Serologic testing for coccidioidomycosis

I read with interest the What Is Your Diagnosis? article by Matula and Reetz¹ featuring a dog in which coccidioidomycosis was diagnosed after travel to Arizona. Because the clinical utility of serologic testing in making the diagnosis was not discussed in the report, I would like to bring it to the attention of practitioners outside the endemic region who may occasionally see these patients.

Serum IgM and IgG antibody titers measured by means of agar gel immunodiffusion have been shown to correlate well with clinical disease² and are readily available through at least two nationwide commercial veterinary diagnostic laboratories. Although direct identification of the organism microscopically or by culture remains the gold standard, serologic testing is a noninvasive, cost-effective way to quickly establish a presumptive diagnosis. This is especially true for patients for which samples of infected tissue may not be readily obtained, such as patients with signs of intracranial or intraocular involvement.

In cases in which coccidioidomycosis is suspected and cytologic or histopathologic examination reveals pyogranulomatous disease without an etiologic agent being identified, serologic testing can provide a diagnosis rapidly and without the potential risk to laboratory personnel inherent with culture.

In addition, in patients with a history of apparently successful treatment of coccidioidomycosis that later develop vague systemic signs of illness such as weight loss or lethargy, a four-fold or greater increase in titer may indicate disease recurrence prior to the development of localizing signs. Serum titers should be measured as part of the minimum database when evaluating these patients.

Finally, because relapse of coccidioidomycosis is not uncommon, practitioners in endemic areas will generally perform titer testing when starting antifungal treatment even in animals in which the diagnosis was made by means of cytologic or histopathologic examination or fungal culture. Most clinicians will continue antifungal treatment until there is clinical and radiographic resolution of disease and an IgG titer ≤ 1:4.

Many pets from all parts of North America travel through Arizona. I hope practitioners examining patients outside the endemic region will consider coccidioidomycosis as a differential diagnosis and will remember that serologic testing may be available through their regular diagnostic laboratory to assist them in their diagnosis and management of these patients.

Minta Keyes, DVM

Cat Hospital of Tucson Tucson, Ariz

Speaking multiple languages

I read the recent JAVMA News story “Speak my language”¹ with interest. At the Cummings Veterinary Medical Center at Tufts University, we offer a translation service staffed by student volunteers and faculty who can assist clients with languages other than English. This program has been very successful since we started it in 2014 at the suggestion of one of our students who was about to graduate. Each year, a student agrees to be the program coordinator and contacts others with the required language skills when help is needed.

Some examples of how the program has been used include providing language support for an elderly Korean couple struggling with a decision on euthanasia and assisting a deaf person by having one of our students communicate in American Sign Language. Each year, the program is updated with new students who wish to volunteer, and we keep a list of languages that volunteers can speak or write fluently. The volunteers are from the first- and second-year classes.

This might be an attractive model for other schools now that veterinary college classes are more diverse than ever before.

Cheryl Blaze, BVSc, PHd, MBA

Interim Hospital Director Henry and Lois Foster Hospital for Small Animals Cummings Veterinary Medical Center at Tufts University North Grafton, Mass

Birds and environmental health

I want to thank JAVMA News for publishing the article “Bird Population Sees Massive Decline.”¹ It is heartening to see that the AVMA is taking the issue of environmental degradation seriously and giving it exposure to the greater veterinary community. There is no better or more important example of one health than bringing the veterinary community into this discussion, because wild birds are vital indicators of healthy ecosystems worldwide.

Reading through the list of suggested actions at the end of the article, one in particular resonated with me: “protect the planet from plastics by avoiding single-use bags, bottles, and wrappers.” I would encourage JAVMA to do its part by no longer wrapping issues in plastic. Use paper if the journal must be wrapped in something, but I would prefer no wrapping at all. If the journal arrives a little beat up, that's a small sacrifice.

Janiene Licciardi, DVM

Bellingham, Wash

Editor's note:

At JAVMA, we are very conscious of the environment and of the important connections among animal, human, and environmental health. Unfortunately, our use of plastic wrap around the journal is mandated by the US Postal Service whenever we run specific types of advertising, and advertising is vital in helping to offset the costs of publishing our journals. Please know that whenever we can deliver the journals to our members and subscribers without plastic, we do so. The printer we use for the journals has a high reputation for environmental stewardship, and we have met with our printer on a regular basis to explore alternatives to the current plastic wrap. Unfortunately, we have not yet identified one that would be feasible, but we continue to explore options.

Studying leadership skills development

I applaud Crowley et al¹ for their recent study and believe their report is a good addition to the literature on leadership skills development. However, I hope the authors will consider studying the effects of Veterinary Leadership Experience (VLE) participation in greater detail and from different perspectives. For example, asking participants to self-report—no matter what instrument is used—does not measure actual changes in behavior. Having peers and instructors report on individuals' behavior before and at various times after they participate in the VLE, although more challenging, could reveal lasting behavior changes (or a lack thereof), thereby informing future modifications to the program.

