Zoonotic pathogens are moving targets. Most originate in wildlife

 as likely evidenced by the latest global threat, 

. Shifts in associated disease patterns result from increased human contact with wildlife, globalization of human travel and trade, broad ecologic changes and vector/pathogen evolution.

, or borreliosis, is the most common vector-borne illness in temperate areas of the northern hemisphere.

 Long established in southern and central Europe, northern Asia and the northeastern United States,

it likely penetrated Canada over the past two decades in concert with the northward spread of its tick vector, 

To better understand the current approaches and major challenges associated with surveillance of emerging tickborne zoonoses, investigators from the University of Guelph’s Ontario Veterinary College used the incursion of Lyme disease into Canada as an archetype for study.

A review of the available literature describing different disease surveillance programs honed in on the emergence of Lyme disease in Canada.

Using two databases, PubMed and Web of Science, the investigators searched publications dating from 1990 through 2016. A total of 339 titles and abstracts were reviewed, of which 107 were determined to be relevant.

Public health surveillance—the continuous collection and analysis of health data for evaluating and planning public health programs—can flag emerging epidemics and assess interventions.

Two surveillance styles exist: passive and active. Through passive surveillance, health data are submitted voluntarily by the public and the medical community, among others.

 For Lyme and other tickborne zoonoses, passive surveillance might involve collection of ticks from people or pets, or human disease reporting. This type of disease oversight is generally inexpensive and lean on time and labor investment.

Active surveillance, on the other hand, is more costly and labor intensive because it involves coordinated efforts by public health officials to gather medical data.

 For tickborne diseases, this might mean collecting both free-living ticks from the environment and ticks from small hosts, and testing them for pathogens in the laboratory.

Passive and active tickborne disease surveillance programs can be coupled as follows: Passive tick surveillance might be employed broadly, for collection of ecologic data, for instance, and then active surveillance can be applied in areas where elevated risk was identified through passive study.

Table 1 outlines the variety of specific approaches for surveillance of 

 and Lyme disease that were tagged and analyzed.

Tickborne zoonoses surveillance programs have many challenges. During the early stages of emergence, low awareness can hinder reporting efforts by the public and the medical community.

 Furthermore, as growing awareness boosts reporting, the true incidence can falsely appear to be surging.

Surveillance programs are further hampered by arbitrary geographical borders,

 communication issues impacting data collection and analysis,

and insufficient resources for extending studies longitudinally.

Finally, ticks themselves are tough to track. Their questing behavior and spot densities are variable and inconsistent.

 Plus, their bites can go undetected, and a delay exists between bite and symptom onset.

 reared its ugly head and announced its spread through Canada in the early 1990s, public health officials and researchers met to address risks.

 Multi-province active and passive tick surveillance programs mapped tick densities, and public education programs were initiated.

 In some regions, passive tick surveillance programs gave way to targeted active surveillance aimed at detecting changes in ticks’ ranges.

In 2009, Lyme disease was declared a reportable disease in Canada,

 and in 2014, the Canadian Parliament passed legislation mandating a national framework for Lyme disease surveillance.

This comprehensive review of surveillance systems for emerging tick-borne diseases highlights the need to make them 

 as vectors, hosts, pathogens and ecologic factors evolve.

 An adaptive approach that incorporates necessary experts,

 and resources sufficient for maintaining long-term research protocols

can enhance surveillance data across all phases of disease emergence, from pre-emergence to endemicity.

Though this framework was created for tickborne zoonoses, it can be applied to a variety of other vector-borne and zoonotic diseases.

Dr. Capuzzi is a small animal veterinarian and journalist based in the Philadelphia area.

1. Jones KKE, Patel NGN, Levy MA, et al. Global trends in emerging infectious diseases. 

2. Jones BA, Grace D, Kock R, et al. Zoonosis emergence linked to agricultural intensification and environmental change. 

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4. Mead PS, Epidemiology of Lyme borreliosis. 

