A Good Day @The AMC!

I had an especially good day at The Animal Medical Center one day last week and so did everyone else. Our hard work was rewarded with positive outcomes for many wonderful pets.

A cancer check up

Becky

Becky, a graceful Golden Retriever, had an appointment for a follow up on her thyroid tumor which was surgically removed nearly a year ago. After surgery, she received a total of four chemotherapy treatments. I administered two drugs, doxorubicin and carboplatin, using an alternating treatment protocol. Now she needed a new chest x-ray since the lungs are where thyroid tumors spread most commonly. It was a tense wait for everyone, her owner and her oncology team, but we were rewarded when the radiology report indicated her tumor had not spread.

A happy heart

The cardiologists saw a Boxer who suffers from a form of heart disease found commonly in this dog breed. In Boxers, fat replaces the normal heart muscle and causes abnormal heart beats which can lead to sudden death. This disease, known as arrhythmogenic right ventricular cardiomyopathy, was first diagnosed by cardiologists working at The AMC and studying Boxers with heart problems. This particular Boxer and her cardiologist were having a good day, like I was. At first she had 22,000 abnormal heart beats measured using a continuous heart monitor called a Holter monitor. Initial results indicated treatment with heart medications decreased the number of abnormal beats to only 51 abnormal beats in over 110,000 beats counted in a 24 hour period!

Renal medicine rejoices over urine

Since every pet urinates, you might think urine would not be a cause for celebration, but The AMC’s Renal Medicine & Dialysis Service does. When kidneys suffer from serious infection or obstruction, they can actually completely stop making even the smallest drop of urine. Using dialysis, AMC’s kidney specialists can replace the filtration function of the kidneys and prevent serious illness from a buildup of toxins in the bloodstream. But until the kidneys start to heal, cats and dogs may not urinate for days. The first time a dialysis patient urinates, an average day becomes a great day since we know the kidneys are finally getting better.

Surgeons perform less surgery and are glad

Henry was diagnosed with a lung tumor. Because his doctors made an early diagnosis, his tumor was small making it amenable to a minimally invasive removal. The surgeons used a thorascope – a device with a tiny camera attached. The camera was inserted into Henry’s chest through a small incision. Its progress toward the tumor was viewed on a large screen monitor. Once the exact location of the tumor was identified, a second small incision was made through which the lung tumor was removed using a surgical stapler. Because of the minimally invasive approach, Henry was discharged from the hospital the next day rather than several days later, which is typical when traditional surgery is used.

Even though these stories are about different pets, different diseases and different veterinary specialists, they share a common theme, improving the health of pets so they spend as little time as possible @The AMC and spend more time at home with their families enjoying life.

Exocrine Pancreatic Insufficiency: Cats Get it Too!

Recently, I highlighted a common pancreatic disorder in dogs, pancreatitis. The following day, the New York Times ”Well Pet” blog wrote about a much less common, but equally serious pancreatic disorder, exocrine pancreatic insufficiency (EPI). The article focuses on EPI in dogs, but cats also can suffer from this disease.

Pancreatic function

The pancreas has two main functions: first to produce the hormone insulin to control blood sugar and second to produce digestive enzymes. Production of insulin is the pancreas’ endocrine function and production of digestive enzymes is an exocrine function. Deficiency of insulin is called diabetes.

Deficiency of the digestive enzymes has a much more descriptive name – exocrine pancreatic insufficiency.

What a cat with EPI looks like

The classic cat with EPI is skinny, greasy, and has bad diarrhea. The absence of digestive enzymes prevents the gastrointestinal tract from breaking food down into it components, and if they are not broken down, the nutrients cannot be absorbed. If your cat has this disorder, he will eat lots of food and lose weight rapidly. Cats with EPI are greasy because they cannot digest fats without pancreatic enzymes and all the undigested fat in their stool gives them nasty diarrhea.

The causes of feline EPI

This disorder is thought to be inherited in certain dog breeds, most commonly German shepherds. Cats never want to be like dogs. Exocrine pancreatic insufficiency in cats does not appear to have a genetic component and is more likely to be the result of chronic damage to the pancreas from long standing pancreatitis. These cats may also be diabetic if the pancreatic damage is severe enough to prevent production of both digestive enzymes and insulin.

Testing the skinny cat

When I see a cat with weight loss, I commonly collect blood for what The Animal Medical Center (AMC) calls a GI panel. This quartet of tests looks at the digestive function of the pancreas and small intestine. One of the tests measures trypsin-like immunoreactivity and is the diagnostic test of choice for feline EPI. Another important test on this panel measures vitamin B12 or cobalamin. A study of feline EPI cases at The AMC and Purdue University found all cats with EPI were deficient in this important vitamin.

Replacement therapy

Once lost, the pancreas do not typically regain exocrine pancreatic function. Management of EPI requires lifelong supplementation with pancreatic enzymes and vitamin B12. Vitamin B12 supplementation is simple: a small injection given under the skin once a week. Pancreatic enzymes come as a powder and are sprinkled on the food. This is where cats can be challenging since many cats refuse food that has been embellished. Raw pancreas (which contains the digestive enzymes) has been recommended, but I haven’t tried it on any patients, yet. The good news is our study of feline EPI showed most cats will respond to therapy.

Resources on pancreatic disease

Exocrine Pancreatic Insufficiency

Pancreatitis

Texas A&M University

WebMD

IDEXX Laboratories

What’s On the Mind of Pet Owners?

A recent survey of both pet owners and veterinarians interrogated the pet health issues each group thought were most important. In last week’s post, I discussed the issues from the veterinarian’s point of view. In this blog I will write from the pet owner’s point of view.

Pet owners said they were primarily concerned with vaccinations, fleas and ticks, heartworms, intestinal parasites, and spending money on medications. This list appears to overlap with the veterinary list on the topic of intestinal parasites, and both owners and vets are squarely focused on preventive healthcare; care to keep their favorite furry, feathery, or scaly companion healthy.

Vaccinations

Vaccinations float to the top of most pet owners’ lists because they save pets’ lives. Before vaccinations were available for common diseases like canine distemper and feline panleukopenia, these diseases spread through neighborhoods like wildfire, often resulting in the deaths of many pets. Decreases in the recommended frequency of some vaccines, coupled with the association between injections and tumors, has raised many questions in pet owners’ minds.

