Slàinte & step 2 towards veterinary spectrum of care

 Picking up from the previous post on veterinary spectrum of care,

here is my attempt at summarizing a few of the article’s proposed action initiatives. These appeared (at least to me) to focus on:

1) Awareness,

2) Education,

3) Research, and

4) Communication, in order to try to improve access to care for animal owners and also overcome barriers that prevent veterinary interventions to these across a wide spectrum of health care needs.

1.     Awareness of the concept of spectrum of care

This makes sense…as I suspect many DVMs & clinic staff members just don’t know that this is a rising concern, or if they do they feel powerless to do much about it or otherwise unable to prioritize and dedicate time towards it.

2.     Education on:

a.     Existing clinical guidelines available for animal health conditions (e.g. Antimicrobial use guidelines such as,  https://onlinelibrary.wiley.com/doi/pdf/10.1111/jvim.14627)

b.     How to critically evaluate these, e.g. Evidence-based practice and use of things like the Appraisal of Guidelines for Research and Evaluation II (AGREE II)

c.     Development and the practice of skills to quickly assess these guidelines for approaches along this spectrum and ideally reduce dollar resources spent on ineffective tests or treatments.

Tools to help DVMs with this offbeat ‘what’s the evidence’ way of thinking, might include websites such as, Choosing wisely

or bestbets for vets.

It’s also critical to keep in mind that ‘evidence’ can come in many forms and levels, and although sometimes all we have is clinical experience as our form of evidence…this (IMHO) should not be discounted.  The key is to recognize and be transparent about this (e.g. lowest level of evidence ) and not be satisfied to settle with this for the future. There is much value (again- at least for me) in sorting out where we are (baseline) and looking towards what we need or would help.

3.     Research!!!!

As in ‘do research’, and do it in (or for) the vet primary care or general practice setting. This will hopefully aid veterinarians faced with these issues, i.e. those that are actually in private practice, aka the hardworking DVMs in the field. This style of research should also focus on the outcomes that we think matter most to the majority of pets and owners (e.g., quality of life, cost). Even if we don’t have all (or very many) of the needed answers for spectrum of care, once again that shouldn’t translate into ‘it’s no use to try’. 

4.     Communication

Much the same thing here…as in ‘communicate’, and do so with all involved groups to figure out what is needed and what is do-able. This type of stuff really does ‘take a village’ and that means, pet-owners, DVMs, clinical staff, baby vets (such as my students here at AVC ), folks in the animal health industry, practice owners, etc. should all get involved to problem-solve.

The bottom-line is, if ‘we’ think this is important stuff for our animals and the profession, then let’s trip the light fantastic and get started bringing these efforts into veterinary curriculums and hopefully from there into clinical practice and to animal-owners. In terms of New Year’s resolutions (for 2019), I think I’ve got a much better shot at this one than 5 minutes of daily meditation.

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Slàinte & steps towards veterinary spectrum of care

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The holidays can be a whirlwind of lights, colour, joy and in my house kids (& dogs) amped up on Santa-induced excitement and treats. There is no other time of year quite like it. However, there is a dark side to the holidays, and as every vet clinic staff member knows (especially those on emergency duty like I just was)…the season can be cold, bleak, and/or simply sad for many- whether 4 footed or two. For some, the diminished dazzle of the season can be related to economic and/or emotional concerns (i.e. sadness, depression, anxiety, or compassion fatigue), and this can be true for animal owners as well as vet teams

In the veterinary profession we are taking baby steps towards recognizing the challenges related to rising economic concerns (i.e. increasing veterinary costs), and the snowball effect that lack of coin has (especially at this time of year) on reducing pet visits to veterinary clinics. This down-sizing (and decrease in dollars available to spend by animal owners) has considerable impact on animal welfare. The most extreme example of which being an increase in decisions to end a dog, horse, or kitty’s life on the basis of financial factors.

Moving forward into 2019 and onward, there is a strong need for veterinarians who are prepared to assess, communicate, and deliver approaches to animal owners which include healthcare options along the spectrum of care, i.e. a range from lower cost to those regarded as ‘gold standard’ (+/- more expensive). Whether options that vary in cost also vary in effectiveness may be an open, yet undetermined (and potentially controversial) question…In other words does the ‘gold standard’ treatment really have a better outcome for the patient and owner? …And although it pains my clinician brain to think it, that is exactly the type of question that ties into a rising need for (and application of) evidence based-medicine and the day-to-day use of this in clinical practice, i.e. a vet clinic near you (and me). Other question examples could include, ‘What is the evidence for promoting one diagnostic test or treatment over another?’ and do we (i.e. you, me, ‘the experts’…whomever those people are) consider that evidence ‘good?’.

