 in the animal health industry in recent years, veterinarians and their clients have more options than ever for providing relief to itchy dogs. And, according to releases from two industry manufacturers, there may be even more therapeutic (and diagnostic) alternatives available in the near future.

 diagnostic biomarker and a stem cell treatment

As many veterinarians are all too aware, canine atopic dermatitis traditionally requires a lengthy diagnostic process based on exclusion and relying on patient history, clinical examination, allergy testing and diet trials. All of these tests, while reliable in their own right, have limitations, according to a release from VetCell Therapeutics.

The company, which manufactures cell therapies for veterinary applications, and a team from Western University of Health Sciences recently published 

 that outlines how certain biomarkers in the blood may be a tool for quickly identifying atopic dermatitis, offering an instant diagnosis and guidance on how to treat the underlying causes of inflammation with cell therapy, the release states.

VetCell Therapeutics and Western University are also conducting 

 on the effects of using mesenchymal stem cells to treat canine atopic dermatitis. The goal of the study is to determine whether stem cell therapy helps patients find relief from inflammation caused by atopic dermatitis and leads to a reduction in scratching. If the results from the trial are favorable (research is scheduled to conclude by the end of this year), the team will pursue a clinical trial.

The end goal for all of this work is to create an FDA-approved stem cell therapy for canine atopic dermatitis, the release states. The company also wants to use the results of the canine study to pursue a human therapy based on the same principles under the guidance of VetCell Therapeutics' parent company, PrimeGen Global.

A new monoclonal antibody targeting canine itch

In related news, Kindred Biosciences recently announced positive results from its pilot study of KIND-016, a fully caninized, high-affinity monoclonal antibody targeting interleukin-31 (IL-31) for the treatment of atopic dermatitis in dogs.

The study was a randomized, blinded, placebo-controlled pilot field study of 62 client-owned dogs with atopic dermatitis designed to assess the effectiveness of KIND-016. A single dose of KIND-016 or placebo was administered on day 0, and the severity of pruritus (determined by the Pruritus Visual Analog Scale [PVAS]) and atopic dermatitis (determined by the Canine Atopic Dermatitis Extent and Severity Index-4 [CADESI]) were assessed at day zero and during weeks one, two, three, four, six and eight.

In addition, PVAS scores were assessed at four hours and on days one, two and three after administration of KIND-016 or placebo. Treatment success for individual dogs at each visit was defined as a reduction of 50% or greater from baseline in either the PVAS or CADESI score.

At week four, 61% of the KIND-016 group met treatment success criteria versus 33% of the placebo group. The reduction in itching, as measured by the PVAS score, peaked rapidly, with treatment showing significant efficacy as early as 24 hours with a trend as early as four hours. The CADESI response was also very rapid, with the treatment success rate reaching 70% as early as week one. While the study was not designed to demonstrate efficacy beyond week four, the majority of dogs that were treatment successes at week four maintained response through week eight.  

KindredBio CEO Richard Chin says the company's biologics plant, located in Kansas, is designed to meet demand of more than a billion dollars of product per year and will soon be fully commissioned.

Articles

VetCell Therapeutics researching stem cell treatment, while KindredBio studies efficacy of new monoclonal antibody for veterinary patients.

Studies initial results point to potential new atopic dermatitis therapies

There is an overwhelming energy associated with survival. Think of a deer in the peak of hunting season, when shots ring out. The gunshot incites a violent movement, but once the deer is in a safe place, it will tremble and shake-moving traumatic energy through its body.

Humans, however, often suppress overwhelming feelings associated with trauma. There's a gap between the body's response to stress and the emotional and physical manifestation we allow to occur.

Connecting the mind and body to cope with the stress of trauma was a topic at the annual International Trauma Conference, held in Boston in May. There, Michael Mithoefer, MD, a psychiatrist in South Carolina, emphasized the importance of “body work,” meaning physical, vibrational and expressive movement, for healing traumatic stress.

“If you are looking for a place to start, start with breathwork, specifically holotropic breathwork. This is a type of breathing that is relaxing but uses hyperventilation to move energy,” Dr. Mithoefer said. “You are depleting your brain of oxygen and blowing off excess carbon dioxide, so oxygen is more tightly bound to hemoglobin. Your body goes into respiratory alkalosis-and arterioles contract. You get less oxygen to the brain which stops the brain attention and shifts to physical attention. You are able to move out of your mind and into your body.”

Peter Levine, PhD, has spent 45 years studying psychological trauma and believes in the importance of restoring your connection between your mind, body and spirit to heal from trauma.