5. Barbour AG, Fish D. The biological and social phenomenon of Lyme disease. 

6. Gray JS. Risk assessment of Lyme borreliosis. 

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8. Ogden NH, Lindsay LR, Morshed M, et al. The rising challenge of Lyme borreliosis in Canada. 

9. Clow KM, Leighton PA, Pearl DL, et al. A framework for adaptive surveillance of emerging tick-borne zoonoses. 

hncbi.nlm.nih.gov/pmc/articles/PMC6376153/?report=classic

10. Pawson R, Greenhalgh T, Harvey G, et al. Realist review—a new method of systematic review designed for complex policy interventions. 

11. Public health surveillance. World Health Organization website:who.int/topics/public_health_surveillance/en/. Accessed March 13, 2020.

12. Nsubuga P, White M, Thacker S, et al. Public health surveillance: a tool for targeting and monitoring interventions. In: Jamison D, Breman J, Measham A, eds. 

Disease control priorities in developing countries

. Washington DC: Oxford University Press; 2006:997-1015.

13. Johnson JL, Ginsberg HS, Zhioua E, et al. Passive tick surveillance dog seropositivity and incidence of human Lyme disease. 

14. Ogden NH, Koffi JK, Lindsay LR. Assessment of a screening test to identify Lyme disease risk. 

15. Nelder MP, Russell C, Lindsay LR, et al. Population-based passive tick surveillance and detection of expanding foci of blacklegged ticks 

16. Naleway A, Belongia E, Kazmierczak J, et al. Lyme disease incidence in Wisconsin: a comparison of state reported rates with rates from a population-based cohort. 

17. McHugh L. Effect of electronic laboratory reporting on the burden of Lyme disease surveillance—New Jersey, 2001-2006. 

18. Braks M, van der Giessen J, Kretzschmar M, et al. Towards an integrated approach in surveillance of vector-borne diseases in Europe. 

19. Diuk-Wasser MA, Hoen AG, Cislo P, et al. Human risk of infection with 

 the Lyme disease agent in eastern United States. 

20. Nadolny RM, Feldman KA, Pagac B, et al. Review of the mid-Atlantic tick summit III: a model for regional information sharing. 

21. Bhide M, Travnicek M, Curlik J, et al. The importance of dogs in eco-epidemiology of Lyme borreliosis: a review. 

22. Duncan AW, Correa MT, Levine JF, et al. The dog as a sentinel for human infection: prevalence of 

 C6 antibodies in dogs from southeastern and mid-Atlantic states. 

23. Rand PW, Lacombe EH, Dearborn R, et al. Passive surveillance in Maine, an area emergent for tick-borne diseases. 

24. Hamer SA, Tsao JI, Walker ED, et al. Use of tick surveys and serosurveys to evaluate pet dogs as a sentinel species for emerging Lyme disease. 

25. Mead PS, Goel R, Kugeler KJ. Canine serology as adjunct to human Lyme surveillance. 

26. Smith FD, Ballantyne R, Morgan ER, et al. Estimating Lyme disease risk using pet dogs as sentinels. 

27. Millen K, Kugeler KJ, Hinckley AF, et al. Elevated Lyme disease seroprevalence among dogs in a nonendemic county: harbinger or artifact? 

28. Herrmann JA, Dahm NM, Ruiz MO, et al. Temporal and spatial distribution of tick-borne disease cases among humans and canines in Illinois (2000-2009). 

29. Qurollo BA, Chandrashekar R, Hegarty BC, et al. A serological survey of tick-borne pathogens in dogs in North America and the Caribbean as assessed by 

Anaplasma phagocytophilum, A. platys, Ehrlichia canis, E. chaffeensis, E. ewingii

30. Savić S, Vidić B, Grgić Z, et al. Emerging vector-borne diseases—incidence through vectors. 

31. Gill JS, McLean RG, Neitzel DF, et al. Serologic analysis of white-tailed deer sera for antibodies to 

 by enzyme-linked immunosorbent assay and western immunoblotting. 

32. Gill JS, McLean RG, Shriner RB, et al Serologic surveillance for the Lyme disease spirochete 

 in Minnesota by using white-tailed deer as sentinel animals. 

