The Scoop, April 2024

Immediate Past President Margot K. Vahrenwald, DVM, CVJ,  talks about the usefulness of tools that AAHA Guidelines present. The AAHA Community asks, “how do you boost team morale when being short-staffed?” This month’s Scoop headlines include: Feline genome investigation, Bird owners urged to take precautions for avian flu, FDA’s Draft Guidance on manufacturing ingredients used in veterinary drug products, Cat with chronic kidney disease gets a second chance, Simulated surgeries boost student confidence, animal outcomes; and more!

View from the Board

Tools to Tackle the Complicated

Working smarter, not harder, is the goal I am trying to apply this year. I’m looking for things that help with continued improvement in the care of my patients without creating inefficiencies that are a drag on time. Or, tools that will prevent my getting lost in the rabbit hole of putting together the puzzle pieces of a case, when the data presented by clinical signs, exam, and diagnostic results are confounding.

Having a reference toolbox to use when your brain cells are spinning like tires on ice is essential. Great visuals, succinct algorithms, and best practices are what help me the most. I keep a small binder clipboard with some of those tools with me all day while seeing patients as a quick reference.

I’ll confess now that I am an AAHA guidelines addict. I’ve always referenced them throughout my career, and one of the perks of being a board member is seeing the evolution and improvements that are offered by regularly updated specific-topic guidelines, as well as the fresh knowledge in newly developed guidelines.

When I saw that two big topics in this issue of Trends were on dermatology and parasites, my brain immediately moved to skin versus endocrine issues and how much our clinical skills and options have improved since I was in vet school, more years ago than I like to admit.

Two of our most recent AAHA guidelines are amazing references for everyday practitioners and new graduates alike to put in their work toolboxes. The 2023 AAHA Management of Allergic Skin Diseases for Dogs and Cats Guidelines and the 2023 AAHA Selected Endocrinopathies of Dogs and Cats Guidelines help with these sometimes frustrating-to-diagnose and/or manage cases, especially when the patient may have concurrent issues. At your fingertips in the guidelines and online at aaha.org/guidelines are resources in not only clinical medicine but also for client and team communications. Each guideline also has additional resources and soon both will offer certificates for a deeper educational dive with CE credit.

Onwards and upwards we go with more tools for our toolboxes with AAHA guidelines.

__________

Margot K. Vahrenwald, DVM, CVJ, is Immediate Past President of the AAHA Board of Directors. She is the owner of Park Hill Veterinary Medical Center in Denver.


Positive Results from Survey of AAFP’s Cat Friendly Certificate Program

The results of a survey of participants in the Cat Friendly Certificate Program, developed by the American Association of Feline Practitioners (AAFP), have been released. Royal Canin conducted the survey in partnership with the AAFP.

The stress of a veterinary visit is an important reason why many cats do not receive regular veterinary care. The AAFP developed the Cat Friendly Certificate Program for all veterinary team members to improve individual knowledge, skills, and in-clinic practices for feline medicine.

Key Survey Findings

  • Nearly 98% of team members reported the program helped them reduce the stress of a feline visit.
  • 92% of respondents believed that, due to the program, cat caregivers are more satisfied with their veterinary experience.
  • 98% reported their skills were enhanced by the program.
  • 98% reported they are now able to create a better experience for stressed feline patients.
  • More than 88% reported they have implemented strategies and techniques to promote positive experiences for cat patients.
  • 76% of all respondents said completing the program better prepared them to make nutritional recommendations to clients.

Photo credit: Annaspoka/iStock via Getty Images Plus


Cat with Chronic Kidney Disease Gets a Second Chance

When Kobe, a 14-year-old cat, was diagnosed with chronic kidney disease ,his owner, Gabrielle Sakel, was very distressed. Most cats with the disease only survive a few years after showing symptoms. As Courtney Price reports in Texas A&M Today, Kobe was fortunate to participate in a clinical trial at the Texas A&M Small Animal Teaching Hospital.

The clinical trial, designed for cats with stage-two to stage-four kidney disease, uses Porus One, a powdery material, to draw toxins from the intestinal tract so they don’t enter the bloodstream. Similar products have been used successfully in humans, but there hasn’t been as much research on their effect in cats, compared to research on human use.