Intestinal parasites

Both pet owners and veterinarians agreed intestinal parasite control was an important issue for pets. How could it not be? Intestinal parasites are high in yuck factor, high in pet discomfort, and on the list of diseases people and pets can share.

Fleas and ticks

These critters are very similar to intestinal parasites with regard to yuck factor and pet discomfort. A pet with a flea infestation may mean you also have a house or apartment with a flea infestation since fleas spend more time off your pet than on. Pet owners want to avoid an expensive exterminator bill by preventing fleas on their pet. Pet owners also want to prevent fleas and ticks to protect their pet against diseases like Lyme disease and blood parasites.

Heartworms

Because heartworms are a serious health concern in both dogs and cats, they are an important medical issue for most pet owners. Nearly every state in the United States reports cases of heartworm in resident dogs and cats. This map shows heartworm cases by state.

Year-round heartworm preventative is a “two-fer” since most prevent both heartworms and some intestinal parasites.

Pet medications

Pet owners want the best for their pet. In my mind, the best are veterinary-specific products. I prefer to prescribe medications developed specifically for veterinary patients rather than human or compounded medications. Veterinary-specific medications assure you, the pet owner, the product has been tested in dogs or cats and will be absorbed, metabolized, and effective in your pet. But, because most pets do not have insurance and medications are paid for “out of pocket,” many times pet owners can be surprised at the cost. As a pet owner myself, I believe that these veterinary-specific medications are worth paying for.

After looking carefully at the two lists of pet healthcare issues, one from pet owners and the other from veterinarians, are they really so different? Both groups’ lists really have only one item and it’s the same one: healthy, happy pets.

Dog Strollers: A Do or a Don’t?

Belle takes a stroll. Photo courtesy the Rabb Family.

One of my most favorite things to do here in New York City is to walk in Central Park.

Filled with beautiful trees, twittering birds, and, of course, dogs, Central Park provides a shady, calm respite from the hustle and bustle of city life. As of late, I have been noticing more dogs being rolled about the park and wheeled to The Animal Medical Center in special dog strollers. Then last week, one of my friends called and asked my opinion about these devices, which he had also noticed were growing in popularity with city dog owners.

Just following doctor’s orders

All I said was, “Your dog needs six weeks of cage rest,” and I could see the pet family slumping in their chairs. They had plans for attending their children’s soccer match and picking pumpkins on the weekend. The thought of excluding their dog from these important events was dreadful. To follow my no-dog-exercise rule, they zipped Rover into a dog stroller and everyone got out of the house for some fresh air while still following doctor’s orders.

Getting there is half the battle

Many of the dogs I have seen in the park have been taken out of their strollers to enjoy the grassy park lawns. Often I notice these dogs are recovering from orthopedic or neurologic disorders and are a bit unsteady on their feet. The stroller allows them to come to the park, walk on the grass, and get stronger. Falling while walking to the park on the hard asphalt and concrete of the city would be dangerous, but a tumble on the grass is much safer until they completely recover.

Tired, small dogs

Small dogs are popular with city apartment dwellers. A Sunday afternoon walk to see the leaves changing color sounds just right for a fall afternoon, but halfway through the walk, your pooch poops out and refuses to walk another step. Either you drag your dog by its leash all the way home or you carry it. Dragging is not appropriate and carrying even a tired 10 pound dog for more than a block or so is hard work; a stroller lets you continue on the walk without breaking your back carrying a tired dog.

A crate on wheels

Many people are proponents of crate training for dogs. Think of a dog stroller as a crate on wheels. You can give your dog a safe place of her own while still being part of the family. The upcoming Thanksgiving holiday represents a perfect time to use the dog stroller. Your dog doesn’t like strangers or children or Uncle Mortimer. Prevent a holiday mishap by keeping your dog zipped in the dog stroller and Uncle Mortimer safe during dinner.

A do or don’t

Doctor’s orders, dog safety, and your back – all good reasons for dog strollers to be on your “Doggie Do” list. A stroller is a don’t for healthy dogs who need regular exercise to maintain themselves in option body condition.

National Veterinary Technician Week 2012

AMC LVT, Monika Wright

October 14- 20, is a celebration of the contributions to the healthcare of animals made by veterinary technicians. Often called “nurses,” these licensed professionals practice under the supervision of a licensed veterinarian. In New York State, veterinary technicians prepare and give medications as ordered by the veterinarian, take x-rays, induce and maintain anesthesia, and assist with medical and surgical procedures. Most importantly, they are critical members of the team caring for your pet. Last year, in honor of Veterinary Technician week, I wrote about the care received by Jack Black the Cat.

Just as in human healthcare, nurses for animals are in great demand. Not only are career opportunities available for veterinary technicians to work in general veterinary offices, but specialization in various disciplines such as oncology or anesthesia, participation in biomedical research, enlistment in the military and even working as a technician in zoo and wildlife medicine are also widely available.

Like all professionals, there is a backstory about the day-to-day life of veterinary technicians. If you are considering a career as a veterinary technician or just know someone whose job it is to be a technician, you may be unaware of what a typical day entails. Hopefully this blog will give you a bit of the inside scoop and provide a greater appreciation for the labors of love they each perform every day for our pets.

Fashionistas need not apply

Looking for a job where you look great and wear fabulous clothes? Unless your skin tone becomes more ravishing when you wear scrub-suit green, being a veterinary technician is probably not for you. However, if you like to change clothes frequently, we can accommodate your needs. A shake of the head can send ear drops flying right onto your freshly laundered ensemble or a pooch with a bloody nose can change you plain shirt into a polka dot one!

Adoption options

Seeing cute animals all day, every day brings a smile to every technician’s face, since like veterinarians, they love being around animals. But loving animals occasionally has a darker side. Every animal hospital provides its employees with plenty of options to adopt a new pet: a basket of kittens left on the doorstep or a dog tied to the lamppost, but every family, even those with a member skilled in providing pet care, has a limit to the number of pets they can handle, both emotionally and financially.

Compassionate technicians may run the risk of trying to help too many of the animals in need that they encounter. Reliable resources for helping these animals are at the tip of the fingertips of the best technicians who know or have learned the limits of their care.

Injury report

Like many businesses, The AMC tracks statistics on workplace injuries. No surprises here: topping the list are bites and scratches, followed by back injuries. Fortunately, licks and kisses are not considered injuries, just part of the fun of being a tech.

A heartfelt thanks to all veterinary technicians

During National Veterinary Technician Week 2012, the veterinarians of The AMC would like to recognize our nearly 80 technicians – and every technician nationwide – for their commitment to their profession and the support of ours.

