Veterinary Forum | September 2009

NEWS TESTING FOR FELINE HEARTWORM DISEASE

FORUM ®

REAL PRACTICE. REAL MEDICINE. REAL NEWS.

SEPTEMBER 2009 • VOL. 26, NO. 9

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Editorial Board ANESTHESIOLOGY Donald C. Sawyer, DVM, PhD, DACVA Janyce Seahorn, DVM, MS, DACVA, DACVIM, DACVECC AVIAN Peter Sakas, DVM, MS BEHAVIOR Debra Horwitz, DVM, DACVB Wayne Hunthausen, DVM Gary Landsberg, BSc, DVM, DACVB

NEUROLOGY Ronald O. Schueler, DVM, DACVIM ONCOLOGY Louis-Philippe de Lorimier, DVM, DACVIM Joseph A. Impellizeri, DVM, DACVIM Gregory K. Ogilvie, DVM, DACVIM, DECVIM-CA OPHTHALMOLOGY Terri Gibson, DVM, MS, DACVO PARASITOLOGY Lora Ballweber, DVM, MS

CARDIOLOGY Andrew Beardow, DVM, DACVIM Robert Hamlin, DVM, PhD, DACVIM

PATHOLOGY Lawrence D. McGill, DVM, PhD, DACVP

DENTISTRY Jan Bellows, DVM, DAVDC, DABVP Edward Eisner, DVM, DAVDC Steven E. Holmstrom, DVM, DAVDC Heidi B. Lobprise, DVM, DAVDC Robert Wiggs, DVM, DAVDC

PHARMACOLOGY Lester Mandelker, DVM, DABVP PRACTICE MANAGEMENT Lowell Ackerman, DVM, DACVD, MBA, MPA Stephen Fisher, DVM Ronald E. Whitford, DVM

DERMATOLOGY Dawn Logas, DVM, DACVD Rosanna Marsella, DVM, DACVD Karen Moriello, DVM, DACVD

RADIOLOGY Victor Rendano, VMD, MS, DACVR Candi Stafford, RVT

EMERGENCY & CRITICAL CARE MEDICINE Nishi Dhupa, BVM, DACVECC ENDOCRINOLOGY Arnold Plotnick, MS, DVM, DACVIM, DABVP EPIDEMIOLOGY John Kaneene, DVM, PhD, MPH EQUINE MEDICINE Joseph J. Bertone, DVM ETHICS Bernard Rollin, PhD

REPRODUCTIVE PHYSIOLOGY Susan E. Piscopo, DVM, PhD SURGERY Sean Aiken, DVM, DACVS A. D. Elkins, DVM, MS, DACVS Joseph Harari, DVM, MS, DACVS Robert G. Roy, DVM, MS, DACVS Don R. Waldron, DVM, DACVS THERIOGENOLOGY Gary J. Nie, DVM, MS, PhD, DACT, DABVP, DACVIM

FELINE MEDICINE Gary D. Norsworthy, DVM, DABVP INTERNAL MEDICINE Anthony P. Carr, Dr. med. vet., DACVIM Richard B. Ford, DVM, MS, DACVIM, DACVPM (Hon) Michael R. Lappin, DVM, PhD, DACVIM Kevin Hahn, DVM, PhD, DACVIM

TOXICOLOGY Sharon Gwaltney-Brant, DVM, DABVT VETERINARY LAW Edward J. Guiducci, Esq. Elizabeth M. Hodgkins, DVM, JD

780 Township Line Road • Yardley, PA 19067 PRESIDENT Derrick Kraemer VETERINARY FORUM (ISSN 1047-6326) is published monthly by Veterinary Learning Systems, a division of MediMedia USA, 780 Township Line Road, Yardley, PA 19067. Single copy: $9.00. Payments by check must be in US funds drawn on a US branch of a US bank only; credit cards are also accepted. Periodicals postage paid at Morrisville, PA, and additional mailing offices. POSTMASTER: Send address changes to VLS, 780 Township Line Road, Yardley, PA 19067. All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright ©2009 Veterinary Learning Systems.

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September 2009 | Veterinary Forum

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SEPTEMBER 2009

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COVER STORY

contents

Finding influenza Paul Basilio

A new pathogen may mean raising red flags on otherwise innocuous signs.

Cover Image: ©2009 Monkey Business Images/Shutterstock.com

20

Business Skills

Learn more to earn more ....................................................6 Dr. Peter Weinstein

As you expand your knowledge, you will become more valuable to your boss, your clients, your patients, your family and yourself.

Clinical Report

Nutrigenomics — overcoming genetics with diet? .........16 Dr. Sophia Yin

According to recent research, scientists are proving that an animal’s genes do not necessarily seal its fate.

28

Peer Reviewed

WHAT’S YOUR DIAGNOSIS?

Reacting to Multifocal Skin Nodules ................................20 Drs. Louis-Philippe de Lorimier and Sébastien Kfoury

A golden retriever mix presented with multiple skin nodules that had been noticed by the owner 4 weeks earlier.

CASE REPORT

Orthopedic and Ocular Abnormality in a Labrador Puppy...28 Drs. Aaron Wehrenberg, A.D. Elkins, Jean Stiles, and Mary Palmer

A 12-week-old male yellow Labrador retriever presented after the owner and the referring veterinarian noticed the dog’s abnormal stance.

FORUM News

Testing for feline heartworm disease...............................26

also in this issue Editorial Board ......................1 Web Contents........................4 Advertisers Index.................29 Market Showcase ................30 Classified Advertising..........31

Whitney L. Myszak

Despite the high prevalence of canine heartworm disease, only about one-third of dogs are tested. For cats, the number is even lower.

Most Unusual Case

A tough nut to crack ...........................................................32 Dr. Simon Fick

To receive breaking news in your inbox, visit ForumVet.com.

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Veterinary Forum | September 2009

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Copyright © 2009 Intervet International B.V. All rights reserved. SPAH-VC-266:9467

on FORUM CHAT | E-NEWSLETTERS | NEWS | VIDEOS | FREE CE | WEB FEATURES | ARCHIVES | ONLINE STORE

WEB-EXCLUSIVE FEATURES

NEWS

■ Purdue celebrates vet school anniversary with

■ Public health goes to

service project at Ethiopian veterinary school.

■ Reaction to the Philadelphia Eagles’ signing of Michael Vick.

■ FTC ”Red Flags” Rule enforcement postponed.

■ Banfield discontinues tail docking, ear cropping.

■ FDA takes action against Teva Animal Health.

■ Hypoallergenic kittens donated to sick children.

■ AVMA GHLIT offers CE credit for pet insurance course — Pet Insurance 101.

■ New AVMA President speaks to delegates.

the dogs ■ Insurance center at DogTime ■ Corry new AVMA president ■ Vaccine protocols: an important part of every practice

WEB ARCHIVES Conduct a search in our archives for more web-exclusive features, client handouts, articles, forms and videos.

CONTACT US E-mail your questions, suggestions, breaking news, corrections, or letters to the editor to: editor@ForumVet.com.

