18 minute read
KIWI POST
Mark Bryan qualified in Glasgow in 1988, and moved to New Zealand in 1995. Kiwi Post
We’ve probably all been there. You see a semiregular client with their ageing dog, which has a bunch of chronic conditions that are currently managed with varying degrees of success. She’s become more acutely unwell and it doesn’t take you very long to diagnose that she now has a splenic haemangiosarcoma. The prognosis is hopeless and you recommend euthanasia.
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For the owner this comes as a shock they are not prepared for and they want to know if there are any treatment options. Radical surgery is unlikely to be successful and the owner at least understands that this would be unfair on the dog. But they press you to consider other medical treatment options. There aren’tany of course, but she may improve on NSAIDs or even preds for a few days.
You press harder on the euthanasia option but the owner insists on ‘giving the tablets a try’. So you send them home with their meds and a lump in your heart that stays with you through the day and only fades on your second glass of wine that evening. That lump in your heart isn’t because your job is crap or being a vet is rubbish or you don’t drink enough wine. It’s because you have experienced moral distress.
Moral distress is defined as being in a situation where you know the right thing to do morally and/or ethically,but you are constrained in doing that thing. The constraints can be manyresource, structure, process, cost, people, time. In our profession it’s remarkably common and the scenario above is a recurring classic. This scenario can be inverted- the same sense of moral distress can occur when you are asked to euthanase a perfectly healthy dog that perhaps the owner can’t afford to treat or mend; or perhaps can’t be rehomed.
Moral distress is recognised as having a significant impact on mental health, although it hasn’t been well studied in the veterinaryprofession. Instances of moral distress may be passing; but recurring instances of moral distress may lead to moral injury, where an event or events become commonplace. If prolonged, moral residue may occur, where an individual feels their integrity or moral values are frequently or permanently compromised.
Moral distress is well recognised in the medical profession but less so in our profession. Which is strange, because when you start to scratch the surface there are a vast number of examples that vets and support staff can give that may happen almost daily.
The commonest involves money generally the ability of a client to be able to afford the care or treatment we know we are able to give. This is an almost universal and daily occurrence in companion animal work, and is probably most acute in sudden emergencies such as pets hit by vehicles which may require urgent, lifesaving treatment but which may also be expensive, and which the client has to decide on quickly.
But it is also a regular feature of production animal work. Almost all of what we do to farm animals has an economic basis- farmers simply wouldn’t allow us to do stuff that lost them money. And whilst from a preventive perspective this is often not too challenging, when it comes to treating acute disease or acute situations it can be difficult. It’s hard to walk away from a C- section in a cow and shoot her instead just on the basis of money.
It’s also often not simply money. It’s often even harder when you know money is a factor but the owner/farmer also wants a probability of success that is impossible for you to give. You know the ones you guarantee are always the 1% that fail, but you know that if you could give that guarantee the surgery may go ahead.
We’ve recently teamed up with Otago University to study moral distress amongst production animal vets and technicians in the South of New Zealand. It’s a small study but an illuminating one. Moral distress can have aclinical and financial dimension as described in the scenarios above, but it may have a broader dimension.
We’ve come across a number of scenarios where participants have questioned their role in what they see as morally or ethically systems. Examples include our favoured topic of poorly managed intensive winter grazing for cattle whilst the vets aren’t directly responsible, they question whether their role is perpetuating a broader system they struggle to defend.
Moral distress seems more acute and more common in younger vets – and that makes sense. Young clinicians are exposed to arange of experiences that may not all sit well with them. They may never have come across them before; or, they may not have the perspective of time that affords older practitioners the view that they are actually making a difference.
In the example of poor intensive winter grazing, older practitioners may see temporal change- improvements over time that have come as a direct result of their involvement. And they can see things are bending towards better, and that their discomfort is temporary. Younger vets may arrive in at a point in time where the bend over time is not visible- and the current state doesn’t sit well with them.
