified as cryptorchid because scrotal migration of a testis after this time is extremely unlikely.1 It is important to assess the inguinal area carefully with the animal under heavy sedation or general anesthesia so as not to miss the presence of an inguinal testis. If one testis is present scrotally and one abdominally, it is also helpful to identify whether the right or left testis is present

It is with great pleasure that I announce the new partnership of the American College of Veterinary Surgeons (ACVS) with Compendium in the “Surgical Views” series. The expertise and experience of the ACVS Diplomates will add greatly to the value of the series. Elizabeth M. Hardie, DVM, PhD, DACVS North Carolina State University

The ACVS is proud to enter into this new cooperative venture with Compendium and series editor Elizabeth Hardie. The ACVS is well known as a world leader in developing innovative surgical procedures and disease research, yet continuing education is also one of the pillars of the College. In addition to presenting at our yearly symposium, ACVS Diplomates host and produce much of the continuing education in veterinary surgery in the United States. Now, with this collaboration, we are expanding our education outreach to a new venue. The ACVS hopes you will enjoy and proﬁt from our Diplomates’ contributions to this distinct continuing education effort. Larry R. Bramlage, DVM, MS, DACVS Chair, ACVS Board of Regents

To locate a Diplomate, ACVS has an online directory that includes practice setting, species emphasis, and research interests (acvs.org/VeterinaryProfessionals/FindaSurgeon).

QuickNotes Generally, a male dog or cat in which one or both testes are absent from the scrotum at 6 months of age is classiﬁed as cryptorchid because scrotal migration of a testis after this time is extremely unlikely.

within the peritoneal cavity. This can be done by gentle manipulation of the scrotal testis in a cranial direction, which will usually reveal the side on which it is located. If no inguinal testes are palpated, it can be assumed that the missing testes are in either the inguinal canal (which is uncommon) or the abdomen. Abdominal ultrasound can be used to conﬁrm the presence SURGICAL of abdominal or inguinal canal testes VIDEO in most cases. If doubt still remains about the presence or absence of testes, a human chorionic gonadotropin To see a video of manipulation to stimulation test can be performed to identify which testis is cryptorchid, conﬁrm the presence of testicular tisvisit CompendiumVet.com. sue.5 For this test, serum samples are

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FIGURE 1

FIGURE 2

In many cases, the cryptorchid testis is readily visible during initial visualization of the peritoneal cavity. In this case, the testis can be seen on the right side, lateral to the descending colon and bladder.

Port position for a totally laparoscopic approach for abdominal cryptorchidectomy in a dog. The subumbilical telescope port is placed first, followed by two paramedian instrument ports.

QuickNotes Laparoscopic examination of the caudal abdomen is a minimally invasive modality for conﬁrming the presence or absence of abdominal testes.

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Laparoscopic examination of the caudal abdomen is a minimally invasive modality for conﬁrming the presence or absence of abdominal testes, and laparoscopic or laparoscopicassisted techniques have been described for removal of abdominally cryptorchid testes.

collected before and 2 hours after administra- Instrumentation tion of human chorionic gonadotropin (50 IU/ As well as the basic components of an endokg IM) and submitted for testosterone assay. scopic tower,10 other equipment required to Unilateral or bilateral monorchidism is very perform laparoscopic and laparoscopic-assisted rare; therefore, it is most likely that abdomi- cryptorchidectomy includes a laparoscope, two nal testes are present,7,9 making exploration of or three trocar–cannula assemblies, and lapthe peritoneal cavity a reasonable next step. aroscopic surgical instruments. The most comTypically, exploration is accomplished via open monly used laparoscope size is 5 or 10 mm, and surgery through a ventral midline celiotomy or the most common lens angles are 0° and 30°. a paramedian laparotomy.5 In cats, a standard Trocar–cannula assemblies can be disposable or ventral midline laparotomy that must usually reusable and are usually 6 mm in diameter to extend caudally to the pubis is performed. ﬁt 5-mm instrumentation. Typically, sterilizable, reusable cannulas are more cost-effective than single-use devices for veterinary use. TO LEARN MORE Instruments essential for laparoscopic cryptorchidectomy include a blunt probe for tissue manipulation and Kelly or Babcock forceps for grasping the testis, spermatic cord, and Basic laparoscopic equipment and the Hasson gubernaculum. For hemostasis during totally and Veress needle techniques are described in the August 2008 article, “Canine Laparoscopic laparoscopic cryptorchidectomy, either a vesand Laparoscopic-Assisted sel-sealing device (e.g., Ligasure [Valleylab Inc., Ovariohysterectomy and Boulder, CO], Enseal [Ethicon Endosurgery, Ovariectomy,” available at Cincinnati, OH], Harmonic Scalpel [Ethicon CompendiumVet.com. Endosurgery, Cincinnati, OH]) can be used. A video demonstrating If these devices are not available, hemostasis the Hasson technique can be achieved using either hemostatic clips is also available at dispensed by a laparoscopic clip applier or CompendiumVet.com. extracorporeal suturing. A knot pusher is used

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

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Whether dogs live in a condo or in the backyard, more of them than ever are at risk for leptospirosis – a deadly, zoonotic disease spread by rats, raccoons, squirrels and other wildlife.1,2,3 Protect your patients with LeptoVax™. Its unique subunit purification process is designed to reduce cellular debris for enhanced safety. And with six convenient combinations to choose from, LeptoVax easily accommodates your canine patients and protocols. Contact your Fort Dodge Animal Health representative. Because, wild as it seems, chances are lepto is in your neighborhood, too.

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©2008 Fort Dodge Animal Health, a division of Wyeth. 1. Michael P. Ward, et al. Prevalence of and risk factors for leptospirosis among dogs in the United States and Canada: 677 cases (1970-1998). JAVMA, Vol. 220, No. 1, January 1, 2002. 2. George E. Moore, et al. Canine Leptospirosis, United States, 2002-2004. Emerging Infectious Diseases, www.cdc.gov/ncidod/eid/vol12no03/05-0809.htm. Vol. 12, No. 3, March 2006. 3. Michael P. Ward, et al. Evaluation of environmental risk factors for leptospirosis in dogs: 36 cases (1997-2002). JAVMA, Vol. 225, No. 1, July 1, 2004.

FIGURE 3

The spermatic cord and vascular pedicle of the testis can be seen entering the inguinal ring in this dog. This finding confirms that the testis is located extraperitoneally.

to place extracorporeal sutures. If a testicular tumor is suspected, resection and placement into a specimen retrieval bag before removal from the peritoneal cavity is advised to avoid port site metastasis.

QuickNotes The possibility of conversion to an open approach should always be anticipated with any laparoscopic procedure.

SURGICAL VIDEO

Surgical Techniques Patient Preparation and Positioning Dogs and cats with cryptorchid testes should be positioned in dorsal recumbency on the surgical table. The inguinal area should be thoroughly palpated again to rule out an inguinally located testis and prevent unnecessary laparotomy or laparoscopy. The entire ventral abdomen from the scrotum to the xiphoid process and laterally to the midabdominal level should be aseptically prepared, as the possibility of conversion to an open approach should always be anticipated with any laparoscopic procedure. After initiating the pneumoperitoneum, place the animal in a 20° to 30° “head down” (Trendelenburg) position to allow caudal peritoneal organs to move cranially, thus improving visualization of the area. In some cases, it may also be beneﬁcial to tilt the animal laterally to better visualize one or both testes.

To see a video of the use of a vessel-sealing device to seal and section the gubernaculum, spermatic cord, and vascular pedicle, visit CompendiumVet.com.

278

FIGURE 4

Only the gubernaculum (no vascular pedicle or spermatic cord) can be seen entering the inguinal ring in this dog. This confirms that the testis is within the abdomen, and a thorough examination of the caudal peritoneal cavity should reveal its location.

Once the telescope port has been established, an instrument port can be established using a 5or 10-mm trocar–cannula assembly under direct visualization in a paramedian location (lateral to the prepuce in dogs; in the left or right caudal quadrant of the abdomen in cats) on the right or left side, depending on which testis is located in the abdomen. Every effort should be made to avoid iatrogenic damage to the caudal superﬁcial epigastric vessels during cannula placement. In most bilaterally cryptorchid animals, the side that the instrument port is placed on is not critical because both testes will still be retrievable from the same port.9 A totally laparoscopic technique is usually performed using a three-port technique. A two-port technique can be used if an operating laparoscope with a working channel is used. A camera port should be placed in a subumbilical position. Two more instrument ports are established in paramedian (lateral to the prepuce) positions on both sides of the prepuce in dogs (FIGURE 1) and in a triangulating position around the caudal abdomen in cats.

Exploration of the Caudal Peritoneal Cavity Port Position Laparoscopic-assisted cryptorchidectomy can be performed using a two-port technique. A telescope port is established in a subumbilical location, using either the Hasson technique or a Veress needle technique. These techniques were described in an earlier Surgical Views article.10

In many cases, after establishment of a pneumoperitoneum, the abdominal testis can be seen immediately on entering the peritoneal cavity with the laparoscope (FIGURE 2). However, if confusion exists, the area of the internal inguinal ring should be visualized. If the spermatic cord and vascular pedicle of the testis are seen entering the ring, the testis is in an extraperito-

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

neal location, either within the inguinal canal or (more likely) in an inguinal location (FIGURE 3). The surgeon should reevaluate the inguinal area if no testis was palpated in that location previously. If only the gubernaculum is seen entering the inguinal ring, the testis is located within the peritoneal cavity, and further inspection of the caudal abdomen usually locates it. Gentle traction can also be placed on the gubernaculum to help in localization (FIGURE 4). In some cases, the testis is obscured by the bladder or other surrounding structures.

