Virbac has launched Multimin, a prescription only, four in one trace mineral injection to combat oxidative stress and its effects in cattle.

Oxidative stress is an imbalance of free radicals and antioxidants which can lead to cell and tissue damage, impacting the health and performance of cattle.¹ Virbac says the trace minerals in Multimin are essential structural components of antioxidant enzymes which are required to neutralise free radicals and combat oxidative stress.^2,3

Multimin, which comes in a 100ml PET bottle, contains zinc, copper, manganese and selenium. It is designed to be administered during or before periods of high demand in dairy and beef cattle, such as breeding, calving, weaning and vaccination. After injection, it reaches peak levels in the blood after 8 hours^4,5 and the liver after 24 hours.^4,5

Virbac says Multimin has been proven in 24 peer-reviewed papers and field trials of more than 6,000 cattle, and that it offers a fast, simple and accurate way to top up essential trace minerals at times of high demand, to help improve cattle health and performance.

Lynda Maris, Virbac Large Animal Product Manager said: "Trace mineral requirements are currently primarily provided through the diet and various forms of oral supplementation. However, reduced oral intake, poor absorption from the rumen and antagonism from other minerals means that during periods of high demand, even in apparently well supplemented animals, a trace mineral gap can occur between the trace minerals required for optimum health and performance versus those available."

Lynda added: "Multimin is a great addition to the Virbac Large Animal range. It represents an exciting new opportunity for vets to strengthen their herd health plans, boost practice revenue and help to further reduce antibiotic usage."

For more information, speak to your Virbac Territory Manager or visit the Virbac stand at the BCVA Congress, 17^th – 19^th October.

References

1. Celi, P. Oxidative stress in applied basic research and clinical practice (Eds.Armstrong, D., Mandelker, L. & Vajdovich, P.). Humana Press, 191–232 (2011). 
2. Hough, M. A. & Hasnain, S. S. Structure of Fully Reduced Bovine Copper Zinc Superoxide Dismutase at 1.15 Å. Structure 11, 937–946 (2003).
3. Rotruck JT, Pope AL, Ganther HE, Swanson AB, Hafeman DG and Hoekstra WG (1973) Selenium: biochemical role as a component of glutathione peroxidase. Science, 179 (4073):588–590. 
4. Pogge, D, Richter, E, Drewnoski ME, Hansen SL. Mineral concentrations of plasma and liver following injection with a trace mineral complex differ among Angus and Simmental cattle. J. Anim.Sci. 90, 2692–2698 (2012).
5. Study data on file. 

A motion to conduct a trial of remote prescribing without performing a physical examination (ie. via telemedicine), thereby redefining what it means for an animal to be "under the care" of a veterinary surgeon, was put before RCVS Council last week. I was there to hear the arguments …

The motion was introduced by Kate Richards MRCVS, Chair of the RCVS Standards committee, who explained that it'd been driven by three things, namely: the Vet Futures Initiative, the RCVS Strategic Plan signed off by Council in 2017 and the RCVS telemedicine consultation that took place earlier this year. 

The latter of these showed that 69% of vets opposed the idea of prescribing without a physical exam, which rather beggars the question why it's being discussed at all. However, as Kate explained, when asked whether certain types of products could be remotely prescribed, the answer was more equivocal: 52% of vets said "yes".

Kate also explained that over the last two years, there had been a number of good quality discussions at Standards Committee and Council, but that decision-making had been "hampered by a paucity of evidence on the opportunities, risks and benefits of telemedicine to animals and the public".

The full wording of motion was: "Council is invited to consider the recommendation of Standards Committee to conduct a limited and time-bound trial to assess the benefits and risks of allowing the remote prescription of POM-V (excluding opiates, sedatives and potentially also critically important antibiotics) where there has been no physical examination."

However, in order for the trial to take place, it would be necessary to make a temporary change to the Supporting Guidance of the Code of Professional Conduct concerning the definition of "Under his care" (Ed's note. C'mon RCVS, isn’t that a bit anachronistic? Both your CEO and your President are now "her". "Under Care" would do it.), adding the words in italics to para 4.1: "A veterinary surgeon cannot usually have an animal under his or her care if there has been no physical examination; consequently a veterinary surgeon should not treat an animal or prescribe POM-V medicines via the Internet alone, other than in circumstance where a telemedicine service is a part of the RCVS telemedicine trial".

In the best interests of animal welfare

Amanda Boag (MRCVS, Vets Now, RCVS President) then reminded everyone that: "RCVS Council needs to act in the best interest of animal welfare and the public, and whilst sustainability of veterinary services is important, it isn't our role to promote anything novel or to protect traditional models."

Really? Strikes me that the sustainability of veterinary services isn’t just "important", it's an essential part of ensuring good animal welfare. Surely, therefore, it most certainly is the role of Council to protect traditional business models or, for that matter, to promote novel methods if (and I stress "if") doing so protects or enhances animal welfare.

Don’t confuse telemedicine with remote prescribing

Jo Dyer (MRCVS, small animal locum, Devon) opened by pointing out that this is not about telemedicine per se. Telemedicine has been going on since the invention of the telephone in the late 1800s, supplemented over the last 20 years or so by photography and video sent over the internet. Telemedicine does not, in and of itself, require a change in regulation.

What this is about, she explained, is the much narrower act of remote prescribing without physically examining the animal, something which would require the profession to redefine "under his care", which in turn "makes up the foundation of what forms the relationship with the owner and the animal in order that we can safeguard the use of medicines, safeguard the animals under our care and safeguard our clients."

No evidence remote prescribing increases access to veterinary services

Jo argued that the only reason Council should be considering the prescription of medicines without a physical examination would be if it were in the interests of animal welfare. And yet, she said, there is no evidence to support this idea.

Some have suggested that it could increase access to veterinary care. However, Jo said she had been unable to find any evidence to support this idea either. Not just in the veterinary profession, but in the medical profession in the Western and the developing world.

