AAVD Derm Dialogue Newsletter Summer 2020

DERM DIALOGUE

SUMMER 2020

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Editor: Norma White-Weithers, MS, DVM, DACVD • Veterinary Allergy & Dematology Consultant, Baldwin, NY 11510 Work: 646-329-4719 • Fax: 631-694-3401 • E-mail: nweithers@yahoo.com Assistant Editor: Tim Strauss, DVM • Frederick,CO 80516 | E-mail: drtim@comcast.net

FROM THE PRESIDENT Dear Colleagues, This is my last letter as AAVD president and I want to thank all of you for your ongoing commitment to the mission of the AAVD by remaining members and helping the academy to promote the specialty of veterinary dermatology. So much has changed in the world since I last wrote and I hope that this finds you all safe and well.

Dr. Outerbridge

I want to remind everyone that the Derm Dialogue is the only source where you can read about what was discussed at the roundtables at the NAVDF meetings and it is only available to AAVD members,. This AAVD publication would not be possible without the

incredible ongoing efforts of Norma White Weithers and the team that helps get the final version of Derm Dialoque to your inbox. If you want to check out past issues go to the member’s section of the website at AAVD.org.

NAVDF did not take place in 2020 so that everyone could plan to attend the 9th World Congress of Veterinary Dermatology (WCVD9) in Sydney, Australia. For the past 3 years the Executive Organizing Committee (EOC) of WCVD9 have been working tirelessly to put together an outstanding world congress for this October in Sydney. Due to the COVID 19 pandemic that is no longer able to proceed as originally planned, more details are in this issue with the official announcement from WCVD9 EOC president Dr. Mandy Burrows. Our colleagues that serve on the WCVD9 EOC are again demonstrating the same prior dedication, effort and commitment that was critical for planning everything in Sydney to now organize the very first on line World Congress of Veterinary Dermatology.

Please keep checking https://www.vetdermsydney.com for updates and make your plans to attend the online congress.

The scientific program planned for WCVD9 is outstanding and although we will miss seeing friends from around the world, we can all benefit from the incredible efforts of all involved in planning WCVD9.

The 2020 AAVD Business Meeting would have taken place at WCVD9 in Sydney. As we are unable to meet face to face, we will be planning a virtual members’ meeting and details will be forwarded to all current members sometime in July. During that meeting we will announce this year’s recipient of the 2020 Frank Kral award, although the actual presentation of the award will occur at the next NAVDF in New Orleans in April 2021. Save the dates of April 21st to 24th, 2021, as hopefully we will all be able to meet together for another great meeting in an amazing location. The AAVD board are making special plans to organize and sponsor a speaker for this meeting.

This year the AAVD again donated $15,000 to the ACVD Research Fund to provide grant funding for the AAVD/ACVD research grant.

We also funded more student awards bringing the total to over 105 student recipients since 2014 when we first started funding the AAVD Senior Veterinary Student Award in Veterinary Dermatology. This monetary naward accompanies 2 years of membership in the AAVD, which we hope helps foster a nlifelong interest in veterinary dermatology, and ongoing membership in the Academy.

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FROM THE PRESIDENT

The board recently met online and we are looking into how we can organize some online roundtables and the summaries of those will be published in the Derm Dialogue. If you do not yet follow us on Facebook look us up. https://www.facebook.com/ American-Academy-of-Veterinary-Dermatology-103605061326842/ . We will be posting information about online roundtables on our Facebook page as we get those organized as well other new opportunities we are planning. Our Facebook page has a link to the World Association of Veterinary Dermatology (WAVD) webinar series, which is comprised of over 30 hours of some of the world’s leading experts speaking on a wide variety of dermatology topics. The AAVD is a proud member organization of the WAVD. It has been my honor to serve as the Academy president. It is the oldest professional veterinary dermatology association in the world and I have faithfully been a member for over 20 years. I want to thank each of you again for your ongoing membership which allows the Academy to provide an opportunity for dermatologists, generalists, internists, nutritionists, veterinarians in practice, academia and industry, veterinary technicians and veterinary students to come together bonded by our passion and commitment to veterinary dermatology. Your membership in the Academy makes a difference.

I wanted to thank the AAVD leadership team: Drs. Rod Rosychuk, Klaus Loft, Rose Miller, Andrew Mills, Verena Affolter, Norma White Weithers, and Jeanne Budgin. Also thank you to our Executive Secretary Jason Harbonic. Dr. Rosychuk will be leaving the board this year after over a decade of service and we all want to thank him for his leadership, wisdom and humor. We will this year be electing members at large to serve on the board so if you are interested or would like to nominate someone please send information to Jason Harbonic at jharbonic@pamedsoc.org.

From the entire board we send our warmest regards and strength in these uncertain and unprecedented times.

Important News from WCVD9 President 9th World Congress of Veterinary Dermatology, October 20-24, 2020, Sydney, NSW, Australia For the past three years, the Executive Organizing Committee (EOC) of the 9th World Congress of Veterinary Dermatology (WCVD9) has been hard at work planning this event with a determination to deliver the very best interactive learning experience possible. Unfortunately, due to the COVID-19 pandemic, the WCVD9 Pty has determined that the Sydney Congress cannot proceed as originally proposed.

Given the circumstances, this is the responsible decision to make on behalf of the veterinary dermatology community to prevent speakers, sponsors, exhibitors, delegates and their families from travelling and increasing the risk of encountering and spreading the virus. This will help to ensure that the global veterinary dermatology workforce is safeguarded and can continue to play a crucial role in the health of animals.

Although the Congress will not take place as originally intended, the WCVD9 EOC are committed to delivering as much of the scientific content as feasible in an on-line format. We will all miss the social interaction and the vibrant experience that is Sydney, but we intend to ensure that delegates have an unrivalled opportunity to experience the best speakers in the world on a wide range of exciting dermatology topics. We are currently working through the logistics associated with delivering an on-line Congress and will be able to provide more information in the next few weeks.

For registered delegates: we will be in contact with you about a refund of your registration fee and any other services arranged through our PCO; please cancel your travel and accommodation bookings.

For speakers: we will be in contact with you regarding the proposed new structure and to ask if you would be willing to provide your lecture material formatted for electronic delivery.

For sponsors and exhibitors: we will be in contact with you about our exciting proposals for an on-line Congress.

If you know of a colleague who will benefit from receiving WCVD9 updates, please forward this newsletter to them.

We appreciate your understanding at this difficult time.

