Saturday, March 1, 2014

Guinea pigs turn three weeks old

Osler and Cushing turned three weeks old today. 

We've often said that being a child portrait photographer would be a tough gig. Well, juvenile guinea pigs are up there in terms of challenges. Getting two guinea pigs to look at one camera at the same time requires a team of assistants.

In Sydney Autumn has hit with a bang...dark skies, rain clouds and even a hint of cold...its a very good day to stay in bed (your pets will love you for it). 

So if you are we've got some interesting reads for you. Dr Karl wrote an excellent piece on ticks as a trigger for meat allergy. Read more here

A hint of Cushing. 
On an equally scary note, scientists ponder what the mass die-off of flying foxes mean here.

Blogger and mosquito guru Cameron Webb posted about the "Anticipating Infectious Threats to Australia" brainstorm hosted by the Marie Bashir Institute for Infectious Diseases and Biosecurity. You can read it here

We've got some great interviews in store for you next week, but til then enjoy the weekend! Oh, and if you need a kitten fix, Liz our nurse is fostering this little gem:
I just realised every photo in this post involves a cardboard box. They do make awesome hides for little animals.


Friday, February 28, 2014

Dental extractions in cats: tips

Hero helps me revise a paper by keeping my notes warm.

Animal Referral Hospital and Sydney Pet Dentistry veterinarian Christine Hawke gave a superb talk last night on the topic of extractions in cats – when to do them, when not to do them.

Depending on which study you read, around 50 per cent of cats (28-67%) suffer from tooth resorption during their lifespan. It is painful.

Dr Hawke discussed different ways of classifying tooth resorption in cats, one of which classifies lesions by type.

Type 1 is inflammatory in nature, often beginning in the root and working its way up to the crown, but on radiographs the root looks like a root. There is a distinct tooth, distinct bone and a periodontal ligament holding the two apart. Crown or not, these babies need to be extracted.

Type 2 occurs when the periodontal ligament is lost and replacement resorption of the root occurs. (Odontoclasts are basically osteoclasts – normally, unlikely bone, the teeth do NOT undergo constant remodelling thanks to a tooth-bone-barrier. But when that barrier is breached, the root surface is exposed due to damage of cementum or the periodontal membrane, the odontoclasts access it. The remodelling process can then continue as part of normal skeletal bone turnover).

On radiographs, these are those “ghost teeth”. You can sometimes see there was a tooth there, but there is NO periodontal ligament. The teeth are being progressively replaced by bone. Attempting extraction, even where a crown is present, can be very frustrating.

But the only way to tell is dental radiographs.

Dr Hawke’s theory that the difference between Type 1 and 2 is essentially one of the degree of inflammation.(Type 3 is a combo of type 1 and 2 in the same tooth).

Diagnosis of tooth resorption in cats requires examination under general anaesthetic with a dental explorer, and intraoral radiographs. (Remember that cats often have additional roots – or as Dr Hawke says, “cats like to throw dental curveballs”).

Many clients ask if these lesions can be somehow filled? The short answer is no. Extraction is the gold standard. Leaving the inflammatory lesions in situ isn’t good.

So what do you do with type 2 lesions? If you are sure its Type 2, coronial amputation is appropriate. First you need to rule out the presence of a periodontal ligament (a thin black line hugging the tooth on radiographs), periodontitis and gingivitis, endodontic disease and retroviral infection.

When done properly this has a very high success rate.

An envelope flap is made and the crown is removed slightly below the crest using a round bur. This ensures that a clot formed over which granulation tissue can form.

So what were the take-home messages?

  • Tooth resorption in cats is common and painful
  • The aetiology is not completely understood
  • Radiographs are essential for diagnosis and treatment planning: “Doing dentistry without x-rays is like doing orthopaedics without x-rays”.
  • Treatment options are limited to extraction of affected teeth and coronal amputation of selected teeth.
Dr Hawke is presenting a seminar on dental disease in pets for the Centre for Veterinary Education on May 4. More info here.

Wednesday, February 26, 2014

Burnout and depression in the veterinary profession

Everyone needs to curl up in a ball now and then, as demonstrated by Bosca.

Burnout, depression, and - unfortunately - suicide are all too common in the veterinary profession, although the profession doesn't have a monopoly on these problems. They seem increasingly prevalent, but we're reflecting on these issues lately due to the loss of several very special people in recent weeks. Whilst I was merely an acquaintance to each of these people, the feeling of sadness is pervasive. It can be very difficult, impossible even, for those left behind to get their heads around why someone made a final decision and it is challenging not to obsess over the details. All I know is that each of them felt somehow trapped.