Laparoscopic-Assisted Cryptorchidectomy The laparoscopic-assisted cryptorchidectomy technique provides a rapid, simple way to recover an abdominal testis and ligate the vascular pedicle and spermatic cord outside the abdominal cavity, thereby obviating the need for intracorporeal ligation techniques.9 In this technique, laparoscopic Kelly or Babcock forceps are placed through the instrument port to grasp the testis or the spermatic cord. At this point, it is helpful to evacuate the pneumoperitoneum to decrease tension during elevation of the testis. Enlarge the port incision by separating the parallel ﬁbers of the rectus abdominus just enough to remove the

Clinical Pearls Laparoscopic examination of the caudal peritoneal cavity can be very helpful in localizing cryptorchid testes and can prevent an unnecessary celiotomy. Laparoscopic-assisted abdominal cryptorchidectomy is a simple, rapid technique that does not require specialized equipment beyond the basic laparoscopic instrumentation. In many cases, neoplastic cryptorchid testes can be removed using a laparoscopic technique. If the testis is ≥8 cm in diameter or has signiﬁcant adhesions to surrounding structures, it may be more practical to perform a ventral midline celiotomy.

testis from the peritoneal cavity. Once the testis has been exteriorized, clamp and double ligate the spermatic cord and vascular pedicle before sectioning. It is important to ensure that ligated pedicles are not bleeding and do not become caught in the subcutaneous fat or muscular tissue of the body wall as they are returned to the peritoneal cavity. If both testes are in the peritoneal cavity, they can usually be recovered through the same port incision. To locate the second testis, reestablish the pneumoperitoneum. If the instrument port was enlarged to recover the first testis, use a larger cannula, hold a moistened sponge around the cannula, or place a temporary purse-string suture around the cannula to prevent leakage of carbon dioxide during reinsertion of the cannula. The second testis can then be withdrawn and ligated in the same manner as the first. If the second testis cannot be advanced to the port site, establish a third port on the opposite side of the prepuce (FIGURE 1) and follow the above steps to withdraw the second testis, although in my experience, this is unlikely to be necessary. The port site incision(s) should then be closed, making sure that the ventral sheath of the rectus abdominus is adequately sutured to prevent herniation of abdominal contents, which can occur through defects as small as 5 mm. After closure of the instrument port incisions and before closure of the telescope port, it is advisable to briefly reestablish the pneumoperitoneum and reinsert the telescope to ensure that good hemostasis has been maintained. Finally, remove the telescope, thoroughly purge the pneumoperitoneum from the peritoneal cavity, and close the telescope portal routinely.

QuickNotes If both testes are in the peritoneal cavity, they can usually be recovered through the same port incision.

Totally Laparoscopic Cryptorchidectomy In the totally laparoscopic cryptorchidectomy technique, the vascular supply and spermatic cord are ligated within the peritoneal cavity before the testis is removed from the abdomen. If the testis is directly visible, it can be grasped with laparoscopic Kelly or Babcock forceps and elevated (FIGURE 5), allowing the vascular pedicle and spermatic cord to be moved away from surrounding structures in readiness for ligation. A vessel-sealing device can be placed into the second instrument port, and the guberCompendiumVet.com | June 2009 | Compendium: Continuing Education for Veterinarians®

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FIGURE 5

The testis is elevated for totally laparoscopic cryptorchidectomy to allow better access to the vascular pedicle and spermatic cord during intracorporeal ligation of these structures.

naculum, spermatic cord, and vascular pedicle sealed and subsequently sectioned. The vascular pedicle can be substantial in large dogs, and care should be taken to ensure adequate hemostasis. The Ligasure and Enseal devices are both indicated to seal vessels up to 7 mm in diameter, and I have used them to seal the pampiniform plexus effectively. However, it QuickNotes is suggested that the vascular pedicle be double The vascular pedicle sealed—once proximally and once distally— before sectioning (FIGURE 6). If a vessel-sealcan be substantial ing device is not available, hemostasis can be in large dogs, and achieved using hemostatic clips delivered via a care should be laparoscopic clip applier. Although 5-mm laptaken to ensure ade- aroscopic clip appliers are available, medium quate hemostasis. or large clips are generally delivered in a 10-mm clip applier. To reduce costs associated with the use of expensive single-use disposable clip appliers, multiﬁre sterilizable clip appliers that can be loaded with cartridges of clips are available (M/L-10, Microline Pentax, Beverly, MA). Another alternative for achieving hemostasis of the pedicle is the placement of extracorporeal ligatures. To place extracorporeal sutures, pass a piece of suture material through one cannula and around the pedicles. Withdraw the suture through the same SURGICAL cannula, tie a modiﬁed Roeder knot VIDEO outside the peritoneal cavity, push the knot into place through the cannula, To see a video of testis and tighten it around the pedicle using removal through the a laparoscopic knot pusher.11 Although subumbilical port, visit this is the least expensive technique CompendiumVet.com. (it does not require any expensive

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FIGURE 6

The vascular pedicle after sectioning using the vessel-sealing device. The pedicle has been sealed in two different locations approximately 1 cm apart to ensure good hemostasis.

disposable equipment), it is likely to be the most time-consuming because these sutures are tedious to place; however, a rapid learning curve has been seen in studies that used extracorporeal suturing.12 When laparoscopic cryptorchidectomy is performed, the testis must be withdrawn through one of the ports. One of the parapreputial ports can be used for this purpose, or the telescope can be replaced into one of the instrument ports and the testis withdrawn through the subumbilical port. If the subumbilical port is used, any enlargement of the port incision will be through the linea alba, resulting in less muscular trauma and therefore possibly less postoperative pain than if a paramedian instrument port is enlarged. After laparoscopic cryptorchidectomy, it is not necessary to reestablish the pneumoperitoneum because the pedicles are inspected for hemostasis immediately after they have been sealed or ligated and sectioned. After the testis has been removed, all remaining ports can be closed routinely.

Resection of Neoplastic or Torsed Cryptorchid Testes Cryptorchid testes are predisposed to neoplasia and torsion, both of which are indications for surgical excision.1–4 Whether a laparoscopic approach is feasible in these situations depends on several variables. If the testis is very large (8 to 10 cm), a laparoscopic approach may be less practical because a large incision will be required to retrieve the testis after its pedicles have been ligated. A second potential problem

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

is the presence of adhesions to other structures, speciﬁcally the bladder, ureters, prostate, and lower gastrointestinal tract. If the surgeon has any concern about the involvement of these structures or encounters technical difﬁculties while dissecting adhesions, conversion to an open approach should be considered. However, laparoscopic resection of a neoplastic testis has been reported in the veterinary

literature.13 In my experience, most neoplastic abdominally cryptorchid testes remain small and mobile enough to be resected laparoscopically in a manner similar to those described above for removal of nonneoplastic testes. If a testis is suspected to be neoplastic, it should be placed in a specimen retrieval bag before being pulled through the instrument port to reduce the possibility of port-site metastasis.

References 1. Romagnoli SE. Canine cryptorchidism. Vet Clin North Am Small Anim Pract 1991;21:533-544. 2. Hayes HM, Pendergrass TW. Canine testicular tumors: epidemiological features of 410 dogs. Int J Cancer 1976;18:482-487. 3. Reif JS, Maguire TG, Kenney RM, et al. A cohort study of canine testicular neoplasia. JAVMA 1979;175:719-723. 4. Pearson H, Kelly DF. Testicular torsion in the dog: a review of 13 cases. Vet Rec 1975;97:200-204. 5. Birchard SJ, Nappier M. Cryptorchidism. Compend Contin Educ Pract Vet 2008;30:325-336. 6. Bellah JR, Spencer CP, Salmeri KR. Hemiprostatic urethral avulsion during cryptorchid orchiectomy in a dog. JAAHA 1989;25:553556. 7. Millis DL, Hauptman JG, Johnson CA. Cryptorchidism and monorchidism in cats: 25 cases (1980-1989). JAVMA 1992;200: 1128-1130. 8. Schultz KS, Waldron DR, Smith MM. Inadvertant prostatecto-

my as a complication of cryptorchidectomy in four dogs. JAAHA 1996;32:211-214. 9. Miller NA, Van Lue SJ, Rawlings CA. Use of laparoscopic-assisted cryptorchidectomy in dogs and cats. JAVMA 2004;224:875878. 10. Gower S, Mayhew PD. Canine laparoscopic and laparoscopicassisted ovariohysterectomy and ovariectomy. Compend Contin Educ Pract Vet 2008;30:430-440. 11. Stoloff DR. Laparoscopic suturing and knot tying techniques. In: Freeman LJ, ed. Veterinary Endosurgery. St. Louis: Mosby; 1999:85. 12. Mayhew PD, Brown DC. Comparison of three techniques for ovarian pedicle hemostasis during laparoscopic-assisted ovariohysterectomy. Vet Surg 2007;36:541-547. 13. Pena FJ, Anel L, Dominguez JC, et al. Laparoscopic surgery in a clinical case of seminoma in a cryptorchid dog. Vet Rec 1998;142:671-672.

