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Thursday, April 2, 2020
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Ergonomics in veterinary medicine

Ergonomics, the science and study of work, can teach us how to apply this information to optimize human well-being and overall work system performance.

Ergonomics is about more than good posture and nifty gadgets. It is the science and study of work, and the practice of applying data and theory to optimize human well-being and overall work system performance. The aim of ergonomics is to study and improve the “fit” between people, their jobs and their environments in order to improve performance, wellness, safety and health. Ergonomics includes physical, mental (cognitive and emotional), and organizational factors, as well as the way these factors interact within the work system. Ergonomics is as important for those in the veterinary field as in other areas of work — perhaps even more important, in some cases.

Musculoskeletal discomfort in veterinarians – the pain of practice

Musculoskeletal discomfort (MSD) and injury are common problems for those in veterinary practice. Over a five-year period, 27% of the cost of AVMA-PLIT veterinary worker compensation claims were due to “ergonomic injuries”.1 Depending on the studies, between 80% and 99% of veterinarians have experienced MSD in the past year, most commonly in the lower back, neck and shoulders. 2,3

While physical strain is an obvious culprit, it is important to remember that pain is not entirely due to biomechanical factors. It may be influenced by psychosocial factors, such as workload and lack of social or managerial support, and individual influences such as life stress, coping skills, and beliefs about and fear of pain. Low job satisfaction and high work stress are important risk factors for MSD in veterinarians. Long days and lack of breaks have been associated with this stress, and MSD has also been statistically correlated with a range of additional psychosocial factors, including stress associated with career structure, time pressures, client attitudes, lack of recognition by the public or by colleagues, lack of understanding from family or partners, and insufficient holidays.2

Physical ergonomics in veterinary medicine

Physical ergonomic risk factors in veterinary medicine include repetitive movements, forceful exertion, lifting, awkward postures, prolonged static loads, vibration or a combination of these. Some of the procedures associated with pain in veterinarians include rectal palpation, dentistry (equine and small animal), surgery, ultrasound examinations, and large animal obstetrics.2

Controlling risk

While some hazards are inevitable in any work situation, there are ways to reduce physical risk by approaching the hazard via a risk control hierarchy (Figure 1). Not all problems will be amenable to all these controls; for example, you can’t completely eliminate the risk of injury from animals in an animal care setting. But the higher up the hierarchy you can work (eliminating the hazard or substituting a less hazardous alternative), the better protected you and your staff will be. Relying on the bottom two controls (rules and protective gear) will not give you a robust safety environment. Different ergonomic hazards may generate different solutions from different places on the hierarchy. In many cases, the staff involved with the task in question will be the ones who can devise the most usable solutions to the problem. This type of participatory ergonomics is capable of producing creative solutions as well as offering employees a sense of engagement in the process.4 Ultimately, this sense of engagement can be key to the staff adopting and using new equipment, protocols and procedures. Finally, thinking about ergonomics doesn’t have to be expensive; many solutions are already available, or may require changes in scheduling and flow rather than the purchase of expensive equipment. Furthermore, solutions that are safer for veterinarians and staff can also be less stressful for people and patients alike (e.g., calm, safe animal handling).

Specific veterinary activities: hazards and solutions

Veterinary practice varies a lot, so it’s not possible to describe the ergonomic hazards of every type of veterinary work. However, here are a few examples of how to minimize risks in certain practice areas.

1. Equine practice can be dangerous: during a 30-year career, equine practitioners can expect seven to eight work-related injuries severe enough to impede practice.5 Equine veterinarians describe dental procedures, obstetrical procedures, and the diagnosis and treatment of lameness as causing the most strain.6

Lameness exams, as well as other procedures performed on the distal limbs of horses, may require extreme postures, the application of force, and repetitive movements, and are thus overall the most ergonomically risky tasks performed by equine veterinarians. Wrist postures travel through extremes of flexion, extension and ulnar deviation during lameness exams. The risks involved in doing distal limb procedures are difficult to eliminate, but can be mitigated by postural awareness, adequate training for support staff, expertise and experience in the practitioner, practice organization (such as rotating duties among vets in the practice), educating horse and owner, and refusing to handle dangerous animals.

2. Equine dentistry is also considered by veterinarians to be very demanding for the arms, shoulders, back and neck. Motorized floats, adjustable equine head support, the use of trained staff to assist, and sedation of the horse may all help mitigate these demands. In multi-veterinarian practices, dividing the work equally among doctors may help reduce the risks from repetitive movements.

3. Small animal surgery has been associated with MSD in multiple studies. In fact, small animal veterinarians perceive surgery as second only to lifting when it comes to the development of MSD.7 A study of spay/neuter vets reported a 99% one-month period prevalence of MSD, with greater discomfort in those surgeons who spend more hours in surgery each week, and in those who work in spay/neuter for a greater number of years.3 Surgeons may reduce their fatigue and discomfort by sitting for surgery, or alternating between sitting and standing. For those who stand, the table should be adjusted to a comfortable height for each surgery. When working on deep-bodied patients, using a saddle chair or sit/stand stool may allow the surgeon to sit close to the table without interference between the table and the his/her knees.

Being able to change position during an operation, or between successive short operations, is associated with decreased fatigue and reduced pain after surgery. “Micropauses” of 15 to 30 seconds taken multiple times per hour reduce discomfort and fatigue and increase accuracy, especially if combined with active stretching or exercises that release the neck and shoulder tension inherent in surgical posture.

The use of efficient and gentle surgical techniques and appropriately maintained instruments can help minimize the forces required during surgery, thus mitigating the risk of high repetition. Further, it is possible to change grasp or technique to avoid awkward or tiring hand positions — e.g. changing between palm and tripod grasp when holding needle holders, or performing closures without the use of thumb forceps in order to avoid the pinch grip used with these devices.

Using a risk control hierarchy

As an example of using a risk control hierarchy, let’s look at a common task in veterinary practice — the lifting and carrying of animals or supplies. The first step is to identify whether there is even a problem with the lifting in your practice by knowing safe lifting limits. However, how much it is safe to lift depends on:

  • Weight of load
  • How many times a day do you lift the load?
  • Distance of your hands from your lower back (closer = better)
  • Height of lift (from floor or from above knee height? How high do you need to lift?)
  • Twisting and side bending
  • Working in a restricted space
  • Good grip versus an irregular, bulky, floppy, unpredictable load
  • Flooring condition (dry, clean, good condition, or wet or uneven)
  • Communication and coordination when lifting as a team.

While many of these factors may seem hard to modify, there are some ways to mitigate them:

  • Weight of load (patients): You can’t change the size of an individual patient, but you could restrict your patient population (for example, become a feline practitioner), if that fits with your mission and community needs.
  • Weight of load (other stuff): Break down large supply packages into manageable armloads. Use two people to lift large heavy objects. Use equipment (rolling cart, dolly) to help lift and move large heavy objects.
  • Distance of your hands from your lower back: The further the object from your center of gravity, the less weight you can lift and carry (or the more strain you will feel from a given lift), so carry as close to your body as you can. A wide stance while lifting from the floor can help you bring the weight as close as possible to the center of your body.
  • Height of lift (patients): Can you lift the standing dog, rather than the down, anesthetized dog? Can you lower the table you’re lifting him onto?
  • Height of lift (other stuff): Store only lightweight items on high shelves. Heavy items that need to be lifted and carried (i.e. cases of wet food or trays of instrument packs) should be near waist level.
  • Avoiding twisting and side bending
  • Working in a less restricted/obstructed space: Remove unnecessary obstructions from your workspace and storage space.
  • Grip on load (patients): Turn a floppy unpredictable load with no handles into a firm balanced load with well-distributed handles (or even wheels!) by using a stretcher. Some clinics recover large dogs on a rolling stretcher so you don’t even have to move the dog from floor to stretcher. Use a rolling lift table to transport patients through the clinic.