Kobe’s disease hadn’t progressed far by the time he entered the trial, and now, having completed it, Sakel says he’s back to running around with his usual energy.


QUOTE OF THE MONTH

“Service to others is the rent you pay for your room here on earth.”

—Muhammad Ali

5 Ways to Increase Brand Awareness for your Practice

By Terrisha Buckley

Ever feel like your practice is invisible? You might need a marketing makeover.

Danielle Lambert’s Snout School provides tools and training for veterinary professionals to DIY their own branding. Lambert has worked with all levels of vet med, including individual professionals, small clinics, larger brands, and well-established practices. She offered these tips for giving your brand and marketing strategy a boost.

1. “Be very clear on the ideal client you want to serve. You don’t have to be for everyone!”

You want to attract the clients who are going to get the best service out of you consistently. If your practice is great at working with senior cats, design a marketing strategy to reach this audience specifically, and let them know you’re there.

2. “Create content that is going to speak to and support that ideal client as they care for their pet.”

Once you’ve defined your ideal client, you can generate content to draw them in. Think about what those clients care about. What are their major concerns? Create content that provides solutions for their problems.

3. “Make your content look consistent visually.”

This is when you get into the details of branding. Your clients should see your content and recognize you because it looks similar to previous social media posts, as well as to your website and advertisements. “Picking two colors and two fonts can go a long way to creating a clear visual brand,” Lambert said.

4. “Identify what makes you different from other practices in the area—as a service provider and as an employer—and make sure you communicate that.”

If you’re in an area with many practices serving the same clientele, whether it’s small animal or pocket pet owners, your message could easily get lost. What sets your practice apart from the rest? What do you offer that others don’t (or don’t do as well)?

5. “Clarify your core values and a brand promise to serve as a guiding light for all the business decisions you make.”

Your marketing statements must match your personal and company core values. For example, if you market yourself as a practice that is all about community accessibility and access to care, then your clients will expect you to offer options to help them pay for veterinary services. “You need to back [these claims] up with flexible payment options that aren’t credit-based, like VetBilling,” Lambert said.

Photo credit: bluebearry/iStock via Getty Images Plus, ©AAHA/Alison Silverman


FDA Issues Draft Guidance on Ingredients Used in Veterinary Drugs

The US Food and Drug Administration (FDA) draft guidance for industry (GFI) #286 (VICH GL0), “Good Manufacturing Practice for Active Pharmaceutical Ingredients Used in Veterinary Medicinal Products,” is now available. This draft guidance has been developed by the International Cooperation on Harmonisation of Technical Requirements for Registration of Veterinary Medicinal Products (VICH).

VICH aims to harmonize technical requirements for the approval of veterinary medicinal products in the European Union, Japan, and the United States. It includes input from both regulatory and industry representatives. VICH guidelines are available for use by other countries.

This draft guidance facilitates a single set of international standards for inspections of facilities that manufacture Active Pharmaceutical Ingredients [APIs] and starting materials for use in such products.

The FDA’s work with VICH aims to ensure regulatory certainty for veterinary products, including predictable and uniform requirements across the EU, Japan, and the United States.

Photo credit: art-4-art/E+ via Getty Images


AAHA Community

How Do You Boost Team Morale When Being Short-Staffed?

We are getting ready to be down at least six staff members who worked in various areas of the hospital from reception, exam rooms, and patient care. This will mean our remaining staff will be scheduled for more hours than they have worked in the past. I would love some input on ways we can boost morale that shows our appreciation in ways other than food. What have you all done?

A:

I would adjust doctor and appointment schedules to reflect your current staff levels. You don’t want to burn out what you have.

A:

We dropped to 4 days of appointments when a similar situation happened to us. We made Friday a pick-up Rx and phone day only 9:00 a.m–3:00 p.m. Consider a skeleton crew on those days with at least one Practice Manager.

__________

AAHA members, share your short-staffed tips at community.aaha.org.

For help, email community@aaha.org.


Diagnostic Platform Adds AI Functionality

AI Urine Sediment analysis has been added to Zoetis Inc.’s diagnostics platform, Vetscan Imagyst. The company says the new application will provide accurate, in-clinic sediment analysis of fresh urine, allowing clinicians to make treatment decisions quickly.