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Quick Course Factors to Consider When Choosing Kitten Vaccines At no time are cats at greater risk for disease than in the first few months of life.1 That’s why it’s important to vaccinate kittens early to induce immunity before they are exposed to pathogens. “Maternal antibodies can block the kitten’s ability to respond to a vaccine,”2 according to Alice Wolf, DVM, DACVIM, DABVP, emeritus/adjunct professor at Texas A&M University College of Veterinary Medicine and chief medical consultant for the Veterinary Information Network. “Every kitten has a different level of maternal antibodies— even kittens from the same litter—and these antibodies can persist for different periods of time.” Some kittens have very low or no maternal antibodies at 6 weeks

of age.3 Studies have also shown that maternal antibody interference may persist beyond 14 weeks of age.2–4 To compensate for variations in maternal immunity, initial kitten vaccinations should begin at 6 to 8 weeks of age and continue at 3- to 4week intervals until the kitten is at least 16 weeks of age.5 Practitioners are encouraged to consult the 2006 American Association of Feline Practitioners (AAFP) feline vaccination guidelines for complete vaccine recommendations.

for adult cats, the AAFP strongly recommends vaccinating kittens against this disease. In an experimental study, susceptibility to FeLV decreased with age, but young kittens were most vulnerable.6 Persistent viremia occurred with 100% of cats infected with FeLV as newborns, 85% of cats exposed between 2 weeks and 2 months of age, and 15% of cats infected at 4 months to 1 year of age.6 Even though owners may claim a kitten is a strictly indoor pet, kittens can escape or owners may eventually allow them outdoors.

The Case for FeLV Vaccination Although vaccination for feline leukemia virus (FeLV) is considered noncore

Choosing the Right Vaccines Some vaccine components, such as preservatives, adjuvants, or pH, can contribute to local inflammation.2 Chronic inflammation has been implicated as a potential factor in the development of vaccine-associated sarcomas (VAS).7 Although the precise cause of VAS is not known, the AAFP Feline Vaccine Advisory Panel suggests using less inflammatory products whenever possible.5 Most products today are killed, modified-live virus (MLV), or recombinant canarypox-vectored vaccines. Killed virus vaccines generally require an adjuvant to bolster the immune response. Most MLV and recombinant feline vaccines, on the other hand, are capable of stimulating an effective immune response without

POSTINJECTION LUMPS: THE 3-2-1 RULE Most postvaccination lumps usually resolve within a few weeks. However, lumps that persist for more than 3 months after the injection, are larger than 2 cm in diameter, or continue to increase in size 1 month after injection should be investigated.5 In these cases, a biopsy and chest radiographs can help determine the diagnosis and prognosis. Cats with vaccine-associated sarcomas require aggressive treatment, and, if possible, injectable vaccines should be discontinued in the future in these cats.5

Sponsored by an educational grant from Merial

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Primary Kitten Vaccine Series5 Initial Dosea

Booster Intervals

Feline panleukopenia virus (FPV)

As early as 6 weeks of age

Every 3 to 4 weeks

Feline herpesvirus-1 (FHV-1)

As early as 6 weeks of age

Every 3 to 4 weeks

Feline calicivirus (FCV)

As early as 6 weeks of age

Every 3 to 4 weeks

Rabies

As early as 8 weeks of age or 12 to 16 weeks of age

Vaccine

Considerations

Core Vaccines

Single dose in the first year; follow state or local statutes

Recommended Vaccine Feline leukemia virus (FeLV) aDepends

As early as 8 weeks of age

One booster 3 to 4 weeks later

Kittens should test negative for FeLV before vaccination

on the vaccine.

adjuvants. The canarypox-vectored recombinant vaccines, for example, stimulate protective immunity and reduce the potential risks associated with an adjuvant. Another way to potentially reduce inflammation at the injection site is with the needle-free VET JET® transdermal delivery system. Compared with conventional needles and syringes, this system disperses a smaller volume of vaccine (0.25 ml) into the tissue through a tiny orifice (about the diameter of a 36gauge needle). Discussing Vaccine Issues with Clients Owners should be instructed to monitor their kittens for signs of possible vaccine reactions. “The most common reaction is a mild malaise or fever that may last for 24 hours,” explains Dr. Wolf. “That’s simply the immune system responding to the vaccine.” Mild swelling at the vaccine site may also occur and generally resolves within

a few weeks. However, a lump that persists or grows can be a sign of VAS. Although the risk of VAS is relatively low (approximately one to two cases per 10,000 vaccinated cats 8,9), the probability that a kitten will be exposed to a potentially fatal disease is considerably higher.10 Still, vaccines are important, even for indoor kittens. “It’s possible for owners to track the panleukopenia virus into the house,” according to Dr. Wolf, “and while less likely, owners can bring respiratory viruses home on their clothing.”11 Kittens may also be exposed to sick cats through porch screens or when boarded, groomed, or traveling with their owners. “Certainly, all kittens need to receive their core vaccines,” says Dr. Wolf. REFERENCES 1. Richards J, Rodan I: Feline vaccination guidelines. Vet Clin North Am Small Anim Pract (31)3:455−472, 2001. 2. Greene CE, Schultz RD: Immunophylaxis, in Greene CE (ed): Infectious Diseases of the Dog and Cat, ed. 3. St. Louis, Saunders Elsevier,

2006, pp. 1069–1119. 3. Dawson S, Willoughby K, Gaskell R, et al: A field trial to assess the effect of vaccination against feline herpesvirus, feline calicivirus and feline panleukopenia virus in 6-week-old kittens. J Feline Med Surg 3:17–21, 2001. 4. Reese MJ, Patterson EV, Tucker SJ, et al: The effect of anesthesia and surgery on serological responses to vaccination in kittens. JAVMA 233(1):116–121, 2008. 5. AAFP Advisory Panel: The 2006 American Association of Feline Practitioners Feline Vaccine Advisory Panel Report. JAVMA 9(1):1405–1441, 2006. 6. Hoover EA, Olsen RG, Hardy WD Jr, et al: Feline leukemia virus infection: Age-related variation in response of cats to experimental infection. J Natl Cancer Inst 57:365–369, 1976. 7. Macy DW, Hendrick MJ: The potential role of inflammation in the development of postvaccinal sarcomas in cats. Vet Clin North Am 26(1): 103–108, 1996. 8. Kass PH, Barnes WG Jr, Spangler WL, et al: Epidemiologic evidence for a causal relation between fibrosarcoma and tumorgenesis in cats. JAVMA 203:396–405, 1993. 9. Esplin DG, McGill LD, Meininger AC, et al: Postvaccination sarcomas in cats. JAVMA 202:1245–1247, 1993. 10. Tizard IR: The uses of vaccines, in Veterinary Immunology: An Introduction, St. Louis, Saunders Elsevier, 2009, pp. 270−285. 11. Gaskell RM, Dawson S, Radford A: Feline respiratory disease, in Greene CE (ed): Infectious Diseases of the Dog and Cat, ed. 3. St. Louis, Saunders Elsevier, 2006, pp. 145−154.

This information has not been peer reviewed and does not necessarily reflect the opinions of, nor constitute or imply endorsement or recommendation by, the Publisher or Editorial Board. The Publisher is not responsible for any data, opinions, or statements provided herein. VAC08PBKITTENVACQCR

CE Article 1

Feline Obesity: Clinical Recognition and Management ❯❯ Debra L. Zoran, DVM, MS, PhD, DACVIMa Texas A&M University

At a Glance Preventing Obesity Page 284

Steps in a Weight-Loss Program for an Obese Cat Page 286

Clinical Evaluation of Obese Cats Page 287

Methods of Assessing Body Condition Page 288

Obesity and Diet Page 289

Creating a Treatment Plan Page 291

a Dr. Zoran discloses that she has received ﬁnancial support from Nestlé Purina Petcare and Pﬁzer Animal Health.

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Abstract: Obesity is one of the most common clinical problems in cats presenting to veterinary practitioners. Because it is a risk factor for other conditions, such as diabetes mellitus and hepatic lipidosis, it not only increases the morbidity of affected cats but may also shorten their life span. In cats, a body weight of greater than 20% over the ideal weight of the animal is generally accepted as obese. The goal of this article is to help all members of the health care team understand how to prevent the development of obesity in young cats and, when confronted with an obese adult cat, how to develop a safe and effective weight-loss program.

epending on the study cited, the number of obese or overweight cats in Western societies ranges from 15% to 35%, with practitioners estimating even higher numbers in some areas.1–5 A body weight of greater than 20% over the ideal weight of the animal is generally accepted as obese for cats, which means that a 4-kg (9-lb) cat that gains 1 kg (2 lb) is considered obese. Obesity in cats not only is a cosmetic problem but also increases the risk of development of diabetes6 and hepatic lipidosis7 and is associated with increased incidences of many other conditions, such as lower urinary tract disease and osteoarthritis.8 Presuming that obesity in cats is similar to that in dogs and humans, this condition will also shorten the life span of affected cats.8–11 Considering the number of cats already affected and the great difﬁculty in getting a 12-kg (25-lb) cat to weigh 4.5 kg (10 lb) again, it is clear that the situation demands veterinarians’ full attention.

Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

Preventing Obesity The commonly stated reason for development of obesity is that an animal is consuming more energy than it is expending.12 This energy imbalance can be due to excessive dietary intake of calories or a reduction in energy expenditure. However, obesity is not just a simple matter of intake or output. Many other factors that can influence or control appetite, metabolism, and homeostasis, including genetic predisposition, sex, neuter status, and hormonal disturbances, may play significant roles in the development of obesity.5,8,12 As a result, it is important to make a concentrated effort to recognize risk factors, monitor young and middle-aged cats carefully to detect excess weight gain early, promote the importance of obesity prevention and the health benefits of weight control from the first veterinary visit, and be actively involved in body assessment (weight and body condition score [BCS]) of all cats at every visit. In other words,

Courtesy of Carol Adams, Lone Oak Veterinary Clinic

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Feline Obesity CE obesity prevention must start early, and the Even when owners measure the amount of veterinary team is essential to recognition, food they give their cats, feeding recommenearly intervention, and success. dations based on the label recommendations There is now ample evidence that neutering for a particular food or traditional maintenance is an important risk factor for obesity in male energy calculations are likely to result in sigand female cats.13–19 For some time, it has been nificant overfeeding. These recommendations recognized that many cats have significant are based on feeding trials in intact, young, weight gain after neutering or during their ado- active cats—not neutered, indoor (sedentary) lescent years, but most clinicians believed this cats—and as a result, they are approximately was due entirely to the type or amount of food 30% higher than most housecats need. While fed. However, several recent studies13–18 have the appropriate number of calories proposed shown that multiple hormonal changes that sig- in the veterinary literature for the maintenance nificantly affect feline metabolism immediately energy requirement in cats ranges from 20 to follow removal of the gonads.a These changes 100 kcal metabolizable energy (ME)/kg/day, affect food intake and energy metabolism and multiple papers have suggested that 70(BWkg)0.75 result in an increase in body fat mass that is represents the resting energy requirement and almost inevitable unless appropriate measures 94 to 125(BWkg)0.75 the accepted range for the maintenance energy requirement for cats. to limit intake are taken immediately.14–19 However, in 2006, the National Research Controlling Food Intake Council recommended maintenance amounts Because gonadectomy is now recognized as a of 130(BWkg)0.40 for obese cats and 100(BW)0.67 risk factor for obesity,13–18 the key factor for pre- for lean cats,21 and several recent studies of neuvention of obesity in neutered animals appears tered cats have shown that feeding cats typical to be careful control of intake immediately after maintenance amounts of food results in weight neutering (e.g., no free-choice feeding) and and (more importantly) fat mass gain.22 Kienzle close monitoring of body weight and BCS to and colleagues23 analyzed the caloric needs in allow adjustments in intake if needed.14,16,18 As a BOX 1 rule of thumb, intake recommendations based on commercial food labels should be reduced Free-Choice Feeding and by 30% for neutered animals to account for the Feline Health hormonal changes resulting in reduced energy needs.14,16,18 Several studies have evaluated the Free-choice feeding of dry food affects role of different amounts of dietary components overall feline health in many ways, including: (e.g., fat, carbohydrates) in the development of obesity after neutering, but the key factors that Inadequate water intake, which can lead to an result in increase in body weight are gonadecincreased risk of constipation and urolithsa,b tomy and free-choice access to food.17,19 FreeLearned preference for dry food, which choice access to dry food is not an appropriate may make it difficult to change to a method of feeding for many cats—particularly therapeutic canned dietc indoor, neutered, inactive cats—for many reaInability of owners to monitor the amount sons (BOX 1). The most important with regard to of food being eaten, which may lead them obesity is the risk of overfeeding (or overeating), to miss subtle signs of illnessd which even in very small amounts can exceed appropriate caloric intake and result in weight a Seefeldt SL, Chapman TE. Body content and turnover in cats fed gain. Further, due to the feline preference (and, dry and canned rations. Am J Vet Res 1979;40:183-185. when eating small meals such as mice, physib Finco DR, Adams DD, Crowell WA, et al. Food and water intake ologic need) for eating multiple meals a day, it and urine composition in cats: influence of continuous versus periodic feeding. Am J Vet Res 1986;47:1638-1642. is best to provide cats’ caloric requirements in c 20 Horowitz D, Soulard Y, Junien-Castagna A. The feeding behavior two to four meals/day.

QuickNotes Obesity is a common, serious medical problem in cats.

of the cat. In: Pibot P, Biourge V, Elliott D, eds. Encyclopedia of Feline Clinical Nutrition. Aniwa SAS, Aimargues, France; 2008:339-378.

a For an overview of some of the metabolic changes related to obesity, see the companion article on CompendiumVet. com.

d Houpt KA. Feeding and drinking behavior problems. Vet Clin North Am Small Anim Pract 1991;21:281-298.

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colony cats and reported that neutered females required 100(BW kg ) 0.40 and neutered males required 120(BWkg ) 0.40 to maintain ideal body condition. In two other feeding studies,24,b investigators determined that neutered cats consuming more than 50 to 60(BWkg)0.67 gained weight and underwent a change in BCS from ideal to obese in just 3 months. In simple terms, an intake of 30% less than maintenance requirements means that most average-sized, indoor, neutered cats weighing 4 to 5 kg (9 to 11 lb) need to eat less than 200 kcal/day, and many may need even less than 180 kcal/day to maintain lean body condition (BOX 2). This is a signiﬁcantly smaller amount of food than is often recommended and represents a critical change in feeding recommendations

QuickNotes Indoor, neutered cats are at greatest risk of becoming obese if their intake is not carefully limited soon after they achieve adult size.

b Bauer JE. Texas A&M University. Personal communication. 2009.

for cats—one that will be extremely difﬁcult to achieve in cats being fed a calorie-dense (highfat) food or allowed free access to dry food.

Increasing Exercise Like many people, indoor cats are sedentary, which has detrimental effects on their physiologic and psychologic health and well-being. Therefore, increasing activity and energy expenditure are very important aspects of weight management in indoor cats. However, it is not easy to induce cats to exercise. Lifestyle alteration is, then, one of the most important additions to any program of obesity prevention or management.25 Exercise is a key factor in health for several reasons: (1) it helps maintain and strengthen lean muscle tissues, (2) it promotes cardiovascular health, (3) it provides mental stimulation and improves overall quality of life, (4) it increases energy expenditure and fat oxida-

BOX 2

Steps in a Weight-Loss Program for an Obese Cat19,23,38,a If the cat is considered to be 60% above its ideal weight, the ideal BW would be 6.25 kg (13.75 lb).

1. Determine ideal body weight: Set a target goal for weight loss. A record of the cat’s ideal weight at an earlier age is the most accurate guide. If you have no previous record of ideal weight, you must estimate an ideal from the current weight. This can be done by using the body condition score (BCS): On a 9-point scale, each point above a 5 represents a 10% to 15% increase in body weight (BW).

2. Determine the amount to feed: Energy allocation.

Using this approach, a cat weighing 10 kg (22 lb) and having a BCS of 9/9 is 40% to 60% above its ideal weight. Using an equation with both BW and the percentage over BCS can provide an estimate of ideal BW: Ideal BW =

100% (normal BCS) × current weight 100% + % above normal BCS

If the cat is considered to be 40% above its ideal weight, the ideal BW is calculated as follows: 100% × 10 kg = 7.1 kg (15 lb) 140%

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If possible, determine how much the cat is currently consuming. This may be difﬁcult if the cat is being fed free-choice or lives in a multicat household without careful observation of intake. If the amount is known, an intake reduction of 20% to 40% from the calculated maintenance requirements for a cat of ideal body condition is a good starting point for weight loss. The diet fed should contain >45% metabolizable energy of protein and be low in fat. The current National Research Council recommendations for maintenance requirements in lean and obese cats are as follows: Lean cat: 100 kcal(BW)0.67 or 60 kcal/kg/ day. For a 4-kg cat, this equals 240 kcal/day (4 kg × 60 kcal/kg/day = 240 kcal/day). Note that many indoor, neutered cats, even if they are lean, need 20% to 30% less than this amount, or less than 200 kcal/day.

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Feline Obesity CE tion, and (5) it increases the metabolic rate.26 If feasible, protected outdoor activity should be encouraged, as it is a great stimulus for play or exercise activity. Cats that are unable to engage in outdoor hunting or play behavior need other opportunities to fulﬁll their physiologic needs for climbing, balancing, scratching, and exercise.25,27,28 These requirements can be met in many ways and can be tailored to the cat and its situation. Toys may work well for some cats, cat trees or play stations are excellent for others, and some cats respond well to interactive toys that reward them with food. Clients do not need to turn mice loose in their house to encourage activity or play, but they do have to engage their cats to create play opportunities. The most important message about exercise that veterinarians should give cat owners is that play and activity are essential components of a healthy feline lifestyle and are necessary

for indoor cats to increase their muscle mass and reduce their risk of obesity.

Clinical Evaluation of Obese Cats The ﬁrst step in identifying and correcting obesity is recognizing it. Obviously, it is not difﬁcult to recognize a severely obese animal, but the veterinarian’s goal is to recognize changes in body weight and condition early so that corrections in diet, intake, and exercise can be initiated to prevent progression to obesity, with all of its associated hormonal changes and comorbid conditions. For assessment purposes, body composition is typically separated into fat mass and fat-free mass (FFM). The FFM is the largest, heaviest portion and includes protein (muscle mass), minerals (bones), and water (intracellular and extracellular). Measuring or assessing the FFM provides essential information about an animal’s

Obese cat: 130 kcal(BW)0.40 or 37 kcal/kg/ day. For an 8-kg cat, this equals 296 kcal/ day (8 kg × 37 kcal/kg/day = 296 kcal/day).

are essential to continued success. Adjustments in the weight-loss program are based on results. If the cat is not losing weight at a rate of 1% per week, the amount of food intake should be decreased by 5% to 10%.

However, to achieve weight loss in an obese cat, its intake must be decreased to 60% of the maintenance requirements: 0.60 × 296 = 178 kcal/day. In practice, this can be rounded up to 180 kcal/day.

Weight loss should be monitored frequently (every 2 to 4 weeks) and, to avoid discrepancies, always using the same scale.

Some obese cats may need to consume as little as 20 to 30 kcal/kg/day to achieve weight loss. This amount of food is very small, and the greatest concern is to maintain adequate protein intake.

Play and activity are essential components of a healthy feline lifestyle and are necessary for indoor cats to increase their muscle mass and reduce their risk of obesity.

Other recommended monitoring tools include BCS, morphometric measurements, and photographs. As with any chronic disease, weight management requires a good veterinarian– client–patient relationship to achieve optimal care and results.

3. Monitor the weight-loss program and make adjustments.

It may be helpful to give owners an estimated time line for weight loss so that they have realistic expectations for results. In general, for a cat to have a 30% decrease in BW, it takes approximately 12 months if the cat is losing 0.5%/week, 7 months if the cat is losing 1%/week, or 4 months if the cat is losing 2%/week.