In this example, progressing down the hierarchy from top to bottom, we were able to substitute the risk by limiting the patient population to smaller patients (or, you could say we eliminated the risk of lifting dogs). We used several engineering controls: stretchers, lift tables, carts and dollies; we eliminated obstacles in the way of the lift; and ensured suitable flooring conditions. These engineering controls go along with or require several administrative controls, such as rules about when staff must use lifting devices, about storage locations, and about clean dry floors.

General advice in ergonomics

Whether you are doing surgery, palpating cows, or entering data, consider the following:

  • Beware of repetitive manual tasks. These tasks may require a combination of repetitive movements that can at times require force, or may be performed with awkward positioning of the hands and wrists. Such tasks can include surgery, dental work, drawing up and administering injections, using computers and tablets, and clipping and prepping patients for surgery. Alone, each of these factors (repetition, force, posture) is only moderately associated with pain in the hand and wrist, but when combined, their association with hand/wrist pain is strong.8 By reducing any one of these three factors, you can reduce the risk of hand and wrist pain. If repetition is required in the job, consider reducing force by using lighter tools or instruments, or find tools or techniques that allow for less awkward positioning.
  • Avoid awkward or tiring positions. In the majority of cases, awkward postures with extreme flexion, extension, or ulnar or radial deviation are not necessary video or take photographs during the task in order to evaluate hand and body motions and postures, and to ensure that inefficient techniques are not leading to awkward positions. Many mobile phones have the capability of recording video, and may be mounted and secured in a nearby location to allow recording of the procedure. Alternatively, a second person may be able to record video while the veterinarian works. After viewing video and noting desired changes, veterinarians may be able to rely on self-monitoring to avoid prolonged static awkward positions.
  • Be aware of common strains. Watch out for postures and manual strains that are common to multiple activities. The degree of neck flexion while using a laptop computer or mobile device is similar to that in surgery; too much time spent in one activity may compound the strain caused by the other. Similarly, using your thumbs on computer trackpads or for texting may exacerbate thumb pain from surgery. Fortunately, these secondary strains can often be reduced by changing our use of technology. A quick text or a short time on a laptop is fine, but for lengthier interactions with technology, consider an external mouse and keyboard to keep neck, wrist and thumb positions as neutral and strain-free as possible.
  • Take micropauses. Studies on office workers9 and human surgeons10 have shown that “micropauses” of 20 seconds every 20 minutes can reduce discomfort and fatigue, and even increase accuracy. Take 20 seconds to stretch, stand up, shake out, move around. It doesn’t matter so much what specific movements you do, only that you take that time to release the muscles you are holding. The benefits may be related more to the neurological “reset” than the actual musculoskeletal results of the stretch.
  • Train your body. To some extent, human bodies can adapt to musculoskeletal strains, given adequate time for rest, recover and adaptation. Ligaments will increase in strength, size and collagen content with use,11 so that veterinarians performing tasks they’re accustomed to may have greater resilience than the new recruit. Performing repeated unaccustomed movements with the hands can be a risk factor for hand and wrist disorders, so it may be valuable to begin new hires with a lighter repetitive task schedule, and then work up to a full schedule once their bodies have become conditioned to the work.

References

1 AVMA-PLIT, Preventing Back Injuries. Safety Bulletin, 2015. 23(2).

² Scuffham AM, et al. “Prevalence and risk factors associated with musculoskeletal discomfort in New Zealand veterinarians”. Applied ergonomics, 2010. 41(3): p. 444-53.

³ White S. “Prevalence and Risk Factors Associated with Musculoskeletal Discomfort in Spay and Neuter Veterinarians”. Animals, 2013. 3(1): p. 85-108.

⁴ Hignett S, Wilson JR, Morris W. “Finding ergonomic solutions–participatory approaches”. Occupational medicine, 2005. 55(3): p. 200-7.

⁵BEVA. “Survey reveals high risk of injury to equine vets”. Veterinary Record, 2014. 175(11): p. 263.

⁶ Loomans J, et al. “Occupational disability and job satisfaction in the equine veterinary profession: How sustainable is this ‘tough job’ in a changing world?” Equine Veterinary Education, 2008. 20(11): p. 597-607.

⁷ Scuffham AM, et al. “Tasks considered by veterinarians to cause them musculoskeletal discomfort, and suggested solutions”. New Zealand Veterinary Journal, 2010. 58(1): p. 37-44.

⁸ Bernard BP, ed. “Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work-related disorders of the neck, upper extremities, and low back”. 1997, National Institute for Occupational Safety and Health, U. S. Department of Health and Human Services: Cincinnati, OH.

⁹ Barredo RDV, Mahon K. “The effects of exercise and rest breaks on musculoskeletal discomfort during computer tasks: an evidence-based perspective.” Journal of Physical Therapy Science, 2007. 19(2): p. 151.

10 Dorion D, Darveau S. “Do Micropauses Prevent Surgeon’s Fatigue and Loss of Accuracy Associated With Prolonged Surgery? An Experimental Prospective Study”. Annals of Surgery, 2013. 257(2): p. 256-259.

11 Solomonow M. “Ligaments: a source of musculoskeletal disorders”. Journal of bodywork and movement therapies, 2009. 13(2): p. 136-154

Reducing cancer recurrence in canine patients

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New research to understand the benefits of surgery and the recurrence of tumors in canine cancer patients after surgical removal.

The relative risk of a cancer recurrence is reduced by 60% in dogs whose tumors are completely removed, according to a recent analysis by Oregon State University researchers. “You want to get all the tumor out if you can,” says Milan Milovancev, an associate professor of small animal surgery in the Carlson College of Veterinary Medicine and lead author of the study. “That’s what most veterinarians, including myself, have thought, but this makes it more official. Now we can say, here’s the data.”

The study reviewed 486 research articles, ultimately focusing on ten studies that met a set of criteria for inclusion in the analysis. Those studies represented 278 dogs surgically treated for cases of soft tissue sarcoma. The researchers found a recurrence of less than 10% in dogs where the soft tissue sarcoma was completely excised, versus 33% recurrence in cases where the cancer was incompletely excised, meaning there was microscopic evidence that tumor cells remained after surgery.

Having a better understanding of the benefits of complete removal of cancerous tumors can help veterinary surgeons better prepare for surgery.

oregonstate.edu/news/complete-removal-tumor-reduces-risk-recurrence-cancer-dogs-analysis-shows

CBD pet supplements — know the law and prioritize quality

Before recommending CBD pet supplements to your clients, take the time to learn the laws and determine which suppliers you can trust.

Cannabidiol (CBD) is the hottest topic in pet health, and many animal parents are eager to understand its potential to help their dogs and cats. Chances are, you’re asked about CBD at least a few times a month – and this is good, because you want your clients asking you for information rather than consulting “Dr. Google”. But be sure to consider your risk for exposure when recommending or prescribing animal health supplements containing CBD.

