Wound management part 1: the healing process and recognition of wound healing stages

51559132_952390804967417_8511078558653743104_nFlorin Delureanu

DVM, MRCVS

Romania

 

Section A

The physiology of the healing process

The most largest organ of the body is the skin. The skin acts like a barrier between the body and environement. Composed by 3 layers (epidermis, dermis, subcutis) and associated adnexa, the skin is a complex organ with many functions and properties: thermoregulation, motion and shape, environmental protection, storage (vitamins, electrolytes, fat, etc.), immunoregulation, sensory perception, secretion, excretion, etc.

Following trauma, the skin is the first organ to undergo changes. A wound represent a disruption in the continuity on anatomical structure with deterioration of the physiological function. There are several criteria for wound classification:

–                by the time that has passed since wound production: acute or chronic;

–                by the thickness of the skin layer that has been injured: full-thickness or partial thickness;

–                by the degree of contamination:

·                clean wounds – made under aseptic conditions (surgical wounds), in which it does not penetrate into the chest cavity, gastrointestinal, genitourinary tract;

·               clean contaminated wounds – in which the respiratory, gastrointestinal, or                            genitourinary tract is entered with minimal contamination;

·               contaminated wounds – wounds with a major break in sterile technique, open traumatic wounds less than 4-6 hours old with inflammatory process without purulent discharges;

·               infected wounds – traumatic wounds with purulent discharges or perforated viscera, more than 6 hours old.

 

After trauma, when the patient shows up in the clinic, it must be stabilized initially. If haemmorage is present, the wounds need to be bandaged with sterile gauze to stop bleeding, and emergency treatment should be initiated according to the patient’s needs. If it is not an emergency and the patient comes to the clinic with an older wound, after obtaining the complete anamnesis and examining the wound, formation of an initial plan of treatment is necessary. Thereby, depending on the type of wound, the approach differs. Four types of wound closure are described:

–                 primary closure, called also healing by first intention represents immediate closure of a fresh wound. This category includes recent traumatic wounds and surgical wounds.

  • delayed primary closure is indicated when the injured tissue have questionable viability or infection is suspected. The closure is delayed 3-5 days in which time the wound is assessed with proper dressings. Also delay closure offers time for proper drainage and the inflammation will decrease. Approximately 5 days after wounding fibroplasia, cytokines and macrophages will protect the wound against infection and closure can be performed. This type of closure is done before granulation tissue formation.

–                 secondary closure is performed after granulation tissue formation. Usually 5-10 days after injury; this type of closure is indicated when necrotic tissue persists and need to be debride many times, when inflammation is prolonged or when signs of infection are still present

.-                healing by second intention represents healing by granulation, contraction and re-epitelisation. This method is applicable for next types of wounds:

·                    moderate to large wounds in young animals that are located on trunk. Kittens and puppies have a fast rate of healing;

·                    wounds located in areas where the closure may create a “tourniquet effect“ (commonly on distal limbs). In this situation the circulation is compromised

;·                    infected wounds and those who presents questionable tissue viability;

·                    wounds that are closed under tension and dehiscence will occur.

How do wounds heal?

Tissue continuity is restored by the healing process. This biologic process begin immediately after injury or incision. Wound healing is a complex process that comprise three phases: inflammation and debridement, proliferation (repair), maturation and remodeling. All these three stages overlap and have a different duration.

Ø              Inflammatory and debridement phase.

After wounding, to avoid exsanguination hemostasis occur. Following the breakdown of blood vessels, endotheline is produced and along with other mediators (serotonin, bradykinin, catecholamines, histamine, prostaglandins) cause contraction of muscle within the vessel walls and hemorage is stopped by vasoconstriction. After 5-10 minutes, vasodilation occur. An increased blood flow to the wound bed and extravasated fluid in the wound will be present. Subsequent vasodilation, leukocyte migration starts (neutrophils and monocytes). At this point the wound will have the classic aspect of inflammation: swelling, elevated local temperature, erythema, pain. In early inflammatory phase the neutrophils predominate and in late inflammatory phase they decrease and monocytes predominate.

The main cells: –endothelial cells: neoangiogenesis-provides oxygen and nutrients to the tissue;

macrophages and neutrophils: debridement, phagocytosis of bacteria

and other pathogens.