 (Acari: Ixodidae): status and changes in prevalence and distribution in Wisconsin between 1981 and 1994 measured by deer surveillance. 

34. Daniels TJ, Fish D, Levine JF, et al. Canine exposure to 

 (Acari: Ixodidae) on deer as a measure of Lyme disease risk in the northeastern United States

35. Hinckley AF, Connally NP, Meek JI, et al. Lyme disease testing by large commercial laboratories in the United States. 

36. Bacon R, Kugeler KJ, Mead PS. Surveillance for Lyme disease—United States, 1992–2006. 

37. Smith R, O'Connell S, Palmer S. Lyme disease surveillance in England and Wales, 1986-1998. 

38. Stefanoff P, Orlíková H, Príkazský V, et al. Cross-border surveillance differences: tick-borne encephalitis and Lyme borreliosis in the Czech Republic and Poland, 1999-2008. 

39. Hukic M, Numanovic F, Sisirak M, et al. Surveillance of wildlife zoonotic diseases in the Balkans region. 

40. Prusinski MA, Kokas JE, Hukey KT, et al. Prevalence of 

 (Acari: Ixodidae) collected from recreational lands. 

41. Canada Health. Consensus conference on Lyme disease. 

42. Ogden NH, Trudel L, Artsob H, et al. 

 ticks collected by passive surveillance in Canada: analysis of geographic distribution and infection with Lyme Borreliosis agent 

43. Milord F, Nguon S. Le risque de la maladie de Lyme au Canada en relation avec les changements climatiques: évaluation des systèmes de surveillance. http://collections.banq.qc.ca/ark:/52327/1988807. Published March 2010. Accessed March 13, 2020.

44. Lyme Disease in Newfoundland. health.gov.nl.ca/health/lyme_disease.html. Accessed March 13, 2020.

45. Alberta health. Tick surveillance 2014 summary. Government of Alberta website: https://open.alberta.ca/dataset/f0b7698f-03d4-4d32-858f-141ec7c3c108/resource/d4ef2edb-2421-4be2-a4dc-cfca183c67d6/download/tick-surveillance-summary-2014.pdf. Published April 2015. Accessed March 13, 2020.

46. Lyme disease fact sheet. Government of Saskatchewan website: saskatchewan.ca/residents/health/diseases-and-conditions/lyme-disease. Updated May 2018. Accessed March 13, 2020.

47. Ontario Agency for Health Protection and Promotion (Public Health Ontario). 

Technical report: Update on Lyme disease prevention and control

, 2nd ed. Toronto, ON: Queen’s Printer for Ontario; 2016. Available at: publichealthontario.ca/-/media/documents/lyme-disease-prevention-technical.pdf?la=en.

48. Lyme disease: A report on Lyme disease epidemiology and surveillance in Nova Scotia. Government of Nova Scotia website: novascotia.ca/dhw/populationhealth/documents/Lyme-Disease-Epidemiology-and-Surveillance-in-Nova-Scotia.pdf Published April 2012. Accessed March 13, 2020.

49. Surveillance map: blacklegged tick risk areas in Manitoba. Government of Manitoba website: https://www.gov.mb.ca/health/publichealth/cdc/tickborne/surveillance.html.Published March 15, 2018. Accessed March 13, 2020.

50. Gabriele-Rivet V, Arsenault J, Badcock J, et al. Different ecological niches for ticks of public health significance in Canada. 

51. National Lyme disease surveillance in Canada, 2009–2012. Government of Canada website: healthycanadians.gc.ca/publications/diseases-conditions-maladies-affections/2009-2012-lyme/index-eng.php. Modified February 9, 2015. Accessed March 13, 2020.

52. Laupland K, Valiquette L. Bill C-442: shining the limelight on the Lyme-like? 

53. Parliament of Canada Private member's Bill - Bill C-442. 2014. Parliament of Canada website: parl.ca/DocumentViewer/en/41-2/bill/C-442/royal-assent/page-ToC. Accessed March 13, 2020.