If you are thinking of a career as a veterinary technician, visit http://www.veterinarytechnician.com.

You will find lots of useful information and even job opportunities in your area.

The Compounding Pharmacy Problem: What Pet Owners Should Know

A rare form of human meningitis has recently been in the news. The outbreak, believed to stem from fungal contamination of a medication compounded to treat back pain, has resulted in several fatalities. The manufacturer of the implicated medication is not a big pharma or an overseas company; the medication was produced by a compounding pharmacy in Massachusetts. The Food and Drug administration has identified fungal organisms in a sealed vial of methylprednisone acetate produced by the compounding pharmacy.

Pets not affected

This outbreak is unusual since the fungi involved, aspergillus and exserohilum, live in soil and water. Exactly how they came to contaminate the medication is under intense investigation. Since veterinarians don’t treat back pain in dogs and cats with steroids like methlyprednisone acetate injected around the spinal cord, there are no reports of fungal meningitis in pets, but veterinarians do use compounded medications, and understanding their role in managing disease in your pet is important.

Compounding defined

Compounding is the alteration of the original drug dosage form for the purposes of ease of administration or because the original dosage form is unsuitable for the purpose intended. Translated for the pet owner, compounding is flavoring a medication to hide the bad taste, dissolving pills into a liquid to facilitate administration, or putting multiple medications into one capsule to help a pet owner comply with a multidrug treatment protocol. Without a good compounding pharmacy, my job would be impossible.

Compounding dangers

Compounding is not regulated by the FDA because it is a process initiated by prescription and on a case-by-case basis. In veterinary medicine, compounding rules have been stretched in an attempt to create cheaper medications. Some compounding pharmacies offer expensive medications at unbelievably low prices. I suspect these cheaper products are being produced by what is known as bulk compounding from raw materials. Just last week, I had to advise a pet owner against using the compounding pharmacy’s cheaper “house” brand of an expensive medication. That medication is not currently available as a less expensive generic. Although I am sympathetic to the financial burden of treating a pet with cancer, my overriding concern is for the patient and the efficacy and safety of the prescribed treatments. Prescribing an approved medication provides some assurance of efficacy and safety for my patients.

Medication safety

Listen to your veterinarian. If they believe a particular medication is better, ask why. If they are concerned about the safety and efficacy of a compounded medication, I recommend trying to make the standard formulation work for your pet.

Learn more about safely medicating your pet.

Misty of Chincoteague

I spent my summer vacation at the beach looking for Misty and Stormy. You may think I was hoping to play beach volley ball with recently crowned Olympic three-peaters, but I was looking for Chincoteague ponies. Misty and her foal Stormy inspired two of my favorite childhood books: Misty of Chincoteague and Stormy, Misty’s Foal, both books by Marguerite Henry.

Assateague and Chincoteague Islands are barrier islands on the eastern coast of the Delmarva Peninsula. From their names, you might think Misty and Stormy came from Chincoteague Island; today the wild ponies live on Assateague Island, just to the east of Chincoteague. Assateague Island is a National Wildlife Refuge and one of the few places in the United States where wild ponies can be seen. Divided between Maryland and Virginia, Assateague National Wildlife Refuge provides homes to two separate herds of ponies, one in each state. I was lucky enough to see the pony herd in Virginia from the beach road and also when using my binoculars from Memorial Park on Chincoteague Island.

Pinto ponies like Misty dominate the herd, although I saw one or two solid color ponies. Chincoteague ponies are ponies because of their small stature, although genetically they are more like horses. Scientists theorize the small stature of Chincoteague ponies resulted from adaptation to the harsh environment of Assateague Island — salty water, limited plants for grazing, and mosquitoes.

Misty of Chincoteague centers on Pony Penning Day, when during slack tide, the ponies swim to Chincoteague and the foals are auctioned to raise money for the Chincoteague Fire Department. Although the ponies are considered wild, they are owned by the Chincoteague Fire Department and they have a veterinarian, Dr. Charles Cameron. They receive twice yearly veterinary care and emergency treatment as needed. Dr. Cameron was kind enough to speak with me about the ponies’ medical care.

Dr. Cameron reports that in just a couple of weeks the ponies will be rounded up for a fall deworming, but the major medical care comes in the spring when the adult ponies and the spring foals swim to Chincoteague for the annual pony auction. At that time, blood is drawn for equine infectious anemia testing and for the last 24 years, the ponies have been vaccinated against common horse diseases such as eastern and western equine encephalitis, tetanus, west Nile virus, and rabies. Rabies is an issue at the shore due to the other wild animals on Assateague Island. During the spring roundup the new foals are microchipped and registered with the United States Department of Agriculture. For the last five years a GPS microchip has been used to allow ponies to be tracked wherever they roam. Unlike the Maryland herd of Chincoteague ponies, the Virginia ponies do not receive any birth control. Management of the herd size relies on the spring foal sale.

A unique medical condition of the ponies seems to be hypocalcemia tetany associated with foaling, also called milk fever in cows. Most veterinary textbooks say this disorder is relatively uncommon in horses, but Dr. Cameron hypothesizes the limited grazing on Assateague Island puts the ponies at risk for this disorder. Treatment with intravenous calcium quickly corrects the problem.

Ponies are like your cat and dog. Pet owners should pay close attention to the care provided to the wild ponies as their care is what your pet should be receiving.

Current AAHA-AVMA canine and feline preventive healthcare guidelines suggest a minimum of one yearly veterinary visits. Microchipping, vaccinations appropriate to your pet’s lifestyle, and annual testing for infectious diseases are required to keep your dog and cat healthy a horse!

Plan, Prepare and Respond: Disaster Planning for Your Pet

September is Disaster Preparedness Month. Whether it is a hurricane, flood, or fire, disasters affect every member of the family, pets included. To help the furred and feathered members of your family weather a disaster safely, here are The Animal Medical Center’s suggestions for disaster planning.

Plan

Advanced planning is critical. Identify a safe place to take your pets in an emergency. New York City shelters will house animals in the event of emergency, but not all shelters will. Check NOW to see if your local emergency shelter plan includes pets. If not, find a boarding facility that will. Make a list of pet-friendly hotels in your area. Visit PetsWelcome.com for a state-by-state listing.

In case you and your pet are separated, be sure you pet is both microchipped and is wearing a collar with ID tags for quick identification.