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E-NEWSLETTERS RS Veterinary Forum Online, a monthly e-newsletter, provides webexclusive articles and news as well is as a preview of this month’s journal. Sign com. up at ForumVet.com.

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IN PRACTICE

By Peter Weinstein, DVM, MBA

BUSINESS SKILLS

Learn more to earn more

Editor’s Note: In this article, Dr. Weinstein discusses the importance of ongoing personal and professional development. By continuing this development throughout your career, you can avoid the large pitfall of professional and personal burnout and keep balance in your life.

— Stephen Fisher, DVM, Column Editor

Professional development involves both career and personal development. This processes of learning and self-development can escalate and diversify on completion of veterinary school. For years, veterinarians are focused primarily on veterinary coursework, sometimes at the expense of other aspects of their lives. After grad-

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uation, they not only need to continue learning, but also may need to devote time to finances, life balance, communication, child rearing and personal health.

Career The goals of career development should be to supplement the skills that you already have, to learn about new techniques, procedures or products and to create new income centers. It is postulated that clinical knowledge doubles every 18 months. With this in mind, you need to maintain your studies just to keep up with the rapidly changing world of veterinary medicine — regardless of state board requirements.

As you expand your knowledge, you will become more valuable to your employer, your clients, your patients, your family and yourself. Therefore, the more you learn, the more you will earn.

To increase your value, one obvious area of focus should be continuing education (CE). It is frequently required for re-licensure, but CE also is important for professional success (see CE Resources).

In many cases, CE conferences include wet labs that can supplement your didactic learning with hands-on experience, such as taking dental radiographs, performing neurologic exams or improving your ultrasound skills.

Personal The personal side of the professional development equation tends to be the least important to us, but should probably be the most important. Mental growth, spiritual growth and emotional growth all fit into this category. There are many resources that can help you refocus your energies on yourself, such as self-awareness seminars, yoga or tai chi. Regardless of how you approach personal growth, it is necessary that you find time for yourself.

Do you spend your days off at the office, or do you set aside time for hobbies and other interests? Develop the ability to completely separate yourself from the office on the days that you are not there. Can you go on vacation

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IN PRACTICE

CE Resources Major veterinary conferences, such as NAVC, WVC, AAHA and AVMA Journal CE articles State and regional veterinary conferences Veterinary school conferences Local association meetings Online resources, such as VIN, Oral ATP, and CEcenter.com Webinars presented by pharmaceutical companies and other sources

without calling the hospital? It may be difficult at first, but learn to leave your work at the office during trips and vacations. Mark your calendar with “You” days when you can indulge yourself for 24 hours without any workrelated interruptions.

Health Reportedly, more than 60% of Americans are overweight. Even though, as a veterinarian, you spend a lot of time on your feet, skipping meals and lifting animals onto tables, you need to recognize the importance of treating your body with respect.

Try finding 20 to 30 minutes each day to exercise — or several days a week. If it’s possible, walk or bike to work.

Your dietary needs also are important. Quick, healthy meals are available many places, so use these as an alternative to fast food when possible. Create the time to counsel yourself on your nutritional health — as much as you counsel your clients about their pet’s nutritional needs.

Having a balance of good nutrition and exercise can help you handle the stress that work creates as well as minimize the physical effects on your body.

The stress of being a veterinarian has a huge impact on your life as well as on the lives of those around you. Relationships are not just limited to family — they include friends and colleagues too. Improving your relationships can go a long way in improving how you feel about yourself and how you approach your work.

Finance Achieving financial stability may mean seeking assistance from advisors, consultants, accountants or financial planners. The goal is to learn how to accrue wealth with the financial tools available to you. Just as you wouldn’t ask an accountant to spay a cat, you may not be the best choice to do your own financial planning.

Internet resources and seminars also may guide you in maximizing your investments and the money that you earn while ensuring sufficient resources for retirement.

Community Personal growth and health are important, but you also should consider giving back to your community.

Sharing your time with the people around you can be fulfilling and a great way to learn about others, as well as yourself. Balance in life comes from being able to focus on all the areas mentioned here while also giving back to those in need around you.

It can be challenging to separate yourself from your business and vice versa. However, if you can learn how to improve yourself in some of these areas you may become more balanced. Never stop learning how to be a better veterinarian, but equally important, never stop learning vF how to be a better person.

Dr. Weinstein is past president of the California Veterinary Medical Association and former medical director of Veterinary Pet Insurance (VPI). Currently, he is providing practice management consulting through his two companies, P.A.W. Consulting and Veterinary Success Services, and is executive director of the Southern California Veterinary Medical Association.

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Veterinary Forum | September 2009

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By Paul Basilio ● Associate Editor

Coughing dogs are old hat in veterinary practice, but a novel pathogen raises a red flag over an otherwise innocuous sign.

C

oughing dogs are nothing new.

You would be hard-pressed to find a veterinarian in general practice who hasn’t come across the stereotypical, recently-boarded, 3-year-old Labrador retriever with an acute onset honking cough that gradually resolves over time.

“I used to tell my students that you’re not a veterinarian until you’ve anesthetized a dog because someone claimed there was something stuck in its throat, but it turned out to be kennel cough,” jokes Elizabeth Rozanski, DVM, DACVIM, DACVECC, assistant professor in the department of clinical services at the Tufts Cummings School of Veterinary Medicine. “Kennel cough dogs tend to have a horrid cough, but they’re healthy and otherwise alert.”

That’s not always the case in dogs infected with canine influenza virus (CIV), a new disease that often mimics the less serious infections that typically cause kennel cough. As a result, many veterinarians are now viewing dogs that show signs of respiratory disease with an extra measure of caution.

“Dogs with influenza are going to behave like humans with influenza,” Rozanski adds. “They’re going to feel a lot sicker than a dog with kennel cough or a person with a cold, and they’re going to feel that way for longer.” Such patients can require significantly more supportive care in order to help them recover. Some can develop pneumonia. And some of these dogs, albeit a small percentage, can even die.

If CIV is present in a facility, such as a kennel or shelter, management can be tricky, says Lesley King, MVB, DACVIM, DACVECC, director of the intensive care unit at the Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania.

“It’s very contagious and it is a new virus, so most of the dogs will have never seen it before and will be susceptible,” she explains. “If the virus gets into a kennel or a shelter, almost 80% of the dogs are going to show signs. It’s the same as if the flu got into a day care center for children.”

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Veterinary Forum | September 2009

Understanding the risk Experts agree that CIV is an important emerging disease and that its elusive nature can make the disease difficult to diagnose, treat and track.

“I don’t think veterinarians know the extent of the disease yet,” Rozanski says.

Although there have been outbreaks of CIV in 30 states and the District of Columbia, it is still very much thought of as a regional disease, meaning that it’s only considered a problem where there are active outbreaks.

“For the practitioner, I think the best bet would be to know what is going on in his or her area,” Rozanski adds. “It’s important to know your community. If the practice down the road has an outbreak, that’s important to know. Make friends with the boarding kennels and see what’s happening in those areas. It will help to understand what’s going on with your patients, which is one of the things veterinarians often struggle with. If you don’t know what someone else has seen, then you have the potential to miss something that’s coming into your area,” she notes.