Jo also noted that the trial proposal was to use commercial organisations which have a financial interest in a positive outcome, which would render the results biased and unreliable.

She then raised the issue of antimicrobial resistance, highlighting the use of cytology and culture sensitivity to make sure the right antibiotics are used. Remote prescribing, she said, would be a retrograde step, even if only non-critical antibiotics could be prescribed remotely.

Spawning a new class of limited service provider

Next she highlighted the impact of the trial on 24-7 cover. Under the proposal, "Those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."

As Jo pointed out, this would by definition mean that any veterinary surgeon, not just those practising telemedicine, could set themselves up as a limited service provider and refer all cases they didn’t want to see (whether OOH or not) to a local practice. This, she argued, should only happen after a proper debate, and not be just the unintended side-effect of regulation change to allow remote prescribing.

In fact, there is evidence that this is exactly what is happening in human medicine. Only the following evening, the BBC aired Diagnosis on Demand: The Computer Will See You Now, a documentary about telemedicine and artificial intelligence in human medicine. It should be required watching for all RCVS Councillors.

The programme makers visited GP at Hand, a telemedicine business based on the Lillie Road in Fulham, London that has been formed in partnership with Babylon. Coincidentally just up the road from where I used to live, it's a pretty nondescript sort of a place, but now home to the fastest-growing GP surgery in the UK. Since late 2017, it has amassed a staggering 30,000 clients from across London, virtually none of whom will ever visit the place. The problem is that GP at Hand has skimmed away fee-paying clients from across the capital that had in effect been helping to subsidise local care elsewhere.

More information needed for such an important decision

Jo concluded by saying that a decision of this magnitude, particularly when it seems to go against the wishes of the majority of the profession, demands checks to ensure no conflicts of interest, legal advice and wider consultation with organisations such as the VMD, Defra, the BVA and its subdivisions and the VDS. Therefore, she would propose a new motion to delay the decision until more information is made available.

Chris Barker (MRCVS, small animal practice, Cumbria) was up next. He felt that the RCVS consultation was very effective and gave a good picture of what veterinary surgeons see as the risks inherent in remote prescribing. However, he felt that the analysis has been marshalled to suit an agenda and minimises the concerns of general practitioners.

Fragmentation and multiple consultants leading to a loss of responsibility

The trial, he said, will lead to fragmentation of veterinary provision and send the message to the public that it is quite OK to go to more than one vet for advice and treatment, and that will lead to confusion and the loss of individual responsibility for the veterinary care of an animal that exists today.

An inspection with no history: not a proper examination.

Chris argued that the act of prescribing demands a physical examination, but that a video consultation could only ever be an inspection. He also highlighted the importance of patient histories and argued that the immediacy of telemedicine simply doesn’t allow a practitioner to get the patient history from another vet.

Chris also argued that the profession is not structured to allow for clients to consult multiple veterinary service providers simultaneously: once a client leaves his practice, he has a duty under GDPR to expunge much of their records, and he for one didn’t much care for the idea of re-registering a client at 2:00am.

Some of the issues Chris raised may of course be solved by technology in the foreseeable future. GDPR already calls for data portability, presumably it will not be long before owners expect the same data portability for their animals' clinical histories.

Who wants clients who only ever call when telemedicine has failed?

Still, his overall point was an important one: whether or not there will be vets out there who are happy to pick up and see failed telemedicine cases at 3:00am in the morning from people who are not clients of their practice and who don’t otherwise contribute financially to the business.

90% of vets say remote prescription is high risk or inappropriate

Lastly, Chris drew attention to a question in the RCVS consultation which asked respondents what risk they thought there would be in a remote consultation when the consulting vet did not know the owner, did not know the animal and does not know the situation in which the animal is kept: "90% of responding veterinary professionals either chose it as high risk or simply not appropriate at all. I know of no better body of people than practitioners in Britain to understand the welfare and the risk to the welfare of animals."

The risk of misdiagnosis

Martin Peaty (MRCVS, equine practitioner, Wiltshire) spoke next, highlighting the risk he saw to animal welfare from misdiagnosis. He drew attention to concerns raised by the Quality Care Commission in human medicine, in particular that there is no access to the long term medical records of the patient, and the risk of misdiagnosis: "And that’s in human patients who can fluently articulate their symptoms", he said, "I think we should be much more cautious in exercising care before allowing remote diagnosis and prescription."

Martin's point seemed especially apposite in the light of an article which appeared in The Times two days later: 'NHS app 'no match for trip to the GP', in which Professor Helen Stokes-Lampard, chairwoman of the Royal College of GPs expressed concerns about online consultation systems, particularly for vulnerable groups, such as children.  

Remote prescribing demands that vets sacrifice principles

Martin also outlined the three principles which underpin current practice: physically examining the animal, considering its history and providing 24 hour care, the latter in part in case of a reaction to a prescribed medicine.

"These proposals ask us to sacrifice these principles for telemedicine businesses whilst for good reason they remain in place for other veterinary practices. I think that is hypocritical. I think it is wrong."

Not enough follow-up

Sue Paterson (MRCVS, a referral specialist who offers a dermatology telemedicine service to the profession and the public, Merseyside) jumped in next. She was unashamedly enthusiastic about the benefits of telemedicine, in particular how it allows practitioners to engage with the public and make veterinary advice more accessible, not to mention because: "I am sick to death of people coming into consults when they have been on Facebook or they’ve been on to talk to Dr Google."

However, despite her enthusiasm and despite finding that users of her service do not want antibiotics, just advice, help and reassurance from people they trust, Sue was still against the idea of remote prescription: "I don’t want to prescribe because I can't follow those cases up, because I can’t maintain the level of client care that I think is really important, so for me, I would not want to see this change to the code."