 

  • Proliferative (repair) phase. About 4-6 days later, after wound debridement, the wound enters in repair phase. This stage lasts from day 5 until day 20 but can be longer and depends on many factors: wound size, location, age, health, etc. Four stages are included in the proliferative phase: angiogenesis, fibroplasia, contraction and epitelisation. The aspect of the wound will change in this phase from red to pink and the quantity of exudate will decrease. This phase is predominated by macrophages, fibroblasts, endothelial and epithelial cells. Due to platelet-derived groth factor (PDGF) and transforming growth factor (TGF-β), fibroblasts migrate in the wound from surrounding tissue. As a response to PDGF
    type III collagen is synthesized by fibroblasts. After 7-14 days, TGF-β increase synthesis of type I collagen. Collagen afford strength to connective tissue. There are more than 20 types of collagen. Type I collagen is present in unwounded dermins in 80% and type III collagen in 20%. Finally, due to TGF-β1, fibroblasts are transformed into myofibroblasts and wound contraction begin. Contraction increases with a speed of approximately 0.6 to 0.8 mm/day. As a response to epidermal growth factor (EGF) and TGF-α proliferation of epithelial cells begin. Epitelisation continue until complete epidermal thickness. The growth rate of the granulation tissue is 0.4 – 1mm/ day. The granulation tissue is very fragile in consistency and act as a barrier to infection.
  • Maturation and remodeling phase. In the last phase of wound healing remodelling and strengthening of collagen take place. Care must be taken at the beginning of this phase because the scar tissue new formed is very thin and fragile and need few weeks until will gain a proper strength. Due to a changing in collagen type (only 10% of type III collagen present in the scar tissue) rigidity rise and the matrix becomes more stiff. Though, the final scar tissue will not achieve the elasticity and strength of a normal tissue. The maximum strength will be approximately 70 % – 80%. Usually this phase starts 3 weeks after wounding and continue until 1 year.

Figure 1. Illustration of approximate time of wound healing stages. Inflammatory phase last between 0-6 days,

52115600_1963395883709645_7962708292625498112_n

Fig 1

repair phase 4-25 days and maturation and remodelling phase 21 days to months. Overlapping of healing stages is represented by the green triangles.

 

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Fig 2

  Figure 2. Illustration of cell distribution in the time of healing;

 

Conditions that delay or impede wound healing

 

Factors who are involved in this process are grouped into several categories:¨             Host factors: hypoproteinemia (malnutrition); age (wounds in elderly patients have a longer healing time compared to young patients); internal organ disfunctions (Cushing Syndrome- excess circulation of glucocorticoids, liver diseases – clotting factor deficiencies, diabetes mellitus, uraemia, hypothyroidism), obesity, immune disfunction, viral diseases (FeLV/FIV), cancer, coagulopathies, self trauma;¨             External factors: infection, foreign bodies (environmental – grass awns, soil; surgical  metal plates, drains), radiation therapy, long surgical time and hypoperfusion;¨             Medication: chemotherapy, glucocorticoids, NSAID, anticoagulants, cytotoxic solution used for lavage; ¨             Mechanical factors: motion, tension, pressure (from bandage).

 

 

Section B

 

In which stage of healing we are?

In order to choose an appropriate treatment method (closure or dressing) it is necessary to recognize the phases of wound healing. Some specific aspects should be considered: macroscopic appearance (infection, contamination, blood, inflammation), time elapsed from wound appearance, amount of exudate, wound size, tissue viability, wound margins. This section will illustrate wound details in different phases of healing.

Figure 3. Ventral view of abdomen of a cat during     Figure 4. Approximate 1 hour old wound located on

spay, midline approach; This is a surgical clean        the left front leg, between digit IV and digit V. Small

wound.                                                                                amount of  unclotted blood and early inflammation

51544716_292749861353945_6836055190253076480_n

Fig 3

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Fig 4

 

 

 

 

 

 

 

 

 

 

 

 

Figure 5. (a)Lateral view of digit V of  left hind in a 6 years old paraplegic female dog. Healthy

granulation tissue is present 9 days post dressings treatment. Mild exudate was present following the

removal of the bandage . (b)The same pacient 18 days after wounding; a nearby photograph was made to highlight the presence of epithelisation present at the wound edge (black arrows). The white color at the

center of the wound represents the reflection of the camera light. (c) Maturation phase- complete

epithelisation present in day 44 post dressing treatment.

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Fig 5

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Fig 5

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Fig 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 6. Dorsal view of the right paw of the hind limb in a cat;

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Fig 6

The deglowing wound shows necrotic tissue, foreign materials devitalised tissue and mild exudate; High local tempreture was present on palpation. The infected wound was debride surgically, treated with dressings and later a full thickness mesh graft was applied. The cat disappeared from home for 2 weeks.

 

 

Figure 7. Left latera view of a 4 years old male Yorkshire beign bitten by a dog; Second intention healing

from the beginning until the end was chosen. Granulation tissue is in the middle followed by epithelisation

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Fig 7

and obvious wound contraction after 4 weeks of treatment with dressings.

 

 

Demodicosis with secondary pioderma and fungal infection (dermatophytosis).

31218656_1929341830411951_7466975273171288064_nDr Daiana Debreczeni

Veterinaru clinic VitalVet

Oradea, Romania.

