C O M P A N I O N 1 0

COMPANION
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2011
COMPANION is a publication for the Sunshine State’s
veterinary community from BluePearl Veterinary Partners.
Medical Director: Erick Mears, DVM, DACVIM
Practice Manager: Stacey Weider, CVPM, PHR
MEDICAL DIRECTOR’S COLUMN
SOON YOU WILL NOTICE BluePearl signage appear on the
exterior of our Florida hospitals. As we founded BluePearl
right here in Florida, we are excited about our new name!
The question we hear most often is, “What does
‘blue pearl’ mean?”
In the vernacular, “blue pearl” means different
things to different people. You might know a blue pearl if …
… you’re a meditation devotee striving to achieve your most
transcended self, which yoga practitioners describe as a
“blue pearl” experience.
… you’ve admired rare bluish pearls on an elegant necklace
and a pair of earrings.
… you’re a devotee of the techno-music duo, Blue Pearl.
But none of those is us.
We are BluePearl Veterinary Partners, a group of
veterinary specialty and emergency hospitals in nine states.
There are more than 200 specialists and emergency
veterinarians – and nearly 800 veterinary technicians,
assistants and support staff — who work together toward a
common goal: partnering with the primary care
veterinarians in our local communities to provide advanced
patient care and outstanding customer service.
Being a part of a family of hospitals with broad
resources and talents allows us to strengthen and improve
each of our individual hospitals. We take pride in the fact
that each hospital is led by a team of local veterinarians
and professionals who know our veterinary community best.
While we do not think of ourselves in terms of
yoga, jewelry or music, the fact is, we strive for perfection as
much as a yoga master, a jewelry maker and a musician do.
We enjoy working with you and your patients, and we look
forward to continuing to improve and expand our clinical
offerings and educational programs, which are enhanced
because we are a BluePearl Veterinary Partners hospital.
Erick Mears, DVM
Diplomate, ACVIM (SAIM)
Medical Director
Learn more about BluePearl Veterinary Partners at
bluepearlvet.com!
What is Facial Nerve Paralysis?
THE FACIAL NERVE (CRANIAL NERVE VII) is responsible
for providing motor function to the muscles of the
face, lips, eyelids and ears. Loss of facial nerve
function results in decreased movement of these
regions. Owners typically notice a drooping of the
side of the face and the pet dropping food or water
from the affected side of the mouth or tearing from
the eye that is affected.
Causes for the loss of facial nerve function
include trauma to the head, neoplasia involving the
brain or middle ear, and otitis interna/media.
Hypothyroidism and Cushing’s Disease have also
Dogs with facial nerve paralysis will not blink when the medial
been associated with the condition, however, their
corner of the eye and cornea are tapped with a finger.
relationship with the loss of nerve function remains
unexplained.
Idiopathic dysfunction is the most common cause for facial nerve paralysis. Idiopathic facial
nerve paralysis is typically acute in onset and can be either unilateral or bilateral. It is not uncommon for
one side of the face to be affected before the other. Cocker spaniels, and in our experience, golden
retrievers, are the most common breeds affected with the idiopathic form of the disease. Facial nerve
function loss may be transient or permanent depending on its cause.
When examining a dog with facial nerve paralysis, get
a good history from the pet owner, checking for recent trauma,
Get a good history from the
ear disease, evidence for progressive signs or concurrent
pet owner, checking for
illnesses, and the presence of other neurologic signs or pain.
A thorough neurologic exam, and evaluation of the ear on the
recent trauma, ear disease,
affected side, is warranted. When performing a neurologic
evidence for progressive
exam, you will find the menace response, palpebral reflex, lip
signs or concurrent illnesses, reaction and ear twitch response to be severely diminished or
and the presence of other
absent on the affected side. Note that sensation is intact in
these individuals and corneal reflex ark is completed by
neurologic signs or pain.
retracting the globe, not by blinking. Advanced diagnostic
imaging is frequently required to find the source of the dysfunction or to diagnose idiopathic facial nerve
paralysis by ruling out other causes. In cats, in the absence of trauma, further diagnostic evaluation is
always warranted as they rarely get the idiopathic form of the disease.
