The VETgirl Beat is a quarterly publication available to all subscribed members of VETgirl. The digital newsletter features highlighted webinars (small animal, large animal, veterinary technician, leadership), tech tips, provider spotlights, and recent happenings.
QUARTERLY BEAT / JULY 2024 ISSUE 21 • JULY 2024 BEAT
EMAGAZINE
THE ITCHY DOG
TECH TIPS
30 MIND MASSAGE RECAP
REAL-LIFE ROUNDS
WHAT'S ON THE CALENDAR? 35
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beat ISSUE 20 • APRIL 2024 TABLE OF CONTENTS
04 WEBINAR HIGHLIGHTS: THE ITCHY DOG: HOW TO IMPLEMENT A PRACTICAL, STEP-BY-STEP APPROACH AND BECOME A DERM ROCKSTAR
20 WEBINAR HIGHLIGHTS: LEVERAGING LEADERSHIP: HOW LEADERS CAN CREATE CONFIDENT, EMPOWERED TEAMS
10 WEBINAR HIGHLIGHTS: FECAL MICROBIOTA TRANSPLANTATION (FMT) HOW, WHEN, AND WHY?
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WEBINAR HIGHLIGHTS: NAVIGATING THE EMPLOYMENT LANDSCAPE: UNDERSTANDING AGREEMENTS, BONUSES, AND CORPORATE CONTRACTS FOR EMPLOYEE SUCCESS
16 REAL-LIFE ROUNDS: DIAGNOSIS AND TREATMENT OF NON- GRAND MAL SEIZURES
30 MIND MASSAGE
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32 TECH TIPS
34 TEAM SPOTLIGHT
35 WHAT'S ON
THE CALENDAR
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THE ITCHY DOG: HOW TO IMPLEMENT A PRACTICAL, STEP-BY-STEP APPROACH AND BECOME A DERM ROCKSTAR
DR. JULIA E. MILLER DACVD
In this VETgirl veterinary technician webinar “The Itchy Dog: How to Implement a Practical, Step-by-Step Approach and Become a Derm Rockstar” on April 7, 2024, Dr. Julia E. Miller, DACVD reviews all you need to know about becoming a derm rockstar! In case you missed the webinar, watch it again HERE or read the cliff notes below!
In both general and specialty practice, itchy dogs make up a large portion of what we see every day. This is why it is incredibly important that practitioners are equipped with a repeatable, step-by-step diagnostic workup for these cases. By developing a methodology, frustration can be minimized, successes may be achieved, and derm really can be fun! WHY SO SCRATCHY? When it comes to dermatology, especially when working up pruritic patients, thorough, derm-specific history questions are a must as they will guide the prioritization of differentials. Skilled nurses and assistants are an invaluable asset in collecting the necessary information to guide the diagnostic workup. Educating the team on the approach to pruritic patients will increase success and efficiency. Another important aspect of the itchy dog workup is a thorough derm PE – truly a nose-to-tail examination. Part the fur and use a flea comb to look for evidence of fleas. If the patient is licking its paws, get up close and personal with the claw folds to look for dermatitis or discharge. If the patient is scooting, do a rectal examination to evaluate the anal sacs, and don’t forget to
check the perivulvar skin in female animals. Thorough derm PEs ensure that causes of pruritus are not missed and guide what diagnostics are warranted.
REMEMBER: ATOPY IS A DIAGNOSIS OF EXCLUSION Not every itchy dog is allergic, and many allergic dogs also have secondary, complicating factors. Before diagnosing a patient with environmental allergies (atopy), it is imperative to rule out ALL other causes of pruritus with derm-specific history taking, a thorough PE, derm diagnostics (cytologies, skin scrapes, etc.), and by assessing response to treatments. Allergy testing (serum or intradermal) should NOT be used to diagnose atopy as false positives are possible and may lead you down the wrong path.
ROCKSTAR TIP:
Rule out ectoparasites in every single itchy dog! Isoxazolines are a fantastic way to do this.
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A FEW IMPORTANT HISTORY QUESTIONS
IMPORTANT DIFFERENTIALS TO RULE OUT IN ALL PRURITIC DOGS 1
1. At what age did the itching start? a. Atopic dogs: >6 months and <4 years of age i. Exception possible if they have moved biozones b. Food-allergic dogs: any age i. Prioritize food if <6 months or >4 years c. Ectoparasites: any age d. Neoplasia: typically middle-aged to older patients
Fleas!
Scabies!
Demodex injai (D. canis is not a pruritic mite unless there are secondary infections)
ECTOPARASITES
Cheyletiella
Pediculosis
Otodectes cynotis
2. Seasonality
Malassezia dermatitis
a. Atopy: seasonal, nonseasonal, or nonseasonal with a seasonal flare b. Food allergies: nonseasonal c. Ectoparasites: typically nonseasonal, particularly in warmer climates d. Neoplasia: nonseasonal 3. Current ectoparasite prevention a. A yes or no is not enough: medication, frequency, if they are up to date, if they
MICROBIAL INFECTIONS
Bacterial pyoderma
Cutaneous epitheliotropic lymphoma
NEOPLASTIC SKIN DISEASE
Flea allergy dermatitis
Food allergy
ALLERGIC SKIN DISEASE
Atopy
Contact hypersensitivity
are using the medication appropriately, and if other in-contact animals are also on preventatives
TO DIET TRIAL OR NOT TO DIET TRIAL Food allergies are no longer thought to be uncommon in dogs, as up to 25% of nonseasonally allergic dogs may have a food allergy. 2 This, however, doesn’t mean that every itchy dog needs a diet trial. If the pruritus is seasonal, a diet trial is not indicated. If ectoparasites and secondary infections have not been ruled out yet, a diet trial is not indicated. If the patient or client cannot complete the strict diet trial successfully, a diet trial is not indicated. It is also important to note that serum, saliva, and hair food allergy testing is currently NOT repeatable or reliable and the only way to definitively diagnose a food allergy is by response to a strict, prescription diet trial. 3
4. Response to previous treatments a. Antipruritics? Antimicrobials? Ectoparasiticides? Diet trials? b. If a patient has not responded to
numerous antipruritic therapies this should be a clue that something has been missed – do more diagnostics!
