A 2-year-old female, spayed Pomeranian had no previous history of skin disease but started losing hair at 1.5 years of age. There is no evidence of either a bacterial or yeast infection based on cytology or of pruritus associated with the skin condition. The only medication administered was oral melatonin (3 mg twice daily) for several months before presentation. What is your most likely diagnosis based on these images?

All the answers should be on your differential diagnosis list, but the most probable cause of the lesions is alopecia X. A full history and dermatologic exam will help determine your diagnostic differentials.

Skin cytology will help rule out a bacterial or yeast infection. A deep skin scrape will rule out demodicosis. A fungal culture will rule out dermatophytosis. Baseline bloodwork will help determine whether further blood testing (e.g., thyroid panel or an adrenocorticotropic hormone stimulation [ACTH]/low-dose dexamethasone suppression test) is recommended.

The final diagnosis of alopecia X is made by ruling out all other possible diagnoses using either a biopsy or an adrenal panel (

). A biopsy will typically show arrest of the hair cycle, as well as a majority of telogen follicles and “flame” follicles. An adrenal panel will often show elevations in adrenal steroid intermediate compounds and/or sex hormones.

Alopecia X is a cosmetic disease that leads to a noninflammatory alopecia in adult dogs. The pathogenesis is not confirmed, but possible causes include abnormalities of adrenal steroid intermediate compounds and sex hormones. Clinical signs vary from a dull hair coat to progressive alopecia and hyperpigmentation that affects the neck, dorsum, ventrum, thighs, and tail. The head and feet are usually spared.

Affected dogs are healthy and lack signs of systemic disease. The most commonly affected breeds include Nordic breeds such as the Pomeranian, Samoyed, Alaskan malamute, Siberian husky, chow chow, and keeshond. The disease can affect dogs of either gender (may or may not be spayed/neutered), and age of onset typically ranges from 1 to 10 years.

What treatments have been reported to help dogs with alopecia X regrow hair?

Trilostane is a competitive and reversible inhibitor of 3β-hydroxysteroid dehydrogenase, an enzyme necessary for adrenal production of glucocorticoids, mineralocorticoids, and sex hormones. It can take several weeks to months for hair to regrow, and the trilostane dose can be decreased if hair regrows.

Melatonin is a neurohormone produced by the pineal gland. It affects the reproductive cycle of animals by impacting sex hormone production. Melatonin may have direct effects on hair follicles, as hair regrowth can occur without significant changes to serum sex hormone concentrations. Melatonin can be given in an oral, injectable, or subcutaneous implant form. It can lead to regrowth in about 40% of patients and can take weeks to months.

Microneedling has been reported to stimulate hair regrowth in a number of cases.

This procedure, which causes mild, localized skin trauma, has an unknown mechanism of action. In cases in which microneedling is successful, hair regrowth is reported within a few weeks to 3 to 4 months.

Additional treatments include mitotane, deslorelin, medroxyprogesterone acetate, and fulvestrant. As noted, alopecia X is considered a cosmetic disease. One must weigh the benefits of hair regrowth with the potential adverse effects of various treatments.



Judy Seltzer, BVedMed, DACVD, graduated from the Royal Veterinary College in London and completed her residency in dermatology at the University of Florida. She has been working in her home state of New York since 2009, currently at BluePearl Veterinary Partners in New York City. She and her husband have a baby girl and four cats, and enjoy traveling, fall festivals, winter activities, and dining out.

Melatonin hair growth: Frank LA, Donell RL, Kania SA: Oestrogen receptor evaluation in Pomeranian dogs with hair cycle arrest (alopecia X) on melatonin supplementation. 

Stoll S, Dietlin C, Nett-Mettler CS: Microneedling as a successful treatment for alopecia X in two Pomeranian siblings. 

Articles

Test your diagnostic skills by examining the following images and selecting the answer you think fits best.

Image Quiz: Hair loss in a Pomeranian puppy

No doubt you’ve been jolted awake with that dreadful 2 am call. You fumble for the phone, introduce yourself as professionally as you can with marbles in your mouth, and hear: “Hey, how do you tell if a dog is a boy or a girl?” Or worse, you lug yourself to the clinic for the frantic client who’s a no-show, and you’re left fuming and utterly incapable of falling back to sleep.

It’s no secret that many veterinarians suffer work-life imbalance—and sleep deprivation is a major contributor.

The National Sleep Foundation recommends 7 to 9 hours of sleep per day, a near impossibility for most veterinary practitioners. But those numbers are only half the story. What the body truly requires is restorative sleep, during which the brain cycles through all the sleep stages (1, 2, 3, 4, and REM) several times over. The magic happens during deep sleep (stages 3 and 4), which is rejuvenating and prepares you well for a day of challenges.

In each 8-hour period of continuous, healthy sleep, the body will ultimately compile 1 to 2 hours of deep sleep.

 Any interruption diminishes the body’s ability to function properly, with unhealthy alterations in hormone production, immune system regulation, and brain activity.

