Banned Substances, Health & Disease I

 Like many others that are active in the equine industry, I get several email updates each day from various publications and newsletters.  Sometimes, which is actually most of the time, it is very difficult to stay on top of everything news worthy.  One topic that always catches my eyes is those stories regarding illegal substance abuse or discussions on banned substances in the equine industry.

This topic has always intrigued me for several reasons.  First and foremost, I have always been perplexed as a veterinarian as to how certain trainers or horse owners acquire certain medications.  I have even scratched my head several times during my career at how farriers were sedating horses for shoeing.  Sure, they are qualified to perform shoeing or trimming, but when did they learn the ins and outs of anesthesia, not to mention the ability to monitor the cardiovascular system.  The point here is that the farriers, just like many trainers, are not qualified to monitor for side effects, not to mention contraindications, but ultimately, the question still remains as to how they got their hands on these medications?  In the end, there is only one source and that is the veterinarian.  In many situations, the medications are prescribed for other reasons or as part of a treatment regimen, but are none the less used in improper situations where they were not intended to be used.  In other cases, we have veterinarians that often times are not even equine practitioners, dispensing these medications to farriers  as well as trainers for a price.

This is frustrating to me as a veterinarian as I believe that most medications are to be used in the situation they were intended.  Antibiotics should not be mass stored in barns for random use and sedatives should be monitored closely.  Things can and do go wrong, even with proper use of these medications, but the chances of this happening skyrocket when in the improper hands.

I was recently reading a story about a pony that passed away suddenly at an event in December of 2012.  The article revealed the treatment sheet for this particular horse, which included two corticosteroids, an NSAID medication, anti-ulcer medications as well as hormones.  I have to shake my head in amazement as I have never had a sick patient on this amount of medication, let alone a competing athlete.  Who dispensed these medications and ultimately, who is liable?  Was there no veterinary supervision or guidance?  The medication contraindication list in this situation is long, but somehow they were still given on a routine basis to this horse. The risk was huge to the horse, but what about the child that could have been riding him and potentially injured as a result?

I guess what truly amazes me is that some of these prescription medications are allowed in competition horses under certain circumstances but yet some herbs are completely banned.  Many prescription medications are often only bandaids for medical problems, potentially covering up serious underlying conditions and can have serious side effects.  Herbs on the other hand actually have the potential to improve overall health and thus positively impact many health conditions with minimal to no side effects.  So, where is the logic?

I look to explore this topic more in the future as it is a hot topic right now, especially in the TB racing industry.  I think we need to raise questions as to why these medications are being used.  Is there a clinical problem?  A lameness?  Attitude adjustment needed?  If we know the reason, then maybe we can find a solution to the problem. There is certainly much controversy as to what is right and what is wrong.  Give me your input, your thoughts and stories.

Look forward to discussing this further.

Tom Schell, D.V.M.
www.curost.com

Cancer and Health 102

In the past week's blog, we discussed cancer briefly, reviewed a couple of x-rays of a dog affected by metastatic cancer as well as discussed the three stages of cancer development.  At the end, we were discussing the stage of cancer "initiation" and impact by current therapies.

The stage of "initiation" is the beginning, where it all began in terms of cancer development.  We raised the question as to if there was a genetic change in a cell line, then why didn't our immune system detect that cell and remove it?  This is a complex question, but I believe that immune system is compromised in those individuals or overwhelmed, which then opens the door for cancer development.  Maybe the immune system is poor due to dietary reasons, concurrent medication use, genetics or even lifestyle influences and stress.  Stress, by itself, is a huge factor in disease development and one study that I read years ago (can't recall the paper title) mentioned that after interviewing cancer patients, it was discovered that a large percentage of those patients were affected by a major emotional event within the prior 10 years.  That emotional event could be job stress, divorce, death in the family...the list goes on.  Stress and emotions impact our overall well being at a cellular level.

