Abstract
ABVP roundtable
Management of diabetic cats in primary care practices: ABVP roundtable report
In September 2014, diplomates of the American Board of Veterinary Practitioners (ABVP; 15 Feline; one Canine/Feline) met in a roundtable format to discuss several issues related to management of the diabetic cat. The impetus for this meeting was generalized dissatisfaction with the outcomes of treatment in their own practices compared with the outcomes reported in the veterinary literature. Two of the roundtable participants, Gary D Norsworthy and Elaine Wexler-Mitchell, summarize the key discussion points and findings. Anne Romeo, a veterinary student, assisted the discussion regarding statistical analysis.
Management of diabetes mellitus is common in small animal practice. The focus of the roundtable discussion was remission and survival, with special attention paid to home blood glucose (BG) testing and diet.
Roundtable data
In preparation for the roundtable discussion, each participating diplomate was asked to examine the records of every diabetic cat in his/her practice that was treated during a 3 year period (July 1, 2011 to June 30, 2014) and not lost to follow-up. Diplomates who supplied this data are listed in Table 1. An additional five diplomates did not supply data but contributed to the roundtable discussion (Table 2).
ABVP diplomates supplying data on 282 cats
P1, P2 and P3 were the three practices contributing the highest number of cats to the roundtable data
ABVP diplomates participating but not supplying data
Eighty-two data points were examined for each of 282 cats. The data were entered into a spreadsheet for compilation and then statistically analyzed. For comparison of categorical data such as diet, remission, home monitoring and feline pancreatic lipase immunoreactivity (fPLI), χ2 testing was used to compare two groups. For statistical analysis of numerical data, such as factors that influence days of survival, a Student’s t-test was used. A value of P ⩽0.05 was considered significant for all χ2 and t-tests performed.
Categories of diabetic cats
The discussion began with the recognition that diabetic cats could be placed in three categories based on duration of treatment:
Category I cats lived 0–7 days (n = 42; 15%). This included cats presented with terminal or severe disease due to ketoacidosis or concurrent disease; and cats belonging to owners who elected not to pursue treatment for a variety of reasons including lack of commitment to the cat and financial or scheduling limitations.
Category II cats lived 8–89 days (n = 80; 28%). This included cats with owners who initially decided to treat but later rescinded that decision because the response to treatment was not sufficiently rapid or not successful; cats with concurrent disease that did not respond to treatment for the concurrent disease; or cats for which the expense or commitment of treatment exceeded their owners’ initial expectations.
Category III cats lived 90 days or more (n = 160; 57%). This included cats with owners who were committed to and performed long-term treatment.
It was noted that the nature of the patients and owners in these three categories was significantly different. Most of the differences were related to the owners’ commitment and financial ability, and these factors had an impact on remission rates and longevity. The emphasis of the discussion was on cats in category III; however, the data that follow include cats in all three categories.
Use of fructosamine and urinalysis
Measurement of fructosamine levels for diagnosing diabetes was not discussed in depth. It was used very infrequently in the diagnostic process. The combination of clinical signs and one or two BG levels was considered sufficient for diagnosis in almost all of the cases. Its primary use was to distinguish diabetes from stress hyperglycemia. Fructosamine testing was included in a routine diabetic recheck in 36/282 (12.8%) cats.
Urinalysis data was not available for most of the 282 cats, either because urinalysis was not considered necessary to make a definitive diagnosis or urine was not available at the time of diagnosis.
Remission
Remission was defined as a clinically diabetic cat being in a state of euglycemia and free of the four clinical signs of diabetes (weight loss [WL], polyphagia [PP], polydipsia [PD] and polyuria [PU]) for 2 weeks or longer without receiving exogenous insulin or other hypoglycemic drugs. Remission rates varied from 8% (practice with n = 12 cases) to 42% (another practice with n = 12); the average for the 282 cats was 26%. The three practices with the highest number of cases (practice [P]1, P2 and P3) had remission rates of 25% (P1; n = 76), 29% (P2; n = 56) and 30% (P3; n = 76). Combined, these three practices accounted for 74% of the total cases. One cat was in remission for about 300 days, but data collection did not include duration of remission on all cats.
