Managing pain during an anesthetic event is integral to veterinary patient care and recovery, and can be achieved via multiple modalities. Pure 

 opioids, the foundation of pain management, induce a wide spectrum of positive and negative effects in animals. Aside from managing pain, positive effects of 

 opioids include sedation and a sense of euphoria; negative effects can include nausea, vomiting/diarrhea and dysphoria. The adverse effects of 

opioids are dose dependent and can be limited with use of a multimodal approach.

When the anesthetist is faced with managing adverse effects of 

 opioid administration, an understanding of the differences between analgesia, pain and dysphoria can guide the appropriate intervention and outcome.

 is defined as the lack of a response to painful or noxious stimuli while in an awake state. The interruption of painful stimuli is integral to veterinary patient care, comfort and recovery.

One of the ways analgesia can be achieved is via administration of opioids and interruption of the pain pathway.

is a noxious stimulus that potentiates a cascade of events. Untreated pain provokes myriad unwanted physiologic responses such as anorexia, self-trauma, central sensitization and maladaptive behaviors, all of which prolong recovery and add unnecessary stress.

 Stress drives the sympathetic nervous system, which activates the flight or fight response.

Pain is unique to each patient and exists in different capacities, including chronic arthritic pain, neuropathic pain, acute pain and traumatic pain. Because further complications can arise when more than one type of pain is present, the anesthetist must simultaneously plan for pain related to chronic problems and anticipate acute pain. For example, an older patient with arthritic hips that is going to be positioned for an abdominal exploratory requires hip support in addition to systemic analgesia.

, a feeling of discomfort or unease, often occurs with administration of pure 

 opioids. Co-administration of anesthetics, underappreciated pain or underlying behavioral issues can factor into the development of dysphoria.

 Of note, administration of opioids in painful canine and feline patients is less likely to promote dysphoria, nausea and vomiting.

Rapidly delivered intravenous opioids—even at clinically appropriate doses—may promote excitement, which is generally brief and typically resolves without intervention.

 By comparison, dysphoric patients are vocal, disruptive, and inconsolable.

An inconsolable patient does not respond to interaction. The dysphoric patient may be bradycardic, disinterested in food or water, and the third eyelids may be visible. Dysphoria can also be accompanied by anxiety, distress, or agitation.

A systematic approach is recommended when determining whether pain versus dysphoria is present. If the anesthetist is uncertain about which treatment is indicated, pain should be ruled out first. A dysphoria management algorithm (Figure 1) provides treatment direction and options.

Treating dysphoria can partially to completely antagonize the untoward effects of pure 

 opioids (Table 1). High doses of naloxone will antagonize the central effects of opioid agonists that may cause the animal to experience acute pain and associated sympathetic stimulation with serious consequences that include tachycardia, hypertension, pulmonary edema and cardiac arrhythmias. It is best to administer naloxone to effect by careful titration, keeping in mind that multiple doses may be needed to maintain antagonistic effects due to its short duration of action.

A common misconception about the painful or dysphoric patient is that the necessary intervention is a sedative or anxiolytic. Administering a sedative to a dysphoric patient does not resolve the dysphoria and potentially compounds existing problems (Fairfield, AF, personal communication, October 3, 2019). Similarly, painful patients will not be comfortable or euphoric after receiving a sedative. Table 2 details appropriate interventions after pain and/or dysphoria is treated or ruled 

Complicating factors that may lead to difficult recoveries include older patient age and pre-existing anxiety. Interaction with and handling by the veterinary team, as well as the increased noise and lights inherent to a veterinary hospital setting, can also lead to rough recoveries. Interestingly, a having a full bladder can lead to a rough recovery as well.

This dog shows classic signs of dysphoria following a surgical procedure: visible third eyelids, open mouth due to panting and the need for full body support by the technician.

In this video, the same dog has been treated with butorphanol (inset), and her eyes have rotated centrally, the third eyelids are no longer visible and she can hold her head up. 

1. Morgaz J, Navarette P, Muñoz-Rascón P, et al. Postoperative analgesic effects of dexketoprofen, buprenorphine and tramadol in dogs undergoing ovariohysterectomy. 

2. Grimm KA, Lamont LA, Tranquilli WJ, et al. 

Veterinary anesthesia and analgesia: The fifth edition of Lumb and Jones

. 5th ed. 2015 Ames, IA: Wiley-Blackwell; 2015.