When we don’t get enough sleep, the brain moves less learned information from the hippocampus to the neocortex, resulting in decreased memory processing and retention.

 In addition to diminished mental capacity (which was implicated in both the Exxon Valdez oil spill and the Chernobyl nuclear explosion

), sleep deprivation causes a host of physical abnormalities

The stomach produces more of the gastric peptide ghrelin (an appetite stimulant) and less leptin (a satiety hormone), increasing appetite and cravings for high-fat, high-carbohydrate foods once awake.

The pancreas releases higher levels of insulin after eating, overloading your fat storage and increasing your risk for type 2 diabetes.

The pituitary gland releases fewer growth hormones, thus inhibiting the body’s ability to repair tissue, increase muscle mass, thicken skin, and strengthen bone.

The adrenal glands produce more cortisol, increasing blood pressure and your risk for heart attack and death. Increased cortisol also breaks down skin collagen so you don’t look your best (let’s get practical here).

The body clears fewer circulating inflammatory cells and produces fewer natural killer cells and protective cytokines that aid in immune function.

Lack of sleep has long-term effects as well. Over the years, various studies on sleep deprivation (generally defined as 5 or fewer hours of sleep per night) have found that it

doubles the risk for death from any cause

increases the risk for colorectal cancer by 36%

increases the risk for cardiovascular disease by 48%

increases the risk for depression, anxiety, irritability, and forgetfulness.

But caffeine is the great panacea, right?

You know who has worse sleep deprivation than health professionals? The military. In fact, 40% of our troops get less than 5 hours of sleep, and that’s stateside. Their sleep plummets during combat. So the US military came up with an algorithm to determine how much caffeine one needs to stimulate wakefulness based on amount of sleep. Lest you all picket the Pentagon for the answer, the algorithm is still proprietary, but Uncle Sam has released a free app that gives general calculations for the average person.

In the short term, caffeine may reduce how much you totter into walls, but it does nothing to immerse the body in that soothing stew of stages 3 and 4 deep sleep. None of the hormone imbalances self-correct with caffeine intake. All of the risks elucidated above remain. Worse, the more caffeine that is in your system, the more likely you are to perpetuate sleep deprivation through insomnia.

), we must master a few techniques to maximize our sleep:

Sleep in a cool room (between 60°F and 67°F).

Standardize the timing and activities of your presleep routine.

Avoid eating heavy meals 2 hours before bedtime to minimize discomfort from gastric reflux.

Avoid too much alcohol near bedtime because its breakdown products can interrupt sleep during the second half of the night.

Get up at the same time each morning, even on weekends and holidays.

Exercise regularly, but not right before bedtime.

Avoid stimulants like caffeine and nicotine prior to bed. Recent research recommends a 2 pm cutoff for all caffeine products.

Take a warm bath or shower 1 to 2 hours before bedtime. The external warmth opens capillary beds in the periphery (limbs), ultimately lowering core body temperature, which improves onset and quality of sleep.

Turn off all blue-light sources, including phone and computer screens, 1 to 2 hours before bedtime.

It’s simple: Get deep, uninterrupted, restorative sleep. One of the surest ways to achieve that in the veterinary setting is to have a competent, compassionate registered veterinary technician answer your after-hours calls for you. Internal data suggests 75% of after-hours calls are non-emergent. By leveraging professional help to answer simple questions, generate next-day appointments, refer to the local emergency clinic, or call your phone for verified emergencies only, you can begin to take back control of your destiny … even when you’re asleep.

Dr. Sawyer is a regional veterinary consultant for GuardianVets Teletriage and Telemedicine Services.

Leavitt J. How much deep, light, and REM sleep do you need? Healthline. October 10, 2019. Accessed July 27, 2020. 

https://www.healthline.com/health/how-much-deep-sleep-do-you-need#deep-sleep

Sorrels M. 10 truly devastating disasters caused by sleep deprivation. Listverse. October 2, 2017. Accessed July 27, 2020. 

https://listverse.com/2017/10/02/10-truly-devastating-disasters-caused-by-sleep-deprivation/

Watson S, Cherney K. The effects of sleep deprivation on your body. Healthline. May 15, 2020. Accessed July 24, 2020. 

https://www.healthline.com/health/sleep-deprivation/effects-on-body#4

The effects of sleep deprivation. Johns Hopkins Medicine. Accessed January 31, 2020. 

https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-effects-of-sleep-deprivation

Murphy B Jr. After 10 years studying sleep, the U.S. military just revealed something eye-opening about caffeine. 

 July 24, 2018. Accessed January 31, 2020. 

https://www.inc.com/bill-murphy-jr/sleep-this-much-drink-this-much-coffee-says-us-military.html

Gannon M. Can any animal survive without sleep? Live Science. March 2, 2019. Accessed January 31, 2020. 

https://www.livescience.com/64873-can-animals-survive-without-sleep.html

Geissmann Q, Beckwith EJ, Gilestro GF. Most sleep does not serve a vital function: evidence from 

. 2019;5(2):eaau9253. doi:10.1126/sciadv.aau9253

Rattenborg NC, Voirin B, Cruz SM, et al. Evidence that birds sleep in mid-flight. 