 

Information about the patient:

Name: Lala

Sex: Female

Age:10 months

Species: Canis familiaris

Breed: Mix

Medical history

The dog had been treated for 14 days at another veterinary clinic for allergy with steroidal non-inflammatory drugs and antibiotics (amoxicillin and clavulanic acid).On presentation at our clinic the owner complained about the fact that the dog was pruritic and had the lesions presented in the pictures shown below.

IMG_0997 IMG_0998

 

 

 

 

 

 

 

 

IMG_0988 IMG_0994 IMG_0987

Diagnostic tests:

Skin citology, Gram stain: Gram positive, rod shaped cocci (Staphylococcus spp.);

Wood lamp examination: positive;

Trichogram: swollen, frayed hair with irregular outline; cortex and medulla structure – abnormal;

Deep skin scraping: positive for Demodex.

 

 

Diagnostic: Demodicosis with secondary pioderma and fungal infection (dermatophytosis).

 

Treatment:

 

– Simparica (sarolaner)  1x/month, repeat until 3 consecutive negativ skin scrapings;

  • Marbofloxacin, 21 days;
  • Bathing with therapeutic shampoo (ketokonazol, clorhexidine formulation) every 3 days;
  • Every 3rd bath another therapeutic shampoo was used (benzoyl peroxide);
  • Dermoscent Pyo spot-on, 1x/week, 4 weeks;
  • FortiFlora probiotics.

Topical gel with onion extract and heparin;

Follow up after 1 month:

IMG_1146 IMG_1153 IMG_1154 IMG_1155

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After 3 months from the initial consultation:

 

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What will make your job easier and what you need to come to work with pleasure?

50286153_10218983474407136_3258501475982114816_n We had a question on our Facebook Page and we would like to share some of the answers ( We will skip the names, so people will be more comfortable):

  1. Hi Luba,
    I have followed your journal for a long time, and I sincerely enjoy your success. Hope there are more people like you, radiant and dedicated to your profession.
    Your question, “What would make your work easier and what do you need to work with pleasure?” I would answer so …
    Our profession is wonderful, our patients too, but we also work with people. For this reason, my answer is exactly the same … people. In my opinion, working atmosphere, our colleagues, our attitude towards each other is very important. Our work is tense and responsible and our day would be lighter if there are more smiles, jokes and teas, mutual help and respect among colleagues.
    I will be glad if I can contribute at least a little bit, in order to be more creative, fruitful and happy at my workplace.
  2. Regarding this issue I think we should look from 2 points of view. From my opinion going to work has always been a pleasure in the last 10 years because passion was my motivation but with the passing of time I understood it is the most important to work in an environment that makes you feel at home because all of us spend more time at work than at home with our families. So the work team need to be united and lead by a leader that work side by side with his employees and motivates each of the members by having a nice attitude and giving money reward when needed.On another hand this job would be perfect if the people’s culture regarding the PET industry will grow somehow in a way more responsible, to give more respect to the medical team, to stop treating us like garbage, to stop asking Dr.Google and to be more aware of what means raising a dog or a cat but that will only happen in another world.

    In conclusion I think passion and hard work are the success key in this field.

  3. I would do it more easily if I didn’t waste my energy on unnecessary things, if I had the understanding and appreciation of my colleagues, encouraging of my mentor, if we stop complaining for things that are difficult to solve or things that don’t work and see all like challenges, replace with the appreciation of things that work, complain but with a good optimist conclusion, make a effort to have good mood and positive energy maybe we can inspire all the team 
  4. The team is most important and the attitude to owners!
  5. THE TEAM!
  6. The team is very important! And a boss who trusts you.

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So, veterinarians from The Balkans are searching a team, good envoirment for work. Noone spoke about payment, schedule and so on.

I would like to ask every single vet to think with heart and see what we all can do, to work in a good envoirment, to trust more our colleagues and just to be kind. I would like to ask all the leaders to think how they can improve the good envoirment in their own clinic, how to create a TEAM , not just couple of vets in one place. As a vets, we would not see our colleagues as a competition, we should see them as a help and support. We are the first once who should respect our job between us and then to expect this from the owners

 

 

with love

Luba Gancheva

Learn and Travel- New Story

20181207_125741Dr Cristian Badineci from Bucharest Romania, with the kindly support of Pamas Trading has done his internship in Central Vet Clinic in Sofia, Bulgaria. Let him tell us more about it:

 

I had the chance to attend a one-week internship in December 2018 at the Central Vet Clinic in Sofia. I recently heard of the Vets on The Balkans project from colleagues sharing the same passion: Cardiology. Thus, with the help of organizers Luba Gancheva and Pamas Trading 12814393_1673705086236432_1339900710371625092_nI managed to come to Bulgaria to meet wonderful people.