He is particularly involved in the applications of a technique he has created called "somatic experiencing." Somatic experiencing helps people identify where trauma may be stuck or frozen in their body and allows for movement of that energy to exit the body. This is done by being able to access body sensations, finding where you are tight or where you have collapsed. Dr. Levine outlines this in detail with specific exercises one can complete on their own in his book 

After years of treating trauma, Dr. Levine found that post-traumatic symptoms are, fundamentally, incomplete physiological responses suspended in fear. Little time is allotted for the working through of distressing events, and we are routinely pressured into adjusting too quickly in the aftermath of an overwhelming situation. While 

 is a specific form of therapy, the necessity to reconnect with our body as a means of healing is evident.

While the techniques mentioned here are specific to trauma therapy, almost every traumatologist advocates for the use of yoga, meditation, tai chi, acupuncture, art therapy, aromatherapy, martial arts, theater, music and even virtual reality as adjuncts to healing from trauma. They all on some level will end up employing you to use your breath or get in touch with your physical body.

Ultimately, traumatologists have acknowledged that there is no one way to heal from trauma, but rather a multimodal approach that is tailored to the individual using known techniques is best.

 speaker Dr. Hilal Dogan, a certified clinical trauma professional, practices medicine in Denver, Colorado. She started the Veterinary Confessionals Project as a senior veterinary student at Massey University in New Zealand.

What might coping with stressors in veterinary medicine look like if we allowed our physical response to trauma to take its course, rather than suppressing it?

Out-of-the-box advice for veterinary professionals dealing with traumatic experiences

Is your veterinary practice sitting on a large profit this year? Need a tax planning maneuver that will generate a maximum deduction for a minimum amount of cash? Consider the Section 179 deduction.

The Section 179 election has existed in one form or another for several years and has long provided a valuable tax benefit for practice owners. The deduction allows a clinic to claim an immediate write-off for qualified assets (purchased or leased) as opposed to taking a depreciation deduction over five, seven or even 10 years.	

> To claim the deduction, the qualified property needs to be signed for 

 in service in the veterinary practice by the end of the year. No signing the paperwork around Christmas then receiving the delivery mid-January!

> Equipment acquired through a capital lease qualifies!

> Some states don't have tax laws that mirror the 179 deduction allowed by the IRS. In California, for instance, the maximum 179 deduction allowed is $25,000. Keep this in mind when doing your tax planning at the state level.

The Section 179 deduction applies to the purchase or lease of tangible personal property (such as a digital radiography, computer equipment or cabinetry) for use in a trade or business. The annual deduction limit is $1.02 million for tax year 2019, subject to a phaseout rule 

(the gradual reduction of a tax credit that a taxpayer is eligible for as their income approaches the limit to qualify for that credit)

. Under this phaseout rule, the deduction is reduced if more than $2.55 million in qualified property is placed in service during the tax year. For most veterinary practices, these limitations are not an issue.

There's also a taxable income limit: The amount of 179 expense allowed as a deduction is limited to the veterinary practice's taxable income that year. However, any amount you can't immediately deduct is carried forward to future years.

For some practice owners, the idea of financing or leasing expensive equipment before the end of the year is an attractive one. The practice owner needs to come up with only a down payment or an initial lease payment, yet still benefits from a deduction for the entire purchase. While this plan is effective in Year 1, things flip in Years 2 through 5, when cash is going out the door toward the loan/lease, but no deduction is being generated. This is otherwise known as phantom income.

In my professional opinion, acquiring a large piece of equipment should be more about how it 

 rather than how it saves you taxes. Will the acquisition make your practice money? Will it elevate your standard of medicine? Any tax benefits are nice, but should be considered secondary.

That said, if the acquisition makes sense for your hospital, then take advantage of the Section 179 deduction.

Tom McFerson, CPA, ABV, is partner at the veterinary accounting firm Gatto McFerson in Santa Monica, California.

If the new equipment for your veterinary clinic will make you money, improve patient care and make work easier for your team, then, yes, the Section 179 tax deduction is a nice bonus from Uncle Sam! Learn more about it here.

Should you rush to buy equipment before Dec. 31?

What's the first thing that comes to mind when you see a senior cat? For Kelly St. Denis, DVM, DABVP (feline practice), owner of Charing Cross Cat Clinic in Brantford, Ontario, it's pain. That's because according to research, senior cats with degenerative joint disease (DJD) are the majority.

 that found radiographic evidence of DJD in 90% of cats greater than 12 years of age, as well as a 2010 study

 that found radiographic evidence of DJD in 92% of cats between 6 months and 20 years of age with equal frequency in 

 age groups. “In the second study, age was the only variable consistently associated with DJD,” she explains. “And for each one-year increase in a cat's age, the expected total DJD score increased more than 13%.”

While radiographic changes don't always correlate with pain, Dr. St. Denis would much rather assume a cat is painful and be wrong than vice versa-especially since these patients are notoriously skilled at concealing signs of suffering. This assumption means her senior feline exams start slow and as hands-off as possible. “Sometimes clients want to push, pull, drag, shake or dump their cat out of the carrier because they don't want to take up too much of my time,” says Dr. St. Denis. “I help them take a step back, open the carrier on the floor and give the cat a chance to come out on its own.”

