Are You Tired? Light The Fire! Dr. Danny Walker, D.V.M.

Transcription

1 Are You Tired? Light The Fire! Dr. Danny Walker, D.V.M. Your role as a veterinary technician is ever changing from your scope of responsibilities to the added value of a practice. Your first name was animal technician and now veterinary nurse is being considered. Regardless of the name you are vital to your team, clients, and patients. With ever changing roles, comes more responsibility which leads sometimes to more stress. We will discuss ways to identify burnout and what we can do to treat the problem. We will also review the latest statistics from NAVTA s 2016 survey. Over 2600 responses from veterinary technicians across the country solidified the vet tech profession as one for the future. The survey covered all aspects of the profession from degrees, benefits, types of products recommended, greatest challenges, most fulfilling aspects, and many other areas of interest. You should be proud of where you are and the influences you have on those around you. Be the best you can be! Light the fire and fan the flame for this great profession.

2 Technician UPDATES IN VETERINARY ONCOLOGY Lorin Hillman, DVM, DACVIM (Oncology) Veterinary oncology is a diverse, rapidly changing field. Cancer is diagnosed more frequently as health care improves and pets are living longer lives. Owners are interested in treatment options that can help their pets live longer with a good quality of life. A good quality of life is the most important goal of veterinary oncology. Treatments are similar to those utilized in human oncology but we try to minimize side effects as much as possible. It is important to have an understanding of cancer terminology and treatment options so you can assist your owners through a difficult diagnosis. Cancer is defined as uncontrolled division of abnormal cells in a part of the body. Cancer usually indicates a malignant tumor or growth. Most malignancies can invade regional tissues and metastasize to other parts of the body. Some malignancies are actual solid tumors such as osteosarcoma (malignant cancer of bone) or mast cell tumors (malignant skin cancer). Some malignancies affect the blood such as acute leukemia or chronic lymphocytic leukemia. Some tumors are benign, indicating a less aggressive behavior without metastasis. Benign tumors may still cause morbidity in a patient due to physical characteristics. For example, a large lipoma on a limb that affects a pet s ability to ambulate normally. Basic tumor types include carcinomas and sarcomas. Carcinomas originate from tissues that cover a body surface, line a body cavity, or make up an organ. Examples include mammary adenocarcinoma that develops from mammary glands and transitional cell carcinoma that develops from the uroepithelium in the bladder. Sarcomas arise from mesenchymal tissue that connects, supports, or surrounds other tissues and organs. Examples include fibrosarcoma that develops from fibrous connective tissues and hemangiosarcoma that develops from cells that support blood vessels. Lymphoma, also called lymphosarcoma, is a cancer of solid lymphoid tissue such as lymph nodes or spleen. Leukemia includes cancers of blood cells and blood forming tissues. Cancer can be diagnosed by cytology or histopathology. Cytology involves obtaining a sample of cells with a needle aspirate. Histopathology involves obtaining a piece of tissue with a biopsy. Grading is a histological diagnosis made by a pathologist and the grading scale depends on tumor type. Stage is a clinical assessment made through diagnostic tests to allow us to determine the best treatment plan for an individual pet. Staging tests include bloodwork, urinalysis, thoracic radiographs, abdominal ultrasound, lymph node aspirate or biopsy, bone marrow aspirate, CT or MRI, FeLV/ FIV testing, and tumor biopsy. The necessary staging tests are determined by the specific tumor type. There are several abbreviations used in veterinary oncology literature and one of the most important to understand is MST or median survival time. The median survival time is the point where half the patients live longer and half the patients live a shorter amount of time. Other abbreviations include: CR- complete remission, PR- partial remission, SD- stable disease, PDprogressive disease, DFI- disease free interval, DOR- duration of response, and DLT- dose limiting toxicity.

3 Technician There are several types of cancer treatments including surgery, radiation therapy, chemotherapy, and novel therapeutics including targeted therapies (small molecule inhibitors, monoclonal antibodies) and vaccines. Surgery still remains our most effective treatment for most types of cancer. Many tumors can be completely removed with surgery or the majority of the tumor can be removed allowing for efficacy of adjuvant treatments. Radiation therapy and chemotherapy can be used as primary or adjuvant treatments depending on the tumor type. Chemotherapy is frequently used in practice and safety is of utmost importance. Personal protective equipment (PPE) should be utilized at all times when preparing and administering chemotherapy. PPE includes gloves (chemotherapy rated nitrile, no powder), mask, gown, and face/ eye protection. Both a vertical laminar flow biological safety cabinet (BSC II) and closed drug transfer system are recommended (and likely soon to be required) for chemotherapy preparation and administration. It is important to counsel owners on handling chemotherapy at home if necessary and to discuss risks of chemotherapy present in urine, feces, vomit, blood, and saliva after administration. Chemotherapy administration should be a positive and safe experience for each pet. Sedatives may be necessary. Some breeds may have a genetic mutation (ABCB-1 gene mutation, formally MDR1) that causes increased sensitivity to certain drugs and chemotherapeutics. The Clinical Pharmacology Lab at Washington State performs the test for this mutation and more information is available at Novel therapeutics are being developed in veterinary oncology and several will be discussed including Palladia 1, Oncept melanoma vaccine 2, monoclonal antibodies 3, B cell lymphoma vaccine 4, and the feline IL-2 immunomodulator vaccine for fibrosarcomas 5. Current and developing treatment options for common cancers will be discussed including lymphoma, mast cell tumors, melanoma, and feline fibrosarcomas. Contact for questions: onco@memphisveterinaryspecialists.com 1 Palladia, Zoetis, Parsippany, New Jersey 2 Oncept canine melanoma vaccine, Merial, Duluth, Georgia 3 Blontress and Tactress, Aratana, Leawood, Kansas 4 Canine B cell lymphoma vaccine, Merial, Duluth, Georgia 5 Feline IL-2 Immunomodulator, Merial, Duluth, Georgia

4 Large Animal Topics in Parasitology for the Veterinary Technician Jason Roberts, DVM This presentation is designed to review the value veterinary technicians can add to mixed or large animal practices by participating in client education regarding parasite testing and product recommendation for effective parasite management. There is a trend of distancing veterinarians and veterinary technicians from close involvement with decision making when it comes to parasite control and management due to the availability and accessibility of parasiticides that are readily available over the counter. Owners can have misconceptions about parasites and treatments. As resistance increases it is critical for veterinarians and veterinary technicians to be informed and educate producers. Veterinary technicians can provide significant knowledge and value to large animal clients by reducing parasite related costs which will increase animal health and profit. At the same time this creates value to the veterinary practice resulting in an increase in diagnostic testing and appropriate recommendations for parasiticides to be purchased. Topics covered in this discussion will include: a brief review of our current understanding of basic parasites of cattle, horses, and small ruminants, current issues regarding parasite diagnosis and testing, farm management strategies to reduce parasitic infection, parasitic treatment with anthelmintics, and anthelminthic resistance. Overview of Basic Parasite Life Cycles The typical life cycle of many gastrointestinal nematodes of grazing animals is similar. The adult nematode lives in the gastrointestinal tract where it reproduces. Eggs are shed in the feces and when conditions are ideal the eggs will hatch into larvae which develop into an infective stage on pastures. The infective stages are ingested while grazing. There are several important factors to consider regarding infective larvae and pasture contamination. First, approximately 30% of the animals typically will be responsible for 70% of the egg output. This is a crucial concept regarding parasite control. Identification and appropriate treatment of this group will have a huge impact on the overall success of the management plan. Secondly, there are not the same number of infective larvae on pastures at all times. Several factors contribute to when grazing animals are at greatest risk for infection. The season plays an important role in parasite reproduction. There are significant variations in parasite life cycles, but typically the levels of infective parasites on pastures are going to be higher in warm and humid weather from late spring and summer through early fall, and then decrease late fall and winter when the weather is cooler. Knowledge of the specific parasite and life cycle of the parasites in a specific location is essential knowledge for formulating a management strategy. The periparturient egg rise allows for increased egg production by adult female parasites and this serves as an important source of pasture contamination in young animals. These pregnant females have decreased immunity during late pregnancy and an increased rate of egg production in existing worms. This leads to a significant increase in pasture contamination, typically in the spring when young are most commonly born. These young animals in their first grazing season have limited natural immunity to gastrointestinal nematode parasites. The infective stages on pasture serve to infect these naïve young animals. Finally, increased stocking density increases parasite numbers. All of these factors and others must be considered when developing a complete parasite control plan for grazing animals.

5 Common Internal Parasites of Cattle, Horses, and Small Ruminants Brief Overview of Internal Parasites of Cattle Ostertagia ostertagi is the most pathogenic internal parasite in most beef herds in the United States. There are two syndromes associated with Ostertagia. Type I Ostertagiasis is seen when the parasite follows the typical life cycle where the adult matures in the abomasum, eggs are shed in the feces, and larvae mature on pastures. Parasite numbers increase in animals on pastures which can lead to significant production losses. Type II Ostertagiasis occurs when environmental conditions are not ideal for larvae to survive on pastures. The adult worms go into a hypobiotic stage in the abomasum and accumulate until conditions are optimum for larval survival on pastures. When conditions are appropriate large numbers of accumulated larva suddenly mature and migrate causing severe abomasal damage. Significant weight loss and diarrhea are often seen. This occurs most often in the fall in southern states following the hot summer where larvae cannot survive on pastures, and in the spring in northern states following the cold winter where larvae cannot survive on pastures. Ostertagia can be a problem for both cows and calves. Ostertagia, Cooperia spp., and Haemonchus spp. are potential problems for calves. Young cattle generally have much higher egg counts than adult cattle due to decreased immunity. Stockers and replacement heifers tend to have the highest egg counts due to their age, increased stocking density, and the potential for resistance due to increased treatment. Egg production varies considerably from one species to another. Haemonchus spp. and Cooperia spp. are prolific egg producers. Ostertagia spp. produces few eggs per female by comparison. These are warm season parasites so greater numbers build in summer months. This information and the species of worm present are important when evaluating egg numbers in cattle. Currently there is less documented parasite resistance in cattle than small ruminants and horses. Resistance seems to be more common in stocker cattle which is likely due to intensive management techniques where large numbers of young stressed animals are kept in smaller areas with more frequent use of anthelmintics. Brief Overview of Internal Parasites of Horses Among well managed horse populations, Strongylus vulgaris infections are now recognized as the major parasite of concern. Young horses less than three years of age are more susceptible to parasites in general and are more likely to demonstrate parasite-associated clinical disease. Cyathostomes can affect all age groups, but the young and the old are generally more susceptible. Fecal egg counts are valuable, but do not reflect the total worm burden due to the potential for a large number of encysted parasites. Other signs of cyathostome infection include enteritis, weight loss, edema, hypoproteinemia, and death. Approximately 30% of horses carry 70% of the parasites. These are the only horses which should be treated frequently as this will reduce resistance pressure. The low shedders can be controlled typically with as few as one anthelmintic treatment per year. The small number of high shedders typically benefit from approximately 4 treatments per year. The most common and pathogenic parasite of foals and weanlings is Parascaris equorum which can cause respiratory disease, poor growth, colic, and death. Many farms with documented resistance to ascarids share these common traits: receive their first treatment prior to 60 days of

