FVMA Advocate Issue 4, 2023

A DVO CAT E ISSUE 4 | 2023

ICTERIC CATS: More Than

Just Hepatic Lipidosis

Adam Honeckman | DVM, DAVCIM (Small Animal Internal Medicine) | Page 6

WHAT AILS THE Paws and Claws

Linda Messinger | DVM, DACVD | Page 12

BETTERNINARY CARE:

Caring About the Caregivers

Heidi Hulon | DVM, CCFP, MHFA | Page 28

President's MESSAGE 7207 Monetary Drive Orlando, Florida 32809 Phone: 407-851-3862 800-992-3862 Fax: 407-240-3710 info@fvma.org www.fvma.org

Greetings, Even though it may not yet feel like it in some parts of the state, it is fall, and it is about that time to renew your FVMA/FAEP membership. The FVMA works hard on our mission to advance the veterinary medical profession, promote animal health and well-being, and promote public health. We provide quality continuing education meetings with excellent wet labs, advocate strongly for our profession on all levels, and offer many benefits and resources for you and your practice. We continue to consider the different disciplines and aspects of the profession, so we can better support our members.

BOARD OF GOVERNORS

DR. JACQUELINE S. SHELLOW President DR. SCOTT RICHARDSON President-elect DR. ALEX 'STEVE' STEVERSON Treasurer DR. MARTA P. LISTA Immediate Past President DR. ERNEST C. GODFREY Trustee Emeritus JIM NAUGLE Executive Director

BOARD OFFICERS

DR. RICHARD B. WILLIAMS AVMA Delegate DR. RICHARD C. SUTLIFF AVMA Alternate Delegate DR. BROOKE EUBANKS District 1 – Big Bend DR. THOMAS E. HESTER District 2 – Northeast

• • • •

Services Include: Abdominal Ultrasounds Echocardiograms Pregnancy Checks FNA Biopsy Guidance

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Benefits to your clients Increases potential for early intervention Maintains primary doctor relationship Eliminates client travel to specialist Diminishes client’s stress & anxiety

DR. TODD FULTON District 3 – Central DR. DONALD S. HOWELL District 4 – Tampa Bay DR. BETH KESER District 5 – Treasure Coast

I am grateful to serve this organization and know the importance of active participation in organized veterinary medicine. The FVMA is here for you. Let us know how we can help.

Reach out to any of us if you would like to become more involved in the FVMA or FAEP. Our upcoming meetings will continue to offer the three-hour Florida Laws and Rules & Dispensing of Legend Drugs course needed for our veterinary license renewal in 2024.

We are actively working on growing the FVMA Foundation, which supports scholarships for UF College of Veterinary Medicine students, veterinary technician students, disaster relief aid, wellness resources for our members and their teams, and our Power of Ten program. We are excited to have become involved in some great community outreach programs. Please consider supporting our foundation.

We will once again be attending Legislative Action days this upcoming Jan. 16-18 in Tallahassee. If you are interested in joining us to advocate for our profession, please contact the FVMA office, and please consider supporting our PAC, so we can continue working hard to protect our profession and the animals we care for.

I hope everyone takes a little time to enjoy the holidays with friends and family. We look forward to seeing you at one of our upcoming meetings.

DR. ROBERT L. SWINGER District 6 – South Florida

Warm regards,

DR. BARBARA LEWIS District 7 – Southwest

Jackie Shellow, DVM, MS

DR. JOHN R. WIGHT District 8 – Northwest

WE RECOGNIZE MORE THAN SUCCESS, WE HONOR HARD WORK, AND WE AWARD SERVICE. NOMINATE SOMEONE FOR THE

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DR. CHRISTINE M. STORTS District 9 – Space Coast

Awards!

DR. SALLY DENOTTA FAEP Representative to the FVMA Executive Board

advance the veterinary medical profession, FVMA MISSION: To promote animal health and well-being, and protect public health.

Opinions and statements expressed in FVMA Advocate reflect the views of the contributors and do not represent the official policy of the FVMA, unless so stated. Placement of an advertisement does not represent the FVMA's endorsement of the product or service.

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Staff

JIM NAUGLE Executive Director ERIKA MEYER Administrative Manager

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LIAM CROSS Database Specialist MARIBEL BLUM Finance & Accounting Manager

YOU ARE THE CENTER OF OUR FOCUS.

IN THIS ISSUE 3 | President's Message

24 | Power of Ten Application

6 | Icteric Cats: More Than Just Hepatic Lipidosis

26 | Annual Conference 2024

16 | Membership Benefits 18 | FVMA Unwrapped

4 | FVMA Advocate

A lot of tasks compete for your time as you manage your practice. From administrative work and equipment maintenance to client communications, appointment scheduling and reminder phone calls, it’s easy to lose sight of what’s most important. Patterson’s experienced support teams help you take care of these details so you can get back to what you love – helping your patients.

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12 | What Ails the Paws and Claws

28 | Betterinary CARE: Caring About the Caregivers

We focus on you so you can focus on them.

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the next diagnostic step to help differentiate between hepatic and post-hepatic icterus. If the common bile duct is >5mm, extrahepatic biliary duct obstruction (EHBDO) is likely. Causes of EHBDO include choleliths, neoplasia, flukes, cholangitis, and pancreatitis.

ICTERIC CATS:

More Than Just Hepatic Lipidosis

Ultrasound of an icteric cat with a severely dilated and tortuous bile duct from an extrahepatic bile duct obstruction.

Image courtesy of Dr. Adam Honeckman

Adam Honeckman | DVM, DACVIM (Small Animal Internal Medicine)

Icterus can be defined as increased bilirubin in the serum, urine, or tissues. Bilirubinuria can be detected earlier than hyperbilirubinemia. Often, serum total bilirubin concentration must exceed 3 mg/dl before it can be detected on physical exam, whereas a serum bilirubin of >1mg/dl can cause the serum to be grossly icteric.

Veterinary Specialty Solutions

Bilirubin is a product of hemoglobin metabolism. Increased levels can occur due to prehepatic (hemolysis), hepatic, or post-hepatic causes. With the exception of Mycoplasma haemofelis (formerly known as Hemobartonella felis), hemolytic anemias are relatively uncommon in cats. Most causes of icterus in cats are hepatic or post-hepatic in origin.

Although hepatic lipidosis is reported to be one of the most common causes of icterus in cats, several other differentials need to be considered. A review of 50 icteric cats seen in the author's practice revealed that only 30% had hepatic lipidosis. Cholangitis was responsible for 20%, and lymphoma was diagnosed in another 20%. Pancreatitis (15%), extrahepatic bile duct obstruction (10%), and other miscellaneous diseases (5%) were responsible for the remaining icteric cats. The disease could also have more than one identifiable cause (i.e., hepatic lipidosis + cholangitis and/or pancreatitis, pancreatitis + cholangitis +/- inflammatory bowel disease).

In cases of pancreatitis, abdominal ultrasonography may reveal an enlarged hypoechoic pancreas surrounded by hyperechoic fat, pancreatic duct dilation, and/or localized peritoneal effusion.