The clinic is located in an area with green spaces, next to a zoo. I had a warm welcome and attention from Dr. Ranko Georgiev, who presented his colleagues and the tour of the clinic. It has a reception hall, a corridor to the large workroom. On the right corridor there are 3 consulting rooms, and on the left 3 imaging rooms. One for radiology and two for ultrasound. Also on the ground floor there are 2 surgical halls. In the basement there are the admissions stations, the meeting room.During my time here, I attended various cases of general medicine, emergency and surgery, but most of the time I spent in the cardiology department with Dr Marin Buckov, Dr Hristina Shukerova and Dr Ranko Georgiev. I have remarked their dedication to this discipline as well as vast experience in cardiology. They participated in numerous workshops and international congresses. I have witnessed many cases, both common like PS and AS, DCM, MVD, HCM, and distinguished, such as a Labrador with Cor Triatriatum Dextrum, a Jack Russell with Revers PDA. cor triatriatum dextrum24246_103549239687374_288378_nAs far as cardiology is concerned, in the clinic can be made specialized consultations and any kind of interventions for solving cardiac diseases in dog, cat and exotic animals. Performing the necessary investigations in a timely manner, Those in critical situation are interned, stabilized and monitored. There are always staff checking out the clinical signs and administering the medication.During my time at the clinic I was impressed by the qualities of this team. I have met respect and common sense both towards people, animals and love for medicine. I witnessed an emergency in which a small dog was sprouted by a wild boar and had an open chest wound and internal haemorrhage. He arrived in hypovolemic shock. They quickly organized a mini intervention team and stabilized the puppy in 30 minutes. 5 people quickly took clinical signs, performed intubation, artificial respiration, 2-member venous approach, restored volley, stopped bleeding. In 15 minutes the surgery room was ready, and the surgery team performed the closing of torax. The next morning, this dog was barking and eating like nothing happened.I was impressed by a doctor who received a chinchilla with kidney failure. The animal was in critical condition since receiving had serious prognosis and died, but this doctor did not stop for 2 hours trying to save it.After this experience I can hardly wait to get back in our practice and apply the new working methods learned here. I attach some pictures of Dr. Ranko‘s interesting cardiology cases to which I have attended. I am very greatfull for this experience.

 

Vets on The Balkans express their gratitude to Centra Vet Clinic and Dr Ranko Georgiev for being part of Learn and Travel and as well to Pamas Trading for the strongly support as always!

Veterinarians from The Balkans-by Luba Gancheva

46844430_566902133733383_7646486880166346752_nVeterinarians on the Balkans

 

I work with them from 3 years and a half. I am one of them. Being very close to them, help me to see how amazing we are. In the region, economically depresses area with many political and administrative complications, working with clients, who don’t have the possibility to pay high level of medicine, we can see them…. Working hard with so much passion and willing to do their best. They have the hugest willing to grow and improve their knowledge, all the time to involve something new in their practice, if spite of, for them is the newest thing and they cant see this new practice in the university, they did not learn this when they were young students.

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All of them coming from universities in very low level of education, and when they jump in the practice, all of them are in shock, feeling that they don’t know anything. And all the efforts to learn and be good vet start again, like you have never done before. I will skip the financial part of the efforts before and after the graduation. Because me, as a vet from the Balkans, I even don’t want to calculate how much money I invested in my education  and how much money I make per year… :) .

Dr Daniela Bajenaru

Dr Daniela Bajenaru

How much hours per day all of them are working and when they go home, may be start reading and so on. They put 1000 more efforts even to convince the owner to do that examination, compare with vets who practice in countries with better economically environment.

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In spite of all these things, I met vets in high professional level, with so much passion and soul full of enthusiasm, doing their best for their patients. I write all these things, because I really appreciate all our efforts and I am so grateful to all the vets from The Balkans, because they give me from their enthusiasm and this is the best feeling ever. This feeling fulfill your heart and you are the happiest person ever. Yes, I have the same difficulties everyday but that feeling is priceless!43715598_336141656947602_6782174039545741312_n421347_10151629937179640_1038846606_n14199647_10154460495808851_4115072769610561786_nBelica_surgery110

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wish all the vets from The Balkans to love themselves more, to appreciate their efforts and job more, to be aware how special they are! Thank you for being part of you!

 

With Love

 

Luba Gancheva

SURREYGlobal Wellness Guru Joins Clinical Experts for VET Festival 2019

unnamedAmerican physical therapist and Master Yoga teacher Lara Heimann will join veterinary experts from around the world on the speaker panel of VET Festival 2019.  The two-day event, now in its fifth year, aims to combine inspiring, world-class CPD for the whole practice team with an outdoor ‘festival’ atmosphere.  VF18_590

Since its inception, the wellbeing of veterinary professionals has been a strong focus of VET Festival and for, 2019, the inclusion of Lara Heimann in the Wellness and Practice Development lecture, takes this to a new level.  She is globally recognised for the unique vinyasa yoga style she has developed and regularly leads international retreats and workshops.