Two years ago I wrote the story below which featured in The Veterinarian Magazine

It is well established that veterinarians suffer a higher suicide rate than the general adult population. In fact, research by former Australian Veterinary Association President Helen Jones found that veterinarians were four times more likely to take their lives when compared to non-veterinarians.

In absolute numbers, the number of veterinarians who commit suicide is not high however compared with the average suicide rate for the general population it is high. Suicide in our profession is the tip of an iceberg that none of us can afford to ignore. It is likely that far greater numbers of veterinarians suffer from burnout - physical and psychological fatigue brought about by chronic stress and anxiety.

In a study of Finnish veterinarians, 40 per cent reported moderate symptoms of burnout and just under 2 per cent reported severe symptoms. In a Belgian study, almost 16 per cent of veterinarians suffered from high burnout. Studies are underway to determine the prevalence of burnout in Australian veterinarians, but there can be little doubt that burnout is a cause of significant morbidity in veterinarians in this country.

What is it about our profession that predisposes us to burnout?

According to Jones, veterinarians become stressed because of the volume and nature of their work.

“Vets do work so hard, especially rural vets,” she says. “Some have real problems coping when the phone constantly rings, especially in one-person practices. People are dependent on veterinarians – particularly rural veterinarians – and the vets feel responsible, so I think they take the world’s problems on their shoulders.”

Jones also believes that some veterinary degree admission procedures only favour high achievers - some of whom cannot cope with failure.  

“I think that some of these bright young things simply don’t know how to fail. I think in the past veterinary graduates have had some unrealistic expectations so that when they could not perform perfectly in practice or when something died unexpectedly, they couldn’t cope.”

Counsellor and veterinarian David Foote, best known for his bereavement counselling service for pet owners, has been working in the field of stress, burnout and suicide in veterinarians for 12 years in addition to offering a bereavement counselling service for pet owners.

“Burnout is the result of a long period, typically years, of chronic stress so sufferers are usually exhausted physically, emotionally and psychologically. Some people recover, albeit slowly, while others never fully recover and are often forced to make difficult decisions including leaving the profession.”

Signs of burnout are many and varied but include fatigue, a broad range of medical problems which are initiated or exacerbated by stress, chronic musculoskeletal problems, insomnia, depression, anxiety, cognitive impairment (such as memory loss), hypervigilance,  work errors, absenteeism and, in some cases, substance abuse.

"Having recently attended the funeral of a colleague who took his own life I have been painfully reminded that perhaps the greatest danger in burnout is that it can be potentially part of a continuum that leads to suicide,” Foote says. 

“To hear his family struggle to speak as they paid tribute to a much loved father, husband and brother was overwhelmingly sad and gut wrenching.”

“I see a lot of people with autoimmune disease,” Foote says. “While there is no proven link between burnout and autoimmune disease it is something I’ve observed anecdotally. Many people also feel an inappropriate sense of embarrassment or shame at being somehow ’weak’ which, in reality, is far from the truth.”

“Put simplistically people become burned out because of choices they have made and not made. Typically in our profession these are people who are overworking, heavily invested emotionally in work, and who feel that if they pull back or leave the work situation they have somehow failed.”

“Burnout has profound effects on the brain so people in burnout often have cognitive distortions which lead to them closing off options and choices especially if they are carrying the sense of shame previously mentioned. A big part of what I do is help clients question these beliefs, open out choices again and understand that taking care of themselves is just as important as taking care of their clients, patients and loved ones. If they aren’t addressed then an individual, once feeling better and more energised again, is likely to repeat the same patterns again.”

Foote provides a safe, confidential environment to talk about those issues and facilitates the process whereby those suffering burnout can turn their lives around.

“It’s about helping them to bring their life back into balance. This includes reducing workload, learning stress management techniques (especially mental and physical calming techniques like mindfulness), prioritising all aspects of self-care including sleep, diet and down time and seeking appropriate medical support. Finding a sense of joy and fun again is also very important.”

Foote also helps people unpick the deeper issues.

“The personal traits, attitudes and behaviours that lead to burnout are formed in our developmental years. We can end up with strong beliefs that, to be worthy or of value, we must strive relentlessly to achieve, be perfect in every way and always put others needs before our own.

Veterinary education can reinforce these beliefs.

“We attract a high number of people who are high achievers and ‘caretakers’, highly invested in meeting the needs of others through kindness and compassion but not so good at identifying and meeting their own.” Foote says.
“In combination with this our profession is set up with some powerful potential stressors including long hours, a high level of responsibility, client expectations and exposure to patient death and client grief. Clients’ high emotional investment in their animals increases our sense of responsibility again.”