A normal ultrasound doesn’t rule out pancreatitis since the sensitivity is only about 11-84%. A fasted spec fPL (run by Texas A&M GI laboratory or Idexx) is the most sensitive and specific test for feline pancreatitis. Alternatively, the PSL assay by Antech has been shown to have a fair correlation with the spec fPL in some studies. The author prefers to use both abdominal ultrasound and the spec fPL (or PSL) to diagnose pancreatitis. The snap fPL test is a screening test (a negative test makes pancreatitis less likely), but a positive test is nonspecific and needs to be confirmed by abdominal ultrasound and/or spec fPL determination.

If abdominal ultrasound does not demonstrate changes consistent with pancreatitis or EHBDO, hepatic icterus is most likely. A diffusely hyperechoic liver is highly suggestive of hepatic lipidosis but can also be seen in diabetic or healthy obese cats. The ultrasound appearance of lymphoma or cholangitis can be variable, sometimes with no abnormalities being found.

LIVER FINE NEEDLE ASPIRATE VS. BIOPSY Cytology or histopathology is needed for a definitive diagnosis of hepatic icterus because ultrasound changes of hepatic parenchyma are often nonspecific. Cytologic evaluation of liver fine needle aspirates may be useful in diagnosing hepatic lipidosis or lymphoma, but often misses necroinflammatory disorders such as cholangitis. Therefore, histopathologic evaluation of a liver biopsy may be superior to a fine needle aspirate.

Image courtesy of Canva.

DIAGNOSTIC EVALUATION When evaluating an icteric cat, the PCV should be assessed.

If the PCV <20%, then pre-hepatic causes are most likely. The exception would be in cats with anemia, and icterus due to simultaneous involvement of the bone marrow and liver (i.e., lymphoma or other myeloproliferative disease). If the PCV >20%, then hemolytic anemia is unlikely, and the diagnostics should focus on hepatic and post-hepatic causes of icterus.

If hemolytic diseases are ruled out, abdominal ultrasonography is

Fine needle aspirate from a liver of an icteric cat containing a large number of lymphoblasts diagnostic for large cell lymphoma.

Image courtesy of Dr. Adam Honeckman

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needed to correct dehydration or electrolyte imbalances (such as hypokalemia and/or hypophosphatemia). In the absence of hypoglycemia, dextrose supplementation is avoided since it may increase hepatic triglyceride accumulation, inhibit fatty acid oxidation, and worsen electrolyte depletion. Empirical antibiotic therapy can be used if cholangitis is suspected. If liver flukes are possible, a therapeutic trial of praziquantel 20mg/kg SQ (or PO) SID x three days is administered. The rest of the treatment regimen depends on the results of the biopsy.

TREATMENT OF SPECIFIC DISEASES Ultrasound of an icteric cat revealed an enlarged hypoechoic left limb of the pancreas consistent with pancreatitis.

Image courtesy of Dr. Adam Honeckman

Since coagulation abnormalities are common in cats with hepatobiliary disease, a coagulation profile (PT, PTT, and platelet count) should be performed prior to performing a liver biopsy. Coagulopathies may be caused by decreased clotting factor synthesis, vitamin K malabsorption, DIC, or decreased platelet function. Vitamin K deficiency has been noted in 5075% of cats with hepatobiliary disease. The author routinely administers Vitamin K1 0.5-1.5mg/kg SQ q 12 hrs for three doses prior to performing a liver biopsy in icteric cats.

Liver biopsies can be obtained either surgically, laparascopically, or ultrasound-guided. Some cases of EHBDO, such as those due to pancreatitis, may respond to medical management and do not require surgery. Surgical biopsies are indicated in cases with EHBDO that require biliary diversion (i.e. cholecystoduodenostomy or cholecystojejunostomy). In most other instances, less invasive methods of obtaining biopsies are preferred. In the author's practice, ultrasound-guided liver biopsies are most common.

Hepatic Lipidosis Hepatic lipidosis may be idiopathic or secondary. The diagnosis of idiopathic hepatic lipidosis is a diagnosis of exclusion. Up to 40-90% of hepatic lipidosis cases are secondary to other diseases – such as cholangitis, lymphoma, pancreatitis, inflammatory bowel disease, cardiomyopathy, diabetic ketoacidosis, or pyelonephritis.

A thorough diagnostic evaluation is necessary to diagnose and treat any potentially underlying cause.

Nutritional support with a feeding tube is the cornerstone of treating cats with hepatic lipidosis. Syringe/force-feeding is stressful for both cats and their owners. Appetite stimulants are not a substitute for a feeding tube and are rarely prescribed in the author's practice. For long-term enteral nutritional support, esophagostomy or gastrostomy tubes are used. A percutaneous endoscopic gastrostomy tube may be used in cats that require gastrointestinal biopsies to rule out GI disease (i.e., inflammatory bowel disease or GI lymphoma) as the cause of anorexia.

PEG tubes, rather than esophagostomy tubes, should also be used if esophageal disease is present. In most other cases, an esophagostomy tube works just as well as a gastrostomy tube. An esophagostomy tube is the most frequently used feeding tube in the author’s practice.

Prior to placing the biopsy sample in formalin, the author generally makes impression smears for cytologic evaluation.

This may make it possible to provide a preliminary diagnosis of hepatic lipidosis or lymphoma. Samples of liver tissue and/or bile are submitted for aerobic and anaerobic culture, especially if cholangitis is suspected. A recent study showed that 14% of liver biopsy cultures and 36% of bile cultures were positive in cats with hepatobiliary disease. Cytologic evaluation of bile may also be useful. In a recent study, microorganisms were detected on bile cytology in 22% of feline bile specimens and inflammation was evident in 19% of cats. While the cat is sedated for the liver biopsy, the author routinely places a feeding tube if hepatic lipidosis is suspected or if the cat has been anorectic for > three days.

Pending the results of the biopsy and culture, icteric cats are treated with nutritional support, if indicated, and fluid therapy (usually non-lactate, non-dextrose-containing fluids) as 8 | FVMA Advocate

If the cat is not stable enough for sedation/anesthesia at initial presentation, stabilization with fluid therapy and a nasoesophageal feeding tube is performed for the first few days. A five or eight French nasoesophageal feeding tube can be inserted with just topical anesthesia in most cats.

In addition to tube feeding 60 kcal/kg/day, cats with hepatic lipidosis are treated with SAMe 20mg/kg/day for its antioxidant effects and its ability to replenish hepatic glutathione. Many clinicians advocate administering L-carnitine 250mg BID, taurine 250mg BID, and thiamine. Subcutaneous cobalamin supplementation should be considered since subnormal levels are present in 57% of cases. Vomiting can be controlled by using maropitant (use 0.5mg/kg SID instead of 1mg/kg SID), metoclopramide, or 5-HT3 antagonists (such as ondansetron or dolasetron). If hepatic lipidosis is secondary to another underlying disease, treatment of the primary disease is also important.

Most (80-85%) cats with hepatic lipidosis can be successfully treated with bilirubin decreasing by 50% within seven to 10 days.

Failure to respond may indicate that the underlying cause of the secondary hepatic lipidosis has not been adequately addressed.

Negative prognostic factors include anemia, hypokalemia, old age, and cases of secondary hepatic lipidosis.

Cholangitis Clinical signs of cholangitis can be similar to hepatic lipidosis, such as anorexia, weight loss, vomiting, and lethargy. Unlike idiopathic hepatic lipidosis, fever (in neutrophilic cholangitis) or abdominal effusion (in lymphocytic cholangitis) may be seen.