Several factors were evaluated that were believed to impact remission. A low carbohydrate diet (LCD; carbohydrate levels of 15% or less on a dry matter basis) was expected to have a major influence; statistically it did not. However, the participants noted that dietary histories were not always reliable, with one owner stating that the cat was on an LCD but their spouse admitting that the cat was eating other foods or snacks that were not low in carbohydrates. It was speculated that incorrect answers were given because some owners did not want to admit inattentiveness or lack of effort to observe (especially in multi-cat households) and others did not want to be chastised by their veterinarian for failure to do so. It was also the participants’ belief that owners may provide fallacious information regarding clinical signs of diabetes (WL, PP, PD, PU) for similar reasons. It was noted that this is a problem with all diseases that rely on owners to supply information regarding treatment and treatment outcomes.
Insulin type was identified as a potential factor in remission. The participants predominantly used four products: commercial protamine zinc insulin (PZIR, ProZinc; Boehringer-Ingelheim, 46%), glargine (Lantus; Sanofi, 91%), lente (Vetsulin; Merck Animal Health, 4%) and neutral protamine Hagedorn (Humulin-N; Eli Lilly, 2%). The total was greater than 100% because all products used in the course of treating each cat were counted, and many cats had been on more than one. There was not a statistically significant difference in any product in terms of their association with remission.
fPLI values were assessed in 61 cats. The participants did not compile data differentiating whether the results were from Spec fPL (IDEXX) or in-house SNAP fPL tests (IDEXX). Although the test results were elevated/abnormal about 50% of the time, an elevated/abnormal result did not correlate with remission. Other factors the participants found that did not have a significant influence on remission included age at diagnosis, occurrence of one or more clinically hypoglycemic events, positive urine cultures at diagnosis and steroid-induced diabetes. It was suspected that cats that lived outdoors or that had indoor/outdoor lifestyles were likely to be more difficult to regulate and have lower remission rates; however, data were not available to prove or disprove this hypothesis. Owner commitment to diabetic treatment was another factor discussed but without sufficient data to quantify.
The roundtable participants agreed that remission is a desirable goal and that attaining remission is multifactorial in nature. They further agreed that attributing it to one factor, especially insulin type, is likely a gross oversimplification.
One practice (P3) differed in the way diabetics were managed in several respects. It had significantly higher exclusive use of LCDs, higher use of PZIR, lower use of glargine, and lower use of home BG testing (Table 3). It also did not utilize glucose curves at home or in the clinic. Monitoring was based on clinical signs, especially weight, and spot glucose checks at about 12 h post-insulin. Its remission rate was 30.2%; the rate for the other practices combined was 24.1%.
Proposed factors in remission in practice (P)3 compared with the other contributing practices
All = all practices in the roundtable; All less P3 = data for all of the practices excluding the data for P3
Determined by Student’s t-test; NA = not applicable
Home glucose testing
Although home BG testing is often stated to be part of the standard of care for diabetic cats, the participants found that it was performed on a long-term basis by only 5–40% of their clients, not counting the two practices that did not promote home testing. Fewer patients were monitored at home than by regular clinic visits, and the number of patients in remission was approximately the same in both groups. The participants discussed that resistance to home BG testing was likely due to owner fear of breaking the human–animal bond, an inability to get good samples and a general lack of owner interest in home testing.
Survival
One hundred and eighty (64%) cats were alive at the end of the data collection period (DCP) regardless of their category. The percentage of cats still alive from each practice at the end of the DCP varied from 25–72%. In the compiled cases, home BG testing positively correlated with being alive at the end of the DCP, but the practice with the highest percentage of cats alive at the end of the DCP (72%) was P3, and it did not recommend home testing. At least some of the factors mentioned above regarding P3 (higher exclusive use of LCDs, higher use of PZIR, lower use of glargine, and lower use of home BG testing) likely combined to influence being alive at the end of the DCP.