We won’t know what we missed, or the consequences of what we missed

Caroline Allen (MRCVS, charity veterinary director, London) said the biggest issue for her is that without a physical examination, she won’t ever know what she missed (the heart murmur, the goitre, the subtle muscle wastage), or for that matter, the animal welfare consequences of what she missed.

As others had done, Caroline highlighted the importance of getting a weight every time and how difficult it is for clients to measure accurately.

Lastly, she made the thought-provoking point that allowing the remote prescription of drugs without a physical examination would risk legitimising Dr Google in the eyes of the public. After all, if no veterinary physical exam is needed, surely owners can just look it up on the internet for themselves?

In defence of the RCVS

At this point in the discussion, RCVS CEO Lizzie Lockett addressed the suggestion that the whole process of investigating and voting on telemedicine was being driven by hidden agendas, something she absolutely and eloquently rejected. She explained that sure, some parties had been more engaged in the whole process than others, but emphatically denied there had been any influence. Council, she said, had asked Standards to investigate and develop a proposal, which it had done diligently. Now it is down to Council to decide whether the proposal stands or falls; the College exists to implement the decision.

RCVS Vice President, Professor Stephen May went further, saying that many present would be aware that he'd been a vocal critic of the way that a number of other regulators in modern society push things out to court for decisions, rather than taking decisions collectively and then sticking by them. "I’m really proud that we are discussing this and I’m really pleased that this is up to us how we move things forward in the interest of animal health and welfare and supporting the public in that."

The need for a more nuanced, less polarised debate

However, he said he was worried about the way the debate was being polarised into a yes or no when he felt the profession should thinking about how it should adapt to the changing circumstances, thinking about cases which are amenable to a distant relationship and in what context that is appropriate, taking into account the risks. 

Remote prescription is already happening, illegally

Melissa Donald (MRCVS, small animal practice, Scotland) questioned whether telemedicine and remote prescription is what the public wants. She said that remote prescription is already happening, illegally from abroad, and that the College needs to have a more robust response than "it’s not our problem". She therefore recommended a further period of consultation, particularly with public focus groups, and internet research to see how much remote prescription is already happening. 

Vets are professionals

Tim Walker (Lay) said he was struck by the need to assemble better evidence. He felt there needs to be more thought given to the transference of responsibility for cases between a telemedicine provider and a traditional practitioner. Tim also felt that the definition of "under his care" will almost certainly need to be rethought in the not-too-distant future, because the idea of a patient being under the care of just one practitioner is starting to look dated; in the human sphere, patients are looked after by teams of people.

Tim highlighted the approach he said is taken by the GMC, which obliges doctors to be able to demonstrate that they have done sufficient due diligence to prescribe, not that they can simply do so automatically under certain circumstances. That, he said, is what professionalism should be about.

Taking the lead

Mark Castle (Lay) said he thought that the public was looking for a choice, that technology is constantly throwing up new opportunities, and he expected that in the future more and more will be able to be done remotely, so he wanted the RCVS to take the lead in this area.

Lucy Goodwin (MRCVS, BSAVA Head of Education) was positive about the idea of conducting a time-limited, controlled trial: "We say we want evidence, so let’s go and collect it", but had a number of reservations. Not least of these was the fact that the participants in any trial would be on best behaviour, so it may not be able to extrapolate the numbers to the profession at large. Beyond that, she was also concerned that the scope of the trial should be better defined, in particular which categories of drug could be included within it. 

Vets don't want a trial of telemedicine

Mandisa Greene said that whilst she is positive about telemedicine as it had been described, and not averse to a trial, she didn’t see the point in a trial when the people who actually do the prescribing don’t want it. 

A voice in favour

Chris Tufnell (Past President) began by declaring that he consults to the Affordable Pet Care Company which is shortly to launch a telemedicine service, although he said the service would be unaffected by the decision being taken by Council. He was also at pains to stress that he hadn’t had any other fingers in this particular pie, in particular that he hadn’t been to any of the Standards Committee meetings or presented to them, or been involved in formulating the proposed trial.

Whether you agree or disagree with Chris, it was at least good to hear someone speaking in favour of the motion. Chris opened by arguing that veterinary surgeons are good at making decisions based on imperfect information: "Client histories, as we know, are of variable quality. We make decisions daily on whether we are happy with the information we get from the practice lab or whether we need to send the sample to a reference lab. When I started in practice, practice lab machines were routinely described as random number generators."

"We make decisions on a daily basis on what the limitations of our abilities are. It’s called professional judgement and what we are proposing here is actually a test of our definition of 'in our care'. We’re talking about testing the possibility of making remote prescriptions. The responsibilities around prescribing won’t change, and those responsibilities include the responsible use of antibiotics."

Chris then argued that all the motion was calling for is a trial of something that unlike, for example, deregulating advertising and practice ownership, is not going to give a slice of the consultation fee to non-vets. He also pointed out that people will always be able to highlight cases that would be completely unsuitable for remote prescribing, but that this is not about replacing the consulting room.

Filling the void

What it is about, he said, is removing barriers to care; filling the vacuum between a concerned owner, and the £60 - £100+ they’ll be charged for a consultation. It’s a vacuum that is currently filled by the 'free' (except it's not) phone advice given out by practices, by Facebook and by Dr. Google. 

He then pointed to an example from the US, where 83% of people who visited https://www.whiskerdocs.com for pet advice and thought their problem was suitable for home treatment, were in fact wrong and ended up being instructed to visit their veterinary practice. This, he said, could lead to better productivity in practice.

Could telemedicine help retention?

Telemedicine, he said, could also provide a role for people thinking of leaving practice, which is potentially an important factor at a time when retention is proving such an issue. 

Evidence-gathering, clinical freedom and professional judgement

Like others, Chris argued that the trial is about putting the RCVS at the forefront of progression in our increasingly digitised society, at a time when remote information from wearables is going to become more and more common. In summary, he said: "This trial is about an evidence-based profession looking for evidence, it’s about clinical freedom and it’s about putting professional judgement in the hands of the professionals."

