GVS Newsletter |
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| Fall 2000 | Volume
2 Issue 2 |
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Georgia
Veterinary Specialists News |
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Meet Our New Surgeon at GVS Dr. Julie M. Duval received her BS, Magna cum laude, (Zoology major) from Duke University, Durham, NG-and her VMD, Summa cum laude from the University of Pennsylvania. She completed her residency in small animal surgery at University of Georgia in 1994 and became board certified by the American College of Veterinary Surgery in 1995. She spent two years as a clinical instructor/faculty at the University of Pennsylvania from 1994-96. Julie is a member of AVMA, ACVS, and Veterinary Orthopedic Society. She has numerous professional publications in veterinary journals including JAAHA, JAVMA, and AJVR; she also enjoys providing continuing education presentations and lectures. Her special interests are portosystemic shunts, reconstructive surgery (soft tissue surgery) and antibiotic use in surgery. When Julie is not working, she spends time away from the practice with her spouse Derek, also a veterinary specialist, two children, ages 1 and 4 years and their family pets. Meet Our New Internist at GVS Dr. Derek S. Duval received his BS, Magna cum laude, (Mathematics & Biology) and VMD from the University of Pennsylvania. He completed his internship at University of Georgia and stayed on as a Clinical instructor for two years in the medicine department. Derek Duval returned to the University of Pennsylvania where he completed his residency in small animal internal medicine in 1996.He is a board certified specialist in small animal veterinary internal medicine and is published in NIM, Vet Clin Path, Compendium on Continuing Education, Feline Practice, ACVIM -Proceedings 1997 and look for his upcoming publication in The 5 Minute Veterinary Consult, second edition due in 2000. Derek's professional interests are gastroenterology, hematology and oncology. When he is not publishing, he finds time to enjoy Aikido, Iaido, home brew and herpetology. Derek Duval makes up the other half of the Duval duo, Julie Duval and their family. GVS
Welcomes It's Third Intern Class
GVS began it's third intern program in July of this year. Our new intern class has grown during the past two years and we invite you to join us in welcoming our six new veterinarians to GVS, Seth Cohen, Barbara Gertz, Sara Love, Rosemary Lombardi, Michael Nawrocki, and Kelli Weaver. See below for more information about our interns. Receiving
Schedule Update
GVS Internal Medicine Service Dr. Mark Dorfman's receiving schedule is Monday, Tuesday, Wednesday and Thursday. Dr. Meri Miller's receiving schedule is Wednesday, Thursday and Friday. Dr. Derek Duval's receiving schedule is Monday, Tuesday, Wednesday and Friday each week. Feel free to contact our customer service representatives regarding referral information and appointment schedule availability of our specialists. GVS
Internal Medicine Service Is Growing!
Derek S. Duval, VMD, DACVIM joined Mark Dorfman, DVM, DACVIM, and Meri Miller, DVM, DACVIM on the Internal Medicine Service at GVS. With the addition of Dr. Duval the medicine service has expanded its' range of services to our clients as well as appointment availability and consultation and diagnostics to support our referring veterinarians and the extension of quantity & quality care to their clients. Dr. Duval enjoys the practice of internal medicine and sharing his talent and expertise along with his team members. To consult with Dr. Duval feel free to contact him at 404-459-0903 ext. 305. What's
New in the GVS Surgery Service
Julie M. Duval, YMD, ACVS joined Jenifer Newton, DVM, ACVS, Chief, GVS Surgery Service in early June of this year. Dr. Duval is thrilled to join the service and expand her range of skill and talent with the GVS team. She looks forward to serving you and your clients and sharing her expertise in surgical medicine. Dr. Duval's specialty practice days are Mondays, Tuesdays, Wednesdays, and Fridays with surgery on Tuesdays and Fridays. If you would like to consult with Dr. Julie Duval feel free to contact her at 404-459-0903 ext. 355. Dr. Duval looks forward to meeting area veterinarians in the opening fall/winter continuing education lecture in October when she will be the guest speaker. This year the American College of Veterinary Surgeons held its 10th Annual Symposium, September 21-24 in Arlington, VA. Incorporated into this meeting were the 28th Annual Surgical Forum and 35th Annual Scientific Meeting. This collective meeting brought together many advances in veterinary medicine practices and the advances in technology. Drs. Jenifer Newton and Julie Duval attended this years' conference
where topics included future treatments of osteoarthritis, non-surgical
management of hip dysplasia, kidney transplants in cats, radiation
therapy and reconstruction in the cancer patient. Look forward to
informative feedback and conference wrap up information from the attendees
