V9I4 (Fall 2019)

Innovative VOLUME 9 ISSUE 4

VETERINARY CARE

WHY WORK-LIFE BAL ANCE M AY N OT M AKE YOU HAPPY TO MAINTAIN YOUR MENTAL HEALTH AND ENERGY LEVELS AS A BUSY VETERINARY PRACTITIONER, YOU NEED TO DO MORE THAN ACHIEVE WORK-LIFE BALANCE. — P. 56

SYSTEMIC APPROACH TO ALLERGIC DERMATITIS

Canine allergic dermatitis isn’t just a local issue — treatment should also address systemic factors using integrative therapies. – P. 14

FALL ISSUE 2019

www.IVCJournal.com

ERGONOMICS IN THE VETERINARY SETTING

It’s just as important for those in the veterinary field as in others — in some cases, even more important. – P. 38

A CLOSER LOOK AT USING CBD FOR YOUR PATIENTS A close-up look at the tricky therapeutic and regulatory landscape of using CBD for animal patients. – P. 31

THE LINK BETWEEN INFLAMMATION AND DEPRESSION

Stress is linked to inflammation, which in turn causes depression. Know what to do about it, and improve your quality of life on and off the job. – P. 10

CRYOSURGERY IN THE VETERINARY PRACTICE

Innovative advances in cryosurgery offer safe and effective treatment options with unlimited potential. – P. 46

HOLISTIC APPROACH TO SELF CARE FOR VETERINARIANS How nutrition and exercise help support your well-being and diminish your susceptibility to “dis-ease”. – P. 24

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contents FEATURES

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INFLAMMATION, DEPRESSION — AND THE ROLE OF DETOXIFICATION

By Nancy Scanlan, DVM

Stress is also linked to chronic inflammation, which in turn causes depression.

Understanding this connection, and what to do about it, improves your quality of life both on and off the job.

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CANINE ALLERGIC DERMATITIS: A SYSTEMIC APPROACH TO MANAGEMENT

By Ron Carsten, DVM, PhD, CVA, CCRT

Allergic dermatitis in dogs is a clinical issue with systemic contributors. Treatment should address both local and systemic factors using integrative therapies that address key body systems.

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A HOLISTIC APPROACH TO SELF CARE FOR VETERINARIANS

By Barbara Fougere, BSc BVMS (Hons), BHSc (Comp Med), MODT, MHSc (Herb Med), Grad Dip VWHM, Grad Dip VCHM, Grad Dip Vacup, CVA, CVCP, CVBM, CMAVA, MNHAA Implementing strategies such as nutrition and exercise into your self care regime supports your well-being as a veterinary practitioner, and diminishes your susceptibility to “dis-ease”.

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CBD IS EVERYWHERE!

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ERGONOMICS IN VETERINARY MEDICINE

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CRYOSURGERY IN THE VETERINARY PRACTICE

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NUTRITION NOOK

KETOPET SANCTUARY: KETOSIS, CANCER AND CANINES — PART 3

By Chelsea Kent; Shannon L. Kesl, PhD; Corissa Antemesaris, CVT; Stacy A. Hodges, DVM; Barbara Royal, DVM, CVA; Loren Nations, DVM, DipABVP KetoPet Sanctuary tested the feasibility of using a ketogenic diet as an adjunctive therapy in dogs with cancer. In the third part of this article, we’ll look at practical applications for dogs at home.

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INNOVATIVE PRACTICE

WORK-LIFE BALANCE — NOT THE ONLY ANSWER FOR VETERINARIANS

By Jenny Elwell-Gerken, DVM

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.

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ESSENTIAL OIL USE FOR PROFESSIONAL SELF CARE

By Melissa Shelton, DVM, CA

This time-honored modality for healing our patients can also be utilized to heal ourselves.

By Karen Gellman, DVM, PhD

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

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By Sara C. White, DVM, MSc

Ergonomics is as important for those in the veterinary field as in other areas of work — perhaps even more important, in some cases.

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By Ryan E. Walrath, DVM

Innovative advances in cryosurgery offer safe and effective treatment options with unlimited potential in the hands of the veterinarian.

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advisory board Dr. Richard Palmquist, DVM GDipVCHM(CIVT) CVCHM (IVAS), graduated from Colorado State University in 1983. He is chief of integrative health services at Centinela Animal Hospital in Inglewood, California, former president and research chair of the AHVMA, and an international speaker in integrative veterinary medicine. Dr. Palmquist is a consultant for the Veterinary Information Network (VIN) and a past president of the AHVM Foundation. He has published two books, one for conventional veterinarians and a second for clients discussing how integrative thinking works.

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Michelle J. Rivera, MT, VDT, is an instructor at the University of Wisconsin and The Healing Oasis Wellness Center, a post-graduate educational institution offering state-approved programs. She is co-owner of The Healing Oasis Veterinary Hospital, offering massage, rehabilitation, chiropractic and Chinese and Western Herbology. Michelle completed the Chinese Herbal Medicine program from the China Beijing International Acupuncture Training Center, and is certified in Chinese Medicine by the Wisconsin Institute of Chinese Herbology.

COLUMNS & DEPARTMENTS

8 Editorial 22 Emerging technology profile

— Torigen

29 From the NASC 30 From the VBMA 35 From the AVH 37 Industry innovations 55 Business profile

— Sustenance Herbs

63 2019 IVC Award Nominees

— call for nominations

64 From the VMAA 65 Marketplace 66 News bites

Dr. Joyce Harman, DVM, MRCVS, graduated in 1984 from Virginia Maryland Regional College of Veterinary Medicine. Her practice is 100% holistic, using acupuncture, chiropractic, herbal medicine and homeopathy to treat horses to enhance performance and those with a variety of chronic conditions, with an emphasis on Lyme Disease. Her publications include the Pain Free Back and Saddle Fit Books, and numerous articles in lay and professional magazines. She maintains an informative website: www.harmanyequine.com.

Dr. Steve Marsden, DVM, ND, MSOM, Lac. Dipl.CH, CVA, AHG lectures for IVAS, the AHVMA, the AVMA, and numerous other organizations. He is co-founder of the College of Integrative Veterinary Therapies and is a director emeritus of the National University of Natural Medicine in Portland OR. He authored the Manual of Natural Veterinary Medicine (Mosby); and Essential Guide to Chinese Herbal Formulas (CIVT). Dr. Marsden is extensively trained in alternative medicine, including Chinese herbology, acupuncture and naturopathic medicine. He has holistic veterinary and naturopathic medical practices in Edmonton, Alberta. In 2010, Dr. Marsden was named Teacher of the Year by the AHVMA; and Small Animal Veterinarian of the year by the CVMA in 2009.

Dr. Jean Dodds, DVM, received her veterinary degree in 1964 from the Ontario Veterinary College. In 1986, she moved to Southern California to establish Hemopet, the first non-profit national blood bank program for animals.

Dr. Dodds has been a member of many national and international committees on hematology, animal models of human disease, veterinary medicine, and laboratory animal science. She received the Holistic Veterinarian of the Year Award from the AHVMA in 1994.

Dr. Barbara Fougere, DVM, CVAA graduated in 1986, and was named the American Holistic Veterinary Medical Association Educator for 2011. Dr. Fougere is the principal and one of the founders of the College of Integrative Veterinary Therapies. She has continued studying over the last 26 years, and has three Bachelor degrees, two Masters degrees, three post Graduate Diplomas, several Certifications and numerous other courses under her belt.

Dr. Christina Chambreau, DVM, CVH, graduated from the University of Georgia Veterinary College in 1980. She is a founder of the Academy of Veterinary Homeopathy, was on the faculty of the National Center for Homeopathy Summer School and has been the holistic modality adjunct faculty liaison for the Maryland Veterinary Technician Program and is the former Associate Editor of IVC Journal. Dr. Chambreau teaches classes in homeopathy for animals, lectures on many topics, speaks on Radio and TV, and is the author of the Healthy Animal’s Journal among other titles. She is now on the faculty of the Holistic Actions Academy, which empowers members to keep their animals healthy with weekly live webinars.

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FALL 2019

EDITORIAL DEPARTMENT Editor-in-Chief: Dana Cox Managing Editor: Ann Brightman Associate Editor IVC: Laurin Cooke, DVM Associate Editor: Emily Watson Senior Graphic Designer: Dawn Cumby-Dallin Senior Graphic Designer: Alyssa Dow Social/Digital Media Manager: Elisabeth Dunphy Web Design & Development: Lace Imson

COLUMNISTS & CONTRIBUTING WRITERS

Corissa Antemesaris, CVT Bill Bookout Ron Carsten, DVM, PhD, CVA, CCRT Todd Cooney, DVM, CVH Jenny Elwell-Gerken, DVM Barbara Fougere, BSc BVMS (Hons), BHSc (Comp Med), MODT, MHSc (Herb Med), Grad Dip VWHM, Grad Dip VCHM, Grad Dip Vacup, CVA, CVCP, CVBM, CMAVA, MNHAA Karen Gellman, DVM, PhD Jodie Gruenstern, DVM, CVA, VP of VMAA Stacy A. Hodges, DVM Chelsea Kent Shannon L. Kesl, PhD Cynthia Lankenau, DVM Loren Nations, DVM, DipABVP Barbara Royal, DVM, CVA Nancy Scanlan, DVM Melissa Shelton, DVM, CA Mark Suckow, DVM, DACLAM Kim Vanderlinden, ND, DTCM Ryan E. Walrath, DVM Sara C. White, DVM, MSc

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The opinions expressed in this journal are not necessarily those of the editor, and different views may appear in other issues. Redstone Media Group Inc., publisher of IVC Journal, does not promote any of the products or services advertised by a third party advertiser in this publication, nor does Redstone Media Group Inc. verify the accuracy of any claims made in connection with such advertisers.

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IVC Journal (ISSN 2291-9600) is published four times a year by Redstone Media Group Inc. Publications Mail Agreement #40884047. Entire contents copyright© 2019. No part of this publication may be reproduced or transmitted by any means, without prior written permission of the publisher. Publication date: September 2019. improving the lives of animals... one reader at a time.

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1. RON CARSTEN, DVM, PHD, CVA, CCRT Dr. Ron Carsten was one of the first practicing veterinarians in Colorado to advocate an integrative approach to patient management. He has lectured on the integrative approach and use of nutritional supplements, published on a range of topics in peer-reviewed journals, taught in a number of college and university programs, was faculty for the NIH National Cancer Institute Molecular Prevention Course, has been involved in research, and is a past NIH National Research Service Award Fellow. As a consultant, he developed the original Standard Process Veterinary Formulas™. Dr. Carsten has an AAS in animal health technology, BS in microbiology, MS in anatomy and neurobiology, and PhD in cell and molecular biology. He is a certified veterinary acupuncturist and canine rehabilitation therapist, and practices integrative veterinary medicine in Glenwood Springs, Colorado.

2. JENNY ELWELL-GERKEN, DVM Dr. Jenny Elwell-Gerken is an integrative veterinarian located in Utah. Once upon a time, she struggled from severe depression, and credits her kids with giving her a reason to pull through.

Now, on the other side, she is living her dream life and has dedicated herself to helping other veterinary professionals end burnout and depression so they can be happier in their lives again.

You can learn more at her website at drjeg.com.

3. KAREN GELLMAN, DVM, PHD Dr. Karen Gellman is a graduate of Cornell College of Veterinary Medicine, and has a doctorate in animal locomotion biomechanics. She has advanced training and certification in veterinary acupuncture and veterinary chiropractic, and has practiced these and other modalities since 1995.

She has been an invited or keynote speaker for IVAS, IVCA, AVDF, IAED and the Danish Veterinary Chiropractic Association. Dr. Gellman is the educational director and teacher in the Postural Rehabilitation training course for veterinarians, and teaches biomedical research programs for high school students at Cornell. She is Research Director of Maximum Horsepower Research, and principle investigator of a current study on equine posture funded by the AHVMA. 4. STACY A. HODGES, DVM Dr. Stacy Hodges is a veterinarian at Block House Creek Animal Hospital in Cedar Park, Texas. She graduated from veterinary school in 2012 from Ross University, and finished her last year of clinics at Auburn. Her special interests include mixed animal, internal medicine, and Eastern medicine.

She has been working with KetoPet Sanctuary for about four years.

5. LOREN NATIONS, DVM, DABVP Dr. Loren Nations owns Veterinary Healthcare Associates in Winter Haven, Florida, and sees referral cases in Internal Medicine and Oncology.

6. BARBARA ROYAL, DVM, CVA, CIAC Dr. Barbara Royal is an integrative veterinarian and IVAS-certified acupuncturist with extensive experience in veterinary care, including nutrition, acupuncture, emergency medicine, pathology, conventional practices, herbal remedies, physical rehabilitation techniques and alternative treatments. The author of three books, including The Royal Treatment, A Natural Approach to Wildly Healthy Pets, she has also been featured in the documentary Pet Fooled. Dr. Royal is the founder and owner of The Royal Treatment Veterinary Center in Chicago and co-founder of the Royal Animal Health University. She is also an adjunct professor at Cal Poly State University in San Luis Obispo.

She is the past president of both the AHVMA and the AHVM Foundation, and a Board Member of PAWS Chicago, a nationally-renowned no-kill humane animal shelter.

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7. NANCY SCANLAN, DVM Dr. Nancy Scanlan is Executive Director for the AHVM Foundation, a board member of the World Association of Traditional Chinese Veterinary Medicine, and a consultant on the Veterinary Information Network. She has been using complementary health therapies in her veterinary practice since 1970, including nutraceuticals, acupuncture, non-classical homeopathy, and Chinese and Western herbs. Dr. Scanlan was Executive Director of the AHVMA for three years and president of the VBMA for two years.

8. MELISSA SHELTON, DVM, CA Dr. Melissa Shelton earned her veterinary degree from the University of Minnesota in 1999, and has owned Crow River Animal Hospital in Minnesota since 2001. Essential oils became a passion for her in 2008, and she is dedicated to providing accurate information regarding oil use in the animal kingdom. Dr. Shelton is the creator of animalEO Essential Oils for Animals (animalEO.info), a line of expertly formulated blends specifically designed for all animals.

9. DR. MARK SUCKOW, DVM Dr. Mark Suckow has dedicated his career to understanding ways to stimulate the immune system against cancer, leading to the formation of Torigen Pharmaceuticals. For more information, visit torigen.com.

10. RYAN E. WALRATH, DVM Dr. Ryan Walrath DVM is a 2001 Graduate of the University of Missouri College of Veterinary Medicine. His first seven years of experience consisted of mixed animal medicine and surgery in Missouri, Illinois and Iowa. For the past 11 years, he has been practicing companion animal medicine and surgery exclusively, in southeast Iowa. His love for the outdoors keeps him on the move and enjoying everything from western landscapes and mid-western lakes, streams and rivers to sunny beaches wherever they may be found.

11. SARA C. WHITE, DVM, MSC Dr. Sara White is a 1998 graduate of North Carolina State University College of Veterinary Medicine, and has worked in shelter medicine and high quality, high volume spay/neuter through most of her career. Since 2006, she has operated Spay ASAP Inc., a non-profit MASH-style mobile spay/neuter clinic, and has spayed or neutered over 50,000 animals in Vermont and New Hampshire. Dr. White also developed an interest in ergonomics, health, well-being and injury in veterinarians and staff, and in spring 2015 completed a Masters of Science in Health Ergonomics from the University of Derby (UK). She founded ErgoVet to provide information and consulting in veterinary ergonomics.

Dr. White is editor of the upcoming textbook High-Quality, High-Volume Spay and Neuter and Other Shelter Surgeries.

12. CHELSEA KENT Chelsea Kent is a Nutrition and Regulation Research Specialist in the pet food industry, as well as the owner of Food Regulation Facts Alliance and Hero's Pets in Littleton, Colorado.