6 age, deworm at frequent intervals less than 60 days, use ivermectin exclusively, do not monitor treatments with fecal egg counts. Appropriate treatment strategies are: foals should receive a minimum of 4-5 dewormings with the first performed no earlier than 2 months of age. Benzimdiazoles or pyrantel is recommended due to their effectiveness against ascarids. The average interval between these early anthelmintic treatments should range from 8-12 weeks with the goal of reducing the number of patent ascarid infections among the foal population while minimizing selection pressure which can lead to resistance. At weaning a FEC should be performed to determine if the foal s worm burden is primarily strongyles or ascarids with at least two additional treatments between weaning and 12 months of age. Perform yearly fecal egg count reduction tests to monitor drug efficacy. Anoplocephala perfoliata is the tapeworm of horses and should be discussed when considering parasite management in horses. This tapeworm has a long prepatent period and can cause colic, diarrhea, small intestinal impactions, and ileocecal intussusceptions. The only treatments effective against tapeworms are praziquantel and a double dose of pyrantel. Twice a year treatment for tapeworms is suggested. Anthelmintic resistance is a significant issue with equine parasites and has been reported for more than five decades. All management plans must include a strategy to minimize anthelmintic resistance. Brief Overview of Internal Parasites of Small Ruminants The most common and most pathogenic parasites of goats and sheep are Haemonchus contortus, Teladorsagia circumcincta, and Trichostrongylus spp. Haemonchus contortus is commonly called the barber pole worm and lives in the abomasum. It also infects llamas, deer, and occasionally cattle. It has a short life cycle with a prepatent period of approximately days when conditions are favorable including warm temperatures and high humidity. Development is delayed in cool conditions and the infective larvae can survive for months on pastures under moist conditions. The adult females are prolific egg layers and can produce several thousand eggs every day. The short life cycle and egg production can lead to severe pasture contamination by early to mid-summer in Tennessee. The adult worm lives in the abomasum and one worm can ingest 0.05 ml of blood daily. Severe disease can be seen in animals with as few as 500 mature worms. Clinical signs include severe anemia, hypoproteinemia, anorexia, lethargy and weight loss. Anthelmintic resistance, including multiple class anthelmintic resistance, is a major issue with parasites in small ruminants and any treatment and control strategy must incorporate methods of controlling and reducing anthelmintic resistance. Large Animal Parasite Diagnosis and Testing Parasite diagnosis and testing has been reduced in some areas due to readily available over the counter parasiticides. Veterinary technicians can provide valuable information to owners by providing appropriate and affordable parasite testing. There are both qualitative and quantitative techniques for diagnosing parasites. Qualitative techniques like simple fecal flotation can be valuable tests to determine if parasites are present, but they do not give a reliable indication of the number of parasites present. Quantitative techniques such as the McMaster technique

7 determine the number of eggs present per gram of feces. These tests can generally determine how heavily parasitized the herd is, with some limitations. In general, when egg counts are low, parasite numbers are low and when egg counts are high, parasite numbers are high. However, there are exceptions, for example, large numbers of parasites may be present, but they are in hypobiotic stages. Other tests which can be helpful in a testing program are the FAMACHA system for small ruminants, and the observation of clinical signs in all species including diarrhea, weight gain or loss, and decreased milk production. Quantitative techniques performed by the veterinary technician can be used to diagnose and treat the relatively small percentage of animals carrying the largest worm burden in a group, determine when treatment should take place, and determine if anthelmintic resistance is an issue on a farm. Veterinary technicians need to educate clients on the importance and value of diagnostic testing. General Farm Management Strategies for Parasite Control Veterinary technicians can greatly improve parasite control programs by discussing farm management strategies for parasite control. When considering farm management there are several factors to consider. There are many environmental and animal factors involved. The ultimate goal is an integrated management strategy to reduce parasite numbers on the farm to a level that has a minimal effect on animal health and productivity without allowing for the development of anthelmintic resistance. Eliminating parasites is nearly impossible and undesirable as this often selects for parasite resistance. The goal from a farm management strategy is to minimize economic impact, or cost, while allowing some exposure so animals develop immunity and minimize anthelminthic resistance. The first and most important factor to consider is the management of pasture contamination. The two primary sources of pasture contamination are young animals in mid to late grazing season and adult females in late gestation and lactation. Many factors play a role in pasture management including stocking density, pasture rotation, species rotation, and forage height. Management strategies need to address both the primary source of pasture contamination and environmental management. Appropriate Parasite Treatment with Anthelmintics Veterinary technicians should play an integral role in educating clients on appropriate anthelmintic use. Much has been written about appropriate and inappropriate use of anthelmintics. General strategies to follow to increase effectiveness include following label doses and directions or using doses recommended by scientific literature. Fasting animals for hours before giving oral products can lead to increased effectiveness. Consensus suggests not rotating products more frequently than yearly. More frequent rotation is believed to lead to multiple class anthelminthic resistance. Targeted or selective treatment of animals is a key piece to appropriate use. Only animals that need to be treated should be treated. This can be achieved by monitoring fecal egg counts and clinical signs. Remember 30% of animals typically are responsible for 70% of the eggs on pasture. The challenge is to properly identify these animals by testing. At the same time, the development of anthelmintic resistance can be slowed or even prevented if 30% or more of animals are not treated. This leaves a susceptible refugia which is critical to managing a parasite population. Technicians play a valuable role in educating clients on the value of testing and assisting in making recommendations based on test results. Most clients are open to the idea of

8 investing in more testing once they realize that fewer animals will be treated and this results in cost savings and better health. It is the job of the veterinary technician to offer this information to clients. Fecal egg counts should also be used to monitor the effectiveness of anthelmintics. This information can be used to monitor potential resistance, determine animals that carry increased worm burdens, and develop a farm history to assist with future planning for parasite control. Anthelminthic Resistance Anthelmintic resistance occurs following a change in a parasite s genetic makeup which allows it to survive exposure to the anthelminthic. Resistance traits are inherited. Resistance requires the presence of resistant genes and the rate of resistance development in a population depends on the selection pressure of the surviving worms to pass genes on. Use of the anthelminthic places selection pressure on the parasite population allowing resistance to increase. Frequent drug therapy subjects parasite populations to selective pressure and allows only resistant isolates to survive, reproduce, and pass on their resistance genes to future generations of parasites. Resistance is demonstrated by reduced effectiveness of an anthelminthic through testing procedures. Typically, once resistance is detected it is widespread on a farm. Many factors are involved in resistance including number of treatments, pharmacokinetics, and parasite biology. Any discussion of parasite resistance must include a discussion of refugia. Refugia is the parasite population that is not killed by the drug treatment. Refugia can be on pasture or in animals. The larger the refugia, the more the resistance genes will be diluted and the more effective the treatment will be. As the refugia becomes smaller, genes selecting for resistance will spread faster. A good example of the importance of managing refugia can be seen in small ruminants. Historically all animals in a group were treated with a dewormer and then moved to a clean pasture. This decreased the size of refugia on the clean pasture and all of the parasites susceptible to the products were killed. The only parasites that remained were resistant to the treatment. This quickly developed a population of resistant parasites. This is why current recommendations are to only selectively treat animals which will leave a large refugia of nonresistant parasites. There are only two ways that resistant parasites are acquired on a farm. Resistance is unintentionally developed and selected for on the farm or resistant animals are purchased. Good management programs will include a quarantine and testing program for new additions to the farm. Veterinary technicians must educate clients on anthelmintic resistance when designing parasite control plans. Summary The key to parasite control is to find the proper balance of environmental control, genetics, and timing of anthelmintics with the goal of minimizing economic impact while at the same time preventing the development of resistance. It is critical to remember that at any time the majority of parasites are in the environment on the pastures and it is important to use a combination of environmental control and anthelmintics. Historically the focus has been primarily on the use of anthelmintics. This is where veterinary technicians can reverse the trend of decreased veterinary involvement in parasite control and become more involved in parasite management.

9 The key goal for parasite control is to deworm often enough to minimize economic impacts while at the same time preventing the development of anthelmintic resistance. Some important points for technicians to consider when designing parasite control strategies are: Deworming recommendations must be tailored to the geographic location and management style of the farm Monitor and treat animals selectively Management must focus on pregnant and young animals Management must focus on the smaller percentage of animals with the most parasites Product selection based on appropriate parasite testing Understanding of parasite Biology Refugia management Decreased rotation of products and infrequent use of products Proper route of administration and dosing Manage pasture contamination Use anthelmintics appropriately Quarantine and treat new introductions Investigate treatment failure In summary, there are many opportunities for veterinary technicians to use their knowledge and skills to educate clients regarding parasite testing and management. Owners can have misconceptions about parasites and treatments and as resistance increases it is critical for veterinarians and veterinary technicians to be informed and educate producers. Most owners will appreciate the improved health and decreased cost associated with buying fewer products and this will open the door for more veterinary involvement. Veterinary technicians can provide significant knowledge and value to large animal clients by reducing parasite related costs which will increase animal health and profit. At the same time this creates value to the practice as diagnostic testing is increased and appropriate products are recommended and sold. Reference list available upon request by providing a self-addressed stamped envelope

10 Scales and Feathers.It s not so bad Cindy Schmidt, DVM Many veterinary technology programs include some classes on exotic animal medicine. However, the emphasis seems to be more along the lines of lab animal medicine. Students are primarily exposed to the anatomy and physiology of small rodents such as mice and rats. Perhaps some students may learn a little about other exotic animals used in research facilities namely rabbits and ferrets. Some of these species are kept as companion animals. The smaller rodents, however, are not as commonly kept as companion animals. Mice and rats are just not as popular as guinea pigs and ferrets. In a regular small animal veterinary practice it is very common to see an occasional guinea pig, rabbit or ferret along with dogs and cats. Most veterinarians and veterinary technologists are fairly comfortable handling these small mammals. Where things get really interesting is when a client brings a Macaw or a Ball Python to the vet clinic. Birds and reptiles elicit a negative visceral response in many individuals. Many people see reptiles, especially snakes, as evil and scary. Birds, particularly the larger parrots, can be intimidating. These species have earned a reputation for bad behavior, some deservedly. For those individuals lucky enough to work in a veterinary practice that sees these very fascinating animals I would like to talk for a little bit about how to properly and safely handle, restrain and treat these animals so that the veterinarian, veterinary technologist or patient is not harmed. We will talk about the process of dealing with a sick bird and a sick reptile. Specifically, we will concentrate on taking a thorough history, restraint, diagnostic sampling and finally, surgical and anesthetic assistance. When making an appointment for an avian or reptile patient, it is especially important to remind the owner to bring the animal in a carrier. This may seem counter-intuitive. It is very important the animal not only is protected from injury when it arrives at the clinic but it also protects the sensitivity of other clients waiting in the reception area. Some people are genuinely frightened of reptiles. Seeing a ball python draped around the owner s neck could lead to quite an outburst. Imagine what could happen if a client walks in with a Mollucan cockatoo on their shoulder and sits next to a client with a trained duck-hunting Labrador retriever. In most small animal practices appointments typically run every 15 to 20 minutes. Because husbandry and nutrition are two of the most common reasons a bird or reptile is sick, a 20 minute appointment is simply not enough time to obtain a thorough history is these areas. Time is often required to reeducate owners about the proper care of their bird or reptile. Most sick exotic animal appointments will take 30 to 40 minutes. No matter the type of veterinary practice one works in, a large amount of a veterinary technologist s time is spent getting thorough histories from clients about their sick animals. In those veterinary practices that see birds and reptiles this is where the differences begin. Husbandry is the single most important component to forming to diagnosis and treatment plan for a sick bird or reptile. Husbandry is defined as the care and management of an animal. In the case of a bird or reptile, husbandry questions have to do with habitat concerns and nutrition. Unlike dogs and cats, birds and reptiles are kept in cages and aquarium style tanks all their lives. Some reptiles, such as green iguanas, require a tropical environment. Others, such as bearded

