Your Pet's Best Friend

Don't use soft rubber dog toys.

This is Louie.  About five days ago, he had a vomiting spell.  We couldn't find anything on physical examination.  His vaccination history is good, and his stool exam was negative.  An X-ray didn't show anything, so we thought he might have a little intestinal infection.  Hey, maybe he ate some garbage.  So, we gave some anti-vomiting medication, sent home some antibiotics.   He didn't vomit again until today.  He also didn't eat anything solid in the last five days, and has lost from 6 pounds down to 5.7.  Whoops.

On today's examination, I can feel a lump in his belly that I couldn't feel before.  The ultrasound gives no more information than the X-ray.  My good old fingers can feel something for sure, though.  So where were you guys five days ago?

I thought it might be an intussussception, but I was wrong.  It's your good old GIFB (gastro-intestinal foreign body, i.e. a non-food item).  The intestine holding it (plus the previous six inches) is really nasty purple-black looking.   That's why we took it out along with the FB.  It feels like a piece of rubber hose, but it isn't.

"Hey, does Louie have a toy elephant at home?...He does?... Have you noticed that the elephant's trunk is missing?...You have?...But you didn't think Louie had it?"

This is why soft rubber dog toys are not a great idea for puppies.  It's also why I'm working late again tonight.  Don't worry about Louie, though.  He doesn't need that intestine.  He'll be fine... if he doesn't do it again.

Dogs swallow needles.

Why do dogs swallow needles?  As Sir Edmund Hillary said about Everest, "...because it's there."  Oddly enough, if they actually get a needle or pin swallowed, more often than not, it just passes on through and comes out in the stool.  Under most (NOT ALL) circumstances, the intestinal tract recoils from those sharp points and the needle just eases on through.   This does not mean you should ignore an occurrence of needle eating.  The needle can certainly lodge in other places, can perforate the gut, and can do a great deal of damage as it travels through.  You should definitely consult your veterinarian if you know your pet has eaten a needle.

Oddly enough, the situation is usually worse if a thread is attached.  In fact, a wad of thread by itself can be a problem.  One end gets caught, the thread is now a "linear foreign body", and the intestine bunches up on it like the waistband of a pair of sweatpants.  The string then saws through the folds, causing multiple holes in the gut, which is VERY bad.  This is called a plicating (folding) foreign body.

That's why seeing this dog who had swallowed a needle had me more worried than usual.  The dog is saying, "Thread?  What thread?  I don't see a thread.  Do you see a thread?"  Like his owner, he's just worried about the needle.

This thread right here.  Now the owner knew he had grabbed up her quilting needle, because A. it wasn't where she left it, and B.  here is the thread she was using, hanging out of the dog's mouth.  Hey, why don't we just pull on it and get the needle out?  Reason #1:  If we break the thread, we've lost our handle that will help us find it.  Remember Theseus and Ariadne in the labyrinth?  (No?  Better google it, then.)    Reason #2: It might be really painful for the patient.

First we took a whole-body X-ray and found that the needle was in the head "somewhere".  That's why we anesthetized our curious friend to look for it.  Fortunately (for me) I could see the eye at the back of the palate (roof of the mouth).  It was also fortunate that I didn't pull on the thread much.  The needle point was directed straight up behind the eye (about an inch deep). Ouch!

We sent him home with a little pain medicine and antibiotics and he'll be fine.

Comfortis + High-dose Ivermectin = Adverse Drug Reaction

I've been thinking about getting started with Comfortis.  We're looking for more information.  I don't think that Comfortis users should panic, but if your dog needed to take extremely high doses of ivermectin (as in being treated for demodectic mange, not as in Heartgard-30), extreme caution is indicated.  Here's a news release:

FDA warns of adverse Comfortis, ivermectin interactions Rockville, Md. — Dogs receiving the drug Comfortis (spinosad) concurrently with high, extra-label doses of ivermectin are having adverse reactions in some cases, the Food and Drug Administration's Center for Veterinary Medicine (CVM) announced today.  The regulatory agency warns that it's received adverse reaction reports that are consistent with ivermectin toxicity. CVM advises veterinarians to not prescribe the two drugs concurrently for canine patients. The safety warning also comes from Elanco Animal Health, which manufactures Comfortis, a monthly oral, chewable tablet used for the prevention and treatment of flea infestations on dogs. The company is addressing the issue, CVM officials say. Visit http://elms.xh1.lilly.com/10788_03_tech_Bulletin.pdf for more information.

