Friday, September 30, 2011

Bad calls

I got two bad calls by the judge at the trial today.  The bad call Lyric got was one of those "gifts" where you should have gotten a fault but didn't.  We were having a good run but just had one communication error and she pretty much came to a complete stop almost on top of a jump before we got going again.  I have no idea why we didn't get called for a refusal but we didn't. Some may make the argument that she hadn't seen the obstacle yet but she was in the last third of the approach so I'm not sure what the rule is on that.  So as far as I'm concerned, we got a "free" Q.  There are a lot of people, including me, who feel kind of guilty about taking those but the logic is that someday you will get a "bad" bad call to make up for it.

Fast forward to Legend's standard run.  We had a QQ and the last of our points to qualify for nationals on the line.  I thought we were clean but a friend informed me we got called on our dogwalk contact.  I know she was in the yellow-she was practically walking down the ramp and I was watching everything closely as I knew what we had on the line.  Stupid karma.  Let me tell you that "free Q guilt" fades really fast when your "rapidly approaching a MACH dog" gets cheated out of QQ!  I didn't ask the judge about it.  It's not on tape and it all comes out even in the end (or in this case by the end of the day).   And the judge may be just as sure that she was not in the contact. 

It is essentially inevitable that Legend will get her two nationals points and her 4 QQs but still...ok, end of ranting.  Tomorrow is another day.  The bottom line is that she ran great today.  We had a smooth as silk jumpers run on a course with very few Qs-quite proud of that.  Hopefully tomorrow she will run just as well and the a-frame and teeter boogiemen will stay far away this weekend. 

Lyric, while still struggling to be consistent in standard is getting into the groove of 24 inch weave poles.  She actually seems to be more comfortable in them that the 20 inch (or 22 or whatever) we have at home.  And I did a few nice rear crosses with her today so definitely some good parts. 

Wednesday, September 28, 2011

That's a good question

At work today a tech was asking if I missed not working on large animals.  And no, I don't.  I hate cows,  pigs are terrible patients,  horses (although I like them) can be dangerous and get sick at odd hours of the night.  Small ruminants are ok but there is not much market for that.  And then I got to thinking, I don't necessarily love small animal practice.  There are a lot of frustrations with this job.  The quality of medicine you practice will always be dictated by how much money the owners are willing and able to spend.  If you are an associate the quality of care is also dictated by the facility, equipment and support staff your employer provides.  If you own a clinic then there is a whole new set of issues to deal with.  And quite frequently working with the public is enough to make you want to bash your head against a wall.  And just think-I paid a significant amount of tuition money for this "honor."  I pay the equivalent of a nice car payment on my student loan every month, and will continue to do so for the next 4-5 years.  And I owed less than average.

If I was to choose a different path in vet med I would specialize in clinical pathology.  It would have been ideal to have pursued a residency right after vet school but the thought of 4-5 more years of "school" made me ill and I really thought I wanted to go into private practice.  There is actually nothing stopping me from pursuing this now but it would involve giving up my life, moving, taking a temporary pay cut, and then moving again to find a job.  Not interested.

I've recently been made aware that pharmacists make good money and work better hours than most vets.  While pharmacology is a challenging subject it is interesting and not one I would necessarily count out as a career choice.

I always said I would never go to medical school because people are "icky," but while watching my favorite crime-drama,  it occurred to me that being a medical examiner would be pretty cool.  Granted I would actually have to complete med school and a residency but once in the real world I couldn't accidentally kill anyone and I could help solve mysteries.  Sounds pretty win-win don't you think?

If I were to go outside the medical field altogether I would pursue a career in graphic art.  I love photography, drawing, painting, photoshop, being creative and designing handouts, brochures, websites, etc.  Working at a desk surely has advantages to to working with people, aggressive dogs and fractious casts. 