Describing the new application, Richard Goldstein, DVM, DACVIM, DECVIM-CA, vice president and chief medical officer, Global Diagnostics Medical Affairs at Zoetis, said, “Its deep learning AI will help in the visualization and identification of urine sediment elements, which are often difficult to capture using traditional urine sediment examinations.”

The application includes a validated sample preparation method and algorithm evaluation to provide more consistent, thorough urine sediment results. This includes an evaluation of red blood cells and white blood cells, squamous and other epithelial cells, hyaline and nonhyaline casts, struvite and calcium oxalate dihydrate crystals, and cocci and rod bacteria comparable to that of a clinical pathologist, according to Zoetis.

Photo credit: Ignatius Harly Putranto/iStock via Getty Images Plus


Bird Owners Urged to Take Precautions for Avian Flu

Since 2022 a highly contagious avian flu has been spread primarily by migratory birds, putting game birds and backyard and commercial poultry at risk.

The highly pathogenic avian influenza [HPAI] virus is shed by infected waterfowl in their feces and respiratory secretions. The virus can remain viable for months in the environment. According to the US Department of Agriculture, since the start of the current outbreak of HPAI in 2022, almost 81.72 million birds (in backyard and commercial flocks) in 47 states have been affected.

Maurice Pitesky, DVM, of the University of California-Davis School of Veterinary Medicine, recommends keeping domestic birds away from ponds and other open water where they may contact waterfowl, the primary reservoir of the disease. He also advises monitoring birds for these symptoms:

  • Reduced egg production
  • Trouble breathing
  • Clear, runny discharge
  • Lethargy
  • Loss of appetite
  • Drinking less
  • Swollen eyes, head, wattles, or combs
  • Discolored/bruised comb, wattles, or legs
  • Sudden death

Photo credit: Anagramm/iStock via Getty Images Plus


Feline Genome Investigation

Researchers investigating the genome of various cat species have recently uncovered novel perspectives on domestic and wild cat evolution. Their work, funded by Morris Animal Foundation and published in Nature Genetics, highlights distinct genetic changes and will be a critical tool for researchers investigating feline diseases and characteristics. The study uncovered a more comprehensive and complete cat genome assembly than was available before.

“Now we’re going to be able to use this to go in and start determining the function of parts of the domestic cat genome that were missing before,” said William Murphy, PhD, the study’s principal investigator and professor of Veterinary Integrative Biosciences at Texas A&M University.

Photo credit: Pgiam/E+ via Getty Images


Simulated Surgeries Boost Student Confidence, Animal Outcomes

Cornell University College of Veterinary Medicine (CVM) researchers have found that simulator-based training improved student confidence, performance, and live animal outcomes during spay surgeries on cats. Their study was published in the journal Veterinary Surgery.

Typically, veterinary students learn surgical skills first from lectures and videos, and later through hands-on experience with live animals. Learning with animal surgery simulators provides students with realistic animal manikins, on which they can practice surgical tasks in a low-pressure environment.

The Cornell researchers recognized the value of the simulator training for veterinary students but wanted to determine if the training impacted outcomes in a real surgical laboratory.

For their study they compared two groups of students, one trained for spay procedures with an instructional video and lecture materials, the other with an additional, two-hour simulation lab.

Each group later conducted spay surgeries in female rescue cats. All cats survived and were subsequently discharged. The simulator-trained group had shorter operation times, higher self-reported levels of surgical confidence, and their patients required less pain management compared to the group that did not train on simulators.

Photo credit: Kerrick/iStock via Getty Images Plus


Morris Animal Foundation Funds 8 Canine Cancer-Focused Projects

Morris Animal Foundation announced the selection of eight new grant recipients who will advance the foundation’s commitment to improve the lives of dogs suffering from cancer through pioneering research initiatives. “The knowledge gained by these studies will advance the understanding, diagnosis and treatment of cancers in both dogs and their humans,” said Kathy Tietje, PhD, MBA, chief program officer at Morris Animal Foundation.

Enni Markkanen, DVM, PhD, principal investigator for one of the studies approved for funding commented, “Our study will [yield] detailed insight into soft-tissue sarcoma tumors by analyzing the exact molecular fingerprint of individual cells.”

