Pravachol

Richard J. de Asla, MD

• Co-Director of Foot and Ankle Division
• Department of Orthopaedic Surgery
• Massachusetts General Hospital
• Instructor, Harvard Medical School
• Boston, Massachusetts

When successful average cholesterol per meal generic pravachol 10mg without a prescription, these medications can help patients avoid spending time in the hospital cholesterol management chart buy 20 mg pravachol visa, improve their quality of life and lead to 6 fewer changes in the chemotherapy regimen cholesterol lowering food tips order cheapest pravachol. For chemotherapy programs that are likely to produce severe and persistent nausea and vomiting cholesterol test guidelines pravachol 20mg without a prescription, there are new agents that can prevent this side effect cholesterol in eggs hdl pravachol 10mg overnight delivery. For this reason cholesterol levels of seafood purchase pravachol american express, these drugs should be used only when the chemotherapy drugs that have a high likelihood of causing severe or persistent nausea and vomiting. Dont use combination chemotherapy (multiple drugs) instead of chemotherapy with one drug when treating an individual for metastatic breast cancer unless the patient needs a rapid response to relieve tumor-related symptoms. In fact, the trade-offs of more frequent and severe side effects may have a net effect of worsening a patients quality of life, necessitating a reduction in the dose of chemotherapy. As a general rule, however, giving effective drugs one at a time lowers the risk of side effects, may improve a patients quality of life, and does not typically compromise overall survival. Available evidence from clinical studies suggests that using these tests to monitor for recurrence does not improve outcomes and therefore generally is not recommended for this purpose. Dont use a targeted therapy intended for use against a specific genetic aberration unless a patients tumor cells have a specific biomarker that predicts an effective response to the targeted therapy. Patients who are most likely to benefit from targeted therapy are those who have a specific biomarker in their tumor cells that indicates the presence or absence of a specific gene alteration that makes the tumor cells susceptible to the targeted agent. In addition, like all anti-cancer therapies, there are risks to using targeted agents when there is no evidence to support their use because of the potential for serious side effects or reduced efficacy compared with other treatment options. The role of the Task Force is to assess the magnitude of rising costs of cancer care and develop strategies to address these challenges. Upon joining the Choosing Wisely campaign, the members of the subcommittee conducted a literature search to ensure the proposed list of items were supported by available evidence in oncology; ultimately the proposed Top Five list was approved by the full Task Force. Advocacy groups were also asked to weigh in to ensure the recommendations would achieve the dual purpose of increasing physician-patient communication and changing practice patterns. A plurality of more than 200 clinical oncologists reviewed, provided input and supported the list. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. Saito M, Aogi K, Sekine I, Yoshizawa H, Yanagita Y, Sakai H, Inoue K, Kitagawa C, Ogura T, Mitsuhashi S. Double-blind, randomised, controlled study of the efcacy and tolerability of palonosetron plus dexamethasone for 1 day with or without dexamethasone on days 2 and 3 in the prevention of nausea and vomiting induced by moderately emetogenic chemotherapy. Phurrough S, Cano C, Dei Cas R, Ballantine L, Carino T; Centers for Medicare and Medicaid Services. Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, Pihl C-G, Stranne J, Holmberg E, Lilja H. Mortality results from the Goteborg randomized populationbased prostate-cancer screening trial. Screening for prostate cancer: A guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Screening for prostate cancer with prostate-specifc antigen testing: American Society of Clinical Oncology provisional clinical opinion. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lunch cancer to geftinib. We achieve this by collaborating with leading professional organization physicians and physician leaders, medical trainees, representing physicians who care for health care delivery systems, payers, policymakers, people with cancer. American Society of Echocardiography Five Things Physicians and Patients Should Question Dont order follow up or serial echocardiograms for surveillance after a fnding of trace valvular regurgitation on an initial echocardiogram. The clinical signifcance of a small amount of aortic regurgitation with an otherwise normal echocardiographic study is unknown. Dont repeat echocardiograms in stable, asymptomatic patients with a murmur/click, where a previous exam revealed no signifcant pathology. Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease. Avoid using stress echocardiograms on asymptomatic patients who meet low risk scoring criteria for coronary disease. There is very little information on using stress echocardiography in asymptomatic individuals for the purposes of cardiovascular risk assessment, as a stand-alone test or in addition to conventional risk factors. Protocol-driven testing can be useful if it serves as a reminder not to omit a test or procedure, but should always be individualized to the particular patient. Leaders in the organization transformed the scenarios into plain language and produced the clinical explanations for each procedure. Echocardiography provides an exceptional view of the cardiovascular system to safely and cost-effectively enhance patient care. American Society of Health-System Pharmacists Five Things Physicians and Patients Should Question Do not initiate medications to treat symptoms, adverse events, or side efects without determining if an existing therapy or lack of adherence is the cause, and whether a dosage reduction, discontinuation of a 1 medication, or another medication is warranted. New medications should not be initiated without taking into consideration patient compliance with their pre-existing medication and whether their current dose is efective