13. SHANNON L. KESL, PHD Shannon Kesl earned her PhD in Medical Sciences from the Morsani College of Medicine at University of South Florida, where she focused on the effects of exogenous ketones for agedependent impaired wound healing. She currently serves as a scientific advisor for the Epigenix Foundation in Los Angeles, California, where she focuses on the effects of metabolism and nutritional interventions on canine and human health.

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editorial

OUR LIVES, WILD AND PRECIOUS

Applying a seasonal perspective to our profession, the autumn of our careers should be a time to harvest what we have sown through years of study and training — for many veterinarians, it’s the culmination of a dream they’ve held since childhood. Why, then, do we so often find ourselves depleted and withered at the end of the day, the month, or even entire seasons of our lives?

We spend enormous amounts of time and energy educating clients about how to restore health and wellness to their beloved animals. We study and practice, always seeking a deeper understanding of what creates health — and what undermines it in our patients. Yet many of us have large blind spots when it comes to examining our own lives as closely as we examine those of our patients. Sometimes, when we choose to explore these blindspots honestly, what we find is deeply unsettling.

As with all wounds, however, illuminating what needs to be healed is necessary and good. With that in mind, this issue of IVC Journal brings light to the essential topic of self care in the veterinary profession.

For example, Dr. Jenny Elwell-Gerken explores the value of examining our mindsets and boundaries instead of just trying to sustain a life-work balance. Drs. Nancy Scanlan and Barbara Fougere dive deeply into the physiology of wellness with their respective analyses of the relationship between stress, inflammation and depression, and the vital importance of performing reality checks on our own physical fitness.

Dr. Melissa Shelton offers simple ways to use the physical, emotional, and mental benefits of essential oil therapy for your own daily well-being; while Dr. Sara White invites us to think about our practices ergonomically, analyzing risks and implementing practical ways to reduce them.

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And Dr. Karen Gellman updates us on CBD dosing and sourcing — with applications for self-care as well.

We also conclude our KetoPet Sanctuary series with case studies that apply this important information to the private practice setting. Dr. Ron Carsten presents an in-depth piece on the intricate relationship between canine allergic dermatitis and key body systems, and the need for a systemic approach to case analysis and treatment. Last but not least, Dr. Ryan Walrath demonstrates the use of cryosurgery innovations for commonly-occurring dermal masses.

As we transition from the long days of summer to the reflective season of fall, I share with you the concluding lines of one of my favorite poems by Mary Oliver, “The Summer Day”: “…I don’t know exactly what a prayer is.

I do know how to pay attention, how to fall down into the grass, how to kneel down in the grass, how to be idle and blessed, how to stroll through the fields which is what I have been doing all day.

Tell me, what else should I have done?

Doesn’t everything die at last, and too soon?

Tell me, what is it you plan to do with your one wild and precious life?”

May all of you, as you daily seek to heal the lives of your patients, treat yourselves as well as each other the very same…with a loving kindness that honors each and every wild and precious life.

Laurin Cooke, DVM Associate Editor, drlaurin@ivcjournal.com

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INFLAMMATION, DEPRESSION, AND THE ROLE OF DETOXIFICATION We’re all aware that stress is common among veterinarians. But did you know that stress is also linked to chronic inflammation, which can in turn cause depression? Understanding this connection, and knowing what to do about it, can improve your quality of life both on and off the job.

By Nancy Scanlan, DVM If you’re stressed and/or have been diagnosed with depression — a fairly familiar occurrence among veterinary practitioners — you may also have chronic inflammation and don’t even know it. The incidence of chronic inflammation increases with age, and there are a wide range of common causes. They include genetic factors,1 exposure to xenobiotics such as plastics and pesticides,2 an unhealthy microbiome,3 the American diet,4 metabolic disease,5 obesity,6 chronic conditions such as heart disease,7 an imbalance of Phase I and Phase II enzymes in the liver (see sidebar on page 12),8 poor early-life nutrition9 and vitamin D deficiency9 — but they also include stress9 and depression.11

and endothelial dysfunction. These symptoms are not only seen in people with cardiovascular disease, but also in most of those who have been diagnosed with major depressive disorders.11 Core features of major depression include an increased reactivity to negative information, a less positive reaction to rewards, a lowered ability to control thoughts, and an extreme focus on physical symptoms. Pain or fatigue can cause major emotional distress to the point where the patient has difficulty functioning in daily life activities. Increased inflammation makes these signs worse.13

Psychosocial stress increases inflammatory cytokines, including interleukin-6 (IL6), interferon gamma, and tumor necrosis factor alpha (TNFα). Affected people also show lower levels of beneficial interleukin-10 (IL10) than those without stress and anxiety.12

Chronic inflammation is a major factor in six of the ten leading causes of death in the United States, as well as in depression (the second most common mental illness in the U.S.).11,14 In fact, there is evidence that while inflammation can cause depression, depression also causes inflammation. Increased inflammation makes depression worse, and high levels of inflammatory markers are associated with depression that is more resistant to antidepressant therapy.15

Chronic stress leads to an imbalance between the sympathetic and parasympathetic systems, marked by increased stimulation of the sympathetic system and decreased vagal tone. An increase in stress hormones influences the immune system to create a pro-inflammatory state, while decreased vagal tone leads to a pro-inflammatory state in the gut. The end result is generalized inflammation, platelet activation, loss of heart rate variability,

C-reactive protein (CRP) is a test for the general level of inflammation in the body, and is easily available as an addition to any blood panel. Inflammation increases with stress, and we all know that many stressful incidents occur in a veterinary practice. Incidence of chronic inflammation increases as we get older, yet CRP is not routinely included in annual blood tests – not even for seniors.

THE RELATIONSHIP BETWEEN STRESS, INFLAMMATION AND DEPRESSION

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Genetic tests are available for other markers of chronic inflammation, including genes for inflammatory cytokines, especially interleukin-1 beta (IL-1β), IL-6, IL-10, monocyte chemoattractant protein-1, TNFα, CRP and phospholipase A2. Moreover, increased blood cytokines mRNA expression (especially of IL-1β) identifies patients that are less likely to respond to conventional antidepressants.1

TREATING DEPRESSION — AND INFLAMMATION • Physicians are starting to use NSAIDs in addition to conventional drugs to treat depression, especially celecoxib and aspirin.

They often get better results than with drugs alone.14,16,17,18 Most studies have used NSAIDs for acute depression, not chronic depression, but it is logical that anti-inflammatory agents should also be useful for chronic depression. It’s likely it would take longer to see effects in cases of long-standing depression.

• Some antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), decrease inflammation. They decrease pro-inflammatory cytokines, including TNFα, interferon (IFN) γ and IL-1, and increase anti-inflammatory cytokines such as IL-10.19,20 • A natural way to accomplish the same effect is to change to an anti-inflammatory diet. Diets high in fruits and vegetables decrease CRP levels, and normalize factors that affect endothelial health, including soluble intercellular adhesion molecule 1, soluble vascular adhesion molecule 1, and E-selectin molecules.21 Metabolic disease, associated with the typical American diet, predicts a poor response to standard treatment for those with depression.22

associated with the types of side effects seen with long-term NSAID use. However, one must be careful using these supplements, since a number of them have hermetic (biphasic) effects, where a low dose can cause one effect and a high dose may cause the opposite.8,29 •A

voiding dietary substances such as glutamate both reduces inflammation and improves depression.30 Induced sweating, both from exercise and from saunas, can increase excretion of phthalate plasticizers.31 Exercise has beneficial effects in general, and can help decrease liver inflammation.32 •T he microbiome also plays a part in chronic inflammation. There are multiple links between gut organisms, diet and depression.

Early life trauma, the effects of various drugs, especially antibiotics, as well as nutritional factors affect the microbiome.

In turn, a change in gut flora composition has been shown to affect depression, positively or negatively, depending on the change. Including prebiotics can help: inulin selectively stimulates colonic bifidobacteria, which play a part in maintaining a proper balance of microbiome species.33

DETOXIFICATION AND MEDICAL FASTING

• Immune cells and gut microbiota influence the brain,23 and fiber favorably influences the gut microbiome.24 Beta-glucans, which promote normal immune function, are plentiful in whole grain foods.25 Consumption of whole grains decreases the risk of inflammatory disease.26

Detoxification is a recognized procedure in reversing chronic disease.38 It is a modified form of fasting, with added nutritional products that support Phase I/Phase II enzyme activity in the liver. In Europe, this procedure is known as “medical fasting”, an established therapeutic approach supported within clinical departments of integrative medicine.38 Research demonstrates its association with deceleration or prevention of chronic inflammatory diseases.39 Medical fasting reduces or prevents the generation of cytokines that promote oxidative stress.40 It decreases free radical generation by mitochondria, decreases oxidative damage to mitochondrial DNA,41 and increases autophagy.42 Most importantly, it eliminates persistent toxicants.43

• Certain herbs, vitamins and supplements also have anti-inflammatory actions27,28 and are not

Fasting can also help depression. Its efficacy on improving mood is well established.44 Symptoms Continued on page 13.

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PHASE I AND PHASE II

LIVER ENZYMES With long-standing inflammation, prolonged exposure to xenobiotics, persistent toxicants that are hard to eliminate — or a Phase I/ Phase II liver enzyme imbalance34 — merely adding antioxidant foods and supplements might not be enough. Toxicants that are not directly eliminated through the kidneys are processed through Phase I and Phase II liver enzymes, and when the level of toxicants exceeds the capacity of the liver to process them, detoxification is necessary to eliminate them.

Phase I enzymes primarily consist of the cytochrome P450 group (CYP450), along with a few others. The role of Phase I enzymes is to take a fat-soluble substance and make it more chemically reactive, by oxidation/reduction and/or hydrolysis reactions. Because the products of Phase I actions are highly reactive, they are also highly inflammatory, but in a healthy balanced liver they immediately react with Phase II enzymes.

Phase II enzymes conjugate those molecules with hydrophilic cofactors. This results in water-soluble molecules that can be excreted through the kidneys. Phase II enzymes include UDP-glucuronosyl transferases, glutathione S-transferases, amino acid transferases, N-acetyl transferases, and N- and O- methyltransferases. The cofactors used for conjugation include glucuronic acid, sulfate, glutathione, various amino acids, an acetyl group and a methyl group.35 There are a number of ways that Phase I/Phase II imbalances can interfere with the elimination of inflammatory substances. When there is a low level of both enzymes, the liver processes waste products and toxins more slowly, and those toxic substances build up in the body. Initially, they are stored in body fat, but when fat depots are full, they remain in interstitial spaces, where they interact with cells and cause inflammation. The same effect occurs with a low level of Phase I enzymes alone, since Phase I treatment is required for Phase II reactions to occur.

When the imbalance is reversed, so that you see an excess of Phase I reactions, or lower than normal Phase II enzyme activity, a buildup of inflammatory highly-reactive electrophilic molecules occurs. This can result in local liver inflammation, or system-wide inflammation, when they are released into the bloodstream.

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If there are not enough cofactors to allow full conjugation of all the inflammatory products of Phase I, the result is the same.

In addition, Phase I enzyme activity can easily be increased, especially with high exposure to toxic substances. It is more difficult to increase Phase II, so the result again is an imbalance, with excess Phase I activity with respect to Phase II activity.36 A determination of Phase I/Phase II imbalances could help with cases of chronic inflammation that do not yield to dietary, herbal or nutraceutical intervention.37 Two labs that offer tests to determine Phase I/Phase II imbalance are Genova Diagnostics in Asheville, NC, and The Great Plains Laboratory in Lenexa, KS. For optimal elimination of toxic substances, a number of principles must be followed. To safely increase this elimination, the level of substances normally processed by the liver must be decreased. This frees up more Phase I/ Phase II enzymes to process toxins. It also allows toxic substances to be released from fat storage, as total blood concentration decreases.

A high amount of naturally-produced waste products will decrease the level of toxic products that can be processed.

Those products will be stored elsewhere in the body — first in the fat and later, when fat depots are filled, in interstitial spaces. They are generally inflammatory, contributing to the inflammatory cascade and causing chronic inflammation.

The best way to remove inflammatory products is to decrease the amount of normal waste products present. A fast eliminates most by-products of digestion, and is part of the detoxification process.

In addition, enough conjugates must be available for Phase II enzymes to work at full capacity. The body must stay hydrated to flush the end products away as quickly as possible. Essential nutrients must be maintained so that organs and muscle are not degraded while the process is going on. Additional nutrients must be added to support microbiome health throughout the process, and to provide antioxidant capabilities. A proper detoxification protocol accomplishes all of this.

Continued from page 11. of depression usually start improving on Day 2 of the fast, with an enhancement in alertness and mood, and a sense of tranquility.45 It is important for fasting to be done properly. There must be enough nutritional support to reduce inflammation from Phase I processes, decrease the chances of overactivating the Phase I process, and to supply enough cofactors for Phase II conjugation to proceed as thoroughly as possible. The detoxification process can be modulated using foods and nutraceuticals.

Fasting also has a dark side. It can decrease the immune system’s performance and cause atrophy in various organs.46 It causes changes in blood glucose regulation, plasma growth hormone (GH), insulin-like growth factor 1 (IGF-1), and insulin-like growth factor-binding protein-3 (IGFBP-3).47 There is a need for some protein and healthy fats during fasting48 to support the body’s daily metabolic processes, so that muscle and organ tissue will not be destroyed in order to provide the required nutrients. When fasting is excessively prolonged and suddenly ended, re-feeding syndrome has been reported,49 which can result in illness or death. Intracellular phosphate, magnesium and potassium may be low, though serum measurements of the three electrolytes are normal. With a reversal of metabolism from fat-based to carbohydrate-based, electrolytes are needed but not available, resulting in hypokalemia, hypophosphatemia and hypomagnesemia. Death from heart failure can occur. Unexplained deaths have been reported in obese individuals who were fasting.50 The best way to avoid these unpleasant effects when detoxing is to use a supplement with nutraceuticals that support Phase II conjugation, decrease the inflammatory effects of Phase I activity without stopping the wanted chemical effects, and supply necessary components to avoid tissue and organ destruction. In addition, rather than abruptly starting and stopping the fast itself, a more gradual introduction to the fast and resumption of a normal diet will avoid reactions similar to re-feeding syndrome.

Two products are available that will do this: Ultra-Clear from Metagenics in CA, and Mediclear from Thorne Research in SC. These products are accompanied by guides for their use and the proper beginning and end of the detoxification process. This approach is superior to some popular fasting methods, including the water fast.

When properly conducted, a fast can decrease or eliminate toxicants that are causing inflammation and depression. With severe depression, fasting should not be done without medical supervision and appropriate supplementation. It is safer if the only object is to reduce potential chronic inflammation without any overt signs of disease, but the healthiest way is still a fast with the addition of proper products to avoid protein degradation in the body, support Phase II conjugation, decrease inflammation, and maintain proper electrolyte balance.

For more information, see Dr. Scanlan’s blog at longerhealthierlife.net.

References available online at IVCJournal.com.

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PEER-REVIEWED

Canine

allergic dermatitis: A SYSTEMIC APPROACH TO MANAGEMENT

Allergic dermatitis in dogs is not just a localized problem; it is a clinical issue with systemic contributors. Therefore, treatment should address both local and systemic factors using integrative therapies that address key body systems.

By Ron Carsten, DVM, PhD, CVA, CCRT Allergic dermatitis is a common and challenging problem in dogs. This article briefly describes canine allergic dermatitis and its local and systemic components, including the influential role of the small intestine, liver, adrenal glands, central nervous system, microbiota and anxiety in allergic inflammation.

The importance of a complete patient evaluation will be highlighted, and the rationale for a systemic approach to management using nutritional supplements, herbs, probiotics and homeopathic medicines will be outlined.

MORE THAN A LOCAL SKIN ISSUE Allergic dermatitis has long been viewed as a disease that’s localized in the skin. It is now clear, however, that it is a complex clinical issue with local and systemic inflammatory processes influenced by secondary contributing factors.