But don't get me wrong, private practice veterinary medicine is not a bad career choice, I don't hate it, and I'm not quitting. I'm just not convinced it's my "dream job." Maybe someday I will find or create the perfect practice. Either way, there are number of significant benefits to being a vet and a lot of days I do enjoy it.  It is a well-respected career, kids think it's cool, friends and family members think it's convenient.  I get to see more puppies and kittens in my day than the average person.  Despite what it seems like there are a significant number of people who take care of their pets, follow your recommendations and thank you for your help.  Some days you get to save a life.  The financial benefits to being able to care for my own pets are huge.  But more than that, actually being my own pets doctor might be the biggest benefit to me.  I have the advantage of a knowledge base that allows me to make sure they are getting the best care.  I can make sure I choose what I want for them in both wellness and preventive care as well as illness and injury.  I'm better prepared to make important and emotional decisions for them.  I don't have to trust that my vet is always giving me all my options, offering appropriate referrals, practicing the most up to date medicine, following modern surgical protocol and taking adequate care of my hospitalized pet. 

So, the big question I get asked is would I do it all over again?  I guess the good news is that as long as time travel is not a reality I don't have to make that decision.  The bad news is that I would, in fact, have to make a decision.  (That's just a fancy way of saying I don't really know and I don't want to think about it :)

Tuesday, September 27, 2011

Before she goes...

Here are some pics of Eva. They are all from my phone so not stellar but it's all I have for now.

She is really a sweetie and we will miss her. And if you feel like you missed out, don't worry, I have another cat available for adoption!

So my knees haven't really bothered me at all since I started running more seriously. Today though it just randomly started bothering me this afternoon. So I packed for the trial instead of going for a run. Hopefully by tomorrow it will be much better. And the weather should be nice this weekend but packing for "nice" aka "in-between" weather is kind of a pain-I ended up with an extra bag because I didn't know what to bring. Don't want to be unprepared.

And just randomly here is an albino fawn that was hanging out near the clinic. It appeared to have a broken leg but was getting along pretty well. The conservation department wasn't interested.

Sunday, September 25, 2011

This week

I finally managed to work the dogs some this week. Legend's discriminations were abysmal the first day but then she seemed to remember and they were much better the next. Lyric only worked discriminations one day-she worked pretty hard on her teeter and dogwalk the other day. But she struggled a lot the day we did do discriminations. Always something to work on.

Cheri and I ran a 5k on Saturday. It went a lot better than our last race. I took almost 3 minutes off my last race time and beat my goal time. Still a far cry from what I would consider "good" but it's amazing what some training can do huh? We are running another race in 2 weeks and then I probably won't race again until spring. I don't like racing in the cold-hurts my lungs. But I do plan on continuing the training as we plan to run a 10k next year.

Other than than had a pretty relaxing weekend, even rode Squirt for a few minutes. Now just 4 days of work and off to a 3-day trial plus taking Eva to her new home!

Thursday, September 22, 2011

Cancer Part 3: Osteosarcoma

Another bad one.

Osteosarcoma (OSA) is bone cancer.  It affects an estimated 8,000-10,000 dogs in the US each year and is more common in dogs than in any other species including humans.  OSA is most common in large to giant breed dogs and the most common location is the distal radius (forearm).  75-80% of OSA lesions are in the long bones of the limbs versus the other bones of the body except in small breed dogs where they occur in equal frequencies on the limbs vs other regions.  OSA of the mandible or distal to the carpus (wrist) or tarsus (ankle) may carry a slightly better prognosis.

The typical presentation is a large breed middle aged to older dog (although it can occur in younger dogs) with a sudden onset of lameness and/or a swelling in the limb that is not associated with a joint.  Presumptive diagnosis is frequently possible with radiographs alone.  Biopsy can used to confirm  the diagnosis but is often only performed it it will change the treatment plan as it increases the risk of a secondary fracture. 
OSA is not curable.  An estimated 90% of dogs have metastatic disease (often microscopic) at the time of diagnosis. The goals of treatment are pain management and control or slowing of metastatic disease.  Amputation alone is palliative (pain control) and results in a survival time of 4-5 months with a 1-year survival rate of 10%.  I don't have any data on survival with pain meds alone but it is likely similar to amputation or shorter as the drugs may be maxed out and still not controlling the pain or they may fracture the leg.  Considerations for amputation include does the dog have metastatic disease in other bones or does he have additional orthopedic problems-arthritis, cruciate tears, dysplasia that would make losing a leg difficult for him or her. 

Amputation plus chemo (various protocols) remains the gold standard of treatment.  Average survival times with the various protocols vary between 250-500 days with one year survival rates only reaching 50% at best.