5. Are other humans or animals pruritic? a. If yes: rule out ectoparasites, especially scabies
WEBINAR HIGHLIGHTS
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ROCKSTAR DIET TRIAL TIPS:
1. Choose the right patient a. Nonseasonal pruritus starting at 6 years of age, up to date on excellent flea, tick, and mite prevention, no clinical or cytologic evidence of neoplasia or secondary infections? Excellent diet trial candidate! b. Nonseasonal pruritus in a 14-year-old Yorkie that has severe exfoliative erythroderma and depigmenting skin on the face? NOT a good diet trial candidate – biopsy for cutaneous epitheliotropic lymphoma! 2. Choose the right client a. Owner has been thoroughly educated on the VERY strict diet trial rules and is on board with the process 3. Choose the most appropriate diet a. Over-the-counter diets should NEVER be considered a diet trial
i. Cross-contamination with undisclosed proteins invalidates the diet 4,5 b. No diet is perfect - it is important to have options for picky eaters c. May need to choose diets with treat or pill-hiding options 4. Use an effective antipruritic therapy for the first 3-6 weeks of the diet trial a. Apoquel® or glucocorticoids are recommended b. Cytopoint® should only be used if the duration of action is known in the patient 5. Feed the diet for the right length of time a. 8 weeks will diagnose >90% of food allergic patients 6-8 b. A full 3 months is typically not necessary – should see response earlier
6. Prove food allergy by challenging with the old diet and increasing itch
7. Follow up with ALL diet trials and discuss long-term options a. Some patients require life-long prescription diets, some may tolerate over-the-counter diets that don’t “contain” the allergen 5
DITCH THE ITCH These patients are being presented because they are itchy - it is imperative that they leave with an effective antipruritic therapy. In most cases, antihistamines are not effective at controlling even mild pruritus and are therefore not recommended. 9 Glucocorticoids offer significant itch relief and may be appropriate in cases of severe inflammation and pruritus, but have frequent, and sometimes severe, side effects. Apoquel (tablets or chewable) and Cytopoint are safe and effective options to manage pruritus that are appropriate to use as a first- line treatments.
If there is significant inflammation in the skin, Apoquel is recommended due to its larger anti-inflammatory profile. If pruritus with minimal inflammation is present, Cytopoint is an excellent option. It is important to remember that response to antipruritics varies from dog to dog and there will always be some trial and error in the process of finding the most effective antipruritic protocol for each patient. In chronic, severe, or refractory cases cyclosporine is often an excellent option, but this medication is not appropriate for rapid relief of pruritic flares as it will take 4-6 weeks to reach full effect.
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MULTIMODAL THERAPY FOR THE WIN! There is no one-size-fits-all approach to managing atopy and it is important to utilize the many tools in the dermatologic toolbox. There are user-friendly topical therapies for reducing surface microbes and repairing the defective epidermal barrier, diets high in essential fatty acids and probiotics, and nutraceuticals to name a few. The most important aspect of choosing the right treatment regimen is knowing the needs of the patient and the abilities of the owner and choosing a plan that is attainable for both. IF AT FIRST YOU DON’T SUCCEED…. You missed something! Do more diagnostics! Most Dermatologists are broken records when it comes to recommending cytology because it is very easy to miss something when only using the PE findings to dictate treatments. Derm diagnostics should be used regularly and should be a consistent part of the itchy dog workup.
THE ANTI-PRURITIC MEDICATION STOPPED WORKING – NOW WHAT? It’s time for a recheck examination! It is quite rare that an effective antipruritic therapy stops working for no reason. When patients whose itch has been well-controlled are flaring it is critical to perform a thorough history (did they stop their flea prevention?) and derm PE with the appropriate diagnostics. In many cases, it’s not that the Apoquel stopped working, it’s that the patient now has a secondary complicating factor like Malassezia dermatitis. Do NOT adjust the antipruritic therapy without a thorough evaluation - flares will happen!
DERMATOLOGY – IT’S ALL ABOUT COMMUNICATION!
Itchy dogs, especially the allergic ones, are not one-and-done cases. They will require numerous rechecks and follow-up care to develop the best treatment plan for the patient and the owner. It’s critical to set expectations from day one and support a true team approach (doctor, nurse/assistant, CSR, owner) to maximize long-term success.
ROCKSTAR TIP:
Malassezia dermatitis may be intensely pruritic. If antipruritic or antibiotic treatments are not working do cytology to look for yeast! Don’t fear the oral azoles!