at controlling/treating symptoms. Medications are often prescribed to treat symptoms that are really side efects of other medications without determining if the pre-existing medication is truly needed or could be discontinued. Do not prescribe medications for patients on fve or more medications, or continue medications indefnitely, without a comprehensive review of their existing medications, including over-the-counter medications and dietary supplements, to determine whether any of the medications or 2 supplements should or can be discontinued. Studies have shown that patients taking fve or more medications often fnd it difcult to understand and adhere to complex medication regimens. A comprehensive review, including medical conditions, should be done at periodic intervals, at least annually, to determine if the medications are still needed and if any medications can be discontinued. Do not continue medications based solely on the medication history unless the history has been verifed with the patient by a medication-use expert. The patient or caregiver should be interviewed by someone with medication-use knowledge, ideally a pharmacist, and medications should be continued only if there is an associated patient indication. If a pharmacist is not available, then at a minimum, the healthcare worker taking the history should have access to robust drug information resources. The history should include the drug name, dose, units, frequency, and the last dose taken; and indication if available. Do not prescribe patients medications at discharge that they were on prior to admission without verifying that these medications are still needed and that the discharge medications will not result in duplication, drug interactions, 4 or adverse events. Treatments and procedures during a hospitalization may impact a patients ongoing need for a medication they were receiving prior to admission. Care should be taken at discharge to consider each medication taken prior to hospitalization in light of the patients current state. Unnecessary medications should be discontinued, duplicate or overlapping therapies should be changed, and the specifc changes should be clearly communicated to the patient. The Joint Commission recommends a thorough medication review at admission and discharge to prevent any unnecessary medications being continued. Do not prescribe or administer oral liquid medications using teaspoon or tablespoon for measurement; use only milliliters (mL) when measuring with an approved dosing device. Serious medication errors, including patient deaths, have occurred because oral liquids are prescribed and/or administered using English measurement 5 units such as the teaspoon or tablespoon. For medical professionals, best practice is using units and volume when prescribing a single-agent liquid medication, to be sure the dose is clear; but for administering, use only mL for measuring the amount. Prescribing using the metric system and dispensing with a metric measuring device will help avoid these preventable errors. Released June 1, 2017 How this List Was Created A task force made up of pharmacists from all practice settings was formed. The task force was oriented to the criteria used to establish Choosing Wisely lists and already established recommendations. Based on this information and on their knowledge of how medications are prescribed, dispensed, and administered, the task force developed an initial list of recommendations. Through a consensus process over time the list was prioritized down to a total of fve recommendations. Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Unnecessary transfusion generates costs and exposes patients to potential adverse efects without any likelihood of beneft. Dont administer plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists. Blood products can cause serious harm to patients, are costly and are rarely indicated in the reversal of vitamin K antagonists. In non-emergent situations, elevations in the international normalized ratio are best addressed by holding the vitamin K antagonist and/or by administering vitamin K. By ensuring a patient receives an appropriate regimen of anticoagulation, clinicians may avoid unnecessary harm, reduce health care expenses and improve quality of life. In particular, they experience an increased risk of alloimmunization to minor blood group antigens and a high risk of iron overload from repeated transfusions. Moreover, there is no evidence that transfusion reduces pain due to vaso-occlusive crises. Do not discontinue heparin or start a non-heparin anticoagulant in these low-risk patients because presumptive treatment often involves an increased risk of bleeding, and because alternative anticoagulants are costly. Unnecessary treatment exposes patients to potentially serious treatment side efects and can be costly, with little expectation of clinical beneft. In the pediatric setting, treatment is usually not indicated in the absence of mucosal bleeding regardless of platelet count. In the adult setting, treatment may be indicated in the absence of bleeding if the platelet count is very low. In patients preparing for surgery or other invasive procedures, short-term treatment may be indicated to increase the platelet count prior to the planned intervention and during the immediate post-operative period. Respondents were asked to consider the core values of harm, cost, strength of evidence, frequency and control. A professional methodologist conducted a systematic literature review on each of the 10 items; the Task Force chair served as the second reviewer. Six principles were used to prioritize items: avoiding harm to patients, producing evidence-based recommendations, considering both the cost and frequency of tests and treatments, making recommendations in the clinical purview of the hematologist, and considering the potential impact of recommendations. Systematic reviews of the literature were then completed for each of the 10 semi-fnalist items. Retter A, Wyncoll D, Pearse R, Carson D, McKechnie S, Stanworth S, Allard S, Thomas D, Walsh T; British Committee for Standards in Hematology. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Dupras D, Bluhm J, Felty C, Hansen C, Johnson T, Lim K, Maddali S, Marshall P, Messner P, Skeik N. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role 3 of thrombophilia testing. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientifc statement from the American Heart Association. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians 4 Evidence-Based Clinical Practice Guidelines. Value of surveillance computed tomography in the follow-up of difuse large B-cell 5 and follicular lymphomas. Surveillance computed tomography scans for patients with lymphoma: is the risk worth the benefts Chalmers E, Ganesen V, Liesner R, Maroo S, Nokes T, Saunders D, Williams M; British Committee for Standards in Haematology. Guideline on the investigation, 6 management and prevention of venous thrombosis in children. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Guidelines on the diagnosis, investigation and management of chronic lymphocytic leukaemia. Guidelines on the diagnosis and management of heparin-induced thrombocytopenia: second edition. Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. The American Society of Hematology 2011 evidence-based 10 practice guideline for immune thrombocytopenia. We achieve this by collaborating with than 14,000 clinicians and scientists from around the world physicians and physician leaders, medical trainees, who are dedicated to furthering the understanding, diagnosis, health care delivery systems, payers, policymakers, treatment and prevention of disorders affecting the blood. American Society of Nephrology Five Things Physicians and Patients Should Question Dont perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. False-positive tests can cause harm: unnecessary procedures, overtreatment, misdiagnosis and increased stress. An individualized approach to cancer screening incorporating patients cancer risk factors, expected survival and transplant status is required. Dont initiate chronic dialysis without ensuring a shared decisionmaking process between patients, their families, and their physicians. This process includes eliciting individual patient goals and preferences and providing information on prognosis and expected benefts and harms of dialysis within the context of these goals and preferences. Limited observational data suggest that survival may not difer substantially for older adults with a high burden of comorbidity who initiate chronic dialysis versus those managed conservatively. Renal Data System, American Society of Nephrology, American Society of Transplantation, Archives of Internal Medicine, Seminars in Dialysis. Food and Drug Administration, the New England Journal of Medicine (multiple publications). Renal Physicians Association End-of-Life Care Guidelines, Pediatric Nephrology, Clinical Journal of the American Society of Nephrology, Journal of 5 Pediatrics, Nephrology Dialysis Transplantation, Archives of Internal Medicine, Nephrology Dialysis and Transplant, New England Journal of Medicine, Palliative Medicine.

Mintz is cholesterol in shrimp good or bad cheap pravachol 10mg with visa, a consumer who bought what he believed to be a healthy cholesterol test methodology purchase pravachol 20 mg, purebred puppy only to find out he was sold a two-year old dog with several health conditions cholesterol definition science buy generic pravachol line, was sued by the seller for libel when he published his story on a blog cholesterol levels by age chart purchase pravachol 20 mg line. Statements on duped dog buyers blog not 93 seller was reversed on appeal after over half a decade of litigating foods to lower cholesterol & blood pressure 20mg pravachol otc. This is to include cholesterol in shrimp cocktail cheap pravachol on line, but not limited to the above mentioned, as well as other venues such as the Better Business Bureau and reports to the Attorney General. July 26, 2016); Michael Booth, Sanctions Mount in Puppy Mill Online Defamation Suit, N. All of the industries lawsuits challenging the ordinances have been unsuccessful, though two cases remain pending in state courts. Even the nations largest retail pet store chain that sells puppies supports consistent regulations. Local and state laws can function alongside this federal regulation, and each would ultimately strengthen protections for consumers and their pets. However, based on the evidence provided, the Commission can conclude, without conducting its own investigations, that the current acts, practices, and use of the terms at issue are misleading to consumers. Further, the Commission can conclude that these practices cause or are likely to cause substantial injury to consumers. Indeed, the Commission has previously issued alerts about scams relating to the advertisement of puppies that are never delivered. Dogs are intelligent, self-determining, emotional, and have distinct personalities. Local solutions are meeting great challenges, and have also proven to be insufficient at addressing the industrys widespread deceptive acts and practices. The rule simply would require pet sellers to disclose information to consumers prior to sale and refrain from engaging in deceptive acts or practices, most of which are already proscribed by general consumer protection laws but often go unfollowed and unenforced. As noted above, there are budgetary constraints to individual enforcement actions. X Definitions a) Adequate exercise and socialization means, for dogs other than puppies under eight weeks old and housed with their mother: (1. This term does not include any entity which is, or is housed on the premises of, a dog breeder or broker, obtains dogs from a dog breeder or broker in exchange for payment or compensation, or resells dogs obtained from a dog breeder or broker and provides payment or compensation to such dog breeder or broker. This term does not include any animal care facility, animal rescue organization, or hobby breeder. If you are covered by this regulation, breaking any of its rules is an unfair and deceptive act or practice or an unfair method of competition under section 5 of that Act. In connection with the sale or offering for sale of dogs to consumers in or affecting commerce, as commerce is defined in section 4 of the Federal Trade Commission Act, 15 U. The legal name, all registered business names, and physical address of the dog