Requests clarification on study of congenital portosystemic shunts

I read with interest the recent study¹ on medical versus surgical management of congenital portosystemic shunts (PSS). The authors are to be congratulated for their substantive work in addressing this important clinical question.

It is not clear to me from reading the manuscript how many of the dogs had clinical signs associated with PSS and how many had subclinical disease. I am inclined to think that most or all had clinical signs because all were treated with lactulose, a drug that is indicated in patients with hepatic encephalopathy. Can the authors please clarify this point? I ask because I sometimes see patients brought in for any number of reasons (eg, acute vomiting associated with a suspected foreign body or routine health screening) in which abnormalities identified as a result of diagnostic imaging or laboratory testing (eg, microhepatia, hypoalbuminemia, and hypocholesterolemia) ultimately lead to a diagnosis of PSS. As a result, I am not infrequently confronted with the question of what to do with a dog that has sub-clinical PSS that was fortuitously diagnosed. My ultimate concern is whether outcome associated with medical versus surgical treatment might be substantially influenced by the presence or absence of clinical signs of PSS or the severity of those signs.

Michael Willard, dvm, dagvim

College Station, Tex

The authors respond:

We thank Dr. Willard for his supportive comments and for highlighting this interesting and important point. The incidence of clinical signs among our study cohort was not unequivocally stated in our original Materials and Methods; however, a criterion for inclusion of a dog in the study was that it have clinical signs. At the time of initial examination, we determined whether each dog had one or more of three specific types of clinical signs—neurologic, gastrointestinal, and urinary—but we did not exclude dogs that only exhibited other clinical signs (such as poor weight gain). Reexamination of our data reveals that 73% had neurologic signs, 38% had gastrointestinal signs, and 35% had urinary signs. Overall, 30% of the dogs had neurologic signs alone, and 52% had signs indicating that two or more systems were affected.

In response to Dr. Willard's wider point, it is always difficult to determine how best to treat animals that have what could be described as subclinical disease, especially for a condition that has traditionally been thought to be progressive. A strong argument can always be made that “if it ain't broke, don't fix it.” On the other hand, perhaps the results of our study may aid decision making for these difficult cases. Although we found that surgical treatment was preferable overall, there was no evidence in favor of surgery at a younger age, even among dogs that had clinical signs, implying that surgical intervention need not occur early in the course of the disease to be successful. It could therefore be argued that it would be appropriate for such dogs with subclinical disease to receive medical treatment alone, unless clinical signs become increasingly, or more frequently, apparent. Having said that, however, our study does not specifically address treatment of such dogs; therefore, recommendations for their treatment would more properly be based on further studies designed to address this issue.

Stephen N. Greenhalgh, vetmb

Nick D. Jeffery, phd

Department of Veterinary Medicine

University of Cambridge

Cambridge, England

Questions methods used in review of pheromone treatments

We wish to comment on the recent systematic review by Frank et al¹ on the use of pheromones to treat undesirable behaviors in dogs and cats. For their conclusions to be valid, it is crucial that systematic reviews be written according to established guidelines, such as those described by the Cochrane Collaboration Back Review Group (CCBRG).² We believe that methodological failures in the report by Frank et al severely impair the validity of its conclusions.

Current guidelines suggest that systematic reviews include only those reports presenting the effects of the investigated treatment on a specific indication.² As an example, in their review, Olivry et al³ include reports describing the effects of various treatments on atopic dermatitis in dogs. By contrast, Frank et al include reports describing the efficacy of feline facial pheromone (FFP) in the treatment of a wide variety of indications, including urine marking, idiopathic cystitis, facilitation of IV catheterization, and adaptation to hospitalization.

According to the CCBRG, evaluation of the methodological quality of reports included in the review must include an evaluation of outcome parameters, such as mean and median efficacy rates and reduction rates. This is lacking in the review by Frank et al, which only states whether statistical analyses were adequate.

Although reports included in the review by Frank et al were independently rated by three reviewers, no information was given on the extent of agreement among raters, other than the statement that “[t]here was little discordance among the 3 reviewers….”

In the grading of evidence quality, the best score was given to reports with > 50 subjects, but there was no indication of how this scoring system was justified.

Frank et al describe the FFP product as including valerian extract when this is only present in the spray product and never in the electric diffuser. Moreover, Frank et al use findings from Yuan et al⁴ to hypothesize that FFP anxiolytic effects should be a result of the valerian extract and its action on γ-aminobutyric acid receptors. In the Yuan et al study, however, the effects of valerian extract and valerenic acid were determined after direct application on neurons, whereas FFP products are sprayed in the environment.

Two reports^5,6 were excluded because “…the owner of the company that produces the commercially available canine and feline pheromones was a coauthor….“ However, this individual is not the owner of Ceva Animal Health, although he did discover these pheromones and is the scientific director of a private research institute.

The guidelines of CCBRG prescribe a respectful and benevolent analysis of the papers published by colleagues in peer-reviewed journals. Let us hope that we soon will read reviews following these guidelines about this new therapeutic approach: pheromonatherapy.

