We are proud to continue to serve you with veterinary education in print, online, and in person in 2021. As you read through our family of publications this month and this year, you might notice small shifts in coverage. One of our major initiatives is to make sure 

 ® provide their respective audiences with the news, clinical insight, and business information the entire veterinary team needs to stay up-to-date, practice your best medicine, and manage your business successfully. 

To that end, dvm360 ® will continue to serve as our primary news publication, covering the latest industry information, issues affecting the profession, research, and advances in veterinary medicine. We’ll also be hearing more of the veterinary student voice this year, with both commentary and clinical content from the youngest members of the profession. And we’re looking to include more of your voice in the magazine this year, so if you want to share your insight about a clinical topic or offer your thoughts about any of the issues facing our profession, let us know. 

 which is undergoing the biggest content shift of our publications, is now geared toward practice owners and managers, with financial, human resources, and other business-related content aimed at providing the tools you need to own and manage a successful veterinary practice. 

 will continue to include news, clinical, and career focused content that veterinary technicians, assistants, and other team members need to help them be more successful at work. And because they affect all areas of practice and all veterinary professionals, each of our publications will cover the all-important topics of wellbeing, leadership, and technology and innovation.

Our conferences have evolved throughout 2020 to match the landscape of our profession and our world, and that will continue in 2021. We are offering 2 virtual Fetch dvm360® conferences early in the year (February 25-27 and May 13-15) followed by several live shows starting in June in Indianapolis, Baltimore, Kansas City, Atlantic City, and San Diego. There truly will be something for everyone in either the virtual or live space.

I encourage you all to participate in the live webinars we host throughout the year. They are free to attend and cover such important topics as technology, clinical mysteries, parenting while practicing, diversity, and much more! You can also take advantage of our newly updated Continuing Education Center (connect.dvm360. com/cecenter), which offers a wide variety of RACE-approved clinical and business-related sessions for the whole team. We’ve even got you covered with The Vet Blast Podcast and live chats on Instagram (@dvm360mag).

We have truly put the “multi” in our medical multimedia company this year. Be sure to follow us on all of our social media platforms (Facebook, Instagram, LinkedIn, Twitter, and YouTube) and subscribe to our newsletters so you stay constantly in the know. Thank you for your continued support as we navigate 2021 together

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On behalf of the dvm360® family, we want to wish you and yours a happy, healthy, and prosperous New Year.

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"I don’t know what’s changed, but my dog growls a lot now.” “Bella is normally so loving, but she just bit my husband when he tried to pet her.” “My dog isn’t acting like himself. I’m worried he’s going to hurt me or someone else.” Although it can be tempting to assume behavioral or training problems are at the root of these issues, such snap judgments (pun intended) may be missing the real causes—and there- fore the real solutions, according to Christopher Pachel, DVM, DACVB, CABC, of Animal Behavior Clinic in Portland, Oregon.

During a recent Fetch dvm360® virtual conference session, Pachel said that, clinically, there’s often more to these patients than meets the eye or shows up on a routine physical exam. “Not every case of aggression has an underlying medical cause,” he said. “And just because we identify a medical cause doesn’t automatically mean that the behavior and medical cause are related.” However, he added, the veterinary community has an opportunity—if not an obligation—to seek to understand the intersection between the clinical issues common in everyday practice and primary behavioral concerns of clients.

Where there is pain, discomfort, distress, or irritability, there may be aggression

Because it would be impossible for Pachel to cover every medical issue that could result in aggression, he focused on what he sees more than anything else. “Starting out really, really broadly, I tend to first think about anything that could be causing any degree of pain, discomfort, irritability, or distress,” he said. In a dog with aggressive tendencies in certain contexts, these clinical triggers can lower the threshold at which the animal reacts, or they may cause a dog with no history of aggression to have a fundamental behavioral change.

Pachel placed these medical causes into 4 main categories, or systems— musculoskeletal, neurological, hormonal, and gastrointestinal (GI)— and discussed the various conditions and common signs associated with each.

Pachel sees these musculoskeletal issues most commonly in practice: 

Osteoarthritis: Pachel admitted he’s biased against young pups when it comes to this diagnosis because he tends to associate it with old age. This is a mistake, he said, because that 2-year-old dog may have had previous trauma (eg, cruciate ligament rupture) at 18 months of age that predisposed the pet to the condition.

Pinched nerve or neurogenic pain: You could see an overlap between musculoskeletal and neurogenic pain, said Pachel.

He also cited tumors or cancers affecting the musculoskeletal system.

Pachel is especially suspicious of musculoskeletal causes when he sees an acute behavior change and some degree of localizable signs (such as an overt limp, lameness, or obvious hesitance to move). However, other cases might be much more subtle or general, such as a dog with decreased muscle tone in its hind end. These must be watched carefully. “Are they weight shifting to be able to remove discomfort from that area?” he said. “They may not be limping or lame. Weight shifting and muscle asymmetry may be what we need to look for.”

Other common signs of musculoskeletal issues include reluctance to jump, difficulty getting into the car or aggression toward the person helping them into the car, increased likeliness of aggression after exercise or first thing in the morning (before they’ve had a chance to loosen up), decreased play or activity, and an inability to settle.