CIV Fact Sheet • First identified in racing greyhounds in January 2004 • First identified in a pet population in Spring 2005 • Virtually 100% of exposed dogs will become infected • Approximately 80% of infected dogs show signs of disease • Approximately 20% of infected dogs will not show clinical signs and can become asymptomatic sources of infection for other dogs • Fatal in fewer than 8% of cases • Infected dogs can spread the virus for 7 to 10 days after onset of clinical signs • Signs include purulent nasal discharge, cough, and a low-grade to high fever

One of the problems confronting practitioners is that fewer newly adopted puppies are local. In the past, many puppies and kittens were adopted from area shelters. However, due to the recent increase in interstate adoption, dogs are showing up in examination rooms with more unfamiliar diseases.

“Here in New England,” Rozanski says, “it is rare for us to see stray puppies. They have done such a good job with the spay and neuter programs that most of our dogs are shipped in from the south or from Puerto Rico. It’s uncommon to

see a mixed-breed puppy in this area because most people get their dogs from the pet store or from a breeder.”

Index of suspicion CIV may be hard to diagnose, but veterinarians can keep their radar elevated by staying abreast of any outbreak news and keeping an eye out for puppies brought in from out of state, as well as for those that have spent time in a kennel or in an area where CIV is prevalent.

September March 2007 2009| |Veterinary VeterinaryForum Forum11 11

“If I see the mythical 3-year-old Labrador that was left at a kennel for a week and had a straightforward cough, then I would most likely have zero interest in doing other tests on that dog,” Rozanski says. “By and large, those dogs are going to get better no matter what I do. The dogs I do have an interest in treating are the dogs that differ even 1% from the [kennel cough] model.”

Although some cases of CIV can be discerned from other causes of respiratory disease by the sound of the dog’s cough — for example, some cases of influenza can cause a soft, moist cough as opposed to the loud, honking cough of Bordetella bronchiseptica — finding influenza poses a unique challenge.

“In an individual dog, diagnosis can be tricky because there are two main ways to diagnose the disease,” King says. “The first is to send a swab — typically from the nose or throat of the dog — for PCR analysis or virus isolation. If you test the dog between 2 and 6 days after exposure, then you’re likely to be able to find the virus there.”

The problem, King explains, is that although most dogs have some clinical signs (fever, nasal discharge, cough) as early as 2 days after exposure, many owners will not bring the dog to see its veterinarian until it becomes more severely ill, or after several days when it becomes apparent that the illness will not go away on its own. “When you get out past a week after exposure, the virus is no longer replicating or shedding,” King says. “You’re going to get a negative result on your PCR test, but your clinical signs at that point may still be quite dramatic. It’s the same as with flu in humans; people are at their most infectious before showing any symptoms.”

In a shelter environment, diagnosis is theoretically easier because if the shelter personnel are aware that CIV is a threat, PCR tests can be conducted 2 or 3 days after admission and the disease is more likely to be found. Funding for PCR tests, on the other hand, can be difficult for shelters to obtain, so the dogs often remain untested and CIV is allowed to spread.

Antibody testing is another method of CIV diagnosis, although it can take 8 to 10 days for the titers to start to rise, which causes another timing problem.

“If a client brought their dog in and it had been coughing for 2 weeks, you wouldn’t do a PCR or virus isolation because it would be too late,” King explains, “but you may do an antibody test. The problem is that often the animals present during that intermediate ‘grey zone’ in days 7 to 10, after the PCR results become negative and before the antibody test becomes positive.”

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Veterinary Forum | September 2009

King adds that ideally, follow-up antibody testing should be conducted to track down a CIV diagnosis.

Flagged for isolation Experts agree that in a perfect world, all coughing dogs would be isolated from other dogs for a quarantine period. This is often not feasible because of space limitations or a client’s lack of awareness about the dog’s infectious state. Certain measures, however, can be taken to minimize the risk of an outbreak.

For example, obtaining a thorough history can be key, King says. “If a dog was just adopted from a shelter or purchased from a pet store and comes into the clinic a few days later with a cough, that is a huge red flag. If it’s a dog that sits at home on its owner’s lap and never goes anywhere, then I would be much less worried. A little bit of background is an important thing to help you say, ‘Okay, this one needs to be treated as an infectious suspect.’”

Another useful containment measure is to keep dogs suspected of having respiratory disease separate from the rest of the practice’s patients. Dogs can be brought through a back door or kept in the owner’s car until an examination room becomes open, King says. “Don’t let potentially infectious dogs sit in the waiting room with other dogs.”

Additionally, staff should wear gowns, gloves and booties while in an examination room with a potentially infectious dog. Viruses and bacteria can be transferred to other patients via stethoscopes and other equipment, so a dedicated isolation room should have equipment that stays in that room.

“The same protocols should be followed for possible influenza cases as would be followed for possible parvovirus cases, for example. When you leave the room you should take off the gown, gloves and booties and leave them in there. Ideally, the dogs should not be hospitalized in the practice, which is fine as long as all they have is kennel cough. The problem is that a small subset will develop pneumonia and will require hospitalization,” says King.

CIV vaccine In May, the United States Department of Agriculture (USDA) granted a conditional license to Intervet/ Schering-Plough Animal Health for its CIV type A, subtype H3N8, vaccine. The vaccine can reduce the incidence and severity of lung lesions, as well as the duration of coughing and viral shedding, the agency said in its release.

“The experimental research suggests that it should be quite effective at decreasing the severity of signs,”

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says King. “It may not completely prevent disease, but it certainly seems as though it will make CIV a much less severe disease and decrease the risk of shedding. I think it definitely has utility.”

Most experts agree that this vaccine is considered noncore, which means it should be used in dog populations where veterinarians are currently using kennel cough vaccines, says Christopher Pappas Jr., DVM, director of companion animal technical services for Intervet/ScheringPlough. “You find the same risk factor in those groups of dogs — the ones that go to doggy day care, that are boarded often or are involved in dog shows.”

Rozanski agrees: “I think the best advice for veterinarians is to look at the risk for each dog and look for the regional risk, then update your vaccination guidelines.”

Although cases of CIV are not as widespread as cases of influenza in humans, continued vigilance is necessary to keep the risk of outbreaks in check. Not enough is understood about the mutation rate of the virus in dog populations to predict its behavior in the future.

“Influenza behaves differently in each species,” Pappas says. “In humans, vaccines are updated annually to predict which strain is going to hit the following year. In horses, the vaccines are updated about every 5 to 7 years. Canine influenza is a new disease, so instead of adding strains to the vaccine, we are monitoring the vaccine in the community to make sure it cross-protects with the new strains that develop, and we will update as necessary. Based on the science, history and research judgment [of CIV], I would think that the CIV vaccine will probably not need to be updated yearly. It’s important to monitor.”

The future The field of shelter medicine has undergone a phenomenal growth in the past few years, which will be beneficial for monitoring and protecting dogs from diseases like CIV. “Shelters do phenomenal things now,” Rozanski says.