in upcoming CE lectures and the next issue of the GVS Newsletter. GVS
2000-2001 Round Table Series
During the summer months GVS enhanced its' continuing education series to include educational lectures, information and material for the technical support staff in the veterinary community. Congratulations to the many technicians and veterinarians who took advantage of the summer CE series. We are planning our fall/winter series and the upcoming schedule and topics will be forwarded to each veterinary practice via postcard mailer. This mailer will provide you the pertinent information regarding the lecture topic, speaker, date and time. The fall/winter schedule will take place on the second Tuesday of each month at 7:30pm beginning in October 2000. Dr. Julie Duval from the GVS Surgery Service will kick off our fall/winter series in October. These CE programs will continue to provide continuing education credits where appropriate and all future programs will be held at The Albert Schweitzer Center Conference facility at GVS. We will make every effort to keep the series informative, current, and enjoyable, so feel free to share any suggestions on topics that interest you. Remember to RSVP early when your announcement arrives, seating availability is limited. Look for your postcard announcement in the upcoming weeks! These veterinarians have chosen to further their education in veterinary medicine through advanced training under the supervision of board certified specialists during their rotations through the various specialty services at GVS. We have high expectations for our millennium class and the continuing success of the internship program. We wish them well during their year at GVS. Dr. Sara Love is a native of Washington, D.C. She received her BS from Radford University in Virginia, and her DVM from the University of Minnesota. Sara spent five-year experiencing nature as an outdoor adventure instructor before attending veterinary school. Her professional interests are internal medicine, specifically hematology and oncology. Sara shares her quality time with her husband Craig. Dr. Michael Nawrocki attended Kansas State University where he completed undergraduate studies and earned his DVM. After completing his GVS internship, Michael looks forward to pursuing a residency in surgery. His special interests are exotic animal medicine and ophthalmology. In his limited free time, Michael enjoys participating in sporting activities, watching KSU football, where he has become accustomed to using the phrase "just wait until next year!" He has two felines Malek the mutant and a newly acquired kitten that has the run of the house. Dr. Rosemary Lombardi received her BS in Biology from St. Bonaventure University, Olean NY. She performed her clinical training at Oklahoma State University School of Veterinary Medicine, and earned ECFVG Certification. She received her DVM from Ross University and her clinical interests include surgery: orthopedic and soft tissue. Rosemary grew up in Syracuse, NY and now resides in metro Atlanta with her feline boys Bailey and Baxter. Dr. Seth Cohen received his BS in Zoology from North Carolina State .university, his DVM from the University of Georgia. His clinical interests include emergency/critical care and internal medicine. Seth was raised in Marietta, GA and returned home as a newlywed, congratulations! Dr. Kelli Weaver received her BS in Zoology from the University of Pittsburgh and her VMD from the University of Pennsylvania. Her goal is to complete her training and residency then pursue a career in internal medicine. Kelli was raised in Pittsburgh, P A, and she enjoys horseback riding, running and spending time with her pit bull friend Ellie. Dr. Barbara Gertz earned her BS in Biology from Washington University in St. Louis and her DVM from the University of Illinois. Her clinical interests lie in internal medicine and gastroenterology. She has fond memories of the outdoors and traveling and she looks forward to making new memories. She takes short trips to Illinois to visit her canine friend Bailey staying with the grandparents while Barb completes her internship here in Atlanta. Helpful
Hints For Your Technicians
This section of our newsletter is devoted to sharing information to assist technicians/and the support staffs of our referring veterinarians in providing quality care to his/her patient. Occasionally it is necessary to get back to the basics. We often get caught up in the fray of our busy day and move through our task quickly and efficiently without so much as a thought! But from time to time it is important to refresh yourself with the ABC's of Patient Care:
Whether you have done the above a million times, it is important to take time out to review and fine tune your patient assessment skills. Look for other "Helpful Hints" in upcoming GVS Newsletter issues. Primary
Hyperparathyroidism