A two-tier service

Lynne Hill (Past President) said her main concern is about having to redefine "under his care" and how remote prescribing via telemedicine would lead to a two-tier level of care, which she thought would be wrong.

She also highlighted that the College had debated the definition of "under his care" in relation to farm animal practice, where some farmers have multiple vets, some of which offer herd health care and nothing else. Deregulating to account for this has, she said, been responsible for the demise of farm animal practice. Quite simply there are less vets around to see animals. 

Show me the money

Lynn also noted the altruistic nature of the debate thus far, and reminded everyone that this is really about business and making money. The companies that are set up to provide telemedicine and possibly take part in the trial will not be in it for the welfare of animals, but to make money.

She also scoffed at the idea that telemedicine and remote prescribing will mean the 10% of people who do not currently have a vet are "now going to get madly involved in telemedicine." The reason they don’t have a vet at the moment, she said, is because they don’t want to pay. Telemedicine doesn’t change that. 

Lastly, as others had done, she highlighted the difference between human medicine, where patients can describe their symptoms, and veterinary medicine, where they can’t.

Leadership is about taking the right decision, not jumping on the bandwagon

"Leadership is not always about jumping on the bandwagon and going forward because something is out there. Leadership is actually about looking and deciding and making the right decision."

The disingenuous antimicrobial argument

Dave Leicester (MRCVS) was up next, arguing that it would be wrong to say that a body of professionals can be trusted to make decisions about animal welfare, but not about prescribing. He also felt it was a little disingenuous to do a lot of hand-wringing over antimicrobials when, as a profession: "We’ve managed to make a 3rd generation cephalosporin the most prescribed antibiotic in cats."

Finally, Dave made the point that in his 15-year experience working for OOH emergency service providers, they’d managed to work very successfully without access to patient medical histories.

Setting veterinary standards

Claire McLaughlin (Lay) reiterated that the role of the RCVS is to set veterinary standards, something it can’t very well do without knowing what is going on in practice, and finding out how these things work in practice. “We need to be in a process which takes us to able to set those standards. Whether the trial that is proposed is the right trial or not, we can’t just say no, it’s fine as it is because people will work within their professional competence. As Eleanor [RCVS Registrar] will tell you, they don’t work within their professional competence because they come before disciplinary committee all the time. I think we would be remiss if we didn’t start a process now or continue this process in a way that allows us to set appropriate standards.”

Colonel Neil Smith (MRCVS, Chief Veterinary Office for the Army) began by declaring that he provides telemedicine services for animals in disparate parts of the world as part of his day job, but these animals are very much under care and there is an existing relationship with patients. He is also involved with the provision of limited veterinary services for homeless people via StreetVet, a charity which has had to form relationships with practices that can cover the 125 hours per week when it is not present. 

Lowering veterinary standards

Neil explained that his "massive" concern with the proposal lies in particular with the part that says: "Given the limited nature of the service that can be provided by telemedicine alone, however, it is proposed that those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."

This, he said, would lower veterinary standards, if all somebody providing telemedicine has to do is point people in the direction of a practice. 

For that reason, Neil said, he could not support the proposal as is, and would instead recommend that it goes back to Standards and is then brought back at the next council meeting with a clearer idea of what the trial is all about.

Accessible care

Caroline Allen then jumped in again, saying that whilst she agreed with the idea that more data is needed, she also thought that telemedicine and remote prescription is being driven by the issue of accessible care, and it is that, in fact, which needs to be investigated and understood and debated first.

The digital age

Past President Professor Stuart Reid highlighted that the veterinary students of today live their lives in the digital environment and their world will be very different from ours. The same goes for pet owners. He reiterated that as the regulator, the RCVS needs to be ahead of the game, and that if this is what the public wants, then it has to find a way of regulating it. 

Stuart finished by saying that he felt conflicted about the vote; that he had significant problems with the proposal and is not entirely sure that a trial is the right thing, but: "In the referendum we're about to have, I want to say yes but I want to see what the deal is as well." He added: "I didn't vote out by the way, in case this gets back to my employers, but I do think we have to think very carefully about throwing the baby out with the bathwater here."

Pressure to prescribe

Martin Peaty then recounted how at a Vivet Conference last year, a provider of telemedicine (which he thought was Babylon) explained that doctors on its system were retained on the basis of a post-consultation customer satisfaction survey. That, he thought, would make it difficult for practitioners not to prescribe things when they know it will affect their job. 

David Bray (Lay), said he believed the telemedicine and remote prescribing will come and it will become more common to have pets treated by multiple vets, so he was fully supportive of a trial. 

When it came to the vote ...

Guessing at which way the people who spoke might have voted, it seemed as though there were probably enough councillors with sufficient reservations about the motion, which would have given the go ahead for the trial, for it to be voted down.

That said, the overall sentiment in the room seemed to be that the discussion about the regulation of telemedicine and remote prescription needs to continue, and not get kicked into the long grass simply because of a disagreement over the proposed trial. 

At this point, Jo Dyer and others stepped in to argue that the decision to proceed with the trial should not be made until the issues raised in the debate had been addressed. There was then a lot of going backwards and forwards, discussing whether this would need a new motion, which is not allowed under Council rules, or whether the existing motion could be amended, which is allowed.

In the end, the decision was taken to hold two votes, the first being to refer the issue back to the Standards Committee which was carried by 18 to 12, with one abstention. 

The second vote was:

"Council is invited to consider the recommendation of Standards Committee to prepare and develop a proposal for a time-bound and limited trial to assess the benefits and risks of allowing the remote prescription of POM-V with appropriate stakeholder engagement and with consideration of the issues that we've discussed today and the detail on them, including 24/7 care and classes of drugs, especially antimicrobials. So we are asking for the detail on that to be worked up on the basis that it will at some time come back to Council."

The second vote was carried by 21 to 8 with 3 abstentions. 