“They do a lot of good studies that help the world. As small animal practitioners, we tend not to think too much about ‘herd’ health, but the emerging shelter medicine field is a great opportunity to look at that. Most of the vaccines are not terribly expensive, but on a multiple-animal basis that adds up. I think the questions we don’t tend to ask in veterinary medicine are about cost. How many animals do we have to vaccinate to prevent one dog from getting sick, and is that cost effective? In human medicine they do those studies on a regular basis, but we tend not to. It would be very helpful to vF know these sorts of things.”

Dr. King is a member of the Intervet/Schering-Plough Animal Health speaker bureau and receives honoraria from the company for presentations. Dr. Rozanski is currently conducting research sponsored by Intervet/Schering-Plough that is unrelated to the influenza vaccine.

September 2009 | Veterinary Forum

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By Sophia Yin, DVM, MS (Animal Science) Column Editor Special to VETERINARY FORUM

Nutrigenomics: overcoming genetics with diet?

Almost every veterinarian has encountered an owner of a portly dog who claims that his or her dog’s obesity must be a result of genetics, not improper feeding.

To some extent, the owners might be correct. There are dogs that have a gene expression profile that predisposes them to being fat. However, according to recent research on how diets can alter gene expression, also called nutrigenomics, scientists are showing that an animal’s genes do not necessarily seal its fate.

“Your DNA tells you everything that you could be,” says Steven S. Hannah, PhD, director of molecular nutrition at Nestlé Purina Petcare. “It doesn’t tell you everything you are going to be. There are many factors, including diet, that modify the ultimate expression of an animal.”

For example, a pilot study published in the Proceedings of the National Academy of Sciences in 2008 suggests that diet and lifestyle modifications in humans can alter gene expression related to prostate health. In the study, 30 men with low-risk prostatic cancer who declined surgery were placed on a strict low-fat diet supplemented with 3 g of fish oil each day. Most fish oil formulations contain between 300 and 500 mg of fish oil, so the study supplements contained 6 to 12 times the normal dose. The study participants also were placed on a strict regimen of exercise and stress management.

After 3 months, the participants showed reductions in weight and body fat as well as the upregulation of 48 genes and the downregulation of 453 genes. Among the modulated genes, some had critical roles in tumorigenesis.

Studies in humans can be quite challenging because some environmental variables can be difficult to control. Animal studies of this type, however, can be less challenging.

First, the researcher identifies gene expression profiles of unhealthy and healthy dogs. Next, he or she hypothesizes about which ingredients can change the profile from that of an unhealthy dog to a healthy one. Then a test product is formulated and fed to the study animals to test whether the gene expression profile changes in a particular tissue.

In the case of arthritis or degenerative joint disease research, scientists at Nestlé Purina compared the gene ex-

16

Veterinary Forum | September 2009

pression profile of arthritic chondrocytes to that of normal, healthy chondrocytes.

“We constructed a gene expression array chip that contains virtually every gene in the dog,” Hannah says.

“It has tens of thousands of genes on it. We took RNA from chondrocytes cells and applied it to the chip.” The chip, in turn, revealed the expression level of every gene with an affected expression.

Researchers identified more than 300 upregulated genes and about 30 downregulated genes in the arthritic vs. nonarthritic populations. In general, the arthritic cells upregulated the expression of enzymes that degrade the cartilage and downregulated enzymes that inhibit the degradation process. In essence, the arthritic cells were primed for cartilage destruction.

The next step was to determine which dietary changes might affect the joint. These tests began in petri dishes.

The researchers grew chondrocytes in cell culture and added inflammatory mediators that would be present with any joint injury. This process made the chondrocytes appear arthritic. The researchers then added nutrients at various concentrations to see which would help the cells to repair themselves. These tests revealed that omega-3 fatty acids provided good results, and the researchers were then able to determine which levels worked best.

Hannah explains the next step: “We can’t feed the nutrient directly into an animal’s joint, so we needed to see if we could get the nutrient from the food into a dog’s joint at the correct concentration.” The researchers wanted to see if fish oil could be digested and absorbed into the joint and if the omega-3 fatty acids were transported to the joint in concentrations shown to be effective in cell culture.

In a subsequent study conducted at Colorado State University, researchers fed a diet high in fish oil to arthritic dogs and examined the dogs’ joint fluid. It was quickly found that the omega-3 fatty acid levels were similar to the levels that had proven effective in the petri dish.

In a separate study, force-plate analysis was used to show that dogs fed high levels of fish oil did benefit in terms of lameness.

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clinical REPORT

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“We were able to verify that the changes in gene expression profile were accompanied by changes in the corresponding protein level as well,” says Hannah. “After being fed the diet, the dogs’ joints contained less metalloprotease, an enzyme that degrades the cartilage, and more proteins that inhibited the metalloprotease. So, the omega3 downregulated the enzymes that chew up cartilage and upregulated factors that inhibit the degradation.”

Nutrigenomics and obesity Another major area of nutrigenomics research focuses on obesity. Several pet food companies, including Nestlé Purina, Royal Canin and Hill’s Pet Nutrition, are investigating this area of study.

“We’ve looked at the gene expression profile in obese patients,” says Todd Towell, DVM, MS, DACVIM, of Hill’s Pet Nutrition, “and we can see a huge difference in gene expression between dogs that are obese and those that are lean.”

Dogs that are obese at the level of gene expression have upregulated systems that make the animals more efficient at storing fat in adipose tissue. The animals that are lean are more efficient at burning fat for energy.

Knowing this, the researchers attempted to design a diet that could encourage weight loss and change the gene profile. They studied overweight animals and fed them a new weight reduction diet, then looked at the gene expression profiles.

Body fat percentage measurements and genomic analysis were conducted at the beginning of the study and then 4 months later.

The dogs on the test diet went from being overweight to being lean and had a change in 254 genes — 240 were downregulated and 14 were upregulated. The diet had changed the dogs’ metabolisms from fat storers to fat burners.

In a similar study, dogs fed a high protein weight loss diet changed from fat to lean, but the gene expression profiles were still those of metabolically obese dogs. The dogs were still fat storers, which suggests the weight would easily be gained back.

Unfortunately, researchers tested the gene expression in blood cells but did not test the gene expression in the fat cells, where fat is actually stored. Nevertheless, the results are promising, and nutrigenomics is proving to add insight to our understanding of medicine and physiology. vF For more information:

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Dr. Yin works at San Francisco Veterinary Specialists in California.

Her website is www.AskDrYin.com.

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Veterinary Forum | September 2009

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WHAT’S YOUR DIAGNOSIS?

Reacting to multifocal skin nodules

By Louis-Philippe de Lorimier, DVM, DACVIM (Oncology), and Sébastien Kfoury, DVM

A 4-year-old, intact male golden retriever-mix weighing 28 kg presented to the Hôpital Vétérinaire Rive-Sud (HVRS) for evaluation of multiple skin nodules that had been noticed by the owner 4 weeks earlier. Topical therapy had been attempted before referral, without detectable clinical improvement.

n physical examination, multiple skin plaques and nodules were noticed on the muzzle, the dorsum, and the flanks, measuring 6 mm to 14 mm in diameter.