Speakers in the comprehensive clinical programme include Dr Antonio Pozzi, Head of the Clinic for Small Animal Surgery at the University of Zurich, Switzerland; Dr Susan Little, co-owner of two feline specialty practices in Ottawa, Canada, and past president of the American Association of Feline Practitioners and Dr Ronaldo da Costa, Professor in Neurology and Neurosurgery at Ohio State University, USA.  Other speakers include:

  • Veterinary cardiologist Professor John E Rush. A Diplomate of both the American Colleges of Veterinary Internal Medicine and Emergency and Critical Care, Dr Rush has been a professor for 25 years at the Cummings Veterinary Medicine Centre at Tufts University in Massachusetts
  • Behaviourist Dr Sarah Heath. A founding Diplomate of the European College of Animal Welfare and Behavioural Medicine
  • Soft-tissue surgeon Professor Christopher Adin. Professor Adin is Chair of the University of Florida’s Department of Small Animal Clinical Sciences and Associate Professor of Soft Tissue

Veterinary nurses are welcome to attend any of the lectures, in addition to those in the dedicated nursing stream. An exhibition of the latest products and services for all veterinary professionals takes place in a dedicated arena.

Lara Heimann

Lara Heimann

Commenting, Nicole Cooper, event director, said: “VET Festival is unique in bringing together cutting-edge, inspirational learning, fun and the great outdoors.  CPD from our world-leading speakers is delivered in a high quality and contemporary setting but, once work is done, we encourage delegates to relax and enjoy free admission for them, their friends and family to the VETFest™ Live Party Night.”

She continued: “With the wellness and wellbeing of members of our profession increasingly in the spotlight, we’re delighted to welcome Lara Heimann for 2019 and hope that she will help our delegates to develop practical solutions to living healthier and more balanced lives.

Supported by MWI Animal Health, VET Festival is a family-friendly event, offering a unique Family Hub, in which parents can listen to lectures while their children play safely without disturbing other delegates.

“Balancing work and family life can often be a juggling act,” Alan White Group Commercial Director at MWI Animal Health, said “particularly in the veterinary profession where time is in short supply. This can sometimes compromise the work-life balance of vets, nurses and other team members.  At VET Festival, the ‘Family Hub’ means that there is no compromise and that both our attendees and their families can get the best out of their time with us – and ultimately, at MWI Animal Health, that’s what we are all about – supporting vets, veterinary practices and the veterinary profession, so that they can do what they do best – providing care for the nation’s animals.”

Tickets can be purchased here: https://www.vetfestival.co.uk/delegate-info/ticket-information

Veterinary companies retailing or promoting companion animal products, primary care veterinary practices or referral practices interested in exhibitor or sponsorship opportunities are asked to contact Kara Hiscox at KHiscox@fitzallmedia.com

Notes to Editors

For more information about VET Festival, please visit: www.vetfestival.co.uk.

An Introduction to Pet-specific Care

ackermanWritten by Lowell Ackerman, DVM, DACVD, MBA, MPA, CVA, MRCVS

Author: Dr. Lowell Ackerman is a veterinary consultant, lecturer and author. He is editor-in-chief for “Five-Minute Veterinary Practice Management Consult,” and he lectures globally on medicine and management topics.

 

[© Lowell Ackerman 2019. No part of this material may be reproduced or copied in any manner without express written consent of author. Some of this material has been abstracted from Five-Minute Veterinary Practice Management Consult, 3rd Edition]

 

For veterinary medicine to provide real value to pet owners and real financial success for veterinarians, there is a need to focus on being proactive, appreciating risk factors, closing compliance gaps and managing through evidence-based guidelines. This is the essence of personalized medicine and an opportunity that veterinarians should embrace.

I define pet-specific care as veterinary care tailored to individual pets based on their risk of disease and their likely response to intervention. It could also be regarded as the right care, for the right pet, at the right time. This is a common sentiment in medicine, and it is known by a variety of other names, including lifelong care, client-centric care, personalized medicine, precision medicine and genomic medicine. At its core, pet-specific care focuses on prevention, early detection and evidence-based management using a pet’s individual risk factors and circumstances to determine the best course of action.

The Situation

All veterinarians intend to practice the highest quality of veterinary medicine possible, but this is not always the case. For example:

  • Animals continue to contract infectious diseases even when highly effective vaccines exist.
  • Animals get parasites despite the widespread acceptance that all pets should have year-round parasite control.
  • Diagnoses are often not made until a pet has overt clinical signs of an illness.
  • Genetic predispositions are not always considered for each pet in a proactive manner.
  • Even well-understood chronic diseases like atopic dermatitis and osteoarthritis are sometimes treated with on-again, off-again regimens despite the lifelong timeline.