Neurologist Mike Kimura says, “Advanced imaging modalities such as MRI can be invaluable in
getting to an accurate diagnosis. Many times, I have been humbled when the presumptive diagnosis is
proven off-base through an advanced imaging study.”
The treatment of facial nerve paralysis is directed at its underlying cause. Treatment in patients
with idiopathic disease is typically unrewarding. Corticosteroids are unlikely to be beneficial unless tissue
inflammation is responsible for the nerve damage. Lateral tarsorrhaphy can be performed in patients with
severe corneal/conjunctival irritation from exposure to keratitis.
Sign up to get COMPANION by email by contacting Alicia Valle at
[email protected]. We promise to use your email solely
to send our newsletter and professional notifications. Would you
like your technicians to receive tech CE notifications and KIBBLE for
Come hear Dr. Mike Kimura and Dr. Sonja Olson discuss
seizure management on June 30. Check out the CE schedule
on the back page or at florida.bluepearlvet.com.
THOUGHT, our technician newsletter? Please have them send Alicia
their email addresses, as well.
BluePearl Veterinary Partners is recognized as
Florida Veterinary Specialists in these locations:
Tampa
3000 Busch Lake Blvd.
Tampa FL 33614
813.933.8944
Brandon
607 Lumsden Professional Ct.
Brandon FL 33511
813.571.3303
Clearwater
4525 Ulmerton Rd.
Clearwater FL 33762
727. 572.0132
Sarasota
7517 South Tamiami Trail
Sarasota FL 34231
813.933.8944
The Villages
748 Village Campus Circle
The Villages FL 32162
813.933.8944
SNIFF…
…Get to know BluePearl’s veterinarians
It’s in the Mix:
Pharmaceutical Compounding
Nicole Salas, DVM
Meet Dr. Nicole Salas, who joined Florida
Veterinary Specialists — now renamed BluePearl
Veterinary Partners — in 2010 after completing a
small animal surgery residency at the Veterinary
Specialty & Emergency Center in Langhorne, Penn. Nicole Salas, DVM
Surgical Services
Before embarking on residency training, she
completed a small animal surgery internship at
Affiliated Veterinary Specialists in Maitland, Fla., and a rotating
internship at Fifth Avenue Veterinary Specialists in New York City.
A graduate of St. George’s University School of Veterinary Medicine in the
West Indies, Dr. Salas spent her clinical year at North Carolina State
University. She graduated with a B.S. from Cornell University.
When not hard at work at one of BluePearl’s Florida locations, Dr. Salas
enjoys time with her family, friends and two pets: her cat, Clarence, and
mini-dachshund, Henry. When not chillin’ on the couch, you might find
her at the beach, kickboxing, or cycling.
WAS THERE A COLLEGE TEACHER WHO CHANGED YOUR LIFE?
When I was in undergrad, a professor told me that I would never become a
veterinarian and that I needed to change my major. I was so heartbroken
that I cried for nearly two weeks. Then I sat up one night and asked myself,
“Who is he to tell me what I am going to become?” I worked hard to get to
where I am now. Throughout undergrad, I worked three jobs, and I made it
all the way to Grenada for vet school and through two internships and a
residency. I couldn’t be happier!
WHAT WOULD YOU BE DOING TODAY OR WHAT WOULD YOU LIKE TO BE DOING
TODAY IF YOU COULD NOT HAVE BEEN A VETERINARIAN?
The only other job I really considered was being a pediatrician, but being a
veterinarian was what I planned to be my entire life, so I couldn’t imagine
it any other way.
WHAT THREE WORDS WOULD YOUR HIGH SCHOOL MATH TEACHER USE TO
DESCRIBE YOU?
Social-butterfly, determined, and busy. I was in a lot of clubs, president of
my senior class, and I played sports throughout the year. Other than
studying, I was either playing sports or working at my part time job.
IF YOU KNEW THEN WHAT YOU KNOW NOW, WHAT WOULD YOU DO DIFFERENTLY?
I would have studied harder and worked less, but that would have left me
with more student loans!
HOW DO YOU UNWIND AT THE END OF THE DAY? WHAT KEEPS YOU UP AT NIGHT?