Date Published: June 24, 2008

A Crushing Injury

Warning: We have a happy ending, but there are some gross pictures.

Crushing injuries are among my least favorite. They not only do a lot of damage, but it is difficult to determine the extent of the damage when you first examine them. Sometimes tissue looks okay, but has had its circulation irreparably damaged. You work diligently to reconstruct the injury and three or four days later everything turns black and rots off. Since you can’t tell for sure whether something will survive, you salvage as much as you can and hope for the best.

This is Duke the Bloodhound. He’s only six months old and already weighs 62 pounds. I estimate that his adult weight will be close to 100 pounds, or about 25 pounds per paw. Actually, dogs tend to carry more weight on their front legs in motion, so maybe 30 pounds per front paw and 20 pounds per rear paw. That would make it bad to have only one front paw; it would have to carry quite a bit more weight than it is designed to.

Duke ran in front of his owner’s truck in the driveway. His owner slammed on the brakes to keep from running over him, but actually stopped the truck on top of his right front paw. Being between a ton-truck and an asphalt drive is very similar to being between a rock and a hard place. Plus, there was a little skidding in the process.

When Duke got free, he ran under some bushes, filling his mangled paw with dirt. This is what it looked like when I saw it soon afterwards.

This is what it looked like when I began to clean it (and yes, he is anesthetized by now).

This is how much I knew was crushed beyond repair and had to just trim off and chuck into the trash (I mean the biohazard container).

This is what it looked like after the initial reconstruction. All he has left is his little toe and the big metacarpal pad, but it looks pretty slick. I was hoping that big pad would survive. While the foot would be far from normal, if he had that much left, I felt it would be enough weight-bearing surface to give his good leg a rest. We are using a LOT of pain medication now, lots of antibiotics, lots of bandage material.

This is Callie. We don’t know what happened to her front toes, as she was adopted from a shelter. Maybe it was a de-claw gone wrong, but we really don’t know. She gets along fine, except for having to stop every now and then – she’ll sit up on her haunches, give those front paws a little shake and then continue about her business.

This is all she has for front feet, and she’s making it pretty fair (although on light duty, admittedly). Callie’s toe-less feet were the reason I opted to try and save some of Duke’s foot, instead of just amputating his leg.

So here we are with Duke again on day 6, when the dead tissue comes apart. It’s not looking so good. Now comes about 10 days of bandage changes and cleaning and removing dead tissue until we finally get down to nothing but live, healthy tissue.

We performed a second reconstruction, on day 15 after the injury. (sorry, lost the picture) Now we have more bandage changes for the next two weeks, plus a few more days of topical therapy in the hospital.

Here we have the almost finished product. Just a little raw spot in the middle, and it’s getting smaller every day. He walks on this foot, even runs on it some. It only took five weeks in the hospital, a gazillion bandage changes, and a whole lot more money than it would have cost to just amputate that leg. I think it’s going to be worth it, though, to have four feet for the rest of his life (even 3 and ¾ feet).

ProHeart-6 Update - more caveats (and how, brother!)

Here’s an update on ProHeart-6. Fort Dodge held their web seminar to educate veterinarians who want to use the product. In order to buy the stuff, you have to sign in (whether or not you listen), then register at the end by clicking all the boxes that say you agree to their stipulations for use. So, now I can order the product… but, do I want to?

In my previous post, I indicated strong interest because of the problems we are having with our large-breed, outside dogs getting a few heartworms, despite taking regular monthly preventive. That is still some incentive.

I have to balance that against all the conditions that we are required to fulfill before using the drug in one of our patients.

The gist of yesterday's educational program covered how safe they think it is, and what they are doing to prove it. Here’s what they’ve been doing so far:

First, there’s the fact that the product has been used continuously since 2000 in Italy, Australia, and Japan and nobody over there believes they are having any problems with it.

Second, they have done toxicity studies with rats and mice (and some dogs) giving hundreds of times the recommended dose, and all those experimental subjects did just fine.

Third, all the ProHeart-6 (and the same product with a different name used overseas) are made in one factory, right here in the good old U.S. of A. The last time that they changed a raw-material supplier was 2002, so we don’t have to worry about any of that contaminated Chinese stuff in our ProHeart-6.

Fourth, they have tested it in combination with many other types of drugs, and there are no problem interactions.

The next phase of proving how safe this stuff is will be their "pro-active Risk Minimization and Prevention" plan, the RiskMAP that they have agreed upon with the FDA-CVM. Every veterinarian who uses the product agrees to report any adverse reactions associated with it. Fort Dodge will collect these and report on them every month, instead of every year (the usual procedure).