If you are a veterinarian who views CBD as a beneficial option for animals, you should feel comfortable talking with your clients about it. Just ensure you know your state’s laws around whether this must be a discussion only, or whether you can recommend and dispense CBD products. Federally, CBD derived from hemp with less than 0.3% tetrahydrocannabinol (THC) was declassified as a Schedule I controlled substance under the 2018 Farm Bill. Unfortunately, many state laws vary, as do the positions of the AVMA and state veterinary medical boards. Congress has publicly stated it encourages enforcement discretion for CBD animal products pending definitive guidance from FDA and its Center for Veterinary Medicine.

Even if you practice in a state that allows veterinarians to recommend CBD, have a protocol in place for documenting that you’ve discussed and/or dispensed a CBD product. Good record-keeping is essential and informed consent should also be documented.

When considering CBD products to recommend, remember that product labels only tell part of the story. Scrutinize company marketing materials, including their websites. If they are making direct or implied claims suggesting the product will treat, prevent, mitigate or cure any disease in any of their materials, including product names, they are breaking the law and misleading consumers.

Don’t be afraid to pick up the phone and call the company to request studies that back up their product claims, and lab test results that confirm the product’s THC content is less than 0.3%. Also ask for proof that the CBD content meets label claims, and that the products are tested for microbial contaminants, heavy metals and pesticides.

The NASC Quality Seal is an excellent way to identify a product from a responsible supplier. To earn permission to display the Quality Seal on their products, a supplier must pass a comprehensive facility audit every two years, maintain ongoing compliance with rigorous NASC quality requirements, and pass random independent product testing to ensure products meet label claim.

For more information

The FDA held a public hearing in May 2019 and opened a public docket (FDA-2019-N-1482) to obtain scientific data and information about the safety, manufacturing, product quality, marketing, labeling and sale of products containing cannabis and cannabis-derived compounds. Below are links to testimony and information from the hearing:

Pros and cons of bandaging horse wounds

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When should a vet bandage wounds? A new equine-based study aims to create a more research-based standard for when bandaging horse wounds should be done.

Should horse wounds be bandaged or not? A new study aims to create a more research-based standard for when bandages should be used.

“We’ve been able to complete a descriptive study, showing what’s going on in these wounds during healing,” says veterinarian Dr. Marcio Costa, one of the researchers. Dr. Costa and his colleagues evaluated wounds in four horses, with and without bandaging. The bandaged wounds developed proud flesh and consequently took about a week longer to heal than those that were unbandaged. However, the bandaged wounds had less contamination from environmental bacteria.

The difference in healing times between limb and body wounds was also assessed. The physiological differences between wounds in these locations result in different healing times (limb wounds take longer to heal). The team hopes to use these findings to further explore best wound management practices. ncbi.nlm.nih.gov/pmc/articles/PMC6261015/

CBD for cats and dogs

A look at endocannabinoid support and the tricky therapeutic and regulatory landscape of using CBD for pets.

The cannabidiol (CBD) craze is in full swing all over North America. Recently, it was announced that even gas stations will be selling it, not to mention supermarkets, coffee
shops and health food stores. Big money is being invested in cannabis worldwide, and as with any trade bubble, there are plenty of players trying to get in, get rich, and get out before the bubble bursts — unfortunately, this “get rich quick” scheme has produced a plethora of unreliable products. Even companies specializing in human CBD products are jumping on the bandwagon and offering pet lines as an “extra” — despite lacking knowledge of veterinary applications, dosing or protocols.

But let’s not throw out the baby with the bathwater! This mania would not exist if utilizing CBD didn’t result in remarkable benefits. While most people are familiar with the marijuana plant’s “high” effects, mediated by tetrahydrocannabinol (THC), Cannabis sativa contains
hundreds of compounds, most of which, like CBD, are not psychoactive, and have untapped therapeutic potential. The native cannabis plant has abundant CBD and a small amount of THC; however, high THC strains have been bred for recreational use.

Is CBD legal, and what about my DEA license?

Unfortunately, this is highly variable state by state. To make things even more confusing, while federal law has declared industrial hemp (less than 0.3% CBD) to be lawful, cannabis has not yet been removed from the list of Schedule One drugs, leaving a lot of room for interpretation.

In some states, like California, even though both medical and recreational marijuana products are legal, veterinarians are not allowed to discuss the medical use of cannabinoids with clients. However, all these laws are rapidly changing and adapting to the hemp industry’s exponential growth over the past 18 months. If you don’t like the regulations in your state, wait ten minutes!

Unfortunately, the legal gray area is preventing vets from giving their clients the expertise they need, which leads animal owners to rely on Dr. Google.

How do phytocannabinoids work?

The endocannabinoid system (ECS) helps the nervous system and immune system communicate. The ECS is suspected to be involved in neuroprotection, immunomodulation, the fighting of cancer, pain reduction, metabolic balance and gastrointestinal motility, with effects in and around the synaptic space.1 Phytocannabinoids (cannabinoids derived from hemp and other cannabis species) can act as partial agonists of the ECS, providing pain relief through coactivation with endogenous opioid receptors. They can also reduce excessive inflammatory responses involved in chronic diseases and aging. THC primarily interacts with the CB1 receptors on nerve endings, which function to regulate neurotransmitter turnover. CBD, on the other hand, has indirect effects throughout the body via CB2 receptors, which have widespread distribution in immune cells, muscles, joints, and organs.

Can my dog or cat get high from CBD?

CBD is not a psychoactive drug. However, in a quirk of physiology, dogs have an unusually high number of CB1 receptors in their cerebellum, making them highly susceptible to THC effects — a big health risk for dogs that accidentally ingest their human’s medical or recreational marijuana “edibles” or bud. While THC is not toxic to dogs, subsequent severe ataxia and dissociation make them susceptible to secondary dangers, such as falling or aspiration pneumonia.

Pharmacokinetics of cannabinoids

Preliminary data in dogs indicates that optimal therapeutic levels are most rapidly reached through trans-mucosal 2 dosing, which avoids interaction with the liver CYP450 detoxification system. However, cannabinoids may compete for CYP450 binding sites, possibly altering or affecting drug clearance time for other medications. This list3 of affected drugs includes, but is not limited to, certain anti-seizure medications and several classes of antibiotics and cytotoxic chemotherapy drugs, so it is critically important for people to seek the advice of their human or pet health professional before using these substances on themselves or their animals. Anecdotally, dosing with cannabinoids has not been found to alter phenobarbital serum levels (G. Richter, DVM, personal communication).

Purified cannabinoids have a bell-shaped dose-efficacy curve; clinical effects increase then fall off with doses exceeding the peak efficacy for that individual. For this reason, some trial and adaptation is advisable when adding CBD to a treatment plan, because dosage may increase or decrease. Occasionally, pets receiving micro-doses of CBD for anxiety may become disinhibited — forgetting about their house-training or failing to control their aggressive instincts. This usually resolves with a further reduction of the dose. Best results are achieved when checking the dosage after three to five days for effects. Desired CBD effects, whether for pain mitigation or soothing the nervous system, should be visible within a day or two, unlike many therapeutic regimens which take weeks to load.

Indications for use of exogenous cannabinoids in animals

There are many useful applications for CBD, the non-psychoactive cannabinoid. (THC is mainly used, where legal, for cancer and end-of-life care. CBD is used for reducing anxiety and phobias, treating arthritis pain and inflammation 4 as well as neurogenic pain, mitigating idiopathic and non-drug-responsive seizure activity,5 and regulating diabetes.6 While cannabinoid research is in its infancy in the US, researchers worldwide have speculated that some neurodegenerative conditions, such as Parkinson’s disease in humans and degenerative myelopathy7 in dogs, may have their etiology in dysregulated function of the endocannabinoid system (ECS). For clinicians who have incorporated CBD into their treatment plans, it is proving to be a useful adjunct in managing many common pet ailments, especially in geriatric pets (see CBD case studies at IVCJournal.com/CBD-case-studies).