3. McPartlin AM. Identifying pain vs dysphoria.Presented at Turtle Mountain Veterinary Clinic, Bottineau, North Dakota; 2016.

4. Krein S. Pain vs. dysphoria. MSPCA Angell website: mspca.org/angell_services/pain-vs-dysphoria/. Retrieved February 13, 2020.

 5th ed. Ames, IA: Wiley-Blackwell; 2011.

6. Palmer, D. Managing rough recoveries. Presented at the 2019 Anesthesia Nerds Symposium, Western Veterinary Conference.Las Vegas, NV; October 2019.

Articles

News

Having a thorough understanding of analgesia, pain and dysphoria is necessary to provide appropriate management interventions that will help achieve a positive outcome for your veterinary patients.


Is it pain or dysphoria? How to tell the difference and what to do about it

The Hospital Design Competition judges praised Tustin Legacy Animal Hospital in Tustin, California, for a nicely detailed interior, great finishes, and a solid, efficient plan. Owners Drs. Celine Hayek and Kristin Negvesky noted that they had “complementary styles and ways of thinking about things,” which combined to create a winning formula for this startup hospital.

Drs. Negvesky and Hayek first found a realtor to help them choose a site. Never having owned a business before, the two say they had a steep learning curve. Thankfully, their real estate agent “had a lot of experience with veterinary hospitals and was a huge help.”

Securing loans and handling financing proved challenging for these newbies, but they say Bank of America was a big help.

“Our main goal was to design a place that gave people a really good vibe when they walked in the door,” says Dr. Negvesky. For them, “client service is No. 1, and we wanted our hospital to feel approachable, with a clean, fresh style.” The pair wanted an easy-flowing plan, with plenty of sunlight, where they were “able to see the back of the hospital from the front.”

There was also one more must-have: “A chandelier, a big one!” says Dr. Negvesky. The doctors got their chandelier and the fresh, clean vibe they wanted throughout their 2,685-square-foot practice, which houses four exam rooms and separate dog and cat waiting areas.

The doctors did want two-door exam rooms, but they had to scrap that idea because it took too much space away from their tight floor plan. Another strategic choice: To focus on practicing medicine, the pair decided not to offer boarding and grooming services as they had originally planned. “We had heard a lot of stories of things not going well for others, and it seems that a lot of negative reviews online stem from boarding and grooming, which should not be a reflection of your medicine,” says Dr. Negvesky.

For help with getting the right vibe for the practice, Drs. Hayek and Negvesky hired an interior designer. They outlined the colors they wanted (blues and greens), the style they were looking for (upscale yet inviting), and the requirement of a chandelier in the reception area, and the designer ran with it.

A week before the practice officially opened, the doctors held a grand opening event to introduce themselves and get to know the community they would be serving. Food trucks, activities, raffles and hospital tours brought in about 100 people, who toured the practice and got to know the owners.

To help start off the first day of business in their new space, they scheduled an 8:30 a.m. appointment with someone whose pet they knew. “We were super surprised, though, when someone we didn’t know walked in at 8 a.m.,” says Dr. Negvesky.

Tustin Legacy Animal Hospital has grown steadily since that first unexpected appointment, no doubt because the two young practice owners started off right and have adjusted course as needed along the way.

For more details about the design of this hospital—and lots of photos—click 


If you’ve got big dreams of building a practice of your own from the ground up, take it from the winner of the dvm360 Hospital Design Competition in the “less than 8,000 square feet” category: It can happen for you.


Six steps to success in building a new veterinary hospital

When we decided to start promoting ProHeart 12 (Zoetis), we were uncertain how successful it would be for our practice. But a light bulb went off for us as we thought more and more about it. If we could get more patients on these injectables, we’d get 100% compliance with heartworm preventive (as opposed to trusting clients to remember every dose at home) and keep sales in the clinic and out of online pharmacies. The best part is, we priced the injectable to be competitive. Here’s how we did it—and you could try it too.

Price less than a popular online pharmacy’s price for a 12-month supply of a popular oral preventive. Explain that to clients.

Create a price sheet by weight for pricing purposes on treatment plans.

Make ProHeart as important as a rabies vaccine in educating clients and team members.

Make sure all the hospital’s doctors feel good about recommending the injectable.