WEBINAR HIGHLIGHTS
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REFERENCES
1. Hensel P, Santoro D, Favrot C, Hill P, Griffin C. Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification. BMC Vet Res 2015;11:196 2. Mueller RS, Unterer S. Adverse food reactions: Pathogenesis, clinical signs, diagnosis and alternatives to elimination diets. The Vet Journal 2018;236:89-95. 3. Favrot C, Steffan J, Seewald W, Picco F. A prospective study on the clinical features of chronic canine atopic dermatitis and its diagnosis. Vet Dermatol 2010;21:23-31. 4. Ungerboeck C, Widmann K, Handl S. Detection of DNA from undeclared animal species in commercial elimination diets for dogs using PCR. Vet Derm 2017; 28: 373–e86. 5. Biel W, Natonek Wiśniewska M, Kępińska Pacelik J, et al. Detection of chicken DNA in commercial dog foods. BMC Vet Res 2022;18:92. 6. Olivry T, Mueller RS, Prélaud P. Critically appraised topic on adverse food reactions of companion animals (1): duration of elimination diets. BMC Vet Res 2015;11:225. 7. Fischer N, Spielhofer L, Martini F, Rostaher A, Favrot C. Sensitivity and specificity of a shortened elimination diet protocol for the diagnosis of food-induced atopic dermatitis (FIAD). Vet Derm 2021;32:247-e65. 8. Possebom J, Cruz A, Gmyterco VC, de Farias MR. Combined prick and patch tests for diagnosis of food hypersensitivity in dogs with chronic pruritus. Vet Derm 2022;33:124-e36. 9. Olivry T, DeBoer DJ, Favrot C, et al. Treatment of canine atopic dermatitis: 2015 updated guidelines from the International Committee on Allergic Diseases of Animals (ICADA). BMC Vet Res 2015;11: 210-225.
ROCKSTAR RESOURCE
• 2023 AAHA Management of Allergic Skin Disease in Dogs and Cats Guidelines
WEBINAR HIGHLIGHTS
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FECAL MICROBIOTA TRANSPLANTATION (FMT) HOW, WHEN, AND WHY?
DR. LINDA TORESSON
PHD
In this VETgirl Webinar, “Fecal Microbiota Transplantation (FMT) - How, When and Why?” on April 24, 2024, Dr. Linda Toresson, PhD reviews all you need to know about fecal microbiota transplantation! If you’re about to treat a chronic IBD or even a parvovirus patient, tune in to learn more! In case you missed the webinar, watch it again HERE or read the cliff notes below!
Faecal microbiota transplantation (FMT) is a technique used to transfer faeces from a healthy donor to a recipient with a disease to restore the intestinal microbiota and metabolome and decrease disease activity. The treatment was mentioned in a Chinese textbook of emergency medicine by Ge Hong in 320 A.D but has very rarely been used in conventional medicine until the last two decades. In people, FMT is superior to antibiotics in recurrent Clostridiodes difficile (rCDI) infection. 1 There is also evidence from several randomized controlled trials (RCTs) that FMT can decrease disease activity and induce remission in people with inflammatory bowel disease (IBD). 1 It has been shown that both the microbial composition of the donor stool and that of the recipient are important for a successful outcome. 2 Patients responding to FMT had increased faecal microbial diversity both before and after FMT compared to non-responders. Gastrointestinal (GI) disorders are by far the most common reasons to perform FMT in people, but multiple research studies have been performed using FMT for other indications, including hepatic disorders, metabolic syndrome, treatment of antibiotic-resistant microbes, neuropsychiatric disorders, obesity, and others. 3 The transplant can be administered rectally as a retention enema, orally as lyophilized faeces in capsules, or deposited in the duodenum or colon using an endoscope. The route of administration does not appear to affect the outcome in people. Likewise, fresh or thawed frozen faeces are equally effective in people with rCDI. 4
Guidelines on FMT from The Companion Animal Fecal Bank Consortium, an international group of experts, will be published later in 2024.
FMT IN DOGS WITH GASTROINTESTINAL DISORDERS Several case reports, case series, and studies have been published on the use of FMT in dogs. An RCT in puppies with parvovirus showed a beneficial effect of FMT. 5 Sixty-six puppies with parvovirus were treated with FMT and standard treatment or standard treatment alone. The puppies were treated with one FMT every other day until recovery (median 1.8 FMTs). A significantly reduced time to recovery and hospitalization time was seen in the FMT group. Survival was also higher in the FMT group versus the other group (79% versus 64%), although this difference was not statistically significant. In a study of 18 dogs with acute diarrhoea, dogs were treated with metronidazole or one single FMT for seven days. 6 At day 7, the faecal scores were similar in both groups. At day 28, the dogs treated with FMT had significantly improved faecal scores versus the metronidazole-treated group. The dogs in the metronidazole group had significant dysbiosis at day 28, compared to dogs treated with FMT and healthy dogs. In a study of 8 dogs with acute hemorrhagic diarrhoea syndrome (AHDS), there was no difference between FMT, placebo, or probiotics. 7 However, the amount of dogs was very small
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and the dogs were treated with one single FMT. AHDS is an aggressive condition, associated with necrotizing inflammation. Therefore, it may be necessary to use multiple FMTs, as in the study on parvovirus. In dogs with chronic enteropathies (CE), there is evidence from several case reports and case series that FMT can decrease disease activity. A recently published retrospective study of 41 dogs with poorly responsive CE showed that FMT as adjunctive therapy could reduce disease activity. 8 Several rectal FMTs (median 3) were given as a series of treatments. Clinical improvement was noted in 31/41 dogs. The majority showed further improvement after FMT two or three. Improvement was indicated by a significant reduction of canine IBD activity index after FMT. A similar beneficial effect of repeated FMTs has been shown in people with IBD. 9,10 In 10/31 dogs, the maintenance dose of corticosteroids could be tapered to lower doses after FMT. Likewise, the use of antibiotics could be reduced or stopped in 3 dogs. The most common clinical response was increased activity level in 24/31 dogs and improved faecal quality in 24/31 dogs.8 Some dogs also experienced less frequent flare-ups or milder flare-ups, weight gain, and improved appetite after FMT.