Limb sparing surgeries are available for dogs who are not candidates for amputation and have similar success rates when combined with chemotherapy.  Radiation can also be used to provide pain control on dogs who are not pursuing amputation.  There has been a 70%  response rate in these dogs and it generally lasts for 2-3 months.  Typically dogs get 3-4 treatments, not the more aggressive 3-4 week course discussed before.

Additional chemo, radiation, and nuclear medicine therapies/protocols as well as other novel treatments are being investigated to try and give us better options for this devastating disease. 

OSA is rare in cats but carries a much better prognosis as it rarely metastasizes.  Many cases are cures by amputation/surgery alone.

Monday, September 19, 2011

Run Free...actually, please don't

I fail to understand why people let their dogs run loose.  We are the only people in our "neighborhood" with a fence and it's getting really old.  I simply don't understand the point of having a dog you allow to run loose 24/7.  If you don't care that at any given time your dog could be hit by a car, stolen, kicked by livestock or attacked by other dogs then how much can you really care about the dog?  It's probably littered with parasites and get no vet care either.  All the more reasons why I don't want it IN MY YARD!

Seriously why do people think it's ok to let their dog wander on someone else's property, harass that person's pets or livestock, pee on their plants and poop in the yard.  I mean the owners don't come in our yard and hang out, they don't let their kids in our yard, why let the dogs and all the associated feces in our yard? 

A few weeks ago a neighbor stopped by while I was mowing to ask if the long haired black and white dog running loose in the neighborhood was ours or did I know who it belonged too.  I have never seen this dog but I have seen her large black lab in our yard on a regular basis.  I pointed out that any dog belonging to us would be INSIDE THE FENCE.  She sheepishly admitted that although they try to keep their dog home they are not very successful.  I guess by try they mean they holler "stay" as they pull out of the driveway because they clearly don't have a fence and the dog is outside all the time. 

I wonder how all the irresponsible owners would feel if I start flinging poop back into their yards?  Ok, end of rant.

But speaking of running I have kept up with my goal of running more and training harder for the next 5k.  I'm excited to see how much I can improve my time this weekend and then again in October.  That will probably be all the races until spring-I don't like to run outside in the cold.  But next year sometime we plan to try a 10k!

Also about running, Eva is getting pretty quick on 3 legs.  Before long she will be as fast as the average cat!

Saturday, September 17, 2011

Cancer Part 2: Lymphoma

In the previous post we discussed lymph nodes as common places for cancer to metastasize to, but there can also be primary cancer of the lymphatic system.  This is known as Lymphoma or may sometimes be called Lymphosarcoma.   Dogs with Lymphoma (LSA) commonly present with the complaint of lumps, swellings or masses around the head and neck.  These are the submandibular and prescapular lymph nodes that the owners are feeling as they pet or groom their dog.  The diagram below shows the locations of the external lymph nodes you can feel in a dog.

Typically, once the veterinarian examines the dog they will find that most or all of the above nodes are enlarged.  There can be two reasons for this 1) systemic illness or infection (remember the lymph nodes clean or drain infection away from the cells) or 2) cancer of the lymph nodes=lymphoma.

Diagnosis can usually be made by cytology/fine needle aspirate but sometimes a surgical biopsy is needed.  Note than most dogs are feeling fine at the time of diagnosis.

This is what a cytology of lymphoma looks like
I tried to find a normal lymph node for comparison but that was harder than anticipated.

Enlargement of the lymph nodes is the most common form of LSA accounting for greater than 80% of cases.  Cutaneous (skin), splenic, intestinal and other extra-nodal forms make up the rest.  Lymphoma is one of the most common canine cancers and occurs in an estimated 24/100,00 dogs annually. 

While LSA typically affects middle aged to older dogs, this disease does not discriminate against age.  I have diagnosed dogs as young as 2-3 years old.  That's really not something you want to do-people do not expect their tail-wagging two-year old dog to be diagnosed with a terminal illness.  Breeds with increased incidence include Boxers, Bassets, St. Bernards, Airedales, and Bulldogs. 