From here, the work of diagnosing DJD begins. Drawing on both published research and her 20 years of clinical practice experience, Dr. St. Denis explained how she follows up on her assumptions during a session sponsored by PRN Pharmacal at a recent 

Degenerative joint disease (DJD) is an umbrella term that includes osteoarthritis (OA), spondylosis deformans of the intervertebral disc, isolated degenerative lesions, traumatic arthritis and non-OA-related degenerative soft tissue mineralization within a joint. OA and spondylosis deformans are the most common causes of DJD in cats.

Dr. St. Denis likens DJD's diagnostic components to puzzle pieces. Sometimes they fit together nicely, and sometimes they don't and you're still left with your research-based assumptions.

Getting a helpful history from your clients can be difficult, says Dr. St. Denis, and it's not just because cats are so good at masking their pain. Unlike dog owners, cat owners are less likely to interact physically with their pets on a regular basis, and cats' rigorous sleep schedule can make it difficult for their owners to observe their activity. This difficulty is further compounded by cat owners being uneducated about what to watch for and perhaps even blinded to changes by a fear of facing the aging of their beloved companion.

According to Dr. St. Denis, equipping your clients to become allies in DJD detection can help you get to a diagnosis sooner, and that client will be more likely to see the need for treatment. “I most often hear from cat owners that their cat is simply getting old, as if that's some sort of excuse for why the cat isn't doing anything anymore,” she says. “We have to adjust their interpretation of that slowing down.”	

 > Hair loss over affected joints (likely due to increased grooming)

> Odd sleeping positions (e.g. with limbs sticking out)

> Sudden dislike of brushing, petting, etc.

Dr. St. Denis notes that it can be helpful to pry when it comes to litter box issues, because cat owners often adjust to a new “normal” without thinking anything about it. New behaviors, such as missing the box with urine, can create unconscious habits, like laying down pee pads, that ignore the underlying issue-such as pain.

In addition to discussing the common signs associated with DJD (see sidebar), Dr. St. Denis recommends training clients to use the 

, a clinically validated questionnaire for diagnosing and monitoring pain stemming from degenerative joint disorders.

As mentioned earlier, Dr. St. Denis starts physical exams by setting the carrier on the floor and letting the cat come out on its own. In addition to being sensitive to potential pain, this approach gives you an opportunity to watch the cat move around the room. “If it's a patient you're familiar with, you're going to notice if there are changes in the way that cat moves, and you might notice changes in weight, behavior and response to handling as well,” she says.

 condition scoring are key parts of the physical exam and client education. Dr. St. Denis has the World Small Animal Veterinary Association's charts on her exam room walls and gets clients to do the scoring with her during the exam.

If you're concerned about identifying painful DJD, you'll need to include an orthopedic exam to look for changes in the joints of both the appendicular and axillary skeleton, says Dr. St. Denis. “You're going to be looking for changes in muscle atrophy, restricted range of motion, crepitus, joint effusion and periarticular thickening,” she explains. “You'll also need to run your hands along the vertebrae to check for spinal pain.”

Radiographs can be frustrating because radiographically normal joints can be pathologically and clinically affected, and those that look affected can be pain-free, says Dr. St. Denis.

 Nevertheless, she notes that radiographs can be helpful in discerning which joints are affected and how severe they are. They can also aid in identifying surgical candidates. “But when you're doing this, don't forget to use pain medication, sedation and anesthesia because this hurts,” she urges. “To get a proper view of any of these joints, cats have to stretch and bend and hold still-all things they don't like.”

At this point, if the diagnostic puzzle pieces aren't fitting together but you still have a hunch the cat is experiencing musculoskeletal pain due to its age, you can also assess the cat's response to therapeutics.

According to Dr. St. Denis, the three main goals of treatment are to reduce pain and inflammation, improve joint function and mobility, and slow the disease process so the cat has a better quality of life for longer, and you have many modalities at your disposal, including nutrition, nutraceuticals, analgesia and environmental modifications.

“First and foremost,” says Dr. St. Denis, “if the cat is overweight, we definitely want to work at a controlled weight loss program because that will help with its overall demeanor, activity levels and how it's feeling. We know that fat cells release proinflammatory mediators, and we don't need to egg on inflammation.”

When selecting a therapeutic diet, you'll need to consider comorbidities, as Dr. St. Denis notes that cats like to have more than one medical problem at a time (e.g. kidney problems and diabetes). “If they're overall healthy senior cats, something like the Royal Canin Senior Consult is a good food because it has omega-3 fatty acids, green-lipped mussels and a number of other features in it that are helpful with joint health,” she says. Other recommended diets include Royal Canin Mobility Support and Hill's k/d + mobility.