There were four cats that lived significantly longer than the others, with time from diagnosis to death being 965, 966, 1084 and 1116 days. Four cats constituted too small a population for computing statistical significance; however, there were some data that appeared relevant. All cats were males and were diagnosed at 10, 12, 13 and 14 years of age. Only one went into diabetic remission, and it became diabetic again after 300 days of remission. None of the four cats died as a direct result of diabetes. Concurrent disease was considered the cause of death or the reason euthanasia was chosen by the owners. Home BG testing was performed with only one of the cats. Three of the four cats ate an LCD exclusively. All four received insulin glargine. One cat developed diabetic neuropathy, and one cat was on corticosteroids (or had recently been on corticosteroids).
Other issues
There were two other important issues that participants discussed. The first was the apparent disconnect between clinical signs and pre-insulin BG values in cats being treated. It was not at all uncommon for the BG values to be between 400 and 500 mg/dl (22.2 and 27.8 mmol/l) or even between 500 and 600 mg/dl (27.8 and 33.3 mmol/l) in cats with no, or minimal, clinical signs, and this was repeatable on subsequent weekly to bi-weekly checks. Although this was relevant to all insulins, it seemed to happen most often in cats being treated with glargine. Cats on consistent diet and dosing of insulin could have BG values above 300 mg/dl (16.7 mmol/l) one week and below 80 mg/dl (4.4 mmol/l) the next, with no change in clinical signs. Participants found this very frustrating.
The second concern came from those who tried to use the tight control approach proposed by Roomp and Rand (JFMS, 2009, 668–682). Hypoglycemic crises occurred with alarming frequency. As one participant put it, ‘Tight control is for the unemployed.’ This reflected the degree of attention that was needed to prevent a clinically hypoglycemic event, and the health and financial crisis that followed.
This is the first published discussion of treatment outcomes managed in primary care settings by ABVP boarded practitioners. All of the participants were well informed on the ‘gold standard’ approach to feline diabetes. The realities of primary care practice were imposed on the individual treatment protocols, and the participants believe the outcomes represent what is commonly found in primary care practice. The roundtable was created in response to a survey of all ABVP feline diplomates regarding treatment of feline diabetes. The consensus of those who responded was that we are not achieving expected remission rates; nor are we finding the reported good control of hyperglycemia with insulin glargine. The participants wanted to share their own clinical experiences with feline diabetes and allay the sense of incompetence that was felt when their feline diabetic remission rates were only 25–30%.
The practice identified as P3 was notable because with its loose control protocol it achieved as good or better results in all categories monitored. It placed more emphasis on clinical signs than on BG values. The insulin of choice in this practice was PZIR, and home BG testing was not employed. The rate of clinical hypoglycemia was 50% that of the rest of the participating practices.
AAFP
2016 practice management meeting examines feline-focused business strategies
AAFP is holding its first Feline Practice Management Meeting on feline-focused business strategies from March 4–6, 2016 in Lake Tahoe, Nevada, United States. Registration is limited to 200, so early registration is advised.
Attendees will be updated and informed through lectures and an interactive workshop led by Karen Felsted CPA, MS, DVM, CVPM, CVA and Eric Garcia. Seasoned practice owners, associates and practice managers will gain understanding and techniques to implement new ideas, use clinic metrics in decision making, unlock their true feline potential, increase effective communication with cat owners, develop their feline marketing, and more.
Quality CE at your fingertips
As an added value to membership, the AAFP Webinar Portal provides complimentary continuing education (CE) and can be accessed from the AAFP Member Center at: www.catvets.com/mbrdash.
The education you obtain through this new portal can go towards the CE requirements for the Cat Friendly Practice program.
Call for samples
Ehlers–Danlos syndrome: DNA study
Ehlers–Danlos syndrome (EDS) type 7C, also referred to as cutaneous asthenia, is a congenital connective tissue disorder found primarily in the Burmese breed, although it can also occur in Himalayan cats and sporadically in domestic crossbred cats. It is suspected of being transmitted as an autosomal recessive disorder.