(IBS) for up to 6 months post-FMT. 11 Increased production of short-chain fatty acids (SCFAs) by beneficial microbes is likely a contributing reason. Short-chain fatty acids stimulate the enterochromaffin cells to synthesize and secrete serotonin. Serotonin is a very important modulator of the gut-brain axis. Many beneficial intestinal microbes can also synthesize neurotransmitters, such as dopamine, Y-amino butyric acid (GABA), glutamate, and noradrenaline, which can have a local effect in the gut, but also modulate the brain and behaviour. DONOR SCREENING, FMT DOSE, AND PREPARATION OF FAECES Screening should be performed to find a donor with lots of beneficial microbes and no potential faecal pathogens. Donors should be re-tested every 6 months. Recommendations for donor screening are available in Table 1.
Improved quality of life and reduced fatigue have been shown in RCTs in people with IBD as well as irritable bowel syndrome
WEBINAR HIGHLIGHTS
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TABLE 1. DONOR REQUIREMENTS/SCREENING
DONORS SHOULD FULFILL THESE CRITERIA
FECAL SCREENING
EXCLUDE
· Normal dysbiosis index · Salmonella spp
· 12 months to middle-age · Body condition score of 4-6/9 · Healthy, no medication · CIBDAI ≤ 3 (dogs) · No antibiotics for 6 months (minimum) · Not being fed a raw food diet · Normal haematology and serum biochemistry · Cats: indoor, preferably single-cat household · Negative for enteric coronavirus (PCR) · FIV and FeLV negative
· Campylobacter jejuni · Giardia and other intestinal parasites · In cats also Tritrichomonas foetus
Consensus is lacking on the FMT dose in veterinary medicine. The amount of donor stool per treatment has varied in different studies. The author uses 5 grams of donor faeces per kg body weight (BW) of the recipient for dogs up to 25 kg BW and 3 grams of faeces per kg BW for dogs > 25 kg. In dogs with CE, 3 FMTs with 10-20 days intervals are given as one set of treatments. If clinical improvement is lacking after FMT 1 or 2, we do not give a 3rd treatment, based on our previous results. 8
We use fresh frozen faeces, stored at -20 °C for a maximum of 3 months, without cryopreservatives. Cryopreservatives increase the number of viable bacteria in frozen faeces, but whether or not adding cryopreservatives, such as 10 % glycerol, actually makes a clinical difference has not been studied. Fresh frozen faeces without cryopreservatives has been used with a good outcome in several of the published studies on FMT in dogs to date. 5,6,8
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If no contraindications are present, I use a low dose of acepromazine (0.1 mg/kg) subcutaneously, given 15 minutes before the procedure. Depending on the individual animal’s temper, some clinicians elect not use premedication or sedation before FMT. Our experience is that premedication makes it easier for the dog to relax and rest after the procedure. This allows for a long contact time between the colonic mucosa and the transplant. The FMT procedure is available in Figure 1. FMT can then be administered with the dog in a standing position, sternal or lateral recumbency. It is easiest to insert the catheter with the dogs in a standing position or sternal recumbency. Several types of catheters, such as red rubber catheters, can be used. We use 16 French flexible suction catheters with atraumatic, rounded tips for most dogs and 14 French catheters for cats and toy breeds. ADVERSE EFFECTS Side effects are usually mild and self-limiting. The most prevalent adverse event in our recent publication was self- limiting diarrhoea or worsening of diarrhoea within 48 hrs after FMT. 8 LYOPHILIZED FMT CAPSULES Lyophilized FMT capsules have been proven effective in people and are quick and convenient. No special preparation of the patient is required before administration. Potentially, it may not provide the same booster effect as rectal FMT, as it is difficult for practical reasons to give the equivalent amount of faeces in capsules as one rectal FMT. Commercial lyophilized capsules provide less information on the microbial composition of the donor stool compared to screened donors from your own fecal bank. In people with ulcerative colitis, the microbial composition of donor stool has been associated with outcome. 2 GASTROINTESTINAL INDICATIONS FOR FMT FMT has saved the life of several of the author's canine patients with non-responsive or poorly responsive CE. In dogs with CE responding to FMT, FMT will not “cure” the dogs, but the disease activity and maintenance doses of concurrent medication
Frozen faeces should be thawed in a 37°C water bath on the day of the procedure or thawed in a fridge overnight. After blending with saline, the volume of the transplant should not exceed 20 ml/kg BW of the recipient.
Remove solid pieces (grass, gravel etc.) from donor faeces
Blend faeces with saline 1:1-1:3 to a suitable texture using a blender a
Filtrate transplant with a sieve or cheese cloth, aspirate in 60 ml syringes
Measure the catheter - the tip should be at level of the last rib of the donor
Attach catheter to syringe and fill the catheter with faeces
Lubricate the catheter, insert it rectally until it reaches the level of the last rib
Give the transplant. Hold one hand firmly on the base of the catheter b
Remove the catheter
Instruct the dog owner to restrict walks and food for the next 4-6 hrs
a Typically the texture of a ”thick smoothie” or purée b This prevents leakage and detachment of the syringe from the catheter
RECTAL FMT PROCEDURE Prior to the procedure, the recipient dog should be walked for 30-40 minutes in order to defecate. Bowel cleansing is not needed.
WEBINAR HIGHLIGHTS
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can often be decreased. However, the author has personal experience with a few young dogs with immunosuppressive- responsive enteropathy that could be weaned off corticosteroids after having been treated with 3 FMTs at
10-20 days intervals. FMT is also used in dogs with acute diarrhoea. At the author’s clinic, FMT is always tried before antibiotics in non-septic dogs with acute diarrhoea that do not respond to conventional treatment.