The goal of weight loss is 1% to 2% of BW per week. At this rate, the cat is less likely to lose lean muscle mass or develop hepatic lipidosis. Typically, cats lose weight more quickly at the start of the program, but metabolic and physiologic responses to weight loss result in signiﬁcant slowing or even cessation of weight loss over a short period of time. Thus, monitoring progress and making adjustments

QuickNotes

Hashimoto M, Funaba M, Abe M, et al. Dietary protein levels affect water intake and urinary excretion of magnesium and phosphorus, in laboratory cats. Exp Anim 1995;44:29-35.

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QuickNotes Clinicians should familiarize themselves with at least one of the clinical techniques for assessment of body composition and use it daily.

metabolic and physiologic status.29 Cats in thin body condition with loss of muscle mass are known to have higher morbidity and mortality and should be evaluated to determine the cause of the loss.30 By contrast, obesity is the accumulation of body fat or an increase in the fat mass. In most cats, obesity represents an increase in fat mass that causes increases in body weight and changes in body composition. Measurement of body weight is the simplest technique for determining increased fat mass. However, there are two main concerns with using only body weight monitoring: (1) measurement of body weight alone does not distinguish the loss of FFM from the loss of fat mass, and (2) scales are notoriously inaccurate or variable—measurements made on different scales can vary signiﬁcantly. When weighing cats, it is important to use a reliable, wellmaintained scale intended for small animals (pediatric scales are excellent) and to use the same scale for all weight tracking to minimize variability and maximize accuracy. However, to better assess body condition, most nutritionists recommend that techniques for speciﬁc assessment of fat mass be incorporated in the physical examination in addition to measuring body weight. In general, the techniques available to clinical practitioners (BOX 3) are easy to use, require no special instrumentation, and can BOX 3

Methods of Assessing Body Condition8 Clinically useful methods Serial body weight Body condition score Morphometric measurements Bioelectric impedance Body mass index Research methods Dual energy x-ray absorptiometry (DEXA) Dilution/isotope techniques Ultrasonography, computed tomography, or magnetic resonance imaging Electrical conductance Chemical analysis Neutron activation analysis

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be performed on an awake cat. They include BCS, morphometric measurements, and body mass index (BMI).29 Tools used in clinical or basic research also exist; detailed information on these techniques has been published elsewhere.8,29,31

Body Condition Scoring BCS is perhaps the most widely accepted and well-known technique for assessing increased fat mass.31–33 The two most common scoring systems are the 5-point system (in which a score of 3 is ideal) and the 9-point system (in which 5 is considered ideal).8,32 However, because half points are often used in the 5-point system, resulting in a total of 9 categories, the systems are essentially identical, and clinical use is based on preference. One disadvantage of using BCS to assess fat mass is that physical palpation cannot distinguish loss of FFM from gain of fat mass. So although BCS can provide a subjective assessment of an increase or decrease in fat mass in obese patients, it is not helpful in overall body condition assessment of FFM. For example, a cat with diabetes may be obese but have also lost muscle mass due to the lack of insulin resulting in muscle wasting. Simple assessment of BCS by palpation cannot accurately distinguish these changes. Another disadvantage of BCS is its lack of repeatability in inexperienced observers. However, for estimating body fat mass in a clinical setting, BCS is an important tool. It provides owners with tangible information about their pets and, when used repeatedly so that familiarity and comfort are achieved, can provide highly reproducible results.8,32,33

Morphometry and Body Mass Index Morphometric measurements and determination of BMI are also easy to use in a clinical setting; however, they are less well known and require more time. Morphometric analysis uses measured parameters to provide an estimate of body composition. The simplest measurements are dimensional evaluations, whereby a tape measure is used to obtain speciﬁc dimensions of the animal. In general, length measurements of the head, thorax, and limbs correlate well with lean body mass,34 while circumference measurements (truncal/ribcage) correlate with fat mass.35 By using a measurement of lean body mass (leg index) with a measurement of

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Feline Obesity CE fat mass (ribcage circumference) in the following equation, BMI can be predicted28:

acids and fatty acids that they are unable to synthesize from other food sources as omnivorous species do.38 The most commonly used 1.5 (ribcage circumference [cm] – leg index measurement [cm]) Feline BMI (% fat) = foods for cats are dry, 9 extruded diets. These In this equation, the ribcage circumference is foods meet the minimum requirements of the measured at the ninth cranial rib, and the leg National Research Council and are nutritionally index is the distance from the patella to the complete and balanced, readily available, easy calcaneal tuber of one hindlimb.36 to use and store, and quite palatable. However, Other morphometric measurements of body they bear little resemblance to a diet of a natucomposition use specific tools to assess fat ral carnivore. Therefore, the distinctive nutricomposition, such as ultrasonography (this ent requirements of cats should be taken into technique has not been validated in cats) or account when designing a weight-loss or mainbioelectric impedance analysis (BIA). In BIA, tenance diet. the conductance of an applied electric current in the patient is measured and used to calculate Protein body composition.29,35,37 Because body fluids As obligate carnivores, cats use protein as an and electrolytes are responsible for the highest energy source even when other energy sources conductance and adipose tissue is dehydrated, such as fat or carbohydrates are available.38 increased adipose tissue results in lower con- However, most researchers have focused on ductance and greater impedance.29 Although fat and carbohydrate energy sources as having several BIA systems exist, none are widely the primary roles in the prevention and manavailable, and there are few reports of their agement of obesity. While it is critically imporuse in cats. BIA can be affected by electrode tant to reduce caloric intake in cats to achieve position, hydration status, consumption of food successful weight loss, this approach has overor water, physical activity, conductance of the looked the important role of protein in feline examination table, and other variables.37 Thus, metabolism. Hoenig and colleagues39 showed further evaluation of this technique is needed that cats consuming high-protein diets (>45% before it can be recommended for routine use ME) had increased energy metabolism, higher in the assessment of fat mass in cats. fat oxidation, and improved glucose tolerance, while cats consuming high-carbohydrate diets *** Clinicians should familiarize themselves with had lower energy metabolism, required fewer at least one of the clinical techniques for assess- calories to meet their needs, and gained fat ment of body composition and use it daily so mass. Others40–43 have also shown that in obese that it becomes not only a normal part of every cats, diets containing high levels of protein physical examination but also a more reliable result in greater loss of fat mass and improved and repeatable tool for assessing fat mass. preservation of muscle mass. This is important Routine use of BCS also shows clients that their because muscle mass is a major determinant veterinarian considers body condition assess- of metabolism. Muscle mass loss provokes a ment to be an important part of their cat’s “starvation” response as the body seeks to prephysical examination and health evaluation. serve itself either through energy metabolism Perception is reality: owners need to know that changes or increased intake. Therefore, loss of obesity is important not only from what veteri- muscle mass increases the likelihood of weight regain, and, particularly in cats, maintaining narians say but also from what we do. muscle mass may be a key to successful weight Obesity and Diet loss.44 Research has shown that even cats conDiet must be considered in any prevention or suming protein at 45% ME lost some muscle treatment plan for feline obesity. Unlike most mass during diet restriction. This finding sugdomestic species, cats are true carnivores. They gests that >45% ME of protein may be needed must consume animal flesh and fat to meet their during weight loss due to the severe restricnutritional needs, or their diets must be supple- tion of intake necessary to achieve reduction mented appropriately with the necessary amino in calories and loss of weight.40,41

QuickNotes Successful weight loss in cats requires preservation of lean muscle tissue and concurrent loss of fat mass, which is best achieved using high-protein (>45% ME), low-energy diets.

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Obese cats appear to adapt to lowerprotein, higher-carbohydrate diets; however, obese cats on high-protein diets have not only improved insulin sensitivity but also greater energy and fat metabolism, resulting in great loss of fat mass during calorie restriction and weight loss.39 Increased protein intake may be particularly important in cats after weight loss, as research also shows that energy expenditure remains decreased.44 In summary, high protein levels are essential for preservation of lean body mass during calorie restriction and weight loss in obese cats and are important for increasing insulin sensitivity, thereby preventing further development of glucose intolerance. In addition, high-protein diets (>45% protein ME) allow a more optimum metabolic status in lean cats.

Carbohydrates

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While protein is a very important component of the feline diet, it is only one part. Carbohydrates serve two major purposes: as an energy source (simple carbohydrates, such as starches) or as dietary fiber (complex carbohydrates). The role of fiber is discussed in a separate section below. Carbohydrates are a major part of most dry and some canned commercial feline and canine diets due to issues of processing, preservation, and cost. The digestibility and glycemic index of dietary carbohydrate varies by source: highly digestible carbohydrates include cooked white rice and potato; less digestible sources include complex grains (e.g., barley, wheat, whole corn). Carbohydrates in highquality commercial pet foods are generally highly digestible and provide a readily available energy source. If the pet is active and needs energy, carbohydrates are used efficiently; however, if the pet is sedentary, any carbohydrates that are not used for energy are stored as fat. The amount and type of carbohydrate in the feline diet are of considerable importance for several reasons: (1) cats’ ability to handle dietary carbohydrate loads are very different from those of omnivores38,45 (BOX 4); (2) because cats use protein for energy, even when excess energy is available in their diet, sedentary indoor cats often do not use the carbohydrate energy present in a diet38,46; and (3) high-carbohydrate diets result in a reduced resting energy metabolism, so cats must consume less food to maintain appropriate body weight.39 However, cats are not unable to use carbohy-

drates; on the contrary, they can digest, absorb, and use them quite well. Nevertheless, the type of carbohydrate is important, as there are significant differences in glycemia, postprandial glucose levels, insulin secretion, and food intake between normal-weight and obese cats.47,48

Fat The role of dietary fat is also very important in feline obesity, as fat provides the greatest amount of energy per gram of diet. As a result, there are a number of commercially available low-fat feline diets for calorie control. Further, several recent studies show that controlling calories from fat in weight-loss programs is essential to achieving successful weight loss.19,21 Nevertheless, dietary fat has many roles in metabolism beyond being a powerful source of energy, and there are key differences in feline requirements for fat that must be considered when choosing a diet. As carnivores, cats require additional supplementation of fatty acids (especially arachidonic acid) and fat-soluble vitamins in their diet that normally would come from the fat stores of prey. Also, fat is a major palatability enhancer, and cats often reject diets with too little fat or in which the fat is oxidized. BOX 4

Major Metabolic/Anatomic Differences in Feline Carbohydrate Handling Compared With Omnivoresa Lack of a sweet taste receptor and gene for sweet taste Lack of salivary amylase (enzyme that initiates digestion of starches) Low levels (5% to 10%) of intestinal amylase and intestinal disaccharidases Minimally functioning levels of hepatic glucokinase (inducible enzyme that affects glucose uptake) Minimally functioning levels of hepatic glycogen synthetase (enzyme that converts glucose to glycogen) Lack of fructokinase and ability to metabolize fructose sugars a

Zoran DL. The unique nutritional needs of the cat. In: Ettinger S, Feldman E, eds. Textbook of Veterinary Internal Medicine. 7th ed. 2009, in press.

