American Heartworm Society (AHS) canine heartworm guidelines

 emphasize the advantages of the protocol over the non-arsenical treatment protocols that have been studied in the U.S. and Europe. While these protocols are needed for dogs that aren't candidates for melarsomine treatment, the hope is that most heartworm-positive dogs can undergo the AHS treatment regimen, which is designed to eliminate the highest percentage of adult worms while minimizing treatment complications.

So, you have the better protocol and access to medications. What can you do to make sure the pet owner isn't put off by cost or a weak recommendation?

Countering cost concerns with adulticide treatment

There's no getting around it: While heartworm preventives are affordable, heartworm treatments can be quite expensive. It's not unusual for clients to develop a case of sticker shock when presented with the anticipated costs. Here's how I work with owners of heartworm-positive dogs to help make the cost of treatment more manageable:

Create a step-by-step estimate that breaks down the treatment steps. 

Treatment estimates that break out the different costs can help clients understand the complexity of treatment as well as the total cost. Owners understand that fees are associated with lab tests and imaging as well as with medications, monitoring and-in some instances-hospitalization. (Editor's note: Worried that if you list all the specific costs that clients will argue to knock some of them off? Itemize the parts of the treatment but don't include individual prices.)

Create a payment plan that mirrors the treatment plan. 

One benefit to the AHS treatment protocol is that the medications are administered in a step-by-step fashion. Because there are 60 days between the initial diagnosis and the first melarsomine injection-as well as another 30 days between the first and second injections-payments can be billed in tandem with the medication. This also gives the client the opportunity to save for the costliest component of treatment: the melarsomine injections.

For clients who aren't enrolled in a pet health insurance plan or who can't afford to pay as they go, programs like 

 can help owners stretch out the treatment costs in a manageable payment schedule.

Many clients today research pet healthcare issues, so it's not uncommon for them to learn about-and ask for-a slow-kill alternative to melarsomine treatment. While it may be tempting for veterinarians to offer alternative protocols to clients on tight budgets, forgoing adulticide treatment is not always in the long-term best interest of the pet. Here's how I handle it:

Because it can take years or more for alternative protocols to achieve results, the progression of pulmonary pathology and damage from adult heartworms continues over an extended period of time. Most clients want what's best for their pet; we do our clients a disservice if we don't provide our best recommendation first.

While non-arsenical protocols eliminate the cost of melarsomine, they aren't necessarily cheap. Doxycycline-which should be used in non-arsenical as well as adulticide regimes to kill 

 species bacteria and reduce the reproductive potential of adult heartworms-is a fairly expensive antibiotic. Meanwhile, dogs on non-arsenical therapy require repeated antigen tests to ascertain their status.	

Just make sure with any change in protocols that you and your team are on the same page on the importance of the change if it affects what pet owners are paying. This is about strong recommendations and strong communication. In my view, good medicine is always good business, and maintaining standards of integrity keeps our patients healthier-and our clients happier-in the long run.

Dr. Chris Duke is founder of Bienville Animal Medical Center in Ocean Springs, Mississippi.

Articles

Show clients the value of heartworm treatment as well as payment help. Tip: Don't let them settle for medically unsound "slow kill" methods.

Counter cost concerns with heartworm treatment

Admittedly, prior to becoming Fear Free certified, I had absolutely zero experience with “calming” nutraceuticals. Even after certification, I found myself unsure that they had a place in my daily recommendations to clients. I found myself reaching for what I “knew” would work, such as trazodone and gabapentin. As I gained more experience with Fear Free practices, I began to find myself in a variety of situations where pharmaceuticals didn’t fit all the needs of my patients.

New patients frequently pre- sent a challenge toward proactively prescribed pharmaceuticals. Many clients with fearful pets seek out our practice because of our Fear Free reputation, but without an existing client-patient-relationship we are unable to prescribe traditional phar- maceuticals. Suggesting an over- the-counter calming supplement for an initial consultation is often helpful to begin the process of reducing fear, anxiety and stress (FAS) associated with the veterinary visit. 

One of my favorite nutraceuticals for felines is alphacasozepine (Zylkene—Vetoquinol), because it often has a gabapentin-like effect on paients with low to moderate levels of FAS. If the consultation reveals high levels of FAS despite nutraceuticals, then we now have the ability to prescribe pharmaceuticals.

