I recently gave a lecture at the Western Veterinary Conference called “What You Know that Ain’t Necessarily So.” The purpose of this was to take some common or controversial beliefs and practices in veterinary medicine and discuss the scientific evidence pertaining to these. This was not intended as a definitive, “final word” on these subjects, but as an illustration of how weak and problematic the evidence often is even behind widely held beliefs. In some cases, these practices or ideas may actually be valid, but without good quality scientific evidence, we should always be cautious and skeptical about them.

Eventually, I will post recordings of the presentations themselves, but for now I am posting a summary of each topic.

Each starts with a focused clinical question using the PICO format.

P– Patient, Problem Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I– Intervention Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

This is then followed by a summary of the evidence available at each of the levels in the following pyramid (which is a pragmatic reinterpretation of the classical pyramid of evidence that is a bit more useful for general practice veterinarians).

Finally, I list the Bottom Line, which is my interpretation of the evidence.

Antibiotics, Endocarditis, & Dentistry

1. Clinical question

P- dogs & cats with periodontal disease

I- prophylactic antibiotics with dentistry

C- no antibiotics with dentistry

O- incidence of bacterial endocarditis

2. Synthetic Veterinary Literature

a. No systematic reviews:
b. No critically appraised topics

c. Guidelines-

…use of a systemically administered antibiotic is recommended to reduce bacteremia for animals that are immune compromised, have underlying systemic disease (such as clinically-evident cardiac, hepatic, and renal diseases) and/or when severe oral infection is present.

American Veterinary Dental College

3. Primary Veterinary Literature

Retrospective review of records for ~59,000 dogs with periodontal disease

periodontal disease was associated with cardiovascular-related conditions, such as endocarditis and cardiomyopathy.

• Concerns about diagnostic criteria
• Many data inconsistent with previous findings
• Study design not appropriate to establish causal relationship

Glickman, L.T. (2009)

• Retrospective case (70)/control(80) study
• No association between dental disease or Tx and endocarditis

Peddle, G.D. (2009)

4. Human Literature

a. Systematic Reviews

There remains no evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect.

Glenny, A.M. (2013)

b. Clinical Practice Guidelines

Today, antibiotics before dental procedures are only recommended for patients…who have:

• A prosthetic heart valve or who have had a heart valve repaired with prosthetic material.
• A history of endocarditis.
• A heart transplant with abnormal heart valve function
• Certain congenital heart defects

American Heart Association

Antibiotic prophylaxis against infective endocarditis is not recommended:

• for people undergoing dental procedures
• for people undergoing non-dental procedures at the following sites:
• upper and lower gastrointestinal tract
• genitourinary tract
• upper and lower respiratory tract

Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures.

National Institute for Health & Care Excellence

Bottom Line

• Endocarditis is rare
• Dental treatment is probably not a major risk factor for endocarditis
• Antibiotics with dentistry are probably not useful in preventing endocarditis

Fun Fact!

• Antibiotics with dentistry are probably not useful in preventing endocarditis
• Overall bacteremia in 6 blood samples-
• Extraction + amoxicillin- 56%
• Extraction + placebo- 80%
• Toothbrushing- 32%

Although amoxicillin has a significant impact on bacteremia resulting from a single-tooth extraction, given the greater frequency for oral hygiene, toothbrushing may be a greater threat for individuals at risk for infective endocarditis.

Lockhart, P.B. (2008)

References
Glenny AM, et al. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database Syst Rev. 2013 Oct 9;10:CD003813.

Lockhart, PB. et al. Bacteremia Associated With Toothbrushing and Dental Extraction. Circulation. 2008; 117: 3118-3125.

Peddle GD, et al. Association of periodontal disease, oral procedures, and other clinical findings with bacterial endocarditis in dogs. J Am Vet Med Assoc. 2009 Jan 1;234(1):100-7.

Glickman LT, et al. Evaluation of the risk of endocarditis and other cardiovascular events on the basis of the severity of periodontal disease in dogs. J Am Vet Med Assoc. 2009 Feb 15;234(4):486-94.

I recently gave a lecture at the Western Veterinary Conference called “What You Know that Ain’t Necessarily So.” The purpose of this was to take some common or controversial beliefs and practices in veterinary medicine and discuss the scientific evidence pertaining to these. This was not intended as a definitive, “final word” on these subjects, but as an illustration of how weak and problematic the evidence often is even behind widely held beliefs. In some cases, these practices or ideas may actually be valid, but without good quality scientific evidence, we should always be cautious and skeptical about them.

Eventually, I will post recordings of the presentations themselves, but for now I am posting a summary of each topic.