Now comes the tricky part: we aren’t going to use it in any animal who has, or has had, or might have any condition that might cause or could be conceivably confused with a reaction to ProHeart-6. If the dog is not 100% healthy and in the prime of life, we don’t give it to him. ALSO, we are going to document that the dog is 100% healthy and in the prime of life. We are going to do this by taking a good medical history (already doing that), doing a complete physical exam (already doing that), and testing to be sure he is heartworm-free (already doing that, too).

If he’s over seven years old, he doesn’t qualify. He’s getting old enough that he might get some age-related problem (Tough break, old-timer.). If he’s younger than six months, he doesn’t qualify (presumably, because he might have some congenital condition that could be confused with a ProHeart-6 adverse reaction. In the web seminar Q&A, the answer to this one was "that’s what’s on the label"… ho-o-kay…). If he’s underweight or has lost weight, he doesn’t qualify (might be sick, get confused with an adverse reaction).

You can’t give the ProHeart-6 injection within 30 days (before or after) a vaccination. That means you will have to schedule a different appointment, at least a month away from your normal yearly check-up.

Oh, and to help prove that you are one of the favored few who are 100% healthy and in the prime of life, a complete blood count and biochemistry profile are required before starting. Whoops, there’s a bit of an extra expense. We often do yearly bloodwork in our senior patients, but (by definition) we aren’t talking about senior patients here.

So, if you’d like to use ProHeart-6, all you have to do is schedule an extra appointment, get some extra labwork, prove that your dog is 100% healthy and in the prime of life, read your handout, and sign the release form stating that you understand it all (including risks of adverse reactions). You can visit their new website for the official line, but I think this means that we are paying for the privilege of doing "beta testing" for Fort Dodge Animal Health.

Do I think it's safe? Probably.

Do I think it will work?  I hope so.

Will I be using it? Maybe.

Chronic Ear Problems and Vestibular Disease

I recently had an email from a reader who is fostering a dog with some pretty severe ear problems.  The dog has had head-tilt and balance problems, as well as an obvious external ear canal infection.  The situation isn't straightening out very fast, so she was looking for more information,  She knows that her veterinarian gets annoyed when clients bring in their internet search information, but she is doing it anyway. 

The problem with an internet search is that many times one finds sites posted by people with no real expertise, or an axe to grind.  This does confuse the issue.  Clients come in with printouts that are not only incorrect, but obviously (to me) illogical and self-contradictory.  It just makes things harder for all of us.

I really like Veterinary Partner. Here's the web address: http://www.veterinarypartner.com/Content.plx
The test of "truth" is whether the information is useful.  Does it agree with other authoritative sources?  Does it WORK?

As always, I feel that the veterinarian who is examining the patient is the doctor who is in the best position to make an accurate evaluation recommendation.  However, here are some general thoughts on the problem, and a reference to a good discussion.

What is vestibular disease in the first place?  I'm not going to reinvent the wheel, here.  Read this article for background: 
http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=564

So, the middle ear (the tympanic bulla, a bony "bubble" on the bottom of the skull) can become infected from the outer ear canal (from the eardrum out) or (less commonly) from a blood-borne infection.  Infection in the inner ear (semicircular canals and cochlea) can come from a blood-borne agent (even a virus), or from an infected middle ear. 

The inner ear and the vestibular nuclei in the brain itself are where the balance and head-tilt problems come from.  Did it start there, or come from an ear infection?  If the dog had a nasty ear infection, that certainly has to be our top suspect as the originating cause.

If the ear was never cleaned out, then you don't know whether you have an eardrum or not. At least 60% of long-term ear infections result in a damaged eardrum. Even if the eardrum appears intact, there can still be problems in the middle or inner ear. Sometimes the eardrum heals over, trapping crud in the middle ear. Thorough cleansing of the ear canal is needed to evaluate the problem.  Then you may still need X-rays, or even MRI or C-T.  Certainly thorough cleaning (possibly requiring anesthesia) and a good scope are necessary to visualize the eardrum (or lack of one).  Before I had a video otoscope (mine is a  MedRx), I guarantee you that I was missing things and not doing an adequate job on some of these.

Sometimes we start out right away with an antibiotic which has a broad spectrum of activity and good penetration into the area.  Culturing the mess before starting antibiotics is not always helpful with ears.  Many dermatologists do not do so, but some do.  Certainly with persistent or recurring infections, one would consider a culture before starting the next round of treatment.