Now considering this stage of development, the question has to be raised as to how does chemotherapy or radiation impact development?  To me, they simply do not.  They may kill certain cancer cells, but they don't impact that genetic change that has taken place in the cell line, when in fact they may exacerbate it.  As long as there is still one mutated cell present in the body and the circumstances have not changed, then the cancer is still present and can redevelop.  The bad thing, in my eyes, is that often times, the chemotherapy or radiation weaken the host's defenses and thus make matters potentially worse. First, they may weaken the host's immune response and second, these therapies in and of themselves are potential initiators and promoters, leading to cellular mutations and potentially new forms of cancer development.  Ever heard of a person recovering from one form of cancer but then develop a new type a few years after chemotherapy or radiation?  I certainly have.

In my point of view, we need to address the concept of ramping up the host's defenses and targeting the cancer cells on a level that does not impact normal cells.  We are all exposed to initiators or potential carcinogens on a daily basis, so how do we handle this?  It would be great to live in a bubble and minimize our exposure, but even in that case, the plastics used in the bubble would be carcinogens.  We can't get around them or away from them.  They are in the air, in our food and even in the water you drink, not to mention our other lifestyle influences such as smoking.

I am not 100% against chemotherapy or radiation therapy, but feel this is not the only method and also feel that we need to support those patients undergoing those treatments.  The immune system is a vital component to prevention and potentially treatment and there are many research projects that discuss this approach and actually a few medications on the market designed to enhance the immune response. We need to look at our diets as well as lifestyle and environment, assessing if there are things we can change or improve.  Diet, in terms of nutrients, is a huge factor not only from an immune system enhancing point of view, but often times various foods or herbs can actually impact cellular signaling between cancer cells, impact cancer cell death as well as angiogenesis.  I have seen animal patients come into our office totally depleted by their current cancer treatments and have seen humans in the same situation.  It seems that we, as a medical society, do not seem to support these patients and provide them with the nutrients they need to heal, repair and recover.  Not sure why, as overall poor patient health appears to contribute to the increased mortality rate.

In terms of patient presentation, they often present at different stages.  We may have a dog or even a horse present with a small skin nodule that is removed surgically, biopsied and reported as being benign.  Then we may have a patient present with full metastatic disease and subsequent organ failure.  They are two different extremes, but should be treated with the same philosophy and that is to improve overall patient health.  In the case of the benign skin nodule, benign is perceived to be better than malignant, and it is, but it is still a sign that cancer or cellular changes are occurring.  Remember, a benign lesion becomes malignant in the "Progression" stage.  So, when encountering a benign lesion, we are essentially in stage 2 of the process, which is good, but still signals that a problem is present.  Should we just remove that benign lesion and send the patient off, or should we evaluate for possible ways to interact and improve that patient's health and immune response?  I, personally, vote for the second option.  In cases of full metastatic disease, obviously we have reached the "progression" stage, and a cure is unlikely, especially if organ function has been compromised.  However, even in this stage there is the possibility of enhancing that patient's quality of life through improved health.  Often times, this level of progressed disease is seen as a hopeless situation, but it is not, at least in my eyes.  I have had patients with metastatic disease be managed well with an improved quality of life for many months or even a year, through dietary changes and alternative therapies.  This is not to say that the disease is gone or 'cured' but more so, the patient improves in terms of quality of life with some possible tumor burden reduction.  I always see opportunities to intervene which may impact disease progression, but unfortunately, some owners and patients give up in their minds and see these efforts as not being worthwhile.