Laboratory abnormalities that may help distinguish cholangitis from hepatic lipidosis may include neutrophilia with a left shift, an elevated ALT>ALP, and hyperglobulinemia.

Cholangitis may occur by itself or concurrently with inflammatory bowel disease and/or pancreatitis (triaditis). In a study by Fragkuo et al 2012, 47 cats (27 sick cats and 20 healthy cats) had liver, GI, and pancreatic biopsies via laparotomy.

• 13 cats had IBD only (eight of which were symptomatic, five from the healthy group), • Six cats had cholangitis only (two symptomatic, four from a healthy group), • 16 cats had IBD + cholangitis (six symptomatic and 10 from a healthy group), • Three cats had IBD + pancreatitis (two symptomatic and one healthy), and

Ultrasound of an icteric cat showing that the liver is hyperechoic compared to adjacent falciform fat. This appearance is typical of hepatic lipidosis.

Image courtesy of Dr. Adam Honeckman

• Eight had IBD + pancreatitis + cholangitis (all eight were in the symptomatic group) So although it is common to have inflammatory changes in more than one system, subclinical cases were fairly common.

In a study by Center et al. 2022 of 168 cats with suppurative cholangitis, many cats had other concurrent diseases. 60/68 (88%) intestinal biopsies had inflammatory bowel disease and 41/44 (93%) pancreatic biopsies had concurrent pancreatitis.

Treatment of cholangitis is based on whether it is neutrophilic (acute and chronic) or lymphocytic in nature. In the author's practice, the lymphocytic form is more common than neutrophilic cholangitis.

SAMe and ursodeoxycholic acid may be used in either form.

For neutrophilic cholangitis, antibiotics (based on culture and sensitivity) are generally indicated for six to eight weeks. In one study, 69% of cats were positive for bacteria on FISH analysis.

In the Center et al. 2022 study of 168 cats with suppurative cholangitis, 94% were positive by immunohistochemistry (vs.

69% positive via routine culture). E. coli and Enterococcus were the most common bacteria involved. Pending culture and sensitivity results, good empirical choices include amoxicillin, amoxicillin-clavulanate, or fluoroquinolones combined with metronidazole. Prednisolone may be added in cases of chronic neutrophilic cholangitis that do not adequately respond after a few weeks of appropriate antibiotic therapy.

Unlike cases of neutrophilic cholangitis, finding bacteria in lymphocytic cholangitis (either by FISH or culture) is rare.

Prednisolone is the cornerstone of the treatment of lymphocytic cholangitis. The initial dose is usually 1-2mg/kg PO BID, then slowly tapered over several months. In a study by Otte et al., 2014 using serial liver biopsies, prednisolone was more effective than ursodiol in reducing inflammation in cats with lymphocytic cholangitis. In another retrospective review of 28 cats with lymphocytic cholangitis, cats treated with prednisolone had a longer survival time than cats treated with ursodiol (>900 days vs. 365 days).

Response to therapy is generally monitored by rechecking the liver enzymes. If there is no response, other immunosuppressive drugs such as chlorambucil, cyclosporine, or methotrexate can be tried. Failure to respond may also be due to poor owner compliance, incorrect diagnosis, concurrent illness not being treated, or occult infectious disease (such as toxoplasmosis).

Some recent evidence suggests that Helicobacter may play a role in cholangitis, but Helicobacter was also found in normal livers.

The prognosis for cats with cholangitis is fair. With neutrophilic cholangitis, a median survival of 29 months has been reported.

With lymphocytic cholangitis, a median survival of 795 days with a 74% one-year survival, 56% two-year survival, and 35% three-year survival was reported by Otte et al. 2013. In another study, the median survival of cats with lymphocytic hepatitis was 37 months.

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esophagostomy, or gastrostomy tubes can be used successfully in many cases of feline pancreatitis. Some cats, however, may require jejunostomy feeding tubes or parenteral nutrition.

In one study, 11/31 (35%) of cats with pancreatitis had bacteria in the pancreas found on FISH analysis. This was most often found in cats with moderate-severe acute pancreatitis. Thus, antibiotic therapy should be considered in cats with moderatesevere acute pancreatitis.

Fine needle aspirate from a liver of an icteric cat. The hepatocytes contain a large number of clear vacuoles typical of hepatic lipidosis.

Image courtesy of Dr. Adam Honeckman

Cats with chronic pancreatitis may benefit from immunosuppressive therapy with either prednisolone or cyclosporine. A study by Wu et al. presented at ACVIM 2022 revealed that either prednisolone or cyclosporine were equally effective in reducing fPL in cats with chronic pancreatitis.

Lymphoma Lymphoma is best treated with chemotherapy. A combination protocol including vincristine, cyclophosphamide, prednisolone, and doxorubicin +/- L-asparaginase is recommended for lymphoblastic lymphoma. The complete response rates for feline lymphoma are approximately 50-75% with a median survival of six to eight months. Some (30-40%) cats that obtain a complete remission survive up to two years.

For lymphocytic lymphoma, therapy with oral prednisolone and chlorambucil is used. Cats with low-grade (i.e., small cell lymphocytic) GI lymphoma have prolonged survival (median survival of 17 months in one study).

Pancreatitis The spec fPL (feline pancreas-specific lipase), run by Idexx and Texas A&M GI laboratory, is the diagnostic test of choice for pancreatitis. A spec fPL > 5.4 μg/L is 48-100% sensitive and 54-80% specific for the diagnosis of pancreatitis. Some studies have shown a fair correlation between the spec fPL and PSL assay by Antech. In comparison, abdominal ultrasound is 1184% sensitive and 73-100% specific. Serum amylase and lipase are not useful for the diagnosis of pancreatitis in cats.

According to a study by Krasztel et al. 2021, the CBC may be a useful screening test for pancreatitis. If the total WBC is <18,000, bands <270, and eos >300, pancreatitis is unlikely (91.8% sensitivity). Unfortunately, an abnormal CBC is not specific for pancreatitis.

Treatment of pancreatitis in cats may involve IV fluids and analgesic medications similar to the treatment of canine pancreatitis. A major difference is that most cats with pancreatitis are not vomiting and require enteral nutritional support to prevent the development of hepatic lipidosis. Nasoesophageal,

10 | FVMA Advocate

ADAM HONECKMAN

DVM, DAVCM (Small Animal Internal Medicine)

Dr. Adam Honeckman graduated from Purdue University School of Veterinary Medicine in 1992 and completed an internship at Purdue in 1993. After four years of general practice in the Chicago area, he was accepted for a small animal internal medicine residency at the prestigious Animal Medical Center in New York City. During his residency, Dr. Honeckman developed a special interest in ultrasonography and endoscopy. After completion of his residency, he started his own mobile internal medicine practice in the Orlando area. After 20 years of mobile practice, he moved to his permanent location and founded Veterinary Specialty Solutions. In his spare time, Dr. Honeckman is also an internal medicine consultant for the Veterinary Information Network.

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What Ails the

PAWS AND CLAWS

It is generally recommended that dermatophytosis be treated with a combination of topical and systemic antifungal agents in addition to environmental clean-up. Often, the recommended treatment goal is to obtain two consecutive negative dermatophyte cultures and/or PCR tests prior to discontinuing antifungal therapies. An excellent and free access resource is Diagnosis and Treatment of Dermatophytosis in Dogs and Cats by Moriello KA, Coyner K, Paterson S, Mignon B. Vet Dermatol 2017.