Imagine the difference to the health of patients and to the bottom line if we ensured that preventive care was provided to all pets in the practice, that we embraced an early-detection model for disease surveillance based on risk rather than waiting for pets to get sick, and that we tailored treatment to patients on the basis of consistent guidelines rather than by relying on individual expertise to dictate how patients are managed.

Most veterinary practices are aware of the importance of prevention, but inconsistencies between doctors in the same practice, a failure to address compliance gaps, and not standardizing hospital-wide recommendations mean too many pets are not receiving optimal care. Practices lose the compensation that would be associated with such care.

Currently, many pet owners only appreciate the need to see a veterinarian for vaccination, routine care or serious illness. This failure to grasp the true value of pet-specific care can adversely affect the health of pets and the financial health of veterinary practices.

Be Pre-Emptive

The area with the most need for improvement is early detection. Veterinary health care teams are very good at working up patients with clinical problems (such as polyuria/polydipsia), confirming a diagnosis and instituting treatment. However, a goal of pet-specific care is to identify problems when they are subclinical and the pet still appears well and when the most options are often available for management or prevention.

So, for example, our human physician counterparts would not be as satisfied with diagnosing diabetes mellitus in a patient; the preferred goal would be to identify the pre-diabetic patient and then manage the condition so that it might never evolve into clinical diabetes. For us to achieve the same level of care, we need to embrace early detection and not wait for animals to be clinically ill before we start routine screenings and intervention.

A comprehensive history, physical examination and appropriate periodic diagnostic screenings are the key components of early detection. Diagnostic screenings might include genotypic testing (e.g., DNA) and phenotypic testing (e.g., laboratory findings or imaging) for heritable or otherwise predictable medical issues.

Early detection is easiest if we first take the time to appreciate risk. Some animals are going to be at higher risk for specific conditions than others, based on genetics, family history, breed predisposition, lifestyle, exposure and other factors. Doesn’t it make sense to screen pets at risk for a variety of conditions proactively rather than waiting until the conditions become problematic?

The earliest screening is typically genotypic testing, which can be done as early as 1 day of age but for practical purposes is usually done at around 12 weeks (and after pet health insurance is in full effect, for pet owners who desire this form of risk management). With recent advances it is now possible to cost-effectively screen for dozens of genetic diseases with a single panel. Such panels include things like von Willebrand disease, progressive retinal atrophy, cardiomyopathy, degenerative myelopathy, MDR1 and cystinuria. A variety of laboratories, such as Orivet, Canine Health Check, Embark and Mars, provide comprehensive panels. However, the goal of such testing is not necessarily to identify problems, but to provide most pet owners with peace of mind that there are not underlying monogenic diseases that need to be addressed. This is the purpose of neonatal screening in human hospitals – to identify the rare individual with genetic errors, but to provide comfort to the majority of parents that worrisome disorders were not found in such screenings.

Genotypic testing is new and exciting, but it won’t uncover all risks, so phenotypic testing is needed for many conditions, including diabetes mellitus and orthopedic disorders, based on a pet’s individual risk factors. While genotypic testing can be done early in life since DNA does not change as a pet ages, phenotypic testing, such as blood work, urinalysis and radiographic studies, is usually performed at ages and intervals that vary with the breed and condition being detected.

Diagnostic screenings can provide baseline values and facilitate long-term monitoring to establish trends that might help to identify subclinical disease. Without early detection and management, many of these conditions can lead to a significant decrease in a pet’s quality of life.

Shared Standards of Care

The final aspect of pet-specific care is evidence-based management. Hospitals should endeavor to codify best practices that are common to all veterinarians in a practice and based on the most current guidelines available. These standards need to be periodically reviewed and updated as new evidence becomes available.

Clients want veterinarians to provide health guidelines in accordance with their pets’ actual needs, so adopting and implementing guidelines, protocols and evidence-based care pathways allows the veterinary practice team to satisfy this desire while simultaneously better meeting practice revenue objectives. A suitable starting point is to consider thorough assessments or questionnaires to determine which risk factors might influence the decision-making process, using the information to establish prevention protocols and early-detection opportunities, and then monitoring pets throughout their lives, modifying action plans as needed.

Early therapeutic intervention has been shown to offer the best chance of successful long-term management of many conditions. Clearly distinguishing between curing a medical condition and long-term control is important when discussing the benefits of intervention and disease management with pet owners.

The Bottom Line

It doesn’t take much imagination to see that personalized medicine allows for the delivery of better medicine. With improved prevention, early detection and evidence-based treatment and monitoring, as well as closing compliance gaps, there are many more opportunities for revenue generation just by providing better medicine. In fact, the American Animal Hospital Association has suggested a significant increase in revenue is possible over the life of a pet just by providing the level of care that most veterinarians already acknowledge is needed.