Encourage team members to put their own dogs on ProHeart. (Sales reps may be able to provide product for the team.) Nothing is more comforting for recommending products and services to a client than a team member saying, “My dog is on it, and I love it!”

Partner with your reps to set goals with enticing rewards. I suggest a three-month goal, so educating clients becomes a habit.

Update team members on the compliance numbers regularly.

It’s easy: No more having to remember to dose every month or shove a pill down the dog’s throat.

It’s affordable: Your pricing should be competitive with noninjectable heartworm preventives, and clients might even benefit from manufacturer rebates.

Concerned that a once-a-year preventive will cut down on client visits? When I look at numbers, single-dose purchasers are less than 30% compliant. With that compliance rate (you can try to check your own), I’d argue clients aren’t visiting the practice more often.

Worried about your margin? Think about the money your practice loses paying talented team members for their time to collect all information and signatures for those online pharmacy requests or to chase down single-dose users.

Scared clients won’t like the change? Pet owners trust their veterinarians and veterinary professionals to guide them to do what’s best for their beloved pets. While online pharmacies may automatically send a single dose monthly, that doesn’t mean it’s actually being given to the pet. Yes, the injectable has the potential for sticker shock, if clients are used to small bills from pills. So, do the math for them and explain the convenience. It can make financial sense for many, and it can make convenience sense for everybody.

Moving to injectables like ProHeart 12 with long durations also allows you to cut back on other drugs (like parasite preventives) taking up inventory space and eating up staff time.

ProHeart 12 was a hit for our veterinary hospital—200 injectables in the first six weeks—and the math that makes it work for us and our clients might work for your practice too. It's worth a try!

Emily Shiver, CVPM, is practice manager at Cleveland Heights Animal Hospital in Lakeland, Florida.

Our veterinary practice didn’t know how great an injectable heartworm preventive would work for us. Here are the details of our plan.

ProHeart for the win: Why injectables work for us 

The itchy cat—fleas aside—is not a common sight. But when cutaneous manifestations of allergy do occur in cats, they can be quite complicated and require multimodal therapy, according to Amelia White, DVM, MS, DACVD, assistant clinical professor of dermatology at Auburn University College of Veterinary Medicine. Dr. White offered attendees her insight about managing several types of allergies in cats this week.

The excessive groomer looks allergic, and indeed may be. “But a cat that grooms excessively might be doing so for reasons other than being pruritic,” Dr. White explained. Cats can respond to uncomfortable conditions like urinary tract infections and anal sacculitis by pulling out their hair.

Overgrooming can also be psychogenic; in many cases, it kicks off because of a true dermatologic condition (e.g. parasite infestation) but morphs into habit even after the underlying problem has resolved. “Allergic can become psychogenic very quickly,” Dr. White said.

Most true allergies in cats fall under eosinophilic granuloma complex (EGC), which can manifest as different lesion types:

Miliary dermatitis: small, raised, crusty papules 

Eosinophilic plaque: elevated, flat thickening with a red-orange center and crusting

Rodent/indolent ulcer: eosinophilic infiltrate that occurs as bilateral, raised lesion(s) at the upper lip margins

Eosinophilic granuloma: linear plaques, often on one or both hind legs, and dome-like masses that may occur in the interdigital tissues.

EGC is treated with multimodal therapy that sometimes includes antibiotics. “Steroids have a very strong inhibitory effect on eosinophils,” Dr. White said.

Feline pruritus can be rooted in parasites. The most common pruritic skin disease in cats is flea allergy dermatitis (FAD), which may or may not be seasonal depending on geographic region. While flea bites themselves are itchy, most cats develop type I and type IV hypersensitivities to flea salivary antigens. The head, neck and caudal half of the body typically manifest bilateral, symmetric alopecia as well as miliary dermatitis.

While there are no age, gender or breed predilections for FAD, atopic cats—as well as cats with 

flea exposure—are most severely affected; cats that are exposed to fleas 

Diagnosis of FAD is generally made by the distribution of lesions and itchiness on the cat, as well as the presence of fleas and/or flea dirt. Trichograms may show broken-ended hairs. Serologic and intradermal skin testing may be diagnostic, although false-positives can occur.