So, how can one impact cancer at various stages?  Natural therapies to me are the most ideal means, which includes a diet free of preservatives, pesticides, dyes and other inorganic material.  The inflammatory process is tightly connected with the progression of many different types of cancer and can potentially be impacted in a positive way through diet and herbal therapy.  Oxidative stress or free radical damage is a major component of the "initiation" stage, in which the free radicals induced by various chemicals directly cause cellular genetic mutations.  The use of antioxidants have shown promise in various cancer therapies and research papers, but are frowned upon by oncologists.  Personally, I find them very helpful in our patients, but the reason that oncologists are against them is that many of the chemotherapy regimens and even radiation therapies actually induce oxidative damage to cells, with the hope of causing cellular death.  Using antioxidants during these therapies is controversial, as the concern is that they might negate the effects of chemo or radiation.  This has yet to be proven to the best of my knowledge.  In fact, many herbs and some antioxidants have been shown to be useful during certain chemotherapy or radiation treatments.  How?  They appear to actually sensitize cancer cells to the effects of chemo or radiation, which makes them more susceptible.  They also can help to protect normal cells from secondary damage.  Curcumin is one major example of herbs with this ability and it has been demonstrated in a few research papers, but still continues to be pushed to the side.

I don't have all of the answers to cancer, but believe that we are missing the bottom line point and that is deterioration of the host with an increased susceptibility to cancer formation.  The incidence of cancer has increased dramatically, at least in my lifetime and we have to question why instead of just focusing our resources on targeted therapy.  Our environment and food sources are changing, which is impacting our health as well at that of our pets.  We have to see this and understand it as well, but yet raise the question as to how to best protect ourselves from the disease.  It is far better to prevent than to treat.  Cancer affects individuals and animals from the very young to the very old, but there appears to be an increase in the incidence in the middle age groups recently.  Women in the 20's and 30's are being diagnosed with malignant forms of breast cancer, when they should be in the primes of their lives.  Why?  It is not a question of producing a more effective chemotherapy, but more a question of why this is happening and why these individuals are more susceptible.  Is it purely genetic?  Not likely in my eyes.  To me it is more a sign that the individual's defenses are compromised or that they are being overwhelmed with various "initiators" at such as high level that they are being overwhelmed.  This should be the focus of research, how to enhance the individual and diminish the exposure to various carcinogens, but it doesn't appear to be of major interest.

In the end, cancer is a complex and horrible disease whether if it is affecting a human or an animal.  The possibilities are there in terms of treatment or better yet, management.  I think and feel we can do more to improve our own health and even improve outcomes when cancer has already been diagnosed.  Often times, this involves us being our own advocates, keeping our own health in mind versus relying on others to create 'cures' to save our lives.

Just my thoughts.

Tom Schell, D.V.M.
www.curost.com

Cancer and Health 101

Cancer is a very common entity in today's society, unfortunately.  I'd say that on average at least 3-4 people out of 10 knows someone or has someone close to them affected by this horrible disease.  We see it on the news, hear about research that may be going on as well as advances and see fund raisers almost every weekend.  The question, at least in my mind, is "are we getting closer to a cure"?

As a veterinarian and someone that works closely with the general public, we have close contact with cancer patients of all types, stages and species.  That someone may be a client or the patient themself.  The disease intrigues me on many levels and my honest opinion to the above question is that we are no closer to finding that cure now than we were 20 years ago.  The therapies discussed at our veterinary conventions are nothing new, with the exception of possible changes in chemotherapy combinations or the use of newer radiation type therapies.  In the end, we have to ask ourselves if we are saving lives, improving lives or just making things worse?  The last report that I saw regarding human cancers was that the overall 5 year survival rate has barely budged.  This is frustrating to me as a veterinarian, researcher and cancer patient myself, considering the large amount of money that is raised and put into research on a yearly basis.  Why are we not closer now than 10 or 20 years ago?

Cancer is complicated topic and when I am asked by clients whether if I think we will ever find that 'cure', my answer is always a resounding "NO".  This is not due to politics or greed in the pharmaceutical venues, but more so because cancer is very complex in its pathology.  Research focuses and discovers certain methods of attacking cancer cells, but their approach is usually through a single pathway and to me there is no single pathway that is going to eliminate the disease.  I am not trying to be depressing in my views, but more realistic and feel that we need to see the big picture if we are going to produce results.