When will you incorporate pet-specific care into your practice?

Author: Dr. Lowell Ackerman is a veterinary consultant, lecturer and author. He is editor-in-chief for “Five-Minute Veterinary Practice Management Consult,” and he lectures globally on medicine and management topics.

LEARN AND TRAVEL….. NEW STORY! Dr Matei Alexandru at Central Vet clinic in Bulgaria

46520505_355142141909610_6510054373484134400_nDr Matei Alexandru from 3vet Original Project Clinic in Bucharest, Romania has done his externship at Central Vet Clinic in Sofia, Bulgaria. What he said about it:

 

Central  Veterinary  Clinc – Sofia – October /November 2018

To go to certain places you need friends, and sometimes you will find friends simply by hitting them in while you’re going through life. A rumor, a link and a helping hand at the right time if you know how to accept them will open your world. Luba, I met her through a rumor, my colleague Stefan made my connection and my helping hand came from Pamas Trading .12814393_1673705086236432_1339900710371625092_n And I accepted the challenge but a bit different from what was initially planned.

At first I was asked what I liked and I answered –  Soft tissues surgery… when I got there I was asked again – What do you like? And I answered – ALL and I had the opportunity to see ALL at the clinic in Sofia .

I saw a waiting room full of people that was held by three receptionists. I went to three meeting rooms on a long hallway leading to the triage / urgent reception area, and in one corner a lab with all of a dedicated man surrounded by books. I went back through two ultrasound halls and stopped in a radilogy room used to its maximum value.46504093_1954656381506155_1879230126814658560_n 46506316_504219466756165_6529017598988779520_n 46507462_343922266187577_8073384407227957248_n 46507771_738542649840914_4496201851145814016_n 46508584_2175589452709070_1243322865311285248_n 46513483_369877663752364_467199421403103232_n 46514154_1186951701472334_2597444006979829760_n 46514502_259039121427825_8745223588467965952_n

Many surgeons can be operated at once and I have enjoyed the idea and the fact that each surgeon has an anesthesiologist who will do his job very well, the surgeon being strictly focused on the surgical side. I have attended and participated in routine and to more complicated operations (new or older fractures remedies, chronic cases without hope of resolution). Through the hard work of dedicated people ,animals with no hope of healing, resumed their lives, and I have learned new things.

In the clinic everywhere is always a line. A line on which doctors walks and split  the chaos of order. I tested my own skin because I tended to go into the surgery  without a mask … it was a good lesson.

I saw smile, confidence and knowledge and felt the strength of a team. I have received the required information without retention, I have debated cases and I was involved in a differential diagnosis … I have seen desperately recovered cases but also the last breaths of patients for whom nothing could be done.46518652_2331664727053218_7447802504802205696_n 46519168_502253150292970_4750675781510758400_n

I have known dedicated doctors only for overnight patients focused on continuous monitoring, I have communicated with specilalists on exotic animal ,cardiology, ophthalmology, internal medicine, reproduction, neurochirurgia, orthopedics, dermatology, endoscopy, oncology … and I was pleasantly impressed of their level of knowledge and the fact that they want to share whit their colleagues the informations without asking for anything in return.I have been invited into their world for a short time to be witness at high-quality veterinary business build on trust and respect. Thank you Ranko Georgiev for accepting me in your house.46485905_349823095794080_9038427446554132480_n

Purina Institute Announced as WSAVA’s First Diamond Partner

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The recently launched Purina Institute has become the World Small Animal Veterinary Association’s (WSAVA’s) first Diamond Partner. Its support will underpin the running of some of the WSAVA’s key clinical committees and initiatives. These include:

  • The Global Nutrition Committee (GNC), which produces research and resources to help the veterinary healthcare team and owners to understand the importance of nutrition in companion animal health
  • The Animal Wellness and Welfare Committee (AWWC), which promotes advances in companion animal wellness and welfare around the world. It will publish its Global Guidelines on Companion Animal Welfare at this year’s WSAVA World Congress
  • The Hereditary Disease Committee (HDC), which raises awareness and understanding of hereditary disease and genetic predispositions in dogs and cats
  • WSAVA One Health Committee, (OHC), which works to highlight the importance of the small companion animal-human interface on the global One Health agenda.Purina pic

The Purina Institute is also a Global Partner for WSAVA One Care, a pioneering initiative to motivate veterinary associations in countries where companion animal practice is still emerging to raise standards of care.

Serving as the global voice of Purina’s science and its more than 500 scientists and pet care experts, the Purina Institute aims to put nutrition at the forefront of pet health discussions.