The various scenarios of moral distress are so common in clinical practice that when I was describing our study and the concept to one of our younger shareholder vets, she said ‘isn’t that just what we do all day every day?! So you’re just studying clinical practice?!’ Which in itself tells us all we need to know and why this work is so important.
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Shining alight on
LASER TECHNOLOGY
Lisa Miller recently spent time in Australia speaking with veterinarians about the benefits of Photobiomodulation (PBMT), or Laser Therapy. Miller, who is the Vice President of Clinical Veterinary Medicine of Companion Animal Health, a division of Enovis (formerly DJO Global), has been working with laser therapy since 2006 and is considered an expert in the field. She has produced numerous articles on laser therapy for veterinary related publications, authored achapter in Wiley Blackwell Publications’ textbook Laser Therapy in Veterinary Medicine,and has also assisted several universities with study design for research into laser therapy.
After graduating from the University of Tennessee in2003, Miller began her veterinary career in general practice but soon went on to complete an internship ininternal medicine at a specialty referral hospital. “While I was at the referral hospital, I was also involved inthe dog show community, and I knew a lot of people who had animals competing in agility and lure coursing, soIbecame interested in rehabilitation and sports medicine,” Miller said. “At that point rehabilitation and physiotherapy for veterinary medicine was still early in its availability in the US, so I went and became certified in canine rehabilitation therapy through the Canine Rehabilitation Institute in Florida and fell in love with that aspect of veterinary medicine.” She then worked in rehabilitative and general veterinary practice for many years.
Miller had never planned to leave clinical practice but accepted the role of Veterinary Medical Director at Companion Animal Health because it enabled her to combine several career interests. “It was an opportunity for me to get back involved with rehabilitation, sports medicine and physiotherapy, which l loved, but also to embrace a love of teaching – because I love teaching and sharing information with colleagues and getting excited about new things.”
Although she was already familiar with laser therapy from her clinical work, Miller’srole at Companion Animal Health provided her with the chance to build the company’s educational and clinical support programs related to photobiomodulation and its applications in veterinary practice. Significantly, as general veterinary practices began adopting laser technology, the versatility of the modality became clear.“Laser therapy is used to treat a lot of different things, not just orthopaedic conditions,” Miller said. “Veterinarians started using PBMT to treat everything involving inflammation and pain, and that drove the adoption of the technology because people were seeing clinical success treating awhole bunch of different things.”
Miller is keen to share the benefits of PBMT with veterinarians in Australia. “Laser therapy can basically be used as an adjunct to safely treat any condition ending in ‘-itis’, as long as we can deliver a clinically appropriate dose of light to the intended tissues,” she explained. “The great thing about coming to Australia was being able to share the success stories and present the explosion of evidence and literature around photobiomodulation and laser therapy with our colleagues there.”
Specifically,PBMT is used to promote tissue repair, decrease inflammation, and provide pain relief via photochemical (as opposed to thermal) means. Operating at a cellular level, the laser targets cytochrome C within the mitochondria. “Laser therapy allows us to displace the nitric oxide that is competitively binding to cyctochrome C in the mitochondrial membrane,” Miller said. “The mitochondria have produced nitric oxide because they are stressed, either from aging, illness or disease, and once you free up the binding site, then oxygen can come back in and do its normal job.”
Benefits resulting from laser treatment include improved vascular activity and nervous function, reduced scar formation and inflammation, and faster wound healing. “We’re not creating supercells – I tell people we’renot creating ‘Captain America’ cells,” Miller explained. “We’re just making them function like they
should have been, optimising their functionality to allow healing. We are recruiting blood supply to the area and encouraging collagen deposition, as well as upregulation of certain cytokines and growth factors while modulating others that are pro-inflammatory.” Significantly, since PBMT provides such benefits in a non-invasive way, it can be used to treat a wide range of acute and chronic conditions.