Julie Duval, VMD, Diplomate, ACVS Recent availability of a reliable parathyroid hormone assay through the Michigan State University laboratory has revolutionized the diagnostic workup for hypercalcemia in small animals. Veterinarians may now be able to suspect primary hyperparathyroidism without the extensive and involved diagnostic testing needed to definitively rule out all other causes of hypercalcemia. However, as hypercalcemia of malignancy is the most common cause of hypercalcemia in the dog, the importance of a good physical examination (including rectal exam) and initial diagnostic workup cannot be overemphasized. The types of neoplasia most likely to cause hypercalcemia are lymphoma, apocrine gland adenocarcinoma of the anal sac, mammary adenocarcinoma and multiple myeloma, and there may be physical examination findings consistent with one of these cancers. Bloodwork to check for renal failure and other general health problems should be performed. Abdominal and thoracic radiographs and abdominal ultrasound could be considered, depending on physical exam findings. Once hypercalcemia has been confirmed by repeat bloodwork and correction for albumin levels [corrected calcium = total calcium + (3.5- albumin)] or determination of ionized calcium levels, submission of serum for a hypercalcemia of malignancy panel (including ionized calcium, PTH and PTH-rP) can be considered. The serum must be submitted under specific conditions for accurate results, so please consult the lab prior to sending a sample. Primary hyperparathyroidism (PHPTH) is generally seen in older dogs and occasional cats, and Keeshond are predisposed. Clinical signs are generally mild and may include PU/PD, urinary tract signs due to calculi or UTI, listlessness or inappetence. Occasionally animals with severe or prolonged hypercalcemia may develop azotemia and uremia. Generally animals with PHPTH have elevated total and ionized calcium levels, a low or low-normal phosphorus, and occasional azotemia or elevated alkaline phosphatase level. Urine specific gravity tends to be low. Other causes of hypercalcemia that need to be ruled out include malignancy, renal failure and Addison's disease. With primary hyperparathyroidism, the ionized calcium level will be elevated and the PTH level will be midnormal to elevated. The normal response of the parathyroid gland to hypercalcemia is to decrease production of PTH, so a normal PTH level in the face of an elevated ionized calcium level should increase the suspicion of PHPTH. The PTH-rP assay measures the level of a protein produced in some malignancies that activates osteoclasts and elevates the calcium level. Consequently, with malignancy the PTH-rP level may be elevated (although not all hypercalcemia of malignancy is caused by PTH-rP), and the PTH level should be decreased or zero. The PTH level may also be elevated with renal failure, but the ionized calcium level is generally normal or even low. Once a tentative diagnosis of primary hyperparathyroidism has been reached, the definitive treatment should involve removal or ablation of the affected parathyroid gland. While ultrasoundguided alcohol ablation of parathyroid masses has been described, the ultrasound technology necessary for that procedure is not widely available at this time and there is some possibility of laryngeal paralysis with that procedure. Currently we recommend surgical exploration of the cervical region and removal of the affected parathyroid glandes). Due to the small size of the four parathyroid glands, parathyroid masses are not always obvious at surgery, although experienced surgeons can generally identify abnormal parathyroid tissue. The delicate anatomy in the region sometimes necessitates the use of delicate instruments and bipolar cautery for resection. Generally, one enlarged gland is found and removed, but occasionally there are two or more glands found to be abnormal. The most common finding at biopsy is an adenoma, but adenomatous hyperplasia or carcinoma may be found. Post-operative monitoring is extremely important, as hypocalcemia is a possible complication. Once the over-productive gland is removed, the remaining glands may be unable to produce adequate amounts of PTH right away due to chronic negative feedback. Therefore, blood calcium levels can drop quickly and are checked daily for at least the first two days after surgery and weekly thereafter. Supplementation with vitamin D (Rocaltrol) is frequently instituted to try to prevent life-threatening hypocalcemia, especially if pre-operative calcium levels were very high. The goal with supplementation is to maintain the calcium level in the low-normal range. Calcium levels will be rechecked weekly, and the dosage of vitamin D will be gradually tapered over 4-8 weeks and then discontinued. Long-term prognosis is generally good, although recurrence is remotely possible. We at Georgia Veterinary Specialists would be happy to consult with you about your patients with hypercalcemia and assist you with their case management. If surgery is indicated, we are prepared to perform cervical exploratories, and we have both the around-the-clock care and the in-house chemistry analysis necessary for post-operative monitoring of these critical patients. Inflammatory
Bowel Disease