The treatment mainstays for FAD are corticosteroids, but immunosuppressants such as cyclosporine (Atopica—Elanco) and oclacitinib (Apoquel—Zoetis) are effective as well. Atopica, which inhibits the inflammatory activator calcineurin, requires 30 to 90 days for onset of action. Twice-weekly dosing has been shown to be 63% effective in cats with EGC. Apoquel can be used off-label in cats at a dose of 1 to 2 mg/kg twice daily, but Dr. White added that it should not be the first choice for treating allergies in cats.

The affected cat, the home environment and all other pets in the household should be treated with flea control products. Prevention can be accomplished through the use of parasiticides effective against fleas as well as through flea exposure avoidance. 

Like flea bites, mosquito bites can also produce hypersensitivity (type I) in cats, with no predilections. Bloody, oozing, pruritic lesions typically develop on the rostrum, ears, face and paw pads. Corticosteroids and insect repellents are effective.

Food allergy is an uncommon cause of nonseasonal pruritus in cats. Raised, crusty, erythemic plaques typically appear on the head, neck, pinnae and abdomen. Signs are typically first seen when a cat is quite young or geriatric, but a food allergy could manifest at any age, Dr. White said.

Once parasites and primary skin infection are ruled out, diagnosis can be made by food elimination trial, conducted over 8 to 12 weeks. The smoking gun is generally 10- to 70-kD proteins found in beef, fish or dairy, although dietary carbohydrates, preservatives and artificial flavors are lesser-known triggers. Food allergy is managed with steroids, antibiotics and dietary change to novel/hydrolyzed protein diets.

Once fleas, food allergy and infectious dermatitis have been ruled out as the cause for nonseasonal pruritus, consider atopy, Dr. White said.

Atopy is cutaneous inflammation often associated with production of IgE against environmental allergens. Atopic cats may have a genetically predisposed abnormal cutaneous barrier to begin with; antigens easily penetrate the skin and are escorted to the lymph nodes by sentinel cells called Langerhans cells. Here, the lymphocytes produce antibodies that initiate the inflammatory cascade.

Atopy is the underlying state that “greases” the immune system: It makes every allergic condition worse, be it flea allergy or food hypersensitivity. It also intensifies allergic responses with subsequent exposures, and seasonal flares can turn into everyday issues. In fact, said Dr. White, 75% of atopic cats have year-around pruritus. “Even in cats that started out seasonal, over time they eventually become nonseasonal,” she said.

Atopic cats have widely distributed lesions, and diagnosis can be made by history, clincal signs and the process of diagnostic exclusion.

Allergen-specific immunotherapy is the gold standard of treatment for feline atopy, Dr. White said. Immunotherapy is developed from results obtained on an intradermal allergy test or serology (which generally shows high levels of IgE in circulation). Vials typically are limited to 10 to 12 antigens apiece, possibly because there is cross-reactivity between different antigens and to avoid diluting therapy to the point of making it ineffective.

Treatment is most effective with a multimodal protocol that includes allergen-specific immunotherapy, anti-inflammatories (corticosteroids, Atopica, Apoquel, antihistamines and essential fatty acids) and allergen avoidance. Because stress can exacerbate pruritic behaviors, Dr. White also recommended the use of behavior modulators like amitriptyline, fluoxetine and clomipramine in cats with intense pruritic behaviors.

When it comes to cutaneous manifestation of allergies, Dr. White advised, lesion 

Head and caudal part of body: Think fleas.

Head, neck and belly: Think food-induced.

Immune hypersensitivities can also encompass locations below the skin surface. Associated signs include upper respiratory abnormalities, nasal/ocular discharge, asthma and inflammatory bowel disease.

Developing a successful treatment plan for common allergies in cats first requires an accurate diagnosis. A veterinary dermatologist provides diagnostic and treatment details to help you put a stop to the scratching.


VMX 2020—Tips and tricks for managing feline allergies

KariDesign/stock.adobe.com/illlustration work by Nicholette Haigler.

 on the legality of using cannabidiol (CBD) and think you're ready to take the plunge! But where should you start? Let's start with what we know.

	In the Wild West of hemp-derived CBD, prior to legalization on the federal level this past December, it wasn't unusual for my clients to tell me they'd started their dog or cat on CBD. (We always ask what botanicals or supplements clients are giving their pets, as many of them have side effects that can be deadly either alone or when given in combination with other medications, so my practice was probably a bit more aware than many.) I was astounded at how many people used these types of products but wouldn't bring it up unless asked.

