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Notorious RBG: she may be wee, but she sure is mighty

In the news this week we have been reflecting on the passing of U.S. Supreme Court Justice Ruth Bader Ginsburg. The truth is I do not follow politics enough to know how meaningful this iconic woman's fight for the rights of women really was: for the equality of all citizens. My husband and I watched the documentary Notorious RBG, and it displays the type of character she was. Someone who chose her words wisely, along with the cases she argued for. Prior to her appointment as Justice, every case she won was one small step towards equality for all people of the U.S. A notable achievement was her presenting argument in front of the Supreme Court in Califano v. Goldfarb (decided 1977). In this case, a widower wished to collect social security benefit so that he could stay home to take care of his son after his wife had passed away. He was denied the benefit, as the benefit was meant for dependent wives or stay-at-home mothers. RBG argued that this was another case of gender discrimination. On the radio yesterday they were discussing the hypocrisy of the Republican Party pushing towards a swift replacement of a Justice Ginsburg before the 2020 election. “Honour Her Wish” was being chanted by many as the dying woman’s final words as Justice were that her replacement not be decided until the country had voted in a new president. Why the hypocrisy? In 2016, 10 months leading up to the election, the Republican dominated Senate refused to allow President Obama to appoint the replacement following the death of conservative Justice Antonin Scalia, who was Justice Ginsburg’s good friend - despite their opposing political views. The seats of the Supreme Court are lifetime appointments and so they are of the utmost importance when it comes to the rights of the people set forth in the U.S. constitution. The decision therefore should not be made hastily. President Trump would like to appoint a woman to replace Justice Ginsburg - though likely our beloved liberal RBG would be replaced by a conservative viewpoint, in the hopes of overturning the right to choose (briefly mentioned in a previous post). There is talk that following Justice Ginsburg’s death, her beliefs will strike a chord with young women to get out and have their voice heard through their ballots. The thought that a progressive country, so-to-speak, would be going backwards in the evolution of humanity really baffles me. Until the new appointment, let's reflect on some of Justice Ruth Bader Ginsburg's work. For more on Ruth Bader Ginsburg's cases take a look here. Including her books.

Fall Migratory Death

I was just chatting with my husband about travelling to Algonquin Park to see the fall colours. The maple trees are just starting to turn, and the Gravenhurst bakery will also be calling our names! While relaxing this evening I also saw a report on a massive die off of migratory birds in the south western U.S. It’s speculated to be multifactorial with weather change and the wildfires being contributing causes to the deaths. No necropsies have been performed yet, so we will need to wait for the results. An ecologist in New Mexico is reporting on her Twitter feed while species of birds have been seen. It brings me back to my vet school days when learning about exotic pets, including birds. For those who don’t know, cooking with Teflon pans, especially at high heat, is toxic to birds. So I wouldn’t be surprised if toxins in the smoke-filled air of the western states is contributing to these deaths. From my brief search on VIN, it appears that birds do not tend to survive house fires with smoke and heat inhalation into the air sacs causing death. Here's a little handout for those bird enthusiasts. There was one comment on these threads about the birds dying due to the windmills we like. I think they were referring to the wind turbines used as renewable sources of energy. A few years, or a decade ago, I took a course in conservation biology. The professor was a specialist in bats. What he found was that flighted mammals are much more prone to barotrauma and death by wind turbines than birds were. Anatomically, birds differ greatly in the structure of their lungs than mammals. Bird lungs are more susceptible to toxins due to their higher efficiency of exchange of air into the blood through the capillary system. Do you know about the canary in the coal mine? Due to human activity, we suppress the natural cycles of wildfires, along with our climate changing, the wildfires are able to grow drastically large with all the fuel that is around. Birds can tolerate sudden changes in temperature, as long as they have enough food. But they cannot tolerate breathing in smoke and flying at the same time. I'll try to come back to update this post as time progresses!

What should I feed my dog?