Mandy Burrows, WCVD9 President

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Contact us General enquiries ICMS Australasia Professional Conference Organiser GPO Box 3270 Sydney NSW 2001 P: +61 (0) 2 9254 5000 E: info@vetdermsydney.com

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Overview of Staff and Leadership AAVD Executive Board

NAVDF Administrative Team

President Dr. Catherine Outerbridge West Sacramento, CA

Members-at-large Dr. Andrew Mills Shoreview, MN

Co-Executive Secretary Jason Harbonic AAVD jharbonic@pamedsoc.org

Immediate Past-President Dr. Rod A. Rosychuk Ft. Collins, CO

Dr. Verena Affolter Davis, CA

Vice President Dr. Klaus Loft Cohasset, MA Treasurer Dr. Rose Miller Coeur d’Alene, ID

Co-Executive Secretary Alexis Borich itchypet@aol.com

ACVD

Meeting Planner Jill Senior JSenior@pamedsoc.org

WAVD Representative Dr. Jeanne Budgin Riverdale, NJ

Exhibit/Sponsor , Meeting Planner

Karin Travitz, ktravitz@pamedsoc.org

Administrative Assistant Jill Bennish, jbennish@pamedsoc.org

Editor, Derm Dialogue Dr. Norma White-Weithers

Baldwin, NY Executive Secretary Mr. Jason Harbonic 1.877.SKINVET (7546838) info@aavd.org

NAVDF Program Committee

Program Chair Sandra Koch

Co-Chair Marcy Murphy

Petra Bizikova Alberto Cordero Brian Scott Klaus Loft

WAVD Committee AAVD Representative to the WAVD, Jeanne Budgin

NAVDF-OC Committee Positions Term Name Affiliation Email Chair 2019-2021 Dana Liska ACVD Danaliskadermvet@gmail.com Co-Chair 2019-2021 Rose Miller AAVD RMillerdvm@gmail.com Treasurer 2019-2021 Kristin Holm ACVD Kshdvm@yahoo.com Sponsorship Liaison

2018-2020

Jeanne Budgin

AAVD

dermgirl02@yahoo.com

Sponsorship Co-Liaison 2019-2021

Klaus Loft

AAVD

klausloft@gmail.com

OC Mbr ACVD

2017-2021

Allison Kirby

ACVD

alliekirby@yahoo.com

OC Mbr ACVD

2018-2022

Kristin Holm

ACVD

kshdvm@yahoo.com

OC Mbr AAVD

2019-2023

Norma White-Weithers

AAVD

nweithers@yahoo.com

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ROUNDTABLE SUMMARIES Nutrition Nuggets Moderator: Dr. Julie Churchill Present: veterinarians from Japan, Israel, USA, industry vet with Royal Canin What are the most frustrating questions or concerns regarding nutrition?

1. Food trials for puppies with suspect food allergies – is it ok, or how important is it to use diets formulated to support growth. a. Few products are approved to meet needs for growth. The second point to remember is that products change and before you prescribe a prescription diet for a puppy, check the product guide, because formulations change.

• Dermatologists are seeing pruritic puppies at a very young age • If possible, delay food trial until the dog has reached 80% of their full adult height •R oyal Canin Adult HP is approved for puppy growth (look at names carefully, it is only that one, not any other RC hydrolyzed products such as canned, not small breed) • Royal Canin venison diet is no longer approved for growth •P roPlan HA had been approved for growth but AAFCO profile for growth made minor changes- although the food did not change it can no longer use a growth nutritional adequacy statement. -Dr Churchill has used this for puppy food trials and likely still okay to use •G et the Product Guides from the food companies so you can compare diets.

2. How are Feeding guidelines on the bag determined? – attendees felt this seemed like too much and might promote unhealthy weight gain.

• F eeding guidelines are a legal requirement for all pet food labels, •C omplete and Balanced means a food contains all the nutrients required by the animal when you feed the correct amount. Pet foods are formulated to be balanced to an average predicted intake • There can be a wide range or individual variation for energy requirements •A AFCO feeding guidelines are made to cover the range average intake - this comprises both the “easy and hard” keepers • I f dog’s intake is dramatically different they may not be meeting their needs (too much or too little).

• I f you have an outlier (such as a puppy that doesn’t need many calories) you may not be meeting their needs; find a lower calorie higher protein option (such as Royal Canin Labrador puppy - good for obese prone pups) •C all the pet food company to discuss their diets for such cases to assure it will meet the needs of that patient.

•M ost hydrolyzed diets are lower in protein because the hydrolysate is expensive • Are highly digestible so almost all is bioavailable • Some vets have concern they don’t have very much protein 3. Pet food Recalls are a concern - create fear, no one wants unsafe food • Two kinds of recalls mandatory versus voluntary •R ecalls have gone up since Food Safety Modernization Act, 2011 (https://www.fda.gov/food/ guidanceregulation/fsma/_ • Followed melamine scare Continued on page 5

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• This changed FDA approach to food from reactive to a proactive approach with low tolerance, leading to an increase in recalls • More voluntary recalls—companies discover problems and remove diets on their own • Recalls may be a good thing as companies will be extra cautious after a recall • The big companies know where their products go so they can find affected product • Companies producing ‘Boutique’ diets can’t always track their product

4. Pet food quality and selecting pet foods What is the concern for ‘boutique’—although there is not a standard definition

• Tend to be smaller ‘local’ companies that don’t fulfill the WSAVA Global nutrition committee: Recommendations on Selecting Pet Foods.

• May not have training in nutrition; or a full time nutritionist (DACVN or PhD Nutrition) on staff • Unlikely to own their own manufacturing company and some are even made in their kitchens.

• Quality of ingredients and changes of ingredients is a concern • The moderator recommends check out WASAVA Nutrition tool kit (https://www.wsava.org/nutrition-toolkit) • Questions to ask companies: - Do you have full time nutritionist in the species you feed (PhD or board certified nutritionist)?

- Do you have quality control procedures in place? Most important is they test the finished product - Do they own their own production plant? Preferred but not required—Co-pack—rent the plant— less control over ingredients or sourcing - Do they have Reasearch and Development—performing, publishing in peer reviewed journals - Will they answer any nutrient question you have The moderator added—They don’t bash other companies • Eg; Fromm is a midwest boutique company that has produced food associated with DCM (dilated cardiomyopathy) - it doesn’t meet all these guidelines • L arger companies have safety measures in place—they know where all their food goes and it can traced • Ingredient choices may lead to substitutions or can be very difficult to obtain a quality supply.

For example, venison can be very difficult to source—they need to contract it well in advance; small companies may not have the buying power to secure quality source consistently 5. Grain Free Diets / BEG diets (Boutique, Exotic and Grain free diets) This issue is complex and still an active investigation by the FDA. • Heart disease associated with these diets; dogs are dying • Vets finding dogs with DCM in a broader range of breeds • Some were taurine deficient (Golden retrievers) but not all • Affected foods may have taurine in them • Exotic proteins—may not know nutrient profile - some may be marginal in sulfur containing amino acids which are precursors to taurine • Moderator is worried about kangaroo—it is difficult to get the nutrition info (amino acid profile, or know about quality), high on the list for DCM • Increased fiber affects microbiome —> taurine deficiency if bacteria consume taurine • No consensus and likely won’t be just one thing causing DCM • If it is caught early, it is reversible or partially reversible • To the moderator’s knowledge, don’t know of any reports in Purina, Royal Canin or Hills diets Continued on page 6

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ROUNDTABLE SUMMARIES

• Cooking can decrease taurine; important that finished product is tested • Formulating food for production is very complicated; why need nutritionist on staff • Moderator recommends no BEG diets for now; she even tries to avoid prescription grain free • May just be seeing tip of the iceberg for diet associated DCM as there are likely subclinical / unreported cases • There is nothing wrong with grain (nutritionally speaking) • Demonized by melamine (wheat flour that was adulterated) • Public doesn’t understand nutrition—think the grains are fillers / unhealthy • People have misconceptions about grain- don’t eat gluten themselves or want a “natural” / “wolf” diet • Pet food companies have worked to meet public demand which was to produce a grain free product • Put a combo of proteins in the diet; makes it hard to do novel protein diet trials • Companies sell inaccurate “allergy tests” to clients for food allergy—gives them an easy way out to test for allergy and support use of certain diets • Clients incorrectly think their pet has a food allergy • Public perceives their pet has food allergy and that food allergies are very common. There seemed to be variation in prevalence depending on where the participants practice.