Regarding the last sign, Pachel referred to a patient named Abby whose owner had described the dog as restless and sometimes aggressive. Upon observation, Pachel noticed some subtle mobility issues. For example, Abby never settled enough to lie down during the appointment, and when she got herself into a corner, she looked like a bus trying to turn around in a narrow street. Abby eventually was diagnosed with an immune-mediated connective tissue disease that was not particularly well differentiated, Pachel said. Once the patient was treated appropriately, her behavior and mobility improved.

When it comes to neurological causes (though some overlap with the musculoskeletal system) of aggression, Pachel most often sees the following:

Regarding shunts, Pachel said, “The vast majority of dogs that are affected by a portosystemic shunt, unless we’re seeing them in that postprandial window or they’re more severely affected and we’re getting that level [of] obtunded mentation, we’re not likely to go, ‘Hmm. I think this is a shunt animal.’ We have to look at the history to be able to see that.”

Regarding seizure disorders, Pachel said that, similar to metabolic issues, the owner may not know about it unless the dog is actively seizing, or the owner has witnessed a tonic- clonic episode with loss of bowel or bladder function. “But it needs to be on that index of suspicion,” he added.

While the signs of neurological disorders vary widely, Pachel listed weakness, pain, postural change, and an altered mental state as common.

The hormone-related issues Pachel most regularly encounters include the following:

Intact vs altered: Aggression can be tied to the reproductive cycle in females, and competitive aggression among intact males can also be seen, Pachel said. “Or we may see testosterone exacerbating other aggression types due to increased emotional arousal,” he added. “I’m not saying aggression is automatically caused by testosterone or fluctuations in estrogen or that all animals should be spayed or neutered, but it’s a worthy thing to explore for an individual animal to determine whether it’s a factor.”

Steroid and cortisol problems (eg, Cushing disease, Addison disease) may occur.

Thyroid dysfunction (hypo vs hyper): “For many of our patients, it’s worth doing a screening test, not only because it may be a relevant medical issue but also because some of the medicines that we reach for [clomipramine (Clomicalm; Elanco), in particular] do have a documented suppressive effect on thyroid levels,” Pachel said. “So, if I’m putting
a dog on long-term antidepressant therapy, I want (but don’t necessarily require) a baseline thyroid reading—ideally a thyroid profile—prior to initiation of therapy.”

Hypothalamic-pituitary-adrenal (HPA) axis dysregulation: Pachel described this as a “catch-all” category that encompasses anything that interferes with the animal’s ability to navigate physical, emotional, or environmental stress.

Sometimes, reaching a hormone- based diagnosis requires patience. Pachel said that, on many occasions, he has suspected a patient of having an endocrine-related concern during the initial visit without being able to obtain definitive evidence during the visit. Many patients required follow-up appointments to confirm a diagnosis. He said, “It’s not always as clear-cut as, ‘Are they hypothyroid?’ It may be a more subtle shift in the early stages for some animals.... We may see indications of behavior changes before we see the classic or pathognomonic clinical exam findings.”

For Pachel, this means that if a patient is a bit hungrier than usual or has put on a few pounds, endocrine problems should not be ruled out without the support of diagnostic testing. “I also want to recognize that not every owner will approve every single test, so we don’t always have the benefit of knowing the results of all these tests from the get-go,” he added. “However, we can still include it in our discussion and have it on our differential list. We can plant the seed of possibility with the owner and follow up, even if they don’t have the interest or resources to do the testing at the beginning.”

In addition to a shift in appetite and weight gain, Pachel cited weight loss, change in overall energy, agitation or anxiety, and changes in skin, hair, and coat as common signs in this category.

The GI system is a tricky category, Pachel said, because these many issues can cause pain and discomfort:

Malabsorption, maldigestion, malnutrition

Pancreatitis, food hypersensitivity, irritable bowel syndrome

Intestinal parasites, bacterial overgrowth

Esophageal reflux, gastric ulcers • Diarrhea, constipation

If the onset of aggression occurs after a dietary indiscretion or a change in food, GI issues could be the culprit. Other common signs include stool changes (quality, odor, texture, presence of blood), pica, picky or ravenous appetite, regurgitation, vomiting, gassiness (including burping), and lip licking. Excessive licking of surfaces (eg, carpeting, furniture, walls) should also raise suspicion, Pachel said. One study ran extensive diagnostics on 19 dogs with excessive licking behavior to examine whether it could be a sign of an underlying GI issue rather than a primary behavioral concern.

 The researchers found GI abnormalities in 14 of the 19 participants and, when treated, the vast majority of these dogs experienced either clinical improvement or complete resolution of the licking behavior.

Even with all these potential medical diagnoses in mind, Pachel still looks at behavioral causes first, and often finds that the client needs his attention before the dog does. When getting the history, look for possible knowledge deficits you can fill. Perhaps the dog has received insufficient training or the wrong training. Maybe the behavior is a normal for the dog’s age. The client may simply need more realistic expectations regarding what is normal.

Animal behavior, regardless of the underlying cause, is complicated. So, if you’re ever uncertain about the next steps you should take with a patient, don’t hesitate to reach out to your local boarded behaviorist. And if you don’t have anyone local, Pachel says you can contact him at 

Sara Mouton Dowdy is a free- lance writer and editor in Kansas City, Missouri.