Each starts with a focused clinical question using the PICO format.

P– Patient, Problem Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I– Intervention Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

This is then followed by a summary of the evidence available at each of the levels in the following pyramid (which is a pragmatic reinterpretation of the classical pyramid of evidence that is a bit more useful for general practice veterinarians).

Finally, I list the Bottom Line, which is my interpretation of the evidence.

Immune-mediated Blood Disease & Vaccination

1. Clinical question

P- healthy dogs & cats

I- routine vaccinations

C- no vaccination (fewer)

O- incidence of Immune-mediated hemolytic anemia (IMHA) and immune-mediated thrombocytopenia (ITP)

1. Synthetic Veterinary Literature
   a. No systematic reviews:
   b. No CATs
2. Primary Veterinary Literature

• Case/control study
• Cases more likely to be vaccinated in previous month (26%) than controls (7%)
• Did not r/o pre-existing disease

Duval, D. (1996)

• 10% of cases vaccinated within 1 month
• No difference between cases and controls in time from vaccination to presentation

Carr, A.P. (2002)

• Proportion of dogs vaccinated within 2 months of onset not different between cases and controls
  • Cases- 16.1%
  • Controls- 44.4%

Davidow, E.B. (2004)

• Proportion of dogs vaccinated within 42 days of onset not different between cases and controls-
  • Cases- 8%
  • Controls- 14%

Huang, A.A. (2012)

• 4% vaccinated within 2 weeks
• Not primary purpose of study

Reimer, M.E. (1999)

• 2.4% vaccinated within 2 weeks
• Not primary purpose of study

Klag, A.R. (1993)

3. Human Literature
a. Systematic Reviews

• Database of 4.2 million children
• 55 cases of IMHA reported 1991-2001
• No association with vaccination

Naleway, A.L. (2009)

• ITP only associated with MMR
• 1-3 children per 100,000 doses
• This is lower than the rate of ITP caused by the diseases MMR prevents! (1:3000 to 1:6000 cases)

Cecinati, V. (2013)

Bottom Line

• Little evidence vaccination causes IMHA/ITP
• No consistent temporal association
• Data are weak
• Overwhelming majority of vaccinated animals do not develop these diseases
• Infection can be a greater risk for IMHA/ITP than vaccination
• Don’t vaccinate more than necessary
• Don’t vaccinate less than necessary
• Don’t avoid vaccination out of fear of IMHA/ITP

Reference

Carr AP, et al. Prognostic factors for mortality and thromboembolism in canine immune-mediated hemolytic anemia: A retrospective study of 72 dogs. J Vet Internal Med.2002;16:504-509.

Cecinati V. Hum Vaccin Immunother. Vaccine administration and the development of immune thrombocytopenic purpura in children. 2013 May;9(5):1158-62.

Davidow EB, et al. Risk factors for development of IMHA-A prospective case-control study. Abstract. VECCS 2004.

Duval D et al. Vaccine-associated immune-mediated hemolytic anemia in the dog. J Vet Internal Med. 1996;10:290-295.

Huang AA, et al. Idiopathic immune-mediated thrombocytopenia and recent vaccinations in dogs. JVIM 2012; 26: 142-148.

Klag AR, et al. Idiopathic immune-mediated hemolytic anemia in dogs: 42 cases (1986-1990). J Am Vet Med Assoc. 1993;202:783-788.

Naleway AL. et al. Risk of immune hemolytic anemia in children following immunization. Vaccine. 2009 Dec 9;27(52):7394-7.

Reimer ME, Troy GC, Warnick LD. Immune-mediated hemolytic anemia: 70 cases (1988-1996). J Am Anim Hosp Assoc. 1999;35:384-391

I recently gave a lecture at the Western Veterinary Conference called “What You Know that Ain’t Necessarily So.” The purpose of this was to take some common or controversial beliefs and practices in veterinary medicine and discuss the scientific evidence pertaining to these. This was not intended as a definitive, “final word” on these subjects, but as an illustration of how weak and problematic the evidence often is even behind widely held beliefs. In some cases, these practices or ideas may actually be valid, but without good quality scientific evidence, we should always be cautious and skeptical about them.

Eventually, I will post recordings of the presentations themselves, but for now I am posting a summary of each topic.

Each starts with a focused clinical question using the PICO format.

P– Patient, Problem Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I– Intervention Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

This is then followed by a summary of the evidence available at each of the levels in the following pyramid (which is a pragmatic reinterpretation of the classical pyramid of evidence that is a bit more useful for general practice veterinarians).

Finally, I list the Bottom Line, which is my interpretation of the evidence.