Patrick Pageat, dvm, phd

Alessandro Cozzi, dvm, phd

Céline Lecuelle, msc

Pherosynthese Research Institute

St-Saturnin d'Apt, France

Comments on diversity in veterinary medicine

I have some questions about the intent of those promoting diversity in our profession after reading the JAVMA news article “Efforts being sustained to promote diversity.”¹

First, what exactly is meant by the term cultural competence? Is the goal to help students better communicate with clients or simply to better understand the background of those of other cultures?

Second, what exactly does Dr. Reed mean by saying, “It's important that (diversity) be institutionalized” and diversity “…won't be compartmentalized to happen, say, every Thursday (when they're in practice)”? Does he believe that students who are not culturally or racially diverse will be unable to deal with those of other races or cultures without formal training? I am certain that Dr. Reed's quotes would be better understood in the context of the discussions that have occurred at the various conferences on diversity; however, I have questions about the goal of such diversity training and how such training would be implemented.

As we might recall from bussing in the 1970s, diversity cannot be forced. I sincerely hope that the veterinary academic community takes this into account. Sadly, such seems not to be the case, as the news article reports that there were discussions about using “.accreditation as a tool to urge colleges to consider methods of incorporating diversity into the curriculum to effect change.” I consider using the threat of losing accreditation to strong-arm veterinary schools into accepting the notion of mandatory diversity training to be highly objectionable. Participation in such programs needs to be kept strictly voluntary, both on the level of the administration and on the level of the veterinary students themselves.

According to the article, as part of the admissions process, the Western University of Health Sciences “.looks at societal needs and pulls from the available pool of students who both scored the best and can meet those needs.” If by societal needs they mean veterinarians who are needed by interest (eg, food animal or companion animal), then this would seem to be a reasonable goal. If their goal, however, is to accept students with a racial or cultural makeup representative of the communities they serve and if they are manipulating the racial and cultural makeup of the incoming veterinary classes on the basis of applicants’ racial or cultural background, I believe that would be discriminatory. I think all of us would agree that the notion that veterinarians of a different racial or cultural background than that of the community they serve are somehow less capable than are veterinarians who have a racial and cultural background similar to that of the community they serve is offensive.

I hope that those who want our profession to appear diverse for diversity's sake alone (ie, for reasons of political correctness) would reexamine their motivations. The idea that we as a profession can or should artificially manipulate the racial or cultural makeup of our members for such reasons alone should strike the members of our profession as pointless and counterproductive to the ultimate goal of serving our patients and clients.

John S. Parker, dvm

Novi, Mich

Reading the July 15, 2010, JAVMA news story¹ about the efforts being made to promote diversity in veterinary medicine made me wonder, once again, where the concern is over the lack of young men in programs around the country. In looking at graduating veterinary school classes, I generally see only about 25% to 30% men. I would think diversity of sexes is as important and valid a goal as diversity in racial background. In my opinion, promoting diversity should include efforts to attract men to the profession.

William L. Campbell, dvm

Parmer Lane Pet Hospital

Cedar Park, Tex

More on foreign veterinary school accreditation

I am baffled at the outcry generated by the recent decision by the AVMA Council on Education to consider accrediting the Universidad Nacional Autonoma de México Facultad de Medicina VeterinariaZootecnia in Mexico City.^1,2 The veterinary school recently upgraded its small animal teaching facility with funding from Banfield, whose long-term strategy includes expansion of its chain of private veterinary clinics throughout Mexico. It is logical to want well-trained local veterinarians to hire there.

I disagree with Dr. Beismer's belief that accreditation “.is likely to have a substantial.[and negative] impact on US veterinarians.”

Mexico is considered an upper middle-income country, and a newly industrialized one, according to the World Bank. Veterinary students increasingly come from urban areas in Mexico and wish to practice small animal medicine for the increasingly affluent Mexican middle class. Mexico's economic development is clearly in our own best interest. Accreditation simply acknowledges the existing linkage between our two economies and seeks to control it by raising the standards of this Mexican veterinary school.

As others have noted, there has been no mass influx of foreign veterinarians since the accreditation of nine other veterinary colleges outside the United States and Canada. Mexican veterinarians are neither illiterate nor stupid, but intelligent professionals like ourselves who would prefer to stay near family and friends. However, a globalized society is a mobile one, and accreditation means that veterinarians who comply with current immigration laws and licensing requirements have the option of working here.

We cannot deny that we live in a global economy, and US veterinarians are part of a network of clients, businesses, and products that span the world. It doesn't really matter whether we like or dislike this fact, but we need our AVMA leadership to see the big picture and plan for a future with fewer borders and more harmonized standards.

I look to the AVMA to support the Council on Education's accreditation of the Universidad Nacional Autonoma de México Facultad de Medicina VeterinariaZootecnia and bring us into the reality of the 21st century.

Beth A. Miller, dvm

Little Rock, Ark