The grant awardees are Hiroyuki Mochizuki, North Carolina State University College of Veterinary Medicine; Krit Ritthipichai, Edward Via College of Osteopathic Medicine; Alison Masyr, Michigan State University College of Veterinary Medicine; Christina Pacholec, Virginia Tech, Virigina-Maryland College of Veterinary Medicine; Heather Wilson-Robles, Ethos Discovery; Enni Markkanen, University of Zurich; Karin Allenspach, University of Georgia College of Veterinary Medicine; Jenny Harris, University of Surrey School of Health Sciences.

Photo credit: jamesbenet/iStock via Getty Images Plus


Merck Animal Health Releases Fourth Veterinary Wellbeing Study

The latest Merck Animal Health Veterinary Wellbeing Study shows that more veterinary professionals are provided access to and are pursuing mental health resources for their overall well-being with continued improvements on the horizon.

The study was conducted in collaboration with the American Veterinary Medical Association (AVMA). This latest study also revealed that veterinary practices and professionals are taking a more proactive approach toward mental health.

This is the first comprehensive study on veterinary wellbeing following the global pandemic. It includes the mental health and wellbeing of veterinary team members, including veterinary technicians and office managers.

Almost three-quarters of veterinary professionals express personal satisfaction with their career, but there are still factors of concern, including exhaustion, work–life balance, and a shortage of veterinary staff, all of which can lead to burnout.

Results of the study indicate there has been a substantial increase in clinics supporting their teams’ mental health and emotional wellbeing.

Photo credit: rosadu/iStock via Getty Images Plus, ©AAHA/Alison Silverman


Purina Donates $1M to AVMF REACH Program

Purina Pro Plan Veterinary Diets has launched the Pro Plan Veterinary Support Mission to help remove barriers veterinarians often face in practice. As its first act, the brand donated $1 million to the American Veterinary Medical Foundation (AVMF) REACH (Reaching Every Animal with Charitable Healthcare) program, offering grants to veterinarians providing immediate pet care when owners experience financial hardship.

The REACH program was created by the AVMF in 2022 to increase assistance to the most vulnerable communities. The program received an additional $200K in funding from Pro Plan Veterinary Diets in 2023 and now has the resources to assist thousands of animals each year.

AVMF Chair Lori Teller, DVM, said, “Purina’s generosity enables the AVMF REACH program to ease the burden placed on veterinarians who provide charitable care and help give more pets and other animals the expert veterinary services they need.”

Veterinarians can visit ProPlanVetSupport.com to learn more about the Pro Plan Veterinary Support Mission.

Photo credit: ©AAHA/Robin Taylor


Monitoring Strategies for Trilostane Therapy in Dogs with Cushing’s Syndrome

By Kate Boatright, VMD

Cushing’s syndrome, or hyperadrenocorticism (HAC), can be a frustrating disease for veterinarians to diagnose and manage. The road to diagnosis can be a long and expensive one for clients. (A guide to diagnosing Cushing’s syndrome is available in the 2023 AAHA Selected Endocrinopathies of Dogs and Cats Guidelines.)

Once a diagnosis is obtained, treatment requires lifelong daily medication and frequent monitoring. The costs of medication and monitoring can add up and create a barrier to treatment for some families. Additionally, there has been some debate about the best testing protocols to use for monitoring HAC treatment. Veterinarians should stay up to date on current strategies for monitoring therapy for Cushing’s syndrome so they can maximize quality of life for their patients and clients.

Trilostane provides excellent patient outcomes

The primary goal of treatment for this disease is to control clinical signs, including polyuria and polydipsia, changes in the hair coat or physical appearance of the pet, and excessive panting. With treatment, these clinical signs can be controlled in most patients, leading to a better quality of life for both pet and family.

Trilostane (available as Vetoryl® from Dechra) is the only FDA-approved medical treatment for dogs with both pituitary-dependent and adrenal-dependent Cushing’s syndrome. It is a reversible inhibitor of an enzyme (3ß-hydroxysteroid dehydrogenase) required for steroid synthesis. While it is considered safer than the historically used mitotane, which is cytotoxic to the adrenal gland, there is still a potential for iatrogenic hypoadrenocorticism.