The lesions were erythematous, round (Figure 1), occasionally confluent, and some showed evidence of surface ulceration and crusting (Figure 2). The only other significant finding on physical examination was bilateral dynamic coxofemoral subluxation. No peripheral lymphadenopathy or abdominal organomegaly was detected on palpation.

O

What’s your diagnosis?

Establish a differential diagnosis and see answer on page 22.

A

Figure 2. Erythematous cutaneous raised plaques on the left flank of a 4-year-old mixed breed dog. The crust is at a site of incisional biopsy.

B

Figure 1. Superficial nodule on the bridge of the nose of a 4-year-old mixed breed dog. (A) Lateral view showing the bulging nodule.

(B) Dorsal view showing the round, erythematous, and partly alopecic lesion.

Have a What’s Your Diagnosis to Share?

We are looking for cases that pose a clinical or diagnostic puzzle that challenges our readers.

For submission guidelines, go to ForumVet.com.

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Veterinary Forum | September 2009

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peer reviewed WHAT’S YOUR DIAGNOSIS? ANSWER

(Case appears on page 20.)

Reacting to multifocal skin nodules The main differential diagnoses were: • cutaneous reactive histiocytosis • multiple histiocytomas • multifocal cutaneous malignancy (mast cell tumors, cutaneous lymphoma, plasma cell tumors) • infectious diseases (deep bacterial folliculitis/furunculosis, dermatophytic granulomas, systemic mycoses), and • immune-mediated diseases (idiopathic sterile nodular panniculitis, multifocal granulomatous inflammation).

Two incisional biopsies (6 mm punch) were obtained for histopathologic analysis, and cephalexin was prescribed at 19 mg/kg BW, PO, q12h pending biopsy results.

Histopathology confirmed a severe, nodular, lymphohistiocytic dermatitis most compatible with cutaneous reactive histiocytosis.

Hematology and a chemistry profile were performed and all results were within the reference range. Other diagnostic tests were recommended (thoracic and abdominal imaging) but declined. Tetracycline was started at 500

mg PO, q8h, and combined with over-the-counter niacinamide at the same dosage and frequency, for long-term administration. On recheck examination 6 weeks later, the cutaneous lesions were 90% improved, though some were still present on the right flank. Essential fatty acids were added to the treatment regimen (AllerG-3, Vet Solutions).

After another 6 weeks, the lesions had all resolved and the frequency of tetracycline/niacinamide administration was decreased to twice daily. Finally, another 6 weeks later (18 weeks following diagnosis), the dog was still free of detectable lesions and the frequency of administration was decreased to once daily. At the time of this writing, he has been treated with once daily administration for 6 weeks, and is still free of cutaneous lesions.

Figure 3. Typical appearance of a benign cutaneous histiocytoma on the caudal margin of the pinna of a 4-year-old female spayed bull terrier.

Figure 4. Localized pulmonary histiocytic sarcoma of the right caudal lung lobe (arrows) in an 8-year-old neutered Bernese mountain dog.

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Veterinary Forum | September 2009

(Answer continues on page 24.)

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peer reviewed WHAT’S YOUR DIAGNOSIS? ANSWER Discussion There are many histiocytic proliferative disorders, classified as neoplastic or nonneoplastic based on their biological behavior and cell lineage as identified with specific immunomarkers.1-3 The neoplastic histiocytic disorders include the benign cutaneous histiocytoma, localized histiocytic sarcoma, and disseminated histiocytic sarcoma (previously known as malignant histiocytosis), while the nonneoplastic disorders include cutaneous histiocytosis (CH) and systemic histiocytosis (SH).1-3 Benign cutaneous histiocytomas generally present as a solitary, round and firm, raised and erythematous lesion, rarely larger than 2 cm in diameter, most commonly observed in young dogs, typically before 3 to 4 years of age, on the cranial half of the body (Figure 3).

They originate from intraepidermal antigen-presenting cells (Langerhans cells).1-3 They may grow rapidly (1 to 4 weeks), and the vast majority will thereafter regress spontaneously following T-cell infiltration, generally over 1 to 2 months.1-3 Histiocytic sarcoma is an aggressive, malignant tumor of dendritic cell origin that can present with a localized or disseminated form at diagnosis. Overrepresented breeds include the Bernese mountain dog, the golden retriever, the rottweiler, and the flat-coated retriever.1,2,4 Multiple organs can be involved including large joints (elbow, stifle), lymph nodes, skin, spleen, liver, lungs (Figure 4), and bone marrow.1-4 The overall prognosis is guarded, especially when disseminated at diagnosis, but clinical responses are observed with standard cancer therapy including surgery (localized form), radiation therapy, and systemic chemotherapy.1,2,4 Two diseases are nonneoplastic and described as reactive histiocytoses: cutaneous histiocytosis, and systemic histiocytosis.1-3,5 Both reactive histiocytic disorders are the result of activated (nonneoplastic) dermal dendritic cells.5 SH is more frequently diagnosed in Bernese mountain dogs, rottweilers, golden and Labrador retrievers, and Irish wolfhounds.1-3,5 With SH, many organs can be affected with lesions, including the skin and subcutis, lymph nodes, bone marrow, scrotum, spleen, liver, lung, and mucous membranes.1-3,5 Affected dogs are most typically young to middle-age (3 to 9 years of age on average), and clinical signs, which can include depression, anorexia, weight loss, conjunctivitis, and difficult breathing, may wax and wane.1,2 Certain clinicopathologic changes, such as anemia, monocytosis, and lymphopenia,

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Veterinary Forum | September 2009

(Continued from page 22)

are frequently reported.1 Various therapies have been described, most typically involving the use of immunosuppressive agents, but prospective studies are needed.1-3,5 CH tends to occur in young to middle age dogs (median 4 years in recent study), has no known breed predisposition, and a male predilection has been described.13,5,6 Contrary to SH, lesions of CH are limited to the skin and subcutis, with commonly reported sites including the head, pinna, nasal planum/nares, limbs, and scrotum.13,5,6 The lesions, as in the case discussed here, are typically haired or alopecic erythematous plaques or nodules.

Nasal planum lesions may give a typical “clown nose” appearance.1-3,5,6 Similar to SH, lesions may wax and wane, and progression from CH to SH has been described.5 Until recently, there were few reports regarding therapeutic options for dogs with CH. A recent retrospective study described 32 cases of CH treated with various therapies.6 That study was the first one to report on the use of tetracycline and niacinamide (+/- vitamin E and/or essential fatty acids), and concluded that it was an effective treatment option for dogs with CH, though patients with nasal planum lesions suffered a higher risk for recurrence.6 Though many dogs of that study responded to other forms of therapy (mainly corticosteroids and other immunosuppressants), the authors recommended niacinamide and tetracycline maintenance therapy to possibly decrease the risk of recurrence.6 Dosages used in that study were 250 mg of each drug three times daily for dogs weighing less than 10 kg and 500 mg three times daily for dogs weighing more than 10 kg.6 vF References 1. Clifford CA, Skorupski KA. Histiocytic diseases. In Withrow SJ, Vail DM (eds): Small Animal Clinical Oncology, ed 4. Elsevier, St. Louis, Mo., 2007.