Prepare

Create a Pet Go Bag for each pet in your household. The Pet Go Bag should contain information about your pet and necessary supplies. These include: your pet’s medical records and contact information for your veterinarian, proof of identification (including microchip number, photo of you and your pets), food, water, medications – enough for one week, pet first aid kit, leash, muzzle, toys, a sheet to use as bedding or to cover the carrier, towel, litter and pan, trash bags. Keep everything together with your pet’s carrier and consider storing your pet’s medical records in the “cloud” using a service like Microsoft Health Vault.

Respond

Remember first responders’ primary goal is helping people, but keep these following tips in mind once disaster strikes: Take your Pet Go Bag if you and your pet are evacuated. If your pet has sustained injuries administer first aid until veterinary help is available. Bathe your pet as soon as possible to clean wounds. Feed your pet only safe food such as that in your Pet Go Bag. Register your family and your pet as “Safe and Well” using the Red Cross website.

For more information about disaster planning for your pet, go to the Federal Emergency Management Agency website.

Let’s Move: Simple Activities to Get Your Cats Moving

First Lady Michelle Obama believes in physical activity as a way to combat childhood obesity in America. Her program, Let’s Move, aims to raise a healthier generation of kids.

Americans are also raising a generation of obese cats because most cats now live indoors. Research has shown that cats living in apartments and inactive cats have the highest risk of becoming obese. Cats with a bowl full of food available at all times are more likely to be obese when compared to cats fed at specific meal times. Many cat owners are unable to recognize obesity in their pet, so there is little early intervention. Here are my suggestions for simple, inexpensive cat activities to get your feline friend moving as part of a healthy cat lifestyle.

Going up, going down

One of the features lacking in most apartments, which may contribute to cat inactivity, is stairs. Using stairs is a good way to build strong muscles in your kitten or cat. My apartment doesn’t have stairs, but I have a step stool which I use to get to the top shelves in my kitchen. Some days I put the step stool out with a favorite treat or toy on top to encourage my kitten to move. The photograph shows my kitten playing on the step stool.

Cats recycle

Kittens don’t need expensive toys; in fact they find trash to be treasure. One of the favorites in my house is an empty toilet paper, paper towel or wrapping paper roll. They can chew, scratch and roll the tubes to their hearts’ delight and the toys are easily replaced when completely destroyed. Another great toy is a wide, sturdy ribbon. I saved one from a gift and tied it to the kitchen drawer handle. I pull the drawer out four or five inches so the ribbon flutters in a breeze. My kittens love to jump up and bat the ribbon and at the same time get excellent exercise.

Cats like shopping [bags]

A shopping day means a bonanza for your cat. Maybe they get a cute new toy, but what they are most excited about is the pile of shopping bags you bring home. My kittens adore a large shopping bag with a small cardboard box slipped inside. The box supports part of the bag where the kittens play king of the hill. The box also creates a space inside the bag for hiding, resting and planning a surprise attack on my ankles. If given a choice, they like bags with stiff paper loop handles which they slip through like children with a hula hoop. The photograph shows how I set up the bag and box and how much my kitten likes playing in it!

Do you have a favorite kitten or cat activity? Write back and let everyone else know how you keep your cat moving.

I Took My Kittens to the Vet: My View From the Other Side of the Table

I did something new last week: I took my kittens to the veterinarian!

Since my father was a veterinarian, he cared for my childhood pets and, of course, I and my colleagues at The Animal Medical Center have taken care of my recent pets. Consequently, I have never made an appointment or sat in the waiting room of a veterinary clinic other than to chat with a pet owner.

Foster care kittens

Last week things changed. You may remember my last foray into fostering.

My family and I temporarily adopted a pregnant cat, helped her deliver her kittens, and subsequently cared for her babies until it was time to let them go. This time, I am fostering two kittens already weaned from their mother. They are both underweight and under socialized. They came to me for a bit of TLC to spiff them up before getting a forever home. The female turned the corner the previous weekend when she started asking for attention and food. Her renaissance made the little orange male look even more malnourished and he retreated into a scruffy ball of fur with no appetite, even for delicately poached chicken breast or the most expensive kitten food from my local pet store.

Had the orange boy been my personal kitten, he would have come to work with me and undergone a full battery of tests. But, my foster care agreement specifies sick kittens come back to the rescue organization for medical care. So, I contacted them first thing in the morning and arranged for an appointment late in the day.

A day of worry

I spent the entire time, from making the appointment until leaving for the clinic, worrying about what was going to happen. Was the kitten so sick it couldn’t be helped? Could the whole problem be the healthy kitten spent all day pouncing on the little one, hoping for a playmate, preventing the little one from eating? The worst worry: what if the healthy kitten was ready for a forever home, the sick kitten required hospitalization, and I had to go home with an empty kitten carrier to an empty kitten palace because both kittens had to stay at the clinic?

The clinic visit

Luckily one of my friends at work drives past the rescue organization on her way home so the kittens and I got a ride, supplemented by a comforting conversation during the trip; the familiar face of the foster care coordinator was reassuring as well. The veterinarian, who might have been young enough to be my son, kindly thanked me for my participation in the foster care program, but when he said the kitten had lost 6 ounces, my pleasure melted away. Because the young veterinarian sees foster kittens daily and kittens are definitely not my core patient base, he gently explained foundling kittens frequently just stop eating for no apparent medical reason. The fix for the problem is simple: force feeding the kitten in the clinic for a few days to jump start their appetite and get them back on track. He also listened to my concern about the disparity in the size and energy level of the kittens. Together we decided the kittens should be separated and I would keep the healthy one while the poor-doer would stay in the hospital.

The moral of the story

I know from experience, it is impossible not to worry about your sick pet. And I also know your veterinarian wants your sick pet to get better almost as much as you do! But a kind word, an open ear, and a treatment plan that took my input about the kittens into consideration put my mind at ease and got the sickly kitten back on the road to good health.

Demystifying General Anesthesia, Part I: Preanesthesia Protocols

Except for the dreaded cone, there is no medical procedure more feared by the families of my patients than general anesthesia. Their concern is well founded since there is always a risk of death, but the risk is very small – about 0.1%, meaning 1 in every 1000 procedures, result in an anesthetic death. This data comes from a large study of private clinics in England where routine procedures, such as neutering, were most commonly performed. The risk of death during general anesthesia rises with illness, advanced age and surprisingly, in the British study, mid-sized dogs.