Miller points out there are far fewer clinical circumstances which would contraindicate the use of PBMT now than there were when the modality was first introduced nearly 20 years ago. “At that time, out of prudence, there was a long list of contraindications – such as never using laser therapy over open growth plates, or the reproductive organs or the thyroid gland,” Miller said. “But in the past several years, almost all those contraindications have become ‘special considerations’ because we now have more research to support the safe use or benefits of laser therapy for a number of these conditions, when used in an appropriate manner. As always, we recommend checking the literature or with your laser manufacturer’s clinical team prior to starting treatment.”
One obvious contraindication of PBMT is that it cannot be used to treat eye conditions. Rather, animals experiencing laser treatment should have their eyes covered or wear protective eyewear during treatment, known in the industryas ‘doggles’. Despite having to wear ‘doggles’, however,most animals – including cats and horses, not just dogs – appear to be fans of laser treatment and find the modality relaxing. “The animals love it!” Miller said. “They’ll fall asleep a lot of times; they’ll drool, or cats will sometimes knead the blanket under them. They should feel a soothing warmth that feels verynice.”
Even though its use must be prescribed by veterinarians, who have the knowledge and clinical experience to know which conditions could benefit from PBMT,another benefit of laser therapy is that the treatment itself can be administered by veterinary nurses. “Laser therapy is veryappealing from a business perspective because it’saservice veterinarians can provide to their patients that is nurse driven and nurse administered,” Miller said. “Our nurses can be doing the treatments while we aredoing other things: looking at other patients, diagnosing, treating, performing surgeries, whatever else needs to be done.” Significantly, pet owners can also be present during treatment (also wearing protective eyewear), so they can observe the effects of the therapy firsthand and see that their pets relax and even enjoy it.
For Miller, one specific case stands out as an example of how beneficial photobiomodulation can be for animals. Rio, a 26-year-old American
quarter horse, was suffering from severebursitis and osteoarthritis of the elbow,which was drastically impacting his ability to walk. Rio’s owner had persisted with multiple treatments, including steroid and hyaluronic acid injections, non-steroidal anti-inflammatories, provision of joint supplement in the horse’sfeed and chiropractic adjustments. All treatments had been tried over a period of 8-12 weeks and Rio showed no signs of improvement. As a last resort, Rio’s owner elected to trylaser therapy prior to euthanasia, as Rio was extremely lame and in obvious pain.
Laser treatment on Rio began with daily sessions because he was experiencing a significant amount of pain, and he showed signs of improved mobility from the first session. After four days, Rio was comfortable enough to walk around the pasture again and treatments were weaned to twice weekly. Within weeks, Rio was moving freely and able to trot, then canter. As he regained his range of movement and mobility in the affected joints, Rio received laser therapy every 4-6 weeks on an ‘as needed’ basis. He lived out the rest of his life happily and passed away naturally at 30 years of age.
“It was an incredible success story, and I love to talk about Rio’s case because it reminds me of those situations where you think: I don’t know how this is going to work, but I’m going to be brave and try,” Miller said. “I’ve tried to retrain myself not to wait for things to be that bad before trying something amazing like this modality.It’s just remembering to pull it out –you know earlier you’ve got this great tool. It has no side effects, like medication can have, and it’snon-invasive. The pets love it. The owners love it. There’s literally no reason to let it sit in the corner.”
Miller is grateful her work with Companion Animal Health gives her the opportunity to communicate the benefits of laser therapy to veterinarians in the United States and around the world, and to continue contributing to the in-person training and on demand knowledge base her company provides about photobiomodulation. “We’re not taught anything about this in veterinary school – there is no formal education on laser physics, and that’s challenging because vets are often people who really like information and want to have that information to make the best decision for ourselves and for our patients,” she said. “At the end of the day, we can feel really good about ourselves as a company because we’resupporting our colleagues in an ethical way,helping educate them about laser therapy and its applications, and developing our protocols based on research. I’m excited for the Australian veterinary community to adopt this technology and see all the great things it can do in their practices.” ■ JAI HUMEL
Advances in the use of Meloxicam as an effective means of analgesia in pig production
Introduction
Intensively housed sows and piglets are subjected topainful procedures with minimal, if any, analgesia provided. These procedures fail to meet threeofthe Five Freedoms of animal welfare, more specifically freedom from discomfort, freedom from pain, injury and disease, and freedom from fear and distress (FAWC, 2009).