2. Coomer AR, Liptak JM. Canine histiocytic disorders. Compend Contin Educ Vet 2008;30:202-217.

3. Angus JC, de Lorimier LP. Lymphohistiocytic neoplasms. In Campbell KL (ed): Small Animal Dermatology Secrets. Hanley & Belfus, Philadelphia, 2004.

4. Skorupski KA, Clifford CA, Paoloni MC et al. CCNU for the treatment of dogs with histiocytic sarcoma. J Vet Intern Med 2007;21:121-126.

5. Affolter VK, Moore PF. Canine cutaneous and systemic histiocytosis: reactive histiocytosis of dermal dendritic cells. Am J Dermatopathol 2000;22:40-48.

6. Palmeiro BS, Morris DO, Goldschmidt MH, Mauldin EA. Cutaneous reactive histiocytosis in dogs: a retrospective evaluation of 32 cases.

Vet Dermatol 2007;18:332-240.

Drs. de Lorimier and Kfoury are affiliated with the Hôpital Vétérinaire Rive-Sud in Brossard, Québec, Canada.

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news

Testing for feline heartworm disease

By Whitney L. Myszak Correspondent

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Veterinary Forum | September 2009

About Pulmonary Intravascular Macrophages Pulmonary intravascular macrophages (PIMs) originate in the bone marrow. PIMs migrate to the lungs, and become “garbage-eating monocytes.”

The inflammation can cause heartworm-associated respiratory disease (HARD), which is often mistaken for asthma or allergic bronchitis.

When the remaining heartworms mature, they learn to suppress the inflammatory response by downregulating the PIMs. When a single heartworm dies, PIM function is restored and a second inflammatory response occurs.

Image courtesy of Ray Dillion, DVM, MS, DACVIM, and Byron Blagburn, MS, PhD, Auburn University

LAS VEGAS — Routine testing and disease prevention are at the forefront of education for feline heartworm disease, according to Lynn Buzhardt, DVM, at a Western Veterinary Conference session sponsored

by IDEXX Reference Laboratories.

“Anywhere canine heartworm disease exists, there is a potential for feline heartworm disease,” she said, noting that if you look at a canine incidence map, there is significant heartworm disease in the United States (see map on page 27).

Despite the high prevalence of canine heartworm disease, only about one-third of dogs are tested. For cats, the number is even lower — fewer than 0.1% of cats are being tested for heartworm disease, said Buzhardt, who is co-owner of The Animal Center, a full-service veterinary hospital in Zachary, La. “Feline heartworm disease has an extremely high incidence compared with renal failure or diabetes,” Buzhardt explained. But unlike cats with diabetes, cats with heartworm disease may be asymptomatic, so clients are unlikely to recognize the need for testing.

“Veterinarians want pet owners to understand that heartworm disease in cats is a serious health threat. Clients need information that is scientifically based but easy to comprehend,” she said.

Educating clients begins by educating staff. Buzhardt explained that if staff members understand why heartworm disease testing is impor-

tant, they can better explain that importance to clients. Start with an explanation of the differences between

Cats are the only carnivores that have PIMs.

canine and feline heartworm disease, such as: • Heartworms have a shorter life span in cats.

• Cats have fewer adult heartworms but suffer significant disease nonetheless.

• Cats can abort the infection before the worms mature.

• Cats have pulmonary intravascular macrophages (PIMs; see box), which trigger an inflammatory response to immature heartworms.

Diagnosing feline heartworm disease can be difficult, but it is possible.

“We use a conglomeration of information when it comes to diagnosing,” said Buzhardt.

Radiographs can help track disease progression. “Abnormal radiographs should be repeated in 2 to 3 weeks to monitor the progression of the disease. Inflammation associated with PIM activity may resolve, and the cat’s signs may subside,” she said.

Serology is another good tool according to Buzhardt. “Antibody and antigen testing can determine positivity at different times over the course of infection.”

An antigen test primarily detects adult female worms, she explained. A negative test is inconclusive because the infection may consist of immature females or male worms or the number of worms may be below the test threshold. However, if a cat tests positive on an antigen test, no more testing is required: The cat is heartworm positive.

“Historically, we felt that a positive antibody test meant exposure

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Courtesy of the American Heartworm Society

Incidence of Canine Heartworm Disease

The spread of canine heartworm disease in the United States has been the focus of considerable attention. In contrast, there is little information on the potential risk for cats.

but not necessarily full disease. However, for a cat to test positive for antibodies, it was more than just exposed.”

A positive antibody test does not indicate whether an infection was naturally aborted or the worms matured to adults. However, the infection will not develop further in cats that are on a monthly preventative, as the medication will eliminate the larvae before they mature, she added.

Disseminating information about feline heartworm disease to clients can help convince them that testing and prevention are important. Buzhardt recommends conveying only three messages to clients: • Heartworm disease affects indoor cats because mosquitoes travel indoors.

• The disease is life-threatening.

• It’s in the clients’ hands to prevent heartworm disease through administering preventatives properly.

Testing for heartworm disease may become a standard of care for cats, Buzhardt said, which would benefit cats and the practice. “Only 4% of cats are on a heartworm preventative, which leaves room to increase clinic revenue while improving feline health.

“In 2007, people spent more on pet health care than on alcohol and tobacco combined,” Buzhardt noted. “Clients have to set priorities when budgeting for pet care. Pet owners can afford what they choose to afford.” vF Dr. Buzhardt reported no potential conflict of interest relevant to this article.

For more information: Buzhardt L. How to introduce feline heartworm disease testing and prevention into your practice. Presented at: The Western Veterinary Conference 2009. Las Vegas, Nev.; Feb. 15-19, 2009.

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CASE REPORT

Orthopedic and Ocular Abnormality in a Labrador Puppy

By Aaron Wehrenberg, DVM, A.D. Elkins, DVM, MS, DACVS, Jean Stiles, DVM, MS, DACVO, and Mary Palmer, DVM, MS, DACVS

ocky, a 12-week-old male yellow Labrador retriever, was referred to our facility after the owner and the referring veterinarian noticed the dog’s abnormal stance. The history included an absence of lameness, ownership for 2 weeks, an appropriate diet, and an otherwise apparently healthy puppy.

An orthopedic examination, along with an overall physical examination, revealed abducted and enlarged elbows (Figure 1). All joints had normal range of motion and no crepitus was appreciated. The only other abnormality noted on examination was brachygnathism causing malocclusion.

Rocky was lightly sedated and orthogonal radiographs of the joints of the forelimbs were obtained (Figure 2).

