Personalized care treatment plans in vet med

Personalized care

We're chatting so much in this day and age about customized care, individualized care, and what does that mean now that we have in Embark’s DNA testing kit available? What does that look like to the pet parent's perspective and to the veterinarian that we have now, like a customizable care program? 

Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT:

 So I think we've kind of evolved as a profession over time. You know, initially we practice medicine, and then we practice species-based care, as in cats are not small dogs. Then we started to practice breed-based medicine. Perhaps these things are more breed-associated than others. This is really the next frontier, so personalized medicine. 

In addition to MDR1, there are other things that are on our genetic test that could offer some personalized care. One that comes to mind for me is a variant in the POMC gene that interferes with satiety. So if you have a fat lab who comes in, which we see every day, you're doing thyroid testing, the owner swears up and down, you know, they're not feeding the dog anything extra, but he's always hungry. 

So this POMC gene really can interfere with satiety and just give a reason for why that pet might be constantly hungry and potentially, maybe overweight. I find it's very helpful to point to something to say, "Hey, this is why your dog maybe has trouble with feeling full." So he's not actually starving, you know? So we can follow this weight management plan. 

 That is one of my favorite studies because if you dig into it, they used assistant dogs in that study and they found that dogs who were really trainable had that POMC mutation, but it makes sense, right? They were food motivated. And so, a lot of dogs that end up in assistance programs tend to be food motivated, tend to be easier to train. It tells us about satiety, and it tells us, you know, things that we wanna know about weight management. 

But the other thing it tells us is making some training recommendations, right? So a dog who has the POMC variant might be more likely to be really trainable with food. But we may be able to talk to pet owners who have dogs that don't have that mutation about some other tactics that they can use for training too when they might be having a tough time at home. So it's interesting how when we learn about genetics, sometimes there's the second layer of other ways that that we can apply that information in practice, which is really cool. 

 There's a practice that has this wonderful thought philosophy that says everyone is a VIP and it's very individualized for the pet and pet parent. And what they do is for every dog whether it be a rescue dog, from a breeder, a puppy, it's included in the initial visit that they already have the Embark DNA test there. What are your thoughts on that? 

 I think that's a great way to, again, build trust between the client and the practice because everybody feels like the plan is really made together. This is individual for my dog specifically. It's not just the breed or the presumed breed mix. This is my dog so I think that's a great tactic. 

Yeah and because they get so excited when they see right and I, to your point, where we're just talking about the human animal bond and we want to bond with our clients in the exam room like that. You want to be excited for them and so having that discussion about genetic testing and being a proactive approach to care I think is so powerful. What are your thoughts on that? 

 One thing I think about, too, is we tend to see trends carrying over from human medicine. So I think about how people's animals are parts of the family, right? And they expect them to get the same sort of personalized treatment that a family member may have gotten or that they may have gotten. And so I think, as human medicine becomes more personalized, and we start to use genomic testing in different areas of human medicine, it's important to understand how that is going to impact clients' expectation of us as veterinarians too. 

For me, this plays into expectations for personalized care based on things that those clients may seek out if they've done a consumer DNA test. If they've looked at their microbiome, if someone in their family has gone through treatment for cancer and they've done personalized care. So I think the more we start thinking about this type of technology and how we can apply it, I think it's fair to think about the big picture too and client expectations.

Videos

Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT, and Lindsey Kock, DVM, expand on a customizable care program using DNA testing.

Personalized care and treatment plans

Behind the science

Once we have the Embark DNA testing going on, what does that look like from a CSR perspective, a technician, and a generalist? 

 Absolutely, so we have a couple of different options with our Embark clinic testing. So the first option is you can carry the tests in clinic. You can buy them in bulk packs, do the swab right there in the exam room, and send it off. The results will go back to the veterinarian first so they have a chance to review those results and then those can be released to the client. That's option one. 

Option two, for folks who maybe don't have a lot of inventory space, would be our recommend and review program. Essentially, the client orders through our website through a special QR code. They get a little bit of a discount on their test purchase and then once that results comes back, they go to the veterinarian and the client at the same time. The veterinarian's experience as far as the very detailed reporting and the support with me is not different, but the client will get the result at the same time. So just two different options for the testing. 

As far as how we've seen this work best in clinics is it is very, very, very helpful to assign a genetics champion to be the one to have that initial conversation about the benefits of genetic testing with your clients. And typically that is a technician or another interested staff member. Embark will absolutely support training that person. We offer lunch and learns to get all the clinic staff kind of up to speed on what the testing looks like, how to have those initial conversations. 