Sleep hygiene. Sleep Foundation.org. July 27, 2020. Accessed July 27, 2020. 

https://www.sleepfoundation.org/articles/sleep-hygiene

Breus MJ. New details on caffeine’s sleep disrupting effects. 

 December 16, 2013. Accessed July 27, 2020. 

https://www.psychologytoday.com/us/blog/sleep-newzzz/201312/new-details-caffeine-s-sleep-disrupting-effects

Sandoiu A. When’s the best time to take a warm bath for better sleep? Medical News Today. July 22, 2019. Accessed July 27, 2020. 

https://www.medicalnewstoday.com/articles/325818.php#2

Gunnars K. Blue light and sleep: what’s the connection? Healthline. May 21, 2020. Accessed July 24, 2020. 

https://www.healthline.com/nutrition/block-blue-light-to-sleep-better

Not getting enough sleep diminishes our focus and is detrimental to our health and wellbeing. Here’s why, and what to do about it.

Got zzzz’s? Fighting sleep deprivation in veterinary medicine

Urinary tract infections (UTIs) are commonly seen in veterinary practice. While treatment in certain patient populations is straightforward, UTIs can become challenging to manage when there are concurrent complicating factors.

With a typical UTI, a queen (of the appropriate age) or bitch urinates small amounts frequently, seems uncomfortable (often in general, but specifically while urinating), and there appears to be blood in the urine. While a culture is still recommended in these cases (due to the rising prevalence of resistant microbes in the environment), a penicillin (e.g., amoxicillin) is a good empiric choice as it concentrates in the urine. A sulfa antibiotic is another good option. Other antibiotics (e.g., enrofloxacin, nitrofurantoin) should be reserved for recurrent cases. As always, sample collection via cystocentesis is preferred.

Managing recurrent UTIs can be complicated, largely because of antibiotic resistance. The first step in treating a recurrence is to rule out or mitigate other causative factors. Imaging for uroliths is important, as these will be a source of recurrence because they release previously protected bacteria back into the bladder.

Additionally, assessment of anatomy is important. Search for vulvar or ureteral abnormalities, both of which can contribute to UTI recurrence. In older patients, transitional cell carcinoma may predispose patients to recurrent UTI. Metabolic disease, such as unregulated diabetes or Cushing disease, may also be at play. Without control of these conditions, the risk for recurrence is much higher, and controlling these conditions may end the cycle of recurrence.

Once concomitant factors have been mitigated, culture-based treatment is still the appropriate course of action. A slightly longer course of treatment is recommended for patients with recurrent UTI (5-7 days as opposed to the standard 3-5 days.) Several other preventive measures have been discussed, but few have been proven efficacious.

 No positive effect was found with direct instillation of any substance into the urinary tract (antimicrobial or otherwise). Pulse antibiotic therapy is commonly used, but this practice is controversial as its effect is not fully clear and it may further increase the risk for developing resistance. Administration of probiotics was tested and not found to be particularly efficacious.

One recommendation that has been found to be effective (in humans at least) is administration of cranberry extract.

 There is also a fair amount of anecdotal evidence, in both veterinary and humane medicine, to suggest its utility. The proanthocyanidin in the cranberry inhibits uropathogenic 

 adherence to the urinary epithelium, preventing an infection recurrence.

Another clinical complication of recurrent UTIs is the presence of subclinical bacteria, in which a patient’s urinary sediment is quiescent and there are no clinical signs of cystitis but the urine culture tests positive. There is strong evidence in human medicine that no treatment is warranted in these cases.

 Some exceptions include patients who are set to undergo any procedure in which bacteremia may be induced (e.g., urinary surgery in which hemorrhage may expose the blood stream to urine).

Finally, a more life-threatening complication of UTIs is pyelonephritis. Patients with this condition present with acute onset of systemic signs (e.g., lethargy, anorexia, vomiting) and are found to have new-onset azotemia. Direct diagnosis requires pyelocentesis (aspiration of the renal pelvis), but this is not commonly performed due to difficulty in performing this procedure. In a patient with new-onset azotemia who is clinically ill and has no toxin exposure consistent with the azotemia, pyelonephritis is largely assumed and treatment (antibiotics) is initiated. This assumption is made in large part because pyelonephritis is the most treatable cause of acute kidney injury. (Keep in mind that this patient population completely overlaps with those suffering from leptospirosis, so appropriate testing and staff safeguards are important until this is ruled out.)

On ultrasound, pyelectasia (dilation of the renal pelvis) is suggestive of but not definitive for pyelonephritis. Ultrasound also helps to rule out other causes of acute kidney injury, such as obstructive ureteroliths, neoplasia, or ischemia. Patients with these conditions require hospitalization and varying levels of fluids and other supportive care. Antibiotic selection should be based on culture, but initial empiric treatment is important. Most commonly, a potentiated penicillin (ampicillin-sulbactam) with a fluoroquinolone is recommended. This is both for broad-spectrum coverage as well as good tissue penetration into the renal tissues with the fluoroquinolone. Prognosis in these cases is fair, although there will be some degree of permanent renal compromise that is not predictable at the outset.