While risk-free anesthesia does not exist, veterinary teams work hard to minimize the risk for every patient undergoing an anesthetic procedure. In November 2011, the American Animal Hospital Association published guidelines for small animal anesthetic procedures. In this blog, I will highlight how the guidelines help to minimize this risk in your pet.

Anesthesia is more than choosing the anesthetic agent; it is a team effort by a highly trained and skilled veterinary medical team. Anesthetic planning, induction, and recovery require multiple steps and multiple team members, beginning with an examination and testing.

Pre-anesthetic evaluation and examination

During this phase, your veterinarian is looking for risk factors – underlying disease or physical abnormalities which will impact the anesthetic procedure. Blood tests are used to identify problems which make anesthesia trickier, such as diabetes or liver disease. An echocardiogram may be recommended if your pet has a heart murmur. Brachycephalic (short nosed) dogs are prone to upper airway problems and are at greater anesthetic risk. The team will need to plan additional monitoring for your flat-faced friend. If the planned procedure carries a high risk of bleeding, a blood type or crossmatch will be ordered to facilitate a blood transfusion. The anesthesia team will also determine if the planned procedure requires only heavy sedation or, because the procedure is a major one, general anesthesia. Whatever your veterinarian’s recommendation, monitoring will be a part of the procedure.

Monitoring protocols and equipment

Immediately prior to the induction of anesthesia, an intravenous catheter is placed in your pet. The intravenous line provides a conduit for administration of fluids and other medications the pet will require. Multiple wires attached to beeping, tweeting boxes will be connected to your pet. These boxes measure blood pressure, blood oxygen levels, and an electrocardiogram before, during, and after anesthesia. An esophageal stethoscope can be inserted into the throat to facilitate constant monitoring of the heart instead of requiring the operating room staff to periodically place a stethoscope on the chest wall. Body temperature, measurement of blood sugar, and other blood parameters help the anesthesia team to determine if respirations are adequate and your pet remains stable.

My next blog will continue discussing anesthetic procedures, starting with premedication, anesthetic agents, and finally the role pet owners play in anesthetic procedures.

The AMC Goes Electronic

AMC staff members work on the new EMR system

This past week was a watershed week at The Animal Medical Center. With the flip of a switch, an electronic medical record (EMR) became a new part of practicing veterinary medicine.

What is an EMR?

The name, electronic medical record, does not do this system complete justice. It is definitely electronic. Consequently, we have computers in every nook and cranny of the hospital attached to three types of new printers – one for collar-style name tags, one for cage cards, and one for blood sample labels. A paper medical record includes notes about examinations, results of blood tests and x-rays, surgery descriptions, and diagnoses. Our EMR includes all those components, but it goes further.

But wait, there’s more

With this new system, I can order x-rays from my 8th floor clinic computer and the radiology team on the 2nd floor knows exactly what I want – faster than we can transport the pet to radiology. Previously, the patient and a paper request were transported to radiology. The same software that records patient information also orders blood tests from the laboratory or pills from the dispensary. For hospitalized patients, all medications administered by the nursing staff are now requested on an electronic whiteboard and recorded with the click of a mouse.

My personal favorite

Each patient has an electronic clipboard and on the top is a handy little box. Once I figured out how to use it, I went back into all my patients’ clipboard records from this week and loaded them up. I can write anything I want in the box. My plan is to use it like an electronic post-it note to remind me when certain infrequently performed tests are due. In Vivian’s box I put the date for her next iron injection, for Cleo the date her urine needs a follow-up culture, and I added the dates of scheduled chest x-rays for several more pets. One of the reasons both physicians and veterinarians are moving to EMRs is to help them become better doctors, and this will definitely help me.

New tools

The EMR allows importing of photograph files, a feature particularly useful for oncologists like me who want to monitor the response of a tumor to treatment. The photographs also help the ER doctors who might not know what the tumor looked like before, but now can click open a JPEG file and see the tumor for themselves. The EMR contains dog and cat diagrams ready for annotation to mark the location of abnormalities found on examination.

Improving the health of all animals

In addition to improving care for individual pets, the EMR will help improve care for all pets by facilitating research. Old style paper medical records cannot be searched for information. Our electronic medical record allows us to search and find all patients with a particular diagnosis or disease. Information gleaned from the records will help us to share information with other veterinarians about successful new treatments. Thus, the EMR will benefit not only AMC patients, but patients everywhere.

Transitioning to any new system is hard work and takes persistence, but with all these benefits, we have entered a new era.

If your veterinarian uses an EMR, some store records in “the cloud” allowing you to view your pet’s medical information anytime. Ask about this feature the next time you visit your veterinarian, as the information could be very valuable during an ER visit.

Allergies in Dogs: 4 Treatments to Help Scratch Your Dog’s Itch

The summer of 2012 will go down in my personal history book as the summer of allergies. Not for me, but for my canine patients. I have received many frantic calls from my cancer patients’ families concerned that their beloved pet’s cancer has returned. After a check-up with me at The Animal Medical Center, I have reassured them the cancer continues to be in remission, but their allergies are way out of control.

Scratching bad

Today, the preferred term for allergies to things in the environment, like house dust mites pollen, mold, trees and grasses, fleas, and even your unsuspecting household cat, is allergic dermatitis. Allergic dermatitis is also known as atopy, allergic inhalant dermatitis, seasonal allergy, or environmental allergy. Whatever it’s called, the manifestation is red skin, “hot spots,” ear infections, recurrent skin infections and scratching like mad. The development of allergic dermatitis requires two things: a dog with a genetic predisposition to developing allergies and an allergen in the environment to incite the allergic response. Allergic dermatitis is a complicated disease and often requires complicated therapy.

Complicated cause

At least three mechanisms play a role in allergic dermatitis in dogs. First, the environmental allergen causes the release of histamine from a cell known as a mast cell, which sets off an allergic reaction. T-cells have a yin-yang effect on the immune system, both ramping up the immune system and blocking a protective effect against allergies. Finally, normal skin protects the body from invasion by allergens. Dogs suffering from allergic dermatitis likely have impaired function of the skin cells, allowing allergens access and predisposing your dog to yeast and bacterial infections.

The net effect of all this cellular hysteria: an itchy dog.

Complex treatment regimen

Given the complexities described in the pathways leading to allergic dermatitis, you should not be surprised to receive a small pharmacy’s worth of prescriptions when your dog is diagnosed with allergic dermatitis. What follows is a brief description of some of the more common medications used to treat allergic dermatitis.