That makes it challenging at times to distinguish a healthy work ethic, care and professionalism (normal professional functioning) from potentially unhealthy professional functioning.

“We have to keep clients happy, we have to foster good relationships and work to the highest standard we can. The catch is when our self esteem becomes too strongly attached to these things or when work takes up too much of our life.”
According to Foote, basic self care and stress management, including how to have boundaries around work, should be taught at an undergraduate level.

“It’s about educating people in how to keep balance in a profession that has a lot of demands that can pull them off balance. Fostering the development of life skills and adaptive coping strategies in undergraduates can be a powerful preventative measure.” he says.

To this end, Foote regularly lectures undergraduates at the University of Sydney. He is also director of the Intern Mentoring Program for final year students.

“Mentoring plays a very important role in that it creates a culture of giving and receiving support, encouraging people to seek support early and understand that asking for it is not a sign of failure.”

“It really is about creating a culture of giving and receiving support, encouraging people to seek support early and understand that asking for it is not a sign of failure.”

Veterinarian Paul Davey, President of the AVA’s WA division and previous coordinator of the AVA’s Graduate Support Scheme for eleven years, is also a strong believer in the value of mentors.

His involvement began with the loss of a fellow veterinarian in 1996.

“He was a classmate of my brother, due to start work with me on the Monday,” Davey says. “Unfortunately on the Sunday before he chose to end his life. There are various theories as to what resulted in him making that final decision, we can only assume it was a combination of disappointment in where he found himself and the stresses of career choice.”

Davey feels mentors can help prevent such tragedies.

“They act basically as a sounding board, a trampoline if you like, a protective net that a new graduate can use in that first critical year or so of practice.”

But Davey advocates mentors for veterinarians at all career stages.

“Over the years it has become obvious that it is not just new graduates at risk of stress and burnout, but there seems to be a peak at two years [after graduation], again at around seven years and again at retirement age or thereabouts.”

“If you can improve resilience and give people skills to make the right choices about career paths and lifestyles early then you may be able to prevent some of this.”

According to Davey, one of the biggest factors contributing to stress and burnout in veterinarians is euthanasia.

“It’s said that we deal with death seventeen times more often than a GP. That obviously has to take its toll. Personally speaking I think it takes a little bit of us each time.”

Another common cause of stress is poor clinical outcomes.

Davey says that poor clinical outcomes are second only to employment issues as a topic discussed between mentees and mentors.

“I wonder whether it should be compulsory to have a lecture stream at every conference called ‘when good cases go bad’ – it is important for veterinarians to understand that even in the best hands things don’t always go according to plan.”

Mentors and colleagues can be a valuable sounding board when things go wrong.

“I believe fairly strongly about talking about these things and expressing our feelings,” Davey says. “Perhaps not always with workmates. I’ve got a group of close friends I can talk to. Just knowing that someone has experienced similar feelings, particularly things like compassion fatigue, makes a big difference.”

Davey argues that work/life balance is key in preventing burnout.

“Being a vet makes it challenging to maintain work/life balance but it isn’t impossible – it just makes our decisions even more important. Our resolve about things such as keeping our sporting interests or hobbies going is going to be tested.”

Like dogs and cats with chronic renal failure or mitral valve insufficiency, veterinarians may suffer from subclinical burnout for years before symptoms become unmanageable. But there is always a danger that severe stress will trigger decompensation.

“A lot of vets are dealing with subclinical mental illness. I think it is important that we get the message out there, get people talking about it, and disseminate information to the rest of the profession.”

Former West Australian Turf Club veterinarian Peter Symons survived three  brain haemorrhages, two brain surgeries and two cardiac arrests – but claims that his experience of burnout or depression was worse than all of those experiences put together.

“It was particularly demoralising because I could not understand what was wrong with me,” he says. “After suffering for six months I saw a doctor and was told I had major depression. Despite never feeling sad or depressed.”

Anti-depressant medication helped, but was only part of the solution.

Symons, together with Dr Clyde Jumeaux developed what is now known as the Brain Fuel Depletion model for explaining the condition currently called depression (and previously called names such as ‘nervous break-down’ and ‘melancholia’.).

“Brain Fuel Depletion has many disguises,” he says. “It goes by a variety of names including ‘burn-out’”.

The central tenet of this model is that when we are stressed, the brain suffers a depletion of neurotransmitters (or ‘brain fuels’), and a concurrent increase in adrenaline.

“The increased level of adrenaline explains common symptoms such as anxiety, panic attacks, insomnia, and "fight or flight" symptoms like irritability, frustration, remoteness or withdrawal,” he says.