UTIs are common, but complications are rare. Appropriate urine culture is the bedrock on which treatment should be based, both for best patient outcome and antibiotic stewardship. While not mentioned above, contacting a veterinary microbiologist can also be helpful in guiding antibiotic recommendations.

A board-certified criticalist at Mount Laurel Animal Hospital in Mount Laurel, NJ, Dr. Greenway earned his DVM from Texas A&M University and is a proud member of the American College of Veterinary Emergency and Critical Care. He was truly inspired by his father, a military veteran, who fostered a deep commitment to animals. His professional interests include emergency (polytrauma, severe anemia) and critical care (septic case management).

Dorsch R, Teichmann-Knorrn S, Sjetne Lund H. Urinary tract infection and subclinical bacteriuria in cats: A clinical update. 

. 2019;21(11):1023-1038. doi: 10.1177/1098612X19880435

Sihra N, Goodman A, Zakri R, Sahai A, Malde S. Nonantibiotic prevention and management of recurrent urinary tract infection. 

. 2018;15(12):750-776. doi:10.1038/s41585-018-0106-x

Weese JS, Blondeau J, Booth D, et al. International Society for Companion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats. 

. 2019;5:8-25.doi: 10.1016/j.tvjl.2019.02.008

Here’s what you need to know about treating uncomplicated UTIs and recurrent infections.


How to manage recurrent urinary tract infections 

Congratulations to all of this year’s veterinary school graduates! If you haven’t yet started searching for your first associate position, now’s the time. We know it can be stressful, but fear not, new grads, here are some tips from Eric Miller, senior specialist of talent acquisition at Banfield Pet Hospital, to help you land the perfect job.

Before you apply for any associate position, Miller advises, to do your research. Understanding what you are looking for in terms of hospital size, location, culture, work-life balance, and other factors will lead you to the practices that are right for you. Look for as much information as you can find about each hospital’s:

Miller feels strongly about cover letters. “You should always attach a cover letter unless the job specifically says not to,” he says. Your cover letter, which briefly outlines your professional work experiences, should be broken into three paragraphs. But first, make sure all of your contact information is correct. “If we can't get a hold of you, we can't interview you,” Miller says.

The first paragraph of your cover letter should include your name, the name of the hiring practice and the position for which you are applying. This paragraph should be customized for every job you apply for. Unlike a generic cover letter, adding these details shows that you are interested specifically in this hospital and this position.

The middle section is where you really get to showcase any achievements or experience that makes you a good fit for this role. Highlight anything that will help you stand out from other applicants.

In your closing paragraph, mention again your interest in the hospital and how ready you are for the position.

Like your cover letter, your resume must be up to date. And be sure to include your name in your phone’s outgoing message so a recruiter or hiring manager will know they have reached the right person.

Make sure you have a professional email address on your resume. If you are using your veterinary school email address, be sure to check how long it will stay active.

Avoid nonessential “filler” information on your resume. “If you're applying for a role as a veterinarian, we probably know you're really good with clients,” says Miller.

Instead, he recommends, mention your achievements, such as volunteer work, research, publications, and successes from previous jobs. This is the type of information that makes you stand out, he says.

Finally, reach out to the employer or recruiter when you submit your resume to reiterate your interest in working at the practice. Another option: reach out to practices that aren’t actively hiring. They might just think of you when they are.

Before the interview, whether it’s on the phone or in person, learn as much as you can about the practice, and prepare questions to ask during the interview. This shows employers you are very interested in the job.

For in-person interviews, Miller recommends bringing five copies because you never know who you will run into. “It would be better for you to return home with four resumes rather than be short one when you need it,” he says.

When the interview ends, politely ask about next steps. And be sure to follow up with a thank you note or email restating your interest in the position. If they give you a timeline for when to expect someone to reach out and it does not happen, follow up.

Be sure to send a thank you note anyway, and let the practice know if you are open to other positions that may become available. Also consider asking why you didn’t get the job. Any feedback may help your interview process in the future.

If you receive an offer, Miller recommends taking a few days to consider it, and reach out to the recruiter or employer with any specific questions you have. Let them know when they can receive an answer.

Miller says it’s OK to negotiate at this point, just be prepared that the practice may not accept your counter-offer.

Congratulations to the class of 2020! As you prepare to enter the workforce, consider these tips to make your job search more fruitful.

Tips for landing your first veterinary associate position

, meaning penalty or fine,” began Mike Barletta, DVM, MS, PhD, DACVAA, during a recent 

 conference session. “It’s like you did something to your body, and now you’re going to pay the consequences.”