Changes in legislation within the EU have mandated the use of analgesia and anaesthesia for castration in pigs >7 days of age, or castration by a licenced veterinarian if <7 days old (Dragset, 2011). Changes such as this emphasise the need for an effective and economical means ofdelivering pain relief to intensively housed pigs and those routinely undergoing painful procedures. This paper will discuss recent findings in the use of Meloxicam as a source of pain relief in pig production systems.
Discussion
Meloxicam is a long-lasting non-steroidal anti-inflammatorydrug (NSAID) licensed for provision to food-producing animals in several countries. As such, it has been investigated for its welfare potential. A recent study (Tenbergen et al., 2014b) assessed the impact of pain during farrowing on sow and piglet welfare. Pain may cause the sow to become restless, leading to an increased risk of crushing, reduced access to milk/colostrum for piglets and a subsequent reduction in piglet immunity.The study involved 3006 piglets and investigated the effects of Meloxicam, delivered to sows shortly after parturition, on nursing behaviour, and survival and growth of piglets. Sows that finished farrowing at about the same time were alternately assigned to either control or treatment groups (0.4mg/kg BW Meloxicam IM) within 12 hours of farrowing. Of these sows, 24 pairs (each 1 x control and 1 x treatment) wereselected and measured for posture, time standing and rectal temperature. The results of this study demonstrated that sows receiving Meloxicam had piglets that gained more (p=0.07) weight after farrowing. While other findings were not significant, further research on the impact of Meloxicam in assisted/difficult farrowings is warranted to assess its potential benefits to the sow under these circumstances.
Previous studies have identified the painful nature of routine procedures such as castration in piglets (Moya et al., 2008; Hay et al., 2003), yet analgesia is rarely provided. One such study demonstrated that Meloxicam administered prior to surgical castration was efficacious in lowering plasma cortisol and ACTH concentrations post-castration (Keita et al., 2010). Furthermore, a reduction in pain-related behaviours was observed post-castration when using Meloxicam (Hansson et al.,2011). However,both studies failed to analyse the impact of NSAIDs on other routine procedures, such as teeth clipping and tail-docking.
Arecent study investigated the effect of Meloxicam administration to piglets when provided prior to castration and tail-docking (Tenbergen et al., 2014a). The effect on growth, mortality and pain mitigation was assessed. Piglets (n=2888) were randomly assigned to either a treatment group (0.4mg/kg BW Meloxicam) or control (placebo injection). Injections were carried out 30 minutes prior to surgical castration and tail-docking. The results of the study concluded that Meloxicam made no significant improvement to pig performance. However, pigs treated with Meloxicam showed significantly reduced isolation behaviours (isolating themselves from other piglets) and lower cortisol concentrations 90 minutes post processing when compared with the placebo groups. The reduced isolation provides increased opportunity for suckling with overall health and performance benefits for the piglets. Cortisol is one of the primary markers for stress associated with the procedure and thus its reduction can indicate a pain-mitigating effect.
As previously demonstrated through weight, behaviour and biochemical analyses, Meloxicam provides suitable pain mitigation and the benefits of improved health and welfare when provided to piglets undergoing painful procedures in early life. However,administration of Meloxicam to individual piglets would incur a significant increase in labour and time, reducing its appeal to producers. A recent study (Bates et al., 2014) investigated the potential for transmammaryadministration of Meloxicam to piglets, the benefit of which is a significant reduction in piglet handling over directly administering Meloxicam. Furthermore, administration to the sow can be performed via oral preparations, reducing the number of injections for both sow and piglet.