Linda Messinger | DVM, DACVD

Atopic dermatitis in a Great Dane.

Image courtesy of Dr. Linda Messinger

Pododermatitis has many underlying causes and can present in a variety of ways in dogs and cats. Allergies are the most common cause of pododermatitis in dogs. Allergies can also be the cause of pododermatitis in some cats. Other causes of pododermatitis include infectious, immune-mediated, nutritional, neoplastic, idiopathic, and other causes. We will discuss several causes of pododermatitis in cats and dogs, along with diagnostics and therapies. The most common causes of nail disease will also be discussed.

PAPILLOMAS Papillomas can affect the paws. Those affecting the footpads can be challenging to treat. Diagnosis can be made by clinical presentation; histopathology can help confirm the diagnosis.

Several treatments have been recommended including surgical

ALLERGIES Allergies, especially to airborne and food ingredients, are the most common cause of pododermatitis in dogs. Pedal pruritus tends to be the most common sign noted in dogs presenting with pododermatitis secondary to allergies. Secondary yeast and/or bacterial pododermatitis are common and can exacerbate pedal pruritus and dermatitis. Skin cytologies are most commonly used to determine the presence of yeast and/or bacteria on paws.

Treating secondary infections and controlling the underlying allergy is important. If secondary infections continue to recur, then the allergy treatments need to be reassessed in addition to evaluating for possible other causes.

MITES Mites (especially Demodex mites) and dermatophytosis can also cause pododermatitis. Demodicosis is typically diagnosed via deep skin scrapings/hair plucks. Dermatophytosis can be diagnosed via ringworm culture and/or PCR. Histopathology may also be helpful in diagnosing demodicosis and dermatophytosis.

Demodicosis in a Mastiff mix.

Image courtesy of Dr. Linda Messinger

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Image courtesy of Canva.

More recently, isoxazolines have been the mainstay for treating demodicosis. Given the high success rate of isoxazolines, trial treatments have also been performed by some. However, most dermatologists agree that it is best to perform diagnostics (deep skin scrapings/hair plucks) to better know what you are treating, especially as Demodex mites are usually easy to find when diagnostics are performed properly. This is especially true in immunocompromised patients where more isoxazoline treatment failures may be seen. Treatment should be continued until two to three consecutive negative skin scrapings/hair plucks are obtained. Underlying causes should be addressed when possible.

as secondary infection can increase patient pruritus and/or discomfort. Prognosis is generally considered poor.

CANCER There are several types of cancer that can affect the paws, including primary lung tumors in cats that metastasize to their digits. Clinically, these cats may present with “infection” of the digits that are non- or partially responsive to antibiotics.

Thoracic radiographs are recommended.

PLASMA CELL PODODERMATITIS Symmetrical lupoid onychodystrophy.

Image courtesy of Dr. Linda Messinger

excision, CO2 laser, and systemic and/or topical antiviral treatments (interferon, imiquimod). Spontaneous regression has been reported. Concurrently, controlling pain and discomfort is recommended, especially as these can feel like a persistent “rock in your shoe.”

IMMUNE-MEDIATED DISEASE The most common immune-mediate disease that affects the feet in dogs and cats is pemphigus foliaceus. Other immunemediated diseases can also affect the paws. Immune-mediated diseases are typically diagnosed via multiple skin biopsies.

Plasma cell pododermatitis is a disorder of unknown etiology that usually affects multiple footpads in cats. The metacarpal and metatarsal footpads are most commonly affected.

Diagnosis is based on clinical appearance and histopathology.

Treatment recommendations include doxycycline, steroids, and cyclosporine-modified. Some have proposed surgical excision of the affected areas and others have suggested benign neglect.

INTERDIGITAL FOLLICULITIS AND FURUNCULOSIS (IFF) Interdigital folliculitis and furunculosis (IFF) occurs most often in dogs who are short-coated, overweight, have anatomical changes, and/or may be secondary to allergies, hypothyroidism, demodicosis, etc.. IFF often starts as a sterile inflammatory process and progresses to papules and nodules that may rupture.

Immunosuppressive/immunomodulating therapies are most commonly recommended in the treatment of immunemediated diseases. Be sure to rule out drug reactions as a cause of immune-mediated dermatosis.

Symmetrical lupoid onychodystrophy (SLO) is a common cause of nail disease, the cause of which is unknown. Often multiple claws on multiple paws are affected. The primary ruleouts are dermatophytosis and vasculitis. Checking the patient’s thyroid hormone status is recommended. In the past, biopsies were recommended for the diagnosis of SLO. Biopsies are no longer recommended if the clinical signs and signalment are compatible with SLO. However, biopsies are recommended if the patient fails treatment. The main treatment plan includes fatty acids, pain control, and pentoxifylline. Doxycycline and niacinamide are falling out of favor as we try to avoid using antibiotics in the long term.

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DVM, DACVD

Zinc-responsive dermatosis is likely the most common nutritional disorder to affect the paws of dogs. This is most commonly seen in Siberian Huskies and Alaskan Malamutes and is thought to be from a defect in zinc absorption. Biopsies/ histopathology are the preferred method of diagnosis. The mainstay of treatment is zinc supplementation.

INTERNAL CAUSES

14 | FVMA Advocate

SYMMETRICAL LUPOID ONYCHODYSTROPHY (SLO)

LINDA MESSINGER

NUTRITIONAL CAUSES

It is believed that 90% of dogs with hepatocutaneous syndrome have footpad involvement. Liver changes and/or pancreatic glucagonomas are seen concurrently. Diagnosis is via multiple skin biopsies, although some may make the diagnosis clinically with classic footpad changes along with the classic “Swiss cheese” appearance of the liver on abdominal ultrasound and elevated liver enzymes on lab work. Treatment involves zinc, fatty acids, and protein/amino acid supplementation.

Controlling secondary infections is also helpful, especially

Secondary bacterial infections are common. Diagnosis is based on clinical presentation and breed. Evaluating for demodicosis and secondary bacterial (and yeast) infection is recommended.

Histopathology is often helpful in confirming the diagnosis and ruling out other causes. Cultures are helpful in guiding antimicrobial therapy. Because these infections are deep, antibiotics are often recommended for at least six to eight weeks. Prednisone/prednisolone can be helpful in reducing inflammation. Long-term, cyclosporine-modified is generally recommended. Booties, light therapy, laser and/or surgery (fusion podopasty) may also be considered.

Interdigital Furunculosis.

Image courtesy of Dr. Linda Messinger

Dr. Linda Messinger is a practicing board-cer tified veterinar y dermatologist at Apex Veterinary Specialty Services in the Denver metro area. She received both her Bachelor of Science and Doctor of Veterinary Medicine degrees from Cornell University. After veterinary school, Dr. Messinger completed a one-year small animal internship at the Animal Medical Center in New York City and then a dermatology residency at the University of Florida. Dr. Messinger has been board-certified by the American College of Veterinary Dermatology (ACVD) since 1993. She has lectured on veterinary dermatology to a variety of professional and lay groups, both internationally and nationally. She has been involved in several clinical trials, many of which were to help patients with allergies. In addition, Dr. Messinger is currently on the ACVD Program Committee which reviews all the abstracts for the North American Veterinary Dermatology Forum. She enjoys all areas of veterinary dermatology. Her pet family includes dogs, fish, and too many cats.