The act of carcinogenesis (birth of cancer) is based essentially on 2 or 3 stages, dependent on what you read.  The first stage is "Initiation" and involves the exposure of the cells to a certain initiator such as a chemical, toxin, radiation or even a virus.  This initiator then inflicts irreversible genetic changes to the affected cell resulting in a permanent mutation, which will be passed onto future daughter cells should that mutated cell replicate.  The initiators affect the cells generally at a DNA level, affecting protooncogenes or tumor suppressor genes, which may then impact certain growth factors, receptors, enzymes, or transcription factors that influence cellular growth and replication.  The second stage is "Promotion", which can be viewed as either a stage by itself or stage 1 and 2 as some promoters can be initiators themselves. In the promotion stage, various promoters affect the mutated cells at either a cellular receptor level or through gene expression, causing the cell to essentially begin to replicate uncontrollably.  The final stage "Progression" is the stage at which a benign tumor transforms to a malignant tumor, which then demonstrates an increased growth rate, invasiveness and metastasis.

Now, many people have either had an animal affected by cancer or have known an individual with cancer, but few have seen cancer itself as a tumor.  Let's look at a case in a dog, to demonstrate how cancer can appear and progress.  In order to know abnormal, one has to know normal.

To the right is an image of a dog's chest or thorax in a lateral view, meaning with them lying on their side.  This is not the most ideal image in terms of totally healthy anatomy, but will work for the purposes of demonstration.  I don't have this image marked for anatomy, but hopefully we can all see the heart and the black areas around the heart are the lungs.  Air shows up as black in an x-ray and anything showing up as white is essentially something that is denser than air.  Take a good look at this image, then compare to the next one to see the differences.

To the left, we have a chest radiograph of a canine patient with metastatic cancer.  In this image, I do have some markers showing the trachea and the heart, but also have red arrows which indicate the metastatic lung tumors that have developed.  When you compare the two radiographs, one can easily see that there is something in the lungs that is showing up as white, nodular type of lesions.  It essentially is not as black was what the normal radiograph demonstrates.  Something is 'added' to the lungs and in this case it is likely small nodular growths.


Cancer is an interesting subject to me because of its complexity.  I am certainly not an oncologist and do not claim to be one, but I do have a different approach to cancer in myself and my patients.  I tend to look at things in a more simplified manner and understand that there is a higher complexity to the disease than what I describe here. All too often chemotherapy and radiation therapy are utilized to battle cancer.  One has to look at what the purpose of these two methods is and overall, the intent is to destroy or kill the cancer cells. Often times, these modes of therapy do more harm than good, affecting normal cells as well as cancer cells, depleting the patient of vital energy and impacting the immune response negatively.  Analyzing this theory, we have to go back to the 3 stages of cancer development.

It has been said that in the average human or animal body, thousands of cells become 'cancerous' on a daily basis.  The question comes as to why some people develop cancer and others do not.  One of our most important defense mechanisms behind cancer development is our immune system.  It is the job of the immune system to recognize mutated or abnormal cells and remove them from circulation.  Knowing this, we have to re-look at the first stage of cancer development.  If we are exposed to an initiator and there is cellular damage or mutation and cancer development, one has to raise two questions.  First, why did the immune system not remove these cells from circulation and second, how is chemotherapy or radiation going to alter this stage?  This is the bottom line stage and we have to look at this stage as the source of potential therapies, at least in my eyes.  Of course, it is not the only stage, but one that I feel is important to prevention as well as managing the disease.

More to follow in the coming week....

All our best,

Tom Schell, D.V.M.
www.curost.com

Vaccines and Impact on Health

As a veterinarian, I routinely vaccinate patients on a daily basis as a perceived part of preventative health.  Vaccines have certainly saved many lives and prevented many infectious diseases from spreading, but one has to question their timeliness as well as possible negative impact on health as well.