1. Although the role of histamine is limited in canine allergic dermatitis, antihistamines, if they decrease itchiness, are very safe and cost effective.
2. Shampoos play multiple roles in the management of allergic dermatitis. Bathing your dog is soothing to the skin and decreases surface allergens, and medicated shampoos decrease surface bacteria and yeast. Hopefully, new shampoos will be developed to help augment the lost barrier function of the skin.
3. Antibiotics and anti-yeast medications are critical in controlling secondary infections in the skin of itchy dogs. The function of deregulated T-cells can be modified by the use of immunosuppressive agents, most commonly steroids, and more recently cyclosporine.
4. Finally, dogs can get allergy shots, a form of immunotherapy where the immune system is gradually desensitized to the offending allergen. For several of my patients, this form of treatment has dramatically improved their quality of life by decreasing their itchiness and skin and ear infections.

What a pet owner can do

If your dog is scratching, as are many of my patients, see your veterinarian. When my itchy dog patients need more specialized skill than I have to manage their allergic dermatitis, I refer them to a dermatology specialist. You can find a board certified dermatologist on the American College of Veterinary Dermatology website.

I hope one or more of the treatments I have described can help make your dog more comfortable in these waning summer months.

Ratchet: The Garbage Hound

Ratchet

‘Garbage hound’ is not a new breed of dog: these dogs have been around for a long time, raiding the trash can for tasty but indigestible morsels. Ratchet, today’s protagonist, is not a hound at all, but a one-and-a-half-year-old rescued pit bull. He’s been at The Animal Medical Center before for digestive problems. Last December, after three weeks of vomiting blue plastic pieces, endoscopy was used to remove bits of blue plastic from his stomach.

On the weekend leading up to the 4th of July, Ratchet had been at the beach when he started vomiting. Once he vomited up a ball and a sock his family thought he would get better, but Ratchet continued to vomit.

Another ER Visit

Back to The AMC Ratchet came, and the ER snapped the abdominal x-ray shown below. The radiologist immediately recognized an intestinal obstruction, likely with some sort of fabric foreign body. Possibly the other sock?

Emergency Surgery

Ratchet’s abdominal x-ray

An intestinal obstruction is a bona fide emergency. The emergency surgeon on call was alerted to Ratchet’s predicament. This was a major middle-of-the-night intestinal remodeling job. The blood supply to four inches of small intestine had been compromised and a leak had formed. To remove the devitalized portion of intestine and the leaking hole, eight inches of intestine were resected and the ends reattached. The cause of this mess was a conglomeration of petrified plastic glove, sticks, and grass.

As a compliment to his tough dog name, Ratchet got a grenade. Not the military kind, but a grenade bulb drain used to suction fluid off his abdomen. This simple yet useful grenade-shaped device is made of soft plastic. Before it is attached to a tube surgically placed in the abdomen, the grenade bulb is compressed. If fluid accumulates in the abdomen, the grenade expands and suctions the fluid out. The drain was necessary because his surgeon was concerned he might develop peritonitis from the leaking and devitalized segments of intestine.

A Quick Recovery

Despite the serious nature of his obstruction, Ratchet quickly bounced back. He never developed the peritonitis his surgeon feared, and within hours of being unobstructed he was asking for food. His quick recovery was, in part, due to his young age and general health, plus the skill of his medical team. Now the challenge for this garbage hound’s future is preventing consumption of potentially obstructing objects.

Advice to Pet Owners

If your pet is a garbage hound, you will need to keep his environment free of articles small enough to be eaten. Vomiting by a garbage hound must be taken seriously, as every episode could be an obstruction requiring urgent intervention.

Can I Have a Dog? Pony? Bunny? 10 Tips for Petless Families

Recently, the news has featured many stories about TomKat. No, not a story about a feline, but the ongoing saga of Katie Holmes and Tom Cruise. One story that caught my eye involved their daughter Suri having a tantrum in a pet store because her mother would not buy her a Morkie, a dog she wanted.

In every family without a pet, there is at least one child begging for one. But for health reasons, travel, or time in the daily schedule, a pet does not always fit into the family’s lifestyle. There are, however, other ways, even without owning a pet of your own, that you can bring animals into your family’s life. Here are my top ten tips to add the fun and adventure of animals to your family without actually owning a pet:

1. Attend the local animal show. The owners of dogs, cats, birds and reptiles love to show off their pets and talk to children about responsible pet ownership. In New York City we have the annual Meet the Breeds dog and cat show, but there are smaller local shows as well.

2. Volunteer to walk dogs at your local shelter or to help socialize the cats residing there.

3. Be a foster pet family. My local rescue group is always looking for host families for cats in need. I wrote about my experiences with my foster cat family last spring.

4. Head to your local library and check out some books on pet care. For the toddler set, try the series about “Sally,” a black Labrador retriever who visits the veterinarian, or for a comprehensive pet care overview, try the Merck/Merial Manual for Pet Health.

5. Participate in your library’s reading program featuring certified therapy dogs to promote reading skills in children. Reading Education Assistance Dogs (R.E.A.D.) has local programs nationwide. Therapy Dogs International sponsors “Tail Wagging Tutors.” What could be better than helping your dog-loving child read better?

6. Volunteer to pet sit for a neighbor while they are on vacation.

7. Become a member of your local zoo. Many zoos have an area where children can pet the animals. In the New York metropolitan area the Wildlife Conservation Society, which includes the Bronx Zoo, the Queens Zoo, the Central Park Zoo, Prospect Park Zoo and the New York Aquarium, has hands-on programs for various age groups, as well as educational exhibits and free demonstrations daily. Some zoos even have sleepovers!

8. If your child is an electronic wizard, there are a variety of electronic games related to pet care. Games are available for multiple game platforms and on the Internet. Try Hamsterz, Dr. Daisy Pet Vet, Paws & Claws, Pet Vet, or Webkinz.

9. Research the high schools in your district to see if they have a specialized program related to animals, such as the Chicago High School for Agricultural Sciences, or the Kansas State University co-sponsored high school program in Olathe, KS.

10. Volunteer at a pet outreach program at your local hospital, Ronald McDonald House, or senior citizens home. The program coordinator will know of a pet volunteer that you can “borrow” for the visits.

If your child is like Suri Cruise and wants an animal, but your inner Katie Holmes tells you a full-time pet is not right for your family, offer your pet-loving child one of these opportunities until the time is right for your family to love a pet of its very own.