Pain is, of course, much more nuanced than its origin implies. According to Dr. Barletta, an associate professor of anesthesia at the University of Georgia College of Veterinary Medicine, pain can be either physiologic or pathologic:

, or acute adaptive pain—the kind that prompts you to pull your hand away when you touch a hot stove, can prevent injury and even promote healing after injury. 

 refers to chronic, maladaptive pain, which Dr. Barletta described as “an expression of the pathologic operation of the nervous system that can follow acute pain if not prevented or treated.”

For Dr. Barletta, treating pain starts with an understanding of its anatomy and physiology, beginning with the difference between nociception and pain (see 

, followed by the five steps in the pain pathway: transduction, transmission, modulation, projection, and perception. With this foundation, the drugs to use for each step and why become more clear.

The first phase in nociception, called transduction, occurs in the periphery and involves special receptors called 

. “These nociceptors are the peripheral end-terminals of Aδ and C fibers,” explained Dr. Barletta. “Mechanical, thermal, and chemical stimuli open different potassium and sodium channels located at the end-terminal of these nerve fibers to activate transduction, in which energy is converted from one form (which can cause tissue damage) to another (an electrical impulse).” If transduction isn’t prevented or treated, he continued, tissue damage will cause the release of inflammatory mediators (histamine, bradykinin, tumor necrosis factor-alpha, interleukin-beta, interleukin-6, nerve growth factor, adenosine, hydrogen ions, adenosine triphosphate, and prostaglandin E2) that can bind to peripheral receptors and recruit more inflammatory cells, resulting in peripheral sensitization. Dr. Barletta referred to it as “inflammatory soup.”

According to Dr. Barletta, these inflammatory mediators can activate nociceptors that are usually silent to cause hyperalgesia (an overreaction to a painful stimulus) and allodynia (a painful reaction to a nonpainful stimulus, like touch). They also decrease the threshold for some receptors. “TRPV1 receptors are a really big deal in pain and usually have a temperature threshold of 45°C (113°F), which means you’re going to start feeling that a stimulus is really hot and painful when it’s at 42°C,” he explained. “Now that decreases to 35°C (95°F). If you’ve ever had a bad sunburn, for example, bathing in lukewarm water can feel super hot—like it’s burning your skin.”

Transduction can be prevented with local anesthetics, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids. “Local anesthetics block sodium channels, which is one of the reasons why we use local blocks when performing surgery,” Dr. Barletta noted. “As for opioids, most research findings concur that we have mu receptors in the periphery, and NSAIDs and corticosteroids decrease the inflammatory response.”

Dr. Barletta said he often gets asked whether animals should 

 be pretreated before a stimulus is applied. His response: “Ideally, yes. We definitely provide a local anesthetic and administer opioids before that.” Whether to give NSAIDs before surgery is a common conundrum, continued Dr. Barletta. “If I want to prevent pain, I should probably give as much as I can before the stimulus, but at that point, I don’t know how the surgery and anesthesia event are going to go down,” he elaborated. “What if the patient is going to be hypotensive for most of the surgery and now maybe its kidneys aren’t well perfused, and then I’m giving an NSAID on top of that? Those kidneys won’t be very happy.”

He explained that there are two options to choose from here: “Some say you should 

 wait to give NSAIDs until after surgery because you never know what’s going to happen. However, I’ve seen someone spay a healthy cat in 2 minutes. The animal doesn’t even have time to develop hypotension in 2 minutes, so in this situation it’s probably OK to administer NSAIDs before surgery.” However, he continued, if you’re performing surgery on an animal that’s pretty sick, such as a dog with hemoabdomen, it’s highly likely you’ll have to deal with hypotension. So, here’s Dr. Barletta’s rule of thumb on the matter: “If the animal is young and healthy and it’s a routine procedure, I don’t have any problem administering an NSAID before surgery. If it’s a critical patient, I’m probably going to wait until postop, as long as everything goes smoothly and pressures are fine.”

“After the nociceptors are stimulated in the periphery during transduction, the electrical signal travels to the dorsal horns of the spinal cord through the nerve fibers—Aδ, C, and (in chronic pain) Aβ fibers—via sodium, potassium, and calcium ion channels in a process called transmission,” Dr. Barletta said. “Aδ fibers synapse in lamina I-V of the spinal cord and C fibers in lamina II, which is also referred to as the substantia gelatinosa.” (See 

To block nociception during transmission, Dr. Barletta recommends local anesthetics, which primarily block sodium channels. “Interestingly,” he added, “alpha-2s can potentiate the local anesthetic effect, and some studies have shown that when you add dexmedetomidine to your local anesthetic it increases the duration of your local bock. Buprenorphine does the same thing.” When asked if he has a preference between dexmedetomidine and buprenorphine, Dr. Barletta explained that he prefers the former for economic reasons: “Buprenorphine is going to be more expensive. Dexmedetomidine is expensive, too, but the volume you use is very minimal, so you’re not actually spending that much money.” He does, however, make an exception if the patient is sick enough that he doesn’t think it will handle systemically administered dexmedetomidine.