Though each individual animal’s response may vary, four levels of CBD dosing are generally used in pets:

Dose (per kg body weight) indications

  • Micro (0.1 mg/kg) — anxiety, fear, stress, behavioral issues, mild pain, muscle tension
  • Medium (0.2-0.5 mg/kg) — osteoarthritis, moderate pain, muscle spasms
  • High (0.5-1.0 mg/kg) — moderate to severe pain, neurogenic pain, degenerative myelopathy, tremors, idiopathic epilepsy, diabetes regulation, IBD
  • Ultra (1.0-5.0 mg/kg) — refractory epilepsy, anti-neoplastic, refractory pain, hospice care

In a recent study at Colorado State University College of Veterinary Medicine,8 high dose CBD treatment was associated with mild transitory diarrhea upon initiation of treatment. After long-term high-dose usage, one third of dogs showed elevated alkaline phosphatase. However, this study lacked a control group to compare environmental and stress effects with the CBD-associated effects. It is also essential to note that these results were found at doses of 10 mg/kg to 20 mg/kg, compared with the dose range of 0.1 mg/kg to 1 mg/kg, administered trans-mucosally, recommended by veterinarians with extensive experience in CBD’s clinical applications in pets. (R. Silver, Cornell NYSVMS seminar, 2018; G. Richter, CIVT webinar, 2019).

A study conducted at Cornell University 4 showed similar elevations of alkaline phosphatase, but also involved dosing at 2 mg/kg to 8 mg/kg orally, rather than the lower doses using trans-mucosal delivery. Neither study showed evidence of hepatocellular damage, so it is difficult to interpret the meaning of the changes mentioned above. It is likely that lower dosing though an appropriate delivery method would prevent them. Preliminary research trials in horses suggest that pain and anxiety reduction can be achieved with as little as 20 mg to 25 mg CBD oil administered trans-mucosally, once or twice a day 9.

Not impressed with CBD results?

Take a closer look at the product quality, administration method and dose amount. Like any therapeutic intervention, details matter!

  1. Is the product you are using reliable? Look for third party lab testing, easy administration, high potency, and companies that stand by their products with a full guarantee. Many new players in the industry are ignorant of cultivars and are putting out inferior products that are poorly extracted with unreliable concentrations. Don’t get fooled by pretty labels and great marketing! Full spectrum CBD oil should have a light herbal bouquet and should not taste like licking a lawnmower, full of grass and solvents.
  2. Is the method of administration correct? It has long been known that oral ingestion of cannabinoids is non-optimal, with estimates that 80% to 90% of CBD/THC is broken down in first pass liver metabolism by the cytochrome P450 system. So avoid any products that have an oral delivery: e.g. treats, biscuits, “chews” or oils that are advertised to go on top of food. In order to be effective, those products must contain five to eight times the dose of CBD that has been shown effective with direct trans-mucosal dosing.
  3. Is the dose correct? High quality CBD, appropriately dosed, should take effect in five to 15 minutes, not weeks to months. Compare the amount of actual CBD in the dose to the chart above, for the indication you are treating. If you know your product is reliable, try a different dose if no results are seen in two to three days. Many pet products have vanishingly small amounts of CBD, like 5 mg/ml, which is great for a Yorkie, but not for a Rottweiler. Know your dosages and use the product that can deliver the right dose in the least amount of oil, so that the pet does not balk at a mouth full of oil.

Full spectrum or isolate?

There is a place for both in your pharmacopeia. Full spectrum advocates like the “entourage effect” of having multiple cannabinoids and terpenes. However, very little is known about the actual benefits of many of the lesser cannabinoids, which occur in much lower amounts. A CBD isolate product can be compounded with other oils, like MCT coconut oil or olive oil, for better palatability, and can be dosed more precisely. Many clients want to use the same products as their pets, for convenience, and some humans need to avoid full spectrum due to the possibility of drug testing at work, which could trigger trace amounts of THC.

How should you choose a CBD product?

When choosing a CBD product to dispense or recommend, it is advisable to consider how “user-friendly” the product is, with doses listed on the label, as well as its reliability. Do not even consider a product that is not made using good manufacturing practices (cGMPs) or does not have third party lab certificates of analysis available for every batch of oil. Better companies will have money-back guarantees on their products, and will be able to answer your questions about the source of their biomass and the overall extraction process. The extraction process can include either ethanol or CO2 extraction. However, beware of poor quality incomplete extraction. In regards to aroma and flavor, full spectrum CBD oil should have a light herbal fragrance without any hint of chemical residues. This is especially important for feline patients — many cats do not appreciate the taste of full spectrum oils, and may do better on an isolate product.

Practical dosing advice

Low potency products (300 mg/oz or less) can be useful for micro-dosing behavioral issues, and for pets under 15 pounds. For anything larger than a toy dog, higher potency products should be utilized, to avoid giving a large mouthful of oil. Additionally, CBD is expensive, and tends to come in small total volume bottles, usually 1 oz (30 ml) in size. It is much easier to achieve excellent compliance from your clients when the total number of CBD mg in the bottle is divisible by 30! It is also useful to remember that oils behave differently than aqueous solutions because of oil’s reduced surface tension compared to water — thus, while eye drops contain about 20 drops per ml, CBD oil has 30 drops per ml, because the drops are smaller. Consider a product that contains 900 mg/oz (30 ml). Each ml will contain 30 mg of CBD, and each drop will contain 1 mg. So for a 55-pound Husky, a dose for anxiety (0.1 mg/kg) will be two to three drops BID; however, for moderate geriatric arthritis (a dose of 0.4 mg/kg), you should start at 10 mg (ten drops or 1/3 ml) and adjust up or down as needed, based on the dog’s response in three to five days.

Cannabidiol can be a useful addition to your clinical pharmacopeia: it is effective at relieving pain and anxiety with little or no side effects, and if administered appropriately, can be a cost-effective way to improve quality of life for aging pets.

Editor’s note: IVC Journal is closely following the advancements in this rapidly-changing industry, and will continue to update readers on the latest research and applications regarding CBD use in animal patients.

* This article is peer reviewed

References

¹Freundt-Revilla J, Kegler K, Baumgärtner W, Tipold A. “Spatial distribution of cannabinoid receptor type 1 (CB1) in normal canine central and peripheral nervous system”. PLoS One. 2017 Jul 10;12(7):e0181064.

²Bartner, McGrath et al. “Pharmacokinetics of cannabidiol administered by three delivery methods at two different dosages to healthy dogs”. Can J Vet Res 2018 82:178-183.

³Zendulka O, Dovrtelova G, Noskova K, et al. “Cannabinoids and Cytochrome P450 Interactions”. Curr Drug Metab. 2016, 17(3):206– 226.

⁴Gamble LJ, Boesch JM, et al. “Pharmacokinetics, Safety,and Clinical Efficacy of Cannabidiol Treatment in Osteoarthritic Dogs”. Front in Vet Sci 2018, 5:165.

⁵Jones NA, Glyn SE, Akiyama S, et al. “Cannabidiol exerts anti- convulsant effects in animal models of temporal lobe and partial seizures”. Seizure. 2012, 21(5):344–352.

⁶Gruden G, Barutta F, Kunos G, Pacher P. “Role of the endocannabinoid system in diabetes and diabetic complications”. Br J Pharmacol. 2016, 173(7):1116-27.