Dog Park Dangers

Dog parks are popping up all over suburban and urban areas, and for good reason. Daily exercise helps keep your dog healthy and gives her a chance to get out and socialize with other dogs and humans. In urban areas, dog parks provide a safe space for daily doggie exercise, but recent research suggests dog parks may not be as safe as we might think.

Parasites

A recent study of dog feces collected from Colorado dogs suggests gastrointestinal parasites may be on the list of dog park dangers. Two intestinal protozoa, Giardia and Cryptosporidium, were found more commonly in dogs frequenting dog parks than in dogs that did not. These two organisms are not controlled by heartworm preventatives as are hookworms and roundworms. Identification of these critters is one reason for your veterinarian’s recommendation of an annual fecal examination for your pet.

Infectious disease

A coughing dog visiting a dog park may be a dog park danger, if he is infected with the bacteria causing kennel cough or the virus causing canine influenza. These two infectious diseases are easily spread between dogs in a dog park and are characterized by non-stop coughing. Parvovirus infection is another infectious disease readily transmitted to a healthy dog when it comes in contact with the feces of an infected dog. The good news is vaccinations are available to prevent these diseases and diligent pooper scooping is critical to prevent transmission of parvovirus as well as intestinal parasites in dog parks.

Dog bites

I anticipated dog bites or other injuries related to aggression would be common in dog parks, but a 2003 publication reported on 72 hours of dog park observations and found little evidence to support my theory of dog to dog aggression as a major problem in dog parks. The authors hypothesize dog owners with aggressive dogs avoid dog parks because they recognize the danger their dog poses to others.

Dog parks danger for other animals

A study of California sea lion strandings showed leptospirosis (a waterborne infectious disease) was more likely to occur in sea lions found in areas with a high density of dog parks. The authors of the study suggest exposure to dogs in dog parks may be in some way associated with the infection in sea lions. Leptospirosis is a life-threatening disease of the kidneys and liver. Dogs, humans, and possibly even cats can be infected, usually through urine-contaminated water. Dog owners should ask their veterinarian if leptospirosis is a concern in their neighborhood and should consider having their dog vaccinated against this disease.

If you live in New York City, a list of dog parks by borough can be found here.

Be sure to tell your veterinarian if your dog plays in dog parks as this information will help direct your dog’s preventive healthcare plan.

Hot Summer, Cool Dogs

Ben enjoying the pool on a warm summer day

Summer is bearing down on the east coast at full steam ahead. The unrelenting heat and humidity have all of us, dogs included, looking for ways to keep cool. Here are my cooling suggestions for your dog, courtesy of Ben, the Border Collie.

Cool in the pool

The photo above shows Ben taking a dip in his pool after an energetic game of Frisbee. Notice the pool is mostly in the shade to keep the water cool and inviting. Dark-coated dogs like Ben are more prone to overheating since their fur absorbs rather than reflects the rays of the sun, so if these dogs are outside in the heat, provide a shady place for resting. Since the water in the pool is not filtered, it should be replaced every day, but the water can be used to water plants or the lawn. The plastic kiddie pool gets my vote since there is no danger of falling in or being unable to get out. Some dogs love swimming in the family pool, but they should never swim alone and should be supervised at all times in the pool area to prevent an accidental drowning. You may even consider a doggie life jacket for the more timid swimmers.

Cool treats

To cool off when he comes inside, Ben likes a frozen treat straight from the freezer. SweetSpots are his favorite. They come in two flavors: peanut butter and honey or sweet potato and molasses. He laps the tasty frozen treat right from the 3.5 fluid ounce container. After a big Frisbee workout, he deserves a treat, but these treats pack a lot of calories: 110 per container of peanut butter and honey and 75 for the sweet potato and molasses. I recommend no more than 10% of daily calories be consumed as treats. So for your dog to follow those recommendations, the 110 calories of peanut butter and honey are enough treat calories for a 60-pound dog. You can make your own frozen treats by putting a portion of your dog’s daily canned food into ice cube trays or hollow feeding toys and freezing.

Have a cold one!

On a hot day, there is nothing like a cold, frosty beer. Beer for humans is dangerous for dogs since it contains alcohol and hops. Lucky for dogs, Bowser Beer contains neither ingredient and is a safe drink for your dog on a hot day. Ben hasn’t tried Bowser Beer, yet, but when he does he can choose from brown ale or cock a doodle brew! While your dog might want a burger to go with his brew, I suggest a squeaky hamburger or hot dog rather than the real thing with his Bowser Beer.

These are all fun summer suggestions, but in all seriousness, too much fun in the sun can prove fatal for your dog. For a serious blog on heatstroke, click here.

Photo: Dr. Ann Hohenhaus

Feline Leukemia Virus

This is the fourth in a series of blogs about fabulous felines written for “Adopt-A-Cat Month.”

Brianna is available for adoption through Petfinder (see below)

Thankfully, veterinarians don’t have to talk as much as they used to about feline leukemia virus (FeLV). Prior to the introduction of universal testing and vaccination against the virus, we cared for cats infected with FeLV on a daily basis. Depending on the variety of the virus, we saw young cats suffering from lymphoma of the thymus or anemia due to bone marrow suppression. Today, most cat owners have their kittens tested at the first kitten check-up or kittens come from the shelter already tested. Cats with free access to the outdoors are at risk for contracting the virus since the virus is spread via contact with an infected cat. The virus gives cat owners another good reason to keep their cats safe by keeping them indoors.

Correcting confusion

Feline leukemia virus infection is not synonymous with leukemia, a cancer of the bone marrow. Feline leukemia virus is a viral infection with similarities to the AIDS virus. Sometimes FeLV coexists with a diagnosis of cancer of the bone marrow, but not as often as it did prior to universal testing and vaccine development. Both diseases—FeLV infection and cancer of the bone marrow—are serious, life-threatening disorders. Only feline leukemia virus is completely preventable by keeping your uninfected cat indoors.

Ubiquitous virus

Feline leukemia virus can be found worldwide, with recent reports of the virus in Malaysia, Egypt, northern and southern Europe, and Iran. Even the cats of island nations are not spared, as the virus can be found in felines of the West Indies, Japan, and Australia. The occurrence of FeLV in the United States varies; it occurs more frequently where cats are allowed to roam freely outdoors and ranges from one to five percent of cats tested.