The local reactions are an intricate and finely orchestrated interaction between the allergen and resident immune cells.

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These local reactions are also capable of recruiting non-resident immune cells to reinforce local immune reactions.

Unfortunately, from a clinical management perspective, the local reactions are not the complete story. Beyond the local reaction is an incredible interwoven pattern of interaction between the immune system, nervous system, endocrine system, skin and mucosal barriers with associated immune elements, and the microbiota. Each reacts to and is influenced by the other, meaning that effective integrative management must support multiple body systems simultaneously.

CANINE ALLERGIC DERMATITIS — ENVIRONMENTAL ALLERGENS AND ADVERSE FOOD REACTIONS

Three main allergy categories have been described: insect bite (i.e. flea) hypersensitivities, adverse cutaneous food reactions, and atopic dermatitis from environmental

allergens.1 Classically, canine atopic dermatitis is defined as a pruritic allergic skin disease commonly associated with IgE to environmental allergens in genetically predisposed individuals.2 Interestingly, an atopic-like dermatitis has been described with similar clinical signs as canine atopic dermatitis; however, an IgE response to environmental allergens cannot be demonstrated,3 implying that IgE-mediated reactions are not always the central process in allergic inflammation.

It is estimated that 10% to 15% of dogs are affected by dermatitis resulting from reactions to environmental allergens.1 Cutaneous manifestations of adverse food reactions are recognized as indistinguishable from the classic environmental allergic disease.3 The incidence of adverse food reactions in the dog is not completely clear, but an estimated 9% to 40% of pruritic dogs and 8% to 62% of dogs with allergic skin disease are affected.4 Approximately 30% of dogs with allergic dermatitis are affected by reactions to both environmental allergens and food.5 Since canine atopic dermatitis is a clinical diagnosis that can result from environmental allergens and adverse food reactions, both will be referred to here as canine allergic dermatitis (CAD), and their intertwined features will be outlined.

Clinical signs of CAD generally include pruritus and erythema. Self-induced alopecia and excoriation are common. Secondary infections occur with microbes like Malassezia with epidermal hyperplasia, hyperpigmentation and lichenification; and Staphylococcus with crusts, papules and pustules. Affected areas include the ventral abdomen, distal extremities, axillae, and the inner pinnae, perioral, periocular and perianal regions. Otitis externa is reported in half of dogs with canine atopic dermatitis.2 The predominant lesions in atopic dermatitis dogs occur in the skin; however, other organs like the digestive and respiratory tracts can be involved.1 Breed predisposition and breed-associated cutaneous distribution patterns have been reported.

Criteria for diagnosing atopic dermatitis have been developed.

Accurate diagnosis and evaluation of secondary factors is essential. Ruling out ectoparasites like fleas is critical. Adverse food reactions can have cutaneous signs that mimic atopic dermatitis in addition to gastrointestinal signs.6 CAD related to environmental allergens is generally seasonal at onset; however, it can exhibit a non-seasonal pattern. The majority of dogs with a seasonal pattern have clinical signs in the spring or summer, while those with a non-seasonal pattern are often worse during a specific season. The presence of pruritus is considered an essential component of diagnosis.

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in 43% of canine atopic dermatitis patients.6 The variability of presentation underscores the need for a systematic approach to patient evaluation, and consideration of the diagnostic criteria for CAD.

ALLERGIC INFLAMMATION: THE SYSTEMIC WEB The allergic reaction has been considered an overreaction to harmless allergens. This brings to mind images of immune cells aggressively attacking a harmless invader. The alternative image is of an immune response that is dysregulated because the mechanisms that would normally keep allergic inflammation in balance are not functioning appropriately. The coordination and control of allergic inflammation is a process involving a complex web of interactions, systems and body tissues, which means this control is not strictly a local problem at the site of allergic dermatitis (see Figure 1).

Regulation involves a series of interactive adjustments that influence each component of allergic inflammation. Some events are rapidacting; others are delayed. When IgE with bound allergen contacts the mast cell membrane receptor FcεRI, the mast cell degranulates, releasing substances like histamine followed by synthesis and release of cytokines and chemokines. Histamine’s rapid reactions include vasodilation and increased vascular permeability.

Cytokine and chemokine reactions, which occur later, include recruitment and activation of inflammatory cells at the local site as a result of increased local concentrations, and from systemic circulation. In the naïve individual, the process takes longer because the allergen has to be initially processed. Antigen processing cells like the dendritic cell (DC) take up the allergen and transport it to the regional lymph or local tissue site.

When the DC presents the processed allergen peptides to naïve T cells, they become T helper 2 cells (TH2).

The TH2 influence later allergic reactions by producing interleukin-4 (IL-4) and IL-13 that combine with

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other co-stimulatory molecules to induce B cells to produce IgE. The IgE diffuses locally and in the lymphatics for eventual systemic distribution in the bloodstream.7 This simplified presentation of the local allergic inflammatory reaction, and the implication of a modest systemic effect, is inadequate for describing the sophisticated systemic influence.

This complex regulation is why allergic inflammation and CAD are so difficult to manage clinically. Stated in another way, allergic dermatitis is a whole body problem (see Figure 1).

The skin and mucous membranes form the first barrier against allergens. Allergens enter tissues in multiple ways — for example, through a damaged or altered surface barrier, penetration facilitated by allergen proteolytic properties,

Figure 1: A generalized overview of systemic processes and supportive care (in green) that can influence the development and management of canine allergic dermatitis. It is not intended to be an all-encompassing representation of the complex interactions that lead to propagation of allergic inflammation. Psychological stress is used here to denote the individual patient’s reaction to what they perceive as stressful or anxiety-provoking external (i.e. environmental conditions) and/or internal (i.e. illness, pain) issues. (CNS — central nervous system; PNS — peripheral nervous system; ANS — autonomic nervous system)

and allergen epithelial binding. Mucosal barrier damage in the intestine can result from inflammation, inadequate levels of certain nutritional factors, and dysbiosis of intestinal microbiota. This inflammation provides opportunity for allergen penetration beyond the mucosal surface, which can elicit local and systemic reactions. Note that “intestinal microbiota” refers to the living microorganisms inhabiting the gastrointestinal tract, including bacteria, viruses, fungi and protozoa,8 as opposed to the term “microbiome”, which includes microbe genomes.

In addition to local and systemic signaling with cytokines and chemokines, an intimate interaction between the immune and nervous systems plays an important role in regulating the inflammatory response. Communication between these systems involves neurotransmitters, endocrine hormones and cytokines.

The autonomic nervous system and hypothalamic-pituitaryadrenal (HPA) axis play central roles.9 There is evidence that a hyporeactive HPA axis significantly increases the susceptibility to developing chronic inflammation. The sympathetic adrenomedullary system also has significant effects on immune regulation and stress responses.10 Lymphoid tissues, including mucosal-associated lymphoid tissue, lymph nodes, spleen, liver and bone marrow are innervated by the parasympathetic nervous system through the neurotransmitter acetylcholine and the sympathetic nervous system (SNS) through norepinephrine.

Neurotransmitter receptors for acetylcholine and norepinephrine are present on lymphocytes as well as serotonin, substance P and histamine. Receptors for neuroendocrine mediators like corticotropin-releasing hormone (CRH) and leptin are present in lymphoid tissue.11 Glucocorticoids are the key effector molecules of the HPA axis. Adrenocorticotropic hormone (ACTH) appears to increase pro-inflammatory cytokines that are modulated by the glucocorticoid production they stimulate. Interestingly, chronic allergic disease has been associated with higher levels of TH2 and reduced glucocorticoid levels.12 A peripheral HPA axis, distinct from the central HPA axis, has been described in the skin. The peripheral HPA axis has similar components and a regulatory hierarchy that exists for the central HPA axis. Keratinocytes are able to produce CRH, ACTH, cortisol, neurotransmitters, neurotrophins, neuropeptides and their respective receptors. This peripheral HPA axis appears to be an important part of maintaining the epidermal barrier and modulating inflammation.12 The liver contains a large population of resident immune cells and is responsible for the production of substances involved in immune reactions, such as cytokines, chemokines and acute phase proteins. This is in addition to its metabolic, nutrient

MANAGEMENT OF ALLERGIC INFLAMMATION • Assess and diagnose patient • Evaluate for secondary contributors u Secondary skin infections u Adverse food reactions u Anxiety and other stresses • Provide whole food concentrate supplement support (Canine Dermal Support™) u Adrenal glands u Liver u Small intestine u Cutaneous and mucosal barriers • Provide gut microbiota support u Probiotic and prebiotic products u Manage gut microenvironment as needed • Provide homeopathic medicines for potential vaccinosis • Manage secondary skin infections u Antimicrobial shampoos • Manage otitis externa • Address adverse food reactions u Food trials or hydrolyzed diets • Manage anxiety and other stresses u Bach flower remedies u Nutraceutical products (i.e. Composure™) u Anti-anxiety or calming herbs u Manual therapies • Re-evaluate patient each four to six weeks u Alter support program based on response and assessment u Consider seasonal adjustments

storage and detoxification functions. The hepatic immune system is exposed to a wide range of dietary, microbial and environmental molecules derived from the gut. Resident macrophages (Kupffer cells), which constitute almost a third of the non-parenchymal cells of the liver, and hepatocytes are able to recognize and remove immunogenic substances without producing inflammatory mediators. This is important because it prevents these immunogenic substances from entering the systemic circulation to elicit a wider immune reaction. Other immune cells in the liver include DC, T cells, B cells and natural killer cells. Even though the hepatic immune system has evolved to have some level of immune tolerance, there is some level of ongoing regulated inflammation that is thought to be beneficial for the liver.13 The intestinal tract provides a selective barrier for nutrient absorption and the exclusion of harmful substances and microbes. This process requires a properly-functioning IVC Fall 2019

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mucosa and mucosal immune system. Intestinal microbiota have significant impacts on health based on their composition and interaction with the mucosal immune system. Interaction between intestinal microbes and the mucosal immune system allows for immune tolerance to microbes and harmless substances while allowing the immune system to react to pathogens. Epigenetic modifications of intestinal epithelial cells following exposure to microbial products facilitate tolerance. Intestinal DC sample intestinal microbiota and transport the bacterial-derived antigens to the mesenteric lymph nodes. This allows the immune system to be rapidly responsive if there is damage to the mucosa and leakage of microbes or microbial metabolites that overwhelm the liver immune system.14 Mucosal barrier health is essential for preventing the absorption of microbes, microbial metabolites and other immunogenic substances. By extension, a healthy mucosal barrier significantly reduces the level of inflammation.

Alterations in the composition of the skin and intestinal microbiota have been linked to allergic dermatitis.15 Interaction between intestinal microbes, dietary nutrients, the gut microenvironment, mucosal immune system and neuroendocrine substances have direct and indirect effects on the composition of the skin and intestinal microbiota.

This can significantly influence the quality of the mucosal and dermal barriers, exposure to allergens, relative levels of allergic inflammation, development of allergic dermatitis, and response to therapy. For example, beneficial microbes directly and indirectly impact the growth and colonization of pathogens.8 This impacts inflammation, mucosal barrier function, and tolerance.16 Studies in humans demonstrate that stress is associated with increased allergic inflammation.9 Stress activates the HPA axis, SNS and sympathetic adrenomedullary system, which lead to increased CRH, ACTH and glucocorticoids. A chronicallyactivated HPA axis results in a dysregulatory effect on inflammation that may be due to low glucocorticoid levels from adrenal exhaustion or tissue receptor resistance. In addition, chronic elevations in ACTH may result in increases in proinflammatory cytokines.11,12 Chronic stress and inflammation result in changes to the dermal barrier that predispose the skin to secondary infections and increased response to allergens.

MANAGEMENT OF CANINE ALLERGIC DERMATITIS Current conventional therapy for CAD involves managing acute flares and chronic skin lesions, and attempts to prevent relapses.17 Avoiding trigger allergens, controlling secondary skin infections, and reducing pruritus form the foundation of

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therapy. This often involves topical and oral therapies, including antimicrobials, antihistamines, shampoos and immunesuppressive drugs. Food elimination trials and hydrolyzed diets are frequently used for adverse food reactions.1 Each option has variable degrees and quality of research support for efficacy.

The selection and implementation of each management component depends on careful patient assessment, severity of clinical signs, and prior history. Clinician experience plays a role in selection of the therapeutic plan.

From an integrative perspective, once a clear diagnosis has been achieved, it is critical to evaluate the patient as a whole so clear therapeutic goals and a management plan can be defined.

Particular attention should be paid to historical factors like prior antimicrobial and immune-suppressive therapy, vaccination history, personality and level of anxiety, and gastrointestinal sensitivities. Identify the presence of secondary infections and ectoparasites. Observe the severity of the pruritus and the allergic dermatitis.

Realistic goals for CAD management include reducing pruritus to a tolerable level and decreasing the severity of acute flares and relapses. It is not always possible to completely resolve all pruritus and prevent acute flares. Immune-suppressive therapies and systemic antimicrobials may be necessary to initially control allergic inflammation and address secondary infections, thereby providing patient comfort or preventing self-mutilation.

Based on a broader view of allergic inflammation and the role of systemic factors, as briefly discussed here, key areas of focus for supportive therapy include the adrenal glands, liver, intestine, autonomic nervous system, immune system, intestinal microbiota, skin and mucosa (see Figure 1). All these areas should be supported at the same time instead of sequentially. Focusing on these areas will provide support for reducing the inflammatory process, improving barriers, and decreasing allergen exposure. Additional areas of support should include managing the anxiety that is not addressed through support of the adrenal glands (see Table 1).

SPECIFIC THERAPIES The systemic approach to managing CAD patients described here relies on published research related to the physiological mechanisms of allergic inflammation and responses to therapy, the author’s decades of clinical experience with allergy patients and whole food nutritional supplements, and his clinical exploration of the organ and gland imbalances that influence allergic inflammation. This perspective led to his development of Canine Dermal Support™ for Standard Process IncŽ.

Consistent clinical response was a critical component in product development and patient management. No controlled studies are currently available to validate this approach in its entirety.

The foundational product for this approach is Canine Dermal Support™, which is a whole food concentrate product. A discussion of the use of whole food concentrates as compared to isolated nutrients is beyond the scope of this article; however, whole food concentrates are an essential component of the systemic approach described here.

Table 1: Influential sites for allergic inflammation regulation Barriers

Epidermis and intestinal mucosa

Neuroendocrine

Adrenal glands and keratinocytes

Immune

Intestinal, hepatic, and adaptive

Sympathetic adrenomedullary system

Adrenal glands and sympathetic nervous system

Intestinal microbiota

Composition and gut microenvironment

The systemic approach (see sidebar on page 17) becomes more effective if the adrenal glands, small intestine, liver, nervous system and intestinal microbiota are supported together as the initial step. Canine Dermal Support contains a combination of whole food concentrates and herbs like Silybum marianum, Emblica officinalis and Taraxacum officinale that provide nutrients and bioactive substances for the adrenal glands, liver, small intestine, nervous and immune systems. If support from this product for targeted tissues is inadequate based on patient evaluation and clinical response, Canine Adrenal Support™, Canine Hepatic Support™ or Canine Enteric Support™ can provide additional help. Herbs like Silybum marianum, beneficial for its liver and bile support, as well as Rehmannia glutinosa for its adrenal and immune benefits, can be employed as needed.

Concern has been expressed regarding the use of supplements containing bovine origin ingredients in patients with a known or suspected adverse reaction to beef. In the author’s experience, this has not been a clinical problem when using the supplements discussed here.