⁷Fernández-Trapero M, Espejo-Porras F, Rodríguez-Cueto C, Coates JR, Pérez-Díaz C, de Lago E, Fernández-Ruiz J. “Upregulation of CB2 receptors in reactive astrocytes in canine degenerative myelopathy, a disease model of amyotrophic lateral sclerosis”. Dis Model Mech. 2017, 10(5):551-558.

⁸McGrath, Bartner et al. “A Report of Adverse Effects Associated with the Administration of Cannabidiol in Healthy Dogs”. JAHVMA 2018, 52:34-38.

⁹Silver, R. Chief Medical Officer for RxVitamins, White paper: “Equine Phytocannabinoid Dosing Study”, 2018.

New interactive rabies map

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An online interactive map that shows the areas within the United States that have pre-exposure rabies vaccination laws for domesticated small animals

As of March 9, 2018, 36 states and the District of Columbia had pre-exposure rabies vaccination laws for domestic dogs and cats.

Earlier this year, LawAtlas.org launched a comprehensive interactive map that provides information on state rabies vaccination laws for dogs and cats. Using the online map, you can explore:

  • which states have a pre-exposure rabies vaccination law
  • which animals those laws apply to
  • the age for primary vaccination and booster vaccination
  • whether a certificate or proof of inoculation is issued and whether a tag or tag number is issued after inoculation
  • whether rabies vaccination is required to obtain a license or registration for the animal, and any exemptions to this law
  • details about vaccination requirements for dogs and cats entering a state.

Compiled by a team from the CDC Public Health Law Program and researchers at Temple University, the data includes the laws from all 50 states and Washington, DC that were in effect as of March 9, 2018. lawatlas.org/datasets/rabies-vaccination-laws.

Work-life balance: not the only answers for veterinarians

When taking steps to maintain your mental health and energy levels as a busy veterinary practitioner, you need to do more than achieve work-life balance.

Veterinary professionals today must protect their mental health and energy. Recent studies show that as many as 85% are experiencing depression and burnout,1 while a study done in 2012 found that 19% had considered suicide.2 In fact, almost every veterinary professional with whom I have spoken has a personal connection to someone who decided to end their life. The good news is that veterinary professionals are waking up to the issue and becoming more proactive about solutions. Work-life balance is a commonly discussed topic — but I do not believe this is sufficient to solve the problem and turn the field around.

What does “work-life balance” mean?

I run a coaching business for veterinary women. Whenever new clients come into my coaching community, I ask them where they want to be in five years. “I want to have more work-life balance,” is one of the most common answers I hear. Yet when I ask them what that means in their lives, most don’t know.

What they do know is that they’re miserable in their jobs. They know they’re tired and exhausted, and feel they never have enough time to relax and recharge. They know something needs to change. Many of these women are looking for new jobs when they find me. And I fully admit that for some of them, that’s the right solution at the moment. But I’m going to tell you a story.

Back in 2013, I was a weekend emergency doctor. I worked days and was on call at night. I often worked from one day all through the night, and then the whole next day as well, with no additional compensation. On paper, that job was horrible. But I was actually happy.

I left for various reasons and took a job in a small town at a small animal day practice. I went from working four days a week (including both weekend days) and two nights a week on call, to a four-and-a-half-day schedule with no nights on call. On paper, this clinic looked ideal, but I was miserable. I hated the job, and I hated where we were living. I had a great work-life balance yet I burned out quickly and felt completely trapped, unsure where to turn next.

I’ve seen similar situations with several of my clients.

Work-life balance is a worthwhile goal — if it is part of the big picture. We also have to work on ourselves so we can be happier at work. If we are unhappy in our jobs because of poor boundaries or mindsets, that unhappiness will overflow into our home life (which is why work-life balance isn’t enough) and is likely to follow us to the next job!

If we instead prioritize working on ourselves, on our mindsets and self care, we can improve our quality of life even while at a job that may not be ideal anymore. It’s then possible to be happier at that job, which cascades into improved overall happiness and an ability to find a better situation in the future.

So how do we improve our mindset and self care within the realms of any work situation?

1. Allow yourself to dream

The first activity I assign to anyone who comes into my coaching community is to dream. I believe one of the biggest problems faced by professionals in our field who feel trapped is simply that we don’t dream anymore. We decided we wanted to be veterinarians when we were so young that we knew what our path was for years, and we stayed on it, through high school, college and vet school, then our first job. It was straightforward and we never stopped to think what else we wanted out of life.

We fell into a pattern. And then, when we began to feel stuck, it never occurred to us that we could break the pattern just by remembering we have other goals and ambitions. I also find that many of my clients struggle to dream because it’s very hard to admit that the goal they worked towards for so long — becoming a veterinarian — isn’t always what they expected it to be. However, just because you’re allowing yourself to start dreaming again, and setting new goals, does not mean you have to leave the field, or that you made the wrong choice by going into it in the first place. It just means you’re looking towards the next steps.

Allowing ourselves to dream is a baby step. It doesn’t require any commitment, and nothing is set in stone. We’re dreaming about how we would like our life to look.

That simple act often creates excitement in our lives again. We become clearer on our goals and excited about our destination, which decreases the trapped feelings and creates more hope for the possibilities.3 Just this one step alone can start to change your mindset, which can dramatically change your life and level of happiness.

2. Look for the roadblocks

Once we’ve allowed ourselves to dream of where we want to be, we have to address those inevitable thoughts of “that’s not possible!” If we don’t address them, they remain obstacles and hinder progress towards our goals.The most common obstacle I see is fear. Everyone has it, but unless we address it, we may either not see our next steps or choose not to take them! I see three common types of fear in my work.

a) Fear of failure4,5 — We’re afraid to try anything new because we may not succeed. That’s a hard pill to swallow for most veterinarians! Additionally, many of us hesitate to proceed if we don’t know exactly how our goals are going to come about because we can’t see every step. Yet we have to take action despite the fear My clients often say, “I haven’t updated my resume to apply for jobs, because what if I don’t get any of them?” “Okay,” I respond. “How many jobs are you getting when you aren’t updating and submitting your resume?” It’s a simplistic example, but this type of thought reversal can be used for almost any situation in which you fear failure. We can never succeed at something if we don’t try!

b) Fear of success6 — “Well, if I’m successful, and I make a lot of money, then everyone is always going to be asking me for money and thinking I’m greedy, and I don’t want that!” Other versions are similar, but you get the point. More importantly, we worry that when we succeed, we may not be able to sustain that success. This almost feels worse than failing in the first place! Simply recognizing that you have these fears is often all it takes to move past them and take action. You can also look for people in your world who have achieved what you want to achieve, without experiencing the things you’re worried might happen. Look for stories that prove your fears wrong!

c) Fear of judgment — Put simply, we put too much thought and energy into worrying about what other people will think. What will they think if we fail? What will they think if we’re successful? The reality is that their opinions don’t matter. I realize that’s easier said than accepted, but the only person whose opinion matters is your own. Obviously, depending on the situation, I’m not telling you to ignore your boss! But when we’re talking about our dreams, what we want out of life, or what we want our lives to look like, so many people hold themselves back because of what other people think. It’s time to stop caring about this so much and live the life you want.

3. Establish strong self care

Self care is often discussed as a way to increase happiness in our lives. However, the concept includes a myriad of pieces. We often hear about self care practices that promote health and help us feel better. Certainly exercising and eating right, in addition to scheduling fun and relaxing activities such as pedicures and massages, can all be part of a self care program. But I believe very strongly that the most important aspect of self care is respecting our own boundaries.7 What are we willing to tolerate in our lives, and what are we no longer willing to tolerate?