Bécuwe-Bonnet V, Bélanger MC, Frank D, Parent J, Hélie P. Gastrointestinal disorders in dogs with excessive licking of surfaces. J Vet Behav. 2012;7(4):194-204. doi:10.1016/j.jveb.2011.07.003

Understanding the intersection between common clinical issues and primary behavioral concerns in dogs.

Snap judgments: Aggression problem or medical condition?

With the increasing research in cancer immunology and genetics, veterinary oncology is changing rapidly. At the Fetch dvm360

 virtual conference, Sue Ettinger, DVM, DACVIM (Oncology)—known as Dr Sue Cancer Vet—presented results from recent clinical trials and discussed newly approved medications and molecular tests used in veterinary cancer. Among the topics Ettinger discussed are novel treatments for mast cell tumors (MCTs), lymphoma, and osteosarcoma, as well as a novel diagnostic test for urothelial carcinoma, including transitional cell carcinoma and prostatic carcinoma.

Tigilanol tiglate (Stelfonta; Virbac) is an intratumoral therapy that received FDA approval in November 2020 for the treatment of nonmetastatic cutaneous MCTs in dogs. Tigilanol tiglate is a protein kinase C activator derived from the blushwood plant in the Australian rain forest that stimulates rapid tumor destruction within 7 days. It can be used for all grades of nonmetastatic cutaneous MCTs, as well as subcutaneous MCTs at or distal to the elbow or hock.

The dose of tigilanol tiglate was optimized based on a multi-institutional, open-label study.

 Dosing is based on tumor volume (tumor volume = ½ [length (cm) × width (cm) × depth (cm)]) as measured on the day of administration, at a dose of 50% volume of drug per volume of tumor. The maximum treatable tumor volume is 10 cm

, with a minimum and maximum dose of 0.1 and 5 mg, respectively (the maximum dose approved in the European Union is 4 mg).

The treatment protocol includes concomitant medications (

). Prednisone is administered on a tapering course beginning 2 days prior to tigilanol tiglate injection, and is continued on a tapering course for 10 days. Beginning on the day of intratumoral tigilanol tiglate injection, a histamine-1 blocker (diphenhydramine) and a histamine-2 blocker (famotidine) are administered and continued for 7 days. The intratumoral injection does result in local swelling and tissue reaction, and the resulting tumor necrosis results in an open wound. Ettinger said that, unlike standard wounds, the tigilanol tiglate injection wound is generally not covered or protected, and pets are permitted to lick the wound site. This disparity from typical wound management requires some significant education on the use of this treatment. In most patients studied, the wound was fully healed by 4 to 6 weeks, and by 12 weeks 98% of patients were fully healed.

Outcomes were evaluated in a multi-institutional, double-blinded, crossover study.

A total of 123 dogs were enrolled. Of the treated dogs, 75% had a complete response (CR) 28 days after the single-dose treatment, and 5% had a partial response, for a total response rate of 80%. By comparison, the control group had a 5% CR rate due to prednisone alone, which was statistically significantly (

 < .001). The 20% of treated dogs that did not have a CR to the first injection were able to receive a second injection, after which the CR rate increased to 87%. At 12 months, 88% of dogs remained disease free. Adverse effects (AEs) were generally mild (grade 1 or 2). The majority (61%) were related to the mechanism of action of the treatment and included a wound, pain, and lameness. Additional AEs that occurred commonly included vomiting, diarrhea, and inappetence.

Ettinger also updated attendees on new treatment options for lymphoma. When reflecting on why owners decline treatment for lymphoma, she noted that associated cost and AEs of therapy often play a significant role. Often, multiagent protocols require frequent veterinary visits. One agent that shows promise is rabacfosadine (Tanovea-CA1; VetDC). Rabacfosadine is conditionally approved by the FDA to treat any type of lymphoma (B-cell, T-cell, cutaneous, newly diagnosed, or relapsing cases). This agent can be used alone or in combination with doxorubicin, and requires only 5 to 6 treatments depending on the protocol used.

 Although rabacfosadine is more expensive than some conventional chemotherapy drugs, the overall costs tend to be lower because of the decreased number of visits.

When used alone, rabacfosadine is administered intravenously over 30 minutes every 21 days for 5 treatments. When administered in combination with doxorubicin, rabacfosadine is alternated with doxorubicin every 3 weeks, for a total of 3 treatments with each agent.

 While conditionally approved, rabacfosadine must be used only as labeled; however, antiemetic agents, antidiarrheal agents, and corticosteroids can be given concurrently. Initial studies enrolled treatment-naïve patients as well as those that had failed prior therapy. Despite this, the overall response rate for rabacfosadine was 77%, with 45% of patients achieving CR.

 When combined with doxorubicin, the overall response rate was 84% (68% CR, 16% partial response).

Rabacfosadine was generally well tolerated, with AEs typical of most anticancer therapies, including hyporexia, anorexia, diarrhea, vomiting, and weight loss.

 To minimize these AEs, Ettinger prescribes maropitant (Cerenia; Zoetis) and capromorelin (Entyce; Elanco) for a full week after each dose. Neutropenia may occur but is typically mild to moderate. Most AEs were mild to moderate (grade 1 or 2). AEs specific to rabacfosadine include otitis, dermatologic reactions (primarily affecting the pinnae and ventral abdomen), and pulmonary fibrosis.