A number of likely reasons contribute to this observation, including the relatively small quantity of bovine IVC Fall 2019

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CASE STUDY:

Lex, intact male boxer 21/2 years Lex had a history of moderate to severe pruritus that was generalized but especially prominent on the face and muzzle, self-induced alopecia, ear sensitivity, and periodic conjunctivitis and episcleritis. Clinical signs first appeared while he was a puppy and were progressive. Treatment consisted of ongoing support with Canine Dermal Support™ and one dose of homeopathic Silicea 30C. Conjunctivitis and episcleritis were initially managed with topical prednisolone ophthalmic suspension 1.0%.

Lex’s pruritus gradually diminished and resolved over a six- to eight-week period following initiation of support. Mild seasonal flares occurred during the first two years of management and then did not recur. The conjunctivitis did occasionally recur. Canine Dermal Support was continued until the dog was 11½ years of age.

origin ingredients in the recommended supplements; also, these supplements support improvement in the intestinal mucosal barrier while reducing dysregulation of the immune reactions contributing to allergic inflammation. A high quality probiotic containing a prebiotic will complement this regimen. Selecting a probiotic product should be based on clinically-demonstrated effects. Determination of probiotic efficacy can be challenging and may require changing probiotics or initiating therapies that change the microenvironment of the gut. This would include using products or herbs that increase the flow of bile, adding soluble fiber to the diet, or facilitating the reduction of high SNS tone if present.

Anxiety and other psychological stresses should be addressed early in the management of allergies since stress can play a significant role in immune dysregulation and the stimulation of pruritus. A variety of approaches is available and should be selected for the individual patient, especially if adrenal support alone does not appreciably change the stress response pattern.

These include Bach flower remedies, supplements like MinChex®, nutraceutical products such as Composure™, herbs or combinations selected for the individual patient, and/or medications. It is also important to consider working with a behaviorist or qualified trainer to find ways to manage stress or reduce sensitivity to stimuli. Manual therapies can be used to reduce pain and activation of SNS responses.

The role that vaccination plays in promoting allergic inflammation is unclear, but clinical observations and reports of dogs with pre-existing allergies have shown increases in IgE following prophylactic vaccination. This increase was present at one and three weeks, but not eight weeks, post-vaccination.18 While the implications are not clear, it shows how allergic dogs could worsen following vaccination, and why there has been a casual observation that allergies are exacerbated four to six weeks postvaccination. In addition, since the IgG was also shown to increase, it is possible to speculate that a low grade chronic inflammatory process could be established in susceptible individuals. The author has found consistent improvements in allergy patients by using the homeopathic rubric related to vaccinations. Commonly-used homeopathic medicines include Silicea and Thuja occidentalis; however, selection should be based on the individual patient. The selected homeopathic medicine, potency and dosing plan can be initiated at the beginning of therapy.

For patients with otitis externa problems, the approach described above is useful in addition to topical management of the ear canals. It is important to treat the infections and reduce inflammation. Anti-inflammatory ear products and washes can be helpful. Since otitis externa can be a long-term problem with occasional flares, it may require ongoing therapy.

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Patients with secondary infections often benefit from antimicrobial shampoos while the systemic management plan is being instituted. Multiple shampoo treatments may be required until control is established and barrier health has improved. Ectoparasites like fleas and lice should be treated and the environment managed as appropriate.

For patients that are excessively pruritic and self-mutilating, a course of diphenhydramine, prednisone or oclacitinib may be indicated. While there is concern that the use of immunesuppressive drugs like prednisone can make later management more difficult, the patient has need for more immediate relief

than can be provided with nutritional supplements alone. If immune-suppressive therapy has been ongoing and the liver and adrenal glands have been impacted, consider additional Canine Hepatic Support™ and Canine Adrenal Support™.

Clinical response to Canine Dermal Support™ and probiotics takes four to six weeks depending on the severity of the clinical condition, presence of complicating factors, and history of previous suppressive therapies. Adjustments to the support plan are made at monthly rechecks, unless needed sooner based on patient condition.

Keep in mind that regardless of how the patient is managed (conventionally or integratively), pruritus is not always completely controlled and acute flares can occur. It is also interesting to note that in addition to the initial benefits of this approach, patients will continue to improve clinically over the course of a four- to five-year period when this approach is continuously used.

Disclosure: The author of this publication formulated and clinically evaluated the original 16 Standard Process Veterinary Formulas™ during product development as a paid consultant for Standard Process Inc.® He is not employed by Standard Process Inc.®, derives no financial benefit and has no equity interest in either Standard Process Inc.® or Standard Process Veterinary Formulas™.

Gedon NKY, Mueller RS. “Atopic dermatitis in cats and dogs: a difficult disease for animals and owners,”Clin Transl Allergy, 2018;8:41.

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² Hensel P, Santoro D, Favrot C, et al.“Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification,” BMC Vet Res, 2015;11:196. ³ Marsell R, Benedetto AD.“Atopic dermatitis in animals and people: an update and comparative review,”Vet Sci, 2017;4:37. ⁴ Olivry T, Mueller RS. “Critically appraised topic on adverse food reactions of companion animals (3): prevalence of cutaneous adverse food reactions in dogs and cats,”BMC Vet Res, 2017;13:51. ⁵ Jackson HA, Murphy KM, Tater, KC et al. “The pattern of allergen hypersensitivity (dietary or environmental) of dogs with non-seasonal atopic dermatitis cannot be differentiated on the basis of historical or clinical information: a prospective evaluation 2003-2004,”1Vet Dermatol, 2005;16:200. ⁶ Favrot C. “Clinical signs and diagnosis of canine atopic dermatitis,”EJCAP, 2009;19(3):219-222. ⁷ Galli SJ, Tsai M, Piliponsky AM . “The development of allergic inflammation,”Nature, 2008;454(7203):445-54. ⁸ Kim D, Zeng MY, Nunez G. “The interplay between host immune cells and gut microbiota in chronic inflammatory diseases,”Exp Mol Med, 2017;49:e339. ⁹ Dave ND, Xiang L, Rehm KE, et al. “Stress and allergic diseases,”Immunol Allergy Clin North Am, 2011;31(1):55-68.

Buske-Kirschbaum A, Geiben A, Hollig H, et al. “Altered responsiveness of the hypothalamic-pituitary-adrenal axis and the sympathetic adrenomedullary system to stress in patients with atopic dermatitis,” J Clin Endocr Metab, 2002; 87(9):4245-51.

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Steinman L.“Elaborate interactions between the immune and nervous systems,”Nature Immunology, 2004;5(6):575-81.

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Lin T-K, Zhong L, Santiago JL. “Association between stress and the HPA axis in the atopic dermatitis,” Int J Mol Sci, 2017;18:2131.

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Robinson MW, Harmon C, O’Farrelly C. “Liver immunology and its role in inflammation and homeostasis,” Cell Mol Immunol, 2016;13:267-76.

13

Steiner A, Radulovic K, Niess JH. “Gastrointestinal tract: the leading role of mucosal immunity,” Swiss Med Wkly, 2016;146:w14293.

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Lee S-Y, Lee E, Park MY, et al. “Microbiome in the gut-skin axis in atopic dermatitis,” Allergy Asthma Immunol Res, 2018;10(4):354-62.

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Pickard JM, Zeng MY, Caruso R, et al. “Gut microbiota: role in pathogen colonization, immune responses, and inflammatory disease,”Immunol Rev, 2017;279:70-89.

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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.

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Tater KC, Jackson HA, Paps J, et al. “Effects of routine prophylactic vaccination or administration of aluminum adjuvants alone on allergen-specific serum IgE and IgG responses in allergic dogs,”Am J Vet Res, 2005; 66 (9):1572-7. (abstract)

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EMERGING TECHNOLOGY PROFILE

THE ROLE OF IMMUNOTHERAPY IN VETERINARY PRACTICE Immunotherapy offers a new approach to cancer, and involves re-educating the patient’s immune system to combat the disease.

By Mark Suckow, DVM, CTO, Torigen Cancer is a devastating disease resulting from mutations that lead to uncontrolled cell growth, which also changes the local microenvironment. Cancer is not only mutated cells, but also a complex tissue composed of cancer cells with an underlying matrix, all promoting tumor growth and metastasis.

Immunotherapy offers a new approach to cancer, and involves re-educating the patient’s immune system to combat the disease. Immunostimulation against specific tumor-associated antigens (TAAs) can result in tumor and metastatic disease destruction. Because tumors are complex tissues, an immune response to a wide array of tumor-specific antigenic targets increases the odds of destroying a tumor.

Torigen is a team of veterinarians and cancer researchers who are building a research company that is able to evaluate emerging therapies for humans and adapt them for veterinary medicine.

The company's first product is a whole-cell tissue vaccine — a personalized cancer immunotherapy created from a patient’s resected tumor that has been used in over 600 veterinary cancer patients. The vaccine includes an enormous menu of patient-specific antigen targets. This article reviews Torigen's autologous approach and product development of monoclonal antibody and targeted neoantigen vaccine strategies.

WHOLE-CELL TISSUE VACCINES The goal at Torigen is to make personalized cancer immunotherapy accessible to veterinary patients. Our whole-cell tissue vaccine is considered by the USDA Center

of Veterinary Biologics to be an experimental product until conditional or full licensure is approved. However, it is available now for use under the supervision and prescription of a licensed veterinarian.

The vaccine is custom-produced using patient tumor material (~5 g). The whole-cell tissue vaccine results in immune presentation of a vast menu of antigenic targets such as those offered by neoplastic cells, tumor extracellular matrix, and tumor-associated fibroblasts. Each of these latter components helps promote tumor growth, metastasis and immunotolerance, and can be directly targeted by the immune system when a patient is treated with a tissue-based vaccine. The more tumor-associated antigens presented, the greater likelihood of a successful immune response. The initial research on this approach was conducted in rodent models using prostate, ovarian and melanoma tumors.

This response was further improved by the addition of a novel adjuvant designed to enhance the cellular immune response. This adjuvant, Matrix Immune Modulator (MIM), consists of “sticky” proteins that allow antigens to bind and be processed by macrophages, promoting an anti-cancer immune response.

The combination of tumor tissue with MIM leads to increased concentrations of specific cytokines that stimulate cytotoxic CD8+ T cells – cells which lead to a directed immunemediated anticancer response.

Figure 1: Sources: "Prevention of denovo prostate cancer by immunivation with tumor-derived vaccines". MA Suckow et al. Cancer Immunology, Immunotherapy 2007. 56(8)1275-1283. "Prevention of human PC-346C prostate cancer growth in mice by a xenogenic tissue vaccine". MA Suckow et al. Cancer Immunology, Immunotherapy, 2007. 56(8) 1275-1283. "Inhibition of prostate cancer by administration of a tissue vaccine". MA Suckow et al. Clinical and Experimental Metastasis, 2008: 2005(8)913-918. "Use of an extracellular matrix material as a vaccine carrier and adjuvant". MA Suckow et al. Anticancer Research, 2008: 28:2529-2534.

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FUTURE DIRECTIONS Torigen strives to be the leader in veterinary cancer immunotherapy. To succeed, the company is investigating ways to further improve vaccine approaches to cancer, for example:

Figure 2: This photomicrograph shows MIM uptake by macrophages.

DyLight 594-labeled MIM was exposed to THP-1 cells activated with PMA (to promote macrophage phenotype). After five hours of exposure to the labeled MIM, the cells were fixed.

Veterinarians are invited to contact the Torigen team (which includes a cancer biologist, veterinarian oncologist and veterinarian surgeon) to discuss upcoming tumor removal cases, in order to better understand how to apply this technology to a specific case. A free tumor collection kit with a prepaid overnight express shipping label for tissue submission will be provided. To request a kit, visit torigen.com.

The tissue collection process is simple. After tumor excision, a portion of unfixed tissue is submitted to the Torigen laboratory.

It is important that the submitted tissue not be placed in formalin. Formalin strongly cross-links tumor-associated antigens, rendering them less effective in stimulating a targeted and specific response.

The product is returned to the veterinary practice in as few as three days from initial surgery — this is important since Torigen’s process “captures” currently-expressed TAAs, providing a contemporary immune stimulation without days or weeks of tumor cell culture or T cell expansion.

Since tumors can mutate rapidly, we believe timely and specific immunostimulation is critical.

The product is administered subcutaneously (1 mL) once weekly for three weeks.

• Immune checkpoint inhibitors will further promote immune-mediated cancer attack. Specific monoclonal antibody therapies, PD-1, PD-L1 and CTLA-4, block the downregulation of T-cells within the tumor microenvironment. When the tumor is “inflamed” or has many T-cells, these therapies can ensure the T-cells remain active in the microenvironment and attack the tumor. The pairing of tissue vaccines with checkpoint inhibitors offers a novel way to fight cancer.

•A nother approach under investigation is the development of innovative neoantigen vaccines. While tissue vaccines offer a wide array of TAAs, Torigen will also create neoantigen vaccines based on identifying the important antigen targets specific to each patient’s tumor (neoantigens), and add additional doses of those neoantigens to the tissue vaccine as a way to magnify anti-tumor immunity. This requires technically-complex full genome and exome sequencing between tumor and normal tissue, and exploiting discovered differences to establish important neoantigens for inclusion in each patient’s vaccine.

Providing effective and affordable cancer immunotherapy to veterinary patients is the goal at Torigen. To that end, the company is committed to educating veterinarians about cancer immunotherapy and further emerging tools in cancer treatment. Our team of experts is available for a consult — contact us to learn more.

The company can provide tumor-specific data on many tumor types based on a database of over 600 patients treated to date — contact 860-519-9956 or info@torigen.com for information.

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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”.

By Barbara Fougere, BSc BVMS (Hons), BHSc (Comp Med), MODT, MHSc (Herb Med), Grad Dip VWHM, Grad Dip VCHM, Grad Dip Vacup, CVA, CVCP, CVBM, CMAVA, MNHAA

As veterinary practitioners, we are well-versed in the importance of good nutrition, sufficient rest, exercise and lifestyle for our veterinary patients.

But 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. Let’s take some time to holistically assess our own health, and look at some efficient practices to improve our own well-being.

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

Physical Health: 1

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Spiritual Health/Connectedness: 1

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Mental Health: 1

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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

IS THERE ROOM FOR IMPROVEMENT — AND WHY 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

THE IMPORTANCE OF BODY CONDITION Increased BMI (see sidebar on page 26) 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

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 insulinmediated 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 Continued on page 26.

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CALCULATING YOUR BODY MASS INDEX

You can use these equations — or for quick reference, see Table 1.

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

Metric units: BMI = Weight (kg) / (Height (m) x Height (m)) English units: BMI = Weight (lb) / (Height (in) x Height (in)) x 703

AFTER YOUR SELF-ASSESSMENT, NOW WHAT?

Do you know what your Body Condition Score is, or “BMI” in human terms? Both BMI and body fat percentage give you valuable health information. BMI is an equation that gives you a numerical rating of your health based on height and weight. As your BMI goes up, so does your risk of developing weight-related diseases.

Take the time to complete this self-assessment of your physical fitness.

Your height (inches) _________

Weight (lbs) _________

Continued from page 25.

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

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What 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

Tables courtesy of Dr. Barbara Fougere

Table 1: Body Mass Index for Adult Men and Women

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 just two short 11-minute sessions per week 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 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,12 and 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.

Continued on page 28.