A recent publication sought to raise awareness of this need for veterinary spectrum of care. Additionally, the commentary didn’t just ‘chit chat’ about need….but proposed action initiatives to try to improve access to care for animal owners and also overcome barriers that prevent veterinary interventions to these across a wide spectrum of health care needs.

Unsurprisingly (at least to me), the bulk of these ideas centred on:

1) Awareness,

2) Education,

3) Research, and

4) Communication.

Because it’s the holidays, (aka my noggin’ is full of egg vs. brainpower), I’ll take a 24 h break (and another thoughtful read of the article) before making an attempt at summarizing a few of this fresh new group’s target areas for veterinarians & the profession.

The Heart of the Matter: Update December 2018

Day 13 on my ‘veterinary publications advent calendar’ opened to reveal something much more nutritionally dense than chocolate…a peer-reviewed (and free-access!) article on dog diet, taurine and the potential association of both with heart disease (dilated cardiomyopathy-DCM)) in 24 DCM diagnosed golden retrievers.

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The study began with a total of 40 (no doubt super cutie) goldens, with 16 dogs subsequently excluded for the usual reasons clinical research is challenging, e.g. not up to ‘snuff echocardiogram (heart ultrasound) results, incomplete diet histories, etc. Importantly, the publication also contained one year follow-up on 16 of these dogs.

Dog diet was clearly identified, and somewhat unexpectedly (& pleasantly) a complete (i.e. treats, supplements, etc.) diet history was available on the dogs. The study team also performed a diet ‘deep-dive’ review of nutritional parameters (i.e. calories, ingredient deck, fibre composition), feeding trial information (yes they did one or nope-they did not) and/or whether formulated to meet AAFCO (or nope-they did not). Additional nutritional information included whether diets were marketed by manufacturers as grain-free and if diets listed legumes (i.e. beans, chickpeas, lentils, peas, pea protein or fibre) within the first five label ingredients.

There are many reasons to give the article a read, but one (or someone trying to avoid excess rambling) could attempt to re-phrase the heart of the matter as:

In the study, dogs (16) diagnosed with DCM and available to follow-up had…”Significant improvement in echocardiographic parameters and normalization of whole blood taurine concentrations from baseline (close to when the dog was diagnosed) to follow-up visits after implementing a diet change and supplementation with taurine +/- L-carnitine…This occurred by a median of 8 months in all but one dog (15 of 16).”

The researchers identified other nutritional tidbits on this golden grouping. Two of the more interesting, (to me at least), being that: 1) many (most) dogs were eating less than their predicted diet intake needs (based on metabolic energy requirements (MER), and 2) that a clear association with diet meat protein (type of meat) was not found…stay tuned on the ‘baa baa humbug’ aspect of that one.

As I said in November, it seems that we all agree that:

a) nutrition is uber-important,

b) obtainment of a complete diet history needs to occur at every veterinary visits, and

c) we still have an awful lot to learn about pet food, taurine, K9 heart and overall health & nutrition.

However, it’s wonderful (possibly Christmas miracle category) to see such a large group of researchers collaborating to try and identify concerns towards keeping dogs safe- and maybe even learning more about what they might (or might not) need nutritionally. And that (i.e. collaboration and raised nutrition awareness) sums up what I’d asked Santa to ‘veterinary gift’ me with in 2018.

My veterinary wish list looks a bit different for 2019...but more on that (and hopefully a cup or two of spiked cider) in the New Year.

 

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B’Lyme-y, should I vaccinate the dog or not?

(Or…all I want for Christmas is for somebody to tell me if I should advise vaccination for K9 Lyme disease)

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On the fairly long list of things the average veterinarian might request from the rosy cheeked & jolly one this holiday season, (after world peace and mandatory pet insurance plans), might be a wish for clear consensus on all things related to Canine Lyme disease.

Failing that, a definitive stance on one aspect, Lyme vaccination, would be kind’ve nice.

Well, Santa (or a team from the University of Guelph) and a sackful of PRISMA prepped systematic review, may have come a bit early this year. Since, seriously, nothin’ says Christmas like meta-analysis, eh? However, bear with me when I translate (likely poorly) that these types of terms reflect a solid attempt by this group of researchers to try and deliver to practicing veterinary clinicians (and pet-owners) a much-needed evidence-based assessment on a topic that doesn’t require a cup of cocoa or a simmering fire to get folks heated. 