I love to go home after a long day at work and just sit down on the couch
with my husband and watch tv. I know that sounds boring, but I love that
it’s thoughtless. When I have a complicated case or a patient who’s not
recovering as I expect, I toss and turn, thinking about what more could be
done or what I could have done differently.
OUTSIDE OF VETERINARY MEDICINE, WHAT DO YOU CONSIDER YOURSELF TO BE AN
EXPERT AT?
I do know a lot about fitness and nutrition. I used to teach cardio kickboxing
and I have taken courses to be certified in kickboxing and floor exercises.
WHAT IS IN YOUR REFRIGERATOR RIGHT NOW?
We recently had a BBQ, so our fridge is full of left over grilling stuff.
Normally it just has water and condiments in it — we’re not great at
cooking at home. I definitely need to cook more.
WHAT IS THE LAST MOVIE YOU SAW THAT YOU ENJOYED?
“Limitless.” I enjoy most movies and I love going to the movies. Before we
moved to Florida, we used to go every weekend!
WHO WOULD YOU LIKE TO TRADE PLACES WITH FOR A WEEK?
I would love to switch roles with someone famous — no one in particular
— just for a week. Who wouldn’t love to have a personal trainer,
nutritionist and someone to help you pick out fashionable clothes?
Services
Acupuncture
Felicity Talbot DVM, CVA
Avian & Exotic Medicine
Teresa Lightfoot DVM, DABVP
Jonathan Rubinstein DVM
YOU MAY THINK THAT THE COMPOUNDING of
medications is a relatively new process,
but it is not.
Compounding drugs by mixing
and reformulating to fit the unique
requirements of the patient is most
frequently requested due to the owner’s
inability to administer a medication
orally. Compounding is also performed to
resize a medication meant for human
consumption or to produce a medication
that is not commercially available.
From the 1800s to the mid1900s, compounding by pharmacists was
Compounding under strict regulations
common practice. Many of the
ingredients used were natural herbs and recipes came out of books or were based
on folklore. As the efficacy of new formulations was scientifically confirmed, older
recipes and homemade concoctions were replaced. For economic reasons,
compounded medications individually formulated by pharmacists were soon
replaced by the mass production of suspensions, tablets, creams, and capsules. In
the 20th century, greater government regulation of the industry further reduced the
practice of compounding.
The Animal Medicinal Drug Use Clarification Act of 1994 allows
compounding for the veterinary field, permitting veterinarians to prescribe extralabel uses of animal and human drugs for their patients.
Using compounded medications is not without risk. The efficacy of the
finished product can depend on the purity of the ingredients and the quality of the
production. Active ingredients may not be compatible with the carrier in which it is
mixed causing it to become inactive. The active ingredient and/or carrier may not be
effectively absorbed by the method prescribed for its administration. The desired
concentration of the active ingredient may not be added correctly to the
compounded product. Finally, studies assessing the efficacy of many compounded
formulations and recipes are lacking.
Therefore, it is important that you have confidence in the compounding
pharmacy with which you are working. You want to use a pharmacy that specializes
in compounding and is willing to research the efficacy of the medications it is
producing. At BluePearl, we use Stokes Pharmacy (800.754.5222) for the
compounding of many of our medications.
An end around the liver
A PORTOSYSTEMIC SHUNT (PSS) IS AN ABERRANT VESSEL or vessels that shunts blood
from the portal vascular system to the systemic vascular system. This causes blood
flowing from the GI tract, pancreas, and spleen to bypass the liver where it would
normally be “processed.” The liver never has the opportunity to remove toxins
absorbed by the GI tract, release anabolic hormones into the circulation in response
to portal constituents, or process nutrients such as fatty acids and proteins for
efficient use by the body. Growth and development of the organs of the body are
frequently compromised.
Most congenital shunts are the result of a single aberrant vessel.
Extrahepatic shunts are more common in small breeds of dog whereas intrahepatic
shunts are more common in large breed dogs. The condition is hereditary in
Yorkshire terriers and, probably, Irish wolfhounds. It is presumed to be hereditary in
other breeds. Portosystemic shunts have also been reported in cats.