 The pulmonary effects occur in 4% of cases and are idiosyncratic. Where they occur, they tend to be delayed, and appear about 5 months after treatment. For this reason, baseline thoracic radiographs are recommended prior to the first dose, and every 2 to 3 months thereafter. Due to the potential respiratory complications, rabacfosadine is contraindicated in West Highland white terriers.

Ettinger provided answers to some frequently asked questions regarding rabacfosadine. The efficacy and safety are optimized for the frequency and rate of administration. As such, it should not be given more frequently than every 21 days, and should not be given at a faster or slower rate than 30 minutes. Vials are single-use and any remaining drug must be disposed of after administration. Rabacfosadine does not cross the blood-brain barrier. It is not a substrate for the multidrug resistance (MDR1) mutation, and standard dosing can be administered to patients with the MDR1 mutation. Another common question, Ettinger said, is whether rabacfosadine can be repeated after the maximum of 5 doses. She confirmed that cycles cannot be repeated in succession; however, once relapse occurs, then the cycle can be repeated.

FDA approval of rabacfosadine is anticipated following completion of an additional, ongoing multi-institutional study of 100 dogs with B-cell and T-cell lymphoma, provided results confirm efficacy and safety.

Based on outcome data, Ettinger said she still prefers the CHOP (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone) protocol as a first-line treatment for B-cell lymphoma; however, rabacfosadine alone or in combination with doxorubicin is her second-line protocol. For T-cell lymphoma, she said there is no consensus regarding protocols, other than that T-cell lymphoma cases have a poorer prognosis. When weighing whether prednisone should be administered concomitant with therapy, Ettinger referred to 2 recent studies in which outcomes were not significantly different when prednisone was administered concurrent to a multiagent protocol. Although it is still commonly prescribed in lymphoma patients, these studies provide comfort in those cases where prednisone is contraindicated (eg, diabetes, unregulated hyperadrenocorticism) or where corticosteroid side effects are intolerable. 

The latest news in urothelial cancer (including transitional cell carcinoma of the bladder [

], urethra, and prostate) is not a treatment but rather a diagnostic test. A novel molecular test, the CADET BRAF test (Antech Diagnostics) detects urothelial carcinoma DNA in urine and avoids the need for invasive testing, which may lead to earlier diagnosis.

 Historically, urothelial carcinoma is often quite advanced at the time of diagnosis, because cases may be misdiagnosed as having recurrent urinary tract infections prior to performing imaging studies or surgical biopsy to achieve the diagnosis of urothelial cancer. Ettinger said 15% of cases have local lymph node metastasis at time of diagnosis, and 20% have distant metastasis. The availability of the BRAF test as a urine biomarker may lead to earlier diagnosis, because noninvasive testing may be more palatable to owners earlier in the course of disease, compared with previous tests that are often delayed because of the desire to avoid invasive testing.

Using a digital droplet polymerase chain reaction assay, the test screens for cells containing a mutation in the 

 gene, which indicates a predisposition for urothelial carcinoma.

 The BRAF test is performed exclusively by Antech, and requires 40 ml of urine (although the test may be performed on smaller volumes if necessary in cases where urine collection is problematic). A voided urine sample must be used, because that allows exfoliation of cells in all areas of the urinary tract, including prostatic or urethral tumors. Urine samples must be placed into a designated container with preservative within 15 minutes of collection to maintain DNA viability; however, multiple voidings can be combined in the same container over 2 to 7 days. Once in the preservative, samples are stable for weeks at both room temperature and refrigerated, and need only be protected from light. The BRAF test screens for cells containing the 

 mutation, and in cases that are negative for the mutation, the BRAF-PLUS test is performed as a secondary screen using a proprietary algorithm to detect a second cell signature present. Results are typically available within 2 to 3 days.

The BRAF test has a sensitivity of 85%, and with the BRAF-PLUS has a sensitivity greater than 95%.

 Specificity is greater than 99.5%, meaning that false positives essentially do not occur.

This test has been validated in more than 7000 dogs, and the mutation was not detected in healthy dogs, dogs with other types of cancer, or dogs with other noncancerous urinary disease, including polyps, inflammation, infection, or chronic cystitis.

Once a positive test result is detected, imaging studies are still required to determine the specific location of the carcinoma (bladder, urethra, prostate), although Ettinger said BRAF tests may be positive weeks before a mass is visible on ultrasound evaluation. Histologic samples are still required for tumor grading. However, having such a simple and noninvasive test is more palatable to both owners and veterinarians, and may promote earlier diagnosis.

Ettinger also finds the BRAF test useful for monitoring treatment response. Test results are reported not only as positive or negative, but with a fractional abundance (FA) score. If the FA score is increasing, then the tumor cells do not appear to be responding to treatment, and another protocol can be attempted. A decreasing FA score is an objective indication of treatment response.

For canine osteosarcoma, a novel recombinant 

 vaccine initially showed great promise when data indicated a median disease-free interval of 615 days and median survival of 956 days (double that of historical controls) in treated patients.

 However, this vaccine was discontinued in January 2020 after conditional licensure was granted, when several patients developed complications from 

In its stead, another immunotherapy protocol is under investigation and showing promise. The ELIAS cancer immunotherapy (ECI) is a personalized cancer vaccine derived from a patient’s tumor cells.