• Diet associated DCM not a current problem as it is in dogs.

• Do we need to change the diet now that we know they are a risk factor for DCM? • Moderator recommends trying to change from BEG (boutique, exotic, grain free diet) to other options to meet the medical need. We can change the food • If you cannot or do not want to change, recommend a cardiac evaluation- an echo

6. Home Cooked diets • Some recommended diets may be a concern as they are exotic or grain free • Home cooked diets are included in the DCM cases • Very likely they are not complete and balanced unless formulated by a nutritionist • Are they still the gold standard for diagnosis of food allergies?

• Beware of free recipes —> you get what you pay for • Is it okay to feed unbalanced home made food if only fed for 60 days?

• They won’t keel over but will receive suboptimal nutrition and it will be recommended by us • If we sanction unbalanced diet for short term, owners may not come back or believe that complete and balanced diets aren’t really important • When moderator formulates a diet she re-examines the pet every 6 months • Diet drift is common with home cooked diets • Client substitutes different ingredients and changes the recommended diet • Much troubleshooting is done with the client • Important to build rapport with client to discuss the diet to promote adherence • *Resources: petdiets.com or balanceit.com are recommended if client can’t get to a nutritionist • balanceit.com is best used diets for healthy pets unless you have experience • Don’t use the formulations for pets with co-morbidities (leave for nutritionists) to formulate and trouble shoot • Concern there is a lack of nutritionists nearby for referral • ACVN.com—are few nutritionists that do remote consults • Food is an emotional discussion “food is love” • Need to use nutritionist for pets with comorbidities

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7. Ingredient list on pet food label—vets have been traditionally taught to look at what are the first 5 ingredients • Realize this is based on weight of the ingredients—first ingredient is the heaviest • Can have two diets with identical lists but be quite different in their composition • What is Ingredient splitting and why does it occur? = list wheat gluten and wheat flour vs wheat • There could be 2 reasons for ingredient splitting. A) to achieve control of the nutrient levels with very specific ingredients, or B) it will move the ingredient(s) lower on the list so it won’t be perceived to have much of that ingredient 8. What to do with selective appetites or GI signs and need for a food trial?

• If they are young and otherwise healthy, likely have primary GI disease if not eating the diet (young dog German shepherd) • What is the dog’s TLI or folate? A GI panel is recommended.

• Fiber - alters the GI flora • If TLI is normal, have you done a trial with a blend of soluble or insoluble ingredients?

• Localize the GI disease with appropriate questions- Is it large or small bowel diarrhea?

• Look for skin and gut connection • One course of metronidazole can alter the GI flora for weeks • Beneful Prepared meals—used at University of Minnesota as a critical care diet instead of chicken baby food, because it is C&B, has 12 grams of protein per 100 kcal (very high protein modest fat diet) 9. How common are food allergies? Seems to be regional. Some feel they see a lot, others not.

• Many atopics are seen without a food component • Some feel there are a lot of food allergic pets • More than 10% in certain regions Vets don’t have time to take extended diet histories or talk about diets. It is recommended we take more time and charge more—clients want to discuss diet with vets.

• Participants shared perceptions of different diet companies • Blue Buffalo is a company in the process of changing.

• Frustration that they have both an OTC and a prescription “novel” alligator diet • Nestle Purina, Hills and Royal Canin—all fit the WSAVA criteria • Rayne meets most of the WSAVA criteria—but diets are very expensive, and difficult to get • Know the parent company - Royal Canin for example is owned by Mars

10. New diets / Future diet options • Hydrolyzed insect diet—cricket diet by Virbac in Europe • Synthetic meats - lab grown meat 11. What about Probiotics?

• Should we use these if antibiotics is prescribed?—we don’t know for sure • Maybe it can wait until we see a problem (diarrhea associated with antibiotic use) • There are now different strains for different body systems • Huge potential for future use-expect more research and clinical application (ex Calming care) • Chronic GI disease Continued on page 8

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ROUNDTABLE SUMMARIES

• VisBiome—Can use this for a big dog, VSL#3 (mega dose multi strain) • Expensive and very popular • May use when performing a diet change • Don’t use if doing elimination trial • Fortiflora—hydrolyzed protein carrier • Can use it to increase palatability of diets (cat and dog) • Can give with metronidazole, no info on its use with other antibiotics • Purina has a lot of research on this—very robust work • Recommend Purina Institute—source for public access to their research • Nutramax—Proviable, don’t believe they have any clinical trials • Iams product is now off the market • Moderator recommends giving it at night - as not eating and drinking • Remember that supplements are not regulated

12. Prebiotics • Oligosaccharide is a short carbohydrate that is not digestible by the “host” (FOS, MOS) • Tiny fiber used by the GI flora • We think there are beneficial effects • Best use for the flatulent dogs—consider inulin and pure probiotic • Beneficial effects are not known 13. How should we change the diet after proven elimination diet trial rules out food allergy?

• Diet should meet WSAVA guidelines • Give client a specific diet choice, actual name of a diet • Take back our role to answer questions and make nutritional recommendations for our patients.

We should be familiar with a few diets - have a short list for certain populations • Ask client: Where do you shop? Which brands do you want? How much do you want to spend?

What is his appetite? Look at the dog—does it love to eat?

• Specialists could send them back to primary care vet for recommendation • Have a short list to draw from that matches the individual needs of the pet. Examples were given.

Labradors often need a low calorie, high protein diet • Beneful Healthy weight (grocery diet) • Royal Canin Labrador diet (specialty store) • No diet more studied on this planet than Purina Dog Chow (Purina life span study) • Online shopping • Be careful where you buy probiotics. Make sure the company is reputable and that it has been stored properly.

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ROUNDTABLE SUMMARIES Cytopoint Updates Moderator: Alberto Martin Cordero, DVM. DACVD. The roundtable started at 8:30 AM and dosing, adverse effects, drug interactions, and ASIT interactions were covered.

Some of the attendees mentioned the use of 1mg per kg to reduce cost.

Sometimes by going to the higher dose range the effects last longer which makes the clients happier; doses up to 3 mg per kg were mentioned with no adverse effects observed.

Dogs with variable and decreasing responses were mentioned. One dog developed a pyoderma response and was hospitalized but the patient had an excellent response for 7 months after allergic reaction.

Some of the attendees treat with corticosteroids before Cytopoint in some patients, in order to decrease the inflammatory response. Loss of effectiveness was observed due to lack of control of secondary infections, and mange.