11 dragons, require a very arid environment. Most birds are naturally foragers. They require opportunities to engage in this behavior. These exotic pets originate in many different countries and climates. They have very unique diets that are difficult to recreate in captivity. As a result, many birds and reptiles suffer from chronic malnutrition. The vast majority of illness in both birds and reptiles can be traced back to a problem with housing or nutrition. The first part of a thorough history involving birds or reptiles is the same as dogs and cats. Namely, identify the species, name and age (if known), and the presenting complaint of the patient. Establishing the age of a bird or reptile can be difficult. Many of these animals have been re-homed one or more times so owners are unsure how old it is. Most birds and reptiles are brought to the veterinary clinic in something other than their regular habitat. The veterinary technologist must ask questions that create a very clear mental picture of the animal s living conditions. It is important to ask questions that require descriptive answers. Examples of such questions are: Tell me about his/her house. What size is the cage/tank? What kind of toys are in the bird s cage? What kind of perches are in the cage? What type of cage furniture is in the reptile habitat? Is there a place to hide? Are there items in the tank that will help with shedding? Is the cage covered at night? Where is the cage/tank located in the house? If it is in a high traffic/noise area some birds and reptiles find that to be a very stressful environment. Normal sleep patterns are disrupted and stereotypic repetitive behaviors can develop. In the case of reptiles, the technologist must also ask about the temperature and humidity of the habitat. Reptiles are ectotherms. This term means that these animals rely on the temperature of their environment to regulate their core body temperature. All reptile body functions such as digestion, elimination and reproduction are dependent on proper temperature and humidity. One often forgotten question is to find out what substrate is being used. Substrate is defined as the material that lines the bottom of the cage or tank. Some substrate material can be toxic to birds and reptiles. The final component of a thorough history involves nutrition. As has been mentioned before, many birds and reptiles suffer from chronic malnutrition. By the time a reptile shows outward signs of chronic malnutrition the problem has been going on for months if not years. One should start by asking what is fed to the animal on a daily basis. Don t forget to ask what kind of fresh food is offered. For example, fruit, vegetables, green leafy food items. Many birds are fed a seed mix or pellet/seed mix diets. Be sure to ask what the bird actually eats from this mix. Chances are the bird only eats the peanuts or sunflower seeds and leaves the rest. This is how nutritional diseases get started. In the case of reptiles it is important to ask how often is it fed. What size food is offered? If insects are being fed, are they dusted or gut-loaded with calcium first? So thus far, the veterinary technologist has made his/her first sick exotic pet appointment and reminded the client to bring the animal in a carrier. The receptionist has checked the client in. The technologist has taken a thorough history and shares this information with the veterinarian. It is now time for the physical exam. The primary role of the veterinary technologist during an exotic physical exam is the same as that for a dog or cat. Namely, restraint. Handling and restraint of birds and reptiles is probably the greatest cause of anxiety for both the veterinarian and the veterinary technologist. If the animal in question is very small, such as a hamster or finch

12 the concern seems to be If I pick this thing up, am I going to kill it? If the animal is large, such The anatomy and physiology of birds and reptiles is vastly different than that of mammals whether they be dog, cat or rabbit. These differences have a direct impact on how we restrain these animals. With a little knowledge of the unique anatomy and physiology of birds and reptiles one can safely and successfully handle, restrain and treat these animals. There are essentially two types of physical examination for birds and reptiles; the hands on exam and the hands off exam. The hands off exam actually begins while you are taking the history. This exam is based primarily on observation. How clean is the cage? If fecal material is present, what does it look like? What food items are with the animal? What substrate is in the bottom of the cage/carrier? Does the animal seem depressed? In respiratory distress? Does the animal have its eyes open? Are the feathers fluffed up? Are the scales shedding? The hands on exam will require one to actually pick up and restrain the animal. Whether capturing or restraining a bird or a reptile it is important that the process be very quick and efficient. This is particularly important if the animal is sick. Picking up one of these animals more often than not will elicit a fight or flight response. While it is rare for a bird to have a heart attack or die from fear it is important to realize the effect that wasted movements could have. Heart rates in a bird can very rapidly go from a resting rate of 200 beats per minute to well over 600 beats per minute during restraint. One can quickly see that multiple attempts at capture and restraint could become life-threatening in a debilitated animal. To safely negotiate the handling and restraint of a bird or reptile one needs to understand their very unique respiratory and cardiovascular anatomy and physiology. We will discuss the restraint of birds first followed by restraint of reptiles. There are some occasions when a complete hands on exam is not possible. Some birds and reptiles arrive at the clinic in such a debilitated state that handling and restraint alone may actually push the animal beyond their threshold to compensate and they could die simply from restraint. In these cases the hands on exam will have to be postponed until the animal can be somewhat stabilized. To safely negotiate the handling and restraint of a bird or reptile one needs to understand their very unique respiratory and cardiovascular anatomy and physiology. The first step in restraining a bird will involve capture. Birds can be presented to the clinic in a variety of ways. Small birds could be brought in anything from shoeboxes to large cages complete with toys hung like Christmas ornaments. Large birds usually arrive in a pet taxi or larger cardboard box. A towel is always used to capture a bird. Proper restraint with a towel can protect the holder/examiner from getting bit and it also keeps the wings safely folded against the body wall so the bird does not escape and fly around the exam room. It is important to know a little bit about the species the technologist is trying to capture. What kind of bird is in the cage/box? Will you need a large towel or a small one? Is it a finch that is not at all likely to bite? Is it a lovebird that most definitely will bite? Has the cockatiel in the cage had its wings clipped? If not, and it gets loose in the exam room, chances are it will fly around the room multiple times before you will be able to catch it again. Birds do not have a diaphragm. They rely completely on the contraction of the intercostal muscles and the movement of the sternum to move air in and

13 out. Once the bird is safely restrained in a towel, the technologist must be consciously aware of its thoracic body wall expansion and contraction. If the bird is too vigorously restrained and cannot move the thoracic body wall it will suffocate. Part of the hands on exam is recognizing when a bird becomes overly stressed, especially a sick bird. There are times when the best course of action is simply to put the animal down until such time as it recovers its equilibrium Picking up a reptile from its container can be slightly intimidating. Some snakes could be brought into the clinic in a pillowcase or Rubbermaid container. Some lizards could be brought in a shoebox with little holes poked all over the top. In these situations it is helpful to know a little about the species in question. How heavy is the pillowcase or shoebox? Where is the head currently? What species is it? Is it a potentially aggressive breed like a Burmese python or is it a very shy, quite breed like a ball python. If the animal is a lizard is it one of the breeds that has tail autonomy? Is it a two foot iguana that could not only bite but could also injure you with its tail? All of these factors go into safely and properly handling and restraining these animals. Once you know the relative size of the animal you will know how to approach its capture and restraint.. Capture and restraint of reptiles is usually done bare-handed. Towels are rarely used. Snakes are grasped just behind the head. A general rule of thumb is it takes one person per foot of snake to properly restrain the animal. The body of the snake should not be allowed to hang freely. Lizards are grasped just behind the head AND grasped just in front of the rear legs. The tail should not be allowed to whip back and forth. Once the physical exam is complete the next step required to make a diagnosis and formulate a treatment plan involves collecting a minimum data base. This typically requires blood sample collection, fecal exams and taking radiographs. Diagnostic sampling involves the same procedures as dog and cats. The techniques and drugs are very similar to those used in mammals with two main differences. First, the equipment required is very small. Second, the sample sizes are also very small. As has been mentioned previously, knowledge of bird and reptile anatomy and physiology is required to Proper technique for collecting diagnostic sampling requires understanding of recognize once again the very unique anatomical and physiological differences with these species. Sample collection in birds will be discussed, followed by sample collection in reptiles. Blood sampling in birds very often requires brief sedation. This is for two main reasons: the site of blood sampling and the stress level of the procedure. Isoflurane by mask is commonly used. The right jugular vein is the most common site for diagnostic blood sampling in most all pet birds. The right jugular vein is approximately 2/3 larger in size than the left jugular vein and is easily visible in a featherless tract of epithelium in the right lateral cervical region. This vein is very mobile and thin-walled. Hematomas form easily. In a small bird such as a sun conure, the length of jugular vein that is available is very short. There is very little room for multiple attempts at venipuncture. In larger birds such as Macaws, ducks and chickens, the basilic vein or medial metatarsal vein may be used. The basilic vein runs along the medial side of the elbow joint on both wings. The medial metatarsal vein is found in a groove on the medial side of the tibiotarsus, near the tiobiotarsal-tarsometatarsal joint (hock joint). A 25- or 26-gauge 1 ml syringe is typicalty used to collect a blood sample. The amount of blood that can be safely taken

14 for diagnostic testing is 1 ml/100 grams of body weight. For example, a parakeet that weighs 65 grams will need 0.65 ml of whole blood drawn. Blood samples from both birds and reptiles are most often sent to an outside reference lab for analysis. These animals have nucleated mature red blood cells. They also have heterophils as opposed to neutrophils. Heterophils have eosinophilic staining rod-shaped granules. They also have thrombocytes as opposed to platelets. Most inhouse lab machines are not set up or capable of recognizing these cell types. The complete blood count is most often read from a blood smear using manual counts. Chemistry profiles have three notable differences from mammal profiles. The end-product of protein metabolism is both birds and reptiles is not BUN or creatinine, it is uric acid. When kidney function is evaluated the uric acid level is what appears on the report. The blood glucose reference range in birds is approximately two times higher than that in mammals. This is because their metabolic rate is significantly higher than that of mammals. Finally, AST (SGOT) is used to evaluate liver function on birds and reptiles. It is a sensitive and specific indicator of hepatic function as opposed to ALT in mammals. Blood sampling in reptiles presents some very interesting challenges. Blood vessels are not readily visible, these are blind sticks. Scales interfere with needle placement. These animals are not typically sedated. Very safe and steady restraint is critical to the success of sample collection. Sample size is even smaller than that for birds. The volume of blood that can be safely drawn from a reptile is ml/kg. Because the sample size is so small in both birds and reptiles, microtainers with dry anticoagulants are used, which are less likely to cause dilution of the small sample. The preferred site for blood collection in a lizard is either the ventral coccygeal vein or the jugular vein. As with birds, a 22- to 25-gauge 1 ml syringe is used depending on the size of the lizard. The ventral tail vein is found on the ventral midline of the tail. It is largest in diameter in the proximal one-quarter of the tail. The jugular vein is used when a larger volume of blood is needed. The primary landmarks used to locate this vein are the tympanum (ear) and the point of the shoulder. The vein lies along an imaginary line drawn between those two sites. The preferred site for blood collection in snakes is the heart. Cardiocentesis is recommended for snakes weighing more than 200 grams. This procedure, obviously, requires very careful restraint. The snake is positioned in dorsal recumbency and the heart is located by visual inspection or palpation. Clearly, this procedure must be performed very gently so as not to lacerate the heart or a large vessel. To take a diagnostic quality radiograph in a bird requires complete immobilization. To accomplish this one could use injectable reversable agents such as dexmedetomidine and atipamezole, or isoflurane and oxygen by mask. Once the bird is properly sedated it must be positioned on the radiograph table in dorsal recumbency with both wings, legs and head fully extended. To maintain this position the bird will have to be secured to the table. Regular masking tape or paper tape is used to secure the wings and legs. This type of tape will not injury the bird s feathers or skin. Long strips of tape are placed over the elbow joint of each wing and fastened to the table. One strip of tape is wrapped around the hock joint of each leg and fastened to the table.