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Feline Obesity CE However, while reducing fat is an important method of controlling calories in feline diets, there are no studies in cats showing the ideal amount of fat in the diet. And as with protein and carbohydrates, it is essential to consider the whole: diets for weight loss in cats should ideally be higher in protein (at least >45% ME), lower in fat (to control calories) but containing enough essential fatty acids to meet feline requirements, and lower in carbohydrates (to prevent reduction in energy metabolism and conversion of excess carbohydrate to fat).

Fiber The fi nal dietary component to consider in weight-loss diets is fiber. Most weight-loss diets add insoluble or mixed sources of fiber, such as cellulose or beet pulp. Dietary fibers have been used in weight-loss diets for many years because of their ability to dilute calories and provide bulk to the diet so that larger volumes of food can be eaten during energy restriction. Fiber aids in glycemic and weight control by promoting slow, sustained absorption of glucose (and other nutrients) from the gastrointestinal tract and by increasing the speed of passage of food through the small intestine. However, this effect, while beneficial for weight loss, results in reduced digestibility of protein49 and may have other untoward effects, such as increased fecal volume, constipation, food refusal, and dry skin.50 As a result, many owners and cats do not tolerate diets with moderate to high levels of dietary fiber (>15% dry matter). No studies demonstrate an optimum amount or type of dietary fiber for use in cat foods for any purpose; however, a moderate amount (5% to 12% dry matter) of mixed fiber may be best.50 If a moderate- to high-fiber diet is chosen, the effects on protein digestibility must be considered and an appropriate amount of protein added to the food to prevent a reduction in protein availability. As with any dietary strategy, increased fiber in the diet should not be considered a “cure-all” for weight loss, but it can be included as part of the overall approach to controlling caloric intake.

Choosing a Weight-Loss Diet Healthy weight loss requires loss of adipose tissue along with maintenance of lean body mass, which is an important arbiter of basal

energy metabolism. Ideally, weight-loss diets should contain protein levels >45% ME and be low in fat and carbohydrates. The number of dry diet choices that meet this profile is extremely small, primarily because most highprotein, low-carbohydrate dry foods are formulated as either diabetic or kitten diets and thus contain a large number of calories due to a high fat content. For example, a typical dry diabetic or kitten food contains 500 to 600 kcal/cup of food. As a result, it is extremely difficult to feed an appropriate amount to a cat that requires weight loss, which, in an obese cat, may be as low as 130 to 150 kcal/ day. In this scenario, the amount of the highcalorie diabetic dry food fed at a meal will be small (< 1/8 cup twice daily)—likely too small to achieve any sense of “fullness” and resulting in annoying begging behavior that makes owner compliance with feeding recommendations very difficult. This point cannot be overstated: too many calories of any kind, including protein calories, will cause weight gain or failure to lose weight. Thus, at this time, the best commercial diets for achieving a high-protein, low-carbohydrate, low- to moderate-fat profile that can provide reasonable portion sizes are canned cat foods. For example, a typical diabetic (high-protein/ low-carbohydrate) canned diet contains 165 to 190 kcal/5.5-oz can. Thus, when the target for caloric intake is 180 kcal or less, it can be easier to achieve the high protein necessary to preserve muscle mass in a portion-controlled diet with these foods. However, canned foods can also be high in carbohydrate or low in protein or have poor-quality ingredients, resulting in ineffective or unhealthy weight loss. One size does not fit all in cat foods, and careful reading of the label can help determine the protein, carbohydrate, and fat levels, which is the start of the process.

QuickNotes Weight loss in obese cats is difﬁcult and requires appropriate dietary intervention to preserve muscle mass, careful control of intake, and frequent monitoring to make adjustments as needed.

Creating a Treatment Plan Successful weight loss in an obese cat requires patience, setting goals, frequent monitoring and readjustment of strategy, and an understanding that reversing obesity is a challenge similar to the management of any chronic medical condition. Persistence and diligence are essential. The key is to set a target calorie intake, weigh the cat monthly, and adjust the amount of food based on weight loss. While

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the most appropriate rate of weight loss is debated, most sources agree that a goal of 1% weight loss per week or 3% to 4% per month is a safe target.8,12,29 If, during periods of monitoring, this goal is not being achieved, calories must be reduced by 5% to 10% and the effects of the new amount monitored. To achieve loss of fat mass, the weight-loss program must consider the cat’s body condition at the start of weight loss, the degree of calorie restriction required, the desired rate of weight loss, and the cat’s environment and ability to increase exercise.29 BOX 2 provides a step-bystep overview of the process. Although this strategy is relatively straightforward (reduce energy intake), it requires patience; careful, long-term monitoring; encouragement and support for the owner; and frequent assessment and readjustment to meet the needs of the cat.

TO LEARN MORE For a more detailed discussion of how free-choice feeding negatively affects cats’ health, please visit CompendiumVet.com.

Conclusion The key to obesity prevention (or correction) is balancing the energy intake/ energy expenditure equation. Because obesity is incredibly difﬁcult to reverse in adult cats and, in many cases, requires lifelong management because of changes in energy metabolism and hormone status, prevention is an essential goal. All neu-

tered cats are at risk for becoming obese due to the changes in their hormonal balance that affect appetite, energy balance, and fat metabolism. Because of these changes, food intake must be carefully restricted following gonadectomy in all cats, and free-choice feeding of dry foods should be strongly discouraged. In indoor cats, for which exercise is reduced by the nature of their lifestyle, energy restriction also becomes paramount to preventing or correcting obesity. Energy restriction can be achieved by low-fat, high-ﬁber diets, but many of these diets are not high enough in protein to preserve muscle and thus result in loss of muscle mass, unhealthy weight loss, and a strong tendency to regain weight. High-protein, lowcarbohydrate, low-fat diets are ideal for weight loss in cats because they preserve muscle mass while restricting energy sources to induce fat loss. However, portion control is ultimately the key to controlling energy intake and is most easily achieved by feeding canned food with a protein content of >45% ME and a carbohydrate content of <10% ME. The key to any successful weight-loss program is patience, persistence, frequent and careful monitoring and assessment, and readjustment of the caloric intake and diet as needed to achieve fat loss and preserve lean muscle tissue.

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11. Wisse BE. The inﬂammatory syndrome: the role of adipose tissue cytokines in metabolic disorders linked to obesity. J Am Soc Nephrol 2004;15:2792-2800. 12. Laﬂamme DP. Understanding and managing obesity. Vet Clin North Am Small Anim Pract 2006;36:1283-1295. 13. Fettman MJ, Stanton CA, Banks LL, et al. Effects of neutering on body weight, metabolic rate, and glucose intolerance of domestic cats. Res Vet Sci 1997;62:131-136. 14. Martin L, Siliart B, Dumon H, et al. Leptin, body fat content and energy expenditure in intact and gonadectomized adult cats: a preliminary study. J Anim Phys Anim Nutr 2001;85:195-199. 15. Harper EJ, Stack DM, Watson TDG, et al. Effects of feeding regimen on body weight, composition, and condition score in cats following ovariohysterectomy. J Small Anim Pract 2001;42:433-438. 16. Hoenig M, Ferguson DC. Effects of neutering on hormonal concentrations and energy requirements in male and female cats. Am J Vet Res 2002;63:634-639. 17. Nguyen PG, Dumon HJ, Siliart B, et al. Effects of dietary fat and energy on body weight and composition after gonadectomy in cats. Am J Vet Res 2004;65:1708-1713. 18. Martin LJM, Siliart B, Dumon HJ, et al. Spontaneous hormonal variations in male cats following gonadectomy. J Feline Med Surg 2006;8:309-314. 19. Backus RC, Cave NJ, Keister DH. Gonadectomy and high dietary fat but not high dietary carbohydrate induce gains in body weight and fat of domestic cats. Br J Nutr 2007;98:641-650.