Using defined inclusion and exclusion criteria, or a ‘what’s out and what’s in’ list to tackle assessment of studies that reported the use of Borrelia burgdorferi (the agent of Lyme disease) vaccines in dogs, the researchers started with 1570 studies. That seems like a lot…. but using their standardized criteria, they ended up with 3 observational (the most current dated 2005) and 13 challenge studies (with only 5 of the 13 (38%) done in the past 10 years, and all done in dogs < 18 m of age).  

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Don’t worry, I am getting to the holiday miracle (or epiphany) portion of this, i.e. should we (or should we not) consider Lyme vaccination effective? [Cue the little drummer boy] The summary of evidence completed by the researchers suggests that vaccination lowers the risk of clinical sign (lameness, anorexia, fever) development in vaccinated dogs vs. unvaccinated dogs.

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However, it is worthwhile (IMHO) to keep reading. [Cue the Grinch, get ready to have your heart shrink 2 sizes too small] As the article goes on to raise a number of concerns regarding study aspects frequently assumed when chatting about Lyme research, such as, were ticks infected with B. burgdorferi (i.e. did anyone check?), were dogs classified as negative before the study began (i.e. did anyone screen for B. burgdorferi status?), and ‘Are these articles relevant for the current vaccines (i.e. have vaccines changed over the years? And if so in what direction?’). Okay- I admit that last concern was mine.

Similarly, there was only one observational study that looked at clinical signs, and as the researchers quite rightly point out, clinical signs of Lyme disease are not all created equal…and this lack of information on clinical signs (individually or clumped together), their duration or severity is fairly critical (essential) for those of us attempting to make recommendations based on risks of clinical disease and with respect to prioritization of canine quality of life.

It is tough to weigh the pros and cons of a vaccine decision without having the questions the researchers outlined answered. However, I think this research team has earned a wassail (or at the very least a latke) for raising further awareness regarding the lack (and limitations) of studies on Lyme disease. Particularly the need for clinically focused studies (i.e. those performed in the field), as unfortunately, a disease model (along with a gold standard test) for B. burgdorferi and Lyme disease in dogs continues to remain on future ‘letters to Santa’ wish lists. 

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It’s going to require some serious sugarplums (or a nutcracker) to entice veterinarians to initiate and participate in broader based studies reflecting what occurs in general veterinary practise for many (most) K9 diseases and prevention strategies. And until this style of research occurs, I’ll assume that Santa is going to leave me (and my still unanswered question regarding Lyme vaccination) on his ‘naughty’ vs. ‘nice’ list.

 

Infection Control

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Infection Control for Dummies (i.e. Me, Myself, and I)

There are any number of things in life I suspect we all know are important, in part because they are necessary. However, the idea of spending time on some of these things (much less learning, teaching or being accountable for them), frequently bores us to tears. I freely admit that I feel this way about infection control.

After applying a simplified (‘dumbed down’) definition for infection control, i.e. ‘How to slow or stop bad (or disease causing-contributing) bugs from affecting a group of patients and caregivers, e.g. hospital staff and clients’… I think most of us would agree that infection control is critically important, needed and should be upheld & supported. However, I confess that the topic area makes me want to slink unobserved out of any room in which it’s being discussed or lectured. After all, I got into vet med to save lives…and that type of heroic action warrants much more time allotment than learning what disinfectant can kill parvo, right? Ahhh…crap (literally!). Imagine my dismay when I slowly, (reluctantly), began to recognize that there was a direct relationship between savin’ lives and infection control (see def’n above).

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This awareness and newfound incentive to ‘take my ‘infection-control (IC)’ medicine’ led me to a number of resources on the topic. One of the latest of these is from AAHA: Their 2018, Infection control, prevention and biosecurity guidelines . These resources were developed to assist veterinarians, personnel and dedicated pet-owners in the reduction and outright stomping out of disease (and infection risks) associated with vet clinics. It’s EPIC that these latest guidelines come with a practical resource section for the entire practice, e.g. identifying high-risk patients for the front-end staff, an outline of action items and accountabilities for the hospital, tables of disinfectants (see ‘ya later parvo poopie!), and a biosecurity tracker to measure veterinary and vet practice infection control prevention incorporation and ongoing success.

Pet-owners were also included in the IC equation, and can help by initiating and considering ways to keep their beloved babies (and in some cases themselves and their 2 legged family) healthy.