15 For the lateral view, the bird is placed right side down. Both wings are lifted dorsally above the spine and taped across the carpi and fastened to the table. Taking a radiograph of a reptile is not as labor intensive. Sedation is usually not necessary. Lizards can be manually restrained for the lateral view. A very sick lizard may tolerate being placed in dorsal recumbency for a ventro-dorsal view. However, if the lizard is healthy, one may have to do a dorso-ventral view. Radiographs of snakes presents a unique challenge for two reasons. First, they have a very tubular body shape which makes getting a straight lateral view difficult. Second, they have a natural instinct to coil and slither along with an innate reluctance to be placed in dorsal recumbency. This makes getting a straight dorsoventral view or a ventrodorsal view difficult. These issues can be overcome with the use of a length of clear PVC tubing or a cardboard paper towel tube. Parasitology in birds and reptiles is, again, different from that of mammals. Internal and external parasites are very uncommon in caged birds. They are so uncommon that fecal samples are not routinely screened for internal parasites. Fecal smears are, however, routinely prepared and examined microscopically. These smears are stained with a standard Diff-quick or gram stain. The GI flora of a bird s gut is primarily gram positive. A fecal gram stain on a healthy bird should have greater than 80 percent gram positive cocci and rods, with scant gram negative organisms and no yeast. The results of a fecal gram stain in a bird is a screening tool. A part of the minimum data base. It gives good information as to the health of the avian gut. Both internal and external parasites are common in poultry and waterfowl. With the increasing popularity of these birds as pets it is not unusual to see these animals in a small animal clinic. Treatment is simple and straight forward. Roundworms are the most common internal parasite of poultry and waterfowl. Again, diagnosis and treatment is simple and straight forward. Therapeutics are similar to those used in dogs and cats with a few notable exceptions. Like dogs and cats, medications can be given per os, intramuscular, intravenous, and subcutaneously. However, the locations for these parenteral medications is very different in birds and reptiles. Per os medications are challenging for owners of birds and reptiles. Either animal must first be restrained. In most cases the mouth must be manually opened. This process often requires more than one person to successfully medicate the animal. For these reasons, this route is not often used for reptiles. As has been mentioned previously, the anatomy and physiology of birds and reptiles is vastly different than that of mammals. Knowledge of these differences is especially important when considering therapeutics, surgery and anesthesia. Birds and reptiles have a renal-portal system. This system is a peculiar, complicated circulatory adaptation unique to these two species. These animals have the ability to shunt venous blood from their caudal extremities directly to the kidneys or directly to the heart. This bypass can occur under a variety of conditions. For this reason, parenteral medications are not given in the caudal extremities of birds or lizards. In snakes, these medications are not given in the caudal half of the body. If medications are given that are excreted by glomerular filtration in these locations there is a chance the drug will never reach the systemic circulation. The preferred site for intramuscular injections in birds is the pectoral muscle on either side of the keel bone. The preferred site for intramuscular injections in

16 reptiles are the epaxial muscles or in larger lizards, the biceps or triceps muscles of the front limbs. Subcutaneous injections are rarely used in birds and reptiles. Neither of these species has any appreciable subcutaneous tissue. This is more of an imaginary space than a true space. Antibiotics should not be administered this way as they can be very irritating. Fluids such as lactated ringers or sodium chloride can be given using this route in birds but only in small amounts (1 to 8 mls depending on the size of the animal). The preferred site for subcutaneous fluid administration in birds is the inguinal area. As one might imagine, intravenous injections and catheters are not as easily placed in birds and reptiles as those in dogs and cats. Intravenous access in reptiles often requires a cut-down procedure. In birds a cut-down procedure would not be necessary but there are only two veins of sufficient size to accept a catheter. They are the right jugular vein and the basilic wing vein. The wing vein is extremely tortuous, making threading a catheter virtually impossible. The jugular vein could be used but securing the catheter in place is extremely difficult. The preferred location for indwelling catheters in birds and reptiles is intra-osseous (IO). There are specific catheters made for this procedure. Large volumes of fluids can be given using this route. In lizards, the preferred site for IO catheterization is either the distal femur or the proximal tibia. With proper bandaging these catheters are well tolerated and can be used for up to 5 days. Intra-osseous catheter placement in birds must involve smaller bones than those in lizards. This is because of their very unique respiratory system. Birds rely on a complicated system of lungs, air sacs and pneumatic (air-filled) bones. If an IO catheter is inadvertently placed in a pneumatic bone it could potentially drown the bird. The preferred site for catheter placement is the tibiotarsus ( shin bone ) or the distal ulna. Like reptiles, with proper bandaging, birds tolerate these catheters very well. They can be used for up to 5 days. The final subject I would like to address is anesthesia and surgery. This area is also greatly different than that of dogs and cats. As with handling, restraint and therapeutics, some knowledge of bird and reptile anatomy and physiology is very important. When one is dealing with mammals such as dogs or cats it is important for the technician to tell the owners to keep the patient npo for at least 12 hours before surgery. This is not the case with the avian patient. Birds have a very rapid GI transit time. They also have a very high metabolic rate. Due to these issues a fast of no more than 2 hours is the recommendation before surgery. Reptiles, being cold-blooded, have the opposite problem. They often go days to weeks between meals and their metabolic rate is very low. Reptiles do not have a problem with regurgitation when anesthetized. Fasting is not necessary. Surgical preparation is once again similar to that of dogs and cats with a few exceptions. The core body temperature of birds is 103 degrees to 105 degrees Fahrenheit. Supplemental heat must be provided even for short surgical procedures. In addition to a high core body temperature, a birds high metabolic rate dictates that surgery time be kept to a minimum. To avoid the serious complication of hypothermia and hypoglycemia anesthesia time should be kept to less than 60 minutes. Injectable pre-op medications are used at the discretion of the veterinarian. This author

17 does not use them. Anesthesia in birds is typically induced and maintained using isoflurane or sevoflurane. Induction is attained with the use of a face mask. Induction can be achieved using one of two methods. First an all-in approach can be used. This involves very high oxygen flow rates such as 3-4 liters per minute. The isoflurane/sevoflurane vaporizer is turned all the way up to 5% isoflurane or 8% sevoflurane. There are advantages and disadvantages to this approach. One advantage is that induction occurs very rapidly. Birds have a very high respiratory rate and they exchange oxygen during both inspiration and expiration. With rapid onset of induction, stage 2 of anesthesia can be skipped. This is the stage where animals typically struggle. One disadvantage to this approach is due to the rapid onset of induction. Careful monitoring of heart rate and respiratory rate is absolutely critical. If the anesthetist is not watching the monitors and listening carefully both heart rate and respiratory rate can plummet with very little warning. The second approach to induction is one of small incremental steps. Oxygen flow rates are still high. However, the isoflurane vaporizer is started at 2% to 3% (4% to 5% for sevoflurane) and gradually increased 1% at a time until the bird is fully induced. The disadvantage to this approach is that induction takes much longer and the bird struggles more. It was only 10 years or so ago that reptiles were anesthetized by placing them in a refrigerator or freezer. Thankfully research has changed this anesthetic technique. Much more humane methods are currently employed. Injectable induction agents are used at the discretion of the veterinarian. Some of the more commonly used agents used for dogs and cats have some disadvantages when used in reptiles. For example, dissociative agents such as ketamine and tiletamine can cause a prolonged recovery and provide virtually no analgesia. Propofol requires an intravenous injection, which is difficult to do in reptiles. Reptiles also require much higher doses of Propofol than mammals (10-14 mg/kg). With the introduction of reversible induction agents a few years ago, there are currently some better choices for injectable medications. Midazolam and Flumazenil come to mind. Whether an injectable agent is used or a face mask is used for induction, maintenance of anesthesia is achieved by endotracheal intubation and the use of isoflurane or sevoflurane. Maintenance levels for isoflurane is usually somewhere between 1.5% and 3% and 3 % to 5% for sevoflurane. Following successful induction, intubation is the next step. This procedure is one of the few things that is easier in birds and reptiles than in dogs or cats. Both birds and reptiles have a glottis but no epiglottis. The glottis is located at the base of the tongue and is much more rostral than it is in dogs and cats. It is easily visualized. The avian and reptile trachea is very large in comparison to the trachea of dogs and cats. These species also have complete tracheal rings. For this reason, uncuffed endotracheal tubes are used. One final unique anatomical difference in birds as compared to dogs and cats is the syrinx. The vocal cords in both dogs and cats are found in the laryngeal area. Birds do not have a larynx per se. Their vocal cords are found in a structure called a syrinx. This structure is found just cranial to the tracheal bifurcation. With the syrinx located this low in the respiratory tract, a bird can still vocalize while anesthetized and with the endotracheal tube placed correctly. Most birds and reptiles in clinical practice are less than 1 kg in body weight. For this reason, nonrebreathing systems are recommended. The smaller the animal, the more important dead

18 space and resistance to air flow become. For short surgical procedures birds can be allowed to spontaneously breathe as long as there is no restriction of movement of the thoracic body wall. Birds and reptiles do not have a diaphragm. Consequently, for longer procedures such as a celiotomy, intermittent positive pressure ventilation (IPPV) either manually or via mechanical ventilators is recommended. After a bird or reptile is fully anesthetized it should be prepared for surgery. The surgical site on these animals cannot be clipped like dogs and cats for obvious reasons. Feathers must be plucked from the surgical site in birds. This process must be done very carefully. The feathers should be pulled out in the direction they are growing to avoid trauma to the skin. The epithelium of birds is only a few cell layers thick and tears very easily. A surgical scrub is performed at the prepared site. Alcohol should never be used. The rapid evaporation of alcohol has a significant cooling effect on the core body temperature of the bird. These animals are already predisposed to hypothermia during surgery so care must be taken not to exacerbate this problem. Surgical site preparation in reptiles is straight forward. The area involved is simply scrubbed in the same fashion as dogs and cats. Once again, alcohol is not used. The reptile s core body temperature must be carefully maintained with supplemental heat. Once the surgical procedure begins monitoring of the patient continues. Constant monitoring is as important, if not more important, than a successful surgical procedure. It is simply not good enough to attach the patient to a pulse oximetry machine and sit back and relax. These animals tend to be very small in size and standard monitoring equipment is not useful. Lung sounds in birds are best auscultated on the dorsum. Heart sounds are best auscultated on the lateral body wall. Bird heartrates are normally so rapid that EKG monitors cannot register a number. Direct monitoring of heartrates with either a stethoscope or a Doppler monitor is required. Reptile heartrates are the complete opposite to those of birds. Their normal heartrates are so slow (10 to 30 beats per minute) that they are often too faint to be heard with a stethoscope. Reptile heartrates must be monitored using a Doppler monitor or by direct visualization. Recovery of the avian and reptilian patient must be in a temperature-controlled environment that closely resembles the natural requirements of the species. Small animal incubators are ideal for this purpose. Most incubators off the ability to provide supplemental oxygen if indicated. These animals should only be extubated when oral and pharyngeal reflexes have returned and the animal is breathing spontaneously. In conclusion, exotic animals are increasingly popular pets. Recent studies have found that 15 million households in this country have a pet bird. Another 5 to 8 million households have a pet reptile. Given the prevalence of these fascinating animals, it is not a question of IF you will see them but rather WHEN you will see them. Hopefully, the information presented here will help you have the confidence and knowledge you need to safely handle, restrain and treat birds and reptiles. References available on request.