“The depletion of neurotransmitters explains the forgetfulness, phobias, sadness - depletion of neurotransmitters in the limbic system - , and some of the physical symptoms such as Irritable Bowel Syndrome - depletion of neurotransmitters in the hypothalamus.”

“Vets, amongst many other professionals, are predisposed to Brain Fuel Depletion because they are big brain fuel users.”

As Symons explains, vets are often doers (working to get through many jobs in a busy day), perfectionists ( a trait required to get good marks to enter the course, and to survive the intensive tuition), and carers (the reason why they were drawn to the profession in the first place).

“People with this combination of personality types ‘chew through’ a lot of neurotransmitters; especially if they work very long hours or do after-hours work.”

Symons believes that medication is very important in allowing the brain to replenish its levels of neurotransmitters/brain fuels, but emphasises that medication should never be taken to support an unsustainable lifestyle.

“You take medication to feel better, and then do a complete assessment of the lifestyle that got you in this position, then change the lifestyle and/or modify your personality to ensure that you are no longer predisposed to it."

Symons’ journey, and the Brain Fuel Depletion model, are outlined in his forthcoming book – co-authored with Jumeaux – Brain Fuel Depletion: At Last Making Sense of Anxiety and Depression, to be published electronically next month.

In it he argues that the key to brain fuel repletion is simplifying one’s lifestyle. Now Director of the Positive Workforce Foundation, Symons says he is much tougher about protecting himself.

“I used to do eight things, now I do three,” he says. “I can still be effective. If you do too much and work 80 hours a week you end up feeling bad and you’re no good to anyone.”

“I used to think anything was possible, now I realise there are some things I just have to let go. I’m much more ruthless because I am not prepared to pay the price. Outside work I don’t take on as much, if I am busy I tell people I can’t fit something in.”

Symons adds that burnout is not a syndrome exclusive to veterinarians. He recalls a recent speaking engagement with a group of young lawyers.

“[My talk] seemed to strike a chord with a room full of motivated lawyers – quite a number of whom told me they were going back to the office after the event. Everybody knows they need to protect themselves, but long-term ingrained habits and personal characteristics are hard to change, because – after all – they are the attributes that have got you to where you are.”

Symons’ advice is to identify and change the habits that may lead to burnout – before they irrevocably change us.

@ENDS

Resources

Remember you don't need to be suicidal to seek help. You can contact these organisations anytime you need support.

Lifeline 24 Hour Crisis Line 13 11 14 or online chat www.lifeline.org.au

Australian Veterinary Association telephone counselling service: 1800 337 068


The Australian Veterinary Association has a stream of the 2014 Annual Conference devoted to graduate support and wellbeing. For more info visit here.

And for very mild stress, don't forget this.

Tuesday, February 25, 2014

Bonding with cats, desirable qualities in employees and pet-themed sweet-treats

Cats. If you don't live with them, you are missing out big time. (Note the cat-friendly, leopard-print decor)
Here at SAT HQ we're in the thick of editing a journal article, which involves sitting on the study floor tearing one's hair out trying to locate the right reference amongst a mountain of articles upon which one's cats are happily outstretched and would rather not move off this one even though you need it right now thanks very much.

There's much going on in the world which merits thoughtful contemplation and serious discussion, but we're keeping it light today. The internet has served up a veritable treasure trove this week. 

This woman's bond with her cat is truly special. (Link courtesy of the one and only Dr Fabulous). The photographer is the subjects grandaughter (you can view more photos here). 

New grads take heed! My dad sent me this article about the qualities Google seek in employees: the ability to learn, leadership, ownership, humility. Good grades help but they're not enough - and there are good reasons. I particularly like the comments about failure. 

With an increasing pool of veterinary graduates it can be tough to find a job. This year's AVA conference has a stream devoted to graduate support, which is greatly needed.

And on a slightly more frivolous note, I wouldn't object if someone turned up with these cakes for morning tea, or even these floral arrangements.

Monday, February 24, 2014

Pixels aren't cells: the benefits and limitations of imaging in the staging of oncology patients

Today's post features Dixie, who doesn't have any medical conditions but enjoys sitting up on the couch and slowly destroying paper bags.
Last week we attended a great seminar by Animal Referral Hospital imaging specialist Dr Karon Hoffman on imaging for staging of oncology patients. Dr Hoffman is a Diplomate of the European College of Diagnostic Imaging, as well as a recipient of the CVE’sHungerford Award. She has both masters and PhD qualifications and is yet another person on our long list of people we want to be when we grow up.

It is always fascinating hearing how specialists of this calibre organise their thoughts. Staging, of course, is the determination of the anatomical spread of cancer and imaging is one part of it (as is physical examination, but also occasionally surgery). It is different from grading, which is performed by pathologists.