Call on

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850.814.9962

e-mail: Richard@TPSGSales.com www.TotalPracticeSolutionsGroup.com

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ELEVATE YOUR VETERINARY PRACTICE WITH VETSOCIAL:

The Social Media Tool for Busy Veterinarians In the fast-paced digital age, your veterinary practice's presence on social media is not just important, it's essential.

The online world is where your clients seek information and recommendations, and connect with potential providers for their pets. According to a recent article on Forbes, seven in 10 Americans use social media and up to 80% of consumers are making buying decisions based on a friend’s social media post.

To help you harness the benefits of social media and elevate your practice, we are excited to introduce our newest member benefit: VetSocial, your all-in-one solution for dominating the social media world.

EXCLUSIVE DISCOUNT PROGRAMS:

WHY DOES SOCIAL MEDIA MATTER FOR VETERINARIANS?

MEMBER BENEFITS:

Today, being a successful veterinarian goes beyond medical expertise. Your practice is a business, and in this competitive landscape, clients have a variety of healthcare options available.

Marketing your practice helps show potential clients what differentiates you from the competition and puts your business front and center when a pet owner goes online looking for veterinary services. VetSocial empowers you to do just that, effortlessly.

WHAT IT DOES: • Expertly Crafted Posts: With VetSocial, you gain access to a treasure trove of expertly crafted, veterinarian-approved social media posts. These posts are designed to captivate your audience, showcasing your expertise while building trust and credibility.

• Save Time with Ready-to-use Content: Focus on what you do best — providing exceptional care to your patients.

You can easily schedule and post content with a minimum investment of time and even post up to 30 days of content in one sitting.

Don't forget to renew your

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BY DEC. 31, 2023!

• Customizable Scheduling: Crafting a well-structured social media strategy has never been easier. VetSocial allows you to schedule posts at optimal times, ensuring your messages reach your target audience when they are most active.

16 | FVMA Advocate

• Attract New Business: A strong online presence leads to new opportunities. VetSocial empowers you to attract new clients and grow your practice. Let your expertise shine and watch as your business flourishes.

REFERENCES

In addition to our new social media member benefit, there are so many other opportunities for you to take advantage of!

Kowalewicz, R. (2022, April 28). How Social Media Impacts Consumer Buying. Forbes. https://www.forbes.com/sites/ forbesagencycouncil/2022/04/28/how-social-media-impacts-consumer-buying/

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Take a behind-the-scenes look and delve into the key moments of the FVMA’s 2023! We've uncovered the various achievements, initiatives, and programs that have defined our year, shedding light on the contributions of our dedicated members, the impactful work of the FVMA Foundation, our commitment to students, our ongoing legislative advocacy, and the diverse range of continuing education we’ve provided.

FVMA MEMBERS

FVMA Foundation

by the Numbers

Total Members: Brand New Members:

FVMA UNWRAPPED: What have we been up to in 2023?

5,675 273

Here’s a breakdown of where FVMA Foundation donations went in 2023:

$10,000

to the AVMA’s Ukraine relief fund, which is being used to provide food, medical care, medical supplies, and emergency support to organizations on the ground providing care to animals.

$25,643

in scholarship funds distributed among UFCVM students and students in veterinary technical colleges around Florida.

$15,000

to Pets Help the Heart Heal, an organization dedicated to helping to improve children's social, physical, and emotional health through the humananimal bond.

18 | FVMA Advocate

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FVMA AT UFVCM We visited UFCVM various times throughout the year to meet with current and incoming students.

Ocala Equine Conference

UFCVM’S CAREER DAY -

Wednesday, Oct. 26 • Almost 100 students

STUDENT APPRECIATION DAY -

Saturday, Aug. 17

• 30 students focused on equine medicine • Organized wet labs at four equine hospitals

STUDENT CLUB AND FAMILY DAY/ UFCVM’S FIRST-YEAR VET EXPERIENCE -

Friday, Aug. 11

• 100 incoming students 20 | FVMA Advocate

• Dr. Ernest Godfey, Trustee Emeritus for the FVMA, was also at Career Day looking to bring new staff to his clinic

FVMA Annual Conference

Continuing EDUCATION

• Five conferences across the state • A look at the numbers:

POWER OF Ten The final session of the year before graduation will be this December. This will be the third Power of Ten graduating class!

Congratulations to the 2022 class! Their awards ceremony was in April during FVMA Annual Conference.

10 th The Gulf Atlantic Veterinary Conference

Total CE: Total attendees:

674 HOURS 2,085

Promoting Excellence Symposium

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Around the

FVMA OFFICE

WEB

ADVOCACY

Our staff loves bringing their four-legged family members to the office. This year we had seven visitors: six dogs and one cat.

We met with with nine state representatives: • Senator Rosson (D-St. Petersburg) • Representative Killebrew (R-Winter Haven)

• Roxie — cat

Congratulations to Dr. Taylor McLendon! Her member spotlight was the top post on the FVMA’s Facebook page for 2023.

• 3.3K accounts reached

• Representative Cassello (D-Boynton Beach)

• Ebert — dog • Tim — dog

On the

Legislative

Roxie

Ebert

• Wren — dog

• Representative Robinson (R-Bradenton) • Representative Nixon (D-Jacksonville) • Representative Maggard (R-Zephyrhills)

• Zero — dog

• Representative Sirois (R-Merritt Island)

• Leia — dog

• Representative Silvers (D-West Palm Beach)

• Rockoe — dog

• Senator Thompson (D-Orlando)

Tiny Tim had the most visits to the office, showing up every week for "Tim Tuesdays!"

Rockoe

Wren

226 Zero

Leia

Monitored 11 bills, including:

How many pets does the FVMA staff have in total?

• 10 dogs • 9 cats • 1 horse 22 | FVMA Advocate

LEGAL Aid Attorney Edwin Bayo is always available to answer questions about the practice of veterinary medicine, pharmacy law, or veterinary board relations. This year he answered approximately 100 questions from members.

• HB 719 / SB 722 Practice of Veterinary Medicine • HB 1047 / SB 1300 Offense Against Certain Animals • HB 1581 / SB 1492 Dog Breeding

As we reflect on the incredible year that 2023 has been, we extend our heartfelt gratitude to our members for their unwavering dedication and support. Your commitment has made this year remarkable, and we're eagerly looking forward to what 2024 will bring, as we continue to grow and thrive together!

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Why should you apply?

GAIN A COMPETITIVE EDGE in your career Are you looking to make your mark in the profession and take your career to new heights? Apply for our Power of Ten leadership Program! Our annual leadership program is designed to help recent veterinary medicine graduates* develop foundational skills in leadership, communication, and business.

Each year, ten participants are selected to join. They participate in four learning experiences and mentoring sessions over the course of a year. Participants will have the opportunity to participate in workshops, webinars, and other unique offerings.

LEADERSHIP SKILLS: Develop a strong foundation in leadership and emotional intelligence, and cultivate the leader you want to be.

•

EFFECTIVE COMMUNICATION: Enhance your communication skills and gain a deeper understanding of various communication styles

•

BUSINESS ACUMEN: Acquire essential business skills that will set you apart in your practice

•

COMMUNITY IMPACT: Learn to utilize your newfound skills within your practice, your life, and your community

•

SELF-AWARENESS: Heighten your self-awareness and maximize your interactions with those around you

•

LIFELONG CONNECTIONS: Experience a supportive environment that fosters meaningful interpersonal relationships and collaborative, lifelong interaction

CURRICULUM AT A GLANCE The 2022 Power of Ten class

APPLICATIONS CLOSE DEC. 31, 2023 *graduated in the past ten years

In-person learning experiences designed to minimize disruptions to your work.