19 How to Care for a Paralyzed Dog Alicia Howser, BVM&S General tips for taking care of dogs that range from ambulatory and just slightly wobbly, to the complete inability to feel their hind legs. As veterinary medicine progresses, more people want to provide as much care for their animals as possible. When a dog is not able to walk, it will affect the quality of life, so it is important to do what we can to help them maintain a good quality of life. The following are some important definitions to know for this lecture. Motor function means that the animal has voluntary controlled movement of a limb. Deep pain is the ability to feel a stimulus that is causing pain sensation. Telling the difference between an animal having deep pain versus a withdrawal reflex can change the care and exercises the dog could need. A withdrawal reflex is a reflex arc that triggers the dog to pull its limb back when its toes are pinched. A deep pain response is the animal responding to a pain stimulus, which is different than the withdrawal reflex. Inactivity leads to muscle weakness and atrophy, so what can we do to help dogs maintain their leg muscles when they have difficulty walking? Helping support these animals while they are trying to ambulate is very important. Putting a sling under their abdomen to help support their back end allows them to get their forelimbs moving and gives them the opportunity to move their hind limbs if motor function is returning. If motor function is present, walk the pet slowly enough so that they have time to place their feet as they walk. As their motor function gets stronger, the sling can be used to help them, but they need to be given the opportunity to bear more of their weight, so try to sling walk them at a level where their feet can touch the ground, but not drag. As the dog gets stronger, you provide less support with the sling and let them do more on their own. Sometimes as pets walk with a sling, since they are not strong enough to completely support their back ends they will drag their feet and scrape their knuckles. If dogs are scraping their toes and bleeding, it should be advised that the pets wear booties on their feet when they are walked. It is important not to leave the booties on all of the time, as this can cause moist dermatitis between the digits. Other things that can be done to help support and maintain muscle tone are passive range of motion exercises and standing exercises. Passive range of motion exercises involve moving the limbs through full range of motion to help keep the joints mobile and the muscles limber. It is easiest to perform passive range of motion with the pet lying on its side. With each limb, move it in a motion that imitates how the pet would flex and extend its joints when walking and running. Each limb should be put through range of motion times and this can be done 2-3 times per day. Additionally, place the pet in a standing position and force them to maintain their balance. If they are very weak in their back limbs then support under their abdomen just enough so that they

20 are trying to push into a standing position on their own. If their muscle tone is decent, and they can maintain a standing position, work on the core muscles by making them shift their weight from side to side. Exercise balls and balance boards can be used with dogs to make it more challenging and activate more muscles at a time. If the pet is not ambulatory at all, along with doing passive range of motion and standing exercises, making sure that they are not lying in one position for too long is also important. Helping a dog flip onto its other side helps avoid pressure sores and lack of circulation from staying in one position too long. If the dog is not able to move around much on its own, they must have a nice padded area to sleep on. Also, not being able to move around much means that they cannot groom themselves well or move themselves away from messes they make. Sanitary baths and haircuts can help to keep a dog more comfortable. Keep hair trimmed/shaved around back end to help keep clean, especially if leaking urine and/or feces. Leaking of urine can lead to urine scald, causing severe redness and sensitivity of the skin, so keeping the pet trimmed and clean will help avoid this issue. If skin becomes raw or irritated, something like diaper rash cream can be applied, as long as the pet won t lick it off. Some people will use diapers on the dogs if they are not able to control their bladders. If they do this, dirty diapers can also cause skin irritation so it is necessary that pets not be left sitting in a dirty diaper for extended periods of time. If no motor function and muscle tone in back legs not very good, pet likely not able to urinate on own. Put one hand on either side of the abdomen, just in front of the pelvis, or if the dog is small enough you may be able to use one hand and cup it around the abdomen. A full bladder feels like a water balloon. Sometimes it can be hard to isolate it and squeeze it. Try putting pressure from front to back. It is best to put constant even pressure on the bladder. Some pets do better if you prop them in a standing position, others will relax when you lay them on their sides. If the pet is really fighting you and tensing its abdomen, the dog likely does not need help expressing its bladder. Lack of neurologic control to the bladder or the inability for the bladder to empty may lead the dog to leak urine. If a dog s bladder gets too full, it will leak urine from overflow as opposed to the bladder rupturing. If a dog is leaking urine, it will definitely need its bladder expressed. Likely scenarios when a dog will need its bladder expressed include when they lack motor function and/or deep pain to their hind limbs. As motor function returns, bladder control usually follows. If there is damage to the nerve roots at L3-4, then bladder function may not return. It is important that a dog only has its bladder expressed if necessary. Doing so unnecessarily can have detrimental consequences, including death. If a pet has had neck or back surgery for a ruptured disc, they have physically had some bone removed from some of their vertebrae. It is critical that post-operative care instructions are followed to aid the pet in making a full recovery and healing well. When a dog has surgery,

21 usually either a ventral slot or a hemilaminectomy, since some bone has been removed, the length of time for restricted activity is to allow the body to form scar tissue and essentially restabilize the vertebra. Being too active too soon can cause the pet to bleed or rupture more disc material at their surgery site, which can cause recurrence of clinical signs or regression of neurologic function. Regression of neurologic function in any respect is important to watch for. Worsening of neurologic function can be evidence of myelomalacia. Myelomalacia is essentially necrosis of the spinal cord. It is unpredictable and can happen after any kind of spinal trauma. When a dog loses neurologic function to its hind limbs, this is an important thing to watch for as it can be life threatening. Signs include a soft, flaccid belly, lack of withdrawal reflexes and loss of reflexes that the pet previously had, and panniculus cuts off higher and higher. If myelomalacia ascends too high up the spinal cord, it will affect the neurologic function of the respiratory muscles including the diaphragm, and the dog can suffocate. If there are signs that the dog is having respiratory difficulty, humane euthanasia is recommended. Along with monitoring the dog s neurologic function once it is diminished, lifestyle changes are recommended. Dogs should avoid jumping up and down, including going up and down stairs. They should not play excessively rough. To help them not jump or go up and down stairs, try to add ramps that the dogs can use. Flooring that is not slippery is advised so that dogs can get good footing. Putting rugs down on hard floors may be helpful.

22 Anesthesia in an animal with a compromised thoracic cavity Alicia Howser, BVM&S Although thoracic surgery is not done on a routine basis in general practice, there are many situations in which this may arise. Examples include repairing diaphragmatic hernias, nicking the diaphragm when performing a gastropexy, or even just in an approach to entering the abdomen, and bite wounds or traumatic wounds penetrating the thoracic cavity. It does not matter if the opening is 2 millimeters or a gaping hole, if it is penetrating the thoracic cavity, the pet needs ventilation until the hole can be closed. The thoracic cavity works normally with negative pressure. When the thoracic cavity is opened, the negative pressure is compromised, and the lungs cannot inflate properly, therefore not functioning properly. Without proper lung inflation, appropriate gas exchange will not occur. This can lead to lack of oxygen to the tissues of the body and increased levels of carbon dioxide. Lack of oxygenation and high levels of carbon dioxide can have detrimental consequences. Whenever an animal is under anesthesia and the thoracic cavity is opened, ventilation must be performed. Some animals may try to breath on their own despite their thoracic cavities being compromised, but they will not be able to take adequate breathes. If a ventilator is available, it can be used. It must be set accordingly for the size of the patient. It is important to know how to set the ventilator and test it before being used. If a ventilator is not available, manual ventilation can be adequate, but a person should be designated for that task specifically. A regular breathing rhythm and rate should be maintained, and it is important not to hyperventilate the patient. Once the chest cavity is closed, any excess air and/or fluid needs to be evacuated to re-establish the negative pressure and allow full expansion of the lungs. This can be done via a chest tube or thoracocentesis. Once negative pressure is achieved, then you can start challenging the pet to breath on its own. The thing that stimulates an animal to take a breath is rising levels of carbon dioxide. To allow the carbon dioxide to rise, start ventilating them less frequently. Wait seconds between giving a breath. You cannot just stop ventilating them because inflating the lungs and allowing for gas exchange helps the body recognize the levels of oxygen and carbon dioxide. Once the animal starts breathing on its own, make sure it is taking adequate breaths, breathing off excess carbon dioxide and maintaining good oxygen saturation. The animal should not be disconnected from a breathing circuit until this is established.

23 RESPECTFUL CAT HANDLING - GETTING PURRSPECTIVE: THE CAT, THE CLIENT, THE CLINIC Margie Scherk, DVM, Dip ABVP (Feline Practice) Vancouver, Canada While the number of cats kept as companions in North American homes is increasing, the number of feline visits to clinics has been declining since Based on the AVMA s 2007 pet ownership and demographics survey, there are 13% more cats than dogs, yet cats fail to receive the same degree of veterinary attention. In small-animal practices, dogs represented 59% of office visits, cats only 39%. The 2011 Bayer Brakke study further noted three client-driven factors that limited the number of feline visits. 1. Inadequate understanding of the need for regular preventive health visits other than for vaccination. 2. Resistance to bringing a cat to the clinic because of the distress caused by placing a cat into a carrier and making the trip to the clinic. 3. The cost of veterinary care, in particular the frequency and size of price increases. (The economy is a separate, external factor.) In November 2012, an online survey of 401 veterinary practice owners was conducted across the USA. The Bayer Veterinary Care Usage Study III: Feline Findings noted that 78% of veterinarians believed that better care for cats represented one of the most significant, missed opportunities for the profession. Yet, while 70% of veterinarians were familiar with the earlier Bayer-Brakke studies, and while most veterinarians recognize that cat owners consider a clinic visit to be stressful for themselves and their cats, nearly one-third of practices do not have staff trained on how to make visits less stressful for clients. Additionally, relatively few practices have adopted procedures such as: exam rooms used only for cats (35%); cat-only waiting areas that are physically and visually separated from dogs (18%); and cat- only days and appointment hours (11%) The study found that 46% of veterinary clinics surveyed had recently started taking specific steps to increase visits among current feline patients, attract more cat-owning clients, and make their practices more "cat friendly. Part of the lack of awareness (at best) or reluctance (at worst) for making simple, inexpensive changes in attitude and facility is that many veterinarians and veterinary staff members prefer, or feel more comfortable, working with dogs than cats. Veterinarians also indicated that dogs are easier to diagnose. The goal of this presentation is to look at practical steps to overcome these obstacles to routine veterinary care for cats in order to benefit cats and their human companions with resulting benefit of clinic growth. IMPROVING CLIENT COMPLIANCE The verb to comply means to act in accordance with a wish or command (Oxford), to conform, submit, or adapt (as to a regulation or to another's wishes) as required or requested (Miriam- Webster). For clients to comply with our recommendations, they have to fully understand and be able to perform desired actions. We need to engage them in the importance of these actions.