Another reason I began to recommend nutraceuticals more frequently was to prevent or reduce FAS in a stepwise manner. Many pet parents still have limited under- standing of the emotional well- being of their pet and the options available to protect and repair it if needed. Some pet parents are more comfortable using the gentlest, most natural option as a first-
line treatment approach. In these instances, I will start with a nutraceutical and then have the pet stop by for a quick technician evaluation to determine FAS level. If the pet is still demonstrating signs of fear and anxiety, then I find many pet parents are comfortable moving toward pharmaceutical options.

Now that my practice is two years into our Fear Free journey, we find that nutraceuticals have a permanent position on our inventory shelves. They help us provide options to new patients as well as be- gin the process of addressing FAS in a gradual, progressive fashion. Nutraceuticals are an effective tool to build trust with pet parents and forge a long-lasting relationship that focuses on the pet’s emotional health and well-being.

Julie Reck, DVM, owns Veterinary Medical Center of Oak Mill in Oak Mill, South Carolina.

I was skeptical at first, but calming nutraceuticals can be complementary to traditional pharmaceutical options.

An OTC way to keep pets calm and carry on

It's that time of year again-too much food, too little time, too much to do and loads of regret. Once the dust of the holiday season settles, it's time to focus on improvements-both within yourself and at your practice. While the resolutions below may not 

 to be self-improving, they are, as they recommend concentrating your efforts on efficient, powerful and constructive tasks, which needs to start with you. So, get goin'!

No, I'm not talking about getting on the treadmill here. I think all of us could put our finger on at least one thing (or person) at our practice that we'd love to get rid of. Well, 

This year, our practice stopped providing radiographs. That probably sounds shocking, but here in central New Jersey, we are practically surrounded by specialty and emergency clinics that provide orthopedics, obstruction removals and other procedures related to radiology. This, coupled with the increase in dependency on ultrasound, meant our practice just didn't see a need to provide the service anymore. So, we sold our equipment and made the two-room suite into an additional exam room and surgery prep/utility room.

If there's a service you can't get your team to enjoy providing, an inventory item you don't really sell or a toxic team member, leave it (or them) in 2018. You'll be glad you did.

Take your practice to new heights … or curbs

Now that you've made room for change, don't slow that momentum. Send a team member to pursue a special certification. Pay a secret shopper to come into your practice and take notes.

Or, try something totally new for your customers, like curbside prescription pickup.

People like having the red carpet rolled out for them. Disney does this well and we should too! A drive-up prescription window would be nice, but if your clinic doesn't have the right configuration, it would probably cost upwards of $40,000 to make it happen. However, you can jump online and pick up a security camera and a metal parking space sign for under $200 total.

Set up the camera to alert you when motion is detected, and take credit card information and vehicle descriptions over the phone when orders are placed. When that white Ford Focus pulls up, run the order out to the owner with a treat in your hand for Fluffy. By taking a few minutes of your day to go the extra mile, you're making a lasting impression on your clients that their needs come first.

Setting an example that's easy for team members to follow should be a priority for yourself. What looks better-trying to do 20 things but only completing 10, or trying to do 10 things and actually doing all 10 of them? Don't be unrealistic with the work that a team member can truly accomplish in a day. We want quality work, but busy days with lots of case load won't help us get it in the end.

Contrary to popular belief, you can (and should) change job descriptions 

 people start doing the job. Start by removing things from their job descriptions that they don't actually do. This sounds like horrible management, but let's be honest-if you bought a microwave expecting it to make toast, you chose poorly. It's the same with hires. You should be seeing their performance from day one, so if some expectations aren't being met, the blame is on you. Sit the team member down and show them the original job description. Then show them what you're removing and why. They'll probably have a terrified look on their face, but by emphasizing that you no longer expect them to do A, they should understand that you fully expect them to have the time to complete B.

Oh, and by the way-it's OK to stop expecting yourself to do so much as well. Cheers to a better year ahead.

Brent Dickinson is practice manager at Dickinson-McNeill Veterinary Clinic in Chesterfield, New Jersey.