As noted in a previous post, cleaning the debris out of the ear (and keeping it cleaned out) is critical to success, as the biofilm protects and enhances the survival of the germs in the ear canal.  As the article suggests, when cleansing solutions get into the middle ear ear, they can affect the inner ear and cause head-tilt and balance problems (usually temporary).  Still, leaving these areas full of pus is worse than cleansing them with warm water.

Many dogs with bad ear infections have a lot of swelling in the ear canal, and this may require some treatment with cortisone (by injection or orally with pills) before you can really clean and visualize the canal. If you are going to have to anesthetize the animal to clean this painful area, you would want to do the cortisone treatment first (for several days).  If the canal is so swollen that you can't get your scope in, you're not going to see much, even with anesthesia.

If your regular doctor is not "into" ear infections, you probably do want to find someone who is.  They can be frustrating, even for the specialists.

When I grow up...

When I was young, my beloved Aunt Jo gave us The Tall Book of Make-Believe.  It is a perfectly wonderful book of stories and poems, illustrated by Garth Williams.  We wore it out, literally reading it to pieces.

When my children were young, Aung Jo sent them a Tall Book, as well.  Here is one of my favorite poems.  Unlike most of my discourses, it is short and sweet.

" When I Grow Up", by Marchette Chute.

When I grow up, I'll carry a stick and be very dignified, I'll have a watch that will really tick, My house will be tall and made of brick, And no one will guess that it's just a trick, And I'm really myself inside.

I recently turned fifty-five.  I have the stick, but rarely carry it.  I have the watch, and carry it every day (can't stand a wrist-watch).  My house is pretty tall, but no bricks.   I don't know whether the trick is working, because I'm not always very dignified.  Somebody might guess that I'm really myself inside.  Maybe I'll be more dignified when I grow up.

ProHeart-6 Returns, with caveats

You may recall that I posted previously on my concerns about our heartworm preventive medicines becoming less than 100% effective.  There seems to be no difference in efficacy between the different medications, nor does it appear to be dose-related (i.e. giving a 100-pound dose to a 51 pound dog doesn't guarantee effectiveness).  I even tried dosing my own dog twice monthly, using different preventive medicines (she got heartworms anyway -- not bad, but she has them).

So what if they were taking preventive medicine constantly?  That's what we used to do with daily preventive medicine, but we had trouble getting all the dogs medicated every day, year round.  We had compliance problems from both the dog and the owner. 

We also used to have continuous daily heartworm preventive medication that was pretty much trouble-free.  ProHeart-6 was given by injection once every six months.  It was a timed-release medication -- basically, you injected a blob of medicine under the skin and it slowly leached into the bloodstream for the next six months.  I didn't have a lot of clients on the product, as it didn't control the intestinal worms like Heartgard-30 or Interceptor, and it didn't control fleas like Revolution.  Also, we had occasional problems with people coming in a month or two late for the next injection (not good).  We had no medical problems with the product, though.

That's why I was flabbergasted when (with no warning from the manufacturer, Fort Dodge Animal Health) the product was pulled from the market.  It was all over CNN after I went to bed, and I didn't look at Veterinary Information Network until after clients began calling on the Saturday morning in September 2004.  The FDA mandated its removal, citing many adverse reactions, including patient death (which I admit is a bad thing).

The funny thing (funny-strange, not funny-haha) was that the product continued to be used in other countries around the world with no apparent problems.  No explanation there, just the FDA "looking out for us" ( I guess Fort Dodge didn't slip them as much cash as Eli Lilly, whose psychotropic drugs list everything they are prescribed for as potential side effects, including suicide.  I don't feel like the FDA is looking out for us so well, there.).

Well, ProHeart-6 is coming back, but I can't buy it until I complete my one-hour web seminar this week.  It will only be available through a "restricted distribution program", whatever that means.  Not only will we not be using it in sick or debilitated animals, we also won't be using it in animals that are underweight, or who have history of weight loss (this being America, there won't be many of those).  AND we can't give it within one month of vaccinations. What that says to me is that they don't want to get blamed for any vaccine reactions.  Fort Dodge doesn't want to take any lumps for somebody else's lumps.  I can certainly understand that, since it took them four years to get the stuff back on the market.  On the other hand, I know that my clients won't exactly be happy about having to schedule extra visits.

On the other hand (is that three hands?), if ProHeart-6's daily continuous release of medication makes it 100% effective in those big outside dogs, they will be picking up more market share with my big, outside dog patients.  I'd sure like to be able to give people back the confidence they used to have in their heartworm preventive.