I wanna talk about our educational school and that school with genetics. I'm curious to get your thoughts on where we should be going in the next five to 10 years with genetic counseling and understanding for the new graduates that are coming out of school. 

 Typically we don't get much genetics education in either vet or tech schools. So typically whenever I speak, I always tell people, “hey, you're gonna be reaching back to your high school biology. We're gonna be talking about Mendel's peas today.” So I think that there is definitely an opportunity. I would say just doing like a brief review of the modes of inheritance, which is the way that a variant is passed on to the next generation, would be really, really helpful if we had that kind of again in vet school. Then, using some examples with either breeding dogs and how to smartly pair them, or with personalized medicine and individual dogs who may be at risk for genetic diseases. 

 I think the new graduates know about this. They're excited about it, but I think they're just learning so much through mentorship and trying to get their communication under control. But I do think that this is a great opportunity for a mentorship opportunity for hospitals to teach the new grads. This is what we should do moving forward, right? 

 Yeah, absolutely. I think one thing to maybe be cautious of not getting too bogged down in is, there's over 350 some odd different variants that we know of in the world of dogs. So I think if you come at it from the perspective of like, "Oh my gosh, I got to know all of the details about all of these disorders,” there's a new one coming out every week, right, that may only affect a certain subpopulation or a certain breed of dog. 

And so I think the recommendation to really focus on inheritance, is huge because it helps you interpret the results for the pet parent. And then making sure that when you do testing, you do it from a reputable lab that lets you know what the inheritance is as well, right? And it tells you what actual marker they're looking at, because that is also important in the interpretation of those results. 

The fact that you can talk to somebody at Embark to go over these results, I was just going to mention that. Because I know that you feel inundated if you get these results, but it's almost as if going through a ClinPath case when you're calling your reference lab, you want to walk through some of the differentials. So it's important. I'm sure you must get quite a few phone calls with that. 

 Absolutely. I talk to veterinarians all day long helping them interpret their results and then again as a theriogenologist, I'm definitely able to help with the breeder clients as well.

Jenna Dockweiler, MS DVM, DACT, CCRT, CVAT, and Lindsey Kock, DVM, explain why the science behind genetics should be taught to vet staff and current students.

Our Fetch conference heads back to Kansas City, Missouri, for another action-packed weekend of continuing education lectures, networking, and fun programs. The conference, taking place August 23-25, 2024, will feature 3 keynote presentations from Michael Bailey, DVM, DACVR, AAAS; Lisa Radosta, DVM, DACVB; and Monica Dixon Perry, CVPM.

Bailey is originally from Hopewell, New Jersey, and he received his undergraduate degree at Rutgers, The State University of New Jersey. He received his DVM from Tuskegee University in Alabama and then completed a small animal rotating internship and radiology residency at Michigan State University in East Lansing. He opened the first veterinary diagnostic imaging center in Columbus, Ohio, and then in Pittsburgh, Pennsylvania.

Bailey now is the medical director of IDEXX, having worked for the company since 2016. He is on the American Veterinary Medical Association’s board of directors, and he is an American Association for the Advancement of Science congressional fellow.

Learn more about some topics in veterinary radiology from an expert in this Q&A style interview:

What makes pulmonary pattern recognition so difficult?

“Oh, you go to the easy question right off the bat,” Bailey joked. “Well, first of all start off remembering that I consider the lungs the window to the body. So heck with the ophthalmologist who say the eye is,” Bailey added with a laugh.

“There are so many changes in the thorax, but there are so many different structures in the thorax that when they start changing, you have to try and differentiate which one has the predominant change and what's the significance of it? So the pulmonary patterns—to answer your question—the changes can be very subtle, you can have multiple changes at the same time, and you have to decide which change is the predominant pattern and then what is the most likely cause or the predominant pattern, and also then the subsequent pattern, so it's a cascade,” Bailey concluded.

What are some of the main causes of upper airway conditions in pets?

“When we're talking about upper airway, let's say we're talking about the trachea at this particular time, we're not talking about the nose. So in the trachea when it comes to pets, if you're talking about small pets, particularly small dogs: collapsing trachea, is probably the most common cause of difficulty. When it comes to large breeds, actually, it's probably going to be a matter of trauma, or foreign body associated with them. Even though there's a number of tracheal problems ,tracheal collapse in large breeds such as shepherds—people have not been recognizing it, so we miss diagnose them. So now it's a matter of ‘Hey, folks started looking for it, it exists,’” Bailey said.