	My point is, if you don't ask, you don't know, and you could be exposing yourself to a legal concern should there be an interaction with a medication you dispense. Not sure about the supplement? Download the 

 that's maintained by the Memorial Sloan Kettering Cancer Center. It's meant for humans, but it's still a great source of information on actions, precautions, interactions and adverse events.

	Luckily for us, CBD doesn't seem to have any dangerous actions or interactions, and, unlike many drugs, it seems to only push body systems toward normal. I say “seems” because, up until very recently, even doing research on CBD was illegal. In the future, as CBD trials are performed, more concrete evidence on adverse and therapeutic effects will be available.

	Although there were not a large number of dogs in the study, a double-blind, placebo-controlled study at Cornell on the effects of using ElleVet's CBD oil on dogs with chronic pain of osteoarthritis showed an improvement in pain scores. More studies need to be done, but this study agrees with the observations of many of my clients who have used CBD products.

	On the human side, the FDA approved a CBD product for the treatment of intractable epilepsy in children-so at least in humans, we know it helps with seizures. The other use in animals (besides pain) for which there's only anecdotal evidence is for the relief of anxiety, including noise phobias.

How do you know which products are best? 

	Prior to December 2018, there were only a handful of animal CBD products available. Now there are countless, and many include products that human CBD dispensaries are pushing for animal use. To help make this easier to navigate, here are my rules for use:

 They may contain substances such as xylitol or other additives that are fine for people, but not so much for dogs or cats.

Ask the manufacturer for an assay from an outside lab.

 You want to make sure the stated strength 

 if they've had their product tested for pesticides and heavy metals.

 Remember, it takes a lot of hemp to make a small amount of CBD, so these unwanted substances may be concentrated as well.

Ask the manufacturer if they have more than one fraction of CBD or if the product contains terpenes.

 We still don't know what makes hemp or CBD work, and it's thought by some that products containing the different subtypes of CBD and terpenes may be more efficacious.

	There are some minor legal implications if you give your clients a CBD dosage to follow when they administer a product to their pet. This can be interpreted as you giving a drug, which can increase your liability should something go wrong. It's best if you tell pet owners to follow the manufacturer's directions.

	And, finally, it's important to convey to your clients that at this point in time, the number of studies supporting the use of CBD are scant, and we really don't know what long-term benefits-or problems-might arise from its use. Your clients want what's best for their pet's condition, and maybe CBD is part of that solution. However, in these early days of legalization, make sure they're aware of all of the cautions we've discussed here.

	Dr. Michael Petty owns Arbor Pointe Veterinary Hospital, Canton, Michigan.

This aint the wild west of CBD exploration anymore. Cannabidiol is becoming legalized, which means your veterinary clients are going to be asking about it more. Heres what you need to know.

Wrangling the topic of CBD with your veterinary clients

showcake/stock.adobe.comDisease: Poor boundaries

	Symptoms may include but are not limited to:

 Boundaries are the lines you draw that help others know how you want to be treated. If you don't have healthy boundaries, you might be passively relying on others to know how you want to be treated. While we would all love for people to consider others before themselves, that's not reality.

 Before I discovered my own boundaries, I was known as a “yes” woman in veterinary practice.

	Stay late to help with that blood transfusion? Yes!

	Need someone to help with that extra shift once a week until we find a replacement? Yes!

	I wanted opportunities to advance my career, and I thought I could handle anything. Until I couldn't. I burnt myself out and ran from practice, trying to find a company that would treat me better. Finally, a good friend called an intervention and told me the truth: You can't put everything and everyone before yourself and still be happy.

	“If the cabin should lose pressure, please put your oxygen mask on first before assisting others”: If you've flown, you're heard it before. Same goes for emotional health-you need to take care of yourself before helping others.

	Think of a time when you've felt resentful, angry or burnt out. These feelings may be a sign that you're ignoring your personal boundaries. When I always stayed late to help, I felt it was expected of me-that I had no choice. I felt angry, exhausted and resentful. Social psychologist Brene Brown advises keeping a 

 for a while to help track moments when you might need a boundary. Other helpful actions include:

 When staying late became the norm for me, I'd have thoughts like, “What would they do if I actually left on time?” I never thought to really think about what would happen. When I took the time to think about it, the answer was reasonable: They'd call in the on-call person, who would get a bonus for coming in. Recognize the story you tell yourself in these situations, and do a reality check. You might find that your fears in setting a boundary aren't as scary as you thought.