The videos on AAHA resource page should keep any millennial happy, and I strongly suspect my students will enjoy using them to keep me on track also. Particularly the clip on ‘Top 5 ways to decrease hospital acquired infections’. In fact, I can almost hear, “Why didn’t you wait for the appropriate contact time before wiping that surface down?” Or even worse…’Ummm, I’m pretty sure you missed a spot with your attempt at hand hygiene’. Along these lines, while I doubt the typical vet would claim to be a fashion plate (it not being a high glamour gig) …I 100% agree that we should all be able to don and doff our PPE (personal protective equipe) properly, particularly if the motivating outcome is safer pets- vs. the front page of InStyle or Canadian Living.

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Infection control is everyone’s job, and while interest and value can be inconsistently (or not at all) applied to simple tenets, i.e. wash your hands, these are basic things that can have the highest impact on health- for our pets and us. And that’s well worth all of us (including a self-admitted infection control dummy like myself) spending time on.

 

Getting to the Heart of the Matter: November 2018 UPDATE

About 4 months ago, I wrote about a specific type of canine heart disease (dilated cardiomyopathy, DCM) and the recent concern over its association with diet (pet food).

This past week a commentary appeared in a veterinary journal on the subject . It was important to see what is considered expert opinion and have a peek at the results of a survey on this concern, as there’s no doubt it’s a complex issue with serious canine health impacts.

The commentary (quite rightly IMHO) highlights the importance of nutrition and incredible value of obtaining a thorough diet history on all pets as part of a clinic visit. Perhaps as importantly (for me), it also indicates that:

1) there is still an awful lot to learn about nutritional needs-requirements (and how these may vary from dog-to-dog and in dogs of different health states),

2) there is a dearth of peer-reviewed studies, articles or commentaries on canine nutrition, and, 3) there are myriad complexities (and lack of clarity) when it comes to pet food formulation, manufacturing and sales.

The commentary also introduces new terminology (i.e. boutique or exotic diets) to the pet food dialogue. I’m not convinced these terms assist with causation of concern (with respect to cardiac disease or any other). I’d also guess they further cloud a complicated issue (and for me at least, conjure images of fancy French shops) …vs. convey what is (or isn’t) known about these diets and why they may be associated with DCM. The connotation of boutique, i.e. ‘perceived as high-end’, is hard to miss as well….

At present, we simply do not know why (or if) these diets may be linked with canine DCM…and there is much speculation on cause, i.e. low taurine, reduced taurine precursors (i.e. methionine and cysteine), deceased bioavailability, increased (high) fibre preventing enterohepatic binding and recycling, increased taurine loss via the gut and potentially a heightened breed susceptibility…or the association may be naught, i.e. there isn’t one. After all, …a LOT of dogs eat diets containing these ingredients (or ingredients in the speculated proportions), and it appears that the vast majority are unaffected.

Unfortunately, along with the lack of veterinary peer reviewed publications on this subject there has not been disclosure by the FDA on what diets are being investigated… However, I strongly suspect (and really hope!) that plenty of canine diet reformulating (change in diet recipe) has been occurring since this concern was raised, and have my fingers crossed that manufacturers are doing things like:

1)    Ensuring all diets have increased taurine (vs. prior levels)

2)    Ensuring all diets with significant amounts of water-soluble fibre (peas, lentils, chickpeas, tomato pomace, beet pulp, pea fibre, pea protein) have even higher allotments of taurine (again vs. prior levels)

3)    Limiting all new canine diets to 30% legumes (i.e. peas, lentils, chickpeas, pea fibre, tomato pomace)

4)    Including additional methionine to try and provide additional precursors for taurine synthesis (if necessary, and vs. prior levels) 

The recommendations provided by the commentary similarly provided insight on what we do not know about laboratory sampling and various dietary supplements, e.g. taurine. It’s a tough order to advise the checking of taurine when there is a known lack of consistency in lab standards for analysis, or good understanding of what sample is optimum, i.e. whole blood or plasma. Additionally, it’s hard to feel good about advising taurine supplementation without a standardized supplement and/or optimal dose…

So, what’s a dedicated dog-owner (or DVM) to do? Ask (or keep asking) the tough questions about the diet your dog (or your client’s dog) is eating, be aware of this concern and critically evaluate what information is available, and after a thoughtful dialogue on what makes that dog unique (e.g.  risk factors, susceptibilities) and what the diet(s) in question does (or doesn’t) contain…make an informed decision (together) on what is best- for that dog.

We may still have a lot to learn about pet food, K9 heart and overall health & nutrition, but in the meantime, we can work together in a collaborative way to try and keep dogs safe- and maybe even learn more about what they might (or might not) need in the process.