In other words, the trial will not now go ahead unless Standards can develop a new proposal which addresses the concerns raised by Council.

VetSurgeon Conclusion

Looked at solely in terms of its impact on animal welfare, this debate seems to come down to one question, which is whether more animals will benefit from easier, cheaper access to veterinary services available via telemedicine and remote prescription than will suffer as a result of misdiagnoses and missed diagnoses that will surely be the inevitable consequence of veterinary surgeons working only from the more limited, and potentially inaccurate or even false information they will get from a video consultation.

For sure, more wearables are coming, and they will overcome some of the problems caused by the fact that animal patients cannot describe their symptoms. Doubtless someone will also invent a set of weighing scales that makes it possible for owners to do the job reliably accurately. Patient histories will surely become more portable. But these things are not with us just yet. 

In any event, it is not just about the immediate impact on the quality of care delivered to patients. The way the trial has been framed thus far takes us in the direction of a two-tier profession. What happens if more veterinary surgeons prefer, or make a better living from working from the comfort of their own home without the added responsibility that comes with providing the physical care. Who’ll do the ‘real' vetting?

If you look at the popularity of human telemedicine, the 30,000 patients who have signed up for telemedicine at the small practice in the Lillie Road in London, it seems obvious that patients want the convenience of consulting online, without having to schlep to the practice and find a parking space. It also seems self evident that if online consultations are offered at a lower price point, it will inevitably lead to more pet owners availing themselves of veterinary advice, though as Lynn Hill said, it’s unlikely to cause a mad rush whilst Dr Google is still free. 

Perhaps, though, there is another valid way to solve this conundrum. Rather than rushing headlong into a trial that could irrevocably change the very nature of the profession, how about establishing some pragmatic ground rules from the outset. For example, that unless by unanimous agreement of Council in the future, telemedicine should only be allowed as an extension of the service offered by existing bricks and mortar practices to their existing clients. 

When it comes to remote prescribing, surely the safest way to regulate it (if you’re going to allow it at all) is to do so on a drug-by-drug basis. Perhaps trial it with the endo- and ecto-parasticides for existing clients of existing practices. Find out whether the convenience of the online consultation leads to higher standards of parasite control for greater numbers of pets. If it doesn’t, then ditch it. Either way, it doesn't preclude trying another category of drug.

That’s my tuppence worth, for what it’s worth, which probably isn’t quite tuppence!

The RCVS Disciplinary Committee has reprimanded Hertfordshire-based Amir Kashiv MRCVS for the inadequate care of a dog with renal failure.

Mr Kashiv first appeared before the Committee in December 2016 in relation to four charges against him regarding his inadequate treatment of a Scottish Terrier called Tanzy which was ultimately euthanased due to renal failure.

The first charge related to Mr Kashiv’s original consultation with the owner in March 2015 and his failure to investigate for renal disease; his failure to discuss with the owner investigations to assess metastatic spread; failure to discuss with the owner alternative options to surgery such as palliative care or euthanasia and failure to explain to the owner key factors with regards to the surgery he had suggested to her, including its nature and extent, the risks involved, the fact another vet would be performing the surgery, and what to expect post-operatively.

The second charge related to the fact that, having admitted the dog as an in-patient at the practice, he failed to conduct further investigations regarding her poor condition; provide any or any adequate pain relief, or fail to record the same; failed to discuss with the owner the dog’s poor prognosis and failed to discuss with the owner the option of euthanasia.

The third charge related to the fact that Mr Kashiv discharged the animal back into her owner’s care when she was not in a fit state for discharge. The fourth and final charge related to the fact that Mr Kashiv failed to keep sufficient clear, detailed and accurate clinical records for his treatment of the dog. 

At his original hearing in December 2016, the Committee found the four charges proven and also found that charges 1 to 3 amounted to serious professional misconduct. However, the Committee decided to postpone the judgement for two years, whilst recommending that Mr Kashiv agree to undertake a structured programme to improve his clinical practice, including putting together a personal development plan, having a mentor, accepting regular practice visits and undertaking additional continuing professional development (CPD).

The resumed hearing took place on Tuesday 18 December 2018, during which the Committee heard evidence from Dr Writer-Davies MRCVS (the veterinary surgeon appointed to review Mr Kashiv’s practice and report back to the Disciplinary Committee over the two year period), Mrs Somers MRCVS, (his appointed mentor), and Mr Kashiv himself.

Dr Writer-Davies told the Committee that she had no concerns about Mr Kashiv’s abilities regarding patient safety and that, in her view, he now meets the standards of a reasonably competent veterinary surgeon. She cited the fact he had gained in confidence when communicating with clients, had undertaken a considerable amount of CPD focused on the areas of concern identified in the case, that she had observed more detailed record keeping from him and that a veterinary nurse had been appointed to assist in running Mr Kashiv’s practice.

The evidence from Mrs Somers also found that Mr Kashiv’s knowledge was in line with that expected of a reasonably competent veterinary surgeon and that she had observed a good quality of care for pets and their owners from him.

Mr Kashiv also gave evidence, which the Committee said demonstrated considerable insight into his previous conduct and a good attitude towards self-reflective practice. The Committee also felt that the testimonials provided by Mr Kashiv showed him to be a kind and caring veterinary surgeon.

Stuart Drummond, chairing the Committee and speaking on its behalf, said: "The Committee considers that, having successfully completed the undertakings, Mr Kashiv is now a safe practitioner. The last two years has allowed Mr Kashiv to develop his skills particularly in the area of communication.

"However, the Committee has not lost sight of the fact that this was a serious case and that there was substantial harm caused to Tanzy.

"The Committee considers that in the intervening two years Mr Kashiv has gained considerable insight, developed better communication skills and remains open to improving his practice. It therefore imposes a reprimand on Mr Kashiv. The Committee considers that a reprimand is the appropriate and proportionate sanction to uphold proper professional standards and to maintain public confidence in the veterinary profession."