A program designed to garner support from practice owners.

FOSTERING LEADERSHIP in the profession Participants receive a full-tuition scholarship, which covers meals, refreshments, and lodging when necessary to attend multi-day events. Upon graduation from the program, your accomplishments will be publicly recognized at our graduation ceremony during FVMA Annual Conference.

24 | FVMA Advocate

•

•

Session One is your class’ induction, which takes place at our FVMA Annual Conference during our Annual Awards ceremony. This occurs in the spring and usually features modules on support.

•

Session Two is a daylong summer seminar usually focused on education and the law. It’s often held at the FVMA headquarters in Orlando.

•

Session Three takes place during The Gulf-Atlantic Veterinary Conference (TGAVC) in the autumn.

This is a weekend-long seminar that usually focuses on leadership.

•

Session Four is a daylong winter seminar focusing on advocacy. It’s often held at the FVMA headquarters in Orlando.

•

GRADUATION! This is a celebration of all your hard work. Like your induction, your graduation takes place at our FVMA Annual Conference during our Annual Awards ceremony.

Visit FVMA.ORG

TO APPLY!

SAVE THE DATE

FVMA Annual Conference 2024

April 18-21, 2024

Dive into our flagship veterinary conference, FVMA Annual Conference, held April 18-21, 2024, at the RENAISSANCE ORLANDO AT SEAWORLD. Cutting-edge lectures, exclusive wet labs, and key industry networking – all held at our exciting new venue – will make FVMA Annual Conference 2024 an unforgettable weekend of education and enjoyment. Conference attendees can look forward to exclusive theme park discounts and other exciting benefits that will be announced soon!

Continuing Education for Every Member of the Veterinary Care Team FVMA Annual Conference 2024 is designed to empower every member of the veterinary care team. With more than 10 wet labs – including offerings for veterinarians and technicians – our annual conference gives you access to an outstanding scientific and clinical program that will give you knowledge and skills you can put into practice the next day.

With sessions on cardiology, exotics, infectious diseases, internal medicine, nutrition, practice management, and more – this is an event you won't want to miss!

Best Friends Forever International Health Certificate Solutions

, s m r o f e h We do t the exam You do

VENUE & HOTEL Renaissance Orlando at SeaWorld 6677 Sea Harbor Drive Orlando, FL 32821

REGISTRATION WILL OPEN SOON!

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BETTERINARY CARE:

Caring About the Caregivers Heidi Hulon | DVM, CCFP, MHFA

“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to walk through water without getting wet. This sort of denial is no small matter. The way we deal with loss shapes our capacity to be present in life more than anything else.

The way we protect ourselves from loss may be the way in which we distance ourselves from life. We burn out not because we don’t care but because we don’t grieve. We burn out because we’ve allowed our hearts to become so filled with loss that we have no room left to care.”

This is what happens to those of us within the veterinary profession. We care a great deal – that is why we are in this profession. The problem is that we do not grieve. We do not acknowledge our feelings in the moment. We go from appointment to appointment to appointment every day. All the negative, sad, difficult emotions/interactions from each appointment are held onto – “I will deal with that later.” They become our negative emotions. That is why we burn out – because our hearts become so filled with loss/stress/anxiety/ fear, that we have no room left to care about anything. This is empathetic exhaustion.

We go into this profession for purpose. Our purpose is to help and to save lives. We are trained to alleviate the suffering in our patients. However, we are not taught how to alleviate the suffering and loss that we will see in humans – clients and self.

It is not just what we see, but what we feel as a result of our interactions. We care. We care a great deal – it is in our job description. What we do not do is grieve or allow ourselves to process what we are emotionally and mentally exposed to.

These feelings build up and then weigh us down. Our ability to care is diminished and damaged as a result.

This can affect anyone within the profession – “All of us who 28 | FVMA Advocate

Image courtesy of Canva.

Self-care

attempt to heal the wounds of others will ourselves be wounded; it is, after all, inherent in the relationship.” To care for someone in pain requires you to be vulnerable, to walk through that water and get wet. We have to be careful not to drown in the suffering of others.

Emotions are brief experiences that last for micro-moments.

Emotions are like waves that rise up on an ocean and then dissipate. Emotions are typically triggered by the perception of our current circumstances. While short-lived, they initiate cascades of other emotions – upward or downward spirals.

Positive emotions – these tiny fleeting emotions – drive us towards both flourishing mental and emotional health.

“We must grieve to process what we feel. We grieve that which we love.”

1. Feelings of energy depletion or exhaustion 2. Increased mental distance from one's job 3. Feelings of negativism or cynicism related to one's job

The status of the “water” changes, but do we? Are we adequately prepared to handle what we face daily in our jobs?

“A smooth sea never made a skilled sailor.” – Franklin D. Roosevelt Why then do we do this? Do you ask yourself that question? You need to be able to answer that question: “I do this because…”

Knowing your meaning and purpose in life is the single most predictive factor for well-being. What is your why? What gives meaning and purpose to your life?

Empathy is at the core of who we are as caregivers. It is both an innate quality and a learned skill. Empathy is the capacity to see things from another’s point of view and feel what that person is feeling. This applies to both positive and negative feelings. Empathy can go one of two ways – empathetic distress or empathetic concern. When we only focus on the other and forget our own feelings, empathetic distress occurs. Empathy is what we emotionally receive from another. Empathy can trigger the pain center in our brain.

Once empathy is established, that leads to compassion.

Compassion is the deep awareness of the suffering of another coupled with the desire to relieve it. It is both emotion and action. It is being present in an energetic way for someone who is hurt or suffering. It is in our job description. Compassion triggers the reward center in our brain. We feel better when we show compassion to others and to ourselves.

Image courtesy of Adobe Stock

Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.

The World Health Organization characterizes it in three dimensions:

Empathetic exhaustion is defined as ‘the cost of caring.’ The price paid by the caregiver in doing their job. A price that includes our emotional, physical, psychological health, and, sometimes, the ultimate price: a life. Why are we so willing to pay so much to do what we want to do?

The components of empathetic exhaustion are burnout +/traumatic stress (primary and secondary).

Image courtesy of Adobe Stock

How can you avoid burnout? Here are some ways: • Work with purpose • Perform a job analysis and eliminate or delegate unnecessary work • Give to others • Take control and actively manage your time • Get more exercise • Learn how to manage stress Traumatic stress is a more significant factor for us. The resulting clinical signs from both look the same. It is the causes that are different. Primary traumatic stress is a trauma, injury, or challenge that occurs to you. Secondary traumatic stress is what you witness/hear about a trauma (the drama of someone else’s trauma). This is what we encounter every day with our patients and clients. You witness their pain, fear, anxiety, stress, regret, and anger. We are “infected” with this secondary traumatic stress.

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Our brain’s tendency to seek out and find the bad leads to focus on negative emotions and activation of SNS and the fight/flight reaction. Cumulative SNS activation affects us in significant ways. Being a caregiver puts an incredible amount of burden on our cognitive processes. Allostatic load refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity. When environmental challenges exceed the individual ability to cope, then allostatic overload ensues.