DNA sampling and shipping instructions can be found at felinegenetics.missouri.edu
The syndrome is the subject of a case series published on pages 954–963 of this issue of JFMS. Corresponding author, Richard Malik, writes: ‘Work is currently being carried out to identify the gene and causal variant(s) of EDS in cats, particularly in Burmese lines. We are keen to obtain DNA from and digital photographs of affected cats. DNA can be extracted from EDTA-anticoagulated blood, cheek swabs and paraffin-embedded formalin fixed tissue blocks (eg, of skin biopsies).’
Details of how to collect and send samples can be found at felinegenetics.missouri.edu, or by emailing Leslie Lyons at
iCatCare
Recognising feline friendly innovation
International Cat Care, the parent charity of ISFM, presented four ‘Easy to Give’ and three ‘Cat Friendly’ awards at its annual awards ceremony in London on September 11. A brief outline is provided below; for more information about the awards go to icatcare.org
ISFM in collaboration with ANZCVS
ISFM has been excited to be collaborating with the Australian and New Zealand College of Veterinary Scientists (ANZCVS) in delivering the feline membership examinations in Europe since 2012. As a further development in this partnership, ISFM is now delighted to be working with the ANZCVS feline chapter in promoting the feline stream at College Science Week – this is the ANZCVS’s annual conference, held on the Gold Coast of Queensland each July. The ANZCVS is the only body to offer a Membership- and Fellowship-level qualification in feline medicine, and the calibre of material presented in the feline chapter program at College Science Week reflects this strength.
Feline abstracts presented at this year’s College Science Week can be found on pages 964–965 of this issue of JFMS. For anyone, particularly young speakers, practitioners and residents, wishing to present feline clinical research or unusual cases, this is an excellent and friendly forum to participate in.
Plans in progress for the feline chapter at College Science Week in 2016 include a pre-congress cutting-edge feline masterclass day, in addition to a whole day of feline medicine in the main stream of the congress. The chapter will have two international speakers, as well as local feline specialists and ISFM’s Veterinary Director Andy Sparkes. Attending College Science Week will give practitioners interested in cats a rich and unforgettable experience. Watch this space for more details!
2016 calendar
The 2016 iCatCare calendar features stunning images reflecting ‘the beauty of cats’. Funds raised from calendar sales go towards iCatCare’s welfare work. For further details see the advertisement within this issue of JFMS
Keeping Cats Safe campaign
As part of its ‘Keeping Cats Safe’ campaign, iCatCare has produced a poster highlighting the dangers of lilies to cats. All ISFM practice members will receive a printed copy of the poster to place in their veterinary practice. The poster can also be downloaded for free or a hard copy can be ordered from icatcare.org/shop. Other hazards that the campaign has recently focused on include glowsticks and fireworks, and antifreeze. To find out more visit: icatcare.org/advice/keeping-cats-safe
Trap–neuter–return videos
iCatCare continues to provide as much information as possible for those in the frontline of cat welfare. With the help of Ceva and the Mrs DM France-Hayhurst Foundation, iCatCare has produced eight new training videos to help advise welfare workers on the best practices for trap–neuter–return (TNR). The videos, which include information on the safe handling of cats, use of different traps and special veterinary considerations, are freely available at: icatcare.org/advice/rescue
Book review
The cat: clinical medicine and management
This is a really practical and useful textbook, providing a wealth of information on aspects of clinical practice that are encountered every day, as well as less common conditions.
This is a large, comprehensive book, but it is also very easy to read and the information is presented in an easily accessible way, even for non-native English speakers and readers like myself. The many coloured photos and illustrations help enormously and are used to convey essential information throughout the book. This is a multi-author textbook, bringing together the experience of about 70 experts, and delivers depth where it is needed.
It is divided into the 10 sections described below (46 chapters), each dealing with a different aspect of feline medicine and, importantly, of the approach to cats – ‘cattitude’.
Feline-specific content
Practice resource
Value for money
Overall reviewer rating
Overall, I found this book to be extremely valuable and well written. It should be on the shelf of every feline vet (and every small animal vet). It is worth every penny!
Susan Little. Elsevier, St Louis, MO, 2012. Hardback, 1424 pages. Price £128, ISBN 9781437706604.