 The vaccine is administered intradermally in a series of 3. After vaccination, leukapheresis is performed to harvest mononuclear cells and plasma, so that the antigen-specific T cells that are primed by the vaccine are reinfused, followed by interleukin-2 injections that further modulate the immune system and stimulate T-cell multiplication in vivo. The entire treatment protocol is completed within 8 weeks, unlike conventional chemotherapy, which continues for many months. In a recent published study of 14 dogs that underwent ECI the median survival time was 415 days and 5 dogs survived longer than 730 days.

 This is very exciting as these dogs had amputation and immunotherapy but no chemotherapy

Rebecca A. Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor at Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins, and is board certified in neurology by the American College of Veterinary Internal Medicine. She is active in clinical and didactic training of veterinary students and residents, and has developed a comparative neuro-oncology research program at Colorado State University.

Miller J, Campbell J, Blum A, et al. Dose characterization of the investigational anticancer drug tigilanol tiglate (EBC-46) in the local treatment of canine mast cell tumors. 

 2019;6:106. doi:10.3389/fvets.2019.00106

2. De Ridder TR, Campbell JE, Burke-Schwarz C, et al. Randomized controlled clinical study evaluating the efficacy and safety of intratumoral treatment of canine mast cell tumors with tigilanol tiglate (EBC-46). 

 Published online June 16, 2020. doi:10.1111/jvim.15806

3. TANOVEA-CA1 package insert. Fort Collins, CO: VetDC Inc., 2016.

4. Thamm DH, Vail DM, Post GS, et al. Alternating rabacfosadine/doxorubicin: efficacy and tolerability in naïve canine multicentric lymphoma. 

 2017;31(3):872-878. doi:10.1111/jvim.14700

5. Mochizuki H, Shapiro SG, Breen M. Detection of BRAF mutation in urine DNA as a molecular diagnostic for canine urothelial and prostatic carcinoma. 

 2015;10(12):e0144170. doi:10.1371/journal.pone.0144170

6. Breen M, Vaden S. Canine transitional cell carcinoma (TCC)/urothelial carcinoma (uc)/bladder cancer in dogs—new research provides an opportunity for early detection. Breen Lab at NCSU. Accessed November 20, 2020. 

https://www.breenlab.org/bladder%20cancer.html

7. Mason NJ, Gnanandarajah JS, Engiles JB, et al. Immunotherapy with a HER2-targeting Listeria induces HER2-specific immunity and demonstrates potential therapeutic effects in a phase I trial in canine osteosarcoma. 

 2016;22(17):4380-4390. doi:10.1158/1078-0432.CCR-16-0088

8. Musser ML, Berger EP, Tripp CD, Clifford CA, Bergman PJ, Johannes CM. Safety evaluation of the canine osteosarcoma vaccine, live Listeria vector. 

 Published online July 30, 2020. doi:10.1111/vco.12642

9. Flesner BK, Wood GW, Gayheart-Walsten P, et al. Autologous cancer cell vaccination, adoptive T-cell transfer, and interleukin-2 administration results in long-term survival for companion dogs with osteosarcoma. 

 2020;34(5):2056-2067. doi:10.1111/jvim.15852

Cancer diagnostics and therapeutics continue to evolve, potentially lessening the associated invasiveness, duration, and cost. 

What’s new in veterinary cancer? 

We prefer to do surgery in the morning—my favorite time of day—before the telephone starts ringing and emergencies begin showing up. It’s peaceful, and surgeries usually can be done without hurry or distraction.

Our clinic is in an area where townsfolk like to hang out, perhaps while a flat tire is getting fixed or rain has stopped their work for a while. One older gentleman, Mr. Ford, would stop by regularly to watch us perform surgery, even though we often start as early as 6 am.

This particular morning was chilly, so my surgery technician, Manda, stoked up our little gas heater to add some warmth to the surgery room. The thing fits on top of a propane bottle and gets red hot.

Mr. Ford was there as usual, and he was a talker. He loved to tell stories, some from his World War II days. We’d heard most of them many times. If someone came in with a horse, he might talk about the prize racehorse he ran in 1955; I’d heard that story a thousand times. Some people would walk away, but others would listen for perhaps 30 minutes or more. He loved it. It was what he lived for. I never complained. It gave clients something to do while they waited, and it made him happy.

That morning, he was standing in front of the red-hot heater, talking about how smart his dog was. Being familiar with that story, too, most of us had tuned him out for the moment as we fished around in a horse’s knee for a bone chip.

I’m not sure who smelled it first, but we all looked up at the same time. Something was burning. About that time, Mr. Ford, in a calm and casual voice, said, “I’m on fire.”

He had backed into the heater until his britches touched the hot grill and began to burn. Smoke was coming from just above the bend of his knee. He was patting himself on the back pockets, trying to put it out. At 84 years of age, bending down that low is possibly more painful than being on fire.

Everyone in the room went into fire mode. Manda started beating the burning pants with a towel, but that just seemed to stoke the heat and create more smoke. The fire grew worse as others in the room looked around for something with which to put it out. I was thinking of throwing Mr Ford on the ground and rolling him around, but decided that might hurt him. Besides, I was sterile for the surgery. We needed water, but there was none to be found—unless we picked him up and put him in the sink.