 If you're new to setting boundaries, start small to test them out and get specific with what you're going to do. If you want to start leaving work on time, set a goal of leaving on time two out of four shifts, for instance. I didn't want to leave my co-workers high and dry at the end of a shift, so I thought it was reasonable to say that I would give myself a 15-minute window to make sure my duties were caught up and that I was able to pass anything else over to the next shift.

 Boundaries need accountability. If you don't uphold a boundary, does it really exist? Consequences don't have to be all-or-nothing; for example, if I had to stay late one day, I wouldn't quit on the spot. I would just make note of it and if it became a pattern or was regularly expected of me, I would need to have a conversation with my manager.

Being uncomfortable saying “no” so often.

 I was terrible at putting myself first, because I was afraid of what saying “no” would do. When I realized that no one was going to care about my wellbeing more than me, I had to choose what I needed over making sure that everyone else felt okay. When you start to create boundaries, you'll need to get used to saying no. Making others uncomfortable is something we avoid like the plague, but it's important that we learn to choose ourselves over discomfort.

 Boundaries can be scary at first. Typically, we battle with the fear of what others will think about us or guilt that we're letting people down. I predicted that my coworkers would think I was lazy, not a team player, and that I wouldn't be offered other opportunities at work. This is another good moment for a reality check. Letting go of fear doesn't mean that you'll never feel fear again-it means you choose to not let fear make the decision for you. If you believe your work is valuable, that you're a hard worker and that you've earned opportunities, then use that evidence to challenge your fear when it sneaks into your thoughts.

 When I told my boss ‘‘no” for the first time, at first, my boss was supportive. As time passed, however, that boundary was pushed. When I got frustrated, I told myself a story about how the pushback was proof that my boss didn't respect me. When I took some time to reality check my situation, I realized it had nothing to do with me: My boss was trying to manage a larger workplace problem, and my boundaries and needs just weren't the first thing on her mind.

	I realized that it isn't always intentional when people push back or ignore boundaries. I also believed that I could still help solve the problem and maintain healthy boundaries. This led me to restate my boundaries with my boss and explain my goal: I wanted to help 

 I wanted be healthy. That conversation led to more collaboration, not a battle.

	If you experience pushback when you set a boundary, do a reality check. Open a conversation with the person. See how your shared goals are in line. If the person continues to treat you badly or is angry with you, ask yourself:

	• Do I care about this person's opinion of me?

	• Is this relationship healthy for me?

	• How can I maintain my boundaries while still working with this person?

	Signs of better boundaries over time can include:

	Until I discovered the power of boundaries, I was afraid of them. I assumed that the more I pleased others, the more successful I would be. Now I see this is counterintuitive: I can only expect others to respect me as much as I respect myself.

	Boundaries are hard in the beginning. They take practice and self-reflection to be successful. The stakes can be high, because the people you most need to build boundaries with are often the ones you care about the most.

	With healthier boundaries, I see less conflict in my relationships and my communication skills have improved. In addition, I take on less guilt, which helps me move past emotional thoughts more quickly. They can do the same for you.

	Kristina Guldbrand worked as a certified veterinary technician for 12 years before becoming an account manager for Veterinary System Services, a company that provides staffing, consulting and hiring help to practices in the Denver, Colorado, area. She has received training through the International Coaching Federation and provides workshops, leadership and wellbeing coaching as well as teambuilding for practices.

Unless your upbringing or work experience presented an example of how to set healthy boundaries, you may not know how to establish and maintain them. When you combine the lack of boundaries with your work as a veterinary professional in a caretaker role, this can create negative emotions. Lets diagnose and treat. 

Diagnosis? Resentment. Rx? Healthy boundaries

Adding more and better preventive care protocols in your veterinary practice can seem daunting: What exactly counts as preventive care? How do you price the services? Will clients accept it? Don't worry-I know from experience that implementing preventive care protocols can work well for your patients, your clients and your practice.