Modulation occurs in the periphery, spinal cord, and supraspinal structures. Focusing on spinal modulation, Dr. Barletta explained that the response to peripheral nociceptive stimuli can be modified in the spinal cord by the release of local endogenous modulators and the activation of descending pathways. Opioids, serotonin, and norepinephrine, for example, can decrease the response to nociception, while glutamate, substance P, and prostaglandins can increase it. And when the response to nociception is enhanced, central sensitization can occur. “This can be the result of brief but intense nociceptor activity, such as a surgeon cutting through skin, or of inflammation and nerve injury,” he continued. “Over time, repeated impulse activity of C fibers, release of a variety of neurotransmitters by the Aδ and C fibers, and activation of N-methyl-D-aspartate (NMDA) receptors can cause central sensitization resulting in enhanced responses to impulses (e.g., hyperalgesia, allodynia).”

The presence of glutamate together with the depolarization of the cell membranes (which displaces Mg++ from the channel itself) in the dorsal horns activates normally dormant NMDA receptors. “This should ring a bell here,” Dr. Barletta paused to explain, “because there’s a drug we use every day in anesthesia that’s an NMDA antagonist: ketamine. Does it help prevent chronic pain? Unfortunately, that’s a hard study to set up. How can I really show that? Using it seems to make sense, but it unfortunately doesn’t work that well when used to treat chronic pain. It’s relief is very temporary.” Another unfortunate fact is that once these NMDA receptors are open and activated, it’s really hard to shut them down. This is one of the many theories that try to explain phantom limb pain, Dr. Barletta added. “You can remove the affected limb, but in the spinal cord all of this is still active. Neurons keep going into the dorsal horn where they release neurotransmitters that activate these NMDA receptors. The signal goes to the brain, and the cortex still thinks it hurts. That’s how nasty chronic pain is.”

Dr. Barletta noted that the downregulation of GABAergic and glycine receptor activity and the activation of microglia also occur during central sensitization. “All of this mimics what happens in the periphery for peripheral sensitization,” he said. “The microglia become activated and do exactly the same thing as white blood cells in the periphery—they start releasing interleukins, tumor necrosis factor, etc.—and all of this will recruit more microglia and it will just keep going on and on and you end up with this windup, or central sensitization.”

According to Dr. Barletta, NMDA antagonists, local anesthetics, opioids, alpha-2 agonists, and NSAIDs all work in the dorsal horns. He also noted that, while not often used clinically, antidepressants and anticonvulsants are used for the purpose in research settings.

“Projection,” explained Dr. Barletta, “involves the transport of the electrical signal from the spinal cord to the supraspinal structures.” Three main large tracts are involved: the spinothalamic tract (from lamina I-V to the thalamus), the spinoreticular tract (to the reticular formation and thalamus), and the spinomesencephalic tract (to the midbrain).

Once the electrical impulse reaches the cerebral cortex, it’s perceived as pain. Some of the drugs Dr. Barletta points out for blocking pain perception may seem strange, such as isoflurane and sevoflurane. “They’re not analgesic drugs,” he explained. “They act at the cortex, minimizing or stopping the perception of pain, but they’re not doing anything with nociception. That’s why if you’re anesthetized just with inhalants, I can perform surgery without you feeling anything, but nociception is still happening. So as soon as I turn the gas off and you start waking up, you’re going to be miserable.” Other drugs that work in the cerebral cortex include opioids and alpha-2 agonists.

Ultimately, pain is a multimodal problem requiring a multimodal plan for prevention and treatment. Dr. Barletta put it this way: “Multimodal analgesia is the idea. We’re trying to block, or even better prevent, these pathways at different locations and with different drugs to decrease the chance of creating chronic pain.”

In explaining how a noxious stimulus in the periphery becomes an electrical impulse in the cerebral cortex, veterinary anesthesiologist Dr. Mike Barletta ultimately makes a case for multimodal pain management.

From periphery to perception: the pathway to pain

For many people, personal and professional life goals are intertwined, and this is certainly true for current and future veterinary practice owners. Reaching your personal goals often depends on having some level of financial freedom, which is only achieved when you reach your professional goals. If your goals include early retirement complete with travel and other luxuries (boats, vacation homes, etc.), then your professional goals will likely be more audacious than if you envision a more modest lifestyle and a later retirement.

The first step in helping improve your overall financial success is to decide (or update) what you want to achieve in your life and create a list of specific goals to get you there. Only once you consider the bigger picture can you begin to refine the details. One of these “details” for many veterinarians is practice ownership.

The definition of personal financial success is different for everyone. Some people have an arbitrary number or scenario in mind that they believe they will achieve if they “grind” their way to the top. But working hard and blindly reaching for the stars may not be as successful as implementing a defined and disciplined approach to investing and saving.

Many people either have no budget or have a budget that is not strict enough for them to improve their finances substantially. The fact is that realizing financial success will likely involve time, effort, discipline, and sacrifice. If you are willing to make tough decisions and take the time to plan the framework for your personal financial growth, then all that is left to do is execute your plans and begin to see the results.