While there are a lot of nutraceuticals available, cat-specific data on these products is lacking. However, Dr. St. Denis notes that data from canine studies can be extrapolated.

 is a protein concentrate from the milk of hyperimmunized cows. “It's been shown to reduce inflammation throughout the body,” says Dr. St. Denis. “It's ideal for long-term use, has minimal side effects and is suitable for high-risk animals like cats with chronic kidney disease (CKD).”

 Injectable chondroprotectants like polysulfated glycosaminoglycan (Adequan) and pentosan polysulfate sodium (Cartrophen) aren't licensed for use in cats, but Dr. St. Denis has seen improvements with their use in her practice. “I've had clients notice changes in their cat's mobility at home, and they'll notice when the interval is up between injections,” she explains. One perk of chondroprotectants is that you can teach your clients to administer the injections on their own.

On the topic of analgesia, Dr. St. Denis begins with some words of caution. “Many products available are not licensed for use in DJD in cats in the United States,” she explains. “Several of these products 

 licensed elsewhere in the world for this purpose but have not yet obtained FDA approval. You should be very aware of licensing restrictions on these products and utilize them carefully.”	

Multimodal: the name of the pain (relief) game

“Pain from affected tissues can travel to the spinal cord and brain via several pathways,” says Dr. St. Denis. “Many mechanisms are involved, including inflammatory, nociceptive, neuropathic and central hyperalgesia.” Hence the need for a multimodal approach.

When explaining this to clients, Dr. St. Denis turns to a transportation analogy. “I talk to them about the 401, which is a major highway that goes into Toronto,” she says. “It has six lanes in each direction. If you block one lane to the highway, you're going to slow traffic down a little bit. But what we want to do is block multiple lanes.”

 Some patients may need you to first address acute pain before you can get to the chronic problems, says Dr. St. Denis. “If I admit such a patient, I might start it on intravenous fluids with a ketamine constant rate infusion as an [N-methyl-D-aspartate (NMDA)] receptor blocker,” she explains. “I will probably start [nonsteroidal anti-inflammatory drugs (NSAIDs)], and I will definitely have it on a narcotic. Buprenorphine happens to be one of my favorite drugs, but I do use gabapentin as well.”

Dr. St. Denis uses the following dosages for feline patients with acute pain:	

Buprenorphine: 0.02-0.04 mg/kg intravenously or intramuscularly at the time of the appointment, or transmucosally 60 to 90 minutes before handling

Gabapentin: 10-20 mg/kg by mouth 60 to 90 minutes before handling.

Dr. St. Denis starts these cats at fairly high dosages (see sidebar)-dosages that also work if you're having the cat come in for an appointment. “If you have cats that are difficult,” she says, “gabapentin provides a sedation effect in addition to analgesia, and a lot of the cats that are difficult in your practice are actually painful, so you're addressing the root issue.”

 Long-term analgesia will be necessary for cats diagnosed with or presumed to have DJD-related pain, says Dr. St. Denis. While there are several options to choose from, she can help you strike two from the list: buprenorphine and tramadol. “Buprenorphine isn't practical or licensed for long-term use for cats with DJD,” she explains. “And clients have such a hard time administering tramadol to their cats due to its terrible taste that I don't really use it. Plus, it has significant side effects. For long-term use, we're better off considering analgesics that can be administered orally at home, have fewer side effects and are not scheduled drugs.”

, which acts in the dorsal horn of the spinal cord-inhibiting voltage-gated calcium channels-can be useful for both acute and chronic pain, says Dr. St. Denis. And while the drug is off-label for use in cats, she notes a 2018 study in which gabapentin was associated with improved owner-identified impaired activities in OA-affected cats.

Gabapentin can cause sedation and an altered or ataxic gait, though these effects wear off after two to four weeks of use. “I let clients know to call us if they become concerned by these side effects, because we'll help them dial the dose back and then we'll move it back up slowly,” says Dr. St. Denis. “We don't want clients abruptly discontinuing gabapentin, because the cat can have a higher level of pain in response.”

She starts with anywhere from 6-15 mg/kg. “It's very tailored to the patient,” Dr. St. Denis explains. “Cats with CKD or muscle wasting, we start low. A healthier, more robust cat may require higher dosages.”

like meloxicam are licensed restrictively in the United States, but Dr. St. Denis says they are still options. “We have a lot of great studies showing safety-that have looked at the effects of long-term dosing on renal function in aged cats-so we know they don't cause any huge problems,” she says.

 “Still, I'll have a conversation with the owner of a cat with [IRIS (International Renal Interest Society)] stage 3 kidney disease before putting it on an NSAID and say, ‘If we want this cat to be comfortable, it may not live as long but may have a better quality of life.' I talk to the client about the risks and rewards and let them make a decision about how they want to proceed.”

In January, robenacoxib (Onsior-Elanco) received new licensing in Canada for long-term use in cats with chronic musculoskeletal pain, so Dr. St. Denis is starting to use it more with her DJD patients. However, it's still licensed only for postoperative pain in the United States.