seller, breeder of the dog, and broker, if the dog seller obtained the dog from a broker; ii. The United States Department of Agriculture license number(s) and any state or local license numbers, along with the name of the state or local licensing agency, for the dog seller, breeder of the dog, and broker, if the dog seller obtained the dog from a broker, or written verification that the 105 dog seller, breeder, or broker is not required to have a federal, state, or local license; iv. The number of adult dogs and puppies recorded on the past three state or federal inspection reports for the dog seller, breeder of the dog, and broker, if the dog seller obtained the dog from a broker; v. Information about the dog sellers process for vetting breeders (such as visiting facilities, reviewing inspection reports, and verifying criminal history), including a disclosure if the dog seller does not see the breeders facility or the puppies prior to sale; vi. The retail sale price of the dog, including any additional fees or charges to be applied before the sale of the dog, and the dog sellers return policy; vii. The name and registration numbers of the sire or dam and the address where they are registered; ix. If the dog was purchased and then returned by a customer, along with the date and reason for the return. A notification that other documentation, including all applicable veterinary records and inspection reports, are available upon request and will be made available regardless of request, prior to completion of sale. For the three years prior to the sale of the dog, a copy of each and every Animal Welfare Act (7 U. For the previous three years, a copy of any and all State or local inspection reports for the dog seller, breeder of the dog, and broker, if the dog seller obtained the dog from a broker, and documentation of any violations of a state or local animal welfare law or regulation by the dog seller, breeder of the dog, or broker, if the dog seller obtained the dog from a broker; iii. A complete record of vaccinations and veterinary care and treatment of the dog, including the name of the person or licensed veterinarian who administered the vaccinations or veterinary care or treatment; iv. Any known congenital or hereditary diseases of the parents of the dog, or the parents other offspring; viii. A list of known genetic and any related health problem that the breed and lineage may carry; ix. The name and registration numbers of the dogs sire and/or dam and the address where they are registered; x. It shall be unlawful for any person to furnish, with respect to any dog, a false guaranty, and any person who violates the provisions of this subsection is guilty of an unfair method of competition, and an unfair or deceptive act or practice, in commerce within the meaning of the Federal Trade Commission Act. Any dog seller utilizing a rating system or consumer reviews or testimonials must a. A law is not in conflict with this Rule if it affords prospective purchasers equal or greater protection, such as more extensive disclosures. If any provision is determined to be invalid, it is the Commissions intention that the remaining provisions shall continue in effect. Conclusion the Humane Society of the United States respectfully requests the Commission to promulgate a Trade Regulation Rule to address the issues raised in this petition. Puppies are not like motor parts,272 they are unique and cherished members of many 272 Inanimate used cars and contact lenses are more regulated. As such, puppies are in need and deserve well thought-out and specific rules to address the deceptive and misleading acts or practices that are unique to the retail pet sales industry. Centrally located on the home page of this website is a link to information about puppy mills and a claim that [t]his website exists to connect caring families with healthy puppies. The report also listed a number of additional violations, three of which were "repeat" violations, including unsafe housing, dirty feeders, and dogs kept outside in the cold without adequate protection from the weather. It has also been cited repeatedly for filthy conditions, for keeping dogs in cages that were too small, for not making the facility accessible for inspection, and for numerous other problems. For example, in March 2016, the Campbells were cited for providing inadequate veterinary care, and in September 2016, housing violations were found. This was requested because the company engages in online pet sales and is required to be licensed. July 26, 2017) (proposed class action claiming The fraudulent scheme can be traced to Petlands animal sourcing practices. This complainant wrote, I recently had the opportunity to speak with one of the new owners of this newest store. According to the complaint, All Pets Club advertises it is the only one of its kind in the industry to be regulated and licensed to sell puppies. Little Dogz (Mount Clemens, Michigan) Little Dogz, a Michigan pet store, closed its doors after consumers sued over buying sick puppies from the store, but only after they returned to court to enforce judgment against the pet seller. Another Petland store was sued by 16 consumers for, amid allegations, violations of the Michigan Consumer Protection Act and knowingly selling puppies that suffered from genetic defects, had infections as well as highly contagious and deadly diseases between 2012 and 2016. But Coco Rose wound up with double pneumonia, a double ear infection and parasites days after leaving Petland Largo. One of these victims purchased a puppy that tested positive for giardia and spent thousands of dollars to treat the new puppy she completely fell in love with. His wife, Trina Kenny, previously served time for crimes relating to the sale of sick horses. This vet diagnosed him with an upper respiratory infection, g[ave him an] antibiotic and sent [him] home with a follow up in ten days. The puppy was given a stronger antibiotic along with a nebulizer however a few days later he needed immediate hospitalization with around the clock care. At this point, Erins veterinarian filled out an "Unfit for Sale" form stating this puppy should never had been sold given his sickly state. She wrote: When I picked the puppy up at the airport she