The first step on this journey is reminding yourself that veterinary medicine is about providing our clients' four-legged family members with the best quality and longevity of life possible. In other words, it covers much of the work you already do: annual or twice-a-year physical exams, early-detection diagnostics and vaccines, as well as prevention of disease from fleas, ticks and heartworms. Every veterinary team, yours included, already has a written or unwritten standard of care that applies to how you treat pets for their annual healthy pet exam, whether your practice calls it a “wellness exam” or “preventive care visit” or some other name. The point is that all practices are already in some way heading down the preventive care path, and the protocols outlined here can help your practice make further progress in a way that's right for your team.

I argue that the standard of care for a practice must ensure that you aren't missing early signs of disease that should be monitored or treated. To do that, a preventive care appointment that includes early-detection diagnostics provides the best value for patients and the highest probability of catching potential concerns as early as possible to address them.

Research from AAHA clearly supports the importance for otherwise “healthy pets” of conducting internal parasite exams, vector-borne disease testing, a complete blood count (CBC) and a serum chemistry profile.1 One in four adult and senior dogs that present for a healthy pet exam will have diagnostic markers that require follow-up, making it critical that we consistently recommend these diagnostics.

How can a typical practice price preventive care services to maximize value for clients? In our practices, we've seen success with pricing preventive care appointments lower than sick patient appointments. We know that preventive care appointments are price-shopped, and being competitive in pricing for these exams-while remaining profitable-can bring new clients in the door.

After all, no practice-no matter how good it is-can wow a client who doesn't come in. A preventive care appointment is an opportunity to create lasting bonds, so a pet owner returns when the dog eats a tennis ball or the cat's chronic kidney disease needs management. We need to respect the lifetime value that a satisfied and bonded client brings to the practice directly as well as through word-of-mouth referrals to our practice for family and friends.

Here's a successful case study example: Our practices established a baseline protocol for early detection that made sense in our region. And we priced it aggressively to gain compliance and increase revenue per patient visit. Our practices are in tick country, and we see many tick-borne diseases that we need to test for annually. As a result, our early-detection diagnostic panel includes an internal parasite test (comprehensive fecal analysis), testing for tick-borne disease and heartworm disease, CBC, serum chemistry profile and SDMA test.

We price our early-detection diagnostic panel (including CBC, serum chemistry profile and SDMA test) about 30% higher than the comprehensive fecal analysis and SNAP 4Dx Plus Test (IDEXX) combination, which generates additional revenue per preventive care visit. Clients find it affordable, and we're able to incorporate diagnostics into more preventive care visits. Some clients may say, “Not at this time,” but they'll never say yes unless we ask them.

Most of the time, early-detection diagnostic results will be within normal limits, so veterinarians and team members need to celebrate this good news with clients. Teams can help clients understand that these tests matter in helping their pets live the best life they can. All too often in veterinary medicine, we become excited about the unusual and are blasé about the “normal.” We sometimes forget that for our clients, the news that their pet is healthy and doing well can be exciting to them.

When your team members see the value being placed on “normal,” they're more likely to feel confident in recommending early-detection diagnostics as well. We need to emphasize the value of preventive care for our patients and clients to our teams within the practice.

Another crucial moment with early-detection diagnostics is when we find problems in otherwise healthy-appearing pets and find opportunities to intervene earlier. When we see markers that concern us, we can talk to clients about the appropriate strategy right away, whether it's treatment or monitoring. Clients appreciate the value of detecting potential disease early, and we're ultimately hoping for better outcomes if we catch something before the pet becomes ill.

Practice managers and owners would all prefer to generate more income during a 20-minute visit, because all of our fixed costs are the same whether we earn $75 or $250. Additional diagnostics is a way practices can earn more revenue during a patient visit.

And because the research indicates that we're likely to find problems when we actually look for them, early intervention not only helps the patient but also provides additional revenue for the practice through the diagnostics themselves as well as additional follow-up activity that may arise. Our practices have seen an increase in dentistry and minor surgeries, such as lump removals, because a more comprehensive panel can be used for most of our preanesthetic protocols.

Ultimately, practice managers and owners need to design the standard of care and protocols for what makes sense for that practice and that location. Educate clients on the benefits of early detection, and make sure that it's part of your preventive care process. Develop an early-detection diagnostic panel that meets your needs and workflow, and price it aggressively to provide value to all of the stakeholders in your practice.

1. American Animal Hospital Association. Promoting preventive care protocols: Evidence, enactment and economics. Indianapolis, IN: American Animal Hospital Association; 2018.