After you take a cup o kindness for auld lang syne, heres what to purge and what to pursue in your veterinary hospital over the coming year. 

3 New Years resolutions for practice managers

Starting as an idea conjured over beers and coffee, evolving into a class project, and transforming into an industry-leading company, Lacuna Diagnostics technology allows veterinarians to send and receive cytology samples digitally. 

Conor Blanchet, MPH, MBA, DVM Candidate (2019), and Lacuna's chief operating officer, noticed the habitually slow turnaround time for cytology samples during his time working in a clinical pathology diagnostic lab. “I witnessed hundreds of samples arrive at our doorstep that had broken in transit, had overheated or were nondiagnostic and the patient had left the clinic days before. I began to wonder-can we do this digitally?” says Blanchet.

Rather than boxing up samples and waiting for lab results, veterinarians are able to upload sample images from a cell phone to 

 using Lacuna Snapshot. Another option for practices, especially operating at high-volume, is the Lacuna's one-click scanning device: Autoscan.

In addition to helping veterinarians move on with treatment quickly and confidently, Lacuna's services also impact the client. “As millennials are the largest demographic of pet owners in the country, every practice is competing for a new set of expectations from their clients. We expect answers now,” Blanchet says.

With Lacuna, answers are provided in as little as 47 minutes. Currently, Blanchet says Lacuna is the only company in the world who offers this service. With the waiting game eliminated, Lacuna's digital pathology technology gives veterinarians confidence for treatment while also providing peace of mind for clients.

“It is often difficult to put a dollar value on the emotional impact of time spent waiting. However, in those times intangibles are the most important,” says Bikul Koirala, co-founder of Lacuna Diagnostics.

Lacuna Diagnostics includes free training, 24/7 support, and direct communication with pathologists. Lacuna's Snapshot solution is $40 a sample, has no ongoing fees and is compatible with iOS, Android and cameras. At $80 a sample, according to Lacuna's website, Autoscan gives you crystal clear images with one click and comes at no cost to start.

Tired of boxing up cytology samples and shipping them out? Fed up with waiting days for the results? The founders of Lacuna Diagnostics were too.

Cytology sample results in 47 minutes? Yep.

, Barden Greenfield, DVM, DAVDC, walked attendees through getting that perfect surgical flap after a tooth extraction.

The first thing to consider when considering a surgical flap is knowing how difficult it can be. “Everybody has troubles with this,” Dr. Greenfield says, “and I don't blame them. We have a lot of flap failure in my specialty practice, and I remember when I was starting dentistry and learning how to do incisions before residency, I had troubles too. So I understand.”

Failure and success aside, though, an animal won't die from a poor flap or lack of a flap. So why do it? In short, to try to control the healing process a bit more. “We flap extractions because if we leave something open, we can't control the narrative with an animal like we can with humans,” Dr. Greenfield explains. “They eat food, they eat dirt, they eat rocks, they eat everything.” 

Your perfect flap went horribly wrong? Check for tumors. 

Dr. Greenfield poses the question to attendees: What if you made the perfect flap? “It's tension free, and everything looks like a million bucks. And then it breaks down.”

His answer? “You'd better start thinking about tumors. A tumor can make a beautiful surgery go bad quickly. Know that it can be something aggressive that's causing it too.”

To further explain, Dr. Greenfield says that a well-done flap will allow the tissue to heal, prevent bone from being further destroyed and prevent localized osteomyelitis from occurring. “When we do a flap,” he says, “it's to cover the defect that we have, and to ensure that the animal's going to get back to its normal activity as a pet as soon as possible.”

Not to mention what could happen if a flap isn't done properly-or at all. The slides he showed attendees of complications with oral nasal fissures and failed flaps were a horror show of necrosis and infection-enough to set your own teeth on edge. “If any of us had this happen to us?” he asks. “Oh, hell, we'd be begging for somebody to put a bullet to our head because it hurts so much. These poor pets are suffering. A proper flap will help prevent this.”

But what goes into a successful flap? A few things, of course. But before any of it can be explained, Dr. Greenfield stresses the importance of having the right surgical equipment-and properly taking care of said equipment.