LSA is a rapidly progressive disease.  Without treatment survival times are approximately 1 month.  Treatment options include prednisone, single agent chemotherapy or multi-drug chemotherapy.  Prednisone alone can extend survival to 2-3 months.  This is a very inexpensive option for owners who don't want or are unable to pursue traditional chemotherapy.  Multi drug protocols are the most successful with 60-80%  of dogs obtaining remission. There are a variety of protocols available, many of which involve weekly or twice monthly treatments sometimes with oral medications given daily.  These protocols can involve a significant time and financial commitment on the part of the owner but can achieve survival times of up to 12 months. 

Incidence of feline lymphoma is estimated to be 200/100,000 annually.  Feline lymphoma is not typically limited to the nodes but can include internal organs, intestines, blood and bone marrow.  A significant amount of cats with lymphoma are Feline Leukemia positive.  Radiation therapy is appropriate for certain forms of lymphoma with multi drug chemo protocols being used for the rest.  Remission rates are approximately 60% with an average 40 week survival time.

Wednesday, September 14, 2011

Cancer Part 1: The basics

I know.  No one wants to hear about cancer.  But this topic, along with all the diagnostics and treatments can be very overwhelming, especially when you are faced with an emotional decision of what to do when your pet is diagnosed with something undesirable.  So with the idea that knowledge is power I plan to do a series of posts of cancer to hopefully clear up a lot of confusion and questions people may have.  Although hopefully no one ever needs to use most of this information!

What is cancer?
Cancer, or neoplasia, is any growth (collection of cells) that have mutated in such a way that they multiply out of control.  These growths can be benign or malignant.  Benign masses are those that don't spread (metastasize), recur after removal, and generally don't invade or destroy surrounding tissues.  Malignant neoplasms are the bad ones-these can spread to other organs, grow rapidly and destroy normal tissues.

So what causes cancer? This is the hardest to answer and at the same time the easiest! Mutations cause cancer. Something in cell division goes wrong and the genes that control further division are no longer working. There are many checks and balances in cell division that repair damaged DNA so that a single mutation is no big deal. It usually requires about 3 mutations before things go haywire. But what causes the mutations? That's the hard one. It's likely a combination of genetics, environment, age, and luck. But no one really knows for sure.

Diagnosing Cancer

Diagnosis of cancer can vary widely.  One of the easiest tests is a Fine Needle Aspirate or Needle Biopsy.  This is a quick test that can be performed with little discomfort to the pet.  Essentially some cells from the mass are sucked into a syringe and sprayed on a slide which is then stained and evaluated.  Sometimes a definitive diagnosis can be reached with just this test.  Sometimes only enough information is gained to decide more testing needs to be done or cancer can be ruled out completely.  Some doctors will look at the slide themselves and some will send to a pathologist.  I will usually look at it and if I'm not sure what it is or I need a second opinion I will send it out. 

Surgical biopsies are probably the most common route of making a diagnosis.  Depending on the size and location the biopsy might be incisional (taking only a piece) or excisional (taking the whole mass).  If a benign mass is removed in it's entirety an excisional biopsy may be curative as well.  Biopsies differ from cytologies (needle aspirates) because the pathologist can look at the tissue structure, evaluate the margins (to see if it was all removed) and grade the tumor on how aggressive it is.  These must be sent to a pathologist where this tissue is sliced into thin pieces, stained and evaluated under the microscope.

For internal tumors other diagnostic procedures are used.  Radiographs or x-rays are usually the first screening test for suspected internal masses.  Radiology is limited in that it is two-dimensional and only shows shades of gray and shapes or outlines of organs and masses.  Ultrasound can help determine more about a mass such as where is comes from and what the structure is like (solid, cystic, etc).  Ultrasound can also be used to for guided needle biopsies of internal masses (so you know where you are sticking!).

Sometimes exploratory surgery is warranted to get a diagnosis or remove the tumor so it can be sent for biopsy. 

For some masses more advanced imaging such at CT or MRI are needed.  These can help determine the extent of the tumor and evaluate tumors in places that are not easily accessible such at the brain, nasal passages or spinal cord.  This information is often used in determining what treatment options are available and in planning radiation therapy. 