Physiological inflammation is due to infection or injury. It requires more energy from the body and has its own psychology (depression, lack of motivation, isolation, etc.). It turns down the volume on a positive emotional state.

The five pillars of physiologic inflammation occur in psychological inflammation: • Redness – more reactive, angry • Heat – more prone to burnout • Swelling – lose our perspective; situations appear worse than they actually are • Pain – emotional or mental pain along with physical pain • Loss of function – we lose our purpose and the ability to do our job well

Mirror neurons, psychological inflammation, negativity bias, and the amygdala hijack all conspire to reframe our reference points for happiness and misery. We become desensitized in our work, meaning it takes more to make us happy and less to make us unhappy. What we found rewarding and inspiring early in our career no longer does the same for us after we experience several negative experiences. The negative sticks to us like Velcro and the positive slides off like Teflon.

Who is at risk for this? Everyone at the hospital is at risk.

Everyone who is exposed to the traumatic stress of patients and clients is at risk. Knowing you are at risk is important. This knowledge allows you to do something about it. We address risk factors for diseases in our patients every day so that we can minimize the effects that they have. The same is true for ourselves and empathetic exhaustion.

Empathy is an innate response that allows us to connect with others. It is also a double-edged sword. Those of us who go into caregiving fields have higher levels of empathy. We fight to save others. It is our gift. It allows us to share emotional empathy with those we are taking care of. However, without managing and protecting our feelings (self-awareness & self-care), we give away our empathy and take on the pain of others as our own. We end up falling on our sword and being injured by our good intentions. That’s the ‘cost of caring’ –How often do you willingly fall on your “sword” in the name of caring for others?

The ProQOLor Professional Quality of Life Score is the gold standard for diagnosing compassion fatigue/empathetic exhaustion. You can find this at www.proqol.org.

What can we do to improve our well-being?

It starts with redefining what it means to be a caregiver. The giving of care part is easy. There is plenty of training for that. What is lacking is caring about the giver – caring for ourselves. The ethical imperative of self-care. It must be a standard of care for those who give care. Improved self-care is the cornerstone of mitigating the impact of compassion fatigue. There are many ways to promote self-care. It must be accepted and applauded by all.

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Regarding well-being, there are eight dimensions to self-care.

Setting boundaries, practicing self-care, resiliency, and fulfilling your purpose can help set you up for compassion, satisfaction, and success. Instead of suffering the cost of caring, reap the reward for caring. You were meant for the profession and the profession should be meaningful to you.

HEIDI HULON

DVM, CCFP, MHFA

A native of Alabama, Dr. Hulon graduated from Auburn University with both her undergraduate degree and DVM. She has practiced in a variety of areas during her career, including small animal practice and shelter medicine. She has been the department chair for a veterinary technology program and a technical veterinarian for Hill’s Pet Nutrition. When possible, she does relief work. Since 2011, Dr. Hulon has been a regional consulting veterinarian for Elanco Animal Health. Her current role is the well-being consulting veterinarian, delivering training focused on wellbeing to veterinary customers across the country. In addition, she teaches a wellness elective to veterinary students at Auburn University’s College of Veterinary Medicine. Dr. Hulon has training in FRANK communication skills, in addition to certifications in insights discovery, compassion fatigue, positive psychology, QPR suicide training, fear-free, the human animal bond, and mental health first aid. Dr. Hulon is very involved in organized veterinary medicine and currently serves on the Alabama VMA Wellbeing, Membership, and Constitution/ Bylaws committees. She is a past president of the Kentucky VMA. When not working, she can be found on the tennis court or attending an Auburn event.

30 | FVMA Advocate

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Have a question? THE FVMA CAN HELP.

PRACTICE Pulse QUESTION: I recently completed the FVMA’s courses about laws and rules. I have a follow-up question regarding DEA licensure.

At the end, the lecture notes stated, “Do all practitioners in a group practice need to be DEA registered? No, a veterinarian who is an agent or employee of another DEA registered veterinarian may, in the normal course of business or employment, administer or dispense a controlled substance.”

I am a full-time relief doctor. Typically, I work alone and independently in the clinic that I'm covering. The regular doctor is not typically present or providing input on the cases. I will see new patients and existing patients who have seen the regular doctor at the practice. Do I need my own DEA license to administer controlled drugs for surgery that I am performing in the clinic, or do I count as an agent of the DEA-registered regular veterinarian at the practice (even if he/she is not present or providing input on the cases)?

A: The non-DEA registered veterinarian can act as an agent of

the DEA-registered veterinarian when acting in the regular course of practice. Just like a nurse to her supervising MD. Regular course of practice means that the DEA-registered veterinarian has purchased the controlled substances and has authorized their use in the practice by other veterinarians. That authorization does not need to be in writing. If the DEA-registered veterinarian is aware and keeping the records as required by law, then his/her presence is not required.

QUESTION: I have a few questions about a DVM overseeing

CVT appointments. I work with a mobile veterinarian who is going on maternity leave next year. We were wondering if it is possible for me to run testing and give vaccines (not rabies) without her physically being in the van, or if she could be virtually present through FaceTime.

I have the same question regarding prescribing medications. Would she be able to do that over the phone?

A: The short answer is no.

The administration of any vaccination by a veterinary aide, nurse, technician, intern, or other employee of a licensed veterinarian, which is not specifically prohibited by Rule 61G18-17.006, F.A.C., requires “immediate supervision” as that phrase is defined in Section 474.202(5), F.S.

One of the benefits of an FVMA membership is our helpline (800-992-3862), which is available to members Monday through Friday from 8 a.m.-5 p.m. Our helpline also provides insight to the FVMA staff of the challenges and concerns of our members. In this feature, we will highlight topics from the questions we received in preceding weeks as a part of an effort to keep our members up to date on current concerns, as well as regulatory and legislative changes.

QUESTION: I am setting up new veterinary software, and

my implementer asked me to determine what needs to be on the prescription labels for medication dispensing for Florida. Could you assist with this matter, please?

A: All containers distributed must be labeled with: - The name of the drug - Strength and quantity of the drug - Expiration date - Instructions as to the use of the drug - The name and species of the animal for which the drug is intended to be administered - The last name of the animal’s owner

(5) “Immediate supervision” or words of similar purport mean a licensed Doctor of Veterinary Medicine is on the premises whenever veterinary services are being provided.

- The name, address, and telephone number of the veterinarian prescribing the drug

As far as prescribing medications is concerned, it is a far easier answer. If it is for an established patient, the veterinarian can do so. If it is for a new patient, the veterinarian must first establish a veterinarian-client-patient relationship (VCPR) in person.

If it is a controlled substance, the following need to be included: - Practice name and address - Serial (prescription) number - The name of the patient

QUESTION: I have been helping one or two mornings a week at

a clinic where the owner was too sick to practice and now has passed away. I don't know what to do about the controlled drugs that are all in her name. The drugs are secure, and I have a DEA license, but the practice is being sold. I anticipate I will only be here a few more mornings until the sale goes through. Any advice?

A: The drugs are now part of the assets of the practice and can

be sold with the practice. A detailed inventory must be created with names, quantities, lot numbers, and expiration dates. The selling veterinarian and the purchasing veterinarian must sign the inventory. Because the selling veterinarian is deceased, you can sign in her stead. If there are any Schedule II substances, a DEA for 222 must be created to document the transfer.