54. Semenza JC. Prototype early warning systems for vector-borne diseases in Europe. 

55. Kulkarni MA, Berrang-Ford L, Buck PA, et al. Major emerging vector-borne zoonotic diseases of public health importance in Canada. 

56. Wardrop NA. Integrated epidemiology for vector-borne zoonoses. 

57. Spielman A, Levine JF, Wilson ML. Vectorial capacity of north American 

58. Dumler JS, Bakken JS. Ehrlichial diseases of humans: emerging tick-borne infections. 

59. Dibernardo A, Cote T, Ogden NH, et al. The prevalence of 

60. Funk S, Bogich TL, Jones KE, et al. Quantifying trends in disease impact to produce a consistent and reproducible definition of an emerging infectious disease. 

61. Smith KF, Dobson AP, McKenzie FE, et al. Ecological theory to enhance infectious disease control and public health policy. 

62. Carver S, Kilpatrick AM, Kuenzi A, et al. Environmental monitoring to enhance comprehension and control of infectious diseases. 

Articles

News


In light of global ecologic changes altering emergence patterns of tickborne zoonoses, investigators mapped out a novel framework for scoping out the influx of ticks—and the diseases they bring—into new geographic areas. 


 Tickborne disease surveillance: An adaptive approach

It’s 2020, and despite the fact that we now live in a membership-driven society in which monthly payments for products and services are the norm, many veterinary practices remain uncertain about whether to offer wellness plans.

You’d be hard-pressed to find someone today who doesn’t have a car lease, a massage membership or a subscription to Amazon Prime, Disney+ or Netflix. These plans allow people to budget their discretionary income on a monthly basis in order to gain access to the things they want—sometimes getting unlimited access to certain services or discounts.

In light of this trend, veterinary practices may want to consider implementing wellness plans as a means to offer clients better access to your services and in turn allow you to care for more pets. Of course, there are two sides to every coin, so be sure to weigh the pros and cons before deciding what makes the most sense for your hospital, clients and patients.

Wellness plans offer clients the option to pay over time for a group of doctor-recommended preventive care services. This option can give some clients access to comprehensive pet wellness care that they otherwise may not be able to afford or may not want to pay for in a lump sum. The ability to budget is something that more and more clients need in order to provide the best care for their pets.

Offering a membership at your hospital can foster client loyalty. Practices can make their “members” feel like part of the “club” by offering them something special when they sign up and congratulating them on social media for choosing the best care available for their pet (“…and with our UNLIMITED exams, Smokey will never have to ‘wait and see’ before coming in to see Dr. Parker…”).

Wellness plans allow veterinary team members to be proactive in caring for pets rather than reactive when a pet becomes sick. Often, these plans incorporate annual early detection screening such as lab work or radiographs that can identify health problems early and allow you to address potentially serious issues before they become life threatening.

Wellness plans can improve your hospital’s cash flow by generating steadier revenue over time, which may help alleviate any seasonal ups and downs. By offering monthly payment options for annual wellness services, you can expect the same payments month to month throughout the course of the year instead of the typical revenue surge during the warmer months.

Wellness plans are hospital specific. If a pet needs emergency or specialist care, wellness plan coverage from your practice won’t apply. Additionally, clients who use multiple hospitals may decide wellness plans are not the best option for them. But don’t fall into the trap of making that decision for them; it’s much better to present clients with the option and let them decide.

Clients can confuse wellness plans with pet insurance. Be sure to head this off at the pass by clearly explaining what your plan includes. This also presents a good opportunity to discuss how pet insurance can complement a wellness plan by allowing the client to budget additionally for accidents or illnesses their pet may experience.

Offering a wellness plan to a client at the wrong time can be seen as putting a sale ahead of the care of the pet. Be careful you don’t come across as pushy by putting your wellness plan before the medicine. Make recommendations for the pet’s wellness care, and then explain how your plan includes these recommendations and will allow the client to pay over time.

Just as Baby Yoda has single-handedly driven Disney+ subscriptions through the roof, wellness plans can help your hospital remain successful into the next millennium. When it comes to implementing them into your hospital and culture, always remember: Do or do not … there is no try.