was small [and] already sick. But her weight at my vets [sic] that same day was just a little over a pound and she was hypoglycemic and dehydrated. Despite my vets [sic] efforts and two extensive visits K[y]lie died late on day two after she coded twice. She has since spent well over $60,000 in veterinary care on Viola to treat her giardia, esophagus mobility issues, joint problems, and allergies. This amount may seem excessive to some and her care has turned into a full time job for Christi, but Christi says that [Viola] has the sweetest spirit and doing what she can to relieve Violas pain is totally worth it to [her]. The stores owner even explains in an interview to a news outlet inquiring about the investigation, When I sell a dog I sell them with health certificates from a vet. Puppies who had been in the store and were previously given this quick vetcheck were seldom reexamined, even if exhibiting signs of severe illness, such as vomiting, bloody stools, coughing, or fevers. The district court judge found the statement that the store sells the healthiest puppies in the nation to be wholly unfounded and in violation of the Virginia Consumer Protection Act. The purchased puppy named Squirrel was taken to Rascal Animal Hospital in Dublin for inspection. A congenital knee and joint problem and a testicle problem that could lead to cancer. A Maine pet seller was charged with theft by deception, illegal operation of a pet shop, as well as animal cruelty after being caught selling dogs with falsified veterinary and vaccine records through various online websites. The Pennsylvania State Police charged a breeder of Siberian Husky puppies with forgery for allegedly providing forged documents showing the puppies were up to date on all shots. However, the pet store assured him that the puppy was healthy aside from a minor cold and had been screened by a veterinarian. I spared no expense in giving Hudson a fighting chance, but he passed away early morning on July 6 (roughly 6 days after picking him up). I had him in an oxygen tank, and later on a breathing machine so oxygen could be delivered to his blood as the antibiotic went to work. I accrued 17,500 in expenses (all documented, including doctors assessment and vets unfit for sale form). The next day after getting him we took him to our vet and a heart murmur grade 2 was heard. Health guarantee contract states that if puppy has congenital defect that purebred breeders will be responsible for treatment Costs for 10 years. Now they are dodging my calls and keep saying that theyll call me back after talking to their supervisor. I am worried for my puppy, the possible future costs, and being lied to through this whole process. A PuppySpot customer bought a Goldendoodle through PuppySpot from a breeder in Ohio, Henry John Miller. The consumer suspects the breeder brought a different, healthy puppy to be examined but shipped a completely different puppy who was very sick. Another PuppySpot customer explained that he received a sick puppy and believes he was given false information about where the puppy came from and that the puppys veterinarian records were falsified. In his own words the complainant wrote, We naively purchased a puppy from Puppyspot. She was diagnosed with yeast infections in both of her ears, an eye infection and a parasite. We were given the name of the owner but cannot find any legitimate information about this person online and we believe the veterinary health report was falsified. The buyer explained that the breeder claimed to have the puppy vet-checked and was given a clean bill of health before the puppy was shipped to Wisconsin 99 Phone Interview with Santina H. However, the buyers own veterinarian diagnosed the puppy with a double ear infection and a urinary tract infection. Other Complaints Vaccine records were provided to a consumer in Texas who purchased a teacup Chihuahua from a breeder. Nowhere was there a vet name nor a location, she did mention she took her to a local community vet. Then the seller went on to say that the patch of hair missing on the puppy was because the momma dog bit her. I rushed her into our vet and immediately they took her to the back and said they needed to keep her an hour or so to get her stable. When I came back to the vet to check her I was informed that I bought a very sick puppy and the breeder needs to be contacted. The puppy had worms despite supposedly being wormed regularly & had Bordatella despite a contract stating he was healthy. The breeder gave me antibiotics that he said were to help transition the puppy from his dirty water to my clean water. Clearly that was a lie & he knew the puppy had kennel cough when he sold him to me. I believe he is running a puppy mill and his adult dogs are not vaccinated or cared for and he is selling sick puppies and lying about them being sick. We also had a separate peice [sic] of paper from the pet store that said his date of birth was 10/16/09. Miller done the pet store a favor for giving him so much business and forged documents so they could release this pet to another owner and cover up his health history I followed the required actions in order for Purebred Breeders to uphold their end of the Lifetime Guarantee by having a Puppy Well Check on 12. Such certificate shall list all vaccines and deworming medications administered to the animal and shall state that the animal has been examined by a Florida-licensed veterinarian who certifies that, to the best of the veterinarians knowledge, the animal was found to have been healthy at the time of the veterinary examination. In the event that the consumer purchases the animal and finds it to have been unfit for purchase as provided in section 828. The consumer has the right to retain, return, or exchange the animal and receive reimbursement for certain related veterinary services rendered to the animal, subject to the right of the dealer to have the animal examined by another veterinarian. PuppySpots highly deceptive promise of an industry-leading Health Guarantee and claim that it has placed over 100,000 healthy puppies provides assurances to consumers that this is a trusted business that seemingly appears to provide broad and long-lasting coverage against genetic defects and major illness.