24 Thus, understanding (education) and on-going caring communication are needed to enhance client compliance. Many clients believe that cats are self-sufficient, have very few needs, and are low maintenance pets. They don t understand that cats live as solitary hunters because they eat small prey; this means that they lack the supportive resources of a society. To avoid showing weakness, they hide signs of illness very well. The first opportunity we have to improve compliance is to teach people to recognize the subtle signs of sickness. Everyone on the veterinary team also has to recognize that any admission of illness by a cat may signal a problem that has been going on for a longer time than one believes. The following clinical signs are things that clients can be taught to look for through newsletters, the clinic website, Facebook and other social media as well as direct client s. Subtle Signs of Sickness ( Clients need to know what to look for and how significant minor changes such as the following can be: 1. Inappropriate Elimination: Regardless of how deliberate it may seem to be, when a cat is avoiding or not using the litter box, they are trying to tell you something. This message may be of physical discomfort or psychological distress. Physical causes include inflammation of the bladder or bowel, arthritis, hyperthyroidism, diabetes, dementia. Psychological distress may be from social disturbance, boredom, the lack of opportunity to act the repertoire of cat behaviours, anxiety due to other animals, children or adults. 2. Changes in Interaction: Changes in how a cat interacts with people, other animals or his/her environment may indicate pain or distress. 3. Changes in Activity: A decrease in energy may be abrupt or gradual. The latter is often attributed to just getting older, however, as there is no medical reason that a healthy individual should slow down due to increasing age, a cause should be sought. Dehydration, pain from anything, including arthritis, hypokalemia ate some of the problems that should be evaluated. The reverse is also true: an increase in energy in a previously normal cat may be an indicator of incipient illness, most notably, hyperthyroidism or hypertension. 4. Changes in Sleeping Habits: This refers both to pattern of sleeping (times of the day and night) as well as postures. A cat with pain or with dementia may either sleep for longer or for shorter periods than previously. With FIV infection, the latter may occur. Night-time yowling suggests a decline in vision or hearing, hypertension, hyperthyroidism, pain or dementia. 5. Changes in Food and Water Consumption: As with sleep, this refers not just to quantity, but also to changes in behaviours associated with these activities (where, how often, amount at each instance, body posture, etc.). 6. Unexplained Weight Loss or Gain: As gratifying as it is to see rapid weight loss in a previously obese patient, even for those on appropriate dietary regimes, it isn t often a dramatic change. Oral pain may result in inappetence. Gradual weight loss may be related to ageing but should be monitored and investigated. Weight gain is most often from excess calories but could also be due to abdominal or thoracic fluid accumulation. Helpful tools include repeated body weight, body condition score and percentage weight change

25 assessments. 7. Changes in Grooming: Excessive grooming may be due to a skin irritation (allergy, fleas, dryness), a neuropathy, or psychogenic (as a way to release endorphins and reduce stress). A decrease in grooming is often associated with pain, often arthritic or oro-dental. Hairballs may be a sign of dermatologic, psychogenic, altered digestive motility or pain. 8. Signs of Stress: Along with aforementioned inappropriate elimination and overgrooming, signs of distress include hiding, chewing on non-food items, a flicking tail, ear placement further back than normal. 9. Changes in Vocalization: Night-time yowling is but one example. Others include a change in tone, pitch, urgency and frequency of vocalizing. 10. Bad Breath: Numerous oral and dental conditions result in halatosis: periodontal disease is extremely common in cats but infected ulcers, tumours, sialoadenitis, abscesses and spread through grooming of odour from anal sacs or an infected body region. Yet, even recognizing that their cat has a problem may not be enough to get the client to bring them in to the veterinarian. Screening to proactively identify disease early and to provide solid medicine can be an even harder sell because people do not like bringing their cats in to the clinic. Many cat owners would rather provide care at home or even skip any form of consultation unless there is something serious going on! This offers us the second significant opportunity to improve the lives of our patients and be of help to our clients. Getting Cats to Your Clinic It is no fun taking a cat to a veterinary clinic (for the owner or the cat)! All veterinary team members should be trained in teaching clients how to make the trip less stressful, starting at home, while in transit, and once they arrive at the clinic. This conversation begins when the client calls to make an appointment or at the first visit with their cat. The American Association of Feline Practitioners (AAFP) has a free downloadable client handout entitled: Getting Your Cat to the Veterinarian (catvets.com/uploads/pdf/2011felinefriendlyclienthandout.pdf). Clicker training can be used to help create positive associations. Catalyst Council ( has created excellent videos that clinic teams and clients can watch to facilitate learning. The frightening experience begins at home. Imagine the scenario from the cat s point of view: The carrier comes out, your caregiver is nervous, she chases you around and tries to force you into the carrier. You resist and may resort to self-defense. There are smells of human sweat, fear, maybe even blood. You may feel so anxious that you soil yourself! Eventually you are in the carrier. Everyone is exhausted. Then you are moved into a car that moves without you moving. You may be a bit nauseated; certainly you are scared. You cry out repeatedly. You may vomit or soil yourself. Then the car stops and you get carried on a noisy and unfamiliar street and into a place with overwhelming smells and sounds! Help! And you are already aroused and anxious.look out! We can reduce the stressors the cat encounters, or, in the case of a new cat, prevent the stressors from occurring by teaching or habituating the cat to associate positive experiences with the carrier, the car, and even the clinic. By leaving the carrier out (or using a Hide Perch Go box/carrier) so that the cat sees it routinely and enters it for treats or other rewards, we dampen

26 the initial tension and fight. Taking the cat on short car rides that are unassociated with the clinic helps recondition the cat s negative associations with the clinic. Finally, taking the kitty to the clinic to be fussed over or only to get a treat will help teach the cat that the clinic isn t necessarily a horrible place. Taking the Household Cat Inventory While there are a lot of cats who never get taken to the vet, there are a lot of cats living with existing clients we never see. We don t even know that they exist! If the cat is well or if the client has had a really bad experience in the past with a cat (or anticipates bad behavior from a cat), they are unlikely to voluntarily bring them in for preventive care. We need to ask whether they have any cats or any other pets when they bring their dog or cat in for whatever reason will help to identify the un-served patients. Improving the Clinic Experience From the client s point of view: It wasn t fun to bring her, she isn t happy about being in the clinic and it isn t fun watching her be manhandled. Once at the clinic, with fear and stress already in place, minimizing or eliminating any further perceptions of threats is extremely important. This requires trying to see the clinic from the point of view of a cat. IMPROVING A CAT S CLINIC EXPERIENCES In many clinics, some veterinarians and other team members do not enjoy working with cats because they may feel anxious about getting hurt. This fear can be reduced by understanding why cats feel that they need to defend themselves, learning to identify the cues, managing the interactions in a positive manner, and making relatively minor changes to what the cat is exposed to. The basis for working cooperatively with cats is being empathic to their nature and behaviors and trying to imagine what their experience is like. Cats are a species with a social structure unlike ours. We need to look at cats differently and adjust our interactions as well as the physical facility to reduce the strangeness and threats that cats experience in the veterinary clinic. Making the environment more feline friendly can be as simple as having visual barriers in the seating/waiting area to prevent cats from seeing dogs. Covering the carriers with a towel will also help so that cats don t see each other. If possible, have separate cat-only waiting area. Reserve at least one examination room only for cats to reduce the smells of predators and to be able to furnish it with cat exam and comfort in mind. Train all staff in respectful cat handling. An excellent and comprehensive resource is the AAFP and International Society of Feline Medicine (ISFM) s Feline Friendly Handling Guidelines, downloadable at: It is well worth reviewing and refining cat examination techniques with the goal of making them less threatening. Because value is perceived worth and because every visit is a valuable opportunity to educate the client, communicate with the client and the cat throughout the entire procedure. Source and provide feline friendly medications, being sure to follow up one or more times with the client to find out how the patient is doing and if the client needs a refresher course on how to administer the medications. Be sure to send home an exam report with home care instructions for the client to

27 refer to. Schedule recheck appointments or the next wellness visit before the client leaves the practice. The AAFP has created the Cat Friendly Practice program through which any interested clinic can raise its cat care IQ. (catfriendlypractice.catvets.com) WHY CATS RESPOND THE WAY THEY DO Relying on the fight or flight response, cats attempt to escape situations they view as dangerous. From the perspective of a cat, humans are, (and what we do is), dangerous. As a result, we see frightened and defensive cats every day. Cats try to avoid physical confrontation through the use of intimidating sounds and posture. This small creature feels more threatened than we do, so we need to refrain from becoming frightened ourselves. Ideally, they would like to flee. When they can t they fight (self-defense) or freeze. Reading and understanding the cues and signals that cats use is important to reducing their fear. It also allows us to respond respectfully. We can learn to avoid using signals that are hostile (e.g., scruffing, making shushing/hissing sounds, looking into their faces). In the wild, the number of feral cats living together depends on the availability of resources: food, water, privacy and safety, latrine availability, and sexual partners. This results in little competition and a social structure that does not require sharing or taking turns. Stress is minimal unless there is a lack of resources. Aggressive communication signals developed in order to keep distance between individuals and prevent contact with outsiders. Physical injury is to be avoided as a cat must be able to hunt and protect herself. If there are enough resources, the natural grouping consists of a colony of related female cats with their young, who they jointly defend and nurse. Males are relegated to the periphery and vie for the prime breeding spot, only one mature tom usually living with the group. FELINE SIGNALING: READING THEIR CUES Tactile sense Touch is very important to cats. They rub against each other (allorubbing), against us, and against inanimate objects. Whether full body rub or a flank, tail, cheek or other body part, this is believed to be an affiliative behavior and is seen between members of the same social group, feline or human. Rubbing is not only tactile, but is also a means of depositing scent. Cats often rub against us; unfortunately, we often misinterpret it as a request to be fed. Allogrooming (mutual grooming) may precede a playful attack, follow a stressful interaction, and appear to be conciliatory or may simply be grooming. Kneading and treading occurs in adults either as a kitten-regressive behavior or as a component of sexual interaction. The neck bite/scruffing is a signal that is used in three contexts: transportation young kittens, sexual, and dominating another cat in a fight. Our use of scruffing fits most closely with the last and probably does not belong in a conciliatory, respectful cooperative setting. (See AAFP and ISFM feline-friendly handling guidelines.)