Some of the attendees mentioned variable duration of effects depending on the season of the year in some patients. Most of the practitioners use Apoquel concurrently with Cytopoint, in case of flares or when the effect has worn off, before giving the next dose of Cytopoint.

Some dogs require Apoquel concurrently a few days a week even with Cytopoint therapy. Clients seems to be satisfied with the effect and duration of Cytopoint. Some dermatology specialist feel that their business has been reduced after Cytopoint was released as they see fewer patients with allergic disease.

Some of the clients referred to dermatologist by general practitioners may feel frustrated after using the drug due to the management and appropriate diagnosis of the disease. It seems that some clients forget about the severity of their dog’s condition as they are no longer administering other drugs as often with the use of Cytopoint and it may take longer for these clients to schedule rechecks with their veterinarians.

Continuing education for the use of this drug, Apoquel and Cytopoint seems to be required by most of the veterinarians.

Immunotherapy is often combined by most of the attendees with Apoquel or Cytopoint. Observation of longer duration of Cytopoint effects as immunotherapy is starting to work is the most common sign. In some patients Apoquel and Cytopoint administration became seasonal after starting immunotherapy.

Some veterinarians send Cytopoint home to be administered by the owners. Zoetis representatives and key opinion leaders recommend not to leave it at a room temperature for more than12 hours.

Freezing must be avoided due since antibodies may be destroyed. A possible case with a side effects of protein-losing nephropathy was mentioned, but there is not enough information in this case to verify causation.

In small dogs it may be less expensive and chosen by the owner before other treatments.

Immunotherapy was mentioned as very important part of treatment and should be recommended to clients as a long-term treatment choice.

Most of the patients require extra care for ears as proactive topical anti-inflammatory therapy or use of ear cleaners.

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ROUNDTABLE SUMMARIES Treatment of Canine Hyperadrenocorticism (HAC) Moderator: Dr. Katharine Lunn 1. We started by defining whether the group were primarily managing pituitary-dependent hyperadrenocorticism (PDH) or functional adrenocortical tumors (FAT) or both. Most attendees noted that they rarely managed FAT, and would typically refer the cases to an endocrinologist or another specialist if FAT was suspected.

2. For work-up, most attendees agreed that abdominal ultrasound is a valuable part of the work-up and these would typically be done by a specialist. However, ultrasound is not performed in every case, and we discussed whether or not it is “wrong� to not do an ultrasound. If the low dose dexamethasone suppression test confirms PDH, then the ultrasound is not necessary for differentiation. One challenge for some dermatologists is that they may not have easy access to specialists who can do ultrasound. Guidelines as to when ultrasound should be more strongly recommended might include older dogs, dogs with other clinical signs or physical examination findings not explained by HAC, or dogs in which FAT is not ruled out.

3. For dogs that are diagnosed with FAT, we briefly discussed whether most clients were pursuing surgery or not. Factors influencing this decision include availability of a good surgeon, expense, whether the pet is insured, and fear of pursuing surgery. Most attendees reported clients being more likely to pursue medical therapy, perhaps related to these being older dogs with other co-morbidities. Also if the patient is responding well to medical therapy, owners may not perceive the necessity for surgery.

4. For medical therapy, we discussed available options. Trilostane was the most commonly used medical therapy in this group. Mitotane is not available in some parts of the world (e.g. UK, New Zealand), and even when it is available, most clinicians are preferring to use trilostane, even for FAT. In general, there was little reported use of mitotane in this group, even though available studies show that neither one is markedly superior, and both have similar rates of complications and adverse effects. Concerns about mitotane include lack of exposure or experience, inadequate monitoring by the client, dogs not seeming to feel clinically well, or potential for hypoadrenal crisis. We briefly reviewed induction and maintenance therapy with mitotane, and how important it is for the clinician to call and check in daily with the owner, in order to identify any subtle changes of reaching the end-point of induction. One of the big frustrations with mitotane is the need to frequently change the dose or re-induce, which is expensive, because repeated ACTH simulation tests are needed.

5. We touched on therapy for the pituitary lesion itself, and most attendees were not involved with this, but might refer the patient elsewhere. Attendees reported occasionally seeing clinical signs associated with the pituitary lesion, such as neurological signs or mental changes, but these signs may be missed in dogs that do not follow up long term with the dermatologist. The studies tell us that 15-25% of dogs with PDH are at risk of developing neurological signs. The most common signs are mental dullness or decreased appetite. These signs can worsen after starting therapy such as trilostane. We discussed that options for managing the pituitary tumor itself include surgery or radiation. Experienced surgeons are recommended for performing hypophysectomy, as the learning curve is steep. Radiation therapy may shrink the tumor but does not always control the endocrine signs. We touched on potential medical therapies for the pituitary\lesion, but these are not often used. Selegiline was not being used by anyone in this group, and most attendees were not familiar with it. This medication does not appear to be very effective for canine HAC, but may be useful for canine cognitive dysfunction.

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6. We discussed the challenge for dermatologists managing dogs with HAC throughout their life.

Some patients go back to their primary DVM or may be co-managed with an internist, particularly if there are co-morbidities. Dermatologists may not always be comfortable with things like blood pressure monitoring or fundic exams, however blood pressure monitoring is important for older dogs.

7. We then focused on trilostane as this is the most commonly used medica:on for this group. We started by discussing the starting dose. Most individuals in the group were using a dose of around 1 mg/kg per dose. Some reported seeing more hypoadrenocorticism when using the 2-6 mg/kg dose. More recent studies support using a dose of 1 mg/kg per dose or less.

8. Most attendees reported using compounded trilostane—either compounded from Vetoryl itself, or from trilostane. Several attendees were not aware of the published study that showed variation within and between batches of compounded trilostane. Clinicians should be aware of the risks of compounding and monitor patients carefully after they get a new prescription filled.

9. We discussed once vs. twice a day dosing. Many give twice daily (e.g. 1 mg/kg q 12 hours), but will start once daily (e.g. 1 mg/kg q 24 hours) if financial concerns. We don’t necessarily know that best dose or frequency for each individual patient.

10. F or monitoring, most attendees will do an ACTH stimulation test after 10-14 days on the medication, and then again in 2-4 weeks after the first stimulation test. ACTH stimulation tests are also performed when the patient has either signs of poorly controlled HAC of signs of overtreatment. Questionnaires or owner journals can be very useful for keeping good records of the dog’s clinical signs.

11. S everal attendees, including the moderator, noted that cases often need a dose reduction overtime.

Sometimes this will be achieved by taking the once daily dose and dividing it into twice daily.

12. A ttendees reported that overall signs of hypoadrenocorticism were seen only occasionally, but some dogs seemed to show a decreased response to ACTH over :me, without a dose change. We discussed the concept of adrenal necrosis, but most attendees had not seen this. One theory is that it is ACTH from the pituitary that is causing the adrenal necrosis. It may be possible to see changes in the adrenals on ultrasound that suggest necrosis. Dogs can present with a hypoadrenal crisis due to either over-treatment with trilostane or actual necrosis.