Based on the radiographs, Rocky was diagnosed with osteochondrodysplastic dwarfism, an inherited disorder found in breeds that are not “normally” chondrodystrophic, including Norwegian elkhounds, Great Pyrenees, Alaskan malamutes, toy poodles, Newfoundlands, Saint Bernards, German shepherds, clumber spaniels, and Scottish deerhounds.1 Osteochondrodysplasia also is referred to as skeletal–retinal or oculoskeletal dysplasia in Labrador retrievers. Radiographic changes include humeroulnar subluxation along with caudolat-

R

A

B

C

eral subluxation of the proximal radius.1 These abnormalities were noted Figure 1. Rocky at 12 weeks of age. on Rocky’s radiographs.

The owner was advised that surgical intervention at that point was not indicated to correct angular limb deformities or allow better congruency of the elbow joints because of osteochondrodysplasia. The owners also were advised that monthly orthopedic examinations, possibly with radiographs to track the progress of Rocky’s joints, would be needed. If at any time the owner or doctors observed a developing lameness, surgery may be needed.

Rocky was referred to an ophthalmologist for assessment. Ophthalmic examination found a complete retinal detachment in the left eye, causing blindness. The right eye had mild retinal dysplasia, and both lenses had early cortical cataracts. A laser retinopexy on the right eye was performed 2 weeks later.

No lameness was noted at recheck examinations at 4 weeks and 12 weeks. Follow-up radiographs revealed bilateral agenesis of the anconeal processes. Monitoring of Rocky’s musculoskeletal system and ocular system will continue (Figure 3).

Skeletal-retinal or oculoskeletal dysplasia in Labrador

D

E

Figure 2. (A) Lateral radiograph of the left shoulder. Note the humerus appears more like a chondrodystrophic breed of dog than a Labrador retriever; (B) Lateral radiograph of the left elbow; (C) Craniocaudal view of the left elbow. Note the proximal radius subluxation; (D) Lateral radiograph of the right elbow; (E) Craniocaudal view of the right elbow. Note the proximal radius subluxation.

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Figure 3. Rocky at 6 months of age.

retrievers is an inherited disease that is most likely an autosomal recessive trait.1 Other studies have inferred that this condition may be caused by a flawed gene that has an incomplete dominant result on the ocular system and a recessive result on the skeletal system.3-6 Affected animals should not be used for breeding. Common findings are a normal body length; however, the extremities are shortened from hindered growth of the femurs, tibias, ulnas, or radii.2 Other orthopedic deformities that may be seen are carpi valgus, hyperextended pelvic limbs, and hypoplastic or ununited anconeal processes.2 As in Rocky’s case, ocular abnormalities also may occur with this condition, including retinal dysplasia, retinal detachment, and cataracts.2 By being aware of this condition, the veterinarian can be diligent in early treatment by seeking the expertise of a veterinary ophthalmologist. Currently, Rocky’s pelvic limbs appear unaffected. As he matures this may change.

In this particular case, we will continue to monitor Rocky during maturation and intervene if necessary, most likely vF with corrective osteotomies.

References: 1. Langely-Hobbs S. Disturbances of growth and bone development.

BSAVA Manual of Canine and Feline Musculoskeletal Disorders. Gloucester, United Kingdom: BSAVA; 2006:58-60.

2. Owens JM, Biery DN. Radiographic Interpretation for the Small Animal Clinician ed 2. Baltimore: Williams & Wilkins; 1999:38.

3. Ackerman L. The Genetic Connection: A Guide to Health Problems in Purebred Dogs. Lakewood, Colo.: AAHA Press; 1999:126.

4. Carrig CB, Sponenberg DP, Schmidt GM, Tvedten HW. Inheritance of associated ocular and skeletal dysplasia in Labrador retrievers.

JAVMA 1988;193(10):1269-1272.

5. Genetics Committee of the American College of Veterinary Ophthalmologists. Ocular disorders presumed to be inherited in purebred dogs, ed 2; 1996.

6. Pugh CR, Miller WW. Retinal and skeletal dysplasia in the Labrador retriever. Vet Med 1995; 90(6):593-596.

Drs. Wehrenberg, Elkins, Stiles, and Palmer are affiliated with the VCA Veterinary Specialty Center in Indianapolis, Ind.

September 2009 | Veterinary Forum

29

CareCredit Flexible Payment Plans .........................................................9 Companion Animal Hyperbarics Veterinary Hyperbaric Solutions ..........................................8 Greenies Dental Chews ........................................................................7 IAMS ProActive Health .................................................................13 Intervet/Schering-Plough Animal Health Canine Influenza Vaccine ..........................................Cover 4 Nobivac Lyme ........................................................................3 Kelco Supply Quiesco Pet Remembrance Products .................................18 Sharn Veterinary Cardell Monitors .................................................................17 Sound-Eklin The Future of Veterinary Imaging .......................................5 VCA Antech Hospital Purchase Programs ...............................................23 Vetstreet Practice Communication and Management Tool ........14,15 Wahl KM2-Speed Clipper.....................................................Cover 2 Western Veterinary Conference WVC 2010 ............................................................................25

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Publisher’s Disclaimer: Advertising appearing in this issue does not necessarily reflect the opinions of nor constitute or imply endorsement or recommendation by the Publisher. The Publisher is not responsible for any statements or data made by the Advertiser.

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NORTH CAROLINA – Well-established, 24-hour, AAHA-accredited 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.

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Place Your Ad Where It Will Get Noticed: Contact Susan Deakins at vetforum@rja-ads.com or call 800-237-9851, ext. 258 September 2009 | Veterinary Forum

31

most

UNUSUAL CASE

A tough nut to crack

By Simon Fick, DVM Grand Blanc, Mich.

©2009 Gavin Smith Photography

I

He had a hamster in a coconut; he freed them both up.

32

t was a slow night at the emergency clinic when a very distressed woman and her two small children walked in. It didn’t look like they had brought an animal with them, but I figured there was a large dog in the car that they couldn’t carry into the office.

I asked how I could help, and that’s when I noticed the woman was holding a small coconut.

“Oh, you have a coconut!” I said, feeling incredibly observant.

The woman didn’t say a word — she just turned the coconut around and showed me the purple-faced hamster that was stuck in the other side. It seems she had purchased a hollowed-out coconut shell with a few holes drilled into it for the hamster to play with, but this hamster wasn’t that tiny. He had crawled into the coconut, poked his head back out and became wedged in that position.

I quickly took the coconut from the woman, rushed into the treatment room and tried to remember the exotic animal electives I took in school, but nothing came to mind. I must have missed the section on extracting rodents from tropical fruit.

I placed a small oxygen mask over the hamster’s head, which improved his color and breathing and bought me a little time to figure out the conundrum. I had already tried applying gentle pressure to his head, but he was firmly stuck. His cheek pouches were empty and not part of the problem.

I briefly considered applying lubricant to his head, but he was wedged too tightly and I didn’t want to further traumatize him. I was going to have to break the shell, which could be difficult without hurting the little guy.

We did not have any orthopedic surgical equipment, such as a pin cutter, and the clinic’s toolbox consisted of a hammer and a large screwdriver. I couldn’t use the hammer because I’d risk injuring the little patient in the process.

Then, my technician did what technicians often do: she came through in the clutch. She knew that the clinic had a number of gardening tools and that our pruning shears might cut through the coconut. I originally pictured a small hand-held pair of clippers in my mind, but she brought out a pair with handles that were about 30 inches long.