In companion animals, we have the DA2PP (distemper, adenovirus, parainfluenza and parvovirus), bordetella and rabies for dogs and the FVRCP (feline viral rhinotracheitis, calicivirus and panleukopenia) and rabies for cats.  In the horse, we have eastern/western encephalitis, tetanus, herpes virus (1/4), west nile and rabies.

I believe that many of these vaccines are very efficacious when used properly, but we need to consider the patient as a whole as well as timeliness when administering them.  In all species, we will initially perform a booster series in the juvenile animal or those animals that are naive and have not been vaccinated before.  After this initial booster series, pets are then assigned to a yearly basis and horses to either a twice yearly or annual series.  The rabies vaccine, dependent on the state, can be assigned either a 3 or 1 year status, dependent on age and vaccine history.

One of the biggest factors to vaccinating is viewing the patient, prior to administering the vaccine.  In companion pets, we always perform an examination prior to administering the vaccine, which helps us to determine if there are any concurrent problems that might be complicated by a vaccine.  This may be indicated by an elevated body temperature, evident skin or ear infection or other health conditions that may be raised by the owner. In horses, likely due to expense and time constraints, it was not always routine to examine the patient prior to administering the vaccines.  Often times, as a vet, we had a barn full of horses needing vaccines in a short period of time.  It was just not efficacious to perform exams or body temperatures on all the horses and it was quicker to run through the barn with needle in hand.  This was something we were taught as veterinary students and unfortunately forced to adhere to due to daily work loads and client financial constraints. 

I have always been in the belief that if my patient had a concurrent health condition, I did not administer vaccines until they have recovered.  Most small animal patients benefited from their exams, but often times equine patients did not. 

Vaccines are designed to stimulate an immune response and are either categorized as modified live or killed vaccines with most vaccines being the later of the two.  Often times, vaccines will have certain adjuvants added to them, which are designed to enhance the immune reaction but also may contain certain preservatives as well.  A killed vaccine contains a modified component of the virus or antigen in which the immune system responds.  A modified live vaccine contains the actual virus or bacteria, but the bug has been inactivated and thus unlikely to produce actual disease but instead just elicit an immune response.  The overall goal is to stimulate an immune response with a 'memory', in which if the body encounters that actual virus or bacteria in the future, the immune system will remember it and act accordingly.  The modified live vaccines are considered more potent and more likely to have side effects potentially.


The typical vaccine response is a low grade temperature as well as 'aches and pains' for maybe 48 hours post vaccine.  The immune system actually lowers right after the vaccine is administered, then gathers it forces and rises over the next few days.  In some cases, it is common for the animals to have a lump formation in the area of the vaccine due to local inflammatory reactions.  This is most common with the rabies vaccine.  Overall, in healthy animals, the reaction is brief or not present at all and they continue on as normal post vaccine.


The problem that comes is when we administer these vaccines to pets or horses when they are clinically challenged with another condition.  This may be detected by an examination by an elevated body temperature or through observation by the owner, but unfortunately, in many cases this information is tossed to the side and ignored by many.  I have seen puppies exposed to parvo virus be administered a parvo vaccine in hopes of preventing the disease.  The problem here is that the puppy has been exposed and the virus is on board, whether if they are clinically sick or not.  We have to remember that after initially vaccinating an animal or person, the immune system actually lowers, then rebounds.  If the pet has been exposed to the virus, we may be opening the door for the virus to replicate if we lower the immune response through vaccination.  This is indeed what happens in many of these instances and owners are questioning why their pet is sick when they vaccinated them.  This happens all to often with dogs because these vaccines are available over the counter for owners to use freely.  The same holds true for horses, such as in the case of strangles.  I have also seen cases where friends of our have taken their children to the pediatrician due to running a fever, found out they have an ear infection and despite this, the doctor vaccinates the child for the flu or other illness while also prescribing an antibiotic.  My general rule of thumb is if I have a pet or horse that has been exposed to a certain antigen, I will wait 7-10 days before vaccinating, which is adequate time for them to become clinically sick.