13. We discussed that trilostane is generally safe and effective, but it definitely can have adverse effects. In fact one study showed that for dogs on trilostane for 4 years, approximately 25% will have an episode of hypoadrenocorticism (note: not 40% as suggested incorrectly by the moderator). These episodes are not necessarily permanent, and often a dose reduction is all that is needed. It was also noted that some dogs could have a normal ACTH stimulation test (which measures cortisol) but have an isolated aldosterone deficiency, and therefore electrolytes should also be monitored in these dogs.

14. S ome attendees reported diagnosing HAC in younger dogs, often small breeds, typically presented for pyoderma or alopecia. That led to a discussion of typical clinical signs. For this group those signs were most often alopecia, pyoderma, and calcinosis cutis. Most common clinical signs noted by dermatologists are not the same as those seen by internists. For internists, PUPD, polyphagia, and increased alkaline phosphatase are common reasons for presentation.

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15. We discussed cats with HAC. They are often very sick, with skin tearing being an important clinical sign.

Trilostane can be used successfully in cats, and there is at least one published case series in this species.

16. Calcinosis cutis was reported to be most common in Boxer Dogs, various bully breeds (e.g. American Pit Bull or Staffordshire Terrier, English and French Bulldog, Pug or Boston Terrier), and other breeds reported included Corgi and Chihuahua. Therapies include control of HAC with trilostane, and use of DMSO. 17. We discussed longevity and lifespan of dogs with HAC. Many attendees noted that these tend to be older dogs with various co-morbidities.

18. We discussed that certain comorbidi:es might be easier to manage in dogs with HAC if they are managed with mitotane rather than trilostane. Examples might include diabetes mellitus or calcinosis cutis. Most attendees did not report targeting lower cortisols in dogs with calcinosis cutis or using mitotane in these cases.

19. Everyone in the group reported using ACTH stimulation tests for endocrine monitoring. Few were using resting cortisols for monitoring, however this may become more common in future because ACTH is sometimes difficult to obtain. Several studies have addressed monitoring without using ACTH stimulation testing, and several protocols and guidelines are available. When using synthetic ACTH, a dose of 1 ug/kg is adequate for monitoring on trilostane, as long as given IV and the post-ACTH sample is drawn at 1 hour. The 5 ug/kg dose is still recommended for diagnosis, although the low dose dexamethasone suppression test is a more sensitive (but less specific) test for the diagnosis of HAC.

WAVD Webinar Series in Veterinary Dermatology • In keeping with its mission statement: promoting the worldwide advancement of veterinary dermatology, the WAVD is pleased to announce the release of a series of twenty-nine foundation level educational webinars which can be viewed free-of-charge at wavd.org/continuing-education/webinars/ • Topics covered by leading experts in their fields include the clinical approach to dermatological cases, diagnostic techniques, allergic and infectious diseases of the skin and much, much more • The webinars are aimed at

• Veterinary students in their final year

• General practitioners wishing to increase their knowledge of the discipline

• Additionally, several contain important new information of value to thosepursuing advanced studies in this subject The WAVD is very grateful to the contributors for taking the time to share their knowledge and expertise with the global veterinary community

WAVD Webinar Series in Veterinary Dermatology •

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In keeping with its mission statement: promoting the worldwide advancement of veterinary dermatology, the WAVD is pleased to announce the release of a series of twenty-nine foundation level educational webinars which can be viewed free-of-charge at wavd.org/continuing-education/webinars/ Topics covered by leading experts in their fields include the clinical approach to dermatological cases, diagnostic techniques, allergic and infectious diseases of the skin and much, much more The webinars are aimed at

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ROUNDTABLE SUMMARIES Feline Allergy Treatment Moderator: Diana Simoes Welcome, introductions Background for RT • Many of us treat cats that suffer from allergy. Our knowledge and our research on feline allergy is far behind that of human and canine allergy. Treatment options are also more limited. As practitioners we can benefit from discussion on how we treat and manage our feline patients.

Define feline allergy (for the purposes of the round table—include environmental hypersensitivity, food hypersensitivity, and flea bite hypersensitivity) Goals • Commiserate on the challenge of managing feline allergy…and also to share different treatment strategies, discover some alternative treatment options, look ahead at what the future could hold for feline allergy So what are the challenges you face in managing feline allergy?

• patient cooperation is often difficult

• owners that refuse to acknowledge the need for flea prevention

• poor owner compliance

• limited treatment options (there’s much room for growth, innovation, and development, both from a research and pharmaceutical perspective)

• multifactorial allergy makes treatment even more challenging Discussion on specific feline allergy treatments: Steroids • One person uses Dex-SP 4mg/ml injectable as PO (0.2-0.4mg/kg or 0.1-0.2mg/kg), can taper down to q 3 days in most cats • One person uses triamcinolone tabs as these are small and have relatively no taste (tapers down to q 3 days) • A couple of people use dexamethasone tablets, as these don’t taste like anything • One person feels that Medrol has more of a taste that cats dislike Atopica • One person uses it often, feels that it works well, and ramps up slowly over time; recommends coating outside of Atopica syringe in something palatable (for ex. baby food) as a chaser • One person adds Atopica to vanilla pudding, tuna or salmon juice, or sprinkles Fortiflora over canned food mixed in with Atopica • One person sees a few cases with gastrointestinal upset, when prescribing Atopica, and has had deaths of cats taking Atopica • One person takes serum trough levels of cyclosporine at 2 weeks (to monitor for hyper-absorption) and speculates that perhaps should be doing it earlier at 7-10 days after starting Atopica. Ideally trough levels are below 600. If levels are really high then follow it a few more times in future. Notes that trough levels don’t seem to correlate with overt clinical signs such as diabetes or gingival hyperplasia • Two people have seen development or worsening of diabetes mellitus when treating with Atopica • One person never gives full dose, and rarely does Toxoplasma testing • Two people have seen a case of atypical disseminated Mycobacterium in cats receiving Atopica Continued on page 14

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Allergy Immunotherapy (SQIT, SLIT) • Most attendees do allergy testing in allergic cats • Several people think ASIT works better in cats than in dogs • One person only does serum testing w/ VARL because she finds skin testing for cats is unreliable, while several persons do IDAT for their feline patients • One person uses Idexx labs and does serum testing • One person does both skin testing and serology w/ Spectrum labs • Most attendees use SQIT, and cats do well on it • One person uses 0.5-0.6cc q weekly at first, then after a year reduces to every other week • One person starts at every other day injectable, and then ends at 0.7cc- 10 days • One person wonders about what withdrawal times are used for drugs w/ serology? One person doesn’t worry about Atopica, one person only worries about long-acting injectable steroids such as Depo-Medrol • One person wonders if anyone has used ASIT for asthmatic cats? One person had 1 case that responded well, and one person had a horse w/ COPD and it also responded well to immunotherapy Elimination diet trials • One person uses RC HP • One person often uses RC Ultamino especially for cats with gastrointestinal symptoms, and has recently been trying Blue Buffalo Novel protein diet • One person uses only home cooked diets, often uses pork meat for the diet trial. If the cat won’t eat the home cooked diet then uses the Rayne diets for diagnostics, and starts to balance the diet when patients are better • One person has had 2 cats that were allergic to green pea, confirmed by single ingredient re-challenge by owners, and so now this person uses RC Ultamino for diet trials • One person has seen rice and potato allergy in dogs and speculates that food allergy to anything is possible Apoquel • One person has used Apoquel in cats and feels that it works about half the time, often starting them at BID dosing (has 4 cats on it right now, SID and it works at 0.6 to 1mg/kg) • One person discusses how there is some evidence that cats metabolize Apoquel faster than dogs, so speculates that if you’re gonna try it, then use 1mg/kg BID, then see how they’re doing • One person does bloodwork twice a year for dogs and cats on Apoquel • One person has seen Demodex in 2 cats that were maintained on Apoquel Gabapentin • One person uses it often by prescribing it as tiny tabs through a compounding pharmacy at 50mg per dosage • One person starts at 50mg BID to TID, and then increases to 75mg once patients are used to it; this same person notes that it seems like TID really works best in patients (gets it compounded as a capsule and then adds it to food) • One person notes that sedation is noted only at beginning of treatment, then it goes away • One person tries gabapentin mostly in allergic cats with a suspected neuropathic or stress-induced component Continued on page 15