28 Olfactory cues The role of smell and scent in feline communication is something we human beings are illequipped to appreciate. It has been estimated that the size of the olfactory epithelium in cats can be up to 20 cm 2, whereas people have only 2 to 4 cm 2 of olfactory epithelium. While olfactory signals may be left by several methods, the one that is most problematic for people is urine spraying. This is a potent communication method that we fail to appreciate. Other forms of olfactory messaging are cheek marking an object or individual, scratching to leave scent from glands below the footpads, and midden, (i.e., leaving a deposit of feces uncovered in a strategic place). All of these have several advantages over visual cues. The message exists over time and in the absence of the sender, allowing for remote communication without the potential for conflict that direct interaction risks. This is especially useful in areas with poor visibility and at night. In this way, these signals help cats spread out over space as well as time-share territory. The disadvantage of this form of communication is that the sender cannot change the message once it has been deposited; it cannot be altered or removed and no adjustments can be made in response to the recipient s reaction. So, urine marking in the home is an attempt to signal to the other cats when I was here and to establish a routine so that the cats can keep a distance by time-sharing the same space without needing to come into conflict. Every time we remove the urine, we interfere with this communication! Because of our less developed olfactory sense, we fail to read the cues a patient may be giving us and are unable to fathom the overwhelming olfactory messages from previous patients and substances used in the hospital that the clinic experience must present to cats. Visual cues: Body language (posture, face, tail) Body language and facial expression are extremely effective at maintaining or increasing distance between hostile individuals. This requires an unobstructed view, adequate ambient light, and, unlike olfactory cues, that the two individuals are in the same space together. Body posture gives the big picture of emotional state (see Figure 1), but facial expression (eyes, ears, whiskers, mouth, visibility of teeth) provides the finer details and changes more rapidly. In a clinic setting, for us to appreciate the mental/emotional state of an individual, to avoid provoking them and getting hurt, it is extremely important to watch and interpret facial changes. As a species that generally leads a solitary existence, survival depends on speed, stealth, selfreliance, and outsmarting others. As a consequence, cats may bluff, When they act aggressively, they are generally hiding fear; stoicism hides vulnerability; subtle changes in behavior mask significant illness. Body postures communicate confidence and physical prowess that may not be present. Keeping a threat at a distance may eliminate the need for a physical confrontation. The arched back Halloween cat typifies this façade of confidence. Making oneself smaller, on the other hand, to minimize threat and evade attention is portrayed by a crouch and withdrawal. In these postures, the weight remains on all four paws so that flight or chase remains possible. A cat feeling less fearful does not need to be on his or her feet. However, an extremely fearful threatened cat will roll exposing his or her abdomen with all four feet ready for self-defense. This cat will also be showing all of its weapons (nails and teeth) and be screaming.

29 Cats have extremely mobile ears. (See Figure 2.) When the ears are forward, a cat is listening and is generally relaxed or alert but not emotionally aroused. Turned laterally, flat airplane ears indicate that the cat is more fearful or feels threatened. When ears are back and tight to the head, the cat is feeling very threatened and frightened. This cat will have a partially or fully open mouth and be hissing, spitting, yowling, or screaming. The cat will protect itself if we fail to reduce the perceived threat level. Ears turned back but erect indicates the most reactive and aggressive state. In this case, the mouth will be closed and the cat will be emitting a low growl with or without swallowing. This is the cat to be apprehensive of. Vocalization This form of communication requires that the recipient is present; it has the benefit of being easy to adjust from moment to moment. As with other signals, cats have a well-developed repertoire of sounds to convey a need or wish to increase the distance between individuals. The sounds made for encouraging socialization are a trill/chirrup, purr, puffing, prusten, chatter, miaow, and sexual calling. The cat that is open-mouth screaming is highly aroused but is probably less aggressive than the cat that is close-mouthed growl/wah-wah/mowling. Cats use a combination of these different signals in any situation. We have to learn to look for all of them and interpret them together. FROM A CAT S POINT OF VIEW: Reducing Threats in Your Clinic We need to reduce exposure to predators (dogs, people, other cats) and other perceived threats. Looking over our clinic/hospital environment, what can we do to reduce the stress and threat level of the physical and social environment? What things or events assault the five senses of a cat? How can we make positive changes to these? Table 1 shows a chart that can be completed by the clinic team. Handling (Examination, Hospitalization, Diagnostics, and Treatments) The goal is to handle our patients respectfully and provide an appeasing environment to build positive, long-term relationships. This is achieved by reducing threat and, thus, the cat s need to react defensively. Avoid doing things in a way that use threatening feline body language or tone. The aggressive cat is upright, stiff-legged, large; sit down to examine him. Never stare a frightened cat in the eyes: examine cats from behind and, other than for ophthalmic evaluation, avoid direct facial viewing. Look at the cat s face using a sideways glance with hooded eyelids. A slow blink is a reassuring signal to a cat similar to a human smile. The aggressive cat growls and uses low tones; use light, upper register tones, perhaps chirruping as cats do when they are relaxed with conspecifics. Shushing a cat to try to calm her as we might a child is the equivalent to hissing at her. Short repetitive sounds should be avoided, since these may resemble spitting rhythms. Purrs, chuffing, trills, and chirrups are welcoming sounds. When cats feel secure and safe, even just able to hide their faces in an elbow or a towel, they allow most procedures. Try to keep all four of their paws on the floor and avoid changing their body position as much as possible. A comprehensive examination, blood and urine collection, body temperature and blood pressure evaluation can all be done without changing the cat s

30 position. Examine her in the base of her own carrier if the lid can be removed. Don t hang a cat s forelimbs over the edge of a table for jugular venipuncture. For the frightened individual, additional lack of support under the paws is not reassuring. Reaching into a kennel to pick up a patient blocks the light; to the cat you appear as a looming frightening stranger. Instead approach the opening of a kennel from the side so that some light still enters. Do not block every chance for escape; if the possibility to have some control over her environment and situation exists, she will be much more cooperative. Because cats rely on flight and fight for survival and are not reliant on others, when it comes to restraint, the mantra holds true: Less is more! Cats inherently resist intimate handling and restraint. By restraining them, we take away their sense of control and cause them to react. It is very easy to condition negative emotional responses. Scruffing is strongly discouraged as it is an act of dominance that cats may resent. Cat bags, masks, and gloves all carry the scents of similarly terrified patients plus other sundry smells (anal gland secretion, pus, blood, halitosis, etc.) A towel is all that is needed to wrap a cat in, in order to protect the handler. Remember, a cat would rather flee than attack. Similarly, stretching is an inappropriate and unnecessary way to apply restraint. Meeting Environmental Needs Improves Health Recently, it has been recognized that emotional well-being is highly dependent on meeting the environmental needs of cats. These include those relating to the indoor and outdoor physical environment, as well as a cat s social interactions, human and otherwise. In the AAFP and ISFM Feline Environmental Needs Guidelines, five pillars are described that form the basis of a healthy feline environment (Ellis, 2013). These pillars are: 1. A safe space 2. Multiple and separated resource stations (food, water, toileting areas, scratching areas, play areas, resting and sleeping areas) 3. Opportunity for play and expression of predatory behaviors 4. Positive, consistent and predictable interactions with humans 5. An environment that respects the importance of a cat s sense of smell When these are not met, cats become stressed to varying degrees. Some may express illness (such as inflammatory bowel disease, lower urinary tract inflammation), while others will manifest their distress through inappropriate elimination. OTHER CONSIDERATIONS As cats age, they tolerate less time in the clinic. Siamese cats are especially prone to becoming depressed. Three days is about as long as a cat can stand the indignities and anxieties of hospitalization, even with daily visits from the owner. Consider capping intravenous catheters and send patients home, having them return for outpatient care. Even for in-hospital care, capping catheters off overnight avoids alarms, which can keep patients awake, and allows greater ease of movement. In either case, administer the overnight fluid volume subcutaneously. Because cats see the world in overlapping clouds of smells, we should strive to provide familiar smells and reduce foreign, medicinal smells. Client-worn shirts or toys from home are helpful in cages. Feline facial pheromone can help to reduce stress. Because cats sense of hearing is tuned more finely than ours, a quiet and reassuring environment is desirable. Cats

31 should not be exposed to the sounds of predators, namely barking dogs. Reducing noises should be addressed when using certain induction agents as some enhance hearing (e.g., ketamine). Avoid changing a cat s diet during hospitalization as is likely to result in inappetence and possibly the development of an aversion. If a change in diet is required for therapeutic reasons, try to make that change gradually at home. Taking a thorough history is especially important given cats tendency to hide illness. Listening carefully to clients and their concerns is extremely important. Often clients detect changes that represent real problems. This is probably more common than the client who is blissfully unaware of significant health problems. By asking open-ended questions, we elicit a more detailed history than using only specific questions. For example, asking, Have you noticed any changes in the contents of the litter box? will probably evoke a yes or no answer. Asking something like, What does his stool look like? Initially, followed by: Would you describe it as hard pellets, moist logs, cowpie, or colored water? When did you first notice this? will probably provide more useful answers. Is there anything else? is a very valuable question. Schedule a recheck appointment to evaluate the effect of any medical or nutritional therapy. Reassessing important variables (e.g., body weight, body condition score, previously abnormal laboratory results) and updating the patient history allows us to provide better care for our feline patients. Care of the client is essential to providing complete patient care. It is only through listening to, educating, and working with the client that we are able to offer the very best veterinary care. Examples of Practical Applications 1. If a cat is uncooperative, a comprehensive physical examination can usually be done using a towel as a protective barrier. Facing the cat away from you is less threatening for her. Confining the cat between your legs as you sit on the floor provides adequate persistent firm restraint that is reassuring rather than frightening. 2. Swaddling a cat s forelimbs and torso may help with blood and urine collection, placing the cat in lateral recumbency for cystocentesis and making the medial saphenous vein. This vein is also a superb choice for catheter placement and administration of intravenous medications. If the cat is allowed to have her front end in a sternal position while the back end is in lateral recumbency, she may struggle less. 3. Allow the client to be with the kitty as much as, and whenever, possible. 4. Recognize that a persistently elevated systolic value above 170 or 180 mm Hg probably represents true hypertension rather than the stress response. If in doubt, repeat the value later during the visit. 5. Feliway (Ceva Animal Health), a synthetic analog of a feline facial pheromone, generally has a calming effect on cats. Spray (or wipe) it into kennels and carriers and even on your clothing before handling an anxious cat. Let the substance evaporate for a few minutes before placing the cat into the sprayed space. Feliway diffusers plugged into treatment and hospitalization areas as well as reception and consultation rooms can help patients relax. ( 6. Elevated blood glucose and glucosuria may be a result of persistent stress. A diagnosis of diabetes, therefore, should be confirmed by finding an elevated serum fructosamine.