Another issue that we often times forget is that we need a healthy immune system to respond adequately to the vaccine.  In many instances, the pet or horse or person, is already challenged by another health condition or maybe they are just not healthy overall.  Here, we can administer the vaccine, but that does not ensure that we will provide a level of protection.  This is seen often in cases of 'vaccine breaks' in which animals have been vaccinated, yet become sick when challenged with a certain virus or bacteria.  I don't think it is reflective of the vaccine as much as it may be reflective of the health of the patient to respond adequately to the vaccine.  One could raise this issue with the human flu (influenza) vaccine as well.  Despite research findings, this vaccine only provide a dismal 5% protection rate based on recent findings.  Why?  Was it the vaccine or was it the patient?  My bet is that it is reflective of overall poor patient health rather than the vaccine. They state that the most 'at risk' population for influenza is the elderly, very young or those with concurrent health problems (which is true)...so these are the ones to be vaccinated, right?  Doesn't make sense to me, as these are the groups that are the most immune and health challenged.  Vaccine administration may help, but then again this is the group of people that may not be healthy enough to respond adequately or worse yet, the vaccine could fuel current health conditions.


We have already discussed concurrent patient disease such as infections being a contraindication to vaccines, but what about other health issues?  Let's look at allergies, respiratory conditions such as asthma, diabetes, insulin resistance and even cancer.  What is the common denominator with all of these conditions?  There are two:  inflammation and a poor immune response.  If we have a patient with ongoing skin allergies, for instance, that has intermittent skin infections and itching, why would we choose to vaccinate this patient?  All we will do is further aggravate the condition and make matters worse for the patient.  The same holds true for insulin resistance in horses.  How many horse owners have seen the case where a horse becomes lame or mildly laminitic post vaccines?  This response is correlated with insulin resistance and inflammation.  In insulin resistant horses, we have a low level of inflammation that is ongoing, like a smoldering fire.  When we administer a vaccine, it is like putting gasoline on those glowing embers....poof!!  This is why they react the way they do.  Some owners may know they have insulin resistant horses, while others do not.  This type of vaccine reaction in any horse should raise the question as to what else is going on in that patient instead of just treating it symptomatically. Cancer patients are yet another category that should have a thorough evaluation of their vaccine regimen.  These patients are already compromised in terms of health and immune response.  Why would we want to challenge them further and potentially disrupt a state of balance?  Are we more concerned that this patient may come down with influenza or parvo than potentially survive cancer?  This holds true for all vaccines, including rabies, in my opinion.


So, what is the answer?  Vaccines are very effective in preventing disease when used properly, but can contribute dramatically to poor health if used unwisely.  I think we need to evaluate our patients more fully prior to vaccinating to determine if they are healthy enough or not.  I also feel that in horses, we need to split up antigen loads and not give everything at one time, especially in those horses that may be compromised.  The problem with doing this is that splitting up vaccines may take several farm calls or office visits to get the full spectrum.  This may entail added costs for the owner, but in the grand scheme of health, it is warranted.  We need to be more aware of our pets and horses, as well as ourselves, and make educated decisions on what we (as owners) feel is the best thing to do, rather than be persuaded by our veterinarian or barn manager.  In companion pets, I feel we need to be reducing vaccine intervals to every three years, which has been shown to be adequate in many circumstances.  This will help reduce unneeded vaccines and possibly reduce long term effects.


In the end, vaccines are a vital tool in our medicine chest, but they need to be used wisely instead of as a revenue stream for major manufactures.  They are a great means of disease prevention, but are not the only way.  We have to remember the patient as a whole and improve health from a generalized perspective.


All my best.


Tom Schell, D.V.M.
www.curost.com