This facet of self care is the biggest reason why just finding a new job isn’t the solution. If you don’t set good boundaries at one job, you’re not going to set them at another. If you don’t know where your boundaries are when it comes to what you will tolerate in your life, then you’re likely putting up with lots of situations that increase your stress.

Sometimes the most difficult part involves boundaries with ourselves. Boundaries such as: “I won’t go on social media every time I have a down minute at work today” or “I’m going to make sure I get eight hours of sleep tonight, no compromising.”

We have to figure out what our own bodies and minds need, and then we have to set and maintain boundaries to protect those needs!8

Self care isn’t just spa days and exercise. It’s also figuring out what we’re willing to allow into our lives, and what we’re no longer willing to tolerate, not only from our jobs, families, and friends, but also from ourselves!

Conclusion

Work-life balance is a worthy goal. But it can’t be the only focus. If your goal is to have more of the “life” part, but you’re still miserable while at work, then your overall happiness will be severely affected and you’ll still find yourself drained. If you work on your mindset and self care, however, then you can improve almost any job, which is automatically going to improve your quality of life. And when your mindset and self care improve, it will be easier to not only achieve the life you want, and obtain that work-life balance you’ve been striving for, but to also enjoy your whole day, not just the “life” part.

References

1americanveterinarian.com/news/recognizing-and-remedying-staff-brownoutburnout

²ncbi.nlm.nih.gov/pmc/articles/PMC4266064/

³psycnet.apa.org/record/2006-11798-011

⁴psychologytoday.com/us/blog/the-squeaky-wheel/201306/10-signs-you-might-have-fear-failure

⁵talkspace.com/blog/5-signs-fear-failure-keeping-best-life/

⁶forbes.com/sites/jackkelly/2018/10/04/how-to-overcome-your-crippling-fear-of-success/#3382ca976970

⁷thriveglobal.com/stories/3-reasons-boundaries-are-the-foundation-for-happiness/

⁸ forbes.com/sites/kathycaprino/2017/05/21/3-steps-to-strengthening-your-boundaries-to-build-a-happier-life-and-career/#62a4c2ca48e6

A holistic approach to self care for veterinarians

Implementing key strategies such as nutrition and exercise into your self care regime supports your current and future well-being as a veterinary practitioner, and diminishes your susceptibility to “dis-ease”.

As veterinary practitioners, we are well-versed in the importance of good nutrition, sufficient rest, exercise and lifestyle for our veterinary patients. But in regards of self care, do we walk our talk by taking as much care of ourselves? Sometimes we’re so busy looking after others that we don’t make the time or effort to do the same for ourselves. This article looks at current research that tells us what we already know intuitively, but probably don’t pay enough attention to in our busy, sometimes hectic, daily lives as veterinary practitioners. Self care is important. Let’s take some time to holistically assess our own health, and look at some efficient practices to improve our own well-being.

Reality Check

First, rate yourself subjectively on a scale of 1 to 10 (10 being the best). Remember, no one sees this but you!

Is there room for improvement – and what should we take notice?

Avoiding death, disability, dementia and cognitive dysfunction are high priorities as we age. Evidence is mounting that these conditions are associated with impaired glycemic control,1 and that a healthy dietary pattern reduces the risk of common diseases such as cardiovascular disease, diabetes and dementia.2 Maintaining your physical health is an important part of self care.

Self care and the importance of body condition

Increased BMI (see image below) and body fat content, especially central obesity, have been associated with endothelial dysfunction.3 The endothelium is a complex organ with endocrine functions, and endothelial dysfunction is considered a key process in atherogenesis, a risk factor for heart disease, and is also linked to Alzheimer’s disease.4 Endothelial dysfunction has also been shown to be directly involved in peripheral vascular disease, stroke, diabetes, insulin resistance, chronic kidney failure, tumor growth, metastasis, venous thrombosis, and severe viral infectious diseases.5 Dysfunction of the vascular endothelium is thus a hallmark of human diseases, including chronic inflammation. The pathogenesis is still not completely understood but is linked to tumor necrosis factor (and reduced nitric oxide production), oxidative stress, dyslipidemia (and insulin resistance) and autoantibodies.6

Dyslipidemia is additionally associated with excess visceral fat, the metabolically most active adipose tissue that causes increased insulin resistance, high triglyceride concentrations, changes in the size of low-density lipoprotein (LDL) particles, and low concentrations of high-density lipoproteins.6

Skeletal muscle comprises approximately 40% of total body mass and is the primary tissue contributing to insulin-mediated glucose uptake and fatty acid oxidation. Mounting evidence suggests that skeletal muscle is also an endocrine organ capable of secreting a variety of factors that act on peripheral tissues to alter metabolic function. Myokines are skeletal muscle specific-secreted factors able to exert humoral effects in vivo and may underlie the health benefits associated with daily physical exercise.

Assessing your cardiorespiratory fitness through peak oxygen uptake

Many studies suggest that cardiorespiratory fitness, measured as peak oxygen uptake (VO2 peak), may be the single best predictor of future health, cardiovascular morbidity, and premature cardiovascular mortality. Recently, a cross-sectional study of over 4,600 men and women (20 to 90 years old) showed that even in people considered to be fit, VO2 — the maximal oxygen uptake (fitness) — was clearly associated with cardiovascular risk factors.7

The same study proposed a model that can provide a rough tool for assessment of cardiovascular fitness.8 The researchers observed that the mean maximal oxygen uptake in women and men were 35 and 44 mL/kg/min, respectively. The material suggested a ~7% decline in maximal oxygen uptake with every ten-year age increase in both genders. Women and men below the gender-specific mean were four to eight times more likely to have a combination of more than three conventional cardiovascular risk factors (i.e. metabolic syndrome) compared to the most fit quartile of subjects. The researchers also observed that maximal oxygen uptake may represent a continuum from health to disease, and that a general 5 mL/kg/min lower maximal oxygen consumption was associated with ~56% higher odds of having metabolic syndrome. The study indicates that cardiovascular fitness may be even more important for cardiac health than previously thought.

You can use an online fitness calculator (ntnu.edu/cerg/vo2max) that asks a series of questions to calculate your VO2 and expected fitness level, as well as your actual fitness level or fitness age.

VO2 max =15.3 x HR Max / HR Rest (or see Table 2)

Your HR Rest is your pulse at rest ________

Your HR Max = 205.8 – (0.685 x age) (Run or cycle as fast as you can for three minutes, take a rest for two minutes and repeat. Your heart rate will peak during the second burst — it’s best not to do this if you haven’t been exercising!)

Your HR max = ________ Your VO2 max = ________

Data from the study mentioned above helps you gauge your fitness by age. Middle age (defined as 35 to 58 years old) is associated with a loss of aerobic capacity, as evidenced by a decline in VO2 max of approximately 8% per decade and an associated functional decline of 15% between young and middle age. The loss of skeletal muscle performance/skeletal muscle endurance capacity is associated with a loss of mitochondrial enzyme activity and impaired mitochondrial protein synthesis at rest. Further, there’s a loss of insulin sensitivity of 8% per decade in both males and females. Together, the loss of skeletal muscle performance is associated with an increased risk of lifestyle diseases such as Type 2 diabetes (T2D) and cardiovascular disease during middle age.9

After your self-assessment, now what?

What holistic self care options do you have to improve your cardiovascular fitness and reduce BMI?