Additionally, individuals participating in the VLE have typically been selected from among those already in leadership positions. A great way to evaluate whether this program improves leadership skills would be to select students who do not currently show “leadership potential.” Wouldn't programs that increase leadership skills be ideally suited for those students who most need to develop those skills? Students already in leadership positions are likely to continue their leadership development with or without special programs. In the workplace, it might make sense to cultivate leadership in those who already exhibit leadership potential. In contrast, at the university level, I would challenge the authors to try to improve leadership from the bottom up. What about a trial year during which the VLE asks universities to send students who need to develop better skills, rather than those viewed as already having potential?

Carin Smith, DVM

Wenatchee, Wash

The authors respond:

We thank Dr. Smith for her kind words and perspective on measurement of leadership skills development. And, we agree that continued work to evaluate leadership development from a variety of perspectives would be very valuable. Engaging others to assess participants' behaviors following the Veterinary Leadership Experience (VLE) would certainly add a measure of validity and robustness to the process. As she pointed out, that would be challenging and was beyond the scope of the present study and the resources available.

We agree and acknowledge that participants in the VLE often self-select or are selected because of an interest in developing as a leader. The innate skills in these individuals are extremely variable, as are their backgrounds, career interests, and experiences. We believe that all veterinary students have leadership potential. Indeed, our profession and society are counting on it. Simply put, our experience is that students are ready to embrace their role as leaders at different times in their professional journeys. In our study, improvement in several important parameters was identified. Still, Dr. Smith raises interesting points, and the authors will continue to seek new ways to expand leadership development in veterinary students, pursue the most effective training methods for VLE participants, and report on these findings.

Susan L. Crowley, PhD

Department of Psychology Emma Eccles Jones College of Education and Human Services Utah State University Logan, Utah

Kendra J. Homan, PhD

Department of Pediatrics College of Medicine University of Cincinnati Cincinnati, Ohio The Division of Behavioral Medicine and Clinical Psychology Cincinnati Children's Hospital Cincinnati, Ohio

Kenita S. Rogers, DVM, MS

Karen K. Cornell, DVM, PhD

The Veterinary Leadership Institute Temecula, Calif

The Office of the Dean College of Veterinary Medicine & Biomedical Sciences Texas A&M University College Station, Tex

Lauren J. Olavessen, DVM

Elizabeth M. Charles, DVM, MA

The Veterinary Leadership Institute Temecula, Calif

Darcy H. Shaw, DVM, MVSc, MBA

Department of Companion Animals Atlantic Veterinary College University of Prince Edward Island Charlottetown, PE, Canada

The problem of student debt

Educational debt is a defining issue of our time. For more than two decades, increases in college tuition—driven largely by cuts in public funding for higher education—have outpaced inflation. Not surprisingly, higher tuition has been accompanied by higher student debt, which now collectively exceeds $1.6 trillion. The median undergraduate debt is approximately $30,000. Median veterinary educational debt is currently $174,000,¹ but if tuition continues its current growth, this figure will top $200,000 by 2025.

As I interact with veterinarians and veterinary students, our conversations frequently turn to educational debt. Its effects are far reaching; debt can, for instance, alter one's career choices, change where one chooses to live, limit one's ability to purchase a home or business, and restrict one's ability to save for retirement. It has been distressing to discover that some indebted students experience food and housing insecurity. A recent graduate explained that she came close to dropping out because of the amount of debt she had accumulated. As it was, she was forced to share dilapidated accommodations and obtain cheap, low-quality food—sometimes stretching meals—to make ends meet. Domestic insecurities are more common than we may realize, especially among socioeconomically disadvantaged students. Such problems will negatively affect health, well-being, and academic success. One is tempted to say it is about time to act, but that would be incorrect. The time to act was about 10 years ago when it was already clear that increasing tuition is not a sustainable budget strategy.

Some ongoing initiatives are helping students manage their debt. These include low-interest loans and loan forgiveness, financial literacy education, and expanded grant and scholarship programs. These are good ideas that should be continued, but they do not address the underlying tuition problem.

To provide meaningful relief, it will be necessary for colleges to adopt operating efficiencies that reduce student expenses and lessen the need to borrow. One way to do this is by allowing the preveterinary requirements to be completed in two years instead of four.² The AVMA's Council on Education has accredited several international five- and six-year veterinary degree programs, and some US veterinary colleges accept students after only two years of undergraduate study. There is no technical reason why this arrangement could not be the norm.

One hesitates to identify the current educational debt situation as a crisis, but it certainly is a serious problem. Debt is damaging the very fabric of the veterinary profession. Sooner or later, prospective students will balk at the amount of educational debt they are likely to incur, and the applicant pool will dry up. Waiting for an enrollment crisis to mobilize necessary action is foolhardy. Action is needed now to reduce the debt burden that is plaguing the lives of veterinarians and veterinary students.

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

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