32 FACILITATING FINANCES The Bayer study showed that clients want costs spread out over time. Fear of large bills is another significant factor preventing owners from bringing their cats to the clinic. Many practices have wellness plans. Additionally, directing clients toward pet health insurance for both preventive and accident/illness coverage before their cats need it is sound medical advice. This could save lives otherwise lost because the owner hesitated to seek care or decided to euthanize the pet because of financial concerns. FACILITATING COMPLIANCE AT HOME Having a library of YouTube links or making your own clinic how-to videos is extremely helpful. YouTube videos made by lay people may have the advantage of being more convincing rather than those by healthcare professionals. Find ones that your staff and you as well as a client think are best. There are many good links. Examples of useful illustrative clips to have on hand include how to: Give your cat a pill (see below) Give subcutaneous fluids: Administer insulin: Measure blood glucose: Use an inhaler for asthma medications: Feeding with a feeding tube: contact me at hypurr@aol.com Change a KittyKollar (video) and Living with an E-tube (handout): Syringe feeding, brushing teeth, etc are also available. Cat caregivers like to show their skills and help others. Similarly, having a selection of web resources that you have vetted and feel comfortable with guides clients to reading materials when they want to learn more about their companion s medical condition. Cornell University has a series of videos on a number of procedures and diseases at They include: Brushing your cat s teeth, Giving your cat a pill or capsule, Giving your cat Liquid Medication, Taking your Cat s Temperature, Trimming your Cat s Nails. Other free videos include: Caring for your Diabetic Cat, Gastrointestinal Diseases in Cats, Cat Owner s Guide to Kidney Disease, Managing Destructive Scratching Behaviour in Cats and A Pet Owner s Guide to Cancer. Everything on the icatcare website has been created by the ISFM and is excellent: They have an extensive library of handouts on medical conditions as well as general cat care, including several videos. Feline Chronic Kidney Disease: Feline Diabetes: and one with humour: Summary: By not seeing cats because we don t know they live with clients or because clients are unwilling to bring them in, we lose the opportunity to: Provide wellness care, Detect disease early when we can prevent or alleviate suffering and save expense.

33 Protect life and enhance welfare. Build trust with our clients, Increase clinic visits. TABLE 1. Chart for Evaluating a Clinic s Perceived Threats to Cats Sense Threat Reduce threat by Smell Hearing Sight Taste Touch RECOMMENDED READING 1. Buffington CAT. Cat Mastery e book from itunes 2. AVMA. US pet ownership and demographics sourcebook. Schaumburg, Ill: AVMA, Volk JO, Felsted KE, Thomas JG, et al. Executive summary of the Bayer veterinary care usage study. J Am Vet Med Assoc 2011;238: Volk JO, Felsted KE, Thomas JG, et al. Executive summary of phase 2 of the Bayer veterinary care usage study. J Am Vet Med Assoc 2011;239(10): The domestic cat: The biology of its behaviour. 2nd ed. Turner DC, Bateson P (eds.). Cambridge, U.K.: Cambridge University Press, Crowell-Davis SL, Curtis TM, Knowles RJ. Social organization in the cat: a modern understanding. J Feline Med Surg 2004:6: Hide Perch Go and Cat Sense: 8. Gourkow N, Fraser D. The effect of housing and handling practices on the welfare, behaviour and selection of domestic cats (Felis sylvestris catus) by adopters in an animal shelter. Anim Welfare 2006;15: Rodan I, Sundahl E, Carney H, et al. AAFP and ISFM feline-friendly handling guidelines. J Feline Med Surg 2011;13: Ellis SL, Rodan I, Carney H, et al. AAFP and ISFM Feline Environmental Needs Guidelines J Feline Med Surg :

34 Figure 1. Interpreting a cat s body posture. Figure 2. Interpreting a cat s ear position and facial expression.

35 FELINE LOWER URINARY TRACT HEALTH METABOLISM AND STRESS Margie Scherk, DVM, Dip ABVP (Feline Practice) Vancouver, Canada Lower urinary tract disorders are common in cats. In previous decades, the focus of study has been on causes and management of crystalluria. As struvite crystalluria was successfully addressed through nutritional changes resulting in urine acidification, the frequency of calcium oxalate crystalluria increased. This encouraged emphasis on urine relative supersaturation (RSS), concentration and a ph neutrality. Nevertheless, cats still present with characteristic lower urinary tract signs (LUTS), namely dysuria, pollakiuria, hematuria, stranguria and periuria. The cause of approximately 65% of non-obstructive lower urinary tract disease is of unknown despite appropriate diagnostic testing. (Possible causes of LUTS are shown in Figure 1. A diagnostic approach to cats with lower urinary tract signs is shown in Figure 2.) These patients are described as having an idiopathic cystitis (IC). It is likely that this syndrome is multifactorial even within the same cat. The course of human interstitial/idiopathic, including interstitial cystitis, is known to be impacted by stress. There is evidence that there are immunological and neuroendocrine components in our feline IC patients as well. Studying feline idiopathic cystitis (FIC) is extremely challenging not only because of its multifactorial nature, but also because clinical signs are self-limiting. In approximately 91% of cats, evidence of discomfort resolves within 7 days without treatment. Subsequent episodes are also acute in nature and occur once or twice a year. As cats get older, the frequency and severity of the flare-up decreases. A small number of cats experience chronic persistent disease lasting weeks to months. Inflammation associated with each incident may result in functional or mechanical obstruction. The first may be caused by urethra swelling, spasm, or reflex dyssynergia, while accumulations of inflammatory debris or the formation of matrix plugs can cause mechanical obstruction. Urachal diverticulae are a possible sequelae to FIC. What causes the inflammation in non-obstructed LUTD? Many studies have attempted to answer this question yet results have been disappointing. Infectious agents, dietary causes (mineral composition, RSS and urine ph), neurogenic, anatomic, traumatic, neoplastic and iatrogenic etiologies are all implicated in some individuals, but the largest category remains idiopathic in origin. Buffington and colleagues have investigated the problem from another angle asking whether a susceptible individual might develop FIC if they are in a provocative environment. Indeed, similar to the human model of IC, he found that affected cats have structurally altered adrenals, more reactive somatosensory spinal tracts and a larger pontine locus coeruleus (LC, the most important source of norepinephrine in the CNS) This suggests that patients with IC have increased sympathetic nervous system (SNS) activity even during periods without clinical signs. He has reviewed published epidemiologic data regarding the role of environment and its physiologic effects on risk for disease, especially in susceptible individuals. External influences include excessive body condition, decreased activity, being restricted to eliminate in a litter box, being strictly indoors, relocation of home, living with other cats and weather changes. Stressors

36 (internal/perceived influences) that affect different individuals to a greater or lesser degree include an impoverished environment, lack of stimulation, noise, restraint, and lack of control over his/her environment (including meals). The stress response invokes changes in immune, neurologic and vascular status, all of which can cooperatively result in inflammation. With sufficiently severe stress, sensory input and inflammatory mediators stimulate the hypothalamicpituitary-adrenal axis (HPAA) and the aforementioned pontine LC norepinephrine system. With chronic stimulation, over time normal control is lost and affected individuals overreact physiologically to threatening or disruptive situations. Buffington and co-workers also identified that cats, as humans, with IC frequently have comorbidities and has called this the Pandora Syndrome. He suggests that the bladder, rather than being the perpetrator of the LUTS, may be a victim of the systemic process associated with the sensitized central stress response system. Comorbid disorders include behavioural, endocrine, dermatological, respiratory, cardiovascular, and gastrointestinal problems. FIC does not necessarily precede the other conditions. In humans, the effects of chronic in utero stress on the health of the offspring are well documented. It may well be that genetic and similar epigenetic events contribute to the susceptibility of an individual making them at risk should they be exposed to provocative events. MANAGEMENT OF CATS WITH FIC Evaluating the efficacy of therapies for FIC is very difficult because of the waxing-waning nature of the disorder. Stress reduction appears to be a cornerstone for managing cats afflicted with FIC. Addressing environmental needs is essential (not optional) for optimum wellbeing of the cat. Environmental needs include those relating not only to the cat s physical surroundings (indoors or outdoors; in the home environment or at the veterinary practice) but also those affecting social interaction, including responses to human contact. Cats need to have multiple and separate locations for each resource (food, water, clean litter, toys, stable scratching surfaces, perches and resting areas). The overview of a therapeutic and management approach to a cat with LUTS is shown in Figure 3. It is essential that cats are able to express their natural behaviours. Cats use olfactory and chemical information to evaluate their surroundings and maximize their sense of security, comfort and feel in control of their surroundings/environment. Depositing pheromones through cheek and paw pad marking as well as urine is key for a cat s sense of control. In some situations, when a cat is marking with urine, it may be possible to get the cat to make a less offensive mark (from a human perspective). Cheek marking wall corners may be encouraged by using Feliway and not washing the cat s natural oils off walls and furniture. Likewise, providing secure, stable scratching surface placed in the location being urine marked, may result in the cat scratching and marking in that manner rather than spraying. The AAFP and ISFM Feline Environmental Needs Guidelines is an excellent resource freely available from: (jfm.sagepub.com/content/15/3/219.full.pdf+html). Pheromone Use Feliway TM is a synthetic analog of a feline facial pheromone that is thought to increase emotional stability. Its use in the reduction of inappropriate urination needs to be studied further. Studies done to date have shown a reduction in urine marking of less than three months duration of over 96%. In cats who had been marking for four months or longer, there was a reduction of marking

37 in 91% of cats after 35 days of environmental treatment. A third study showed that while there was a significant reduction in all households in which Feliway TM was applied, 2/3 of the households still experienced some marking. The product is sprayed directly on places soiled by the cat and also any prominent vertical locations in the environment. A daily application is necessary until the cat is noted to exhibit facial rubbing on the site. If the cat does not exhibit facial rubbing, then daily application to the environment should be continued for one month. Plug-in diffusers provide a constant, slow release of pheromone covering an area of 500 to 700 square feet (50-70 m 2 ), but must not be covered, placed behind a door or under furniture. Diet and Drugs Feeding a diet that produces dilute urine with a neutral ph seems to help cats have fewer recurrences of FIC or any type of lower urinary tract disease. Canned food helps to ensure that the urine is dilute, making it less concentrated (hence, less irritating) and reducing the chance that crystals can form. Having plenty of fresh water available in multiple places in a form the individual cat likes will encourage drinking. Some cats prefer drinking from a recirculating water fountain, others prefer wide bowls. Feeding a diet that has omega-3 fatty acids along with antioxidants may also provide beneficial anti-inflammatory effects. Finally, being consistent both in time of feeding as well as diet being fed is very important in reducing stress. Many drugs have been used to try to reduce the reoccurrence of FIC. Amitriptyline may be helpful in some cats if it is given on an ongoing basis. It is an antidepressant and agent that stabilizes mast cells which may degranulate in some individuals with FIC. Glucosaminoglycans have also been studied and have variable, but generally poor, results. Best results appear to occur with diet, environmental and stress management rather than drug therapy. SUMMARY Lower urinary tract disorders are common in cats. Once appropriate diagnostics have ruled out direct causes, for most cases of non-obstructive LUTD, a more global approach needs to be taken, looking at and addressing the role of the cat s external and internal environments.

38 Figure 1: Possible causes of lower urinary tract signs in cats with or without co-morbid conditions (Pandora Syndrome) (from Chew D, Buffington CAT, FLUTH Symposium 2014) Figure 2: Diagnostic approach to cats with lower urinary tract signs (from Chew D, Buffington CAT, FLUTH Symposium 2014

39 Figure 3: Algorithm showing a therapeutic and management approach to a cat with lower urinary tract disease