Most importantly, he says you should be using sharp equipment. “In the boy scouts,” he says, “you learn a dull knife is a dangerous knife. The same can be said with your periodontal equipment. If you've got dull stuff, you're going to macerate tissue. You don't want your barber fixing you up with a dull razor-you'll be looking brutalized. A sharp piece of instrumentation is essential. Ship it out to get sharpened or buy new stuff.” 

Another important factor with your equipment? Small and delicate wins the race. From little scissors to little needle drivers, Dr. Greenfield stresses that everything should be small. As he perfectly explained to attendees: “When you show up for surgery, don't show up with a shotgun to do delicate work.”

Once you've got a grip on proper instrumentation, Dr. Greenfield has three goals for veterinary professionals to meet when they're looking for that perfect surgical flap. Here's a quick breakdown of each factor.

First and foremost, Dr. Greenfield says that flap needs to be tension-free. “Zero tension,” he tells attendees. “Z-E-R-O. Zero tension. Because if you have any tension on that flap, it will fail. I promise you that it will fail.“

Second, Dr. Greenfield wants to make sure you've got plenty of space to work properly. “You need to have adequate exposure of the surgical site. Your base and your incision need to be wide enough to bring that ‘window shade' down to close over that defect.” 

Finally, your flap should be pulled down properly, covering all of your bases. “A very important factor is that your edges should be over bone and not over where the alveolus was, because that has a tendency to not heal as well,” Dr. Greenfield told attendees.  

Another important piece of information to keep in mind is the importance of saving the teeth, especially in dogs. Because what, Dr. Greenfield asked attendees, are canines to a dog? Hands. “It's their hands,” he says. “Before you reach for that scalpel blade to take out a broken tooth-if there's a dentist close by or someone who's very capable of doing a good job of saving those teeth-If there's any way to get those teeth saved, do it because it saves their hands.” 

Its hard, but rewarding for you and your dentistry patient. Here are the main points to keep in mind when searching for success with a surgical flap after a tooth extraction. 

Veterinary dentistry wins: The perfect surgical flap

As soon as the cat jumps on the counter, the first instinct for many owners is to break out the spray bottle, but that isn't the best way to stop unwanted behaviors. Though cats have gained a reputation for being untrainable, veterinary behaviorist Julia Albright, MA, DVM, DACVB, argued that with persistence and creativity, feline behavioral modifications can lead to a healthier, happier cat at a Fetch dvm360 session in Kansas City.

Even though the spray bottle seems to work in the moment, Dr. Albright says, “We're superimposing that our cat should know better, but their cognitive abilities are not the same as ours.” It's not that cats are stupid, but their brains aren't the same as ours. Verbal language is one of the big differences. While a child can reason that they have been sent to their room because they kicked their sibling, all cats and dogs understand is the context around them.

Because of that, punishment has to be immediate-less than one second after the bad behavior occurs, according to Dr. Albright. Consistent, too. Punishment should be doled out every single time the cat misbehaves.

Humans, though, don't have particularly good timing or the consistency to punish a cat effectively. Before deterrence, there are actions owners can take to go on the offensive, addressing unwanted behaviors at the source.

When a cat gets sprayed with water for peeing on the rug, the only thing the punishment accomplishes is suppressing the surface level behavior. Instead, Dr. Albright advocates for going deeper and addressing what might be causing the bad behavior.

“We're looking at pain, discomfort, endocrine issues and other things, but even if there isn't an obvious condition, mental health is health,” Dr. Albright says. “Behavioral issues should be considered a medical issue.”

Cats need mental stimulation to provide outlets for natural behavior-hunting, roaming and searching. “Play is important,” Dr. Albright says. “I ‘prescribe' exercise for my patients and find breaking down the task into chunks of about two minutes (about the duration of a TV commercial) three to four times a day makes it much more doable for clients.” Play that engages a cat will boost their mood, help foster a bond with their owner and cause an overall improvement in behavior.

Because in the wild, cats spend a couple of hours a day searching and killing food, Dr. Albright advocates for treat-dispensing toys that make the cats work a little harder for their food. “They don't have to be fancy,” she says. “You can make a puzzle box out of a priority mail box. It slows them down and makes them think about it.”

