One health and domestic violence

I want to thank Hodgson et al¹ for their recent commentary on engaging family physicians in one health and their discussion of how focusing on the human-animal bond can enhance patient care for both physicians and veterinarians.

However, it is also important to remember the role the human-animal bond can sometimes play in connection with violence in the home, whether domestic violence, child abuse, elder abuse, or other forms of interpersonal violence. It has been shown, for example, that 71% of battered women report that their abuser threatened to harm, did harm, or killed their pet.² Also, children who grow up in violent homes are more likely to abuse animals and other humans.²

Despite this known link between violence against animals and violence against people, advocates working with victims of child abuse and domestic violence frequently do not ask about pets in the home.³ As noted by Hodgson et al,¹ when physicians and others in the human health-care field include questions about patients' pets, they have an opportunity to develop a stronger bond with their patients and learn more about their patients' home environment.^1–3

Although many different instruments exist for evaluating animal abuse in connection with violence against humans,⁴ even if physicians do not use formal questionnaires and only ask basic questions, such as “are there pets in the home?” and “do you worry about your pets?”, they can gain insight into family dynamics. As mentioned by Hodgson et al,¹ “when talking about their animals, patients reveal clinically relevant information about social determinants of health.”

The concept of one health needs to include veterinarians and physicians. But, it also needs to include consideration of both the positive and negative consequences of the human-animal bond.

Jennifer A. Woolf, DVM, MS

Woolf Veterinary Forensics Consulting Inc, Dublin, Calif

Atopic dermatitis in dogs

In their recent review article on the pathogenesis, diagnosis, and treatment of atopic dermatitis in dogs, Nuttall et al¹ have done a masterful job addressing an extremely complex malady. But, I wonder about the cost of the various diagnostic tests being proposed and the ability of clients to pay for them. Also, the review did not address potential adverse effects of the immunosuppressive medications the authors advocate.

Oral administration of essential fatty acids has been documented to be beneficial in many dogs with atopic dermatitis. This raises the question of whether nutrient deficiencies and nutrigenomics may also play a role.

A notable omission from the review was a discussion of the possible benefits of vitamin D in treating dogs with atopic dermatitis.² Vitamin D is less costly than many other proposed medications and may be safer for long-term treatment.

Michael W. Fox, BVetMed, PhD, DSc

Golden Valley, Minn

The authors respond:

Thank you for your kind commentary on our recent review article about atopic dermatitis in dogs. It is wonderful that we better understand the complex pathogenesis of this chronic inflammatory disease. There is certainly much more to learn, particularly with regard to variations among breeds and individuals in response to treatment. Humans with atopic dermatitis appear to have endotypes,¹ and likely we will discover that dogs do as well.

We are advocating for a diagnostic workup to determine the cause of itch in dogs as the most cost-effective way to manage skin disease in the long run. Careful attention to the history and clinical signs will aid pattern recognition, narrow the differential diagnoses, and reduce the use of unnecessary tests. Skin scraping and cytologic examination are very cost-effective tests. Still, it is important to establish a diagnosis of atopic dermatitis before using treatments such as essential fatty acids, other nutritional support, and vitamin D, because these interventions are likely to be ineffective in dogs with other pruritic dermatoses. Allergy testing and immunotherapy, although more expensive, can change the progression of this disease and, when successful, reduce the need for lifetime medication. It is true, though, that there are costs associated with having an allergic dog.

Our article was meant as an overview of how improved understanding of this disease has translated into effective treatments. Thus, we did not address the details of all potential treatments. We rely on our colleagues in practice to work with pet owners to pick the best solution for each individual, taking into account efficacy, safety, and costs associated with long-term administration. Important efficacy and safety information is provided by the manufacturers for each of the branded medications mentioned and is supported by peer-reviewed publications as well as continued pharmacovigilance. Targeted medications give us the opportunity to treat dogs with atopic dermatitis effectively over their lifespans. Although there is potential risk associated with the use of any therapeutic agent, the opportunity to reduce the severity of clinical signs these allergic dogs experience can balance that risk. Happily, over the past decade, cyclosporine has been associated with good benefit-risk ratios,^2,3 and long-term use of oclacitinib is considered safe and effective as well.⁴ The International Committee for Allergic Diseases in Animals has recommended the use of these medication in their recent guidelines.⁵

We agree that nutritional support (eg, oral administration of fatty acids and other nutrients) is key in helping to restore the skin barrier, and we alluded to that in our discussion in that section. In particular, the use of diet to delay or prevent the development of atopic dermatitis in Labrador Retriever puppies is striking.⁶ Certainly, much more work is needed with regard to the role of diet in this disease. The reference you provided on the short-term use of vitamin D in dogs with atopic dermatitis is encouraging, and to our knowledge, it is the only one of its kind published in a peer-reviewed journal. Of some concern was the potential for toxicosis and the need for monitoring that was recommended. It is hoped that additional well-controlled studies will be published on the safety and efficacy of long-term use of vitamin D in dogs with atopic dermatitis. Thank you again for your thoughtful comments.

Timothy J. Nuttall, BVSc, PhD

Royal (Dick) School of Veterinary Studies, Colleges of Medicine and Veterinary Medicine, University of Edinburgh, Midlothian, England

Rosanna Marsella, DVM

Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Fla

Michele R. Rosenbaum, VMD

Valerie A. Fadok, DVM, PhD

Veterinary Professional Services, Zoetis Inc, Parsippany, NJ

Andrea J. Gonzales, PhD

Global Therapeutics Research, Zoetis Inc, Kalamazoo, Mich

Teaching effectiveness: it's personal

I am writing in support of recent letters^1–3 emphasizing the importance of teacher quality in student learning and the effect of teacher quality on the veterinary profession.

Throughout my career, I have often asked veterinary students and alumni what aspect of their learning experience they valued most. Overwhelmingly, the answer has revolved around mentoring, with most respondents suggesting that the most important part of their education was the personal support and career guidance they received from faculty members. These responses suggest that, when it comes to teaching, providing personal guidance is every bit as important as conveying didactic information. Mentoring is difficult to evaluate and quantify, but its impact is enormous.

As class size increases, it becomes harder and harder for teachers to get to know each student personally. Still, many faculty members are skilled at handling the demands of larger classes and do an excellent job relating to individual students. Mentoring is particularly important for students in need of special assistance or intervention.

Through their interactions with exemplary role models, students become not only familiar with facts and methods, but also imbued with the spirit of scholarship and professionalism. To paraphrase a sentiment attributed to Albert Einstein, among others: education is what remains when you have forgotten everything you learned in school.

Peter Eyre, DVM&S, BVMS, BSc, PhD

Professor and Dean Emeritus, Virginia-Maryland College of Veterinary Medicine, Virginia Tech Blacksburg, Va