One last key component of Dr. St. Denis' multimodal approach to pain management involves considering the cat's environment. This includes keeping it active (e.g. food puzzles and playtime with the owner) and improving its access to resources (e.g. providing a low-walled litterbox on every floor of the cat's home and installing nightlights for cats with diminishing vision).

Feline DJD is more common than we think, says Dr. St. Denis. “The pain is real, but the nature of cats as a prey species means this pain is often silent,” she says. “Once we successfully identify DJD in our feline patients, utilization of a multimodal approach is the best option for success. And if you simply think it 

 be painful, assume it is because the cat's not going to tell you.”

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

1. Hardie EM, Roe SC, Martin FR. Radiographic evidence of degenerative joint disease in geriatric cats: 100 cases (1994-1997). 

2. Lascelles BD, Henry JB 3rd, Brown J, et al. Cross-sectional study of the prevalence of radiographic degenerative joint disease in domesticated cats. 

3. Bennett D, Zainal Ariffin SM, Johnston P. Osteoarthritis in the cat: how common is it and how easy to recognize? 

4. Vandeweerd JM, Coisnon C, Clegg P, et al. Systematic review of efficacy of nutraceuticals to alleviate clinical signs of osteoarthritis. 

5. Gingerich DA, Strobel JD. Use of client-specific outcome measures to assess treatment effects in geriatric, arthritic dogs: controlled clinical evaluation of a nutraceutical. 

6. Guedes AGP, Meadows JS, Pypendop BH, et al. Assessment of the effects of gabapentin on activity levels and owner-perceived mobility impairment and quality of life in osteoarthritic geriatric cats. 

7. Guillot M, Moreau M, Heit M, et al. Characterization of osteoarthritis in cats and meloxicam efficacy using objective chronic pain evaluation tools. 

8. Gowan RA, Lingard AE, Johnston L, et al. Retrospective case-control study of the effects of long-term dosing with meloxicam on renal function in aged cats with degenerative joint disease. 

9. Gowan RA, Baral RM, Lingard AE, et al. A retrospective analysis of the effects of meloxicam on the longevity of aged cats with and without overt chronic kidney disease. 

While sweeping generalizations may be a bad idea in other situations, feline expert Dr. Kelly St. Denis says its best to assume that all senior cats in your practice are suffering from the pain of DJD.

Joint disease in cats: Assume the worst and treat for the best

Cats have become an increasingly popular nonrodent model for studying type 2 diabetes mellitus (DM) in humans. Feline and human type 2 DM share several clinical and physiologic similarities: Both diseases tend to develop in middle age, are associated with obesity and insulin resistance, and influence loss of beta cells in the pancreas. Many of the underlying mechanisms of insulin resistance and DM progression, however, remain elusive.

In a recent study, researchers at the University of Copenhagen in Denmark explored a possible link between feline DM development and the microbiome.

Previous studies suggest that, compared with healthy individuals, human patients with type 2 DM have significantly altered gut bacterial populations. Specifically, diabetic patients have reduced populations of the intestinal bacteria responsible for producing butyrate, an important player in metabolic and immune function. A lack of butyrate may be a key component in the development of insulin resistance.

The investigators used genetic sequencing techniques to compare fecal microbial populations in healthy and diabetic cats. They recruited 82 client-owned cats for the study, including healthy cats and cats diagnosed with DM. All animals were at least 6 years of age, lived mostly indoors, and had not received any medications that could potentially alter intestinal bacterial populations, such as antibiotics, prebiotics or probiotics.

Cats were divided into one of three categories based on health status and weight:

Diabetic cats were diagnosed with DM either prior to or on the day of recruitment and had a median body condition score (BCS) of six (out of nine). Many were receiving insulin treatment to help manage their condition. Control cats with a BCS of four to five were categorized as healthy-lean, whereas those with a BCS of seven to nine were designated as healthy-overweight/obese. Disease-free status was confirmed in all control cats via patient history information, physical exam and complete blood count, biochemistry and urinalysis results.

Next-generation sequencing of bacterial 16s ribosomal RNA was performed to estimate bacterial populations in fecal samples from each cat. A subset of 10 diabetic, 11 lean and 13 overweight/obese cats was then placed on a high-protein/low-carbohydrate commercial diabetic diet for four weeks, after which fecal bacterial populations were re-examined.

Overall gut microbial diversity was reduced, and gut microbial communities were altered, in diabetic cats compared with lean healthy cats. These changes persisted after a four-week dietary intervention with a commercial diabetic food and also became more distinct for DM versus healthy overweight/obese cats. Throughout the study, healthy lean and overweight/obese cats maintained similar gut microbial communities, which suggested that disease and not body composition was primarily responsible for the microbial changes seen exclusively in the diabetic population.

When specific bacteria were examined, the researchers found that diabetic cats had significantly altered proportions of bacteria in the Prevotellaceae and Enterobacteriaceae families, as well as bacteria responsible for producing the short-chain fatty acid butyrate. 