If you’re on the fence about whether to add wellness plans to your practice offerings, consider these obstacles and opportunities first.

The pros and cons of veterinary wellness plans

As always, the facilities that earned high honors in this year’s dvm360 Hospital Design Competition boast features that improve hospital efficiency, offer an excellent patient and client experience, and are just plain gorgeous. But building or remodeling a veterinary hospital is no easy task, as these practice owners have learned. We asked the owners some of these award-winning hospitals what advice they would offer other veterinarians who are considering building or remodeling. Here’s what they had to say.

“The best piece of advice we can give is to conduct a thorough research process,” says Michael Foster, DVM, owner of merit award winner 

, in West Saint Paul, Minnesota. His team also found feedback from peers and the community during the design and construction process to be especially helpful and encourages other clinics to seek as much advice as possible.

“An effective hospital design comes from the heart, and the ability to engage with other professionals, including at the 

, gave us a chance to express our story through the design of our hospital,” he says.

“Be sure you have a robust and realistic budget that considers all categories of the project,” adds Jonathan Kaufman, DVM, owner of 

in Baltimore, Maryland, one of two runners-up in the over-8,000-square-feet category. “Rather than relying solely on the architect or bank for complete cost estimates, do your own research on potential expenses from start to finish so you’re thoroughly prepared before you present a budget to the bank.”

Determine specifically what products and equipment you want to incorporate, says Samuel J. Kopman, DVM, owner of merit award winner 

 in Vancouver, Washington. “There are a lot of decisions to make and having a good idea of what you want will make it go easier,” Dr. Kopman says. Another piece of advice: Have a good working relationship with your architect and contractor. “We had weekly meetings with our contractor during the building process,” he says.

Many of this year’s Hospital Design Competition winners echo the advice of father and daughter Dale S. Lonsford, DVM, and Charmel Rodick, DVM, who own merit award winner 

 in Deer Park, Texas. “We strongly advise using an architect and builder that have experience and expertise in designing and building animal housing facilities, Dr. Lonsford says. They also recommend having a solid grasp of your budget and letting the architect and the builder know you are serious about staying within it.

Keneth Skinner, DVM, co-owner of the over-8,000-square-feet award-winning 

 in Prescott, Arizona, agrees. “A professional veterinary hospital architect will guide you and keep your project going in the right direction. They know what you need, and they know about the things you did not know you needed,” he says. “They help all of your ideas make it to the blueprints and they make every step of the way a little easier. To have a project partner that understands your vision from the beginning is the only way to build.”

A veterinary-specific architect will know the most about animal-specific facilities and materials, says Steve Hotchkiss, DVM, who owns 

 in Fort Worth, Texas, the second runner-up in the over-8,000-square-feet category.” Believe [your architect’s] estimates for pricing,” he advises. “I was sad that they were right on target. I thought I could build it for less.”

Robert Mankowski, DVM, co-owner of merit award winner 

 in Mount Laurel, New Jersey, offers this excellent advice. “Communicate well with your staff regarding updates and progress, and thank them for their patience while building excitement for the new facility,” he says. “Expanding and renovating your practice is a huge adjustment,” he adds, “so expect at least a year to settle in and build protocols.”

When asked what advice she would offer to other hospitals embarking on a new build or remodel/expansion, Marion Sewell, DVM, owner of merit award winner 

 in Ruston, Louisiana, suggests looking at and visiting as many veterinary hospitals as possible, and paying close attention to materials and floorplans. But above all, she says, “Have fun!”

Words of wisdom about building or remodeling a veterinary hospital from some of the 2020 dvm360 Hospital Design Competition winners.

Winning advice for veterinary hospital design

A plethora of dietary options exist for dogs and cats today. This allows owners to make nutritional decisions previously not available. These decisions may be made for many reasons, some of which are not related to the health or wellbeing of the pet. As a result, these diet decisions affect the available circulating metabolites in the pet. The authors of this study wanted to find out what the circulating metabolites in a dog or cat would be if they were allowed to self-regulate their nutrition.