Table 2: VO2 Max Values for Men and Women

WOMEN Age (years)

Very poor

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-65

< 27 < 26 < 25 < 24 < 22 < 21 < 19 < 18 < 16

Age (years)

Very poor

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-65

< 32 < 31 < 29 < 28 < 26 < 25 < 24 < 22 < 21

Poor

Good

Very Good

27-31 26-30 25-29 24-27 22-25 21-23 19-22 18-20 16-18

Fair

32-36 31-35 30-33 28-31 26-29 24-27 23-25 21-23 19-21

Average 37-41 36-40 34-37 32-35 30-33 28-31 26-29 24-27 22-24

42-46 41-44 38-42 36-40 34-37 32-35 30-32 28-30 25-27

47-51 45-49 43-46 41-44 38-41 36-38 33-36 31-33 28-30

Poor

Fair

Average

Good

Very Good

Excellent > 51 > 49 > 46 > 44 > 41 > 38 > 36 > 33 > 30

Men 32-37 31-35 29-34 28-32 26-31 25-29 24-27 22-26 21-24

38-43 36-42 35-40 33-38 32-35 30-34 28-32 27-30 25-28

44-50 43-48 41-45 39-43 36-41 35-39 33-36 31-34 29-32

51-56 49-53 46-51 44-48 42-46 40-43 37-41 35-39 33-36

57-62 54-59 52-56 49-54 47-51 44-48 42-46 40-43 37-40

Excellent > 62 > 59 > 56 > 54 > 51 > 48 > 46 > 43 > 40

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HIGH-FRUCTOSE FOODS

Many foods we consider healthy are surprisingly high in fructose, including fruit, although the phytochemicals and fiber in whole fruits modulate fructose uptake. Fruit is

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

still considered important to the human diet, but limit consumption to two or three small pieces per day.

Foods to eat sparingly:

• Honey, agave, molasses, maple syrup

• Fruit juices, including tomato juice

• Fat-free salad dressings

• Raisins and other dried fruits

• Pickles, vinegar, sauces

• Canned or bottled fruit and fruit jams

• Breads (watch for added sugar)

• Healthy breakfast cereals including muesli

• Flavored low-fat fruit yogurts

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 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.

Continued from page 27.

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

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Cukierman-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.

1

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.

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.

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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.

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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.

12

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.

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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.

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From the NASC Selecting supplements for your practice – 5 important questions to ask

By Bill Bookout

Animal nutritional and health supplements can play an important role in keeping your patients healthy and happy, particularly when used as an element of whole animal care.

If a client asks about adding a supplement to her pet’s regimen, it is important to help her understand the types of supplements available to her: •N utritional supplements — vitamins, minerals and other ingredients intended to provide nutritional value as part of a complete and balanced diet.

•H ealth supplements — products intended to support maintenance of normal biological structure and function, such as a joint supplement or a calming aid.

When researching supplements to offer at your practice or recommend to clients, we suggest you reach out to manufacturers for answers to the following questions: 1. Who formulates the product?

It is important to select products formulated by qualified professionals with knowledge and expertise in pet supplement formulation, and with a

BOTTOM LINE:

solid track record of producing animal nutritional or health products.

2. What quality standards does the company follow?

They should be following current Good Manufacturing Practices (cGM Ps) modeled after the FDA’s cGMPs for human dietary supplements as defined in 21 CFR Part 111, and for animal food defined in 21 CFR Part 507 of the Federal Food, Drug and Cosmetic Act. 3. Is the product independently tested by a reputable analytical lab?

Independent testing consists of a third-party analytical lab verifying products that were purchased from the marketplace to ensure the product meets label claims.

4. Is the product labeled properly?

•P roduct claims: If a product label overtly claims — or even implies — the product will treat, prevent, mitigate or cure any disease, the supplier is breaking the law and misleading consumers.

• Lot number: Lot numbers demonstrate the manufacturer likely complies

with some type of quality standards requiring product traceability and are essential in helping manufacturers notify customers if there is a problem.

• I ngredients listing: Ingredients should be listed in descending order by amount but be aware that large numbers followed by “PPM”, meaning parts per million, actually indicate a dilute concentration of the ingredient.

5. Does the product have the NASC Quality Seal?

The NASC Quality Program provides strict guidelines for product quality assurance in production, adverse event reporting and labeling standards. To earn the National Animal Supplement Council’s Quality Seal, suppliers must pass a comprehensive facility audit every two years and maintain ongoing compliance with rigorous NASC quality requirements.

Bill Bookout is president and founder of the National Animal Supplement Council. He has more than 30 years’ experience in the animal health industry and holds a bachelor’s degree in physical sciences from the University of Wyoming, and a master’s degree from the Pepperdine University Presidents and Key Executives MBA program.

It is important to establish faith in the companies you deal with. Don’t be afraid to question suppliers until you find those who will welcome your inquiries and are eager to gain your trust!

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From the VBMA

The Veterinary Botanical Medicine Association is a group of veterinarians and herbalists dedicated to developing responsible herbal practice by encouraging research and education, strengthening industry relations, keeping herbal tradition alive as a valid information source, and increasing professional acceptance of herbal medicine for animals.

Submitted by Cynthia Lankenau, DVM

DID YOU GUESS LAST ISSUE’S MEDICINAL HERB? Bidens pilosa, Xian Feng Cao, is a very important herb in today’s animal health crisis of Lyme Disease and Lyme co-infections.

It has shown incredible promise in the treatment of Babesia, with potential for treating mycoplasma infections as well. Bidens has many pharmacological activities, including antibiotic, antibacterial, anti-dysenteric, anti-hemorrhagic, anti-inflammatory, anti-malarial, antimicrobial, antipyretic, astringent, carminative and hepatoprotective. It is an immune modulator, liver protectant, vulnerary, and also offers neuroprotection. It clears Fire and Heat toxins and removes Stagnation. It is a plant that can grow aggressively on disturbed land, so we have no fears of overuse!

CASE REPORT In June of 2018, a five-year-old neutered Goldendoodle named Bailey was diagnosed with Lyme and Babesia.

He had been treated twice with his conventional veterinarian’s protocol of antibiotics but still suffered from anemia, fatigue and chronic stiffness. In September, his owner decided to use additional therapies. Bidens was one of the leading herbs in the herbal formula Bailey was given. By early November, his symptoms had resolved.

RECENT ACTIVITIES • J anice Huntingford, DVM, recently presented another popular webinar on “Herbs Used for Post-Surgery Recovery and Rehab”. This and all other past webinars are available for purchase at vbma.org.

• T he VBMA hosted a speaker track at the International Herbal Symposium, which featured Drs. Cheryl Schwartz, Joyce Harman, Rona Sherebrin and Cindy Lankenau.

The veterinarian track included topics on climate stress, microbiome, Lyme, and CBD usage. Participants could also attend any of the nine other speaker tracks given by herbalists from around the world. Tapes of these lectures are available at Tree Farm (treefarmtapes.com/products/14thinternational-herb-symposium-2019-full-conference).

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•E ighteen VBMA members and their families enjoyed the trip of a lifetime on our Ecotour to the Aigas Field Centre, located in the Scottish Highlands just southwest of Inverness. Aigas is one of the foremost nature study centers in the world and was established 40 years ago

by Sir John Lister-Kaye, one of Britain’s best known conservationists, naturalists and nature writers.

We observed many diverse species of plants and animals, including sundews, butterworts, gorse, wild goats, whooping swans and red kites. We learned about the center’s wildcat breeding program (the Scottish Wildcat is virtually extinct in the wild), their beaver reintroduction program, and their twin flower propagation program.

We all had a remarkable time, hiking the grounds and visiting archeological sites, visiting one of the remnants of Scotland’s ancient Caledonian pine forests, and being part of a vibrant group of like-minded veterinarians.

In the next column, we’ll highlight our herb walk and other activities at the AHVMA Annual Conference from September 7 to 10 in Nashville, Tennessee. And keep an eye open for upcoming webinars — Kendra Pope, DVM is scheduled for the late fall!

NAME THIS HERB!

Join the VBMA at vbma.org to find out. The answer will also be published in the next issue of IVC Journal.

PEER-REVIEWED

CBD is everywhere!

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

By Karen Gellman, DVM, PhD

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.

Continued on page 32.

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Continued from page 31.

Cannabis was first declared a Schedule One controlled substance in the 1970s, meaning that the FDA and DEA considered it to have no therapeutic value with great potential for abuse. Since that time, it has been illegal to study cannabis or use it medicinally in the US. However, we now know there are many therapeutic applications for cannabinoids, with little potential for abuse and minimal to no toxicity. Delisting cannabis is likely to happen this year or next, especially after the Farm Bill of 2018 made industrial hemp (cannabis with less than 0.3% THC content) legal in the US as an agricultural product. This will allow for a much greater range of federal research into the medical benefits of cannabis (see Box 1).

BOX 1

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.

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 (see Box 2).

BOX 2

There is even evidence that some of our early ancestors might have recognized the medicinal benefits of the cannabis plant.

The BBC (British Broadcasting Corporation) recently reported that archeologists discovered a brazier with traces of high THC cannabis in a 5,000-year-old excavation site in China.

Evidence of high-THC cannabis strain residues from ancient times supports the idea that humans have been utilizing this medicinal plant, and cultivating it to increase its desired properties, for many thousands of years.

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

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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-mucosal2 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 (see Box 3).

INDICATIONS FOR USE OF EXOGENOUS CANNABINOIDS IN ANIMALS There are many useful applications for CBD, the nonpsychoactive cannabinoid. (THC is mainly used, where legal, for cancer and end-of-life care (see Box 3). CBD is used for

reducing anxiety and phobias, treating arthritis pain and inflammation4 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

BOX 3

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 transmucosal 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.

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WHAT ABOUT ME? As mammals, we share a lot of the

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).

same physiology and pathology amounts of money are being

invested in the cannabis industry because savvy business types

see the potential health bonanza.

There are many more human CBD products than pet CBD products, but the same rules apply for

finding reputable products, as discussed in Box 2.

CBD helps soothe the nervous

system and relieves pain — what many veterinarians need for

themselves! Users report that

CBD can help them sleep better, reduce anxiety/stress reactions,

A study conducted at Cornell University4 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 day9 (see Box 4).

BOX 4

as our four-legged friends. Huge

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.

and mitigate the chronic pain

issues that come from lifting Great Pyrenees onto the exam table or

hanging onto a horse’s leg while he tries to escape to the next county.

Can CBD help you? Follow the

same guidelines as listed in Box 2.

Get the best product you can find, take a lower dose for stress relief

and a higher dose for pain. Active research programs are looking into CBD’s efficacy in treating

neurodegenerative diseases like

multiple sclerosis and Parkinson’s

disease. It probably won’t be long before more serious regulation of cannabinoids evolves.

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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.

EDITOR’S NOTE:

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.

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.

¹ Freundt-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. ² Bartner, 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. ³ Zendulka O, Dovrtelova G, Noskova K, et al. “Cannabinoids and Cytochrome P450 Interactions”. Curr Drug Metab. 2016, 17(3):206– 226. ⁴ Gamble LJ, Boesch JM, et al. “Pharmacokinetics, Safety,and Clinical Efficacy of Cannabidiol Treatment in Osteoarthritic Dogs”. Front in Vet Sci 2018, 5:165. ⁵ Jones 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. ⁶ Gruden 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. ⁷ Fernández-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. ⁸ McGrath, Bartner et al. “A Report of Adverse Effects Associated with the Administration of Cannabidiol in Healthy Dogs”. JAHVMA 2018, 52:34-38.

From the AVH

The Academy of Veterinary Homeopathy is comprised of veterinarians who share a common desire to restore true health to their patients through the use of homeopathic treatment. Members of the Academy are dedicated to understanding and preserving the principles of Classical Homeopathy.

HEALING THE HEALER:

SELF-CARE FOR VETERINARIANS It’s simple: if we do not take care of ourselves, we are less able to care for others. The suicide rate among veterinarians is over three times the national average, according to a CDC study released on January 1, 2019.

AVMA Immediate Past President Dr. John de Jong, DVM, says we need to adopt a “holistic all-hands-ondeck approach to make real progress” with this problem. I agree, but what does self-care really mean? Eat right, exercise and get enough sleep?

In my life before homeopathy, self-care meant self-medicating, and that path nearly cost me my livelihood and my life. Homeopathy saved me, leading to a better way of dealing with my health issues and a more profound understanding of health and disease. Under the guidance of homeopaths, I stopped all allopathic medicines and learned to rely on better nutrition and homeopathy.

Rhus tox beats ibuprofen any day. Ignatia helped dissolve the grief and despair after my dad’s death. Cat or dog bites on the hand respond well to Arnica and Lachesis, rather than ibuprofen and antibiotics.

Homeopathy also provided my remedy for compassion fatigue and burnout after 20+ years of allopathic practice. I now feel great peace of mind, knowing I’m caring for myself and others, and above all, doing no harm.

Submitted by Todd Cooney DVM, CVH

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

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7 TIPS EVERY CLIENT NEEDS TO KNOW Dr. Amanda Ardente, DVM, PhD

As vets we know that pets are cherished members of many families. Day in and day out, they are with us during every insignificant moment and every important occasion. Pet parents tend to take that constancy for granted, until something pops up to alert them that something is wrong — perhaps their animal skips a meal, does not greet them at the door, refuses a favorite treat, or has an accident outside the litterbox.

w E ncourage pet parents to maintain their animals’ oral health with daily brushing at home and dental cleanings, ideally every six to 12 months.

e E stablish a recommended vaccination schedule. rR ecommend a diet formulated for the patient’s life stage.

Making an appointment with the veterinarian when pets are healthy is not usually a top priority among clients. However, veterinarians can help clients take preventative steps towards their pets’ health care by encouraging a proactive approach, saving their clients time and money and helping their patients live long and healthy lives.

What tips can you recommend to help your clients support their pets’ health and longevity?

q Schedule yearly physical exams to make sure all systems are functioning optimally. Thorough exams should minimally include heart and lung auscultation, ocular and otic exams, abdominal palpation, fecal floatation, urinalysis, complete blood count, and biochemical profile.

EARLY AND RAPID INTERVENTION Any problems identified during a veterinary visit can then be discussed and further worked up and/or treated, as needed.

With some conditions, early and rapid intervention can optimize the long-term prognosis. Here are a few examples: • Dogs prone to cataract development, like Golden Retrievers, Schnauzers and Poodles, benefit from early supplementation of Omega-3 fatty acids, lutein and grapeseed extract.

• Older dogs and cats may become disoriented in the middle of the night and benefit from cognitive support supplements.

• Large breed dogs, like Rottweilers and Great Danes, may benefit from joint support supplements, including glucosamine and chondroitin, started early in life.

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t

Some examples include: a.

Puppies fed a diet formulated for growth until approximately one year old, or based on breed. b. Senior cats fed a diet formulated for the geriatric feline, to optimize body weight, muscle maintenance and kidney health.

S uggest early antioxidant and probiotic supplementation, particularly for conditions the pet may be predisposed to (e.g. cataracts, arthritis).

y E ncourage regular exercise for the pet, e.g. getting outside for walks or runs with owner at least once a day.

u P romote importance of consistent grooming in order to prevent matted hair and development of skin conditions.

Don't forget to remind your clients that keeping their pets healthy involves more than responding when the animal does not feel well. It is about taking a preventative approach, making sure their pets are thoroughly checked, even when appearing healthy on the outside, to make sure their insides match! In the long run, catching signs of illness or aging as soon as possible will allow for earlier intervention, potentially less money spent in an emergent situation, and a longer, more healthful life for your clients’ best friends.

Dr. Amanda Ardente is a veterinarian and nutritionist. She resides in Gainesville, FL, and is the owner of a nutrition consulting company, Ardente Veterinary Nutrition LLC.

industry innovations Breakthrough test detects chronic diseases in animals

A ground-breaking new test developed by Hemopet, a non-profit animal blood bank, uses saliva to detect chronic diseases in dogs and cats. The cellular oxidative stress test, CellBIO, measures isoprostane, the biomarker lipid that leads to obesity, infections, tissue inflammation and even cancers.

CellBIO builds on NutriScan, another saliva-based diagnostic test developed by Hemopet that tests for food intolerances. According to Hemopet founder, veterinarian Dr. W. Jean Dodds, these tools can anticipate problems in dogs and cats, giving animal parents a chance to prevent problems with diet and supplement changes.