One way to determine where to make cuts in spending is to categorize your goals as needs, wants, or wishes. This allows you to see what you can do now and what will have to wait, giving you a broader understanding of what you are able to accomplish and when.

One of the best ways to create a disciplined budget is the “50/30/20” rule. This method dictates how much of your after-tax earnings you can allot for three types of spending:

50% is spent on your essential fixed costs and (e.g., rent/mortgage, groceries, utilities).

30% goes toward your wants (dining out and other discretionary spending).

20% flows right into savings/investing and paying down bad debt (credit cards, high-interest loans, etc.). 

To make a real difference in your financial habits and bottom line, this 20% number is the “magic sauce.” If your spending is allocated correctly, you should reach your desired position in due time.

The value of a practice is realized by an owner when the practice is sold. Understanding what drives practice value and how to improve it is critical. There are two primary markets in veterinary medicine today in which a practice can be sold. The first is the historical market, which is when a practice is sold from one veterinarian to another. The second is the corporate market, which is when a practice is sold from a veterinarian to a corporate entity that owns numerous practices (and may or may not be owned by other veterinarians).

The amount buyers in each market are willing to pay varies, but the practice’s profitability is almost always the most important determinant of practice value. Whether you are 2 years or 30 years away from selling your practice, this is a critical metric to understand, yet most owners don’t know what that number is for their practice. Improving profitability not only will increase your practice’s value at the time of sale, it also will increase your cash flow during ownership.

Determining your practice’s profitability

Calculating the true operating profits of a practice is not a simple task. None of the standard financial or management reports a practice usually gets include this figure. Neither the taxable income from the tax return nor the net income from the profit and loss statement represents true profitability.

The operating profit is the difference between the operating revenue and the expenses a practice incurs. Operating revenue and expenses include only those items normally and necessarily seen in day-to-day practice operations, such as fees for professional services, and drug and medical supply expenses. These items should be listed at fair market value.

For ease of comparison with other practices, a hospital’s profit margin is generally stated as a percentage, which is calculated as practice profits divided by gross revenue. However, some items must be calculated differently to determine operating profit versus taxable income or net income. These include practice owner payments, facility and equipment rent (if these items are owned by the practice owner and leased to the practice), services provided by family members to the practice, depreciation, interest on debt, and perks. The resulting percentage is the true operating profit of the practice, and it is important to compare this percentage with other investments you have and with that of other practices. An operating profit of 20% or higher is considered superior, 12% to 13% is average, and less than 6% is poor.

This all may sound a little daunting, but there are resources available to help. If you work with a veterinary financial adviser, this person should be able to calculate your profitability. 

 also offers resources to help guide you through this calculation process.


Converting profitability into practice value

Once the profitability figure is determined for a veterinary hospital, that number must be converted into the practice value via an appropriate capitalization rate (or cap rate). In practical terms, the cap rate is the required rate of return an investor needs in order to be persuaded to make an investment. There is no one correct rate for all situations—the rate is determined by the market and will vary depending on both external factors (e.g., the state of the economy) and internal factors (e.g., the level and quality of the company’s earnings, the amount of competition in the area). The rate is a reflection of the risks associated with owning and managing a veterinary practice, and continuing to generate the current level of profits. The inverse of the cap rate is a multiple; for example, if the cap rate is 20%, the multiple is 5 and the formula used to derive practice value is as follows:

Annual earnings × Multiple = Practice value

To increase practice value, the management team needs to either increase profitability or decrease the risk associated with owning the practice (i.e., the risk associated with maintaining the practice’s current profitability).

A lack of profitability stems from revenues that are too low, expenses that are too high, or a combination of the two. Profitability can be improved in many ways, from increased marketing to better inventory control to improved team productivity.

A wide range of factors affects the risk related to owning a veterinary practice, including client demographics, the state of the facility, the quality of the management team, and the range of services offered, among others.

Increasing practice value involves three steps:

Understand where the practice is doing well and where it needs improvement.

Working with a financial advisor or practice consultant may help not only in gaining a greater understanding of the issues that impact profitability but also in identifying and implementing solutions.

Synergy between practice and personal financial goals

It is very possible to have a thriving business and a personal financial state that has ample room for improvement and vice versa—the two are not mutually exclusive. Having a well-organized personal financial life can impact how your practice is run, and a well-run practice sets the stage for a fruitful personal financial future. The common dominator between these two aspects of financial fitness is planning.