“There's not been a whole lot of publication on it. And largely because what we'd say are the radiographic signs of a collapsing trachea: the plane, which we see it in the large breed dogs collapse in a different plane. So you don't see the narrowing. It's actually a slight enlarging but people don't recognize it as a collapse,” he added.

What are some things veterinary professionals can look for in radiographs that indicate an upper airway condition is present?

“Well, if we're trying to decide if it’s an upper airway condition, a lot of it is going to be presentation: how does the pet present? So, the coughing pattern, the sounds of the cough, and then once we have the 

 that there's an upper airway problem, you decide what's the next best diagnostic step? Radiographs are a very good diagnostic step and they're relatively easy to perform. I also believe that studies such as bronchoscopy are an excellent upper airway examination, you get to actually see what's the dynamics of the luminal size—if we want to talk about into the head, the nasal passages, but then down into the larynx, and the trachea and the bronchi. So by doing bronchoscopy, you can see all of those changes,” Bailey said.

How often do you see extrathoracic respiratory disease in practice?

“It's more common than people know. I call it from the nose to the toes because you can have something anywhere along that's leading to respiratory disease. We miss a lot of the non-thoracic respiratory diseases, or we miss diagnose them. It's a matter of realizing, once again, how can all these things tie into each other?” Bailey stated.

“I'm hoping that people can realize that it's not a flat two-dimensional topic. This is multi-dimensional. And you can't just throw it in on a radiographic table or CAT scanner and figure the answer is going to come out just like that. We have to put a lot of thought into what's happening. And it does require a lot of training in order to try and pull all this together. So that's why we have all the specialties that are developing so that we can have people who help our general practitioners pull together. We're a team. Hopefully we all work together as a strong team,” Bailey concluded.

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Atlas, 2-year-old cat. (Photo courtesy of UC Davis School of Veterinary Medicine)

A 2-year-old male cheetoh cat (Bengal/ocicat cross) named Atlas came to the University of California, Davis School of Veterinary Medicine after a jumping accident left him lame. The Orthopedic Surgery Service at the UC Davis veterinary hospital took x-rays of Atlas, finding a displaced fracture of the right femoral head that would need surgery. After discussing the options with owners Sheila Dukas-Janakos and Ross Hite, Atlas received a total hip replacement, which utilizes a stem implant placed in the femur topped with a ball joint that interacts with a cup implanted in his pelvis.

X-ray showing the implant used for Atlas’ total hip replacement. (Photo courtesy of UC Davis)

Total hip replacement is a procedure that is relatively new on cats, as there is limited research on the long-term effects. UC Davis was confident in this route for Atlas because the studies that have been done have shown positive outcomes. The university surgeons utilized a 3D computer assisted design planning system to aid them in the surgery. After a successful surgery, Atlas was hospitalized for a month to monitor his recovery. Once he was cleared to return home, he was placed back on strict cage rest for 2 more months.

Three months post-operation, x-rays of Atlas showed success with the implant remaining in a stable position, and the cat’s gait was normal without noticeable lameness. Four months post-op and Atlas was allowed to slowly return to normal activity. The most recent update from Atlas’s owners came 8 months post-surgery and they reported that their cat is 100% recovered with no restrictions to his normal activities.

“We couldn’t be more pleased with everything the UC Davis surgery team did for him,” Dukas-Janakos stated.

Cases like Atlas have been in high demand for UC Davis recently so to combat this caseload increase for orthopedic surgeries, UC Davis is set to open the Center for Advanced Veterinary Surgery in the coming weeks. This standalone center will be located nearby the main veterinary hospital and will have 25 rooms and 7,300 square feet of space including 3 state-of-the-art operating rooms.

All equipment for this new facility is funded fully by donors, so interested parties can visit the UC Davis website for more information and details.

Young cat back to full activity after total hip replacement. News release. University of California, Davis School of Veterinary Medicine. March 29, 2024. Accessed April 4, 2024. 

https://www.vetmed.ucdavis.edu/news/young-cat-back-full-activity-after-total-hip-replacement

Center for Advanced Veterinary Surgery. University of California, Davis School of Veterinary Medicine. Accessed April 4, 2024. 

https://www.vetmed.ucdavis.edu/center-advanced-veterinary-surgery

UC Davis reports a full recovery from its recent patient, Atlas, after a displaced fracture

Successful total hip replacement surgery on 2-year-old cat

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