Vector-Borne Transmission Vectors are animals and insects that act as intermediaries and transmit infectious agents from an infected animal to a susceptible dog cholesterol genetic buy 20 mg pravachol with amex. Oral Transmission Infectious agents can be transmitted by vectors Oral transmission occurs when infectious agents either mechanically or biologically cholesterol chart age buy generic pravachol 10 mg on line. This often occurs through eating or transmission occurs when the infectious agent is drinking contaminated food cholesterol drug new purchase genuine pravachol, treats cholesterol levels lab values buy generic pravachol 20mg on line, or water cholesterol medication pain purchase pravachol in united states online, and simply transported from dog-to-dog by a vector oral contact with contaminated environmental such as a human or a fy cholesterol levels test buy cheap pravachol 10mg line. It can also the vector, usually through a blood meal from occur through mouth contact with contaminated an infected animal. Effective Ensuring a safe food and water supply, and close fea, tick, and mosquito preventive measures are attention to cleaning and disinfection, will reduce important ways of reducing vector-borne disease the chances of oral transmission. Infectious Disease in Dogs in Group Settings 8 Principles of Infection Prevention and Control Infection prevention and control strategies are designed to protect dogs, personnel (owners, handlers, trainers, staff), and the community. These strategies require that everyone involved play an active role and consider actions that protect animals and people from the spread of infectious diseases. Infection prevention and control measures can be broadly divided into two main categories: measures to decrease dog exposure to infectious agents and measures to decrease dog vulnerability to infectious agents. Eliminating or decreasing Exposure is one of the Vulnerability of a dog to an infectious agent the most important aspects of infection control. In general, dogs with good an infectious agent, then disease simply cannot overall health and nutritional status are less occur. Infectious Disease in Dogs in Group Settings 9 Evidence-Based Recommendations to Prevent Infectious Diseases in Dogs at Group Settings the authors developed 64 recommendations Each category is discussed below, emphasizing aimed at preventing infectious disease in dogs practical steps that can be taken at the individual in group settings based on careful review of the dog level, dog group level, and environment level existing literature, input from a focus group of (checklists summarize these recommendations for stakeholders and key opinion leaders, and a the dog owner and setting organizer; Appendices survey of canine group settings participants. Addressing all three levels is important in level of evidence for each recommendation is reducing infectious disease in dog group settings. The recommendations can (a summary sheet with all recommendations is be grouped into nine categories: available here). General recommendations It is important to understand that not all recommendations are applicable or feasible 2. Enteric (intestinal tract) disease prevention recommendations to reduce these risks. Disease recognition and response General Recommendations Risk Assessment and the Infectious Disease Identifying disease risks allows for development of Control Plan venue-specifc control and prevention strategies, protocols, and management practices. Examples It is easiest to prevent infections if the risks are include participation requirements, hand washing/ known in advance. Some infectious agents are sanitizing stations, isolation areas in case commonplace throughout certain environments dogs become sick and cannot be immediately and may be naturally present at certain group removed from the premises, and environmental settings, while others present a risk only if management. The risks will vary at preventing the entry and spread of infectious based on the nature and location of the group diseases at a particular group setting should be setting, the activities that are expected to occur, the developed and together form an infectious disease facilities and housing, the duration of the event, the plan. The plan should also include instructions time of year, and the individual dogs participating. These include recognition of infected assessment for each specifc group setting or dogs and dogs to whom they may have passed event should be performed and strategies put the infection, isolation, medical evaluation, and in place to reduce infection before it occurs. Infectious Disease in Dogs in Group Settings 10 For each group setting, a written infection bite prevention, recognition of a sick dog, effective prevention and control plan should be in animal handling and restraint techniques and place and include strategies aimed at the communication techniques to interact with individual dog, the population of dogs, and the owners. For these reasons it is recommended that control are often in-line with other areas, such as organizers involve other relevant stakeholders, animal welfare. Dogs that are comfortable with including a veterinarian, when performing a risk reduced stress will be at a lower risk for infectious assessment, developing an infection control plan, disease transmission than dogs in more stressful or revising an existing infection control plan. Canine welfare guidelines have been Every group setting should have access (onpreviously developed and may be particularly site or off-site) to a veterinarian who can assist useful for guiding facilities that temporarily house with developing and implementing infectious groups of dogs. Exclusion Criteria for Participation in Group It is recognized that developing an effective Settings infection control plan takes time and resources. It Event offcials and facility managers are is recommended that, where appropriate, relevant encouraged to establish policies that prohibit parent organizations and overseeing bodies assist entry and participation of dogs showing signs of in preparing model or draft plans for a given event infectious disease. Dogs that are suspected groups can review their particular risks as stated to be infectious or with signs of infectious above and personalize a draft plan to address disease. In addition to ensuring that participants are aware of disease management practices, it is