I pulled the arthroscope out of the cannula and aimed it at Mr. Ford’s leg. Manda saw what was happening and turned the pressure on the pump to high. The lavage fluid hit the burning pants, and in seconds the fire was out. I realized that I never broke sterility.

It was all just a comma to Mr. Ford, who, cool as a cucumber, resumed the story about his dog exactly where he had left off while the rest of us were coming down from our adrenaline rush.

Mr. Ford passed away a few months back. We all miss him and his many interesting tales. But what we’ll remember most is that chilly morning when his trousers caught fire.

I can’t help but wonder how many surgeons can say they’ve extinguished a burning pair of pants with an arthroscope and never broken sterility?

Bo Brock, DVM, owns Brock Veterinary Clinic in Lamesa, Texas. His latest book is Crowded in the Middle of Nowhere: Tales of Humor and Healing From Rural America.

Sometimes sheer panic is the impetus for ingenuity.

Tools of the trade

In human medicine, the physical examination has seen technology gradually usurp what once was the Gladstone bag–wielding, house call doctor of the 19th century and, later, the exam room physician. A 2012 meta-analysis showed that general physical exams did little to reduce morbidity and mortality in human patients.

However, this is not the case for animals, thanks to their inability to verbalize what ails them—and to questionable observational skills some owners apply to filling in those critical blanks.

According to Lauren Demos, BVMS, DABVP (Feline), chief veterinary officer at 

 and past president of the American Association of Feline Practitioners, physical exams are at the core of what veterinarians do. In her 

® virtual conference lecture, Demos related the physical exam as the process of obtaining objective, anatomical, physical findings through observation, palpation, auscultation, and sometimes percussion; this information, she said, should be integrated with the patient’s history, particularly current clinical signs and household issues.

With physical exams being such an important component of pet health—especially for cats because they are unlikely to reveal the signs of illness—veterinarians must outwit the feline instinct to avoid exploratory processes. What do we do with the patient who slips through our hands, turns away from us, crouches, stiffens, conceals, bats, and lurches? We’ve got to streamline.

First, maintain a catcentric environment in the hospital. Minimize general activity, smells, and noises ranging from music to door slams, Demos advised. “Things that people are not aware of, cats are so acutely aware of and can be acutely sensitized to,” she said.

Second, equip each exam room with the necessary tools and supplies so that once the cat enters, the work is quick and seamless. Include these key items:

Stethoscope (neonatal stethoscopes are best suited to the higher frequency of feline heartbeats)

Third, ready the cat for examination. For fractious cats, muzzles, gloves, nets, and cat bags are useful. But towels, Demos said, are perhaps the most effective and client-friendly restraint tool. Gabapentin (100 mg per cat), which brings calm to even the fieriest felines, can be dispensed 2 to 4 hours in advance of the appointment.

Tranquility can sometimes be achieved with pheromones sprayed on towels and carriers. For some cats, however, full sedation is the only option that renders them safe to handle (see 

The initial steps in the exam include gathering the patient history from the owner, obtaining vital signs, and performing a visual exam. Here are some tips:

 What is the problem, and how long has it been going on? Why is the client bringing the cat in now for this problem? Are other signs occurring, such as coughing or vomiting? What about diet and medications? Recent changes in the household? Updates on previous or chronic conditions?

Temperature, pulse, respiration, and body weight:

Temperature is impacted by stress/travel.

Pulse should range from 160 to 206 beats per minute (up to about 300 beats per minute in hyperthyroid cats).

Respiration should be less than 20 breaths per minute (up to 30 breaths per minute in cats with cardiac disease).

Body weight trends are important. Weight loss without dietary change is significant. Kittens normally weigh 1 lb per month of age until age 6 months.

 While taking the history, observe the cat’s appearance, gait, behavior, and mentation, as well as its use of senses (vision, hearing, and smell).

Once all the heavy lifting—from reviewing the chart to passively observing the cat—is completed, the final component is the physical exam. It should also be the shortest part, at less than 5 minutes. “The less you touch the cat, the better,” Demos said. “Don’t release your hand from the cat until you’re done with the exam.”

Developing a rote, streamlined process aids in achieving this goal. It also improves quality, she added. “Having a process through which you travel helps you to standardize this and hopefully decrease the risk that you’re going to miss something.”

Demos follows the same procedure every time. With the cat standing on the exam table facing her, she works from head to tail:

Mouth (left side, right side, incisors/canines, open mouth)

Abdomen (kidneys, liver/stomach, bladder, stool quality, presence of fat/fluid/masses)

She then performs an ophthalmic exam, starting with the anterior eye to evaluate the cornea, sclera, nictitans, and conjunctiva. In the subsequent fundic exam, she looks for retinal detachment and hyperreflectivity, vascular translucency, and signs of trauma and parasitism.

Most cats dislike internal ear exams, so Demos saves this for last. Using an otoscope, she examines the ear canal and ear drum, looking for things like ceruminoliths, scar tissue, and granulomatous changes.

She recommends having an assistant present during the exam to prevent the cat from backing away. To put a stop to purring, which hampers auscultation, she suggests moving the cat to a different room, picking the cat up, occluding the nostrils, or waving an alcohol-soaked gauze near the nose.