CellBIO kits are complimentary and reports are emailed within five to seven days to animal parents, and to their veterinarians, if desired. cellbiomarkers.org

“Smart” handpiece on new therapy laser

Accurate laser therapy dosing just got a lot easier. Companion Animal Health® introduces the first “smart” handpiece, the Empower IQ Delivery System, to the small animal market. It comes standard on the company’s newest therapy laser, the CTX-IQ. This innovative product has been engineered to produce consistent clinical outcomes, while supporting staff with real-time guidance.

“Achieving consistent dosing is the key to clinical outcomes in laser therapy,” says John Mercurio, the company’s VP. “With the introduction of advanced dosing software and the Empower IQ delivery system, consistent and accurate dosing is easier to achieve.”

The handpiece offers both haptic and visual feedback that alerts the user when he/she should adjust treatment speed, thereby ensuring patients receive the most accurate therapeutic dose of energy. companionanimalhealth.com/product/ctxiq

Supporting ocular health in animals

You want to do what you can to ensure your patients maintain optimal eye health. The patented worldwide leader in pet vision, Ocu-GLO™ has been developed by board-certified veterinary ophthalmologists and is backed by clinical research. Supporting animal ocular health for over a decade, this product provides key antioxidants such as grapeseed extract and lutein, which work synergistically to protect the eye from oxidative stress. In addition to the company’s flagship line of liquid gelcaps, the product is now available as a powder blend (Ocu-GLO™ PBXL) for medium to large dogs, and for cats. Ocuglo.com

Stay comfortable during veterinary procedures

Maintaining your physical comfort and avoiding eyestrain are paramount when you’re doing surgery or other procedures on your patients. SurgiTel’s mission is to offer the best in vision, comfort and ergonomics. Patented lightweight optics and LEDs, coupled with Oakley frames, translate into all-day comfort for the veterinary practitioner. The company’s unmatched loupe declination angle means your body is in the correct ergonomic position, reducing pain and risk of injury. surgi-tel.com

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ERGONOMICS IN

VETERINARY

MEDICINE

By Sara C. White, DVM, MSc

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

EXAMPLES OF

ERGONOMIC DOMAINS IN VETERINARY MEDICINE •P hysical: humans interacting with patients and objects; lifting, standing, sitting, typing, doing surgery or other procedures

•C ognitive: mental workload and mental tasks u I ncludes divided attention — e.g. a technician simultaneously watching a surgical patient, recovering animals, electronic monitors and co-workers •E nvironmental: temperature, noise, lighting, airflow •O rganizational: systems, management style, communication.

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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. E quine practice can be dangerous: during a 30-year career, equine practitioners can expect seven to eight

Figure 1: Control methods higher on the hierarchy are potentially more effective and protective, leading to inherently safer systems with reduced risk of illness or injury. Adapted from the National Institute for Occupational Safety and Health (NIOSH).

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 ameness exams, as well as other procedures performed on L 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. S mall 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 Continued on page 42.

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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:

• 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.

• Weight of load

• 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?

• 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?)

• 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.

• Twisting and side bending

• Avoiding twisting and side bending

• Working in a restricted space

• Working in a less restricted/obstructed space: Remove unnecessary obstructions from your workspace and storage space.

• Good grip versus an irregular, bulky, floppy, unpredictable load •F looring 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.

•W eight 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.

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• Grip on load (patients): Turn a floppy unpredictable load with no handles into a firm balanced load with welldistributed 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.

Figure 2: This surgery table is too low, so the surgeon bends forward at the waist, upper back and neck.

Figure 3: This surgery table is too high.

The surgeon has to raise her shoulders and abduct her elbows, leading to neck, shoulder and arm fatigue.

A

Figure 5: Appropriate table height and appropriate patient placement results in a correct posture for this surgeon.

Figure 7 A & B: Methods for grasping the needle holder. (A) The tripod grip allows finer control and uses muscles of fingers and hands to manipulate the instrument, and (B) the palm grip relies more upon muscles of the hand and arm than upon the fingers.

B

C

Figure 6 A, B & C: When sitting for surgery with a small patient (A) the surgeon is able to sit close to the table and maintain relaxed upper body positioning. But with a large dog (B), the surgeon sitting on a standard stool raises her shoulders and abducts her elbows to clear the patientâ&#x20AC;&#x2122;s body. She is unable to lower the table or raise her stool, since her thighs are already in contact with the underside of the table. Using a saddle-shaped stool when operating on a large dog (C) allows the surgeon to achieve appropriate upper body position while still remaining close to the surgery table.

A

A

B

Figure 4: Placing this cat in the center of a standard-sized surgery table causes the surgeon to lean forward and reach to access the surgery site, causing strain and fatigue.

Figures 2-12 courtesy of Dr. White and ergovet.com

WORK SURFACE HEIGHTS AND GRASPING TIPS

Figure 8: The pinch grip is used for thumb forceps. This grip can be fatiguing and may exacerbate discomfort in people with hand pain.

Figure 9: Use of force when tying knots in large-gauge suture with the tripod grip places strain on the tendons and ligaments of the thumb and wrist.

B

Figure 10 A & B: Exteriorization of the testicle during closed castration of large dogs requires force. Grasping the testicle by hand (A) leads to an awkward hand posture with ulnar deviation of the surgeonâ&#x20AC;&#x2122;s wrist, and requires considerable grasping strength in the fingers due to the testicleâ&#x20AC;&#x2122;s shape and slippery texture. Using a hemostat across the spermatic cord (B) allows the surgeon to maintain a straight position through the wrist, and allows a more secure grip.

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B

Figure 11 A & B: Sometimes poor posture can be solved by improving surgery technique. When a continuous subcuticular closure is performed from left to right by a right-handed surgeon (A), the surgeon’s posture is twisted and her arm is abducted. However, when the surgeon sutures the same incision from right to left (B), she remains upright, with her only postural concern being the wrist extension and ulnar deviation of her right wrist.

A

B

Figure 12 A & B: Neck position during surgery may be influenced by the fit of glasses. (A) When glasses block the lowest portion of the visual field, the surgeon’s neck angle is 40°, but (B) when the glasses are designed to sit low enough on the nose to include the lowest portion of the visual field, the surgeon’s neck angle decreases to 32°.

Figures 2-12 courtesy of Dr. White and ergovet.com

A

Continued from page 39.

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.

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GENERAL ADVICE IN ERGONOMICS Whether you are doing surgery, palpating cows, or entering data, consider the following: •B eware 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.

•A void awkward or tiring positions. In the majority of cases, awkward postures with extreme flexion, extension, or ulnar or radial deviation are not necessary for performing most veterinary tasks, although we may inadvertently use awkward grips and techniques. Since it can be difficult to observe one’s own movements during a procedure, it can be useful to record

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.

•B e 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 strainfree as possible.

•T ake 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.

•T rain 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.

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

1

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.

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.

10

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

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IVC 9:4

DON'T MISS ANOTHER ISSUE!

Advertorial

DEAL WITH DENTAL ISSUES WHILE AVOIDING TOOTH EXTRACTIONS

By Kim Vanderlinden, ND, DTCM

Pets brought in with red bleeding gums also often suffer from reduced quality of life. Besides being painful, dental issues can prevent a pet from eating well, cleaning himself and sleeping properly. Unfortunately, the problem can also be difficult to treat without extraction — until now.

PET PARENTS CAN MISS EARLY SIGNS Dental issues can be missed by pet parents early on, but eventually the bright red inflamed gums or even bleeding can’t escape notice and the patient will be brought in to see his vet.

As you evaluate pocket depth and bleeding sites, it is important to make a recommendation that will allow the patient to keep his teeth, if possible.

CETYLATED OILS AND DENTAL DISEASE Veterinary researchers have tried various solutions, such as fish oils and Omega 3s for gum health, but have since found that cetylated oils applied topically are far more effective. Research on cetylated oils for dental disease has been published twice in the Journal of Periodontology.

reduced periodontal pocket depths. Outstanding results were also seen in clinical trials using cetylated oils with people.

DentaPet is made of a patented blend of natural food oils. It is completely non-toxic and ready to restore health to gingival tissue. Vets and pet parents alike have found that cats and dogs like the taste, and it can even help improve their breath.

It’s very safe and reasonably priced — the cost to patients is less than $20 a month. DentaPet works so well that benefits to gingival health are guaranteed, and so there is literally no financial risk to pet parents.

DentaPet is used and recommended by leading dental health educators, trusted veterinarians and prevention-minded pet parents. There have even been cases when using the product removed the need for full mouth extractions.

You can view a short YouTube video of Dr. Sharon Forster in which she stares her experience with DentaPet (youtube. com/watch?v=lhEY9SJ-PBE). For more information, visit HopeScienceVet.com.

DENTAPET OFFERS OUTSTANDING RESULTS Researchers from a Canadian university applied DentaPet (cetylated oils) or a placebo (olive oil) to cats’ gums for six weeks. The DentaPet group of cats benefited from both a dramatic reduction of bleeding when sites were probed, and

Dr. Kim Vanderlinden almost drowned when he was six — then his uncle's black Lab jumped in, grabbed him and swam him to shore. He's grateful to be giving back by providing to animals formulas he developed for people. Dr. Vanderlinden has degrees in both Naturopathic and Chinese medicine, and wrote a book on IP6 for cancer, bone density and sugar metabolism — for a free electronic copy, email drkimv@hopescience.com.

IVC Fall 2019

45

By Ryan E. Walrath, DVM

I N T H E V E T E R I N A RY P R AC T I C E Innovative advances in cryosurgery offer safe and effective treatment options with unlimited potential in the hands of the veterinarian.

Canine and feline dermatologic problems make up a substantial part of any small and/or mixed animal practice. Lesions ranging from small nodules to lumps and bumps are included in the daily questions clients ask practitioners during routine annual examinations and preanesthetic screenings of their animals. A large percentage of these masses can be benign proliferations of various gland tissues, or accumulations of abnormal but benign cell growths, while others are neoplastic tissues with invasive and metastatic potential. Traditionally, these masses have been excised with a scalpel and/or surgical laser, requiring the use of sedation or general anesthesia. While this has been an industry standard for many years, many patients presenting with skin lesions often have other problems, leading to safety concerns with chemical immobilization. Cryosurgery offers an attractive option for these patients, since it can be utilized with minimal or no sedation, collateral tissue damage and post-operative care.

ADVANCES IN CRYOSURGERY While cryosurgery is not a new modality, the tools used to deliver the required temperature change are evolving, making the target areas very precise. This enhanced precision reduces collateral tissue damage, leading to faster healing and less scarring. The capacity to achieve this precision is also what makes the biggest difference in treating smaller lesions. The specific unit I use in my practice is the CryoProbe X+, which runs at about -127°F. This specific model includes five separate tip sizes that can be used to match the lesion being treated, and can be operated with available 8g and 16g cartridges.

(While treatment is often done without sedation or general

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anesthesia, the locations of some lesions will still require chemical immobilization to achieve desired results).

Thanks to the precision of the micro-applicator tips, there is no collateral damage to healthy tissue, resulting in no discomfort to the patient. As such, treatments are very controlled and can be longer in duration if necessary. There is no required post-operative care; there is no bleeding, and sutures and cones are unnecessary, a wonderful benefit for both patients and caregivers.

The following discussion identifies common lesions the author has treated with cryotherapy, but the modality’s use is certainly not limited to these.

• Sebaceous adenomas One of the most common skin ailments of aging and geriatric patients is the sebaceous adenoma. Also known as nodular sebaceous hyperplasia, this lesion is characterized as a benign non-haired soft tissue proliferation with an oily to crusted surface. The depth of abnormal tissue is often very superficial although the tissue can extend deep into the epidermis in some lesions. Cryosurgery is very effective for these, and one treatment is typically curative with very little follow-up required.

• Cutaneous histiocytomas Cryosurgery is very useful in the treatment of cutaneous histiocytomas. These benign and often solitary tumors often appear in places where surgical excision can be difficult. When they appear on the head, digits and

Note:

Many masses on the , cavity may require geface ears and oral for patient immobilizneral anesthesia of treatments. The ation and accuracy not necessarily painfutreatment itself is but the sound and initl to the patient, sensitive tissues will ial cooling of the patient to react. In often cause the I have found it more these situations, someone pet and comfobeneficial to have rather than use rest rt th. e patient raint

ears, there is little room for excising while obtaining adequate margins without cosmetically affecting the closure. While these lesions can be deep and relatively dense, I have experienced successful outcomes with cryotherapy in completely resolving lesions as large as 1cm in diameter and ½cm in height. Larger masses may require an additional treatment or two to achieve complete resolution.

• Mast cell tumors Mast cell tumors are often highly invasive and metastatic masses that can lead to very debilitating disease; higher grades and stages often result in diffuse systemic involvement. While cryosurgery is not my first line of choice in treating the masses that develop, it can be used as an additional modality to treat smaller nodules within the skin in areas where removal would be difficult. I have successfully treated smaller solitary Grade 1 nodules less than 1cm in diameter, with minimal to no recurrence.

When treating these masses, I have found it beneficial to treat the nodule itself, along with 2mm to 4mm margins, and re-treating the same area after thawing has occurred.

• Acral lick granulomas Cryotherapy can also be used on chronic inflammatory

lesions, such as acral lick granulomas, as an additional treatment modality. I have found it useful to intermittently freeze portions of the granulomas, along with using traditional therapies.

• Epidermal and follicular inclusion cysts These commonly-encountered nodular masses can respond well to cryosurgery. If possible, the author recommends either Continued on page 49.

IVC Fall 2019

47

Pretreatment evaluation

Before and after cyst removal

Prior to cryosurgery implementation, it is imperative that current standards of care be followed, with appropriate

Before and after meibomian gland adenoma treatment

cytological and histopathological diagnostic steps performed as indicated. If a mass is deemed malignant with metastatic the mass with aggressive surgical intervention, radiation and chemotherapy would be indicated based on oncologist recommendations should the patientâ&#x20AC;&#x2122;s owner elect to pursue that line of treatment.

Once a mass has been diagnosed, the use of cryosurgery can be employed for nearly any lesion on the skin, as well as some mucus membrane tissues.

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IVC Fall 2019

Process of eyelid tumor resolution Photos courtesy of H&O Equipment, Inc., manufacturer of CryoProbe

potential, addressing

Continued from page 47. expressing or draining the lesions of any fluid or material prior to freezing with cryotherapy. This dramatically reduces the time required to freeze the area, permitting more effort to be directed at the tissue responsible for producing the material.

If deep tissue nodules are being treated, or if draining of the lesions requires a scalpel or hypodermic needle, heavy sedation or general anesthesia is recommended for patient comfort.

• Meibomian gland adenomas For meibomian gland adenomas measuring 1mm or less, my preferred initial treatment option is cryosurgery over surgical excision. These common eyelid masses are full thickness proliferations often filled with a material that can be expressed with gentle pressure. I would suggest treating the tissue with cryotherapy from both palpebral and ocular sides to ensure all abnormal tissue is treated. There is little to no cosmetic change after healing.

•E osinophilic granuloma complex, ulcerative paradental stomatitis and oral neoplasia Oral lesions such as eosinophilic granuloma complex, ulcerative paradental stomatitis and oral neoplasia that don’t involve bony tissue can be treated with cryotherapy when conventional medical and surgical techniques are not feasible. The lack of excess tissue for closure, despite efforts to elevate from the bone, can make it difficult to surgically close these lesions, leaving some

cases to heal by second intention alone. I have used cryosurgery to debulk the main mass or lesions with promising results. I will reassess the areas on a regular basis and elect to refreeze the tissue as often as needed to suppress new growth formation.

CONCLUSION Veterinary practices today are filled with innovative technological advancements that assist us in effectively treating patients in an ethical and compassionate manner. While traditional surgical and medical practices will always provide the foundation for our therapies, additional modalities such as cryosurgery also have their place. By adding a cryosurgical unit to my treatment toolbox, I have been able to offer another option for commonly-seen dermatological lesions that is quick, effective, less invasive, and requires little to no anesthesia.