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20. Beata CA. Feline behavior: can nutrition really make the difference. Royal Canin Feline Symp 2007:30-33. 21. National Research Council. Nutrient Requirements of Dogs and Cats. Washington, DC: National Academy Press; 2006. 22. Hill RC. Challenges in measuring energy expenditure in companion animals: a clinician’s perspective. J Nutr 2006;136:1967S-1972S. 23. Kienzle E, Edstadtler-Pietsch G, Rudnick R. Retrospective study on the energy requirements of adult colony cats. J Nutr 2006;136:1973S-1975S. 24. Belsito KR, Vester BM, Keel T, et al. Impact of ovariohysterectomy and food intake on body composition, physical activity, and adipose gene expression in cats. J Anim Sci 2009;87:594-602. 25. Bufﬁngton CAT. Dry food and risk of disease in cats. Can Vet J 2008;49:561-563. 26. Patterson CM, Levin BE. Role of exercise in the central regulation of energy homeostasis and in prevention of obesity. Neuroendocrinology 2008;87:65-70. 27. Indoor cat needs. The Indoor Cat Initiative. Accessed May 2009 at vet.ohio-state.edu/ 747.htm. 28. Roudebush P, Schoenherr WD, Delaney SJ. An evidence based review of the use of therapeutic foods, owner education, exercise, and drugs for the management of obese and overweight pets. JAVMA 2008;233:717-725. 29. German AJ, Martin L. Feline obesity: epidemiology, pathophysiology, and management. In: Pibot P, Biourge V, Elliott D, eds. Encyclopedia of Feline Clinical Nutrition. Aim-

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Feline Obesity CE argues, France: Aniwa SAS; 2008:4-43. 30. Scarlett JM, Donoghue S. Associations between body condition and disease in cats. JAVMA 1998;212:1725-1731. 31. German AJ, Holden SL, Moxham G, et al. A simple, reliable tool for owners to assess the body condition of their dog or cat. J Nutr 2006;136:2031S-2033S. 32. Laﬂamme DP. Development and validation of a body condition score system for cats: a clinical tool. Feline Pract 1997;25:13-18. 33. Burkholder WJ. Use of body condition scores in the clinical assessment of the provision of optimal nutrition. JAVMA 2000;217:650-654. 34. Hawthorne A, Butterwick RB. Predicting the body composition of cats: development of a zoometric measurement for estimation of percentage body fat in cats [abstract]. J Vet Intern Med 2000;14:365. 35. Burkholder WJ. Precision and practicality of methods assessing body composition of dogs and cats. Compend Contin Educ Pract Vet 2001;23:1-10. 36. Elliott D. Is my cat fat? Proc Nestle Purina Nutr Forum 2007:28-32. 37. Stone RA, Berghoff N, Steiner J. The use of a bioelectric impedance device in lean and obese dogs to estimate body fat percentage. Vet Ther in press, 2009.

38. Morris JG. Idiosyncratic nutrient requirements of cats appear to be diet-induced evolutionary adaptations. Nutr Res Rev 2002;15:153-168. 39. Hoenig M, Thomaseth K, Waldron M, et al. Insulin sensitivity, fat distribution, and adipocytokine response to different diets in lean and obese cats before and after weight loss. Am J Physiol Regul Integr Comp Physiol 2007;292:R227-R234. 40. Laﬂamme DP, Hannah SS. Increased dietary protein promotes fat loss and reduces loss of lean body mass during weight loss in cats. Intern J Appl Res Vet Med 2005;3:62-68. 41. German AJ, Holden S, Bissot T, et al. Changes in body composition during weight loss in obese client owned cats: loss of lean tissue mass correlates with overall percentage of weight loss. J Feline Med Surg 2008;10:452-459. 42. Szabo J, Ibraham WH, Sunvold GD, et al. Inﬂuence of dietary protein and lipid on weight loss in obese ovariohysterectomized cats. J Vet Med Res 2000;61:559-565. 43. Michel KE, Bader A, Shofer PS, et al. Impact of time limited feeding and dietary carbohydrate content on weight loss in group housed cats. J Feline Med Surg 2005;7:349-355. 44. Villaverde D, Ramsey JJ, Green AS, et al. Energy restriction results in a mass-adjusted decrease in energy

expenditure in cats that is maintained after weight regain. J Nutr 2008;138:856-860. 45. Cave NJ, Monro JA, Bridges JP. Dietary variables that predict the glycemic responses to food in cats [abstract]. Proc Nestle Purina Forum 2007:73. 46. Morris JG, Rogers QR. Metabolic basis for some of the nutritional peculiarities of the cat. J Small Anim Pract 1982;23:599-613. 47. Bouchard GF, Sunvold GD. Effect of dietary carbohydrate source on post prandial plasma glucose and insulin concentrations in cats. In: Reinhert GA, Carey DP, eds. Recent Advances in Canine and Feline Nutrition, Iams Nutrition Symposium. Wilmington, OH: Orange Frazier Press; 2000:91-105. 48. Appleton DJ, Rand JS, Priest J, et al. Dietary carbohydrate source affects glucose control, insulin secretion, and food intake in overweight cats. Nutr Res 2004;24:447-467. 49. De-Oliveira LD, Carciolﬁ AC, Oliveira MCC, et al. Effects of six carbohydrate sources on diet digestibility and postprandial glucose and insulin responses in cats. J Anim Sci 2008;86:2237-2246. 50. Kirk CA. High protein, low carbohydrate diets: are they for all cats? Royal Canin Feline Symp 2007:4-7.

3 CE CREDITS

CE TEST 1 This article qualiﬁes for 3 contact hours of continuing education credit from the Auburn University College of Veterinary Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumVet.com. Those who wish to apply this credit to fulﬁll state relicensure requirements should consult their respective state authorities regarding the applicability of this program.

1. A cat with an ideal weight of ____lb and an actual weight of ____lb would meet the currently accepted deﬁnition of obese. a. 9; 9.9 b. 7; 8.2 c. 11; 13.5 d. 14; 16.4 2. Cats digest carbohydrates differently from omnivores because they a. have high levels of intestinal amylase. b. lack salivary amylase. c. have increased function of hepatic glucokinase. d. have high levels of fructokinase. 3. Which feeding approach is most likely to lead to healthy weight loss? a. meal feeding of high-carbohydrate dry food only b. free-choice feeding of high-carbohydrate canned food only c. free-choice feeding of high-protein dry food only d. meal feeding of high-protein canned food only 4. Risk factors for obesity in cats include a. appetite and energy changes caused by

hormonal imbalances after neutering. b. a sedentary, indoor lifestyle. c. overfeeding. d. all of the above 5. Successful weight loss in obese cats is characterized by all of the following except a. preservation of lean muscle mass by feeding a high-protein diet. b. loss of fat mass at a rate of 1% to 2% per week. c. control of caloric intake by meal feeding and portion control. d. activity restriction. 6. Which condition has not been associated with obesity in cats? a. hepatic lipidosis b. hypertrophic cardiomyopathy c. diabetes mellitus d. osteoarthritis 7. Which clinical method of evaluating body fat mass in cats is most likely to be affected by technical issues? a. BCS b. morphometric measurement c. BIA d. BMI

8. In neutered cats, energy intake recommendations on commercial food labels must be decreased by approximately ________ to prevent the development of obesity. a. 20% b. 25% c. 30% d. 35% 9. Which statement regarding label recommendations for feeding cats is true? a. They are based on twice the maintenance energy requirement. b. They are based on the needs of intact, active cats. c. Pet food manufacturers overestimate energy needs to avoid underfeeding cats. d. They are based on the needs of neutered cats. 10. Weight-loss diets for obese cats should contain _______ ME of protein to promote fat loss and prevent loss of muscle mass. a. >30% b. >35% c. >40% d. >45%

CompendiumVet.com | June 2009 | Compendium: Continuing Education for Veterinarians®

293

Product Forum Digital Radiography

Veterinary Dental Equipment

Quantum Medical Imaging has partnered with Agfa Healthcare to release the CR30-Oracle veterinary system. The CR30-Oracle can perform multiple functions, including image acquisition, processing, and distribution. With the veterinary conﬁguration, the system has a custom splash screen, has all veterinary DICOM attributes, and excludes all human exam trees. Quantum Medical Imaging | 631-567-5800 | www.quantumvet.net

The VetPro 5000 Dental Delivery System is designed by Midmark speciﬁcally for veterinary use. The unit features a whip-style delivery head to allow more positioning options, and the handpieces automatically activate when removed from their holders. The VetPro 5000 has a small footprint to save ﬂoor space and operates at less than 50 decibels. Keeler Instruments | 610-353-4350 | www.keelerusa.com

Telemedicine Services Topical Flea Protection Summit VetPharm has released Vectra for Dogs and Puppies, a topical, monthly ﬂea control product. This newest addition to the Vectra line contains dinotefuran and pyriproxyfen combined in a single-dose product. Vectra for Dogs and Puppies can be used on dogs as young as 8 weeks and provides protection against all stages of ﬂeas. Summit VetPharm | 800-999-0297 | www.summitvetpharm.com

IV Line Tracing Labels EPS’ customizable line tracing labels help prevent medical errors by making it easy to label and trace IV lines. With one label on the IV infusion container and another on the end of the tubing, IV lines can be quickly located and identiﬁed. The customizable labels are available for laser or thermal printers and can be designed using MILT 3.0 software. EPS, Inc. | 800-523-8966 | www.medidose.com

Feline Herpes Treatment Enisyl-F Lysine treats are formulated to help regulate signs of feline herpesvirus infection and lessen the frequency of ﬂare-ups. The treats contain L-lysine, which has been shown to lessen the severity of signs and reduce viral shedding associated with herpesvirus infection. Designed to be palatable, the treats can be administered routinely or during active ﬂare-ups. Vétoquinol | 800-267-5707 | www.vetoquinolusa.com

IDEXX Telemedicine services are now available on vetconnect.com for faster responses and greater efﬁciency. The service simpliﬁes the process of getting a second opinion from IDEXX specialists and allows telemedicine consult requests to be processed before the patient visit. Veterinarians can use the service to submit diagnostic criteria such as electrocardiograms and radiographs. IDEXX Reference Laboratories | 888-433-9987 | www.idexx.com

Mange Protection The EPA has approved a new label claim for ProMeris for Dogs, adding protection against demodectic mange mites and control of chewing lice. ProMeris is a low-volume, topical spot-on that controls ﬂea and tick infestations and prevents reinfestations on dogs and puppies aged 8 weeks and older. ProMeris for Dogs is waterproof and available in ﬁve different sizes to accurately dose dogs of different body weights. Fort Dodge Animal Health | 888-776-6374 | www.promeris.com

Client Services Lifelearn has launched ClientEd Online, a new Web-based client education service at lifelearncliented.com. ClientEd automatically organizes a practice’s client education articles online for easy accessibility. ClientEd is compatible with Macs and PCs, is accessible at any time, and offers three different library series. Lifelearn, Inc. | 800-375-7994 | www.lifelearncliented.com

The product information presented here is provided by the manufacturers and does not reﬂect endorsement by Compendium.