Annual physicals are recommended for adult cats (>1 year), whereas senior cats (>11 years) should be examined every 6 months. Kittens are typically examined in conjunction with their vaccine series through 16 weeks of age. Demos identified the neglected juvenile phase as 6 to 8 months of age. Because this is the stage where problems may begin manifesting, she advocated getting cats back in during this period to check that permanent dentition has erupted properly, flag juvenile gingivitis, and rule out problems like retroviruses and ear mites.

Customized schedules should be created for cats experiencing chronic conditions:

 Blood pressure reading 2 to 4 weeks after medication has begun

Despite their secretive nature and distant demeanor, cats can reveal themselves to physical exams built on advanced planning, speed, and economy of touch.

Joan Capuzzi, VMD, is a small animal veterinarian and journalist based in the Philadelphia, Pennsylvania area.

Krogsbøll LT, Jørgensen KJ, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. 

. 2019;1(1):CD009009. doi:10.1002/14651858.CD009009.pub3

A systematic, streamlined examination style that uses minimal touch to maximize data while minimizing stress. 

Finessing the feline physical

The KC Animal Corridor recently announced Kerri Marshall, DVM, MBA, as the winner of the 2020 Iron Paw Award, which recognizes the efforts select individuals make to holistically expand the veterinary profession. This year’s winner was acknowledged for her technological advancements that have impacted the veterinary industry on a global scale.

“We are thrilled to honor Dr. Marshall with this year’s Iron Paw Award,” says Kimberly Young, president of KC Animal Health Corridor, in the release. “The technology she is spearheading for our industry is vital to the success of veterinary practices. Her impact will be felt by veterinarians and their patients around the globe.”

Marshall is the chief information officer at Compassion-First Pet Hospital where she leads a team that is committed to globally creating digital ecosystem designs that move the veterinary space forward. According to a KC Animal Health 

, the team’s core mission is to help generate more collaboration between local veterinarians and their clients.

What’s more, Marshall was the former chief veterinary officer and board member at BabelBark, where she launched the first horizontal technology platform which aided veterinarians in becoming leaders within the digital pet space. She has also worked as both executive vice president of consumer experience and chief veterinary officer for Trupanion, where she changed their reimbursement program to direct payment.

“I am honored to receive the Iron Paw Award and excited the Corridor acknowledges the ever-growing impact technological innovation will make on the animal health industry,” says Marshall. “Veterinary medicine is entering a new era of technology-enhanced communications with clients, who are often very technology savvy and equate quality of medicine with the use of modern technology. Well-designed technology customized to our workflow can greatly improve the client and veterinary team experience.”

KC Animal Health Corridor has named the winner of its 2020 Iron Paw Award, which spotlights individuals who advance the veterinary space through dedication, innovation, education, and spreading public awareness.

KC Animal Corridor announces 2020 Iron Paw Award recipient

Who says building a new animal hospital has to be boring? Definitely not Marion Sewell, DVM, owner of Ruston Animal Clinic in Ruston, Louisiana. Her design elements reflect her flair for fun, from skeleton-print wallpaper (yes, wallpaper!) to an outdoor exam room housed in a screened-in porch. One of her main pieces of advice to others undertaking the building process is just that: Have fun!

It’s no surprise that Ruston Animal Clinic (RAC) won a Merit Award in the 2020 dvm360

Hospital Design Competition. The new, freestanding clinic is an upgrade from the 50-year-old facility that once housed the hospital. The fun aesthetic that Sewell brought to the redesign, along with a solid floor plan and attention to detail, caught the eye of the competition judges, earning the hospital an award for design excellence.

Sewell, a 2007 Louisiana State University School of Veterinary Medicine graduate, bought RAC 12 years ago from the original owner. The well-established hospital served the community well, but with only 3 exam rooms there was limited space to grow. Thankfully, she was able to find a piece of land a mere one-eighth of a mile away in a new business park. The new facility is located on a busy highway north of town with new subdivisions and plenty of room for future additions and growth.

Sewell makes it clear that moving into a new building doesn’t negate the years of history and hard work that went into the practice before her. “We weren’t starting over; instead, we were moving a 50-year-old established practice into a new facility,” she says. “Therefore, I wanted the new clinic to reflect the familiarity of the former facility and the practice style that had been so well received by our community. I was not trying to ‘remake’ RAC but rather provide a facility where we could continue to practice progressive medicine, with enough square footage to house our equipment and parking spaces to accommodate our clientele.”

In building anew, Sewell was able to double the number of exam rooms, from 3 to 6, and enlarge the square footage of the hospital—and the size of the land it sits on. The 1 acre of land offers plenty of room to add on to the back of the hospital if future needs call for it.

The company that financed her purchase of the original hospital also financed a good portion of the new build project. She also got a Small Business Association loan to help take care of the debt on the initial loan.

From the moment you walk toward RAC, you can tell it’s a place where you’ll want to spend some time. Or, at least you’ll appreciate the beauty of the space while you’re there. A large wrap-around porch encircles the practice, with multiple outdoor seating areas for clients who choose to wait outside. Inside guests are greeted with bright colors, whimsical art, and even wallpaper in various places throughout the building.

“I wanted the new RAC to be inviting and friendly with an eclectic feel,” says Sewell. “Each exam room is a different color. I used the art from the original clinic, some of which I’ve been collecting for years, in the new clinic so people recognized it. The furnishings are comfortable and not clinical. And I used wallpaper! Most thought it was a risky move to put wallpaper in a veterinary clinic. However, I think it represents our quirky design ideas.”