Prevotellaceae bacteria were less abundant in diabetic than in healthy cats, and reduced populations correlated with increased serum fructosamine, a common marker used to diagnose DM and estimate long-term blood glucose concentration. Previous studies have shown that oral supplementation with 

bacteria can increase glucose tolerance in mice, which highlights this bacterial group's possible role in diabetes development.    

Also, serum fructosamine correlated positively with the presence of Enterobacteriaceae bacteria in the intestine. This finding agreed with previous studies in which obese rodents and humans with type 2 DM had increased populations of gram-negative bacteria (including 

) in the intestine. The Enterobacteriaceae are known contributors to low-grade inflammation, which is a precursor to insulin resistance.  

Finally, the study revealed a lack of butyrate-producing bacteria in the intestinal microbiome of diabetic cats. Previous studies have shown that butyrate increases insulin sensitivity and impairs inflammatory cytokine function. Therefore, reduced levels may promote inflammation and the development of DM.

Microbiome-related studies are becoming increasingly popular, and changes in gut microbial diversity are now linked to the development of several diseases in humans and companion animals. In this study, cats with DM demonstrated several alterations in intestinal bacterial populations, many of which parallel changes observed in humans with type 2 DM. These major changes were not observed in healthy obese cats, suggesting that factors other than body composition are instrumental in feline DM development.

While switching to a high-protein/low-carbohydrate diet is a frequent component of feline DM treatment, dietary change failed to normalize the intestinal bacteria of diabetic cats. For this reason, the authors stated that additional measures to support patient microbial populations (such as oral probiotics or fecal transplantation) may become important considerations for optimal management of feline DM in the future. 

Dr. Natalie Stilwell provides freelance medical writing and aquatic veterinary consulting services through her business, 

. In addition to her DVM, obtained from Auburn University, she holds a MS in fisheries and aquatic sciences and a PhD in veterinary medical sciences from the University

1. Kieler IN, Osto M, Hugentobler L, et al. 

Diabetic cats have decreased gut microbial diversity and a lack of butyrate producing bacteria

In a recent study, feline diabetic patients demonstrated similar changes in gut bacteria to those seen in human patients with type II diabetes mellitus.

Journal Scan: Feline diabetes and the gut microbiome

As a group, veterinarians are trained for quick and confident decision-making in surgery, with little room for error. Profession-wide, we also reside in a culture of shame-or at the very least, we usually don't welcome conversations about our surgical mistakes. Even if we were brave enough to discuss a mistake, it could result in malpractice litigation, loss of a job or damaged self-esteem. We live with the internal conflict of being taught about the uncertainty of surgical outcomes alongside the unacceptability of surgical error.

In veterinary medicine, debriefing or counseling at the individual level after a surgical or medical error is not part of our wider culture. Instead, we hide, try to put on a brave face and try to survive day-to-day, gritting our teeth through adrenal-squeezing surgeries … or just drop out of the profession altogether.

When it comes to surgical errors, there is the obvious victim-the patient-but there is also a second victim, and that is the surgeon. The term “second victim” was coined by Albert Wu, MD, MPH, professor of health policy and management at the Johns Hopkins School of Public Health, in his description of the impact of errors on medical professionals. Bottom line: In situations of medical or surgical error, the veterinarian who makes the mistake needs help too.

If the concept of helping veterinarians deal with trauma from a surgery gone wrong had existed when I first entered the workforce, then my career (and mental and emotional health) may have looked very different.

Six months out of school I experienced my first surgical trauma while performing a spay on an in-heat, overweight, adult large-breed dog by myself. During surgery I panicked and almost passed out from fear. The dog survived and I got through, but the seed of trauma was planted.

Over the next couple of years, I unknowingly watered that seed by performing more terrifying surgeries without support. I began to experience fear when I was scrubbing, or when I was opening a surgical pack. That morphed into chronic anxiety, and I would feel afraid while I was driving to work, not sure what surgeries were lined up for me.

Pretty soon, by Friday afternoon I was already dreading going back to work on Monday. I was miserable and didn't know who to talk to. I tried talk therapy, alcoholism, praying, berating myself, and so on. Nothing worked.

 by Sara C. White, DVM. In it, she lays out the four ingredients that are necessary to cope after surgical trauma: technical learning, perspective, emotional learning and support. Whether you engage in those things or not predicts whether you will survive, thrive or stop performing future surgeries altogether.

It made a lot of sense. She demonstrated how veterinarians tended to do better if they sought support from colleagues, learned from their mistake, and maintained the proper perspective that no one is perfect (that's why it's called practice!).

The thing that stood out to me the most was the concept of emotional learning. I realized all the “strategies” I was using were actually making things worse. It wasn't that I was a bad veterinarian, it was that I lacked the tools and awareness needed to change patterns that had been established by trauma.