Pre-anesthetic Bloodwork in Healthy Animals

1. Clinical question

P– healthy dogs & cats

I– routine cbc/chem before anesthesia

C– no bloodwork

O– mortality, complications, change plan

2. Synthetic Veterinary Literature

a. Systematic Reviews- none
b. CATs- none
c. Guidelines- none

3. Primary Veterinary Literature-

• cbc/biochemistry profiles for 1537 dogs
• university surgery population
• variety of ASA stages
• No indication in PE/Hx for labwork in 84%
• Recategorized in ASA level- 8%
• Procedure postponed- 0.8%
• Additional therapy- 1.5%
• Change in protocol- 0.2%
• Complications in 1.9% of patients
  • Lab values normal or unrelated in 84% of these
  • 3.8% incidence with lab abnormalities
  • 1.8% incidence with normal labs (no statistical difference)

The changes revealed by pre-operative screening were usually of little clinical relevance and did not prompt major changes to the anaesthetic technique…In dogs, pre-anaesthetic laboratory examination is unlikely to yield additional important information if no potential problems are identified in the history and on physical examination.

(Alef, 2008)

• 101 dogs
• Private practice
• > 7 years of age (avg=11)
• Routine and emergent cases
• 87% had no pre-existing conditions
• New problem found- 29.7%
• Anesthesia cancelled- 12.9%
• Further tests- 5.9%
• Euthanized- 4%
• Procedure postponed- 1%
• Additional therapy- 1%
• Age did not predict abnormalities
• Abnormalities not associated with complications

This study concluded that screening of geriatric patients important and that sub-clinical disease could be present in nearly 30 % of these patients. The value of screening before anaesthesia is perhaps more questionable in terms of anaesthetic practice but it is an appropriate time to perform such an evaluation.

(Joubert, 2007)

• 100 cats > 6 years old
• Not pre-anesthetic screening, just general screening
• No know abnormalities on Hx
• Many not normal on PE
• Lots of abnormalities
  • 13% increased wbc
  • 29% increased creatinine
  • 15% increased BUN
  • 25% increased glucose
  • 4% increased T4
  • 6% increased ALT

Some new diagnoses

• 14% FIV positive
• 2% CKD
• 1% hyperthyroidism
• 1% UTI
• Relevance to pre-anesthetic screening?
• Some abnormalities were related to choice of reference interval
• Many abnormalities were clinically irrelevant
• Not truly screening since some had PE abnormalities

(Paepe, 2013)

4. Human Literature

a. Systematic Reviews

CBC

• Abnormal <1% to 5%
• Change protocol- 0.1% to 2.7%

Hemostasis

• Abnormal 3.8-15.6%
• Change protocol- rarely

Biochemistry

• Abnormal <1% to 5%
• Change protocol- rarely

Urinalysis

• Abnormal 1-35.1%
• Change protocol- 1% to 2.8%

The tests reviewed produce a wide range of abnormal results, even in apparently healthy individuals.

The tests lead to changes in clinical management in only a very small proportion of patients, and for some tests virtually never.

The clinical value of changes in management which do occur in response to an abnormal test result may also be uncertain in some instances.

The power of preoperative tests to predict adverse postoperative outcomes in asymptomatic patients is either weak or non-existent.

For all the tests reviewed, a policy of routine testing in apparently healthy individuals is likely to lead to little, if any, benefit.

The clinical importance of many of these abnormal results is uncertain.

(Munro, 1997)

b. Guidelines

• Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery
• Performing routine laboratory tests in patients who are otherwise healthy is of little value in detecting disease.
• Evidence suggests that a targeted history and physical exam should determine whether pre-procedure laboratory studies should be obtained.
• American Society of Anesthesiologists

Bottom Line

• If you test, you will find abnormalities
• The clinical significance of these abnormalities is unclear
• You will find more abnormalities if pre-test probability is high
• Indication for test in Hx
• Abnormality on PE
• There is no evidence testing healthy patients reduces morbidity or mortality

What’s the harm?

• Expense
• Risk of testing
• Overdiagnosis
• Expense
• Stress
• Direct harm

References

Alef, M.; Praun, F. von; Oechtering, G. Is routine pre-anaesthetic haematological and biochemical screening justified in dogs? Veterinary Anaesthesia and Analgesia 2008 Vol. 35 No. 2 pp. 132-140

Munro J, et al. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess. 1997;1(12):i-iv; 1-62.

Paepe D, et al. Routine health screening: findings in apparently healthy middle-aged and old cats. J Feline Med Surg. 2013 Jan;15(1):8-19.

Joubert K.E., Pre-anaesthetic screening of geriatric dogs. J S Afr Vet Assoc. March 2007;78(1):31-5.