I had to use the tools available, so I placed the tip of the shears into a hole next to the one where the hamster was stuck. I told my technician to watch her fingers, as I also worried about cutting off one of the hamster’s legs.

I gently squeezed the clippers and cracked the part of the shell next to the little guy’s head. I made another small cut and extracted the beleaguered hamster. After a few minutes of oxygen he was fine.

I triumphantly walked into the waiting room and held the hamster and the remains of the coconut up to the client. “He’s going to be just fine,” I said.

“You broke our coconut!” she replied. vF I guess they were more attached to the fruit.

Veterinary Forum | September 2009

We believe you re too good to be micromanaged. We believe in providing more resources, not taking them away. We believe a econd opinion, or third, or fourth, can make yours even stronger. We believe in getting out of the way and letting doctors be octors. We believe you own your career. We believe you went to vet school for a very furry reason. We believe people need eterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in iving you the tools you need to do your job. We believe no matter how good you are, you can always get better. We believe t xcellent doctors make excellent colleagues. We believe mentors can learn as much as mentees. We believe in saving the lives f Pets and improving the lives of vets. We believe that you should be focused on your patient, not your paperwork. We belie hat flexible hours make for refreshed doctors. We believe cats aren’t the only animals that purr. We believe we’re helping fam es along with their Pets. We We believe believe experience experience is is powerful powerful medicine. medicine. We believe in providing more resources, not takng them away. We That you’re a healer – not an administrator. yours even stronger. We believe in getting out of the way and etting doctors be doctors. We believe you own And that the right resources make good doctors great. for a very furry reason We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time aw om it. We believe in giving you the tools you need to do your job. We believe no matter how good you are, you can always g etter. We believe that excellent doctors make excellent We We believe believe you you should should look look forward forward to to work. work. mentees. We beli That your your practice practice isis part part of of who who you you are. are. be focused on your patient, not your paperwork. W n saving the lives of Pets and That elieve that flexible hours make for refreshed doctors. We But that your loved ones at home need you too. We believe we’re elping families along with their Pets. We believe you’re too good to be micromanaged. We believe in providing more resourc ot taking them away. We believe a second opinion, or third, or fourth, can make yours even stronger. We believe in getting o f the way and letting doctors be doctors. We believe you own your career. We believe you went to vet school for a very furry eason. We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some me away from it. We believe in giving you the tools you need to do your job. We believe no matter how good you are, you c lways get better. We believe that excellent doctors make excellent colleagues. We believe mentors can learn as much as ment We believe in saving the lives of Pets and improving the lives of vets. We believe that you should be focused on your patient, ot your paperwork. We believe that flexible hours make for refreshed doctors. We believe cats aren’t the only animals that pu We believe we’re helping families along with their Pets. We believe you’re too good to be micromanaged. We believe in provid ng more resources, not taking them away. We believe a second opinion, or third, or fourth, can make yours even stronger. We elieve in getting out of the way and letting doctors be doctors. We believe you own your career. We believe you went to vet chool for a very furry reason. We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in giving you the tools you need to do your job. We believe no matter h ood you are, you can always get better. We believe that excellent doctors make excellent colleagues. We believe mentors can earn as much as mentees. We believe in saving the lives of Pets and improving the lives of vets. We believe that you should b ocused on your patient, not your paperwork. We believe that flexible hours make for refreshed doctors. We believe cats aren’ Banfield, believeyou’re in our too veterinarians. he only animals that purr. We believe we’re helping families along with theirAtPets.

Wewe believe good to be microWe’ll give you the tools you need to do theor fourth, can managed. We believe in providing more resources, not taking them away. We believe a second opinion, or third, best jobbe possible: fromWe resources modern make yours even stronger. We believe in getting out of the way and letting doctors doctors. believeand you own your caree to a healthyas work/life balance, we We believ We believe you went to vet school for a very furry reason. We believe peopletechnology need veterinarians much as Pets do. keep doctors thetools forefront veterinary ou’re better at your job when you’ve had some time away from it. We believe in our giving youatthe youofneed to do your job We believe no matter how good you are, you can always get better. We believe that make care.

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We believe a second people. them Because at Banfield, you aren’t just opinion, o hird, or fourth, can make yours even stronger. We believe in getting out of the way and letting doctors be doctors. touching patients – you’re touching the futureWe believe ou own your career. We believe you went to vet school for a very furry reason. We believe people need veterinarians as much of medicine. s Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in giving you the tools y eed to do your job. We believe no matter how good you are, you can always get better. We believe that excellent doctors mak We’re Banfield. We believe in vets. xcellent colleagues. We believe mentors can learn as much as mentees. We believe in saving the lives of Pets and improving t ves of vets. We believe that you should be focused on your patient, not your paperwork. We believe that flexible hours make or refreshed doctors. We believe cats aren’t the only animals that purr. We believe we’re helping families along with their Pets We believe you’re too good to be micromanaged. We believe in providing more resources, not taking them away. We believe a econd opinion Visit us at banfield.net/veterinarians We believe in getting out of the way and letting doctors be doctor We believe for a very furry reason. We believe people need veterinarians as much as Pets do. We believe you’re better at your j when you’ve had some time away from it. We believe in giving you the tools you need to do your job. We believe no matter h d l b b l h ll

With the introduction of the first vaccine for canine influenza,

only the love is contagious.

Now you can provide your patients with more comprehensive protection against respiratory infection.

Love is not the only thing in the air. Canine influenza virus (CIV) has been confirmed in dogs across 30 states and the District of Columbia, and its prevalence is rising.1 And because most dogs are naive to the virus, virtually every naive dog exposed will become infected.2 CIV is highly contagious and sometimes deadly. Clinical signs associated with CIV can be confused with kennel cough making accurate diagnosis difficult. Now you can broaden the respiratory protection you currently offer to patients with the addition of the first vaccine for canine flu, Canine Influenza Vaccine, H3N8.

Canine Influenza Vaccine, H3N8 —a killed virus vaccine from Intervet/Schering-Plough Animal Health—significantly decreases clinical signs of disease and reduces viral shedding, and its safety has been confirmed in a study involving more than 700 dogs.3

Notice: This product license is conditional. As with all USDA conditionally licensed products, data submitted to the USDA supports a reasonable expectation of efficacy.

Safety was established in trials involving more than 700 dogs.

So while CIV, like love, can be easily spread and hard to identify, it no longer has to be so overwhelming. To learn more, contact your Intervet/Schering-Plough Animal Health representative, visit www.doginfluenza.com, or call our technical services team at 800-224-5318.

References: 1. Syndromic surveillance data of Cynda Crawford, DVM, PhD, University of Florida, and Edward Dubovi, PhD, Cornell University. 2. Key facts about canine influenza. CDC Website. Available at: http://www.cdc. gov/flu/canine. Accessed May 1, 2009. 3. Data on file, Intervet/Schering-Plough Animal Health.

Copyright © 2009 Intervet International B.V. All rights reserved. SPAH-VC-284:9412