In this study, 10 sows were randomly assigned after farrowing to a treatment group (30mg/kg BW Meloxicam) or control group (Meloxicam excipient) with treatment/control being administered over two consecutive feedings. Blood samples weretaken from both sows and piglets to assess the pharmacodynamics of Meloxicam, pain markers (cortisol and Substance P) and infrared skin thermography used to identify thermographic changes among piglets. Most significant of the findings was evidence of Meloxicam within the plasma of the piglets at multiple time points following the commencement of treatment in the sows. The results showed that concentrations of Meloxicam were maintained in both sows and piglets for 72 hours following the cessation of treatment beforeagradual decline in plasma concentration was seen. A significant (p<0.05) reduction in the concentrations of PGE2 at each time point indicates that Meloxicam in the lactating sow was an effective means of pain mitigation during castration and tail-docking in the piglets.
Differences wereseen in plasma cortisol concentrations, with Meloxicam treatment showing lower concentrations for the first 10 hours following processing. Furthermore, infrared thermography showed a significant (p<0.0001) reduction in cranial temperature post-castration following Meloxicam administration, again suggesting reduced pain and stress. The primary limitation of transmammary drug administration is dosage, as this will vary depending on milk consumption by the individual piglet.
Conclusion
Routine procedures such as surgical castration and tail-docking areassociated with pain and stress, as reflected by biochemical and behavioural responses. The provision of NSAIDs, such as Meloxicam, to both piglet and sow improves welfare. Transmammary Meloxicam supplementation now provides a practical means of pain relief to suckling piglets prior to painful procedures. ■ LYNDON CLEARY
References
Bates, J.L., Karriker, L.A., Stock, M.L., Pertzborn, K.M., Baldwin, L.G., Wulf, L.W., Lee, C.J., Wang, C., Coetzee, J.F. 2014 Impact of transmammarydelivered Meloxicam on biomarkers of pain and distress in piglets after castration and tail docking. Plos One,9:12, e113678 Dragset, J., Norwegian Food Safety Authority European declaration on alternatives to surgical castration. http://ec.europa/food/animal/welfare/ seminars/docs/EU_declaration_surgical_castration_ pigs_en.pdf viewed 12/03/2015 FAWC (FarmAnimal WelfareCouncil), last updated 16 April 2009 FAWC London, viewed 12/03/2015, http://webarchive.nationalarchives.gov.uk/20121007 104210/http:www.fawc.org.uk/freedoms.htm Hansson, M., Lundeheim, N., Nyman, G., Johansson, G. 2011 Effect of local anaesthesia and/or analgesia on pain responses induced by piglet castration. Acta Veterinaria Scandinavica,53: no. 34, 1-9. Hay, M., Vulin, A., Genin, S., Sales, P., Prunier, A. 2003 Assessment of pain induced by castration in piglets: Behavioral and physiological responses over the subsequent 5 days. Applied Animal Behaviour Science,82:3, 201-218. Keita, A., Pagot, E., Prunier, A., Guidarini, C. 2010 Pre-emptive Meloxicam for postoperative analgesia in piglets undergoing surgical castration. Veterinary Anaesthesia and Analgesia,37:4, 367-374. Moya, S.L., Boyle, L.A., Lynch, P.B., Arkins, S. 2008 Effect of surgical castration on the behavioural and acute phase responses of 5-day-old piglets. Applied Animal Behaviour Science,111:1-2, 133-145. Tenbergen, R., Friendship, R., Cassar, G., Amezcua, M.R., Haley, D. 2014a Investigation of the use of Meloxicam for reducing pain associated with castration and tail docking and improving performance in piglets. Journal of Swine Health and Production, 22:2, 64-70. Tenbergen, R., Friendship, R., Cassar, G., Amezcua, M.R., Haley,D. 2014b Investigation of the use of Meloxicam post farrowing for improving sow performance and reducing pain. Journal of Swine Health and Production,22:1, 10-15.