A group of UK-based investigators from Davies Veterinary Group and the UCL School of Pharmacy has published the results of a study which suggests Keppra (levetiracetam) shows promise for the treatment of feline audiogenic reflex seizures (FARS).

The condition, which was first documented by the same investigators last April, affects older cats which typically exhibit myoclonic seizures (brief, shock-like jerks of a muscle or a group of muscles) in response to certain high-pitched sounds. Both non-pedigree and pedigree cats (in particular, Birmans) may be affected. A range of sound stimuli has been reported, including the crinkling of tin foil and a metal spoon dropping into a ceramic feeding bowl, through to firewood spitting and even texting on a phone. While avoiding the triggering sounds can reduce the incidence of seizures, this is not always practical, so this research is potentially good news for owners of affected cats.

The study, Levetiracetam in the management of feline audiogenic reflex seizures: a randomised, controlled, open label study, has been published in the Journal of Feline Medicine and Surgery¹.

It compared the efficacy of two antiepileptic drugs, levetiracetam (a relatively novel medication that has proven effective in studies of people with generalised epilepsies that experience myoclonic seizures) and the much older first generation drug phenobarbital, in 57 cats diagnosed with FARS. Cats were treated with one or other drug over a 12 week period; and owners were asked to record the date, number and type of seizures, any signs of illness, side effects and changes in activity or attitude, as well as whether they thought their cat's quality of life had improved, remained the same or deteriorated since starting the medication. 

All cats receiving levetiracetam showed a reduction in the number of days that they experienced myoclonic seizures by at least half. In comparison, only 3% of cats showed the same reduction when treated with phenobarbital. The majority of reported side effects, such as lethargy and inappetence, were mild to moderate in both groups and these resolved after about 2 weeks in the cats treated with levetiracetam; in the phenobarbital group, however, side effects were relatively persistent. Owners of cats treated with phenobarbital perceived no benefit from using the medication; in contrast, all of the owners of cats treated with levetiracetam commented that their cat appeared brighter and more responsive after the first couple of weeks of treatment. Moreover, five cats treated with phenobarbital were switched to levetiracetam after the study, as their owners desired improved seizure control. 

Having established that levetiracetam is an effective and well-tolerated treatment for cats with hallmark myoclonic seizures, the next step is to identify whether levetiracetam will also prevent so-called generalised tonic–clonic seizures. This is another seizure type seen in cats with FARS, and is what most people think of as a 'seizure', with the cat losing consciousness and its body stiffening and jerking, often for several minutes. 

Lead author on the paper, Mark Lowrie, said: "It is great to find a medication that works so well at controlling these seizures. Levetiracetam is not licensed in cats but it has proven to be a very safe drug. For affected cats to benefit, it is important that vets recognise the signs as this newly defined syndrome of FARS and that this medication is used in preference to other, less efficacious, anti-epileptic drugs."

Reference

1. Lowrie M, Thomson S, Bessant C, Sparkes A, Harvey RJ and Garosi L. Levetiracetam in the management of feline audiogenic reflex seizures: a randomised, controlled, open-label study. J Feline Med Surg. Epub ahead of print 21 December 2015. DOI: 10.1177/1098612X15622806.

Eurovet has launched Comfortan, the first EU-authorised methadone in the UK, available as an injectable solution for use in dogs.

Eurovet says that whilst methadone may seem an unfamiliar analgesic choice for some vets in practice, that is about to change very quickly.

Ruth Vernon Technical Services Manager at Eurovet says that prior to the launch of Comfortan, reports show that usage of methadone to manage pain in animals is much higher than previously thought: "We have become aware that many practices are using methadone routinely for orthopaedic procedures and that several specialists use it in preference to any other analgesic where rapid onset of action and profound analgesia is important. This opioid provides vets with an animal analgesic with very rapid onset of action: exerting an effect in just 10 minutes of intravenous administration and 15 minutes of intramuscular administration. Comfortan is licensed both as an analgesic and as a premed in combination with a neuroleptic drug. As a full opioid agonist, Comfortan results in very effective pain relief, particularly when used for moderate to severe pain. Comfortan provides pain relief for approximately four hours and can be re-dosed to achieve the desired level and duration of pain relief."

Ruth is anticipating high demand for Comfortan from launch: "Comfortan enables many more patients to be given methadone immediately to control their acute pain without their vets having to go through lengthy protocols involved in using products off-licence, so we think that more vets are about to become convinced of the benefits.  Comfortan is licensed for veterinary use and it offers the convenience of a 10 ml vial with a shelf life of 28 days. Those who have not used methadone before, or indeed anyone with a query about storage or monitoring, can source all the information and advice they need by contacting us at Eurovet Animal Health."

For further information contact Eurovet Animal Health on 01223 257933, e-mail: office@eurovet-ah.co.uk, or visit: http://www.eurovet-ah.co.uk/

Vet Futures, the joint initiative by the RCVS and the BVA to help the profession prepare for and shape its own future, has published a guest blog in which an academic argues that the profession needs to introduce safeguards to prevent inappropriate profit-seeking behaviour.

David Main is Professor of Animal Welfare at the School of Veterinary Sciences at the University of Bristol, with research interests in welfare assessment, animal welfare education and intervention strategies to improve welfare.

In his blog (www.vetfutures.org.uk/discuss), Professor Main says he believes the vast majority of individual veterinary surgeons and practices are not motivated by money and do have animals’ best interests at heart, but that the differences between the business structure of veterinary and medical practitioners in the UK means the profession is always at risk of standing accused of excessive profiteering. 

He said: “Since we still live in the age of the media scare story, it would seem prudent for the profession to embed some anti-profit seeking safeguards in our regulatory controls before, rather than after, a problem is highlighted.” One suggestion he makes is for the prohibition of turnover-based incentive schemes in favour of incentives based on health outcomes. 

He believes that such safeguards, which he says could be incorporated into the RCVS Practice Standards Scheme, would be a “healthy demonstration” that the profession has animal welfare rather than profit as its main priority.