Not just your domestic cat

The cat currently sleeping on your computer is not the only type of cat that can contract FeLV. Wild cats are also at risk, with reports of the virus in the Florida puma, Iberian lynx, cheetah, ocelot, and the wild felids of Brazil. Another reason to keep your cat indoors is to prevent spread of the virus to wild felines. Infection with FeLV adds survival pressure to wild feline species already endangered by reduction of their natural habitats resulting from global warming and urbanization.

Common co-infections

Feline leukemia virus infection increases the occurrence of other infections: feline immunodeficiency virus, toxoplasmosis, and heartworms. The exact cause is unknown, but possibly outdoor cats are exposed to more infectious agents or FeLV may pave the way for a second infection through suppression of a cat’s natural immune defenses.

To find the prevalence of FeLV infection in your area, as well as other infections check out the parasite prevalence maps.

Brianna is available for adoption through Petfinder.

Lost in Translation

Veterinarians request a lot of information from pet owners. We interrogate them: What does his cough sound like? We dictate to them: Give these pills three times a day. And we expect them to understand a foreign language — doctor talk. Mistranslated doctor talk results in communication gaps between veterinarians and pet owners. Here are some examples from last week’s patient visits at The Animal Medical Center.

Barfy is regurgitating twice a day.

This “lost in translation” example comes from the innocent misuse of the word regurgitate. Medically speaking, regurgitate is similar to vomiting, but there is an important difference. When a dog regurgitates, a forceful heave-ho and wretch are missing. The food or liquid comes back up without an increase in abdominal pressure. Picky, I know, but, as a veterinarian, this information is diagnostically critical. Dogs and cats that regurgitate have an esophageal problem, and those that vomit typically have a problem further down the digestive tract. This picky distinction directs my diagnostic evaluation, so I have to get it right or I bark up the wrong diagnostic tree, so to speak.

Is Fluffy urinating more than usual?

This translation gap was my fault. The poor cat owner didn’t know how to answer. Was I asking more in frequency or more in volume? I tried to avoid using doctor talk to ask what was really on my mind; was Fluffy pollakiuric or polyuric, the special words for increased frequency of urination or increased volume of urination. Increased volume of urination suggests diseases like diabetes, kidney failure or a kidney infection. Increased frequency of urination suggests a bladder infection, bladder stones or possibly a bladder tumor. Once again picky, but critical.

My cat, Peter, gets dialysis at home every other day.

This comment was made by a patient new to The AMC and it caught me off guard. The AMC is the only center for dialysis between Boston and Philadelphia and this cat was a local from 89th Street in Manhattan. Dialysis happens in the hospital and not at home. What really happened was the owner had been trained by her regular veterinarian to give fluids subcutaneously to her cat to help combat the effects of failing kidneys. Cats with kidney disease often become dehydrated as their failing kidneys waste water by producing excessive amounts of urine. Supplementing feline fluid intake with subcutaneous fluids keeps cats feeling and eating better because they are not dehydrated. Dialysis, also used to treat failing kidneys, filters the blood through a machine to remove waste product since the kidneys no longer perform this function. Same disease, different treatment.

If you are not sure what your pet’s veterinarian just told you or can’t understand the question you were just asked, don’t hesitate to ask for clarification. Don’t let your pet’s diagnosis get lost in translation.

Bronchoscopy: In the Words of a Dog Owner

I was happy to receive an email from an old friend of mine, but was concerned when the subject line said, “Summer’s cough.” My friend no longer lives in New York City and was updating me on a medical procedure her dog, Summer, had earlier that day. The procedure, a bronchoscopy, was performed by board certified small animal internal medicine specialist, Dr. Leyenda Harley, an alumna of The Animal Medical Center’s internal medicine training program and a former staff doctor here.

Jenny wrote: “Summer has been coughing for some time and initially an antibiotic improved the cough, but then it got worse. Dr. Harley recommended bronchoscopy.”

The procedure

Bronchoscopy involves threading a special endoscopy unit (bronchoscope) through the mouth, down the trachea, and weaving it in and out of various bronchi to determine the cause of disease in the respiratory track. A camera is an integral component of the bronchoscope, allowing the veterinarian to view the inside of the airways. A bronchoscope can also be used to remove stuck objects from the trachea of dogs as I wrote in a previous blog.

Summer had bronchoscopy and bronchoalveolar lavage. Bronchoalveolar lavage involves flushing a small amount of sterile saline through a channel in the bronochoscope and retrieving the saline which, after swishing around in the lungs, will contain infective agents, blood and lung cells, and, hopefully not, tumor cells.

The results

Jenny went on to say: “The main findings in Summer included red and inflamed lower airways with a moderate amount of mucus throughout. To see a video of the inflamed airways and the mucus plug, click here. When the bronchoalveolar lavage fluid was examined under the microscope, many neutrophils (a type of white blood cell usually indicative of bacterial infection) were seen. Samples of the material in her airways were sent to a laboratory for cytology, PCR, and culture with antibiotic sensitivity [standard operating procedure following bronchoscopy].”

When specially trained veterinarians, called clinical pathologists, look at samples of cells obtained from various fluids, lumps, or tissue using a microscope, it is called cytology. Polymerase chain reaction, or PCR for short, hunts for scraps of DNA belonging to infectious organisms which might be the cause of illness in your pet. The sterile saline collected after it was used for bronchoalveolar lavage is placed in special media to promote bacterial growth and facilitate identification of the best antibiotic to eradicate the bacterial infection.

“Bronchoscopy also identified a mucous plug in one small lower airway, and using the special bronchoscopy brush, the plug was removed and sampled for the laboratory. No inhaled foreign objects like a bit of plant material [or thankfully no tumors] were identified.”

The treatment

All these tests helped direct Summer’s therapy. In an emailed update, Jenny wrote, “She received Baytril as treatment for a Pseudomonas infection and prednisone [steroids] to decrease inflammation. Today we started the inhalation therapy, and it went well. I hope that she will continue to improve to the extent that she will not have to be on Flovent indefinitely.” Flovent is an inhaled [steroid] administered through a device called Aerodawg, similar to a spacer used to treat children with asthma.

Between the medications and a change in halter style, Summer’s cough has markedly improved and Summer is ready for summer like all of us.

Many thanks to Jenny for letting me transcribe her clear and informative email into my blog, to Dr. Harley for providing the images, and to Summer for sharing her successful treatment with readers of Fur the Love of Pets.