Derek Duval, VMD, DACVIM GVS Internal Medicine Service Inflammatory bowel disease (IBD) is a common disorder in cats and dogs. IBD occurs when an immune stimulus attracts inflammatory cells to the gut lining. These cells release chemical mediators which cause inflammation and attract additional immune cells which propagate the inflammation. Although many underlying causes exist, a specific etiology is not found in 70% of cases. Typically cases present with chronic histories of diarrhea or vomiting, but cases can present with acute episodes or with complications due to chronic protein loosing enteropathy with or without GI signs. Clinical signs can include vomiting, diarrhea, weight loss, recurrent bloating, abdominal pain or abdominal effusion. Blood work can show hypoalbuminemia, panhypoproteinemia, lymphopenia and hypocholesterolemia. Occasionally, an immune response will lead to hyperglobulinemia and increases in specific white cell lines (i.e. eosinophilia). Associated disorders that patients can present with include small intestinal bacterial overgrowth, exocrine pancreatic insufficiency, intestinal parasitism, food allergy, and peri-anal fistulae. Work up typically includes fecal parasite examination, complete blood count and chemistry panel. In cases being investigated for hypoalbuminemia or hypoproteinemia, urinalysis and bile acids assays may be helpful in ruling out protein losing nephropathy and decreased protein production by the liver. Additional diagnostics might include folate/cobalamin levels for bacterial overgrowth and trypsin-like immunoactivity (TLI) for exocrine pancreatic insufficiency. Biopsy and histopathology is needed to determine a definitive diagnosis. Although surgical biopsies can be obtained, endoscopy is preferable for several reasons. First, the endoscopy allows us to examine the mucosa and obtain good mucosal biopsies from multiple sites. Second, the procedure is quick and less stressful for the patient than surgical biopsies. Finally, in patients with marked hypoalbuminemia, healing can be greatly impaired making surgery a risky proposition. Upper gastrointestinal endoscopy can generally be performed as an outpatient. Colonoscopy generally requires bowel preparation prior to endoscopy and generally requires overnight hospitalization. Infiltrates of immune cells within the intestine can include lymphocytes, plasma cells, neutrophi1s and macrophages (histiocytes). In addition to the inflammation secondary lesions such as ulceration, erosions, and dilation of the 1actea1s can be seen on the biopsies. Treatment is aimed at decreasing the inflammation and removing underlying etiologies. Inflammation is controlled with prednisone. Typically we start with an immunosuppressive dose (1 mg/pound bid) and decrease and wean the prednisone over 6-8 weeks. Many patients can come off prednisone entirely, but some require long term or chronic therapy. Dietary management is useful to rule out or treat underlying food allergy. Novel protein diets such as fish & potato or recently kangaroo & oats have been the mainstay of dietary therapy. Recent advances with hydrolyzed diets such as Hill's z/d or Purina's HA have protein sources that have been treated to limit immune responses, make these very exciting alternatives. The novel protein diets or hydrolyzed diets need to be fed exclusively for 6-8 weeks to determine if a food allergy exists and dietary therapy is needed. Dietary management can be tried at the onset of signs, following endoscopy or if prednisone therapy alone fails. Treatment of coexisting bacterial overgrowth, exocrine pancreatic insufficiency or parasitism is also warranted. Generally, dogs and cats with IBD do very well with treatment. Long-term treatment can be required in some patients. Serious problems can occur due to long-term prednisone treatment or due to severe protein loss. Patients with protein loosing enteropathy are at risk for thromboembolic disease and can have pulmonary thromboembolism or portal vein' thrombosis. In generally, the prognosis is good for dogs and cats with IBD. Differential diagnoses for IBD include other infiltrative disorders (i.e. lymphoma or mast cell tumor), infectious diseases (i.e. histoplasmosis), ma1digestion, malabsorption and metabolic diseases (i.e. liver, renal or pancreatic disease). At Georgia Veterinary Specialists, we utilize a video endoscope system to get good quality examinations in all sized dogs and cats. In addition to biopsy specimens, we can document our examinations with color photographs. We are "happy to discuss your gastrointestinal cases with you and assist you in the management of their disorders. GVS
Clinician & Office Management Voice Mail Extensions
The following extenstions are listed if you only wish to leave a voice mail message for one of our clinicians or management team members. Dial (404) 459-0903, then ask the attendant or customer service representative to forward your call to the appropriate extension number. |
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GVS Interns
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