Portosystemic shunts are most commonly diagnosed in young animals,
although they have been found in animals as old as 10 years of age. Clinical signs
may be subtle. Intermittent gastrointestinal upset, lethargy, stunted growth, pica, or
neurologic signs such as circling, head pressing or seizures may be seen. In many
patients the first abnormality noted may be a slower than expected recovery from
anesthesia. Dysuria (from urate bladder stones) or even mild elevations in the liver
Cardiology
Alan Spier DVM, PhD, DACVIM
Nicole Piscitelli DVM
Sarah Silverman DVM
Critical Care
John Gicking DVM, DACVECC
Miryam Reems DVM, DACVECC
Terry Corona DVM
Juliet Gladden DVM
Jacqueline Nobles DVM
Dermatology
Michael Canfield DVM
Heather Willis-Goulet DVM, DACVD
Nadine Znajda DVM
Emergency Medicine
Kate Brammer DVM
Dee Ann Dugger DVM
Colleen Elligott DVM
Sonja Olson DVM
Allison Shreve DVM
Steve Tutela DVM
Marie Yakubik VMD
Xylitol: A not-so-sweet sweetener
XYLITOL APPEARS TO BE EVERYWHERE THESE DAYS. It has become popular as a sugar
substitute for human consumption. You can find it in chewing gum, baking
products, sugar free candy and weight loss food items. The reason for xylitol’s
popularity is that it is just
as sweet as sucrose but
lacks sucrose’s caloric
content and insulin
stimulating effects.
Xylitol is naturally found
in the fibers of many
fruits and vegetables. It
is presently produced for
mass consumption by
hydrogenation of xylose which has been extracted from wood and corn sources.
Xylitol first became popular in the 1800s when it was determined it could
be used as a sweetener for people with diabetes mellitus. More recently xylitol has
been shown to have significant dental benefits.
Studies have shown xylitol to inhibit streptococcus bacteria proliferation in
the mouth thereby slowing plaque formation and tooth decay. By alkalinizing the
saliva, xylitol also potentiates the deposition of calcium and phosphate salts into
dental enamel. It has consequently been gaining use in such products as
toothpaste, chewing gum, and mouthwashes. Other studies have suggested that
xylitol may be useful for inhibiting osteoporosis and the development of infections.
In one study, cats who drank water supplemented with xylitol demonstrated reduced
dental plaque and calculus formation.
Xylitol does not appear to be toxic to humans or cats. This is not the case
in dogs where it appears to excessively stimulate insulin release. Severe
hypoglycemia can develop as early as 30 minutes after ingestion or as late as 12
hours later, potentially leading to depression and seizures. The exact toxic dose for
dogs has not been determined. Clinical signs of hypoglycemia have been reported in
dogs ingesting >0.1 g/kg.
Recent reports also indicate that xylitol can cause liver necrosis in dogs.
Hypoglycemia is not a prerequisite for liver damage to occur. Signs of liver failure
could include loss of appetite, bleeding, and gastrointestinal upset. Most dogs will
demonstrate signs within 72 hours of xylitol ingestion. The toxic dose for potential
liver failure has been reported to be >0.5 g/kg. The mechanism for liver necrosis
remains undetermined.
Ameroid rings placed around the shunting
vessel slowly squeeze the vessel obstructing
blood flow.
Ultrasound demonstrating an irregular tortuous
shunt vessel
values on routine blood work in clinically normal dogs are reasons to consider the
possible presence of a PSS.
Bile acid testing should be considered in any patient with clinical signs or
blood work abnormalities compatible with a PSS. An excessively high post-prandial
bile acid value (usually greater than 100 mg/dl) should prompt a search for a PSS.
Imaging is typically performed to confirm the presence of a PSS.
Internal Medicine
Anthony Ishak DVM, DACVIM
Brian Luria DVM, DACVIM
Erick Mears DVM, DACVIM
Melanie Otte DVM, DACVIM
Cathy Meeks DVM
Neurology
Michael Kimura DVM, DACVIM
Oncology
Virginia Coyle DVM
Curtis Kane DVM
Ophthalmology
Tammy Miller Michau DVM, DACVO
Michele Stengard DVM, DACVO
Radiology & Diagnostic Imaging
Wendy Gwin DVM, DACVR
Val Sadler DVM, DACVR
You can find Xylitol in chewing gum, baking products,
sugar free candy and weight loss food items.