Vetoryl® is available in multiple capsule sizes which can be combined to achieve the necessary dosage. The labeled dose is 2.2–6.7 mg/kg/day, though many veterinarians start at lower doses or twice daily dosing. Many of the authors of the AAHA guidelines start around 1 mg/kg twice daily in their patients. The medication should be administered with food to improve absorption.

Monitoring trilostane therapy: Laboratory testing

Regardless of what dosing is used, routine monitoring is essential to ensure clinical signs are well-controlled in patients while avoiding overdoses that can lead to iatrogenic hypoadrenocorticism.

Monitoring utilizes a combination of pet owner reports of clinical signs, physical examination, and laboratory testing. There are multiple strategies reported in the literature for monitoring Cushing’s syndrome, but there is no consensus on which monitoring protocol is superior.

In general, rechecks are recommended at 10 to 14 days and 30 days after starting trilostane or adjusting the dosage. Once control is achieved, monitoring is recommended every 90 days. The primary goal of the first recheck is to ensure that patients’ cortisol productions is not being oversuppressed. Dosages may be decreased based on clinical signs and lab testing at this appointment but should not be increased.

At the one-month recheck, medication dosage is increased if clinical signs of HAC are not controlled, but laboratory testing ensures that the patient’s adrenal glands are not oversuppressed and that maintaining the current dose or increasing to a higher dose is safe.

When patients remain uncontrolled, veterinarians should be sure to assess for comorbidities that may have similar clinical signs and/or complicate disease management, such as concurrent diabetes mellitus.

ACTH stimulation test

Traditionally, the ACTH stimulation test, performed 3 to 5 hours after trilostane administration, has been utilized for monitoring cortisol levels. However, the test has never been validated for this use and some studies have shown poor correlation between clinical signs and ACTH stimulation test results.

As the ACTH stimulation test is the definitive test for diagnosing hypoadrenocorticism, it is a good tool to screen for iatrogenic hypoadrenocorticism. An algorithm is available from Dechra to guide veterinarians in monitoring treatment with Vetoryl® using the ACTH stimulation test.

Unfortunately, the cost of repeated testing can quickly add up, especially if being performed twice a month while trying to gain control of the disease. Additionally, cortrosyn, the synthetic ACTH that is used in the test, is sometimes not available.

Prepill cortisol measurements

An alternative monitoring strategy utilizes a single cortisol measurement collected prior to pill administration. In a study by Macfarlane et al (2016), prepill cortisol measurements were better able to distinguish level of disease control than the ACTH stimulation test and were well correlated with results of an owner questionnaire assessing clinical control.

This monitoring strategy may reduce the costs of laboratory monitoring, since only a single cortisol level is needed and no cortrosyn is required. However, patients may need additional testing such as electrolyte checks or an ACTH stimulation test if they are showing clinical signs consistent with hypoadrenocorticism.

Additionally, most dogs in the study received once daily trilostane dosing, so more research is needed to see if this testing is as reliable in dogs receiving twice daily dosing.

The essential role of the client in monitoring

Regardless of what laboratory testing protocol is utilized, veterinarians must rely on their clients’ observations of the pet. Clinical signs are the most important factor in determining if a dosage increase is needed.

Client questionnaires are available from Dechra and as part of the 2023 AAHA Selected Endocrinopathies of Dogs and Cats Guidelines. These questionnaires provide an objective way for clients to provide information about their pet’s clinical signs.

Clients should also be educated on the potential for iatrogenic hypoadrenocorticism and stay alert for clinical signs of this condition. If clients note clinical signs of lethargy, vomiting, diarrhea, and inappetence, they should stop the medication and schedule a recheck for their pet, as these can be signs that the pet is becoming oversuppressed.

Take home points

While Cushing’s syndrome can pose a diagnostic and therapeutic challenge, most pets do well with treatment. Clinical signs are an essential component of monitoring. Clients must observe their pet carefully and share their observations with their veterinary team to meet treatment goals.

Laboratory monitoring helps to ensure that current doses are safe and the adrenal glands are not oversuppressed but should not be the sole factor in deciding to increase patient dosages if there is good clinical control.

Photo credit: Pekic/iStock via Getty Images Plus

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