Also published in Spanish: El Gato: Medicina Clínica y Tratamiento. ISBN 9789505554218
Martina Naceradska is the owner of the first Cat Friendly Clinic in the Czech Republic. – Editor
SAGE
JFMS publisher SAGE celebrates 50th anniversary
SAGE Publications, which has been publishing JFMS since 2012, and launched its sister title JFMS Open Reports this year, is celebrating 50 years as an independent, academic and educational publisher. From small beginnings, SAGE now has offices globally and boasts an impressive publishing portfolio. It has also been named the International Academic and Professional Publisher of the Year for 2015. Here we mark the anniversary of ISFM’s and AAFP’s publishing partner by tracing its remarkable story to date.
The beginning
In 1965, Sara Miller, at the age of 24, started SAGE in a one-room office in New York, United States. Having worked for just over 3 years for two publishers, she was disenchanted with large-scale publishing houses and decided to start out on what has turned into a lifelong mission: to support the dissemination of usable knowledge by publishing innovative and high-quality research and teaching content.
Sara, who worked by day as a consultant at three small publishers, and by night as SAGE’s sole employee, carried out all of the copyediting, proofreading and even the licking of stamps. Nine months later, in September 1965, SAGE’s first journal, Urban Affairs Quarterly, was produced.
The following year Sara married her mentor and champion for her plans, George D McCune, and they moved the company to California. It is the combination of their names (‘SA’ from Sara and ‘GE’ from George) that makes up ‘SAGE’.
Global expansion
From these humble beginnings, SAGE has expanded globally: SAGE London being formed in 1971; SAGE India in 1981; and SAGE Asia-Pacific in 2006. Today, SAGE has nearly 1500 employees across five continents.
Expansion to science, technology and medicine publishing
Until the mid-1990s, SAGE published journals mainly in the social sciences and had, aside from nursing, never published in science, technology and medicine (STM). In 1998, SAGE had its first success with a new launch title in engineering, shortly followed by the purchase of the number 1 journal in robotics, International Journal of Robotics Research. From here, growth in medical publishing followed.
Sara Miller McCune, the founder and Executive Chair of SAGE Publications. (inset) Sara at the age of 20, as editor-in-chief of her college’s senior yearbook (1960) in New York City, United States. Courtesy of Sara Miller McCune
Over the past two decades, SAGE’s STM program has grown faster than that of any other publisher in the sector and SAGE has established itself as one of the leading medical journal publishers.
Digital publishing and open access
With the development of the Internet in the 1990s, SAGE quickly recognized that the information it was publishing needed to be available in electronic formats and, by the beginning of the new millennium, had completed the transition of all of its journals to its first online platform.
As a founding board member of the Open Access Scholarly Publishers Association, SAGE has also been at the forefront of efforts to ensure a sustainable future for open access publishing. It now offers open access as an alternative route to publication, making scientific and scholarly research literature freely available and reusable.
Family business
In 1989, Sara and George appointed George’s son, David F McCune, as president of SAGE. In 1990, George sadly passed away suddenly of cardiac disease but Sara continues to serve as the Executive Chair of SAGE.
As Sara’s day-to-day involvement in running SAGE decreased, she went on to support a range of philanthropic projects, including providing books for university students in India and London, as well as helping to set up medical clinics in rural India. In 2008, Sara’s achievements were celebrated by Women’s Campaign International at its event ‘Shattering the glass ceiling: honoring inspirational women around the globe.’
SAGE is rare among publishers of its size in that it is still independent and privately owned. Sara has ensured that in the future it will become owned by a charitable trust, securing SAGE’s continued independence.
SAGE today and in the future
SAGE’s current publishing portfolio extends to over 850 journals as well as over 800 new books a year. With its sights set on becoming the world’s leading independent academic and professional publisher, SAGE’s remarkable story looks set to continue throughout the coming decades and beyond.
JFMS is published by the SAGE London team. Claire Minto (right) led the publisher’s successful tender for the journal and was its first Publishing Editor. Jennie Atkinson (left) is the current Publishing Editor for JFMS and JFMS Open Reports