The immediate treatment for xylitol ingestion, similar to other toxicities,
should include the induction of emesis followed by the administration of activated
charcoal. Unfortunately xylitol is absorbed very rapidly after ingestion.
• The ingestion of a subtoxic dose of xylitol warrants observation and monitoring of
the dog for 24 hours.
• If a toxic dose of 0.1 – 0.5 g/kg is ingested, in-hospital observation and
monitoring of glucose and liver values should be performed. In patients with
significant hypoglycemia, intravenous fluids supplemented with glucose should
be administered until normal glucose concentrations can be maintained without
supplementation.
• For toxic dose > 0.5 g/kg, at least 72 hours of intravenous fluid therapy, frequent
monitoring of glucose and liver values, and the prophylactic administration of
hepatoprotectants such as s-adenosylmethionine and N-acetylcysteine are
suggested.
When in doubt about the quantity of xylitol ingested, aggressive treatment
should be considered as a precaution. Additional treatments will depend on the
patient’s clinical signs and lab results. Prolonged treatments will be required in
patients with significant liver damage. The prognosis would be at best guarded in
these patients.
Radiographs often show a small liver but otherwise are unremarkable. In our
experience, ultrasound examination of the abdomen has been very sensitive (8092% sensitivity) for identifying PSS’s. Ultrasound has also proven useful for
identifying other hepatic diseases, concurrent intra-abdominal abnormalities, and
urate bladder stones. Urate bladder stones will not typically appear on routine
radiographs. Other imaging methods used to confirm the presence of a PSS include
portal scintigraphy (the visualization of portal vascularity via radioactive dye
injected into the spleen), CT scanning, and mesenteric portography (the
intraoperative injection of radiopaque dye into a portal vessel for radiographic
viewing). In some patients, an exploratory surgery will be performed based on the
patient’s signalment, clinical signs, and blood work alone.
Surgery is the treatment of choice for a single PSS. Attenuation of the
shunting vessel, utilizing an ameroid ring or cellophane band placed around the
shunting vessel, or insertion of intravascular coils into the vessel, is the preferred
method of surgical treatment. The goal is to slowly decrease the volume of blood
flowing through the shunt vessel over time. Complete and immediate ligation of the
shunting vessel is no longer recommended due to complications of portal
hypertension, i.e. excessive backpressure within the portal circulation. Patients
Continued on next page.
Rehabilitation
Felicity Talbot DVM, CVA
Surgery
Helga Bleyaert VMD, DACVS
Michael Reems DVM, DACVS
Cory Pinel DVM
Nicole Salas DVM
Natasha Stanke DVM
Soft Tissue Sarcomas: An Exercise in Frustration
TUMORS CAN ARISE FROM A NUMBER OF DIFFERENT TISSUES within the submucosa. Many of
these tumors exhibit similar biological behavior. Consequently, pathologists will
frequently group them under the term soft tissue sarcoma. Examples of soft tissue
sarcomas include hemangiopericytomas, neurofibromas, peripheral nerve sheath
tumors, and fibrosarcomas.
Soft tissue sarcomas are typically classified as low, intermediate, or high
grade. These histopathologically defined categories are based on the appearance of the
most aggressive-looking portion of the tumor. The goal of this classification system is to
predict the local behavior and metastatic risk of the tumor. Most soft tissue sarcomas
are classified as low grade. High grade tumors are uncommon.
All grades of soft tissue sarcomas are locally invasive sending microscopic
tendrils from the main tumor out into the surrounding tissues. This can make it quite
difficult for these tumors to be completely surgically excised. With the exception of high
grade tumors most soft tissue sarcomas will not metastasize. The metastatic rate for
soft tissue sarcomas as a group approximates 10%. By contrast, high grade soft tissue
sarcomas have a 50% chance for metastasis.
Surgery is the preferred treatment for soft tissue sarcomas. However the
opportunity to achieve a surgical cure is frequently limited by the ability of the surgeon
to remove all the microscopic tendrils. The tendency for these tumors to develop on the
limbs or over the thoracic wall and vertebral column makes wide surgical excision
around these tumors difficult. If wide surgical margins are not obtained, regrowth of the
tumor is almost certain. The median survival time for dogs treated with surgery alone in
one report was less than 1.5 years.