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Anti-histamines/Behavior modifiers • One person uses Prozac (1-2mg/kg SID, prescribed through pharmacy) and gabapentin often for cases with suspected stress • One person uses amitriptyline, starting at 5mg SID, finds that it’s one of most potent anti-histamines, and is good for back fur mowing patients, along with gabapentin • One person sometimes uses doxepin or Clomicalm • One person wonders if we underestimate stress in cats, especially cats with Lower Urinary Tract Disease • One person agrees that stress is underestimated in the feline pet population, and refers to behaviorist Cerenia • One person has used it in 2 cats, and it helped in one cat, and didn’t help in the other case, however the second case the owner couldn’t give it because the compounded version tasted awful • One person has used it, had trouble with cost of the product PEA (Retinyl) • 2 persons have tried it on several cats but they won’t eat it • One person notes that there is a wide range of PEA available and that it can be challenging to know which to use and the dosing schedule CBD oil • One person wonders about the potential for CBD oil to help cats with stress induced or behavior induced component to their allergies • One person tried it and thought it helped a cat they had, but then the cat relapsed a month later Miscellaneous • One person wonders what to do with a cat who refuses to take oral medication of any kind?

• One person treats with injectable Dexamethasone + clothes + Soft Paws • One person asks about injectable cyclosporine usage, and there is one person who has tried it and it was very expensive • One person notes that there are concerns with injectable cyclosporine being a rather thick substance and painful as a result, and with the potential to cause sterile abscesses • One person wonders if anyone has had reports or questions about tropical rat mites from owners ? One person has, and mentions a publication describing the parasite and risk for zoonosis in December 2018 Vet Derm journal.

• One person wonders about preferences for flea control? One person has used off label oral canine Bravecto in a case of a cat with intolerance for topical preventives • 2 people like using Cheristen because it is a one size fits all, it’s like topical Comfortis, and it’s a green product that has been used on organic veggies and finds that owners like that about the product

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ROUNDTABLE SUMMARIES What Could Veterinary Profession Learn from Startups Moderator: Dr. Klaus Earl Loft standing in for Dr. Lidiya Alaverdova BACKGROUND: Welcome to a world where everything is possible. Starting a small business or a startup, reaching a new audience via social, disrupting existing business models. The sole definition of a startup has changed from a newly established company to a mindset/ culture/a way of running a business that puts people at heart and doesn’t stop until they find a way to bring value. Basically, startups are watching human health and veterinary space because there are unmet people needs. They will look for disruption by offering new products, services and new ways of delivering them (telemedicine, telehealth, connected care). Think Amazon Prime, Uber and online pharmacies. How they made impossible a new reality by giving people something they wanted.

What should we keep in mind when it comes to startups?

• They are absolutely obsessed with uncovering real people’s needs and taking personal responsibility for solving real problems. What client tensions are you planning on solving in the next 6 months?

• They are redefining the conventional ways of doing things (and they often use design as a tool). Startups are exploring new formats and services that aren’t offered today, but are of high value. They are the ones who blur the definitions, push the borders (e.g. what we define as a boundary of veterinary dermatology will not be something a startup will define themselves). They will look at everything and anything even distantly connected to dermatology. Something that you today would not imagine being part of your job.

Think now what is it!

• Startups will focus on new business models and ways to operate (maybe they will brutally change the retail environment, maybe they will introduce new dermatology subscription models or increase access to specialists in the rural areas by experimenting with telehealth, telemedicine and telecare…) What are your thoughts on the business model of the future?

• Startups focus on service. How about you?

• They are socially responsible and have a clear purpose (being it a cause, saving our planet, helping families who can’t afford pet care). And they are not shy to tell the world about matters they care for. What is your purpose besides offering dermatological advice?

• Startups are so much more than a brand new company trying to disrupt. They do seem to have a particular culture and team dynamics. And those are not for everyone. And oh please we are not talking about the ping-pong tables in veterinary clinics! But perhaps it is time to explore how do we motivate veterinary dermatologists to think & act as a startup.

Veterinary dermatologists are in a perfect position to innovate. We must learn and understand how startups are coming up with new ideas and actively think if our current business model has a chance to be here in 10 years. If we continuously explore new ways of doing business to delight people we serve (and maybe even pets!) we may stand the chance. If we don’t act now—startups will eventually disrupt. Not all of them will succeed, but it only takes a few. So what should vet dermatologists think about?

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Discussion about the use of the attendees use of technology to communicate with clients; Some allowed owners to text/call directly with the doctors, others had systems where messages were screen by reception, nurses and filtered to reduce time spent fielding calls. Lots of people used email to allow flexibility with clients sending images, updates, questions, request for refills etc. This was generally used to allow for being able to respond to clients questions, requests, concerns in between other tasks during the work day. There is no easy simple solution to this problem without sacrificing privacy or spending time when away from work.

The value of telemedicine has lots of limitations to veterinary dermatology, but could be a way to enhance some of the follow up communication. Major concerns are the lack of completeness of the clinical “picture”.

Most attendees agreed that they had seen images sent to them via phones or emails and they had not been able to make sense of the submitted information. But when seeing the patient in real life were able to make the clinical connection in seconds. This appears to be an unmet potential for a start-up, since the owners/ clients have an “expectation” and desire instant gratification (at times unrealistic). The clinicians and their staff have a need for control of the process, boundaries, completeness of information given to them in order to ensure that the “service” provided to the client/owner is correct and they also need to be able to make a living from it.

Other topics of discussion were about the frustration often felt when advice given for “free” at groomers, pet stores etc. However, the group agreed that we could see the client’s need for instant response/gratification as a consumer. Since the group could relate to the same need for instant fulfillment of a need when we are in the store or looking to buy online, this fits into the consumer mindset change seen in the recent years where consumers are able to get services and purchases on demand instantly with the help of phone apps, computers, next-day delivery, online buying like Amazon etc. Several attendees did have online refill/pharmacy orders for their clinics/hospitals but found it hard to compete on price/free shipping etc. with large online retailers like chewy.com, 1-800petmeds and the like. This trend among clients asking for online refills of foods, medicine etc. appears to be growing, likely compounded by the technology getting faster, better, and more available in all aspects of the consumer market. It is further compounded by the growing proportion of clients being Millennials. The trend among veterinarians might be slow to follow this demand and there appears to be yet another start-up potential here.