The Institute will connect the most innovative minds in pet health by facilitating knowledge exchange and collaboration with veterinary and scientific thought leaders around the world. As a champion of nutrition, the Purina Institute will share the company’s latest scientific breakthroughs and will provide objective, fact-based information sourced from the wider scientific community on current trending topics across pet and human nutrition.

Commenting, Dr Jane Armstrong, External Relations Director for the Purina Institute, said: “We have supported the WSAVA for many years and, as its mission aligns closely with that of the Purina Institute, we felt it was the right time to step up and build an even stronger relationship.”

“The Committees we support align with the Purina Institute’s focus.  Purina has long been a pioneer in advancing the science of pet health, so we look forward to the opportunity to participate in global nutrition conversations through the GNC. Additionally, our research on the human-animal bond reflects our commitment to making lives richer for pets and the people who love them. This is a key driver for our interest in the AWWC.”

“We are particularly excited by One Care as it supports the development of companion animal medicine around the world.  The Purina Institute embraces its goals, especially the development of regional leadership to enable veterinary organizations to support individual practitioners.”

She added: “The WSAVA is the largest and most important global community of companion animal veterinarians. The team at the Purina Institute look forward to working closely with it on initiatives that advance the missions of both organizations.”

Dr Shane Ryan, Incoming WSAVA President, said: “The work carried out by our Committees is helping to transform companion animal medicine around the world but it would not be possible without the help we receive from our industry partners.  On behalf of all of our 200,000 members, I would like to thank the Purina Institute for its most generous support and we look forward to working with the team in the months ahead.”

Diamond Partnership is the premier level available under the WSAVA’s recently launched Partnership Program.

BRAIN TUMORS- 3 CLINICAL REPORTS

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DR SVETOSLAV PENCHEV

United Veterinary Clinic

Varna, Bulgaria

CLINICAL CASE 1

Old Dogs with sudden onset of seizures

 

The 1st clinical case is about 13 years old, castrated Belgian shepherd with acute onset of cluster seizures. Before 5 years the dog was operated ( total mastectomy and ovariohysterectomy) , because of mammary gland tumor.  Another vet made the blood analysis and there is no change in laboratory results. Contrast MRI study  was performed.

MRI findings:1 2 3 4

There are two, oval shaped, T1 hypo- and T2 hyperintense,  intraaxial mass lesion with cystic component. One is in right piriform lobe and another one is in the left olfactory bulb/ frontal lobe. The masses nonuniformly enhances following contrast administration, with more intense enhancement peripherally.  Mass effect with mild brain edema surrounding the lesions is present.5 6

 

Thoracic x-ray show :7

Multifocal nodules with soft tissue opacity in lung parenchyma

The reason of seizures are  metastatic brain tumors in  the right piriform lobe and in the left olfactory bulb and there are multifocal metastatic nodules in the lungs. Although the dog was operated ,  the primary mammary gland tumor is the reason of this condition

There is no feedback with the owner about dog`s condition.

 

CLINICAL CASE 2 8

Next case is about a 9 years, female, not castrated Labrador retriever with acute onset of cluster seizures. The dog present  proprioceptive deficit on the right fore and hind limb. There is no history of previous seizures.  By abdominal palpation mammary gland mass was find.

There is no change in the blood analysis.

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MRI findings:

There is   oval shaped T1, T2 mixed intensity mass in the parietal part of left cerebral hemisphere with surrounding brain edema. Mass margins are well defined on T2. Peripherally enhancing following contrast administration is present with mass effect and midline shift to the right

12 13 1411

 

 

 

Thoracic x-ray show multiple oval shaped masses with soft tissue opacity

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In this case we have the same condition. The metastatic lung and brain disease are due the primary mammary gland tumor.

The dog`s owner prefer to euthanized the dog, because the seizures getting longer and stronger.

 

 

 

 

 

 

CLINICAL CASE 3

The last case is about a 9 years, not castrated, female Jack Russell terrier with depressed mental status from a month and acute onset of seizures. The dog reacted with hypersensitivity in right cranial nerves, proprioceptive deficit in left fore and hind limb and proprioceptive ataxia. MRI contrast study was performed. MRI findings:    17 18 19 20

 

 

There is a one, irregularly shaped, T1 hypo and T2- mixed intensity intraaxial mass involving the right midbrain. The mass intensely, but nonuniformly, enhances following contrastadministration. There is a mass effect and surrounding brain edema.

In this case there is no history of neoplastic disease. This midbrain mass has a characteristic of primary tumor and It is the cause of the seizures.   Every dog after 5 years of age, who presented with a new onset of seizures should be suspected for a brain tumor. The most common indication for brain tumor in dogs are seizures, especially seizures that began for the first time in a dog older than five years of age. Other signs suggestive for a brain tumor include abnormal behavior, vision problems, circling motions, uncoordinated movements and  lethargy.