FDA: https://www.fda.gov/AnimalVeterinary/ResourcesforYou/AnimalHealthLiteracy/ucm616279.htm

 

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The risks of importing (and traveling with) pets

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We live on an island, and sometimes life on PEI can bring various ‘Alice in Wonderland’ quirks. This past week quite a few folks traveled to the island, and probably more travelers would have reached PEI, if not for the ‘predictably unpredictable’ November weather that resulted in flight delay and bridge closure. A number of travelers brought their pets with them during their visit to PEI (i.e. once the bridge opened), and it made me ponder (not for the 1st time), the infectious disease risks associated with animal importation. Although these risks are highest from imported animals lacking a known medical history (e.g. strays, rescue animals, etc.), particularly those who come from countries with known infectious disease, these risks are still present (albeit on a reduced scale) with any type of animal importation, including owned pets.

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A colleague of mine spends a good deal of time trying to eradicate the incursion of canine influenza into our fair country Canada- and he’s been remarkably successful at this (https://www.wormsandgermsblog.com). However, every time I see an update on canine flu, I heave a deep sigh (hope someone buys that guy a beer!) and wish that the practise of importing higher-risk animals from other countries was something that either, a) didn’t happen, or b) if considered absolutely necessary, was thoughtfully considered (& vetted) prior to doing so. Since, these types of canine influenza outbreaks (or the risk of them occurring) seem largely avoidable with a bit of rational planning, i.e. imported (or adopted) dogs from countries with known flu (e.g. Asia, or portions of the U.S.A with known risk), should be isolated from other dogs for 28 days, until the risk of disease (and disease spread) has passed. 

Over the past number of years, I’ve done consults for or seen patients in Canada that are ill with diseases including leishmaniosis, coccidioidomycosis, hepatozoonosis and trypanosomiasis. These diseases may sound like the poem of the Jabberwocky, but they are in actuality infectious concerns that can affect dogs (and sometimes humans) from places outside of Canada. However, when dogs travel (with their humans) or are imported from other countries, these infectious concerns (just like with canine influenza) may ride along (or cross bridges) also.

As such, I’d gently suggest that any animal importation should be done with a degree of thoughtful consideration (i.e. risk assessment on a sliding scale), in order to minimize adverse impacts on the entire animal community (local, regional and national). Probably this is a tough ask, but as we approach the holiday season (and no…black Friday isn’t a holiday), perhaps it’s a request that’s in keeping with a sense of community, accountability and what is ‘looking a lot like Christmas’ in many parts of Canada?

 

 

Winter is Coming! (Could Leptospirosis be coming, too?)

Winter is coming (& canine leptospirosis may be more likely) … In B.C. and other parts of Canada.

On September 14th, I posted a draft map (http://www.canadian-k9.com/puppy-tales-blog/) provided by our collaborative research team (Universities of Guelph and PEI) on Canadian canine lepto test positive incidence.

This past week, an article quoting a veterinarian in Sooke, British Columbia was released, warning dog owners about a local sick dog that had been diagnosed with leptospirosis and encouraging vaccination to prevent more sick dogs (https://www.goldstreamgazette.com/news/veterinarian-warns-dog-owners-of-leptospirosis-in-greater-victoria/)

Test results (like those on our map) don’t equate with clinical disease in all instances, and that’s important to keep in mind. However, based on our preliminary assessment of the Canadian lepto test results, it’s also not too surprising (to me) that dogs in BC are at risk of (and are it seems) being diagnosed with leptospirosis. How many dogs are being diagnosed or are sick is quite another topic, since lepto: 1) isn’t always on dog owners’ (or veterinarians’) radar, and as such may be missed by not being considered or tested for, and 2) the lepto vaccine isn’t considered a ‘core’ vaccine in the traditional sense, and thus not used when perhaps it may be beneficial (https://www.aaha.org/guidelines/canine_vaccination_guidelines/practice_vaccination.aspx).

Lepto has been worrying me (hence the blogging), and there are few things I hate more than disease in dogs that I consider largely preventable through awareness and vaccination. The end result of that concern is that we’ll be expanding the Canadian K9 Lifetime Study in early 2019 to try and sort out a few more canine welfare troubles…or make a solid attempt on it.

Ongoing we’ll include Leptospira spp. serovar testing on puppies (and as they grow up-dogs) and also be expanding new puppy enrollment into Western Canada. We appreciate the support of those in the Canadian Veterinary Community who have helped us enroll such amazing puppies and pet-owners. We simply cannot do our work to raise awareness and help protect dogs without this- and it is our hope that you will continue to help us achieve these expanded Canadian K9 goals.

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