I recently gave a lecture at the Western Veterinary Conference called “What You Know that Ain’t Necessarily So.” The purpose of this was to take some common or controversial beliefs and practices in veterinary medicine and discuss the scientific evidence pertaining to these. This was not intended as a definitive, “final word” on these subjects, but as an illustration of how weak and problematic the evidence often is even behind widely held beliefs. In some cases, these practices or ideas may actually be valid, but without good quality scientific evidence, we should always be cautious and skeptical about them.

Eventually, I will post recordings of the presentations themselves, but for now I am posting a summary of each topic.

Each starts with a focused clinical question using the PICO format.

P– Patient, Problem Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I– Intervention Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

This is then followed by a summary of the evidence available at each of the levels in the following pyramid (which is a pragmatic reinterpretation of the classical pyramid of evidence that is a bit more useful for general practice veterinarians).

Finally, I list the Bottom Line, which is my interpretation of the evidence.

1. Clinical question

P– dogs with naturally occurring mitral valve disease (MVD)

I– angiotensin-converting enzyme inhibitor (ACE-I) before onset of congestive heart failure (CHF)

C– no ACE-I before onset CHF

O– time to CHF, survival

2. Synthetic Veterinary Literature

a. Systematic Reviews- none

b. Critically Appraised Topics (CAT)-

Best Bets for Vets
Benazepril in dogs with asymptomatic mitral valve disease
(1 study, significant weaknesses)

There is insufficient evidence to suggest that dogs with asymptomatic mitral valve disease treated with benazepril will live longer.

3. Primary Veterinary Literature

Long-term treatment with enalapril in asymptomatic dogs with MVD and MR did not delay the onset of heart failure regardless of whether or not cardiomegaly was present at initiation of the study.

(Kvart, 2002) SVEP: Scandinavian Veterinary Enalapril Prevention Trial

Chronic enalapril treatment of dogs with naturally occurring, moderate to severe MR significantly delayed onset of CHF…Improvement in the primary endpoint, CHF-free survival, was not significant. Results suggest that enalapril modestly delays the onset of CHF in dogs with moderate to severe MR.

• No difference in primary endpoint (time to CHF)
• Questionable secondary endpoint (all-cause mortality)
• Selective exclusion of some subjects from analysis
• Questionable selection of time points for comparisonBNZ had beneficial effects in asymptomatic dogs other than CKC and KC affected by MVD with moderate-to-severe MR.

(Atkins, 2007) VETPROOF

• No difference overall in development of CHF or “cardiac events”
• Questionable endpoints (all-cause mortality)
• Differences between groups in disease severity

(Pouchelon, 2008)

4. Human Literature-

a. Systematic Reviews

CE inhibitors…reduced the RF, RV, and left ventricular size by a modest degree in chronic primary MR.. and may offer a pharmacologic treatment option to delay the deleterious hemodynamic effects of left ventricular volume overload.

(Strauss, 2012)

b. Guidelines

• In the asymptomatic patient with chronic MR, there is no generally accepted medical therapy.
• There has not been a consistent improvement in LV volumes and severity of MR in the small studies that have examined the effect of ACE inhibitors.
• in the absence of systemic hypertension, there is no known indication for the use of…ACE inhibitors in asymptomatic patients with MR and preserved LV function.
• If LV systolic dysfunction is present, primary treatment of the LV systolic dysfunction with drugs such as ACE…[has] been shown to reduce the severity of functional MR
• (American College of Cardiology/American Heart Association, 2006)

Bottom Line–

• Research is conflicting
• Cardiologists disagree
• Critical review of the evidence does not suggest ACE-I
  • Delay onset of CHF
  • Prolong survival when begun before CHF

References

Atkins CE, et al. Results of the veterinary enalapril trial to prove reduction in onset of heart failure in dogs chronically treated with enalapril alone for compensated, naturally occurring mitral valve insufficiency. J Am Vet Med Assoc. 2007 Oct 1;231(7):1061-9.

Kvart C, et al. Efficacy of enalapril for prevention of congestive heart failure in dogs with myxomatous valve disease and asymptomatic mitral regurgitation. J Vet Intern Med. 2002 Jan-Feb;16(1):80-8.

Pouchelon JL, et al. Effect of benazepril on survival and cardiac events in dogs with asymptomatic mitral valve disease: a retrospective study of 141 cases. J Vet Intern Med. 2008 Jul-Aug;22(4):905-14.

Strauss CE, et al. Pharmacotherapy in the treatment of mitral regurgitation: a systematic review. J Heart Valve Dis. 2012 May;21(3):275-85.