Seventeen dogs and 27 cats were used from a study colony. Each was allowed to free feed from a choice of four different diets-one high in protein, one high in fat, one high in carbohydrates, and one with balanced macronutrients. Cats were fed freely throughout the day but stopped when a predetermined maintenance caloric intake was reached. Dogs were separated and fed once daily for a one-hour feeding period and were limited to a predetermined maintenance caloric intake. This was continued for 28 days for both cats and dogs. Plasma concentrations of multiple different metabolites were measured at the beginning and end of the trial.

Dog saw relatively few metabolite changes when allowed to self-regulate, with the only significant difference being higher concentrations of arachidonic acid. Cats saw significant increases and decreases in various amino acids as well as higher concentrations of highly polyunsaturated fatty acids.

This study confirms that different food choices affect dogs and cats on a much greater metabolic level than was previously known. By allowing the animals to self-select, the authors attempt to establish what may be a normal baseline for these animals. This may provide the base for future study into differences in specific diets.

1. Hall JA, Jackson MI, Vondran JC, et al. Comparison of circulating metabolite concentrations in dogs and cats when allowed to freely choose macronutrient intake. 

 2018 Nov 15;7(11):bio036228. Link to article: 

http://bio.biologists.org/content/7/11/bio036228

Michael Nappier is assistant professor of community practice in the Department of Small Animal Clinical Sciences at the Virginia-Maryland College of Veterinary Medicine in Blacksburg, Virginia.

The dogs and cats in this study were free to eat from four different diets with varying macronutrients. So when given their druthers, lets see what they devoured, as assessed by their circulating metabolites.

Journal Scan: Given the choice, what diet would a pet choose?

Compared with maintenance diets, therapeutic renal diets generally have restricted protein, phosphorus and sodium levels. The quality of the protein in these diets is extremely important. Diets containing highly digestible protein with the correct balance of amino acids minimize nitrogenous waste. These calorically dense diets contain reduced amounts of dietary phosphorus, increased omega-3 fatty acids, antioxidants, B vitamins and potassium to help prevent hypokalemia, which has been shown to contribute to renal dysfunction. They also contain buffers to help control acidemia, which may contribute to muscle wasting. Protein sources of lesser quality generally contain nonessential amino acids that may be catabolized to urea and may contribute to increased clinical signs in patients with advanced stages of chronic kidney disease (CKD).

Therapeutic diets: the gold standard in CKD

Almost 20 years ago, results of a study by Elliott et al. showed that cats with CKD fed a therapeutic renal diet lived significantly longer than cats fed a maintenance diet (median survival time, 633 vs. 264 days).1 In another randomized double-blind study, cats fed a therapeutic renal diet experienced 26% fewer uremic episodes compared with those those fed a maintenance diet.2 None of the cats fed the renal diet died during the study, but 22% of those in the control group died.

In a presentation at the 2017 Hill's Global Symposium, Jessica Quimby, DVM, PhD, DACVIM, noted that “…based on published evidence, feeding a dietetic renal food is the single most effective management option for improving survival and quality of life in dogs and cats with CKD. While new emerging evidence highlights the benefits of dietetic renal food in dogs with IRIS [International Renal Interest Society] Stage 1 CKD, more research is needed to confirm the most optimal nutritional management in early stages of the disease.”3

Most renal diets fall within the Association of American Feed Control Officials' minimum requirements for adult maintenance diets for healthy dogs and cats. There is no evidence to support the premise that dogs and cats eating therapeutic renal diets will lose muscle weight or body weight if the patient is eating its daily caloric requirements of the diet. Results from a 2-year randomized controlled clinical trial showed no difference in body condition score or body weight in cats with CKD eating a renal diet versus a maintenance diet.4

Restricting dietary phosphorus has been shown to help slow the progression of renal disease. Several studies have shown that feeding therapeutic diets increases survival rates and significantly reduces plasma phosphorus and parathyroid hormone levels compared with feeding diets higher in phosphorus.5 As renal disease progresses, however, it may become impossible to keep phosphorus concentrations within the IRIS guidelines using diet alone. If serum phosphorus remains high 4 weeks after transitioning to a therapeutic renal diet, a phosphate binder should be considered.