Case in point: The reception area features wallpaper covered with animals, with animal skeletons visible from certain angles. “I find it fun!” she says. “I searched for animal wallpaper for over a year to find just the right choices. I even ordered 1 wallpaper from the UK, picking the paper and coordinating paint colors myself.”

The paint contractor pushed back a bit on hanging the wallpaper, so Sewell and a friend did it themselves. That’s how committed she was to the idea of incorporating quirky designs into the practice.

Another element she loves is the inclusion of exotic pets into the decor, in the art and other touches. “Our exotic-pet families love being included,” she says.

Another fun design element: An outdoor exam room. If the weather permits, Sewell takes advantage of the outdoor exam room she had built off the porch area. This space gives nervous clients or patients a larger space in which to work, calming nerves. And, frankly, it gives everyone a chance to get outside for a bit. Of course, cats, birds, and exotic pets aren’t eligible for the outdoor exam space, as they can too easily scamper or fly away, she says.

Building a beautiful, creative space to practice in is a win. And earning a Merit Award in the dvm360

 Hospital Design Competition is icing on the cake. But what Sewell is most proud of? “Coming in on budget. I closely watched all the expenses and succeeded in keeping a strict budget,” she says.

Her final words to others embarking on a building project are these: “Look at and visit as many veterinary hospitals as possible, pay close attention to materials and floor plans. And have fun!”

Sarah A. Moser is a freelance writer in Lenexa, Kansas.

Creative elements tie together this Louisiana charmer. 

Have fun, will build

During the coronavirus disease 2019 (COVID-19) pandemic, Kingston Animal Hospital’s resources were stretched thin. A surge in pet ownership left staff members struggling to manage increased workloads, making occasional temper flare-ups unavoidable.

One morning, a 95-pound dog came to the clinic for curbside care. Sally, a technician, brought Rover from his car into the clinic for an examination and nail trim. Because Rover was so aggressive, she required assistance from 2 other technicians and the veterinarian. Rover was cautiously restrained and responded well to patience and petting, but exhibited threatening behavior during the nail trim.

Sally attempted to place a muzzle on Rover’s mouth, but he resisted by moving his head and growling. After several unsuccessful attempts, she grew frustrated and smacked Rover in the face with her bare hand, sternly saying “no.” Sally immediately regretted her actions and left the examination room.

The remaining 2 technicians and the on-duty veterinarian unanimously decided it was best to return the dog to his owner. Instead of informing the client about what happened, they simply recommended that, in the future, Rover be given an anxiety-relieving medication before visiting the clinic.

All staff members involved in Rover’s care were extremely concerned and upset. They reported everything that happened to the clinic’s medical director, who in turn interviewed everyone. The medical director had a tough decision to make. Sally had worked at the Kingston Animal Hospital for 7 years and was a well-respected technician with no history of abusive behavior toward any of her patients.

During Sally’s interview with the medical director, she exuded embarrassment and was very apologetic. She said that 2 weeks prior, she had to quarantine because of a family member’s potential COVID-19 exposure, and that her son was attending school virtually from home. She explained to the director that the combination of these stressful scenarios, topped with financial issues, had impaired her judgment and shortened her temper.

While the medical director felt strongly that physical animal abuse of any kind is the single worst offense at a veterinary facility, Sally had no previous history of abusive behavior, was a longtime employee, and was remorseful and highly apologetic. The director also considered the unique stresses of a once-in-a-lifetime pandemic and decided not to fire Sally.

The director did, however, require Sally to apologize to her coworkers and notated the incident on Sally’s record, indicating that any recurrence of this behavior would result in immediate termination. This notation was then cosigned by the medical director and Sally.

But what about the pet owners? Should she tell them what transpired? Because the medical director didn’t observe any visible signs of harm to the dog and because she believed she had adequately addressed the situation, she didn’t tell the owner. Her reasoning? She didn’t think anything good would come from informing the pet owners about this embarrassing, violent episode.

Do you agree with the medical director’s decision? We would like to know.Let us know your thoughts at dvm360news@mmhgroup.com.

This dilemma is extremely upsetting, to say the least. Pandemic stress, a short-tempered staff member, and an aggressive dog led to a disastrous situation. There is never a good reason or an excuse for physically striking a pet patient. Excessive physical restraint frightens dogs. It’s as simple as that. This large, frightened, and aggressive dog should have had a temperament assessment before treatment. That would have most likely led to appropriate sedation and a nonstressful treatment experience.

Given the current state of affairs, I agree with the medical director’s decision not to terminate Sally. However, I disagree with not informing the pet owners. Without identifying specific staff members, the medical director should have told the pet owners what occurred and shared the disciplinary measures taken to ensure it wouldn’t happen again.

The pet owners may have accepted this explanation, or they may have strongly detested it, refused to return to the practice, and filed a complaint with the state board. Nevertheless, the medical director should have been transparent with the client and let the chips fall where they may.

Marc Rosenberg, VMD, is director of the Voorhees Veterinary Center in Voorhees, New Jersey. Although many of the scenarios he describes in his column are based on real-life events, the veterinary practices, doctors and employees described are fictional.

Should a team member be fired for one isolated incident of physical abuse toward a seemingly aggressive patient during these stressful, unprecedented times?

dvm360 January 2021

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