Dr. Felsted has spent the past 20 years working as a financial and operational consultant to veterinary practices and the animal health industry. She served as CEO of the National Commission on Veterinary Economic Issues for 3 years. Dr. Felsted is active in multiple veterinary organizations, has written extensively, and speaks regularly at national and international veterinary meetings. She owns 

PantheraT Veterinary Management Consulting

Miles Saunders owns and operates MNS Wealth Management LLC in Westport, CT. He can be reached at 

Westport Office: 55 Greens Farms Road, Suite 1 Westport, CT 06880 – Phone: 203-571-2312 www.mnswealthmanagement.com Registered representative offering securities and advisory services through Cetera Advisor Networks LLC (doing insurance business in CA as CFGAN Insurance Agency LLC), member FINRA/SIPC, a Broker-Dealer and a Registered Investment Advisor. Cetera is under separate ownership from any other named entity. For a comprehensive review of your personal situation, always consult with a tax or legal advisor. Neither Cetera Advisor Networks LLC nor any of its representatives may give legal or tax advice. All investing involves risk, including the possible loss of principal. There is no assurance that any investment strategy will be successful. Asset allocation is an investment strategy that will not guarantee a profit or protect you from loss.

For veterinary practice owners, professional and personal goals and growth go hand in hand. Success is achieved through time, effort, discipline, and sacrifice—and a little professional guidance.


Make it happen: Personal and practice financial growth for veterinarians

Nobody saw the COVID-19 outbreak coming. It didn’t take long for conditions to escalate and veterinary clinics all over the country to shift from having a bright outlook for the start of a brand new decade to dealing some of the most crippling business challenges they have ever faced.

Fortunately, a majority of the industry has been quick to course-correct, finding ways to 

 while also complying with social-distancing protocols, including offering curbside care and medication pickup, and collecting patient histories electronically before appointments. But nothing tells the story of how veterinarians quickly adapted to changing protocols and consumer demands than the rapid adoption of telehealth during the pandemic.

This article explores the sudden spike in veterinary 

, the long-term outlook of the trend, and what practice owners need to be doing in tandem with these changes to propel their practices forward.

Over the past decade, considerable strides have been made in the advancement of telemedicine, yet healthcare providers and consumers alike have been slow to adopt this trend on a large scale, and the veterinary industry is no exception. The authors of a December 2019 survey study reported “a lack of both knowledge of telehealth and telemedicine and its utilization among veterinarians surveyed.”

Soon after this study was published, COVID-19 completely shifted the momentum. Veterinarians who might have otherwise been slow or resistant to try telemedicine were suddenly thrust into a situation in which they needed this tool to continue serving their clientele.

Telehealth platform Medici reported a 48% increase in overall veterinarian registration in March and a 170% increase in pet telehealth consultations month over month.

 Industry experts say this trend is likely to stick around even after the pandemic has ended, especially as clients become accustomed to the convenience of remote appointments.

Of course, the accelerated growth of telehealth in veterinary practice would not have been possible if, due to COVID-19, state and federal governments had not eased certain restrictions that typically exist for veterinarians.

In response to the coronavirus crisis, the Food and Drug Administration announced in March that it would temporarily suspend enforcement of certain aspects of the laws surrounding veterinary telemedicine to make it easier for veterinarians to treat animals during the pandemic.

 Specifically, the agency decided to overlook the rule that requires veterinary clinicians to establish the veterinarian-client-patient relationship (VCPR) through in-person examination before prescribing medications and issuing feed directives through remote consultations. Temporary relaxation of this requirement made it easier for clinics to treat animals remotely during COVID-19.

The pandemic has also left state veterinary boards reexamining their requirements on telemedicine.

 Some states are temporarily adjusting their own VCPR and other requirements for veterinary telemedicine, while others are standing by previous standards. In addition, some state veterinary associations have been finding ways to expand the telehealth resources available to their members. The New York State Veterinary Medical Society has partnered with TeleTails as its exclusive virtual care platform,

 for example, and the Washington State Veterinary Medical Association has partnered with the veterinary telehealth service Petriage.

While it is unclear how long the federal and state governments will continue to loosen their restrictions in response to COVID-19, the fact is that the industry and world at large are starting to see what regulatory circumstances may be more conducive to the practice of telemedicine by veterinary care providers. Not only does veterinary telehealth help bridge the gap in care during challenging times like the pandemic, but it also provides a higher level of convenience for pet owners, as well as potential time and cost savings for practice owners.

With that being said, it is possible we are headed into a future that encourages veterinarians to offer telehealth services, whether through fewer regulatory restrictions (for states that may decide to change their policies permanently), increased education, improved access to telehealth platforms, and/or partnerships. These factors could help make telehealth more of a mainstay with fewer barriers to adoption, similar to what we see in the human healthcare sector.

The key point to remember is that telehealth is not going away. So, it’s important to be thinking about how this aspect of care fits into your long-term practice plan and begin adjusting your business and marketing strategies accordingly. Here are three tactics to keep in mind when designing your telehealth business model.

The COVID-19 climate has given veterinary clinics the chance to get their feet wet with telehealth, laying down the foundation to make it a part of their permanent business models. Even after all shelter-in-place and social distancing orders are lifted and veterinary clinics have resumed normal business operations, many will continue offering telehealth services, so you will want to be a practice that is ahead of the curve. Offering telehealth enables you to provide more convenient options for patient care, making you that much more desirable as a choice for veterinary services.

If 2020 has taught veterinarians anything, it’s that they need to be ready to adapt if they want to stay competitive.

Vetted August 2020