Are you ready for the secret? In essence, desensitizing and counter-conditioning a dog to overcome fear isn't much different than doing the same for a human. We just tend to be much nicer to fearful dogs than to ourselves.

The steps I learned to rewire my traumatized brain into something healthier went like this.

1. Identify the physiological and thought patterns that occur when you are anxious about surgery, and write them down

What happens in your mind and body when you get triggered by something that scared you in surgery? For me, my heart would start racing, I would feel nauseated, my hands would shake, I would get really snappy, I would breathe more shallowly, etc. Thoughts like, “I hate surgery!” or “I am not a good surgeon!” would swirl, and I would obsessively mull over my surgery schedule all morning.

Imagine, instead of watching a dog for signs of fear, you are watching yourself. Identifying and knowing what happens when you get triggered will help you understand your own fear biology.

2. Identify your triggers, and write them down

	Once you have identified your physiological and emotional signs of fear and anxiety, it is time to identify the cues in your environment that are causing your sympathetic system to go haywire. Is it when something goes wrong in surgery? Is it when you are scrubbing? Is it the night before? Knowing your triggers will help you understand when your amygdala has been thrown into fight, flight, or freeze.

	If you have been scared by surgery, then you need to work beneath your fear threshold. Yes, I know that presents certain challenges, but if you don't, you may never heal. Start small with procedures that don't scare you-mass removals, dental extractions, neuters. Maybe it is just being in the surgery room without panicking. Enlist a calm companion. If you do well and don't get triggered (remember your signs!) then move onto something bigger. If you get triggered, step it back to something smaller, and 

. It's just like slowly moving the reactive dog closer to a bike while working beneath that dog's reactivity threshold. Write down three surgical baby steps you can take in your journal.

If you take your baby steps successfully, then reward yourself! It doesn't have to be something big. It can be a movie night, or a Starbucks drink, or a walk by yourself after work. Just like you give the dog treats for not losing it over a bike, you need to give yourself treats to create new neural pathways. Write down three rewards that you will give yourself next to your baby steps and then be consistent in doling out those rewards.

This might sound weird, but beating yourself up after a surgical mistake actually makes the whole situation worse, and reinforces the trauma patterns in your brain. You have been through something hard; be patient with yourself and develop a habit of positive self-talk that will buoy you through difficult procedures.

Did you know you can actually calm your nervous system down with the power of breathwork? It's true! If you find yourself ramping up in fear, try utilizing 

. Both techniques shut down the sympathetic system and activate the parasympathetic system, something you will need if you are going to keep your head in surgery.

7. Utilize pharmacology and experts when needed

Just like in dogs, sometimes you need a little something extra to raise the reactivity threshold. Don't be ashamed to talk to a therapist and ask for pharmacological assistance if you need it. I went through 20 sessions of neurofeedback and talk therapy. It's not a sign of weakness, it is a sign of strength, awareness and much needed self-love to seek help when you need it.

Remember, the second victim is real. Don't minimize or negate the presence of trauma and fear in vet practice-arm yourself to do something to change the outcome. And remember you can always, always, ask for help.

Dr. Sarah Wooten graduated from UC Davis School of Veterinary Medicine in 2002. A member of the American Society of Veterinary Journalists, Dr. Wooten divides her professional time between small animal practice in Greeley, Colorado, public speaking on associate issues, leadership, and client communication, and writing. She enjoys camping with her family, skiing, SCUBA, and participating in triathlons.

In veterinary medicine, there exists a culture of shame surrounding surgical error. Here, one DVM shares her experience with mental and emotional trauma during surgery and offers 7 steps to help veterinarians rewire their brains after a traumatic event in practice.  



Advice for veterinarians: Surgical trauma and the second victim

Ms. Bertrand sat quietly on the chair in the exam room. Her aging poodle, Birdie, was perched on her lap. I could smell the dog's mouth the second I opened the door. There's just no mistaking the odor of putrid teeth tangled with hair and pus. Birdie was in for her “annual” checkup (the last one was about five years earlier).

I asked all the usual questions: “How's Birdie doing?” 

I checked her chart-no change in weight since the last visit. By all accounts, Birdie was happy and healthy (excusing, of course, the cesspool that was her mouth). I lifted Birdie's lips and pointed out the dental disease to Ms. Bertrand. I painstakingly explained all the risks associated with the condition. I did all the things. I made all the recommendations.

I'd love to say that Ms. Bertrand consented to everything and that we got Birdie scheduled for a full dental with all the bells and whistles. I wish I could say that we immediately drew blood for her preop labs, ran the ECG, filled the antibiotic prescription and got the signed estimate for the dental radiographs, nerve blocks, cleaning, polishing and extractions. Yes, that would have been ideal.