REFERENCES
1. Jaramillo AP, Awosusi BL, Ayyub J, et al. Effectiveness of fecal microbiota transplantation treatment in patients with recurrent clostridium difficile infection, ulcerative colitis, and crohn’s disease: a systematic review. Cureus 2023;15(7):e42120. doi:10.7759/ cureus.42120 2. Paramsothy S, Nielsen S, Kamm MA, et al. Specific bacteria and metabolites associated with response to fecal microbiota transplantation in patients with ulcerative colitis. Gastroenterology 2019;156(5):1440-1454.e2. doi:10.1053/j.gastro.2018.12.001 3. Green JE, Davis JA, Berk M, et al. Efficacy and safety of fecal microbiota transplantation for the treatment of diseases other than Clostridium difficile infection: a systematic review and meta-analysis. Gut Microbes 2020;12(1):1-25. doi:10.1080/19490976. 2020.1854640 4. Chapman BC, Moore HB, Overbey DM, et al. Fecal microbiota transplant in patients with Clostridium difficile infection: A systematic review. J Trauma Acute Care Surg 2016;81(4):756-764. doi:10.1097/TA.0000000000001195 5. Pereira GQ, Gomes LA, Santos IS, Alfieri AF, Weese JS, Costa MC. Fecal microbiota transplantation in puppies with canine parvovirus infection. J Vet Intern Med 2018;32(2):707-711. doi:10.1111/jvim.15072 6. Chaitman J, Ziese AL, Pilla R, et al. Fecal microbial and metabolic profiles in dogs with acute diarrhea receiving either fecal microbiota transplantation or oral metronidazole. Front Vet Sci 2020;7:192. doi:10.3389/fvets.2020.00192 7. Gal A, Barko PC, Biggs PJ, et al. One dog’s waste is another dog’s wealth: A pilot study of fecal microbiota transplantation in dogs with acute hemorrhagic diarrhea syndrome. PLoS One 2021;16(4):e0250344. doi:10.1371/journal.pone.0250344 8. Toresson L, Spillmann T, Pilla R, et al. Clinical effects of faecal microbiota transplantation as adjunctive therapy in dogs with chronic enteropathies—a retrospective case series of 41 dogs. Veterinary Sciences 2023;10(4):271. doi:10.3390/vetsci10040271 9. He Z, Li P, Zhu J, et al. Multiple fresh fecal microbiota transplants induces and maintains clinical remission in Crohn’s disease complicated with inflammatory mass. Sci Rep 2017;7(1):4753. doi:10.1038/s41598-017-04984-z 10. Paramsothy S, Kamm MA, Kaakoush NO, et al. Multidonor intensive faecal microbiota transplantation for active ulcerative colitis: a randomised placebo-controlled trial. Lancet. 2017;389(10075):1218-1228. doi:10.1016/S0140-6736(17)30182-4 11. Johnsen PH, Hilpüsch F, Valle PC, Goll R. The effect of fecal microbiota transplantation on IBS related quality of life and fatigue in moderate to severe non-constipated irritable bowel: Secondary endpoints of a double blind, randomized, placebo-controlled trial. EBioMedicine 2020;51:102562. doi:10.1016/j.ebiom.2019.11.023
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DIAGNOSIS AND TREATMENT OF NON-GRAND MAL SEIZURES
DR. MISSY CARPENTIER DACVIM (Neurology)
In this 30-minute, VETgirl Real-Life Rounds, Dr. Missy Carpentier-Anderson, DACVIM (Neurology) will discuss diagnosing and treating (or better yet managing) patients that have non-grand mal seizures. Tune in as she reviews seizure types, from focal seizures to orofacial and the controversial fly biting.
IS IT EVEN A SEIZURE? The straightforward grand mal (tonic-clonic) seizures can be tricky enough to manage, then you add in all the other types and things can just get confusing! Let’s try and make it easy. Regardless of what the seizure looks like, a seizure is a seizure PERIOD and needs to be treated as such. Most types of seizures can all be managed similarly, however, there are a couple of focal seizure nuances that you should be aware of and will be discussed below. Before you start managing a seizure patient, you need to first confirm that the patient is truly experiencing a seizure. By far the best tool that we have to assist us is a video of the suspect seizure event, but if that isn’t available we need to do some investigating. Here is a list of information that you will want to get from the owner about the possible seizure, as well as a chart for signs that you will be looking/listening for during the three different stages of a seizure.