So once you have detected a tumour, why perform staging? In the most basic sense it is to determine tumour size, the extent of invasion and margins, involvement of regional lymph nodes and identification of metastases.

Much of this is achieved through imaging, which is also important for surgical planning. Fortunately some tissues (fascial planes, tendons, cartilage and bone) are more resistant to invasion by neoplastic cells than others but even benign tumours recur with incomplete resection so we want to achieve clean margins the first time. Knowing where to cut is vital!

Dr Hoffman discussed the pros and cons of different imaging modalities commonly used in the staging of veterinary oncology patients.


Just like a work of art...Dixie strikes yet another thoughtful pose.
Radiography
Advantages: provides global information, is relatively inexpensive, especially useful for imaging the appendicular skeleton.

Disadvantages: superimposition of structures, may not be read in detail (Dr Hoffman said that our eyes tend to really see an area of the radiograph about the size of a 20 cent piece…so if we don’t cast our eyes over the whole film we’re missing a lot), increasingly replaced with CT and MRI (especially for the head and axial skeleton).

Interestingly, for a metastases hunt, Dr Hoffman suggested that sometimes four views of the thorax are helpful: both laterals plus ventrodorsal and dorsoventral projections. While most publications recommend three views, Dr Hoffman has worked in some centres where four thoracic views is the standard.

There are two potential exceptions to the three (or four) radiograph requirement: lymphoma (usually thoracic lymph nodes, pleural effusion and pulmonary infiltration can be appreciated on two lateral views) and mast cell tumours which rarely metastasize to the lungs.

Of course, evaluating the patient for concurrent disease is important for staging and prognostication, but according to Dr Hoffman abdominal ultrasound would be a better investment of resources for dogs with MCTs than thoracic ultrasound.

Sonography

Advantages: excellent for evaluation of soft tissue and fluids, provides guidance for fine needle aspiration and biopsy, useful for monitoring response to treatment (e.g. tumour size), often won’t need a general anaesthetic. Ultrasound is excellent when the operator is methodical, thorough and experienced.

Weaknesses: operator dependent (you will miss the lesion if you don’t point the transducer at it), provides local (not global) information, 3-dimensional interpretation is in the operator’s mind.

Sonography is less helpful in the case of osteosarcoma (OSA) as these generally metastasize to the lungs, however extraskeletal OSAs occur and can be detected on abdominal ultrasound.

Dr Hoffman spent a lot of time discussing what can and cannot be inferred from imaging. As veterinarians we are frequently asked to take a best guess at what a lump is likely to be – but owners will often use this information to make life-or-death decisions.

Nodules on the liver or spleen are common but Dr Hoffman said that many animals have died because these are found on ultrasound. Such nodules may represent metastases, but they may also be benign lesions.

Without a biopsy it is difficult to make an assessment. One might suspect that these are neoplastic but further evidence should be sought.

She cited Aristotle: “It is the mark of an educated mind to be able to entertain a thought without accepting it”.

In other words, consider neoplasia as a differential, even the most likely differential if it fits the clinical picture, but don’t seal the deal without further evidence.

Splenic masses are a case in point. We tend to fear that every splenic mass represents a haemangiosarcoma, but this accounts for only 1/3 of splenic masses. Another 1/3 are non-neoplastic, and the remaining 1/3 are tumours of some other kind, 50% of which are malignant. Which means that 50 per cent of splenic masses are curable!

Computed tomography

Advantages: avoids the problem of superimposition by taking imaging “slices” of the subject, and utilises various algorithms to optimise contrast, provides 3-D image for surgical planning and may help avoid abortive surgical attempts, very sensitive in detecting lung lesions (CT can detect lesions of 1mm in diameter, radiology can only detect lesions from 4-7mm in diameter - though the prognostic significance remains unknown since most literature on prognosis involves data based on radiographic assessment for metastases). CT is superior when compared to MRI in detecting the size of length of OSA

Disadvantages: costly, available in fewer centres, requires general anaesthesia.

MRI

Advantages: provides cross sectional imaging, excellent to illustrate tumour margins and metastases, sensitive for detecting inflammation.

Disadvantages: slower than CT, costly, available in fewer centres, requires general anaesthesia.

Scintigraphy

Advantages: excellent screening for lesion detection (especially skeletal metastases and thyroid cancer), permits functional studies.

Disadvantages: low resolution, available in fewer centres.


Her take home advice was this: “People want to know what a tumour is based on the gray scale on the screen. The pixels aren’t cells and while we need a gross structural idea of where the tumour has gone we also need to know the cell line and the characteristics of that cell line.”