Cryosurgery has been readily accepted by my clientele and well tolerated by my patients, making it a great fit for my practice.

Disclosure: The work expressed in this article is from Dr. Walrath’s direct clinical experience of using CryoProbe in his private practice since 2016. He is not a paid consultant or remunerated in any way.

IVC Fall 2019

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nutrition nook

KSanctuary etoPet :

KETOSIS, CANCER AND CANINES — PART 3 Non-profit organization KetoPet Sanctuary has tested the feasibility of using a ketogenic diet as an adjunctive therapy in dogs with cancer. In the third part of this article, we’ll look at practical applications for dogs at home.

By Chelsea Kent; Shannon L. Kesl, PhD; Corissa Antemesaris, CVT; Stacy A. Hodges, DVM; Barbara Royal, DVM, CVA; Loren Nations, DVM, DipABVP

KetoPet Sanctuary (KPS) has demonstrated the utility of a canine diet that induces a state of nutritional ketosis. When strictly adhered to and monitored, a ketogenic diet (KetoDiet) has been shown to increase the efficacy of standard of care and adjunctive treatments, thus prolonging survival and quality of life in canine cancer patients. While the stringently-controlled conditions at KPS cannot be replicated in a home environment, nutritional ketosis can be achieved and monitored by committed dog owners. In combination with integrative therapies, results that align with those at KPS can often be achieved.

EMPOWERING THE DOG PARENT Ketosis is a nutritionally-induced metabolic state in which the body preferentially uses ketone bodies as energy.

Ketosis is achieved by fasting, caloric control, and/or control of macronutrient ratios (high fat/adequate protein/ low carbohydrate). In the overwhelming fight for survival during cancer, diet is an accessible tool available to all pet owners. No one can fully control the cause or outcome, but dog parents can control what they put in their pets’ mouths,

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which can provide them with a sense of empowerment in the care of their canines.

NUTRITIONAL KETOSIS AND CHRONIC DISEASE Modern dogs are burdened with a variety of physiological and metabolic challenges due to the dramatic difference between the nutritive profiles of rendered, high glycemic-response kibbles and any possible, accessible nutrient profile found in nature.1 High-heat processed feeds (kibble and canned) are contaminated with heavy metals,2 excessive levels of minerals,3,4 fat soluble vitamins,5 anti-nutrients,6 carbohydrate levels that inhibit ketosis,7 advanced glycation end products (AGEs)8 and pathogens.9 A shift to fresh low-carbohydrate food decreases exposure to these toxins and metabolicallydamaging macronutrient ratios.

With and without additional therapies, nutritional ketosis has resulted in recovery from chronic skin issues, ear infections, odors (mouth and stool), chronic pancreatitis/hyperlipidemia,

ocular discharge, chronic bladder stones, UTIs, obesity, arthritis and food allergies (as confirmed with allergy testing), as well as increased energy and mobility. Dr. Barbara Royal reports an 80% success rate in many of these conditions.

However, treatment plans that depend solely on a metabolic component have not been found to be significantly successful in the treatment of cancer. Rather, ketosis has been shown to improve the efficacy of standard of care and integrative oncology therapies while also providing protective benefits to healthy cells.

Dr. Royal has experienced resolution of recurring mast cell skin tumors, hemangiosarcomas, bladder cancers and osteosarcomas in cancer patients that have dramatically exceeded their expected expiration dates, as well as shrinking and stabilizing of lymphoma (perhaps the most

The importance of

TESTING

In order to determine if ketosis has been achieved, it is important to remember that ketone and glucose testing is vital. Successes and failures cannot be fully understood without the data obtained through testing. Most crucially, results acquired from testing allow veterinarians and owners to make educated, not theoretical, decisions on how to modify canine patient diets to attain necessary metabolic changes. Even with veterinary support and education, most pet owners do not test with regularity, if at all. Like all tools, the KetoDiet is only effective when used correctly by applying proper macronutrient ratios in accurate amounts, and then validating results via testing.

PRIVATE PRACTICE CASE #1 Breed: Pitbull Age: 5 Sex: Male Diagnosia: Squamous cell carcinoma of the ventral abdomen Standard of care: Surgery, Palladia, Piroxicam, Metronidazole and Famotidine Adjuvant therapies: KetoDiet, HBOT, vitamin B12 Additional medical issues: dry eye, treated with Tacrolimus, chronic skin allergies, treated with Atopica

Date of diagnosis

Date of KPS entry

Prognosis

Survival time

Feb 26/16

Apr 21/16

730 days with chemo

834 days; deceased June 8/18

Average blood glucose

Average blood ketone

69 mg/dL

0.65 mM

Case #1 was originally in the KetoPet program but was categorized as “Did Not Complete” due to missing milestones that were necessary in order to complete the program. While in the Ketopet program, the lesions on and around the dog’s prepuce reoccurred approximately every three months and were surgically removed with CO2 laser. Surgical standard of care in conjunction with his KD and HBOT kept the lesions under control for 19 months.

In October 2017, due to a reoccurrence of a prepuce lesion (2”x1.7”), Palladia, Piroxicam, Famotidine (2x/day) and vitamin B12 were initiated.

By December 2017, the tumor had decreased in size to 1”x1”; however, the patient experienced a loss of appetite and hemorrhagic gastroenteritis, so the Palladia was discontinued.

He subsequently experienced a recurrence of the mass in the bulbus of the penis and the urethra. In February 2018, he underwent penis amputation and perineal urethrostomy, followed by a regimen of Palladia and Piroxicam until May 2018. That month, the SCC had returned and metastasized to the lymph nodes. On June 8, 2018, the dog was euthanized in the presence of his loving family.

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PRIVATE PRACTICE CASE #2 Breed: Mixed breed/Rottweiler Age: 8 Sex: Male Diagnosis: Atrial hemangiosarcoma Standard of care: Doxorubicin, Pericardiocentesis, Metronidazole, Cerenia, Mirtazapine, Ciprofloxacin, Rimadyl, Famotidine Adjuvant therapies: KetoDiet, HBOT, turkey tail mushroom extract, Yunnan Baiyao, mistletoe (Viscum album) extract, Carprofen, Dichloroacetate, Poly-MVA Additional medical issues: Thrombocytopenia Date of diagnosis

Start of KetoDiet

Prognosis

Survival time

Sept 26/17

Oct 2/17

66 days with chemo

132 days; deceased Feb 5/18

Average blood glucose

Average blood ketone

80 mg/dL

0.03 mM

Case #2 presented to the clinic on September 26, 2017. He was in respiratory distress caused by pericardial effusion. The emergency team performed a pericardiocentesis to stabilize him, at which time an atrial mass was discovered. Yunnan Baiyao was used to control bleeding while he was transferred to the oncology team. Chemotherapy was initiated on September 28 in conjunction with HBOT and mistletoe subcutaneous injections. The patient experienced GI side effects to Doxorubicin, which resolved with supportive care including IV fluid therapy, Metronidazole and Cerenia.

Once side effects resolved, the ketogenic diet was introduced along with I’m-Yunity. The patient

was monitored very closely, with frequent cardiac ultrasound imaging. He responded well, although continued to require serial pericardial taps due to spontaneous bleeding and effusion. He received his fifth and final treatment of Doxorubicin on December 28.

The patient presented on January 9, 2018 with lethargy and a painful swelling of the right rear limb.

Radiographic and ultrasonic images indicated a fluidfilled mass, which was suspected to be metastasis.

Mistletoe IV infusions were introduced, followed by Poly-MVA and DCA infusions. The patient declined in health status on February 2 and was euthanized at home with his family on February 5, 2018.

notably responsive cancer at KPS) with nearly two years of no progression when chemo wasn’t tolerated. She has also experienced resolution of severe vaccine-induced intractable seizures (uncontrolled by general practice, critical care and neurology veterinarians) after implementing a KetoDiet.

In addition, open-minded veterinarians are trying other adjuvant metabolic therapies (see sidebar on page 54). If you are seeking to incorporate integrative therapies with the metabolic component of nutritional ketosis into your treatment plan, these are the tools to research and consider.

DISCUSSION

Ultimately, the most important factors for success are knowledge, effort and compliance. As with us, the health of our canine companions can be transformed by the food they are fed. The transition from cereal (kibble) or canned diets to fresh feeding (a KetoDiet) can initially seem daunting. In short order, however, it will become habit and seem simple. The KetoDiet can improve a dog’s health on its own, or in conjunction with other therapies, in the treatment of cancer, making the benefits wide-ranging and priceless. Additional resources on how to implement

When properly executed and monitored, inducing metabolic ketosis and applying adjunctive integrative therapies with standard of care treatments can result in increased longevity and quality of life when compared to standard of care alone.

The positive clinical responses veterinarians have seen, and the intriguing research on ketogenic diets for cancer in human literature, warrant additional investigation into this non-toxic and relatively inexpensive holistic therapy for canine cancer patients.

Continued on page 54.

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PRIVATE PRACTICE CASE #3 Breed: German Shepherd Age: 6 Sex: Female Diagnosis: High grade lymphoma Standard of care: CHOP 25week protocol, Metronidazole, Cerenia, Gabapentin, Tramadol, Dasuquin Adjuvant therapies: KetoDiet, HBOT, mistletoe (Viscum album) extract, Doxycycline Additional medical issues: Pancreatitis, ruptured cranial cruciate ligament Date of diagnosis

Start of KetoDiet

Apr 2017

May 2017

Prognosis

Survival time

12 months with CHOP

(as of Jul 1/19) 27 months, in remission

Average blood glucose

Average blood ketone

58 mg/dL

0.25 mM

Case #3 presented in April 2017 with generalized peripheral lymphadenopathy that had been ongoing for one month.

Lymph node aspirates were obtained during a previous visit to her regular vet; the cytology report confirmed high grade lymphoma. The patient was lethargic and hyporexic.

HBOT and CHOP were initiated during her first visit. She responded very well to chemotherapy. Her lymph nodes decreased in size, and her appetite returned to normal in the first week, so CHOP was continued.

In June 2017, as she arrived at the oncology department for her scheduled chemotherapy, she vomited in the lobby. She was lethargic, “punky” and dehydrated. The medical workup revealed gastrointestinal inflammation and mild pancreatitis.

The clients explained that she was very bored with her bed rest, which was due to a ruptured cranial cruciate ligament.

In her frustration, she broke into the pantry and ate an entire bag of cat food. The combination of her KetoDiet plus the large bolus of carbohydrates taxed her pancreas. Her chemotherapy treatment was rescheduled to give her time to recover from the dietary indiscretion.

By August, she was completely transitioned to a strict ketogenic diet. The clients started daily leash walks for metabolic conditioning as they fully committed to the metabolic therapy protocol. In the months that followed, the dog’s weight went from 102 pounds (BCS 8/9) to 86 pounds (BCS 5/9). This weight loss helped maintain comfort for her CCL injury. She completed CHOP in October 2017 and initiated mistletoe therapy in January 2018. As of July 2019, she remains in remission.

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Continued from page 52. a KetoDiet for canines can be found in IVC Journal (Volume 9, Issues 2 and 3 — Parts 1 and 2 of this article), the KetoPet website, and the KetoPet Group and Ketogenic Dog Group on Facebook.29, 30 The authors want to acknowledge the veterinarians, dog parents and advocates who have shared the benefits of KetoDiets for many disease states. To the dog parents of our cases, thank you for sharing your stories.

ADJUVANT THERAPIES TO CONSIDER USING WITH KETODIETS FOR CANINE CANCERS

Breed: Golden Retriever Age: 9 Sex: Male Diagnosis: B-cell splenic lymphoma with mediastinal lymphadenopathy Standard of care: CHOP 25-week protocol, Metronidazole, Cerenia, Mirtazapine, Famotidine Adjuvant therapies: KetoDiet, HBOT, IV vitamin C, Metformin, Atorvastatin, Doxycycline, Mebendazole, Carprofen, Novox Additional medical issues: Atopy

Date of diagnosis

Start of KetoDiet

Feb 2018

Mar 2018

Prognosis

Survival time

6 to 8 months with CHOP

(as of Jul 1/19) 17 months, in remission

• Atorvastatin14

Average blood glucose

Average blood ketone

• Doxycycline15

41 mg/dL

0.25 mM

• Mistletoe extract (VAE)11

• 3-Bromopyruvate (3BP)12 • Metformin13

• Mebendazole16 • Dichloroacetate (DCA)

17

• Poly-MVA18 • Cox-2 inhibitors19 • Berberine, curcumin (turmeric root isolate), resveratrol and nutraceuticals20 • Turkey tail mushroom21 • Yunnan Baiyao22 • EGCG (Epigallocatechin gallate)23 • Artesunate/Artemisinin24 • CBD/THC25 • Hyperbaric oxygen therapy (HBOT)26 • High dose IV vitamin C (HD IV VC)27infusions • CO2 laser28

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IVC Fall 2019

Case #4 presented in February 2018 with an acute history of lethargy and inappetence. The medical workup revealed diffuse infiltrative splenic lesions.

Ultrasound-guided splenic aspirates confirmed a lymphoma diagnosis, and PARR analysis determined B-cell. The client elected CHOP protocol, which was initiated on the day of diagnosis. The ketogenic diet was introduced in March, although the transition was not fully implemented until June due to compliance issues.

The patient experienced a good remission as a result of CHOP, although he did initially experience some gastrointestinal side effects to chemotherapy agents. Chemotherapy doses were lowered, and his family adhered more strictly to the ketogenic diet. Once it was fully implemented, his average blood glucose level decreased from 111 mg/dL to 41 mg/dL; blood ketone measurements remained relatively the same at 0.2 versus 0.25. Mistletoe therapy was initiated two weeks before the last CHOP chemotherapy treatment. The KetoDiet and mistletoe injections were continued after CHOP was finished.

In October (one month after chemotherapy), the dog’s submandibular lymph nodes became mildly enlarged; however, he remained asymptomatic and all medical measuring parameters remained normal. The metabolic protocol, inspired by Care Oncology Clinic protocols,10 was initiated and included Metformin, Mebendazole, Doxycycline, Atorvastatin and Novox. Once the dog was fully adjusted to the metabolic protocol, serial hyperbaric sessions and high dose intravenous vitamin C infusions were initiated.

He remained asymptomatic for several months, but the lymph nodes became further enlarged in February 2019, so rescue chemotherapy was administered. The dog remains in partial remission, enjoying a good quality of life with a combination of chemotherapy and metabolic therapies.

References available online at IVCJournal.com

BUSINESS PROFILE

r Joyce and he tly dog, Aja, ap the named after n ca West Afri rests. goddess of fo is s es dd This go in worshipped s re ltu cu y man for her wisdom sed and plant-ba ens. m gi re g in heal

Herbs for Life Inc ,

.

supports animal health with unique botanical medicinals

Over ten years ago, Joyce Belcher decided to turn her passion for holistic health into a business. She expanded her studies to focus on herbs and, launched Herbs for Life, Inc. in 2008. Belcher worked with several holistic and integrative veterinarians, creating custom formulas for various illnesses by learning what needed to happen in the animal body with respect to specific plant medicines and how they could heal.

Offering a unique line of organic pet supplements as well as herbal medicinals, Belcher’s new company quickly began to thrive…and so did her customers.

From the start, Herbs for Life, Inc. has been dedicated to quality.

Every product is made using non-GMO, certified organic or wild-harvested ingredients, and no chemicals are added or used in the manufacturing process. Belcher prides herself on safety and efficacy and plans to continue growing without losing focus of her mission. “Our mission and passion is, and has always been, to help pets get healthy and stay healthy as nature intended,” she says. Whether an animal needs a daily supplement to balance his immune system, or a botanical medicinal to address a more serious issue, Herbs for Life, Inc. is a go-to brand veterinarians can count on.