High sodium levels in diets fed to patients with CKD may cause sodium retention due to the expansion of extracellular fluid volume, hypertension, fluid overload and edema. However, excessively limiting dietary sodium may cause a negative sodium balance resulting in reduced extracellular fluid volume, plasma volume and glomerular filtration rate (GFR). Dietary sodium has been shown to have no impact on blood pressure in dogs and cats. Restricting sodium may contribute to muscle wasting in cats.5

Cats with CKD are prone to potassium deficiency; however, this is not common in dogs. Decreased potassium levels may be caused by anoxia, vomiting and increased urinary losses due to polyuria. Serum potassium should be monitored and supplemented when necessary. For cats with hypokalemia, oral supplementation with potassium gluconate should be considered if diet alone does not maintain serum potassium concentration above 4.0 mEq/L.5 Oral administration is the safest and preferred method unless a critical emergency exists or oral administration is impossible or contraindicated. Oral potassium gluconate appears to be tolerated well by most patients. The dose is adjusted based on the patient's clinical signs and serum potassium levels, which initially should be checked every 2 to 4 days until stable and then every 2 to 4 weeks thereafter.

The daily energy requirement (DER) for dogs with CKD is 1.1 to 1.6 times the patient's resting energy requirement (RER); for cats the DER is 1.1 to 1.4 times RER. A slow transition (dogs over 1-2 weeks or more, cats over 3-4 weeks or more) is recommended to increase the likelihood that the patient will accept the new diet and to enable a gradual change in urinary sodium levels.

Educating owners about the importance of feeding appropriate diets to these patients and the need to transition gradually is vital. Cats, in particular, can be resistant to diet changes. A number of tactics can be used to help the pet become accustomed to the new food:

Offer the old and new diets in separate side-by-side dishes rather than combining them in a single dish.

Offer the new diet in a flat dish rather than a bowl, even if the pet normally eats from a bowl.

Add low-sodium tuna juice, chicken broth or even water to the food.

Provide antiemetics for nauseated (or suspected nauseated) patients.

Offer appetite stimulants, which may be especially effective when started at the hyporexia or dysrexia stage.

It is not unusual for the CKD patient to eat only a small amount of food or to stop eating altogether. In a 2015 survey of owners of cats with CKD, reduced appetite was reported by 43% of owners; 77% of those owners coaxed their cat to eat 50% of the time.6

Patients with CKD that do not consume their daily caloric requirement will suffer muscle loss as it is catabolized to provide energy to the body. Reduced food intake also means the patient is not consuming adequate protein, which will also lead to muscle loss.

 An often underutilized option is the use of an esophageal feeding tube. Not only can E-tube feeding extend a patient's life, it can help improve quality of life for both the patient and the owner. Veterinary therapeutic diets may be made into a slurry, and most clients can manage assisted feeding easily at home. Clients can also administer the multiple medications that many CKD patients have been prescribed via the feeding tube, often more easily than by mouth. Additional water administered via the feeding tube can eliminate the need for subcutaneous fluids; not only is this easier for most clients but the water is used more easily by the body.

1. Elliott J, Rawlings JM, Markwell PJ, Barber PJ. Survival of cats with naturally occurring chronic renal failure: effect of dietary management. 

2. Ross SJ, Osborne CA, Kirk CA, et al. Clinical evaluation of dietary modification for treatment of spontaneous chronic kidney disease in cats. 

3. Quimby J, Becvarova I: Protein requirements for cats and dogs with early chronic kidney disease-Is there an answer. Presented at the 2017 Hill's Global Symposium. May 5-6, 2017. Washington, DC. 

http://hillsglobalsymposium.com/library/download_notes/L19-Quimby%20Becvarova%20-%20Protein%20Requirements%20in%20Dogs%20and%20Cats%20in%20Stage%201%20CKD.pdf

4. Ross SJ, Osborne CA, Kirk CA, Lowry SR. Clinical evaluation of dietary modification for treatment of spontaneous chronic kidney disease in cats. 