When I lifted the lip on Birdie's mouth, Ms. Bertrand was legitimately shocked. She had lived with the dog for 14 years, and at home Birdie was as energetic as ever. She never missed a meal (which mostly consisted of cheap canned dog food and an occasional scrambled egg). She barked at the mailman every day like clockwork. She still got excited when she saw the leash, and she chased the backyard squirrel up the tree every chance she got. In Ms. Bertrand's eyes, there was nothing wrong with Birdie.

When I explained all the hidden health risks of ignoring the dental disease, she nodded politely and said she understood, but she only had $40 left from her social security check each month, and that's why it had taken her so long to get Birdie in to begin with. In another three months, she 

 be able to afford a basic cleaning and a few extractions, but no more.

So now what? What do I do with Birdie's wretched mouth?

 Do I ignore it and send the two of them out the door because there's no way she can afford the “standard of care” for veterinary dentistry? Do I turn my back on the ticking time bomb in Birdie's mouth and cross my fingers that she's not back in my exam room six months from now with complications?

Option No. 2: Treat to the gold standard.

 Do I move forward with all the recommended procedures, use all my expensive equipment and generate a $1,000 bill-knowing full well Ms. Bertrand will never be able to pay that? Spacing the procedure or charges out over several months would still generate the same overall expenses. We charge 18% annual percentage yield on unpaid balances (similar to many other alternative payment options). At $40 per month, it will take her three to four years to pay that off. Let's be real: Birdie and Ms. Bertrand may 

be gone by then. If she does attempt payments and defaults, will I need to make the (poor) business decision to write it off? Or worse, send an elderly woman living on social security to collections? All these scenarios seem likely to end in a social media firestorm where I'm accused of being a greedy, profit-driven, heartless veterinarian.

 Do I instead perform the dental procedure taught to me by my mentors in rural mixed practice? The kind where I check basic blood parameters and use my stethoscope, eyes and ears for anesthesia monitoring? Where I remove the teeth that are visibly rotting and falling out, using fingers and elevators to make an educated guess about the viability of tooth roots? Where I employ only minimal force for extractions, then clean, polish and send the dog home on antibiotics, anti-inflammatories and education about at-home care? Do I perform a dental Ms. Bertrand can afford (and will need several months to pay), knowing that if I do, I risk being accused of malpractice by my colleagues? And if I post about it in an online veterinary group, will I be vilified for performing basic techniques?

I ponder my choices and ultimately choose the one that gets Birdie's mouth cleaned up the fastest: option 3, where I do everything I can while trying to respect Ms. Bertrand's budget. I explain all the risks and outcomes and do what I can to get Birdie home barking at the mailman as quickly as possible.

I refuse to use the ‘noncompliant' label

 judge Ms. Bertrand for declining procedures and products she can't afford. I 

 condemn her or label her noncompliant. I 

 disrespect her because she's not able to spend the equivalent of more than a year's worth of Birdie's food for a top-of-the-line dental procedure.

 bring up the visit at the next dental CE I attend-and I won't lose any sleep over that. I'll sit politely in the middle of the room and doodle in my notepad as it's implied that I'm being cruel to dogs like Birdie and will likely get sued by people like Ms. Bertrand.

The reality is that my practice is full of Birdies and Ms. Bertrands, and I'm a better veterinarian because of it. Clients and cases like these continually push me to trust my instincts to be an excellent communicator. They teach me just how far $200 can stretch diagnostically. They're the reason I have my 

 books memorized. I have them to thank for sharpening my common “sense-ability.”

All that said, they're also the reason I have a love/hate relationship with this common oral health procedure and all the conversation and marketing that goes with it in our profession.

Dr. Melissa Detweiler is an associate veterinarian at Bern-Sabetha Veterinary Clinic in Sebetha, Kansas. In her free time, she enjoys reading, being out in the yard during the warm months, running, fishing, following K-State sports and, above all, spending time with her husband, children and their Rottweiler mix, Lucy.

When a pet owner can't afford the highest standard of veterinary dental care, what choices do we have left?

Why the 'dental' divides our profession

USP 800 may sound like an overly ambitious sunscreen-or a cool new jet airliner-jokes Vicki Pollard, CVT, AIA, on site at the HospitalDesign360 conference in Kansas City. It's a regulation created by the United States Pharmacopia, and it's 

 important to the veterinary industry, because it deals with compounding of hazardous drugs specifically in veterinary facilities.

This new rule involves the safety of your veterinary team as well as your patients, Pollard says.

“If compounded drugs are contaminated in that process, from a biologic standpoint they can harm your patients, but if they're not handled properly, they can be dangerous for your team,” she says.

USP 800 was created to keep everyone safer in the veterinary environment. It involves facility changes, like adding additional rooms, but it also involves a change in operations and how you deal with drugs in your facility, Pollard says.

Want to know the specifics? Watch the video below.

USP 800 is very important in how your faculty handles compounded drugs, says veterinary architect Vicki Pollard, CVT, AIA, at HospitalDesign360 conference.

Vetted November 2019