Adaptogens and tonic herbs form the basis of Belcher’s products. Boasting herbal and superfood formulas for dogs, cats and horses, these wellness blends are created with optimal synergy for optimal results. Her Detox Liver Cleanse, for instance, has been a game-changer for the health of many animals. It works to remove heavy metals, restore normal healthy function of the eliminatory organs (liver, kidneys,

lymphatic system, blood and neurological systems), and like all her products, contains no inactive ingredients.

Because there are no fillers, the dosage is significantly smaller than with most other supplements. This means you get more bang for your buck, and the animal’s body doesn’t have to work as hard to reap the benefits. “Fillers have to be processed out of the body,” says Belcher. “Many companies use fillers to make their products less costly, but the animal has to consume a much larger dose and the kidneys and liver then have to work hard to rid the body of what it has no use for, taxing these organs of elimination.” Fillers also reduce the amount of nutrients the body absorbs. Because most herbs are watersoluble, they will pass through the kidneys quickly, and are 100% absorbable. This also makes them safe to take on an ongoing basis.

Given that Belcher’s primary goal has always been to help animals, it’s not surprising that she supports several rescue organizations by donating products, funds and consulting time when there’s a need. She also regularly contributes to several animal health publications. Recently, however, she felt the name of her supplement line, Pet Wellness Blends, didn’t fully encompass the values she so strongly upholds, so she rebranded.

This line can now be found under the name Sustenance Herbs, a title that better reflects its ability to support and maintain health. “Sustenance refers to something consumed that sustains life or health,” says Belcher. “And the happiness that pet owners express when their dogs, cats or horses are healthy, happy and feeling great is what keeps me going!

SustenanceHerbs.com

IVC Fall 2019

55

integrative practice

— NOT THE ONLY ANSWER FOR VETERINARIANS

By Jenny Elwell-Gerken, DVM

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

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IVC Fall 2019

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.

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Continued from page 57.

WITH WHOM ARE BOUNDARIES IMPORTANT?

•O ur clients: At what times are we willing to talk to clients (e.g. no texts at midnight!)? How do we allow our clients to treat us?

• Our bosses: This includes availability to mentorship, discussing concerns and more. These conversations ideally happen at the beginning of employment, but as a previous practice owner, I would rather employees raise concerns at any time rather than be unhappy!

• Our families: The biggest area in which I see boundary issues is when we feel obligated to be present when we need down time, or when we start setting new goals for ourselves and our families think we’re dreaming too big.

Sometimes it’s better to pick and choose who gets to hear our goals and dreams!

• Ourselves: This is the most overlooked area. It can include mindless activities that drain our energy (social media). It includes how we talk to ourselves (no more negative self-talk!). It can include complaining and procrastination. When we think about what we’re allowing in our lives or are no longer willing to tolerate, we have to include ourselves in that investigation!

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.

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y clients often say, “I haven’t M 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!

If we seek a new situation out of desperation, we’ll take our problems with us. If we look when we’re in a good mental place, the right situation is much easier to find!

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?

T he reality is that their opinions don’t matter. I realize that’s easier said than accepted, but the only person IVC Fall 2019

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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.

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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-happierlife-and-career/#62a4c2ca48e6

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ESSENTIAL OIL use for professional self care

By Melissa Shelton, DVM, CA

This timehonored modality for healing our patients can also be utilized to heal ourselves.

Crossed wrist position for essential oil grounding exercise.

Too often, I read of a veterinary colleague who has taken his or her own life. It’s always such tragic news — one that leaves your soul heavy and your heart broken for those left wondering “why?” I have also experienced many forms of burn-out and emotional hardship. While I feel I am a resilient person, there are times when I just want to throw in the towel and walk away. This is life. This is normal. During such times, I use my modality of choice — Veterinary Aromatic Medicine, the use of essential oils for physical and mental well-being — to give me extra emotional support.

As veterinarians, in an occupation that can be quite stressful, I feel it’s important that we engage in regular self care routines to help us cope with our day-to-day struggles. Meditation, Reiki, grounding practices, yoga, prayer, getting a massage — all these options are wonderful for our self care — and all can be made even better with the use of essential oils. No matter which method you choose to relieve your stress, I urge you to always strive to include some essential oils in your practices. I can guarantee you will find them quite synergistic.

There are many essential oils, and every one of them will carry some sort of emotional effect. I will list some of my favorites in this article, but realize that any essential oil can become quite important in your own life, regardless of what anyone tells you its property is “supposed to be”. Trust yourself. If the scent

or feel of an oil calls to you and makes you feel better — go with it. You know yourself better than any book or report on supposed effects.

ESSENTIAL OILS FOR EMOTIONAL SUPPORT • Black Spruce (Picea mariana) is rich in spiritual connection.

It can help release emotional blocks, and is balancing and grounding.

• Melissa (Melissa officinalis) is indicated for depression, grief and anxiety.

• Cedarwood (Cedrus atlantica) is reported to aid in a full night’s sleep, and to help with stress and anxiety. Note: Several species fall under the name “Cedarwood”.

• Roman Chamomile (Anthemis nobilis) can support bravery, strength and reduce anxiety.

• Frankincense (Boswellia carterii) is one of the more recognized essential oils and is often used with meditation and prayer to help release the past, move through transitions, increase life force, and for depression and anxiety.

• Ylang Ylang (Cananga odorata) is very balancing, and is indicated for low self esteem, to filter out negative energy, increase thought focus, and restore confidence and peace.

• Bergamot (Citrus bergamia) is well recognized in the aromatherapy community and has been indicated to reduce insecurity, aid with depression and anxiety, and help release negative emotions.

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ESSENTIAL OILS effectively relieve stress and anxiety

I have always been impressed by the power of essential oils to not only improve my patients’ physical well-being, but to support their emotional states as well. These benefits are not limited to our animal patients. Clients also report feeling less stress when offering essential oils to their animals, even in the case of palliative treatments for terminal cases. I recently rescued a donkey from a kill pen situation, and the essential oils I selected for his care to help prevent flies on his horribly fly-bitten legs not only supported his physical healing, but also reduced his stress, helping him adjust emotionally to his new home by giving him feelings of grounding and peace.

When I treat an animal with essential oils for his physical needs, emotional responses can occur in myself as well as the animal.

There is a wealth of research on the ability of essential oils to relieve stress and anxiety.1,2,3,4,5 Just visit PubMed, do a search, and you will find a great many articles on essential oils. This is definitely an area with a strong base of scientific investigation and evidence.

Continued from page 61.

While this is nowhere near all the essential oils available on the market today, it does represent a nice variety for you to start developing a relationship with. If these essential oils are part of a blend, you can still find their individual properties within. I would encourage you to smell each of the single essential oils. I often teach people to go outside, make contact with the earth, and take a few deep breaths. Then inhale the essential oil you have selected. If you cannot find the time or place to be outside, anywhere will truly work, even if you have to hide in the office bathroom!

When you inhale the essential oil, see how it makes you feel. I often close my eyes and inhale through each nostril, left and right, independently. Your brain will detect the essential oil differently through each side, and you may notice the oil will smell different.

Think about how the oil makes you feel.

Lighter? Free? Peaceful? It does not always matter what I or a book tells you a particular oil does. What matters is what the essential oil does for you, and if you enjoy it.

Once you find several oils you enjoy, you can try your hand at blending a few. I often find that if several single essential oils are very pleasant to me, I may enjoy them even more within a blend. Most blends created for emotional purposes can be used at quite low

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concentrations — incorporating 1% to 3% of essential oils within a carrier oil such as fractionated coconut oil (also called MCTs or medium chain triglycerides).

ACCESSING ESSENTIAL OILS DURING A BUSY WORKDAY Here is of my favorite grounding exercises to do with essential oils. I often use a blend I initially created to calm my own dog. It primarily contains Roman Chamomile, German Chamomile, Frankincense and Ylang Ylang, diluted with fractionated coconut oil. I place several drops of this blend on the insides of my wrists. Then I place my wrists together, so they cross and touch with the essential oils in between them. I close my eyes, take several deep breaths, and visualize peace flowing throughout my body with each breath. The grounding that takes place is quite amazing. I have never had someone try this exercise who didn’t feel something quite profound.

There are many options for accessing the supportive benefits of essential oils, even if you are in the workplace or have a “fragrance-free” philosophy. I am incredibly sensitive to artificial and chemical fragrances, and can even detect from several feet away when a person was riding in a car with a “smelly tree” air freshener. However when people are wearing properly-diluted natural

essential oils, I do not experience headaches or recognize obnoxious odors.

• Diffuser jewelry has become very popular. You can find bracelets, necklaces and even rings designed to let your apply your essential oil(s) of choice to an absorbent pad, a lava rock, or other natural material. You can then experience continual benefits from the low levels of oil that naturally evaporate off the jewelry; when feeling especially stressed or in need of a break, inhale deeply from the site of the essential oil application.

Diffusion jewelry has become quite fashionable as well as discreet. Since many people naturally touch and play with a necklace or jewelry — you can easily administer a “stronger inhale” from your jewelry piece, even when in public.

• Inhalers are another wonderful portable option. They emit a very low odor so others cannot detect it, and can be used “as needed” within the workplace and beyond. These inhalers are similar to nasal “sticks” sold as decongestants. The plastic tube (about the size of a lip balm) contains an absorbent wick on which the essential oils are placed. To use, uncap the tube, hold it to the nostrils and inhale deeply. This can be incredibly therapeutic, not only for stress and anxiety, but for physical needs as well.

Allergies, sinus irritation, nasal drip and more can benefit from the use of an inhaler. If you want to be discreet about using an inhaler for workplace stress, remember that it’s becoming more

ESSENTIAL OILS ARE

MULTI-TASKERS One of the things I admire most about essential oils is their diverse range of uses. I love the fact that something as simple as my essential oil bathroom spray can help with my emotional well-being. You may think you created an essential oil spray to just deodorize the bathroom, but if you have selected truly natural oils with their full properties intact, spraying the mist in the air and inhaling it can also affect your spiritual and emotional state.

I use this method for my clients and patients all the time. I will add “catappropriate” essential oils to baking soda, then sprinkle it in the litter box. If I select oils that are grounding to the cat (Valerian, Vetiver) or oils that attract him to the litter box (Catnip), I not only deodorize the litter box, but also relieve the cat’s stress and encourage him to use the litter box. While most humans do not need to be encouraged to use the bathroom (thank goodness!), you may find you want to use your restroom a bit more just so you can spray your essential oil mist into the air and breathe it in!

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CONSISTENT USE FOR COMPASSIONATE SELF-CARE

commonplace for people to use inhalers during a respiratory illness. No one has to know you are treating your stress unless you choose to share the fact with them.

• Don’t forget about diffusing essential oils into the air with a cool mist ultrasonic diffuser. There are many names and styles of diffuser on the market today — I wholly recommend the water-based diffusers, especially if they are to be used around animals. While there is much hype about essential oil diffusion being dangerous for animals, I can assure you from following thousands of patients that when the correct essential oils are selected, and water-based diffusion is used, essential oil diffusion can be incredibly helpful both physically and emotionally. I ran a diffuser in my surgical area, and found it greatly reduced my stress and anxiety when I encountered a challenging case. Over time, we also found the animals in my care awoke from anesthesia in a much calmer state. Animal facilities all over the world now safely diffuse essential oils for animals, staff and clientele.

The benefits of essential oils for animal patients are as varied as your imagination allows. The hardest part of this equation is to actually use essential oils for our own self care. This is why diffuser jewelry and the use of essential oils with items like bathroom spray can provide important exposure for a person in need. It is far easier for me to dismiss the notion of a nice relaxing bath at the end of a hard day than it is to actually draw the bath. I encourage you to find several essential oils or blends you enjoy, and get creative in how you can easily and consistently expose yourself to their benefits. I am certain you will not be disappointed. ¹ Zhang N, Yao L. “Anxiolytic Effect of Essential Oils and Their Constituents: A Review”. J Agric Food Chem. 2019 Jun 13;. doi: 10.1021/acs.jafc.9b00433. [Epub ahead of print] PubMed PMID: 31148444. ² Lowring LM. “Using therapeutic essential oils to support the management of anxiety”. J Am Assoc Nurse Pract.

2019 May 30;. doi: 10.1097/JXX.0000000000000227. [Epub ahead of print] PubMed PMID: 31169787. ³ Sánchez-Vidaña DI, Po KK, Fung TK, Chow JK, Lau WK, So PK, Lau BW, Tsang HW. “Lavender essential oil ameliorates depression-like behavior and increases neurogenesis and dendritic complexity in rats”. Neurosci Lett. 2019 May 14;701:180-192. doi: 10.1016/j.neulet.2019.02.042. Epub 2019 Feb 28. PubMed PMID: 30825591. ⁴ Al-Harrasi A, Csuk R, Khan A, Hussain J.“Distribution of the anti-inflammatory and anti-depressant compounds: Incensole and incensole acetate in genus Boswellia”. Phytochemistry. 2019 May;161:28-40. doi: 10.1016/j. phytochem.2019.01.007. Epub 2019 Feb 22. Review. PubMed PMID: 30802641. ⁵ Hocayen PAS, Wendler E, Vecchia DD, Kanazawa LKS, Issy AC, Del Bel E, Andreatini R. “The nitrergic neurotransmission contributes to the anxiolytic-like effect of Citrus sinensis essential oil in animal models”.

Phytother Res. 2019 Apr;33(4):901-909. doi: 10.1002/ptr.6281. Epub 2019 Feb 3. PubMed PMID: 30714232.

From the VMAA

The Veterinary Medical Aromatherapy ® Association (VMAA) is an organization of veterinarians and veterinary technicians dedicated to the responsible use of aromatherapy in animal practices. Their mission is to promote standards of excellence in animal aromatherapy, to provide outreach and education to veterinarians and axillary animal practices, and to promote continual improvements in Veterinary Medical Aromatherapy®. The VMAA is elevating the veterinary profession through innovation, education, and advocacy of integrative medicine.

ESSENTIAL OILS FOR YOUR EMOTIONAL WELL-BEING

As a holistic modality, essential oils’ claim to fame is their ability to support physical well-being, while also possessing a natural chemistry that affects emotional balance.

The plant fragrances utilized in aromatherapy can have an uplifting impact on a veterinary practitioner’s depressed mood, or calm the frayed nerves and anxious attitudes that go with the daily highs and lows of being an animal care professional. An essential oil’s natural chemistry traverses the nasal passages and comes into immediate contact with the amygdala, the brain’s emotion and memory center.

Top oils that I utilize every day as a busy integrative practitioner are Copaifera reticulata (copaiba) oil, Citrus aurantifolia (lime) oil, Cedrus atlantica (cedarwood) bark oil, Vanilla planifolia (vanilla) absolute, Ocotea quixos (ocotea) oil, and Lavandula angustifolia

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(lavender) oil. The vanilla scent takes me back to peaceful childhood days of baking with my family. The oxygenating power of cedarwood opens my mind. Lavender makes me feel rested. Ocotea’s chemistry helps balance my blood sugar.

The beta-caryophyllene in copaiba deals with my chronic inflammation. The lime contains all-important d-limonene and is refreshing and delicious!

Select a quality brand of essential oils with FDA-approved “internal use” labeling. The oils listed here can be combined and splashed into a glass of fresh ice water for impactful daily sipping! This blend can be applied topically as well. I love to use a roller bottle and apply these oils every day to the back of my neck or my wrists and forearms as a healthy, calming and balancing perfume. Use this blend and don’t forget that self care makes you a happier and more effective doctor!

Submitted by Jodie Gruenstern, DVM, CVA, VP of VMAA

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REDUCING CANCER RECURRENCE IN CANINE PATIENTS

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

Image courtesy of LawAtlas.org

news bites

NEW INTERACTIVE RABIES MAP 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.

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. today. oregonstate.edu/news/complete-removal-tumorreduces-risk-recurrence-cancer-dogs-analysis-shows

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RESEARCHERS WEIGH PROS AND CONS OF BANDAGING HORSE WOUNDS 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/

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