Treating Cancer
Treatment options are widely varied but the three most common are surgery, radiation, and chemotherapy or a combination of these.  As mentioned before the goal of surgery can be two-fold: get a diagnosis and cure if possible.  When removing a mass we try to get "clean" margins.  This means getting all the tumor cells so we try to plan our incision in such a way as to get some extra normal tissue when we remove the mass.  We are lucky in that dogs and cats have a lot of extra skin so this is quite frequently possible.  Sometimes though when the mass is in more difficult areas such as the tail or legs we are not able to get the entire mass.  Amputation or adjunctive chemo or radiation may be needed in some of these cases.  Removal of internal masses varies depending on what organ the mass originates from. 

Chemotherapy is commonly used in several types of neoplasia.  People frequently ask if chemo in dogs is like chemo in people.  And the answer is yes, and no.  In dogs we tend to not be as aggressive with chemo as we are in people.  Part of the reason for this is that dogs don't have a lifespan of 80 years.  So if we can give a geriatric dog 12-18 months of quality life that's considered a good success, by then the dog may have reached the end of his life anyway.  In a person we are often trying to get 10-30 years or more of quality  life so treatments are more aggressive.  Most of the time chemotherapy in veterinary medicine is not going to get you a cure, just time. 

But, that being said the biology of chemo is the same in animals and humans.  Chemo targets rapidly dividing cells (ie cancer cells).  Other rapidly dividing cells include bone marrow, the GI tract and hair follicles so these systems are subject to side effects.  Red and white blood cells and platelets are all made in the bone marrow-this is why a complete blood count (CBC) is monitored during chemotherapy.  If the blood counts get too low it makes it easy for the patient to become ill, and hard for them to fight infection if they become ill.  The destruction of the GI lining is why chemo patients have nausea and vomiting but we have excellent drugs to overcome these issues. Now, about the hair.  Generally speaking dogs don't lose hair (not all their hair anyway) on chemo.  Remember, only about 1/3 of the hairs are growing at any time-the rest are already falling out or dormant.  So, mostly you won't notice any abnormal hair loss during chemo.  The exception is continuously growing breeds such as poodles, these dogs might lose a lot of hair.

Cost of chemo can vary widely-some are very cheap, some are very expensive.  And many protocols require multiple drugs.  Some clinics don't perform chemo treatments and the time and expense of traveling to the referral facility must be factored in.  In addition to the cost of the drugs there is also the cost of the required monitoring bloodwork which will vary with the protocol and drugs used.  And although most drugs are administered via injections, some are given orally at home.

Radiation therapy is frequently used when complete excision is not obtained or where surgery is not an option and/or the type of tumor is not chemo responsive.  A benefit to radiation is that the beam is targeted at the affected area and there are not systemic effects as there are with chemo.  However any structure near the beam can be damaged.  For example if the radiation site is near the eye the tear ducts or lacrimal gland can be damaged.  Radiation in the oral cavity can cause ulcers or tongue sores.  Hair will frequently not regrow in areas of radiation.

Traditional radiation therapy involves treatment up to 5 days a week for about 4 weeks.  Radiation must be done at a special facility and is expensive.  If you don't live near the facility it can mean leaving your pet for days or weeks at a time for treatment.  Also, because pets don't sit still radiation require anesthesia for every treatment.  Not all pets are candidates for this.  So, while this can be a very useful and often painless treatment option there are several limiting factors.

Other treatment options or variations of these treatment options exist but are outside the scope of this post and are best discussed with an oncologist.  The best treatment for your pet is the one that meets your goals while taking into consideration your pet's comfort level and condition as well as your financial situation and lifestyle.

Staging of the cancer is one of the important steps in determining both prognosis and treatment options.  Staging means determining how much, if at all, the disease has spread.  Although cancer cells can in theory spread (metastasize) to anywhere, the two most common places are the local lymph nodes and the lungs.  Lymph is a fluid that bathes most tissues of the body and essentially  acts as a "cleaner" draining infections, dead cells and other "trash" from the body.  Cancer cells travel through the lymph vessels and then set up shop in the closest lymph node to the mass.  There are nodes on the outside of the body that you can feel if they become enlarged and these can be checked via needle aspirate or biopsy for tumor cells.  Internal lymph nodes are harder to check.  If they are grossly enlarged they  might show up on radiographs or if surgery is being performed they can be checked at that time.  Cancer spreads to the lungs because all blood circulates through them so any tumor cells traveling in the blood stream will eventually end up there and can get stuck in the tiny capillaries and start proliferating.  Therefore, thoracic radiographs are another tool used in staging.  Abdominal films are also sometimes done depending on the type of tumor, location, and expected behavior.  One additional note on checking for metastatic disease-while radiographs clear of metastatic disease is obviously good, it is not a guarantee that there is no spread of disease.  A metastatic lesion must reach a certain size (a certain number of cells) before it shows up on the x-ray.  The same is true of a lymph node-it can easily have some irregular cells in it without being enlarged.  This is why chemo may be frequently recommended in cases even where the met check is clean.