The group sharing of experience was helpful, but mostly brought to the attention that the field of veterinary medicine needs to reinvent itself via using a start-up mindset in order for the field to not being the “victim” of the next Uber or Amazon type business coming in and “disrupting” the current model.

Additional reading:

www.mckinsey.com/industries/consumer-packaged-goods/our-insights/the-new-model-for-consumer-\goods https://www.mckinsey.com/industries/consumer-packaged-goods/our-insights/agility-at-scalesolvingthe-growth-challenge-in-consumer-packaged-goods https://kingkong.com.au/hismile-grew-tiny-20k-investment-40-million-ecommercepowerhouse3-years-detailed-case-study/ https://techcrunch.com/2018/01/27/tech-startups-want-to-go-inside-your-mouth/ The Myth of the Entrepreneur How Intuit Builds a Better Support System for Entrepreneurs Why There’s No Such Thing as a Corporate Entrepreneur Why Lean Startup Changes Everything Big Companies Should Collaborate with Startups

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WORK-LIFE INTEGRATION FOR VETERINARY DERMATOLOGISTS ROUNDTABLE SUMMARIES Moderator: Lidiya Alaverdova DVM

WORK-LIFEJohn INTEGRATION FOR VETERINARY DERMATOLOGISTS C. Angus, DVM, DACVD; Meagan R. Painter, DVM DACVD; Zhisong (Sean) Participants: Moderator: DLidiya DVM Qiao, Ph.D., Rose Miller,Alaverdova DVM, DACVD: Note-taker & time-keeper: Klaus Earl Loft, DVM Participants: John C. Angus, DVM, DACVD; Meagan R. Painter, DVM DACVD; Zhisong (Sean) Qiao, Ph.D., Rose Miller, DVM, DACVD: Note-taker & time-keeper: Klaus Earl Loft, DVM BACKGROUND:

Today the boundaries between one’s professional and personal life are constantly blurBACKGROUND: Today the boundaries between one’s professional and personal life are constantly blurring. ring. It is impractical to think of work-life balance as a complete separation between It is impractical to think of work-life balance as a complete separation between worlds. Technology means worlds. Technology means that we’re all available 24/7. Everyone (and particularly that we’re all available 24/7.

Everyone (and particularly emerging group of millennial clients) demands emerging group of millennial clients) demands instant reaction and instant connectivity, instant there reaction connectivity, thereEach are no noasked breaks.ourselves Each of usthe probably asked ourareand no instant boundaries, no breaks. ofboundaries, us probably age-old selves the age-oldisquestion: is it ever to possible juggle work andlife home life effectively?

Well,answer the answer question: it ever possible juggletowork and home effectively?

Well, the could depend on how well we integrate it—ratheritthan simply relying on getting balance the right. This is could depend on how well we integrate – rather than simply relying the on getting particularly true right. for veterinary professionals, who quite had a ‘balance’ towho begin withquite because balance This is particularly true fornever veterinary professionals, never hadpet lives and client’s demands In light of lives the dramatic increase in suicide rates in our profession—it a ÔbalanceÕ tooften begincome withfirst. because pet and clientÕs demands often come Þrst.

In light of dramatic increase suicide rates our profession it is veterinary important dermatologists we exis important wethe explore a more realisticinterminology andinmore importantly-how plore a more realistic terminology and more importantly how veterinary dermatologists could help make work-life integration a reality. could help make work-life integration a reality.

Key DeÞnitions: BALANCE

INTEGRATION

50% work / 50% life

Complete integration of 4 critical spaces: Work, Home/Family, Community & Private/ Alone Me Time

Either / or

Integration

Right/ Wrong

All valuable

One size Þts all

Flexible

Work Harder

Work Smarter

Burn Out risk + Low Engagement

Productivity + Satisfaction + High Engagement

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Key Examples: TODAY

IN THE FUTURE OF INTEGRATION

DeÞned Schedules

Flexible schedules that allow integrating day to day life

Time off is strictly scheduled and generally restricted (e.g. vacation)

Systems are in place to handle ad hoc time offs, making them ÔnormalÕ

Break from work is not generally acceptable, maternity leave is limited

Sabbaticals are generally accepted, maternity leaves are ßexible

Veterinary work can only be done in the clinic environment

Some work can be done from home with the support of technology (Telework, Telemedicine, Telehealth, Digitalization of paperwork)

Passion projects (new specialty, professional course of choice or even a hobby) only funded by the individual as if Ônonwork relatedÕ

Employer supports, encourages and even funds individual ÔpassionsÕ to ensure overall wellbeing, happiness and development

Exercising strictly before or after work

Yoga, mindfulness, gym at the clinic

Leaving work at the set time with an expectation to shut off

Flexibility in working hours with the opportunity to Þnish off paperwork at home using todayÕs technological advantages

Leaving work shift exactly at X pm as per Bringing the child to work after school agreed standard shift schedule to pick with someone to watch over should there up a child after daycare be a need Using lunch break to walk the dog or run a chore

Bringing the dog to work, taking care of a chore while at work

A single policy for all

Flexible policy based on the individual situation

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The benefits of work-life integration Work-life integration is a great way to give equal time and attention to all areas of life, without having to sacrifice one for the other. It is more realistic to achieve and it brings a new outlook on work. Veterinary professionals have the advantage to make it happen due to the nature of their work. Work-life integration doesn’t look the same for everyone—and how one chooses to organize their time will depend on both their professional and personal commitments. Whilst work-life integration is often a useful way to fulfill personal and career goals simultaneously, nobody expects veterinarians to merge both areas of their life completely. Attention must be paid to well-being and overall happiness and, crucially, veterinary professionals must do what’s right for them personally. It might not work for everyone—but done right, work-life integration could be key to improving your career happiness and reducing levels of stress, anxiety, burnout and suicide.

ROUNDTABLE DISCUSSION & DESIGN THINKING WORKSHOP Approach and Methodology The Team approached the discussion from the Design Thinking perspective and completed the following steps of the process:

1. Deep understanding what is the problem with work-life integration among veterinarians with special interests in dermatology by conducting empathy introductions and sharing personal experiences

2. Creation of a persona and reframing the challenge that we are trying to solve for

3. Brainstorming what can be done to help Hannah with her problem

4. Discussing the outcomes of the brainstorming.

Should the roundtable session duration be longer, the team would have continued to work their way through the Design Thinking Process, by prioritizing and improving brainstormed solutions, creating & testing prototypes of the solutions with real dermatologists and eventually landing on a workable solution or a range of solutions.

Empathy Introductions As participants of the roundtable were sharing their stories in connection to work-life integration, all others were taking notes to capture key observations. Group then debriefed on whom they met, what surprised them, what were the key needs, feelings, pain points, quotes.