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Compendium: Continuing Education for Veterinarians® | June 2009 | CompendiumVet.com

MARKET SHOWCASE

CLASSIFIED ADVERTISING VETERINARIANS WANTED

GLASS DOORS

Northgate Veterinary Supply, the makers of Ultra Cage and Econocage, now offers choice of glass door or rod gates. Available in standard and custom sizes.

VETERINARIANS WANTED

CALIFORNIA – Incredible opportunity, great lifestyle. Make

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over $125K/year—work a ﬂexible schedule. No after-hours, no emergencies, no night calls, no on-call responsibility. Work in close proximity to LA, Palm Springs, Big Bear, and coastal living in a fully equipped, progressive, multi-doctor small animal practice that cares about you. We offer compensation packages with perks. APPLY NOW — there’s no limit to your earning potential! Contact Steven Butchko, DVM: 5488 Mission Blvd., Riverside, CA 92509; phone 951-686-2242; fax 951-686-7681.

GEORGIA – Associate veterinarian wanted at three-doctor small animal practice located on Georgia’s beautiful coast in historic Savannah. Workweek averages 34 hours; alternating Saturdays; no emergencies. Great clients and staff. Nearby surgeon and ophthalmologist for referrals. Base pay plus production. Email resume to Dr. Kicklighter at dbk204@comcast. net or fax to 912-920-1970. Phone: 912-920-4204.

TEXAS Associate Veterinarian Full-time position for enthusiastic individual with excellent work ethic. Busy small animal clinic located in thriving West Texas has full diagnostic and surgical capabilities, including ultrasound, endoscopy, and neurosurgery. All interested applicants welcome. Call 432-332-5782.

CONTINUING EDUCATION

NEW JERSEY – Enthusiastic, hard-working, and motivated part-time veterinarian needed at our well-equipped small animal hospital in Mercer County (central New Jersey). Our outstanding client base has continued to grow with the practice over the past 10 years. Work with a highly trained staff in a very comfortable and laid-back practice atmosphere. No afterhours emergencies. New graduates welcome. Please contact Dr. Cruz: 609-468-7116 or mcruzdvm@gmail.com.

Fast. Easy. Inexpensive. WhereTechsConnect.com is your answer!

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Contact Lisa Siebert to place your ad today. Call 215-589-9457 or email lsiebert@vetlearn.com.

NORTH CAROLINA – Well-established, 24-hour, AAHAaccredited small animal hospital in central North Carolina needs an emergency/critical care veterinarian and an associate veterinarian. Located only hours from the mountains and coastlines, our busy, progressive, and expanding five-doctor practice is fully equipped and staffed by 25 highly motivated veterinarians, technicians, and lay staff. Established more than 27 years, our hospital has an excellent client base and strong emphasis on quality care. Work in a great practice environment with an excellent opportunity for career development. Competitive salary and benefits include 401(k), profit sharing, CE, and insurance. Experience preferred. Send resume to Dr. Karl B. Milliren, 303 National Highway, Thomasville, NC 27360; email tvh303@cs.com; fax 336-475-0140.

For classified advertising information, call Liese Dixon at 800-920-1695.

Index to Advertisers For free information about products advertised in this issue, e-mail the product names to productinfo@compendiumvet.com. Company

Product

Page

Atlantic Coast Veterinary Conference

2009 Conference

273 259, 260

Bayer Animal Health

Profender

Dechra Veterinary Products

Vetoryl

255, 256

Fort Dodge Animal Health

CaliciVax

Inside front cover (US only)

LeptoVax

277

Hill’s Pet Nutrition

Prescription Diet r/d Canine

Inside front cover (Canada only)

IDEXX Laboratories, Inc.

Real Time Care

Back cover

Intervet/Schering-Plough Animal Health

Mometamax

253, 254

Tri-Heart Plus

296, inside back cover

Merial

Quick Course: Kitten Vaccinations

282–283

Northgate Veterinary Supply

Glass cage doors and rod gates

295

Novartis Animal Health

CEforVetsandTechs.com

251 (US only)

Veterinary Emergency and Critical Care Society

IVECCS 2009 Symposium

271

Veterinary Learning Systems

VetLearn.com

281

Vetstreet

Pet Portal Service

267

WhereTechsConnect.com

Job Marketplace

295

Looking for new team members? Buy 2 Ads, Get 1 FREE!*

HUR Offe RY! r E Soo nds n!

**See Page 281 forr details.

In Memory Chewable Tablets Brief Summary: Please consult full package insert for more information. INDICATIONS: Tri-Heart® Plus chewable tablets are indicated for use in prevention of canine heartworm caused by Dirofilaria immitis and for the treatment and control of ascarids (Toxocara canis, Toxascaris leonina) and hookworms (Ancylostoma caninum, Uncinaria stenocephala, Ancylostoma braziliense) in dogs and in puppies 6 weeks of age and older. PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with Tri-Heart® Plus chewable tablets. A mild hypersensitivity-type reaction, presumably due to dead or dying microfilariae and particularly involving a transient diarrhea has been observed in clinical trials with ivermectin alone after treatment of some dogs that have circulating microfilariae. Keep this and all drugs out of the reach of children. In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans. ADVERSE REACTIONS: The following adverse reactions have been reported following the use of ivermectin at the recommended dose: depression/ lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions and hypersalivation. Caution: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. HOW SUPPLIED: Tri-Heart® Plus chewable tablets are available in three dosage strengths for dogs of different weights. Each strength comes in convenient packs of 6 chewable tablets. Store at controlled room temperature of 59-86˚ F (15-30˚ C). Protect product from light. For technical assistance, call Schering-Plough Animal Health Corporation 1-800-224-5318 Manufactured for: Schering-Plough Animal Health Corporation, Summit NJ 07901 Manufactured by: Heska Corporation, Des Moines, IA 50327 ©2006 Heska Corporation, all rights reserved. ANADA 200-338, Approved by FDA Tri-Heart is a registered trademark of Schering-Plough Animal Health Corporation.

Anna Worth Past President of AAHA

nna Elizabeth Worth, VMD, an outstanding leader and talented veterinarian, passed away on Saturday, May 16, following a long and valiant battle with cancer. She was 55 years old. “It is with heavy hearts and deep sadness that we say goodbye to such a compassionate and talented individual,” said John Albers, DVM, executive director of AAHA. “AAHA will forever be indebted to Anna’s unwavering devotion and leadership to the association and to our profession.” A 1978 graduate of the University of Pennsylvania School of Veterinary Medicine, Worth, with her husband, served as a director and owner of West Mountain Animal Hospital, an AAHA-accredited practice in Shaftsbury, Vermont, for more than 25 years. Worth was AAHA president from 2008 to 2009 and had served on the association’s board of directors since 2002. She was also heavily involved in other aspects of the association. Worth was instrumental in the creation of the AAHA Helping Pets Fund. Worth had an active interest in animal welfare and was a past president of the Society for Veterinary Medical Ethics, as well as past chair to the Vermont Animal Cruelty Task Force, the Vermont Animal Welfare Committee, and the Euthanasia Board for Animals. The Massachusetts Society for the Prevention of Cruelty to Animals presented her with the Veterinarian of the Year Award in 1992. She was also active in her state association and within her local community. Worth is survived by her husband, Bob Bergman, VMD; son, Bo Bergman, DVM, his wife, Megan, and their newborn daughter, Anna Frasier; and daughter, Sarah M. Bergman. In lieu of ﬂowers, contributions in memory of Anna Worth can be made to the AAHA Helping Pets Fund online at www.aahahelpingpets.org or to the Southwestern Vermont Regional Cancer Center. Adapted with permission from AAHA.

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Compendium: Continuing Education for Veterinarians® | June 2009

“We’ve moved all our clients to Tri-Heart Plus.” ®

Easy affordability improves compliance for heartworm prevention. The value and protection of Tri-Heart Plus makes it possible to protect more patients and support a 12-month protocol. Building your heartworm practice around Tri-Heart Plus adds value for you and your clients. ®

Tri-Heart® Plus provides proven protection against heartworms, roundworms and hookworms.

All dogs should be tested for heartworm infection before starting a preventive program. In a small percentage of ivermectin/pyrantel treated dogs, digestive and neurological side effects may occur. Tri-Heart is registered trademark of Intervet Inc. or an affiliate. © 2009 Intervet Inc. All rights reserved.

SPAH-THP-114R

See Page 296 for Product Information Summary

Real. Time. Care.TM

Positive outcomes regardless of results

Real-time care lets you give your clients what they expect: answers now. Your ability to handle cases efficiently and thoroughly, with confidence and empathy, sets you apart. For them, that makes all the difference. That’s real-time care. That’s IDEXX in-house diagnostics. Learn more. Join us for our Client Value Webinar Series. www.idexx.com/ihd

IDEXX In-House Diagnostics IDEXX VetLab® Analyzers | IDEXX SNAP® Immunoassay Tests | IDEXX Digital Imaging