important to ensure that all staff and volunteers working in the group setting are also well informed. Training for all staff on canine infectious disease risks and prevention within the group setting should be required and documented. A comprehensive training program might also include humane treatment of animals, Infectious Disease in Dogs in Group Settings 11 In addition, dogs recently recovered from an certifcates prior to travelling into their jurisdiction infectious disease may still be contagious. If to help ensure that diseases are not imported with the disease is known then a veterinarian can the animal. Some governments allow exemptions help determine how long the dog is likely to for shortterm travel/housing such as dog shows, remain infectious. Valid health certifcates for a potentially contagious but unknown illness, a out-of-state/ province/country dogs should minimum waiting period of two weeks following be required for entry into group settings as resolution of signs would reduce, although not indicated by jurisdictional regulations. In this requirement may be challenging (and compliance case, the dog should be excluded from taking poor) for some settings, such as dog shows and part in dog group setting events during these agility events, where frequent, often weekly, intertwo weeks. All dogs should have a record of decrease susceptibility to certain infectious vaccination status. Some vaccines will nearly eliminate the record), which can be presented upon request risk of infection, while others will reduce the risk to event organizers. Inadequate vaccination has been shown to be a primary factor in numerous infectious disease outbreaks in dog group settings. It is important to keep in mind that vaccination requirements for a group setting are established not just to protect the dog that is vaccinated, but also to reduce the risk to all of the dogs participating in the group setting. Dogs should receive all core vaccines as appropriate for their age in accordance with published guidelines and maintain a current Core Vaccines vaccination status for diseases of greatest risk Core vaccines are those that all dogs should in group settings (Appendix 3). These are all highly contagious diseases that often result in death of infected dogs. Following the initial puppy series and revaccination at 1 year of age, boosters for these vaccines are generally recommended every three years. Infectious Disease in Dogs in Group Settings 12 Canine Vaccination Guidelines also have vaccine and vice versa can cause serious and recommendations specifcally for dogs in potentially life threatening side effects. The shelter setting has much in If the vaccination status of a dog is unknown common with other group settings including dogs or not current, at a minimum a single dose originating from various locations, concentrated of vaccine should be administered prior to housing environments, potential direct contact involvement in the setting with an adequate with unfamiliar dogs, increased opportunity for time for the development of immunity. When disease transmission through fomites and shared vaccinating for canine distemper virus, canine surroundings, and potentially increased dog parvovirus and canine adenovirus in an adult stress. For these reasons, the authors agreed dog, immunity can be expected in 3 to 7 days. Based intranasal/oral booster within the 6 months prior to on the associated risks, canine parainfuenza participation. Intranasal/oral vaccination jurisdictions, it is required that rabies vaccination for Bordetella bronchiseptica and canine be performed by or under the direction of a parainfuenza virus is recommended to help veterinarian. Nosodes, controversial homeopathic remedies that are prepared by taking diseased matter from a sick animal such as tissue or nasal discharge, do not stimulate immunity directed at specifc infectious agents and should not be considered a replacement for core vaccines. For dogs with existing, documentable medical conditions for which vaccination is not recommended, a letter from the dogs veterinarian describing the condition should be considered in place of vaccination. Though rare, there are some dogs that are properly vaccinated but for various reasons do not For all vaccines, it is important dogs receive their develop protection. As the number of dogs that are primary series and boosters prior to involvement unor under-vaccinated increases in a setting, the in the setting, with enough time for them to risk of disease (including outbreaks) increases. An Vaccine-preventable diseases must also be important note of caution: vaccines should not be considered in all aspects of infectious disease given by routes other than those approved on the control plans as previous vaccination does not label. Infectious Disease in Dogs in Group Settings 13 Antibody Titers as A Substitute for Vaccination For this reason a series of vaccinations are given at prescribed intervals in an effort to vaccinate Part of the expected immune response to vaccination is the development of antibodies puppies soon after maternal antibodies wane against a specifc infectious agent. For some and before exposure to the vaccine preventable diseases, measuring the level of these antibodies disease agents occur. In a typical home setting, (titer), following the initial vaccine series, is an where the risk of exposure is low, the established effective way to demonstrate that the immune recommendation is to vaccinate with core vaccines system responded to the vaccine. Yearly measurements of antibody titers have been increasingly used as an indicator of suffcient immunity against certain infectious diseases, though immunity involves far more than antibodies. The use of titers to determine whether or not vaccination is necessary is controversial. For many vaccine preventable diseases, especially those that are not considered core, a specifc titer level does not indicate adequate protection against disease. Although titer levels provide information about the past and the current status of immunity against some diseases, they do not In animal shelters, dogs are concentrated in predict the future. Additionally, low titer levels different locations with varied backgrounds, all do not necessarily mean a dog is susceptible of which increase the risk of disease exposure. While titers do provide important the recommendation for puppies in shelters is to information