1. High Intensity Interval Training (HIIT)

You could start running one hour per day, three to four times per week, join a gym, or even walk daily for 30 minutes. The belief is that that the more time you spend exercising, the better. You will be pleased to know that High Intensity Interval Training is another option. HIIT has caused a stir because studies over the last decade demonstrate that a few minutes of intense exercise a day can make a significant difference to your metabolism and VO2; it can get you fitter faster than standard exercise, improve your insulin sensitivity, build muscle tone, and reduce fat in the most time-efficient manner. There is evidence that just 40 seconds of intense activity can make a difference. Researchers have recently reported improved insulin sensitivity in young men following six weeks of HIIT training involving three sessions per week of two 20-second sprints against 7.5% of bodyweight — a total of ten minutes exercise over six weeks.10 A study also demonstrated the benefits of HIIT in untrained middle-aged adults, three males and 11 females. Over eight weeks, with twice-weekly training consisting of ten six-second sprints with one minute of recovery between each, there was significant improvement in aerobic capacity (8% increase in VO2 peak), physical function (11% to 27%), and a 6% reduction in blood glucose.9

Another study showed that three minutes of intense intermittent exercise each week, with a total time commitment of 30 minutes, including warm-up and cool-down, increased skeletal muscle oxidative capacity and markers of health status in overweight/obese but otherwise healthy men and women. Each session began with a two-minute warm-up, followed by three 20-second all-out sprints interspersed with two minutes of recovery followed by a three-minute cool-down. Peak oxygen uptake increased by 12% after training (32.6 ± 4.5 vs. 29.1 ± 4.2 ml/kg/min), and resting mean arterial pressure decreased by 7%.11

So even implementing just two short 11-minute sessions per week into your self care routine can make a significant difference, and have the potential to improve and maintain physical function and reduce the risk of disease. While time is a major barrier for all of us, can you afford not to invest 11 minutes twice a week for your health? Alternatives to sprinting include hurtling on a stationary bike with resistance, squatting, rowing, lunging, planks, skipping, pushups, step-ups, boxing, or anything that makes you open-mouth breathe and raises your heart rate! If you can’t engage in HIIT, then consider aerobic and/or resistance training.

2. Nutrition

Nutrition is a key pillar to self care. We all know what good nutrition is, but do we eat well to optimize health and well-being? Metabolic syndrome, dysglycemia and insulin resistance are insidious and silent. Between 32% and 34% of all adults (31% to 34% of men and 33% to 35% of women) in the United States have metabolic syndrome. Over 50% of people with hypertension have dysglycemia,12and both are components of metabolic syndrome. Although only more recently defined and investigated, metabolic syndrome epitomizes the integrative nature of modern chronic disease, given its endocrine, metabolic and cardiovascular underpinnings.

The most important causes of insulin resistance are a high-fat refined-carbohydrate diet and physical inactivity.13 In 2006, the Harvard School of Nutrition hosted a conference called Metabolic Syndrome and the Onset of Cancer, during which several papers were presented showing that hyper-insulinemia was related to breast, prostate and colon cancers. It has been known for over a decade that adipose tissue dysfunction is a central underpinning link to obesity in the pathogenesis of metabolic syndrome and Type 2 diabetes, and we now know that adipose tissue is a dynamic, metabolic endocrine organ, secreting various cytokines, chemokines and adipokines.

Table sugar (sucrose) is a disaccharide composed of two monosaccharides: glucose and fructose. Sucrose is a common ingredient in industrially-processed foods, but not as common as high-fructose corn syrup (HFCS). Whereas sucrose is equal parts fructose and glucose, HFCS has more fructose (usually 55%) than glucose (the remaining 45%) and is the most frequently-used sweetener in processed foods, particularly in fruit drinks and sodas. Feeding sucrose to rats stimulates the sympathetic nervous system (SNS), and increases heart rate, renin secretion, renal sodium retention and vascular resistance. These interact to elevate blood pressure; sucrose-fed rats have increased blood pressure. Sucrose feeding also induces insulin resistance, as part of a broader metabolic dysfunction. People who consume 10% to 24.9% of their calories from added sugars have a 30% increased risk of mortality from cardiovascular disease compared to those who consume less than 10% of their calories from added sugars. Worse, those who consume 25% or more calories from added sugars have an almost threefold increased risk.14

It’s time to take a stock of sugar consumption in the foods you eat on a regular basis. Around 300 years ago, humans consumed a few pounds of sugar per year — now, Americans consume anywhere from 77 to 152 pounds of sugar per year, with 13% consuming at least 25% of their total caloric intake as added sugars. This equates to an intake of added sugars of 24 to 47 teaspoons (about 100 g to 200 g) per day, with an average daily fructose consumption of 83.1 g (about 16 teaspoons)!

Spend some time analysing your own diet using nutritiondata.com(also a useful tool for looking at animal diets).

We all know that the cornerstones of self care and good health — good nutrition, exercise, and taking care of our emotional health — apply to ourselves as well as our animal patients. We must commit to walking our talk and practicing what we preach, so we may achieve the vibrant health and well-being we strive for so diligently in our patients.

References

1Cukierman-Yaffe T, Anderson C, Teo K. “Dysglycemia & cognitive dysfunction & ill-health in people with high CV risk: results from the ONTARGET/TRANSCEND studies Unsuccessful Aging & Dysglycemia”. Am Soc Clin Oncol Educ Book. 2015;35:e66-73.

² Harvie M, Howell A, Evans DG. “Can diet and lifestyle prevent breast cancer: what is the evidence?” BMC Geriatr. 2015; 14: 36. Mar 21.

³ Sundell J, Laine H, Luotolahti M et al. “Obesity affects myocardial vasoreactivity and coronary flow response to insulin”. Obes Res. 2002; 10:617-24.

⁴ Lathe R, Sapronova A, Kotelevtsev Y. “Atherosclerosis and Alzheimer – diseases with a common cause? Inflammation, oxysterols, vasculature”. BMC Geriatr. 2014 Mar 21;14:36.

⁵ Rajendran P, Rengarajan T, Thangavel J. “The Vascular Endothelium and Human Diseases”. Int J Biol Sci. 2013; 9(10): 1057–1069.

⁶ Steyers C, Miller F. “Endothelial Dysfunction in Chronic Inflammatory Diseases”. Int J Mol Sci. 2014 Jul; 15(7): 11324–11349.

⁷ Aspenes S, Nilsen T, Skaug E et al. “Peak oxygen uptake and cardiovascular risk factors in 4,631 healthy women and men”. Med Sci Sports Exerc. 2011 Aug;43(8):1465-73.

⁸ Nes B, Janszky I, Vatten L et al. “Estimating VO2 peak from a non-exercise prediction model: the HUNT Study”. Norway Med Sci Sports Exerc. 2011 Nov;43(11):2024-30.

⁹ Adamson S, Lorimer R, Cobley J. “High Intensity Training Improves Health and Physical Function in Middle Aged Adults” Biology (Basel). 2014 Jun; 3(2): 333–344.

10 Metcalfe RS, Babraj JA, Fawkner SG, Vollaard NBJ. “Towards the minimal amount of exercise for improving metabolic health: Beneficial effects of reduced exertion high intensity interval training”. Eur. J. Appl. Physiol. 2012;112:2767–2775.

11 Gillen J, Percival M, Skelly L et al. “Three Minutes of All-Out Intermittent Exercise per Week Increases Skeletal Muscle Oxidative Capacity and Improves Cardiometabolic Health”. PLoS One. 2014; 9(11): e111489.