5. Hand MA, Thatcher CD, Remillard RL, et al (Eds): 

, 5th ed. Topeka, KS: The Mark Morris Institute; 2010:785-791.

6. Markovich JE, Freeman LM, Labato MA, Heinze CR. Survey of dietary and medication practices of owners of cats with chronic kidney disease. 

Ed Carlson, CVT, VTS (nutrition), is the technician learning and development manager at InTown Veterinary Group.

Therapeutic diets are the gold standard in managing veterinary patients with CKD. Heres why, and how to coax these pets to eat.

Nutritional management of chronic kidney disease

No veterinary dental extraction is the same. Each animal you work on has its own specific anatomy. “No animal is ‘normal,'” says Mary Volker, DVM, DAVDC, “none actually have the normal dentition they should have with the normal amount of roots.”

However, despite the fact that each extraction will be different, there are three key factors you can focus on with every patient to help ensure your procedure will be a success: exposure, an adequate surgical flap and adequate bone removal.

“Exposure is very important because there should be no reason you should put a high-speed hand piece into an area you can't see,” says Dr. Volker. Seems like common sense, but she says people sometimes don't give themselves enough room to work, and this increases risk.

An adequate surgical flap, especially for difficult teeth is “half the battle” says Dr. Volker. And for bone removal? Start with about half, she says, but keep in mind that you might run into issues like absorption or ankylosis that require a little more.

 in Kansas City, for more insight from Dr. Volker about these three critical factors for success in performing tooth extractions.

The key to conducting a safe and successful tooth extraction is giving yourself enough room to work, says Mary Volker, DVM, DAVDC.

Veterinary dental extractions: Three critical factors

This patient is an active, outdoor dog that has been historically healthy until the gradual onset of weight loss and lethargy over the last few weeks. This particular dog spends much of his time in the woods behind the owner's house. The owners are extremely concerned about the recent development of ulcerative lesions and draining tracts on the nasal planum and paws.

This is a case of cutaneous and systemic blastomycosis caused by 

. This patient likely became infected via direct inoculation, inhalation of spores from its wooded backyard environment, or both. This dimorphic fungus lives in damp environments, especially those containing decaying organic matter. Cytologic examination of 

 reveals broad-based, budding yeast. You will also see a thick, refractile double cell wall. Direct smears or aspirates of affected tissue are appropriate samples to be viewed cytologically to obtain this diagnosis. Biopsies of affected tissue can also be submitted, which will likely reveal nodular to diffuse, suppurative to pyogranulomatous dermatitis with associated budding yeast or septal hyphae.

 can cause cutaneous or systemic disease. Common clinical signs include lethargy, weight loss, dyspnea, coughing, uveitis and cutaneous lesions. Cutaneous lesions can include papules, nodules, plaques, subcutaneous abscesses, ulcerations and draining tracts. If blastomycosis is suspected, performing thoracic radiographs and a thorough ophthalmic examination are essential.

Multiple therapeutic options are available, with the current medication of choice being oral itraconazole. Fluconazole and terbinafine work well in conjunction with one another, as well as ketoconazole in conjunction with amphotericin B. Fluconazole as a single line of therapy is also an option, though course of treatment is usually longer with this drug than with itraconazole. Systemic treatment should last for at least 60 days, being sure to treat 30 days beyond resolution of clinical signs.

Below is a skin cytology from a 3-year-old male neutered Doberman pinscher with cutaneous lesions. Whats going on?

Vetted April 2020

Tickborne disease surveillance: An adaptive approach

The pros and cons of veterinary wellness plans

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Journal Scan: Given the choice, what diet would a pet choose?

Nutritional management of chronic kidney disease

Veterinary dental extractions: Three critical factors

Image Quiz: Cytologya Doberman with weight loss, lethargy and lesions on his nose

What to know before you buy a veterinary clinic

Journal Scan: Punitive training makes dogs pessimistic

MRI patterns help identify Chiari-like malformation in dogs

Orthopedic outcomes improve when veterinary surgeons and rehab teams collaborate