Professor Main also argues that the profession urgently needs to deliver on society’s expectation of vets as animal welfare experts: “Veterinarians could perhaps... do more at an individual level to act as animal welfare advocates. It is easy to inform clients on the technical rationale for a specific husbandry change but then walk away knowing full well the client will not action the advice. In the medical profession, advanced communication techniques are becoming more widely accepted to promote positive change within their patients. Perhaps we should be more explicit in teaching our veterinary students influencing skills.”

In response to David’s blog, this month’s Vet Futures poll asks visitors ‘Do vets always act as animal welfare advocates?’

The previous month’s poll, which was based on an article co-written by Erwin Hohn and Adi Nell from MediVet, asked to what extent vets would be willing to work collaboratively with others if it would benefit all. Of the 50 people who answered the poll, 60% said they would be completely willing to work with others, 32% a lot and 8% to some degree – no one said they would be unwilling to work with others.

Bova UK has launched a range of pharmaceutical specials for the small animal market.

The Australian company, which launched in the UK offering equine specials in March 2017, says that while some human healthcare companies are authorised to supply veterinary specials under licence in the UK, it is currently the only company in the UK to have specific veterinary authorisation to manufacture sterile specials.

There are six formulations in Bova’s new small animal range with a further 23 formulations scheduled to be introduced in the first half of 2018. However, Bova says that due to advertising restrictions, only verified veterinary surgeons will be able to see its formulation list.

For more information, contact Bova Sales Manager Emma Jones on tel: 07780443731 or Victoria Dawson on 07780443738 or visit www.bova.co.uk.

The company will also be at BSAVA Congress this week on stand 817, where they will be offering the chance to win an afternoon champagne tea at the Ritz.

New research from the Royal Veterinary College (RVC) has revealed that flat-faced dogs and spaniels, amongst others, are more prone to keratoconjunctivitis sicca (KCS), aka ‘dry eye’.

The study¹ was led by the RVC’s VetCompass Programme and is the largest study using anonymised veterinary health records to explore dry eye in dogs. The study included 363,898 dogs that were followed for a year to identify 1,456 dogs affected with dry eye.

The study found that one in every 250 dogs overall is affected by the condition, but certain breeds are especially prone.

The worst affected breeds were: American Cocker Spaniel (5.90%), West Highland White Terrier (2.21%), Cavalier King Charles Spaniel (1.91), Lhasa Apso (1.86%), English Bulldog (1.82%), English Bull Terrier (1.65%,) and English Cocker Spaniel (1.60%).

Other findings included:

• Twenty-two breeds showed increased risk of dry eye compared with crossbred dogs including: American cocker spaniel (x 52.33), English Bulldog (x 37.95), Pug (x 22.09), Lhasa Apso (x 21.58) and Cavalier King Charles Spaniel (x 19.79).
• Two breeds showed reduced risk of dry eye compared with crossbred dogs: Labrador Retriever (x 0.23) and Border Collie (x 0.30).
• Brachycephalic breeds had 3.63 times the risk of dry eye compared with mesocephalic breeds.
• Spaniel breeds had 3.03 times the risk of dry eye compared with non-spaniel breeds.
• Breeds with bodyweight at or above the mean for their breed and sex had 1.25 times the risk of dry eye compared with dogs weighing below the mean for their breed and sex.
• Dogs in lower bodyweight groups had higher risk of dry eye: dogs weighing 10.0 - < 20.0 kg had 5.49 times the risk compared with dogs weighing 30.0 - < 40.0 kg.
• Dogs aged ≥ 12 years had the highest risk of dry eye (x 29.44) compared with dogs < 3.

The authors of the study have recommended that vets help reduce the frequency and impact of KCS by testing for the adequacy of tear production as part of the annual physical examination of all dogs but especially for the list of predisposed breeds as they approach advanced age.

Dr Dan O’Neill, Senior Lecturer, Companion Animal Epidemiology, at the RVC, and author of the paper, said: "We all love those glossy puppy dog eyes, but this study shows that sadly not every dog enjoys good eye health. This research identifies that flattened faces in some breeds makes these breeds more prone to this painful dry eye condition. Work is urgently going on to improve the health of many of these flat-faced breeds, but in the meantime the message from everyone who cares about dogs is to ‘stop and think before buying a flat-faced dog."

Rick Sanchez, European Specialist in Veterinary Ophthalmology says: "Taking a fresh dip into an old, dull looking disease like KCS has shown us there is more for us to learn than we thought. Ultimately, all of us, clinicians, nurses, researchers, breeders and dog owners are, in one form or another, care givers for our beloved animals. All of us need whatever new information we can set our eyes on to inform our next steps in improving canine ocular health. There’s no better eye opener than evidence-based scientific findings. I hope this research helps all of us raise awareness about canine KCS and that it helps us keep those animal eyes looking fresh and healthy, as they should.”

Bill Lambert, Health, Welfare and Breeder Services Executive at The Kennel Club commented: "These findings are important to help us to identify which dogs are most at risk of developing dry eye. Ultimately, this should help owners that may need support in spotting the initial signs, as well as ways to treat affected dogs and how to prevent it occurring in the future. The data from this fascinating research will also be used to collaboratively create strategies to tackle health priorities with the breed clubs of affected breeds."

Reference

1. O’Neill et al. (2021) “Keratoconjunctivitis sicca in dogs under primary veterinary care in the UK: an epidemiological study” Journal of Small Animal Practice. The full paper can be accessed here: https://onlinelibrary.wiley.com/doi/full/10.1111/jsap.13382

Photo: Cavalier King Charles Spaniel with KCS. By Rick F Sanchez BSciBiol DVM DipECVO CertVetEd FHEA.JPG

Veterinary Nurse Kim Houghton has launched Wild Inside Adventures, an opportunity to take part in a programme which offers hands-on experience with some very exotic species whilst at the same time helping communities that normally have no access to veterinary care.