SEIZURE INFORMATION
SEIZURE ACTIVITY STARTED
ANY KNOWN TOXIN EXPOSURE
TOTAL SEIZURES
SEIZURE FREQUENCY
DESCRIPTION OF SEIZURE ACTIVITY, TIME OF DAY, ACTIVITY PRIOR TO SEIZURE ONSET, ETC
LENGTH OF SEIZURE
PRE-ICTAL PHASE
POST-ICTAL PHASE
BEHAVIOR BETWEEN SEIZURES
AED'S CURRENTLY BEING ADMINISTERED AND ANY RECENT DRUG BLOOD LEVELS
IF PATIENT CHRONICALLY ON AED'S, HAVE RECENT LEVELS BEEN CHECKED, HAVE ANY DOSES BEEN MISSED, ETC
IMPROVEMENT OF SEIZURE ACTIVITY WITH AEDS
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AURA / PRODROME / PRE-ICTAL
SEIZURE / ICTAL
POST-ICTAL
· Symptom · Apprehensive behavior · Pacing · Agitation · Seeking out the owner
· Tonic clonic · Clonic tonic · Pure tonic · Atonic · Myoclonic · Petit mal? Questionable in animals · Focal · Orofacial – especially cats · Fly biting · Focal vs GI vs sensory vs OCD
· Altered mentation – most often hours but can be days · Confused, disoriented, aggressive · Blind · Restless / Pacing · Ataxic
· Polyphagic · Polydypsic
Once you have established that you are dealing with a seizure, if it happens to be a focal, orofacial, or fly-biting event, here are a couple of key points to remember:
FOCAL SEIZURE This is caused by abnormal excessive neuronal discharges in a specific region of the brain and does NOT need to be associated with a sinister cause (i.e., brain tumor). It should be lateralized and it can occur in one of three ways: 1) Isolation 2) Focal seizure with impaired awareness 3) Focal seizure progressing to a generalized seizure OROFACIAL SEIZURE Orofacial seizures are exhibited by dominating orofacial motor signs and tend to be laterally dominant. Hypersalivation is a predominant sign. This is a common seizure type in felines, and when present, you should have Feline Limbic Encephalitis-Hippocampal Necrosis Complex on your list of rule-outs. This is an immune-mediated disease where antibodies are formed against voltage-gated potassium channels, a fact that is important to remember because these cases need anti-seizure medications and steroids to treat the underlying pathology. FLY-BITING SEIZURE/EVENTS Fly-biting seizures absolutely exist, however, it is much more common that patients exhibiting fly-biting have underlying gastrointestinal disease (esophagitis, GERD, gastritis, etc.). When a fly-biting patient is brought to you, treat for GI disease first (unless they are exhibiting other neurologic signs). Common GI treatments include an elimination diet, omeprazole, and +/- prednisone.
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NEXT STEP? NEUROLOCALIZATION – YOU DON’T WANT TO SKIP THIS ONE!
DIFFERENTIALS
DEGENERATIVE Lysosomal storage diseases
DEVELOPMENTAL Hydrocephalus, cortical dysplasia, lissencephaly
ANOMOLOUS
Idiopathic
Liver disease, renal disease, mitochondrial encephalopathy, hyponatremia, hypernatremia, hypocalcemia, hypoglycemia, hypoxia...
METABOLIC
WHY NEUROLOCALIZE? NECESSARY TO COME UP WITH YOUR MOST ACCURATE LIST OF DIFFERENTIALS
NEOPLASTIC
Primary or metastatic
NUTRITIONAL
Thiamine deficiency
INFLAMMATORY MUO, SRMA, infectious, feline = limbic encephalitis
Pesticides (metaldehyde, OP'ss, carbamates, pyrethrin...,) Lead, EG, Mycotoxins, Caffeine
TOXIC
TRAUMATIC
TBI, skull fractures
VASCULAR
CVA – ischemic or hemorrhagic
Once you develop your list of differentials, further diagnostics should be discussed with the owner to conceive the best course of action for your patient. Some of these may include:
WHEN TO START AED?
DIANOSTICS
2015 ACVIM CONSENSUS
· Complete blood count and chemistry · Liver function test
· Identifiable structural lesion present or prior history of brain disease or TBI · Acute repetitive seizures or SE (ictal >5 minutes or >/=3 or more generalized seizures within a 24-hours period · >/=2 or more seizure events within a 6 month period · Prolonged, severe or unusual postictal periods There are many options for anti-seizure medications in our canine and feline patients. When choosing the right AED for your patient, keep in mind that not only do we need to manage the seizures, but we also need to manage the side effects of the medication and owner satisfaction.
· Bile acids · Ammonia
· +/- Thoracic radiographs · +/- Abdominal ultrasound
· MRI · CSF
Once you have diagnosed your patient, you will treat the underlying disease process (if one is identified) that is the cause of the seizures. However, regardless of the underlying cause, in most cases an anti-seizure medication needs to be part of your treatment plan. Below is a chart to help determine when you should initiate anti-seizure medication.
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INCREASE INHIBITION
DECREASE EXCITATION
PRE-SYNAPTIC Ca CHANNEL
GABA-R
SVA2
VG-Na CHANNEL
GLUTAMATE-R
* * * *
PHENOBARBITAL
KBR
*
LEVETIRACETAM
* *
*
ZONISAMIDE
*
TOPIRAMATE
PREGABALIN
When it comes to choosing an anti-seizure medication, your main goals will be to either increase inhibition or decrease excitation in the brain. Below is a list of the most common AEDs and their main mechanism of action.
When it comes to focal seizures, I prefer to use either pregabalin or levetiracetam, but of course there are other AED options as well. Please see the chart below for AED options for your patients.
DOSE
SIDE EFFECTS
MONITORING / OTHER TID BITS
Sedation Weakness Ataxia Disorientation
2-4 mg/kg PO Q12hrs (d) 1-4 mg/kg PO Q12hrs (c)
Monitoring under investigation, currently use human recommendations of serum concentration of 2–5 mg/L *Great for neuropathic pain – 2 mg/kg PO q12hrs
PREGABALIN
*can do q8hrs in refractory cases *start low, especially in cats
Polydpsia Flatulence
5–45 ug/ml
20 mg/kg PO q8hrs with regular levetiracetam 30 mg/kg PO q12hrs with extended release levetiracetam
*Intravenous use for status patients or cluster seizures *Patients commonly defecate XR capsules - doesn't affect efficacy *Cannot split XR tablets for every day use, but if using in emergent situation for immediate use you can (extra dose post seizure, etc)
LEVETIRACETAM
Sedation
*Increase dose if patient on phenobarbital
I understand how stressful and confusing managing seizure patients can be. Hopefully this will provide you with some guidance. And don’t forget, you can always reach out with questions!
carpentier@mnveterinaryneurology.com
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LEVERAGING LEADERSHIP: HOW LEADERS CAN CREATE CONFIDENT, EMPOWERED TEAMS
DR. WENDY HAUSER
In this VETgirl Webinar, “Leveraging Leadership: How Leaders Can Create Confident, Empowered Teams” from June 5, 2024 by Dr. Wendy Hauser of Peak Veterinary Consulting reviews how leaders can adapt in this post-pandemic world. In case you missed the webinar, watch it again HERE or read the cliff notes below!