Nancy Drumm is general manager of four AAHA-accredited hospitals in the Capital District of New York and blogs on one of IDEXX's veterinary-facing websites at practicelife.com.

I advocate for more early-detection diagnostics, as I think they make sense for pet health, for client peace of mind and practices bottom line.

A clean bill of health is a reason to celebrate

	Humans have been breeding dogs for thousands of years, but it wasn't until recently that someone thought to ask if human preferences for certain canine traits have affected brain anatomy.

	That someone is Erin Hecht, PhD, an assistant professor of neuroscience from Harvard University. She found inspiration as a graduate student at Emory University while watching a nature program about domestic dogs and selectively bred Russian foxes. According to an interview with 

, Hecht was surprised to learn that the scientists were only concerned with genetics and evolution-not neuroscience. “I thought, ‘How is this possible? No one's thought about looking at their brains,” she told the 

	Eager to fill in the gap, Hecht reached out to Marc Kent, DVM, DACVIM, a professor of small animal neurology at the University of Georgia College of Veterinary Medicine, who gave her access to magnetic resonance imaging (MRI) scans from dozens of his canine patients.

	“The first question we wanted to ask was, are the brains of different breeds of dogs different?” Hecht said in an interview with 

. And after analyzing the MRIs of 62 dogs representing 33 breeds, she and her colleagues found that their brains are indeed different, that the differences aren't randomly distributed and that the differences aren't caused by variations in brain size, body size or skull shape.

	The researchers discovered that neuroanatomic variation is focused in specific networks of the brain that significantly correlate with behavioral specializations like sight hunting, scent hunting, guarding and companionship. They also note that most of the variation was observed in the terminal branches of the phylogenetic tree, which indicates strong, recent selection in individual breeds. “Together,” the researchers conclude in the abstract, “these results establish that brain anatomy varies significantly in dogs, likely due to human-applied selection for behavior.”

interview, Jeffrey Stevens, PhD, director of the University of Nebraska's Canine Cognition and Human Interaction Lab, discussed some of the study's limitations. For starters, he explained that not everyone is convinced of the usefulness of mapping behaviors to breeds because individuals within the same breed can vary a lot. Stevens also noted that the dogs weren't performing breed-specific tasks at the time of their MRI scans, calling into question whether any big conclusions linking breed and behavior can be drawn.

	Further potential limitations stem from the fact that all of the research participants were house pets, not working dogs that regularly put their breed-specific talents to serious use. This fact is important because, as Dr. Hecht explained to 

, studies have shown that the brain changes as it learns a new language or motor skill. In other words, the brain anatomy of an old English sheepdog who spends his days herding sheep in the New Zealand countryside could look very different from that of an old English sheepdog who lives the life of a pampered Instagram darling in a Chicago apartment (lending further support to Stevens' first concern). With this in mind, Stevens suggested that a future focus on working dogs could reveal even stronger correlations.

	Speaking of the future, Hecht, whose lab also studies brain evolution in humans, told 

 that further research on dog brains could provide insight into the brains of their masters-an idea that wasn't taken very seriously by other scientists and funding agencies when Hecht first began her research back in 2012. Using border collies as an example (perhaps because she has two of her own), she explained that while they're remarkable herders, they aren't born knowing how to herd.

	“Learning plays a crucial role, but there's clearly something about herding that's already in their brains when they are born,” she said. “It's not innate behavior, it's a predisposition to learn that behavior. That's analogous to what goes on with humans with language. They don't pop out of the womb being able to speak, but clearly all humans are predisposed in a very significant way to learn language. If we can figure out how evolution got those skills into dog brains, it might help us understand how humans evolved the skills that separate us from other animals.”

	Hecht is now specifically studying working dogs-both champions and their less successful littermates-in an attempt to better understand how dog brain anatomy has been shaped by recent evolution. “We're looking for animals raised in the same environment where, for whatever reason, one has excelled and one dropped out,” she told the 

	1. Hecht EE, Smaers JB, Dunn WD, et al. Significant neuroanatomical variation among domestic dog breeds. J Neurosci 2019;39(39):7748-7758.

	Sarah Mouton Dowdy, a former associate content specialist for dvm360.com, is a freelance writer and editor in Kansas City, Missouri.

A recent study suggests that selective breeding has significantly altered the anatomy of dogs brains. 

Vetted March 2020