Participants travel around South Africa working on game reserves, commercial farms and in poor communities, getting experience of game capture, providing veterinary care in townships and rural areas, working in a private clinic and handling and treating large farm animals.

There are also a range of weekend activities, including kayaking, quad biking, game drives, horse riding, surfing, beach walking, bars and restaurants.

Kim said: “We’ve designed the programme so that it’s suitable for people with a wide range of experience, including veterinary and veterinary nursing students, young people considering a career in the veterinary profession and animal lovers.”

For more information, visit: wildinsideadventures.com

Veterinary surgeons Mandy Knight and Jen Rowland have won the BVA's second annual photography competition, out of almost 500 entries from across the UK.

Mandy, an Australian-born small animal vet, won in the 'You and Your Work' category with her photograph "Happy Enterotomy", which captures a smiley squeeze-toy being removed from the stomach of a Labrador.  

Mandy, who is currently taking time out from full-time work, said: "I am so thrilled to be able to share this photo. It was actually about 10 years or so ago that I encountered this dog. We knew from radiographs that he had eaten a ball, but it was a lovely surprise to make the incision into the stomach and have this happy little chap beam out at us! We have such a cool job as vets, and this just nails it."

Jen captured the judges' attention with her image of rare and native North Ronaldsey and Dartmoor sheep grazing under the Milky Way in Northumberland in 'The wonderful world of animals’ category'.

Jen, who works in mixed practice in Aberdeenshire, said: "I am completely shocked and delighted to have won this competition and it has definitely inspired me to get out with my camera more often. I was very lucky to get this shot as it was a single thirty second exposure - I had some very cooperative models!"

Commenting on Jen’s photo, competition judge and award-winning wildlife photographer George Stoyle said: "Jen Rowland has clearly put some thought into her photo and has shown skill in its execution. From a technical perspective, the exposure used for the sky is just long enough to make the stars visible whilst minimising star trails, and artificial light has been used just enough to highlight the sheep and the rest of the foreground. The entire scene along with the ragged appearance of the sheep gives the image a feeling of wild, remote, windswept moorland, which I love."

Alongside the two winning photographs, five photos in the ‘You and your work’ category and eight in ‘The wonderful world of animals’ category received Highly Commended awards – ranging from giraffes to gannets and Lackey Moths.

British Veterinary Association President Gudrun Ravetz said: "We are delighted by the number and quality of the entries we received this year. The veterinary team is uniquely placed to capture the many wonderful facets of its work on camera, and we are pleased that our members have shared their eye-catching snapshots for BVA’s photography competition, offering us a vet’s-eye-view of their daily work and interaction with the wonderful world of animals."

Mandy and Jen each receive £250 worth of gift vouchers from John Lewis. Their winning images alongside the commended photographs will premiere in an exhibition at BVA’s Members’ Day at W5 Odyssey Belfast later this month (21 September).

The BVA Veterinary Photographer of the Year gallery can be viewed at: www.flickr.com/photos/britishvets/albums

Photos:

• 'Happy Enterotomy' © Mandy Knight. CC BY-SA 2.0.
• 'Rare and native North Ronaldsey and Dartmoor sheep grazing under the milky way in Northumberland' © Jen Rowland. CC BY-SA 2.0.

Boehringer Ingelheim has announced that Vetmedin has been granted a new licensed indication: for the treatment of asymptomatic mitral valve disease (MVD), and cardiomegaly.

The research on which the new indication is based is described by Boehringer as the largest and most cutting-edge study in veterinary cardiology.

The EPIC study (Effect of Pimobendan in Dogs with asymptomatic MVD and Cardiomegaly)¹ demonstrated that Vetmedin delayed the onset of heart failure for dogs with asymptomatic MVD, providing on average 15 months additional symptom-free time, as well as extending overall survival. 

Indeed, Boehringer says the worldwide study was so conclusive - involving 360 dogs, in 36 centres, in 11 countries across four continents - that it was terminated early as it was deemed unethical to withhold Vetmedin from dogs in the placebo group.

Panny Morgan, Vetmedin brand manager at Boehringer Ingelheim, said: "Vetmedin delays the onset of heart failure in dogs with asymptomatic MVD and cardiomegaly, providing 15 months extra symptom-free time; that’s almost 10% of a dog’s lifetime.

"Prescribing Vetmedin to dogs with an MVD murmur and enlarged heart will not only extend a dog’s lifespan, but it will also have a major impact on their quality of life."

For further information on Vetmedin, contact your Boehringer Ingelheim territory manager or visit www.vetmedin.co.uk. 

Reference

1. Boswood et al. Effect of Pimobendan in Dogs with Preclinical Myxomatous Mitral Valve Disease and Cardiomegaly: The EPIC Study—A Randomized Clinical Trial. J Vet Intern Med 2016;30:1765–1779


Bayer Animal Health, maker of Seresto flea and tick collars, has carried out some market research which suggests that as many as one in ten pet owners have been duped into buying counterfeit pet medicines. 

For the research, 2000 pet owners were asked whether they they had bought counterfeit pet medicines online. 31.3% said yes. They were then asked if they had reported the matter. 62.2% said they had. Finally, they were asked what the outcome of their report was. 60.9% said their purchase was confirmed as a fake, suggesting that at least one in ten pet owners - probably more - have bought fake pet medicines.

Bayer says the true number of owners affected is likely to be even higher, as a further 12% of pet owners in the survey said they believed that they may have bought fake pet medicines but had not reported it. 

The research also showed that 87% of shoppers purchased pet parasite prevention products from unaccredited sites that have been known to sell counterfeit pet medicines. Indeed since April this year, the VMD has removed over 500 veterinary medicine listings from online marketplaces.

The message to clients is that chasing the lowest price for veterinary medicines can be a false economy.

Photo: Can you tell whether this product is fake or not?