Creating Persona & Reframing the challenge Meet Hannah (made up persona based on the summary of round table attendees “brainstorm” on life-work balance concerns ), 39 years old, married with 2 kids, working as a veterinary dermatology specialist (passed the board exams approx. 2 years ago). Hannah is a successful and busy professional. She is overwhelmed and is unsure as to what is next for her. ‘I worked so hard to get here and now that I am here—I still am not happy. What is worst is that I don’t even know what makes me happy…’. Hannah is a perfectionist, high achiever and Type A personality. She knew she wanted to be board-certified in Dermatology and the path to here was clear, although not always easy. Now that the standard path is finished, key professional goal achieved - the reality starts to kick in. She is overwhelmed by all the expectations of her work and family, scheduling, difficult clients, desire to please people around her with no positive reward. She doesn’t know when or how to turn off and feels drained. There is no time for her. She doesn’t know how to say ‘No’ and finds herself trapped and unhappy. She doesn’t know what is next for her and how to be happy and she is afraid to fail. ‘I did everything as I was supposed to, and it just never feels right’.

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The Reframed Challenge: We are trying to help Hannah, 39 y.o., an overwhelmed veterinary dermatologist to figure out what is next and how to feel happier by better integrating work & life.

How might we help Hannah? What if ….

The list of ideas based on Team’s brainstorming (These suggestions are likely transferable): • Hannah needs to pay attention to her feelings (what makes her happy, what makes her sad, what causes stress, anxiety at work and outside of work) • She needs to ask for help with house chores (cleaning, laundry, nanny), so that home/family time is not defined by doing housework • She needs to spend time thinking about what success means to her and determine her own happiness • Hannah needs to document things/events/moments that spark joy • Reframe commute time as ‘Me’ time.

• Express gratitude. Perhaps a gratitude journal?

• Setting small goals and feeling good about achieving them (got kids ready on time, went on a date with her husband, talked to a friend = achieved personal goals) • Schedule ‘Me’ Time even during the working day. How can the dermatological community lobby the employees to support this?

• Arrange for childcare (stop trying to do it all!). Could there be support from the employers, since so many dermatologists are parents?

• Find a hobby outside the dermatology (only for her) • Call friends and have a proper conversation vs a small texting • Redefine perfection. Could there be more education, workshops, webinars that help increase self-awareness and develop coping strategies?

• Find an opportunity to laugh and not take things too seriously • Practice failure (It is OK not to “win/be 100% on everything”) • Exercise on a regular basis.

• Find a counsellor/coach or mentor. Could AAVD/ACVD establish a list of subsidized coaches who could be available for veterinary dermatologists?

• Be gentle on herself • Fire difficult clients if they create unnecessary stress Homework and commitments

1. Read ‘Leading the life you want. Skills for integrating work & life” by S. Friedman

2. Complete personal assessments to increase self-awareness and understand individual needs • www.Jfe.qualtrics.com • www.lifecoach.com/free-quizzes/emotionalindex

3. Commit time to daily reflection by using these easy tools:

• Start Where You Are Journal of self-reflection (provided as a gift to roundtable participants)

• Personal notebook/dairy & your favorite pen

4. Practice and experiment with work-life integration concept. Work with your employer to develop a small initiative in your clinic (arrange for one if you are a practice owner!)

5. Share what you have learned with others and support those in need.

6. Stop to enjoy when things are good, remember that feeling for a “rainy day”

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SUMMARY There are so many opportunities for veterinary professionals to establish work-life integration. The profession is solely responsible for the well-being of veterinarians and for offering support and guidance to the members of the veterinary community. Regular workshops (live and online) are advisable to further identify solutions, develop conceptual prototypes on how to change the way we operate to better integrate all aspects of life: work, home/family, community and personal ‘ME’ time, so we can live healthier and happier lives while continue helping animals with dermatological issues.

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ROUNDTABLE SUMMARIES Video Otoscopy Roundtable Moderator: Martha Friedman, DVM, DACVD I. What type of scopes do people use? a. Storz

i. Some comments include that individuals are interested in finding smaller units that can be easily used in exam rooms to show clients ear pathology

ii. Issues using the laser in a Storz scope b. MedRX: is compatible with the laser c. Otopet: is compatible with the laser II. Volume? a. Volume of video otoscopy was highly variable between participants

i. Ranged from <10 a year to 3-4 per week III. When to recommend? a. Everyone agrees that chronic otitis and significant discharge warrant imaging and video otoscopy when feasible b. One participant uses video otoscopy with sedation (no intubation) and 4l4ng the head down to clean many ears with discharge

i. This is done in dogs with perceived intact tympanic membrane, but small risk of

aspiration may exist

ii. Discussion that an â&#x20AC;&#x153;ear flushâ&#x20AC;? may mean different things to different people. For example, a myringotomy under general anesthesia vs cleaning the external canal well under sedation c. Some recommend prednisone to reduce canal stenosis and topicals based on cytology, followed by imaging and video otoscopy if symptoms persist IV. CT a. All agree that CT is always ideal when otitis media is a concern b. Push for it even harder if a mass is suspected c. Multiple individuals recount finding pathology on CT they would have otherwise missed d. Takes the guesswork out of whether to do a myringotomy

i. Most feel if there is significant middle ear involvement you WILL catch it on imaging

ii. Will not do a myringotomy with a normal CT V. Otitis media in cats a. In many cases there is obstruction of the Eustachian tube > fluid build up in middle ear > inflammatory response (but not necessarily infection) > this alone can cause neurologic signs

i. Many cats will have or have a history of respiratory disease

ii. This is typically mucoid material

iii. Culture still recommended if a myringotomy is performed b. Question of whether a myringotomy is beneficial if fluid is mostly in the ventral medial aspect of bulla

i. Some feel a flush is still beneficial vs others question benefit and prefer medical management c. Recurrence in these patients is common Continued on page 24

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VI. Once pet is asymptomatic does anyone repeat CT or myringotomoty+culture? a. Most agree a CT would be nice, but people don’t want to pay for it

i. Others argue CT changes may lag resolution of clinical disease b. Repeated myringotomy is not without risk c. Some feel clinical signs are what maaers and that myringotomies may be overdone VII. Do you read your own CT’s? a. Some have access to a radiologist or radiology support b. Many believe that practice makes perfect and we can easily become competent at reading our own VIII. When to refer for surgery? a. If the canal changes cannot be reversed or the bulla has significant changes surgery may be cheaper than the cost of chronic medical management b. Recognize some people are at the dermatologist because they are opposed to surgery c. Maybe bulla lysis is a reason to choose surgery over video otoscopy d. Quality of life is important to discuss e. Make sure people understand the dog already can’t hear in bad ear (since they sometimes avoid surgery because of fear of hearing loss) f. Don’t forget if surgery is unilateral, you still need a dermatologist to manage the other ear assuming there is an underlying disease that may affect both IX. What people instill into the middle ear during video otoscopy? a. Ciprofloxacin ophthalmic solution (esp in cats – also safe in children with middle ear disease) b. Dex SP c. TrizEDTA/Baytril/Dexamethasone d. 10-15 mg/mL of amikacin solution

i. This is not without risk for possible idiosyncratic ototoxicity X. Auricular block a. Some do it with general anesthesia and some in place of general anesthesia when not performing a myringotomy b. Abstract attached for technique

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