“Cats are not untrainable,” Dr. Albright stresses. She says another effective tactic to avert unwanted behaviors is teaching acceptable alternatives. For instance, a cat that looks like he is about to chase another cat can be trained to run jump on his cat tree instead. The benefit to positive reinforcement is preservation of the human-animal bond and the relationship between the cats. Relying on punishment also only stops the behavior in front of the owner.

After addressing all underlying issues, if the cat is still misbehaving, it may be appropriate to use a humane deterrent. Something that delivers a correction based on the behavior rather than the presence of the owner is the best. “Having behavior control in a situation and consistent repercussions result in a less stressed animal,” Dr. Albright says.

For cats that scratch where they aren't supposed to, owners can fortify furniture with double-sided sticky tape. A carpet runner for office chairs turned upside down is aversive to cats and can discourage them from jumping on counters. For an environmental change, frosted contact paper covering windows can keep cats from seeing other felines outside and put a stop to territorial spraying.

Dr. Albright emphasizes that these types of interventions should be “least invasive, minimally aversive.” Start with small actions, moving up a notch at a time. 

Ultimately, enrichment is the solution to a happy, well-behaved cat according to Dr. Albright. Making sure a cat is healthy and its basic needs are met will result in an enhanced bond with its owner.

Tell your veterinary clients to put the spray bottle down, and let's talk.

Feline behavior modifications that actually work

Pets have made a migration of biblical proportion from the backyard to the bedroom and from the kennel to the kitchen to the couch. Most pet owners now self-identify as “pet parents,” and in one survey from Pfizer Animal Health in 1997, many respondents were willing to state that the family dog was a better companion than the other humans in the family. If this trend continues, veterinarians and their healthcare teams will always have a job to do!

Veterinarians are the only physicians who take care of their patients from womb to tomb, and as a result of the amazing advances in veterinary medicine in recent decades, our patients are living longer and better than ever before. While old age is not a disease, there are important medical issues that are associated with aging. For instance, we know that approximately 20% of cats and dogs across all ages suffer from the inflammation and pain of osteoarthritis (OA).1,2 We also know that the incidence of OA increases with age. Among cats 10 years of age and older, more than 90% are likely to have OA in at least one joint.2 The sheer number of these patients demands our attention.

Knowing that one of OA's pain-generating elements is inflammation, decreasing inflammation becomes a critical aspect of managing OA and maximizing patient comfort. Moreover, once pain is present, 

inflammation (inflammation beyond the OA-affected point) can enhance and amplify the pain experience, regardless of where the pain originates.

We know that all pain is complex, subjective, easy to overlook (especially in nonverbal species) and challenging, as managing it means changing how we do things (and we humans aren't always quick to embrace change!). But despite our reluctance to try new things, it's useful to remember that unmanaged (or undermanaged) pain leads us down a dark rabbit hole in which pain moves from a minor nuisance, to decreased quality of life, to unbearable suffering, and it can ultimately result in physical pathology that leads to death. In other words, it's 

an exaggeration to state that pain kills.

Managing pain that no longer serves a useful physiologic protective purpose means thinking beyond the pharmacological tool we typically reach for first: nonsteroidal anti-inflammatory drugs (NSAIDs). To manage inflammation and its associated pain from a multimodal perspective means we must recognize all the ways inflammation can arise and how we can target it.

Most chronic patients are less active because they're not comfortable moving as they once did. Consequently, they're often overweight or obese. The white fat that accumulates in overweight and obese patients secretes inflammatory and proinflammatory hormones that can enhance and amplify the chronic pain experience. For this reason, normalizing body composition-decreasing both the pet's weight 

the size of its fat compartment-is a critical component of any multimodal pain management strategy.

Normalizing body composition goes beyond simple calorie restriction. Calorie restriction alone will shrink the body mass but will proportionately keep the fat compartment (in other words, a large marshmallow will simply become a smaller marshmallow). It's important to use a nutrient profile proven to allow the pet's body to burn fat selectively for its energy. Reducing the body's fat compartment can make a positive impact on reducing overall inflammation, and that in turn can help reduce the pet's OA pain.

There are two other nutritional strategies to reduce inflammation and pain: omega-3 fatty acids (specifically eicosapentaenoic acid, or EPA, and microlactin (the active ingredient in PRN Pharmacal's 

 products). The omega-3 should be in the triglyceride form for optimal absorption and utilization, and generally, the daily total should be divided into two doses-one in the morning, and one at night.