12 Cheung B, Wat N, Tso A et al. “Association Between Raised Blood Pressure and Dysglycemia in Hong Kong”. Chinese Diabetes Care. 2008 Sep; 31(9): 1889–1891.

13 Roberts C, Hevener A, Barnard J. “Metabolic Syndrome and Insulin Resistance: Underlying Causes and Modification by Exercise Training Compr Physiol”. 2013 Jan; 3(1): 1–58.

14 DiNicolantonio J, Lucan S. “The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease” Open Heart. 2014; 1(1): e000167.

 

Juvenile hip dysplasia in the canine

A case study of canine juvenile hip dysplasia involving the use of digital thermal imaging. How this tool can enhance patient analysis and treatment.

Gloria, an 11-month-old intact female Rottweiler, was presented for evaluation after a history

Figure 1: Gloria’s radiography at ten months of age

of rear limb lameness. Radiography at ten months of age (Figure 1) demonstrated signs of juvenile hip dysplasia: significant abnormalities of the coxofemoral joints with flattening and remodeling of the femoral heads bilaterally, which was more pronounced on the right side along with right coxofemoral subluxation.

Physical exam — The exam confirmed pain and decreased range of motion in the coxofemoral joints, and offloading on the right side.

Physiological screen with digital thermal imaging — The patient was acclimated to room temperature, was not handled during acclimation, and remained calm during image capture. Three digital thermal images were taken with a Digatherm IR 640 unit.

Analysis of the thermal images — Marked thermal asymmetry was evident between the lateral images of the rear limbs. The RH lateral image showed hyperthermia from the hip extending distally, becoming more pronounced over the lateral aspect of the tibia.

The average temperature in Zone 1R, over the right hip, was 85.1°F (29.5°C) (Figure 2). The LH lateral image showed hypothermia radiating cranioventrally from the sacral area.
The average temperature in Zone 1L, over the left hip, was 79.5°F (26.4°C) (Figure 3). The average temperature difference (T) was 37.6°F (3.1°C). This marked difference in temperature represents a physiological hyperthermia on the right side and a physiological hypothermia on the left side. A dorsal thermal image of the lumbar and sacral area showed patchy asymmetrical hypothermia over the right lumbosacral junction and throughout the left caudolateral sacral area (Figure 4).

Figure 2: Digital thermal image right hip, lateral view
Figure 3: Digital thermal image left hip, lateral view
Figure 4: Digital thermal image lumbar and sacral spine, dorsal view

Interpretation of the thermal images — The thermal images are consistent with radiographic evidence of juvenile hip dysplasia and the symptoms of rear limb lameness.
They support the physical exam findings of pain and decreased range of motion in the coxofemoral joints along with offloading on the right side.

Areas of hyperthermia are noted throughout the thermal image of the right rear leg, which radiographically shows the most severe coxofemoral joint changes. The areas of hypothermia noted in the left lateral and dorsal images are consistent with pain activation of the sympathetic nervous system, which can lead to peripheral vasoconstriction.

Hypertrophic cardiomyopathy in cats – a silent killer

Hypertrophic cardiomyopathy (HCM) often goes undiagnosed until a cat is in heart failure. Understanding HCM can help early disease detection and client education.

Photo courtesy of Morris Animal Foundation

Hypertrophic cardiomyopathy (HCM) is by far the most common type of heart disease diagnosed in cats. The disease is difficult to detect when a cat has no obvious clinical signs. That means most cats are diagnosed when they have signs of congestive heart failure, arterial thromboembolism or even sudden death.

 

 

Despite the prevalence of hypertrophic cardiomyopathy, we’re still learning more about the disease, how to treat it and how to accurately diagnose it before the condition becomes life-threatening. Results from a study funded by Morris Animal Foundation offer new hope that a simple screening to detect HCM early can improve treatment and outcomes.

Cat’s heart showing HCM are courtesy of Dr. Kate Meurs, researcher at North Carolina State University.

Thorough physical examinations are the cornerstone of veterinary appointments, but several studies have shown that few cats with subclinical heart disease have telltale physical exam abnormalities. For example, most practitioners know the presence or absence of a heart murmur doesn’t mean a cat has or doesn’t have hypertrophic cardiomyopathy. While the presence of a heart murmur typically triggers further testing, such as echocardiography, detecting occult heart disease remains difficult.

Cat’s heart showing HCM are courtesy of Dr. Kate Meurs, researcher at North Carolina State University.

Echocardiography is the gold standard for diagnosing hypertrophic cardiomyopathy in cats. Elizabeth Rozanski, DVM, ACVIM, ACVECC, and colleagues at Tufts University knew that several barriers to this test exist including cost, proximity to a boarded cardiologist, and the skillset and equipment required to perform a full echocardiogram. They were also aware that focused cardiac ultrasound (FCU) was gaining popularity in human hospital emergency rooms as a quick way to assess patients for serious cardiac conditions. Dr. Rozanski wanted to determine if a non-specialist practitioner (NSP) could be trained to perform FCU to increase detection of occult heart disease in cats.

 

NSP Training and Results

Dr. Rozanski and her team developed an FCU protocol and trained 22 NSPs to perform the procedure. The NSPs screened 289 cats without signs of heart disease. All patients had follow-up echocardiograms by a board-certified cardiologist.

Dr. Rozanski found that the NSPs were very good at detecting moderate and severe heart disease in the study population. They were less skilled at detecting mild disease, but Dr. Rozanski was encouraged by the results and hopes more practitioners can learn FCU and incorporate it into their practice. Dr. Rozanski published her results in the Journal of Veterinary Internal Medicine.

Further research into HCM

Another important project funded by Morris Animal Foundation centered on hypertrophic cardiomyopathy was the REVEAL study. Published in 2018, the study was a collaborative effort among veterinary cardiologists at 50 veterinary hospitals located in 21 countries. In total, 1,730 cats were examined over a 10-year period. Philip Fox, DVM, MS, DACVIM/ECVIM (cardiology), DACVECC, the lead author of the study and a Foundation-funded grantee, was curious to learn more about the natural history of occult hypertrophic cardiomyopathy. He felt that because prior studies often were located at one referral facility and generally focused on cats with severe disease, results were skewed toward adverse outcomes and short survival. Dr. Fox wanted to learn more about the outcomes for cats who had HCM but were preclinical.

Dr. Fox, who is Head of Cardiology at the Animal Medical Center in New York City, and colleagues compared cats with asymptomatic hypertrophic cardiomyopathy to apparently healthy cats. The cats with hypertrophic cardiomyopathy were further divided into cats with nonobstructive or obstructive forms of hypertrophic cardiomyopathy. The study found that during the study period, congestive heart failure or arterial thromboembolism (or both) occurred in 30.5% of cats with either form of HCM. The study also noted that cardiovascular death occurred in 27.9% of cats with either form of hypertrophic cardiomyopathy. His conclusion was that cats with HCM had a high risk of morbidity and mortality. Interestingly, the study did not find a significant difference in morbidity or morality between cats with nonobstructive and those with obstructive forms of hypertrophic cardiomyopathy. Dr. Fox published his findings in the Journal of Veterinary Internal Medicine.

Concluding thoughts

Although we’re making progress, we still have a lot to learn about hypertrophic cardiomyopathy in cats. Early detection is important for long-term monitoring of patients and for client education. Unfortunately, there remains a significant knowledge gap in understanding which preventive measures, if any, can delay onset of clinical signs or improve long-term survival. Morris Animal Foundation continues to support research in this important area of feline medicine. Our hope is that we can fill this knowledge gap and improve the lives of cats everywhere.

 

 

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