Good Medicine, Good Practice: Follow-ups, personal evidence base keys to clinical success

It all started at the Mayo Clinic four decades ago. My sister needed heart surgery, and the doctors told my parents: "We have had 13 patients with this condition, and this is how they were treated ... and the outcomes were ..."

The experience fueled my passion for evidence-based medicine. Follow-up history is a great wealth of data for a practice; it is the result of previously treated patients at the hospital. It can be as basic as knowing that all the hamsters treated in the practice for wet tail have responded to fluids and enrofloxacin in the water. Or it might be more complex, such as comparing 1,000 cruciate repairs during a 20-year time period with three major techniques that have been used in your practice.

Maybe we learned some harsh lessons about pain relief. The research on butorphanol originally called for 50 mg per horse intravenously to treat colic. But we found that 10-20 mg was appropriate for most equines. We also found that when butorphanol is combined with a nonsteroidal anti-inflammatory drug (NSAID), the analgesic effects were better.

We've also learned that when alkaline phosphates are elevated, one likely will find a malfunction of some sort, such as Cushing's, pancreatitis, chronic stress or sludge in the gallbladder. Alkaline phosphate elevations are not as spurious as we had come to believe, or was it taught that way?

Evidence shows that virtually all cats with a systolic gallop will have other conditions at work, such as hypertension, hyperthyroid, renal, anemia or one of the cardiomyopathies. The resultant course of treatment: get all of these cats to the ultrasound room, get a blood pressure, and ask some questions.

It wasn't too long ago that cardiomyopathies were found too late. Then, we were told to use digoxin, but follow-ups in our population that used ACE inhibitors showed that they were more commonly associated with survival. This probably has to do with a relationship to a finding in human medicine of digoxin induced anoxia and subsequent fatigue of the heart muscle. The more conservative approach worked best, especially when we added 81 mg of aspirin to the treatment plan.

And while we were sleeping, it does seem that the number of dogs with cauda equina syndrome clearly outnumber those with hip dysplasia. The importance being that severe cauda equine syndrome responds to a nice basic spinal decompression, whereas hips, well, it's a tough choice. Perhaps cortisone at the L7S1 junction is the way to go, as it is done with some human spinal conditions.

Moving on

In handling diabetics, with 1,000 cases, clearly those getting two to three insulin shots regularly and either Lente(2) or Ultralente have an easier time obtaining stable fructosamine levels.

In our area, heartworm prevention is best given year round. Our data demonstrates that during a 30-year period, 44 dogs have come back positive when removed from the preventive during the winter, and three have tested positive when on the prevention year round.

Heartworm-infected dogs seldom react adversely to treatment when pretreated with a month of enalapril and baby aspirin.

It is so simple not to diagnosis Giardia. We have all been told that one just cannot see the cysts. But one must look for them with the oil immersion; this is an extra step, but honestly, how many of us take the time with fecal to do "oil"?

And once the Giardia parasite is discovered, one finds out which of the metronidazole doses works (usually after treating about 1,000 cases).

Follow up is everything in clinical medicine

Human medicine scholars have great data, have funded studies, and they make a huge effort to collect follow-up data.

Consider the storm surrounding Vioxx, Celebrex and this whole family of NSAIDs in human medicine.

We do not have such data in veterinary medicine. Nosocomial issues must be followed in human medicine — it is a federal standard. But even American Animal Hospital Association standards do not require nosocomial tracking.

The point? If we are not looking for a disease, then we won't find it.

Put the kennel air at 15 changes per hour, and one might need fewer Bordatella vaccines.

In human ear infections, the percent of response to ear tubes through the inner ear has been documented.

But for external otitis in dogs, until we treat 100 ears with a systemic antibiotic, we can't determine the role of antibiotics.

Humans have great data on response to assorted drugs in various cardiac problems. In veterinary medicine, we have academic pass-down into the practitioner's environment, and we mostly just assume that it is correct.

But sometimes we must challenge the data.

Yes, we do see some immune-mediated problems in some dogs three weeks after vaccine administration. But we cannot blame all of life's problems on vaccines. And when we decrease vaccine use, will we see a re-emerging group of diseases like distemper? Recently identified cases from an otherwise "clean" community get our attention.

There must be a balance in all of this.

What are we to do out here in ClinicLand?

• Assume that 10 percent of what is fact is wrong.

• When in doubt, check it out.

• Three-visit rule: At the third visit for a clinical problem, step back, reassess, confirm the diagnosis, read up and get a second opinion.

• Follow everything. Keep, at the least a mental picture of clinical situations, compare treatment plans, surgical outcomes, and question things.

• 1, 10, 100, 1,000 Rule — track cases and situations until one gets to 1,000; this is how one becomes proficient.

• Compare 10 to 10 — When introducing new techniques, new drugs and new plans, compare the new with old.

Dr. Riegger, dipl. ABVP, is the chief medical officer at Northwest Animal Clinic Hospital and Specialty Practice. Contact him at www.northwestanimalclinic.com

Riegger@aol.com, telephone and fax (505) 898-0407. Find him on AVMA's NOAH as the practice management moderator. Order his books "Management for Results" and "More Management for Results" by calling (505) 898-1491.