· Authoritative: Clearly conveys the vision and invites employees to be part of the process; allows the team autonomy in how they achieve the goal. · Affiliative: Relational leadership approach, where people come first, goals and tasks second. This approach positively influences empathy and communication. · Democratic: Collaborative approach, where team members’ perspectives are elicited and incorporated in creating business initiatives. Outcomes are trust, respect, and organizational commitment. · Pacesetting: High-performance standards are set and role-modeled by the leader. Employees who cannot meet these high demands become demoralized; due to rigidity, autonomy in how work is done is greatly diminished. · Coaching: Helps employees identify and achieve career goals. Delegates effectively and understands that short-term failure is a learning opportunity that leads to long-term learning and results. A veterinary leader may use multiple leadership styles throughout the day. For example, when managing a critical emergency, the leader may be very ‘coercive’ and directive, which is needed to lead the team during a stressful event. When trying to gain buy-in for a new hospital initiative, both the ‘democratic’ and ‘affiliative’ styles are helpful.
The pandemic and its aftermath have created permanent changes in the way businesses operate, with significant impacts on veterinary hospitals. Stress and anxiety, commonplace in practices pre-pandemic, have increased significantly with operational changes and uncertainty related to personal wellbeing and economic security. To manage these changes, leadership must adapt to help both their teams and veterinary hospitals thrive. Leaders need to expand their skill sets to create favorable practice conditions, where employees are empowered, and leaders successfully manage themselves by understanding how their actions (or lack of actions) impacts their followers. What are ways that leaders can adapt to the ever-changing needs of the veterinary workforce? LEADERSHIP STYLES Seminal research 1 conducted in the early 2000’s identified that leaders’ emotions influence and shape their leadership style, which directly impacts workplace culture and psychological safety. In a related article 2 six leadership styles were identified:
· Coercive: Employees must comply with the leader’s wishes; characterized by top-down leadership style that excludes the employee in decision-making and daily operational processes.
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During the pandemic directive leadership styles, such as ‘coercive’ and ‘pacesetting’, were detrimental to the workplace culture. 3 In hospitals where leadership used these styles, employees felt less emotionally safe. This factor, in combination with the stresses of managing overwhelming caseloads, understaffing, and uncertainty drove many talented professionals to abandon the veterinary field. In general, businesses whose leadership embraced the ‘affiliative’, ‘democratic’, and ‘coaching’ leadership styles were able to focus on creating new ways of doing business that energized and engaged their teams. These actions empowered employees and gave them a sense of control, which was missing during the pandemic. 4 The aftermath of the pandemic has seen increased turnover in veterinary hospitals and increasing dissatisfaction in the workforce. While salaries and benefits have substantially increased, discontent continues as employees seek more meaningful work. Brave leadership for the present requires a blend of the following styles: · Authoritative, where employees have the autonomy to design their work and how it is completed. · Democratic, which allows veterinary teams to co- create outcomes with their leaders. · Coaching, which will create pathways for continued growth and development of the team members and encourage a culture of learning.
A critical component in utilizing effective leadership styles is an understanding of “Followership”. The act of leading involves two parties: the leader and the follower. A leader cannot lead if they don’t have followers. The ability of a leader to lead isn’t impacted by followership, but by following behaviors. Followship behaviors are heavily influenced by the actions of the leaders. It is through this relationship that co-created outcomes occur. This concept is foundational to brave leadership. MANAGING A LEADER’S BEHAVIORS By its very nature, veterinary medicine is filled with the unexpected; as a result, teams work in unpredictable workplaces daily. Well-meaning leaders contribute to the stress and anxiety that their teams experience, often unknowingly, through their words and actions. Brave leadership demands that leaders understand the impact of how they act and communicate with their teams and that they strive to minimize negative behavioral patterns, as identified in a recent article 5 :
WEBINAR HIGHLIGHTS
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N egative L anguage There is a strong connection between a leader’s moods and how they choose to express themselves verbally. Words that increase followers’ sense of anxiety or cause them to be fearful, such as “appalling,” “substandard”, or “disappointing,” should be avoided. Leaders should be aware of their moods and listen to their messages. Alternatives to the harsh words above could be those that convey a more positive tone, yet convey the seriousness of the situation, including “surprising,” “room for improvement”, or “opportunities for growth”. I rregular or U npredictable A ctions Instability and uncertainty are triggers for anxiety and stress. To counterbalance the unpredictable nature of caring for pets and their owners, leaders need to have a stabilizing influence by acting in dependable, consistent ways. Leaders can have a steadying effect by being transparent, open, and authentic in all communications, both verbal and written. Consistent messaging helps to prevent confusion and minimizes the opportunity for misinterpretations. E motional V olatility The impact of leaders’ emotions on the people around them (‘mood contagion’) is well-documented. 1 If leaders are excitable, their stress tends to amplify emotions within their teams, and chaos ensues. When leaders can temper their emotions, and remain calm and composed, their followers will imitate them helping to further reduce anxiety within the team. E xtreme N egativity When teams are stressed or anxious, negativity further demotivates them and increases insecurity. Leaders should project optimism during times of uncertainty. Well-founded and truthful reassurance will help followers feel more confident, which lowers the levels of anxiety and stress in the workplace. I gnoring E mployee E motions Humans are emotional creatures, so it is expected they’d bring emotions with them to work. When leaders fail to focus on emotions that are present in the workplace, they lose the opportunity to manage the emotions and their impact. This is worsened when leaders solely focus on their own emotions. Leaders can modulate stress and anxiety in the workplace in two ways: · Recognize how deeply their actions impact their followers, both positively and negatively. Self- awareness allows leaders to modify their emotional responses, resulting in less emotional whiplash experienced by the team.