they can be diffcult to interpret and start vaccination earlier than home settings, at 4 interpretation varies between diseases. For canine to 6 weeks, and to shorten the interval between parainfuenza, Bordetella, and other noncore boosters to 2 weeks so that there is a narrower vaccines (leptosporosis, Lyme disease, canine window during which maternal antibodies are infuenza), titer levels are not considered reliable too low to protect the puppy and vaccination for predicting immunity and do not adequately has not yet stimulated immunity (Welborn 2011). For rabies, most Similar conditions are found in many canine group jurisdictional laws currently require vaccination settings, so following the vaccine recommendations and demonstration of titer level is not an allowable established for high risk settings such as shelters is alternative. This may also be the case Vaccination of Puppies for puppies kept at home who live in close contact with dogs that frequent canine group settings, as When puppies are born their immune systems dogs do not have to be infected to carry disease are not fully developed leaving them susceptible to many infections. The levels of maternal the risks of this exposure to possible infection must antibodies decrease over several weeks falling to be carefully considered. In some cases the benefts a level where vaccines can stimulate an immune of having a puppy in a group setting outweigh the response. As the maternal antibody level decreases Even if they are undergoing the recommended the puppy also becomes vulnerable to disease. Infectious Disease in Dogs in Group Settings 14 series of vaccines, additional precautions should be taken to protect them from potential exposures that could lead to infection. Healthy young dogs that have not completed their core vaccination series can be permitted to take part in certain group events intended for puppies, providing that other preventive measures described in this document are effectively used; for example, routine environmental cleaning and disinfection, minimizing dog-to-dog contact, establish cohorts, and prompt exclusion of sick or potentially infectious dogs. Typically, rural, where dogs are likely to drink, swim or owners select these, in consultation with a otherwise have contact with environmental water veterinarian, based on individual disease risks sources, such as ponds, lakes, streams, or even including a dogs geographic location, setting, puddles that persist in poorly drained areas. Those managing group settings should can spread this infectious agent in their urine, utilize the same strategies, in consultation with a so consider their presence and the likelihood of veterinarian, to determine which, if any, noncore contaminating shared outdoor areas and open vaccines should be recommended based on the water sources. This is especially important for likelihood of exposure associated with travelling geographic locations and time periods known to to or participating in a particular venue. When vaccines such as Lyme, leptospirosis, and vaccination against leptospirosis is warranted, the canine infuenza virus should be considered 4-way vaccine that contains serovars Canicola, based on a risk assessment of the potential Icterohemorrhagiae, Grippotyphosa, and Pomona for exposure to these infectious agents in the is recommended. Concerning activity would be ongoing be considered in areas endemic for Lyme disease transmission in a defned area or outbreaks when the group setting or activities increase the noticed in association with group settings such chance of exposure to potentially infected ticks. Group setting events such as feld trials, herding, hunting, and organizers may also consider requiring vaccination scent tracking among others. Infectious Disease in Dogs in Group Settings 15 Insect and Wildlife Control Recommendations Many infectious agents that affect dogs are For outdoor areas, including exercise and maintained and spread by wildlife (Appendix 1). Preventing or living in event facilities and dog housing dog access to stagnant water sources is also areas. When appropriate, restricting dogs infectious diseases directly through contact with to leash control can also reduce exposure risks. Canine distemper outbreaks frequently occur in raccoon populations; leptospirosis is often associated with wildlife; rabies is most frequently spread by bats and raccoons; and Salmonella is passed in the feces of many types of animals, especially birds. Risks will vary based on proximity to wildlife and the presence of infectious agents circulating in those populations. Procedures, both indoors and outside, should minimize and manage waste that can attract rodents, raccoons, and other wildlife. Feces, unnecessary organic debris, and garbage (including uneaten human and dog food) should be immediately removed to assist in insect and wildlife control. Some canine sporting events, such as search and rescue, scent tracking and hunt trials are conducted in natural feld conditions where wildlife Outbreaks have occurred due to lapses in wildlife cannot be controlled. Facilities for important to be aware of the local risks and ensure group settings should be designed or selected with that owners are also well informed. For example, consideration given to preventing wildlife access, barn hunt trials often use rats and rat droppings especially in areas where dogs are housed. Dog during training and competition, leading to an food can also attract wildlife and should be stored increased risk for diseases such as leptospirosis, in a manner that prevents such access. The effective control program against insects, rodents, use of pet rats and their droppings will typically and other wildlife should be used in and around decrease but not eliminate these risks. Infectious Disease in Dogs in Group Settings 16 Vector Control and Vector-Borne Disease Recommendations Fleas, ticks, mosquitoes, and triatomes (kissing bugs) can carry infectious agents spreading them from dog-to-dog, and sometimes to people. Almost all dogs have exposure to feas Additionally, insects such as fies and cockroaches through outside activities, and feas can survive can carry infectious agents on their bodies, indoors and in sheltered locations year-round. For potentially spreading diseases such as Salmonella group settings in many locations in Canada and and canine parvovirus.

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