So that was pretty long but I think it gives a start in the understanding of cancer.  Next we will discuss individual diseases.

Tuesday, September 13, 2011

Just for fun

I ended up with the afternoon off since work was slow.  So I have been looking through old pics on my computer.  I thought I'd share some just for fun.  Most of my really old photos are not digital and I didn't feel like doing any scanning but here's what I came up with.

A long lost photo of Oreo
 Zodiac when he was younger and not so gray!

 Legend the year we got her
 Posing for her ILP pics
 Graduation day-the mules were our vet school mascots
 Squirt over the years

 Jelly-much younger
 My four boys

Sunday, September 11, 2011

Still Four

We spent two days at the Agility Ability trial in Lawrence this weekend.  And other than being a nice social outing, it was not a big success.  The girls did each pick up jumpers Qs on Friday but we totally struck out on Saturday.  Although admittedly I NQ'd both dogs in jumpers by being unable to remember the course correctly.  After we finished I was really glad I was going home because the last thing I wanted to do was run another day after all that.  So we still need 4 QQ's.  And   I was hoping to at least finish up the last few points we needed to qualify for AKC nationals but at least I knocked it into the single digits.  We'll get there.

And although I'd be by happy to finish our MACH anytime, anywhere I kind of wanted to do it at Columbia because they give out black and gold, Mizzou themed bars-how cool would that be for an alumni? So I had it worked out that we needed one double every trial between now and then to have 19 going into that weekend.  Now I'm one behind so we need two doubles at one of the next 3 trials including Columbia.  So, we shall see...

We have a few weeks to train before our next trial and I'm glad for the little mini break and after two trials so close together-we only had 3 days off between the last two since I did Monday and then started again on Friday.

And I have not updated on Eva in awhile.  She's doing great on her three legs.  She's out of her splint now (by her own doing) and getting around better all the time.  We still keep her pretty confined as the fracture is stable but not fully healed.  Soon she will get spayed and sent off to what sounds like a great new home.  They are reportedly very excited about her and I'm sure she will be very happy and spoiled. 

Monday, September 5, 2011

Sweet Sixteen

I would say that Legend again made me wait until the last day of the trial to get a QQ but since I single handedly blew a QQ on Saturday I guess that's not really the case!

We had a great weekend at the Triune agility trial this weekend in Blue Springs.  The weather was warm on Saturday and then we had some rain but yesterday and today were perfect-windows open at the trial site and everything. 

Plus, the girls ran great.  They nailed weave poles every run, attacked the teeter in all their standard runs, did the table nicely and Legend did all her A-frames.  Plus they had a great attitude and good times all three days.

Lyric was a little wild first thing Saturday and did a few extra laps around the ring  but was super fast!  The Saturday jumpers course was tough and she gave it a good try but had a few bobbles.  Sunday though, she got her first QQ! Today she was a bit distracted by something to sniff  in the ring in standard but did get another Q in jumpers on another challenging course.

Saturday Legend had a beautiful run in standard.  But....I forgot to turn soon enough to the weave poles and when I did turn at the last minute I plowed in to her pretty hard.  I guess the judge felt I was aiding the dog by knocking her back onto the course and we NQ'd.  But she still made the weave pole entrance despite the horrible angle I gave her and nearly getting knocked down!  She went on to Q in the tough Jumpers course so I was super bummed about that one.  Yesterday she also Q'd in jumpers but had two off courses in standard.  Today we picked up not only a QQ #16 but a third place in standard-we don't place much in the 20 inch excellent B class!

This picture is after I ran into her-I was laughing about the collision and also happy that she still got the entrance.

These photos were scanned so they are not the greatest quality, but still cute!