· Create a space where team members can share what emotions they are bringing to work each day. This can be verbal, such as in a team huddle at the beginning of each shift where leaders ask their followers “What are you bringing to work today?” This can also be accomplished visually, by creating a mood indicator chart on which team members can place different signs of their emotional state.
THE ROLE OF TRUST IN BRAVE LEADERSHIP
In veterinary hospitals, teamwork depends on the ability to effectively collaborate with one another. Successful collaboration starts with the actions of the leader and depends on trust, which forms when followers believe that the leader’s intentions are fair and truthful and that the leader will make decisions that support their well-being and best interests. When a leader’s actions cause stress and anxiety in the workplace, are inauthentic or when leaders fail to show that they care about their followers, trust can be broken. Brave leadership requires that leaders build a culture of trust by being authentic, displaying sound logic, and showing empathy. 6 A uthenticity Authenticity is often associated with “sincerity, honesty, and integrity” 7 ; it happens when leaders are genuine, meaning they bring and express their true selves to work. To be authentic, a leader’s words must align with their actions, which are supported by their values and beliefs. Furthermore, the leader must find common ground with followers by learning from and sharing past experiences with them. Trust is formed when team members get to know and understand their leaders, and each other. When leaders are inauthentic, it sends a message to employees that the workplace is not a safe space to reveal who they really are. This leadership action results in less willingness by followers to be vulnerable to the leader, which inhibits trust. L ogic Veterinary team members trust their leaders to make decisions that are in the team’s best interests. When leaders are indecisive, lack follow-through, or poorly communicate with followers, trust breaks down. To maintain trust, leaders need to share the reasons for their decisions using easily understood logic.
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REFERENCES
E mpathy Called the building block of compassion, empathy is “the awareness of others’ feelings, needs, and concerns”. 8 When leaders express empathy to their followers, it conveys to the veterinary teams that they are cared about and valued. Actively communicating empathy involves gaining an understanding and appreciation of the employee’s situation and verbally reflecting it back in a supportive way. SUMMARY It has been said that “Change is the only constant in life”. 9 When faced with rapidly evolving employee expectations, what’s a leader to do? They too must adapt by: 1. Understanding the different leadership styles, and when to use them. 2. Embracing the dynamic relationship of leaders and followers. 3. By understanding the impact of how they act and communicate to their teams. 4. Working to consciously shape their words and actions to create more supportive work environments. 5. Growing trust through authenticity, logic, and empathy. ABOUT THE AUTHOR Wendy Hauser, DVM is the founder of Peak Veterinary Consulting and has practiced for 30+ years as an associate, practice owner, and relief veterinarian. She has worked in the animal health industry as a pet health insurance executive and as a technical services veterinarian. Dr. Hauser, passionate about education and innovation, consults with both industry partners and individual veterinary hospitals. She is a regular presenter at veterinary conferences, facilitating workshops on hospital culture, associate development, leadership, client relations and operations. Frequently published, she is the co-author of
1. Goleman D, Boyatzis RE, McKee A. Primal Leadership: The Hidden Driver of Great Performance. Harvard Business Review, December 2001. https://hbr.org/2001/12/primal- leadership-the-hidden-driver-of-great-performance 2. Goleman D. Leadership that Gets Results. Harvard Business Review, March 2000. https://hbr.org/2000/03/leadership- that-gets-results 3. DeSmet A, Rubenstein K, Schrah G, Vierow M, Edmondson A. Psychological safety and the critical role of leadership development. McKinsey and Company, February 2021. 4. Laker B, Patel C, Budhwar P, Malik A. How Leading Companies are Innovating Remotely. MIT Sloan Management Review, December 14, 2020. https:// sloanreview.mit.edu/article/how-leading-companies-are- innovating-remotely/ 5. Chamorro-Premuzic T. 5 Ways Leaders Accidently Stress Out Their Employees. Harvard Business Review May 11, 2020. https://hbr.org/2020/05/5-ways-leaders-accidentally- stress-out-their-employees 6. Frei F, Morriss A. Begin with Trust. Harvard Business Review May-June 2020. Pages 112-121 7. Goffee R, Jones G. Managing Authenticity: The Paradox of Great Leadership. Harvard Business Review, December 2005. https://hbr.org/2005/12/managing-authenticity-the- paradox-of-great-leadership 8. Goleman D. Working with Emotional Intelligence. New York, NY: Bantam Doubleday Dell Publishing Group 2008 9. Gillette H. Why Change Is the Only Constant and How to Embrace It. PsychCentral. December, 2022.
“The Veterinarian’s Guide to Healthy Pet Plans.” Learn more about Peak Veterinary Consulting at https://peakveterinaryconsulting.com
WEBINAR HIGHLIGHTS
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