Microlactin is a protein extracted from the milk of hyperimmunized cows that has been demonstrated to reduce systemic inflammation in multiple species, regardless of etiology. Microlactin uses a different pathway in the body than corticosteroids and NSAIDs, which means it can be given alongside either of these. It takes 10 to 14 days for microlactin to reach peak effects, and at that point, it may be reasonable to begin reducing the dose of the NSAID or steroid.

Because inflammation can have a detrimental effect on many body systems and tissues, the benefits of reducing systemic inflammation can reach beyond reducing the inflammatory pain of joint OA. The strong linkages among inflammation, obesity, OA and chronic maladaptive pain point to a need to decrease the patient's fat compartment (by reversing overweight and obesity) to reduce both systemic and joint inflammation. Reducing pain and inflammation will in turn allow the pet to be more active, further contributing to reduced inflammation, better health and improved and sustained quality of life.

Bland S. Canine osteoarthritis and treatments: a review. 

Dr. Robin Downing, who holds a master's degree in clinical bioethics, is a diplomate of the Academy of Integrative Pain Management, a diplomate of the American College of Veterinary Sports Medicine and Rehabilitation, a certified veterinary pain practitioner, a certified canine rehabilitation practitioner, and hospital director at the Downing Center for Animal Pain Management in Windsor, Colorado

The linkages among inflammation, obesity, osteoarthritis and chronic maladaptive pain call for a multimodal rethinking of the best way to help our veterinary patientsincluding taking their fat compartments into consideration.

Going above and beyond NSAIDs to banish pain and inflammation

, several attendees were eager for wisdom from speaker and veterinary nutrition expert Angela Witzel Rollins, DVM, PhD, DACVN, on one such crossover supplement: coconut oil.

“I often have clients ask me if they can use coconut oil as their pet's fat source,” she said. “I have to tell them no, because it lacks essential fatty acids like omega-3 and omega-6 fatty acids.”

And while the addition of coconut oil to a pet's diet has been anecdotally linked to all sorts of health benefits (including improved cognitive function and reduced joint inflammation), Dr. Rollins said that because there haven't been any studies evaluating the benefits of coconut oil in dogs or cats, we simply don't have the scientific evidence to support these claims.

Can an MCT diet decrease seizure frequency?

Twenty-one chronically antiepileptic drug-treated dogs with idiopathic epilepsy participated in a six-month randomized, double-blinded study designed to compare a medium-chain triglyceride diet with a standardized placebo diet.

 Seizure frequency and seizure day frequency were found to be significantly lower when dogs were fed the MCT diet, suggesting it's possible use as a therapeutic option for epilepsy treatment.

The same applies to using coconut oil to control seizures. Dr. Rollins said that although coconut oil is high in medium-chain triglycerides (MCTs), which have recently received attention as a potential treatment for dogs with seizure disorders (see sidebar),1 the MCTs found in coconut oil differ from those used in the study.

“The primary MCT in coconut oil is lauric acid,” she explained, “and the studies that have been done in dogs with seizure disorders have used capric and caprylic acid. So for that reason, I wouldn't say, ‘Hey, you can just give coconut oil and that may help with seizures.' We just don't know, because no one has done these studies with lauric acid.”

Dr. Rollins stressed that she isn't closed off to the idea of recommending coconut oil for seizures and other internal ailments someday, but she wants to wait for the proof-especially since coconut oil is 90% saturated fats, and conventional wisdom would suggest taking a cautionary approach to ingesting any oil that's a solid at room temperature. In the meantime, this might require some flexibility with the client who's absolutely certain that his dog needs coconut oil in its diet.

When an attendee asked what she should tell such clients, Dr. Rollins was ready with a suggestion: “Go with a teaspoon a day. As long as you don't induce pancreatitis, a small amount should be fine.”

1. Law TH, Davies ES, Pan Y, et al. A randomised trial of a medium-chain TAG diet as treatment for dogs with idiopathic epilepsy. 

If questions about coconut oil are popping up in your exam room, just a spoonful of advice from veterinary nutritionist Dr. Angela Rollins should help give you some direction. 

Vetted January 2019