When surgical excision of the soft tissue sarcoma is not complete, ancillary
therapy should be pursued as soon as healing has occurred. Most tumors will show
regrowth within months. Once the tumor starts to regrow it becomes more difficult to
treat. Therefore if the pet owner wishes to resolve the condition without removing the
pet’s leg, subsequent radiation therapy is recommended. Studies have demonstrated
that radiation therapy, when administered after debulking of visible disease, will
prevent regrowth of soft tissue sarcomas in up to 85% of patients for at least 5 years.
In most cases, this represents a cure.
The best time to treat a soft tissue sarcoma is when it is small or immediately
after it has been removed. Don’t wait for it to regrow. Should you have a patient with a
suspected soft tissue sarcoma, give us a call to discuss treatment options.
2011 Upcoming CE & Events
DATE:
TIME: TYPE:
TOPIC/SPEAKER:
LOCATION:
CE:
Jun 4
Jun 25
Jun 30
Jul 12
Jul 14
Jul 16
Jul 28
Aug 9
Aug 10
Aug 25
2pm
7pm
7pm
7pm
7pm
2pm
7pm
7pm
7pm
7pm
Urinalysis 101 / Jamie Blanchet CVT, VTS (SAIM)
Urinalysis 101 / Jamie Blanchet CVT, VTS (SAIM)
Critical Care Lecture Series: Seizure Management / Mike Kimura DVM, ACVIM (Neurology) & Sonja Olson DVM
Cruciate Disease – How to Diagnose & Treat / Mike Reems DVM, ACVS
New Classifications of Canine Heart Disease / Alan Spier DVM, ACVIM (Cardio)
Hemacytology – Preperation & Evaluation / Chastity Knopp CVT
Critical Care Lecture Series: General Toxicology / John Gicking DVM, ACVECC & Juliet Gladden DVM
New Classifications of Canine Heart Disease / Alan Spier DVM, ACVIM (Cardio)
Canine Liver Disease – How to Diagnose & Treat / Melanie Otte DVM, ACVIM
Critical Care Lecture Series: Does the Yellow Patient Need Surgery / Erick Mears DVM, ACVIM & Mike Reems DVM, ACVS
BluePearl Clearwater
BluePearl Brandon
BluePearl Tampa
BluePearl Clearwater
BluePearl Brandon
BluePearl Tampa
BluePearl Tampa
BluePearl Clearwater
BluePearl Brandon
BluePearl Tampa
1 hr
1 hr
2 hr
2 hr
1 hr
1 hr
2 hr
1 hr
1 hr
2 hr
Tech
Tech
Doctor
Doctor
Doctor
Tech
Doctor
Doctor
Doctor
Doctor
An end around the liver
Continued from page 3.
with extrahepatic shunts typically do well with shunt attenuation; 80 -85% of patients
achieving a successful outcome. By contrast, intrahepatic shunts can be difficult to
reach and have a success rate of generally 50%. Cats also do not do as well following
shunt attenuation.
Unfortunately, attenuation of the shunting vessels is not without potential
sequella. Acute hemorrhage, DIC, hypotension, ascites, hypoglycemia and seizures have
all been described. Long term complications may also develop after surgery including
chronic portal hypertension, inadequate attenuation of the shunt, and progressive liver
disease due to concurrent portal vein hypoplasia.
Another congenital condition characterized by the microvascular shunting of
blood within the liver, either in conjunction with macroscopic shunts or as a primary
entity, can mimic a PSS. This abnormality was initially called hepatic microvascular
dysplasia (HMD). More recently this condition has been termed portal atresia. Since there
is no shunt vessel to attenuate, medical management is the only treatment option.
Please don’t hesitate to give us a call if you are suspicious for the presence of a
PSS in one of your patients.
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3000 Busch Lake Blvd.
Tampa, FL 33614
BluePearl’s newsletters are produced for the Sunshine State’s veterinary community with support from Your Partners in Education: Abbott Animal Health, Antech
Diagnostics, Boehringer Ingelheim, Hill’s Pet Nutrition, Novartis Animal Health, Pfizer Animal Health, Stokes Pharmacy, Virbac Animal Health, Webster Veterinary