- The name of the prescribing practitioner - Directions for use - Cautionary statements such as: “CAUTION: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed.”

QUESTION: We have a client who is temporarily out of state. Her dog is on Trilostane long-term and needs to have her prescription refilled within the next several weeks, prior to coming back to Florida. She made a call to a local Costco pharmacy and was told by the pharmacist that our veterinarian could write or call in a prescription to the out-of-state Costco, and they would be able to fill as instructed. We want to be sure this is within Florida's pharmacology regulations.

A: This is absolutely proper. The prescription includes a call-in order, and the pharmacist in the other state is willing to accept and fill it. In the reverse scenario, the Florida pharmacist could do the same thing.

QUESTION: How long should I maintain my liability insurance after retiring if I don't plan to practice any longer?

A: You should contact your insurance company to discuss this.

Insurance companies usually offer “tail coverage” that runs for two (2) years, which is the statute of limitations for negligence, after the doctor retires/stops practicing. The premium is much less than the premium during practice because no new possibilities for claims are being generated.

QUESTION: Does a mobile, mixed-practice veterinarian need to

have an HCCE permit? I only take my vehicle out into the field for large animal patients.

A: If you are a solo practitioner, you do not need an HCCE permit.

However, you may have problems buying drugs from some wholesalers that require the HCCE as part of the transaction.

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CLASSIFIED ADVERTISEMENTS PRACTICE FOR SALE/LEASE PRACTICE FOR SALE – CRYSTAL RIVER, FL Overview: • Integrated Medicine Practice located in Crystal River, in the heart of the Nature Coast.

• 4500 sqft building on 0.7 acre of land with a large paved 24-spot lot.

• Prime corner location on the main road in the county, near the center of town.

• Solar-powered with battery backup, ensuring no power issues and minimal power bills.

• LED lighting throughout for a fatigue-free environment.

• Reme Halo air sanitation in air handlers for top-of-the-line sanitation safety.

Current Setup: • 2,500 sq ft used as a veterinary practice, featuring 4 exam rooms and 2 offices, lab/ storage/ break area.

• 2,000 sq ft utilized for massage and wellness (human) practice, with 4 additional treatment rooms.

• This practice can be relocated for veterinary facility expansion.

• Team experienced and trained in both conventional and holistic modalities, including Veterinary Orthopedic Manipulation, Homotoxicology, Frequency Specific Low-Level Laser, Stance, Ozone therapy, and minor diagnostic ultrasound.

PRACTICE FOR SALE – BRADENTON, FL: Free Standing Custom Built 4,200 sqft Building. Hurricane-resistant with Reinforced Concrete Walls, Metal Roof, and Auto Backup Generator Power. Separate DOG and CAT Entrances, Large Treatment Area, Sx Suite, In-House Lab, Cat Kennel, 3 Exam Rooms, AND Large Air Cond. Dog Kennel can easily be converted to add Exam Rms, Offices, Sx Suite, etc. Wonderful Location, Quality Practice, GREAT CLIENTS. For Details Email, Call, or Text Owner: swflpetvet@gmail.com (941)773-4546.

PRACTICE FOR SALE – BRADENTON, FL: Free Standing 4,200 sqft Building w/ 3 Exam Rooms, Separate DOG and CAT Entrances. Wonderful Location, Quality Practice, GREAT CLIENTS. Lg A/C kennel area can be converted to add Exam Rms, Offices, and Sx Suite. Call or Text (941)773-4546 for Details.

PRACTICES FOR SALE – GAINESVILLE AND OCALA, FL: Fully equipped practices for sale in Gainesville and Ocala. Clinics are set up and ready to go. Cheap lease, client base included. Great space for a start-up. Email jstewart@ruralking.com PRACTICE FOR SALE – ZEPHYRHILLS, FL • Has digital x-ray, AVImark software, up-to-date anesthesia and lab equipment.

• Beautiful town to raise a family.

• $700,000 with $40,000 down and 5% interest amortized over 240 payments.

• $4,355.71/mo. With a lease of $2,000/mo. The debt and lease payment can be earned in one day’s collected revenue.

• Will have an option to purchase the property at an MAI appraisal value.

Practice Statistics:

• This practice has been there since the fifties.

• 2023 Expected Gross Income: $750,000.

• Will mentor if requested.

• 11% annual increase in Gross Revenue over the prior 10 years.

• Ask for ZH 407-529-5651

• Solo vet compensation after expenses: $150,000+, working 4 days/wk.

PRACTICE FOR SALE – BARTOW, FL

Current Operations:

• Has digital x-ray, AVImark software, up-to-date anesthesia, and lab equipment.

• Open for day exams and treatments only, with no overnight or emergency services.

• Beautiful town to raise a family.

• Operating hours: 9 AM to 5 PM, Monday to Friday.

• Can work it for several months with the option to purchase.

Potential for Growth:

• $460,000 with $25,000 down and 5% interest amortized over 240 payments.

• Opportunity to expand into more conventional surgical and radiology suites.

• $2800/mo. With a lease for $2,000/mo. The debt and lease payment can be earned in one day’s earnings.

• Possibility to develop additional spaces for other services and treatments.

• Increased DVM working hours optional income booster.

Location Advantages: • Out of the primary hurricane paths, even though it’s located near the Gulf.

• Equine country, offering the potential to bring equine services if desired.

• Clients come from surrounding counties for our specialty services.

• Minutes from boating, paddleboarding, snorkeling, and diving, as well as waterfront dining, bike trails, and more!

Owner’s Involvement: • The current owner, Dr. Trish Kallenbach, is the DVM managing and practicing.

• Dr. Trish is willing to mentor and work with the right person for continued integrated practice services into the future.

• Asking Price: $750,000, practice and building (recent appraisal of building $650,0000), and owner financing options are considered.

Contact Information: • Dr. Trish Kallenbach DVM • Phone: 352-220-0183 • Email: trish@dr-trish.com PRACTICE FOR SALE – NORTH PALM BEACH, FL: Small Animal Practice Closing in Palm Beach County. All equipment for sale. Get a great deal on one or multiple items. Call Dr. Miles at (561) 379-8748 or email to crbobmiles@aol.com

• Option to purchase the property after the first calendar year with an MAI appraisal value.

• Will gross $460,000/yr. just three days per week. (Doctor works Mon. Wed., Fri. approximately 16 hours per week) If one opened for more days & worked longer days, it would of course gross much more!

• The practice has been there since the early sixties.

• Will mentor if necessary.

• Well-established grooming shop next door.

• Ask for Bt 407-529-5651.

PRACTICE FOR SALE – WINTER PARK, FL • Has digital x-ray, AVImark software, up-to-date anesthesia, and lab equipment.

• It has a very high per capital income and an excellent school system.

• Excellent location to raise a family.

• Can work it for several months with the option to purchase.

• $325,000 with $25,000 down and 5% interest amortized over 240 payments.

• $1,979.87/mo. With a lease for $2,600/mo. The debt and lease payment can be earned in one-two day’s revenue.

• Will gross $325,000/yr. The doctor works at that clinic about 8 hours per week. If one opened for more hours, it would of course gross much more!

• The practice began March 2015.

• Will mentor if requested.

• Approximately 40,000 cars go by the clinic daily.

• Ask for WP 407-529-5651.

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