Annual wellness appointments is when I ask what pet owners are feeding. There are sooo many options out there, so how do you choose?? Most pet owners look at the ingredient list, because this is how they do their own shopping. With the internet, pet owners are so much more knowledgeable. Gone are the days when you 100% respected the education of your veterinarian, seriously. Back in the day, you had no internet, so you took the advice from the educated professionals. No offence to anyone who works in the pet food industry, but where did you go to school and get your nutrition degree? Do you have a PhD in nutrition? In the medical world, you cannot call yourself a “specialist” unless you are a diplomat, written a board certification for a specialty. What is a Veterinary Nutrition Specialist? So glad you asked! In North America, veterinarians can specialize in nutrition. What that means is they typically did a four year bachelors degree, usually in a science, then four years of veterinary medical school, then an internship or worked as a general practitioner, then a three to five year residency, often with a Master’s or PhD. So when it comes to nutrition, or any other topic, I’m going to turn to the board-certified specialist in that topic - not the one with a blog post about it ;) and definitely not the high school student behind the cash register at the pet food store, or the person who decided to make a pet food in their garage. Many people don’t want to hire a specialist. Specialists cost money, and the internet is free. The advice in my wellness appointments isn’t free either, however, I do a lot of follow-up, on my own time. Checking in with the pet owners to see how things are going, as long as they have taken my advice. Ok, I’m blabbering! A veterinary nutritionist is the most educated person that you can get your pet’s nutrition advice from. Period. These nutritionists in North America, can be found through the American College of Veterinary Nutritionist. Guess what? You do not have to hire a specialist to figure out what to feed your dog. Their website has an area for pet owners, with some resources - links to pages like guidelines on how to feed your pet. I just checked and some of their links on their website need to be updated, so if you are here later and my links aren’t working, please let me know! WSAVA Guidelines on Nutrition How to Choose a Good Diet The Global Nutrition information posted on the WSAVA site is similar to everyone looking to the WHO for their public health information. Here's a quick little guide from their site. There is soooo much information online, it's overwhelming. The last thing I want is to argue with a new puppy owner who read on Google some bad reviews about meat by-products in their puppies food that was recommended, so they are now going to feed their puppy a raw diet. My job is to inform. I can't tell owners what to do, and their pet's health depends on building a team with the clients to better the pet's health. The veterinarian should work with the client and point owners in the direction towards reputable websites so that they can make an informed decision. Like this site: Pet Nutrition Alliance.
Pet Nutrition Alliance Dare to Ask Survey First - I select for Nutritional Expert, then I select whether the company provided information on their AAFCO standards. See below. Finally, I want to know that a Veterinary Nutritionist was involved in formulation of the diets. Again, these are Doctors of Veterinary Medicine that did a residency in Nutrition - including a board examination to obtain this level of education called a Diplomate. ACVN is the American College of Veterinary Nutritionist ECVCN is the European College of Veterinary and Comparative Nutrition Just an FYI, this really works better on a desktop computer, so I suggest going there when you have time. Ok, now you are armed with some knowledge to choose an appropriate diet for your pet! Large Breed Puppies Our veterinary school training in nutrition was pretty limited, but the one thing that was stressed was that large breed puppies cannot be fed like small breed puppies. Large breed puppies should also not be fed like adult dogs! A few important things to consider is that large breed puppies should not be over fed, as there is an increase in orthopedic conditions when the puppies bones and body grow to quickly. Large breed puppies should not be fed a high-protein/grain-free diet, because these diets will not have appropriate calcium levels and they tend to be much higher in calories. The diet should not say "All Life Stages" and along with AAFCO labeling it should read "Large Breed Puppy" on the packaging. Note: I do not receive any monetary gains from my recommendations below. This is for the readers' benefit only! Purina Pro Plan Puppy Large Breed Chicken & Rice Formula Hill's Science Diet Puppy Large Breed Chicken Meal & Oat Recipe Dry Dog Food Eukanuba Large Breed Puppy Dry Dog Food Royal Canin Large Puppy Dry Dog Food Royal Canin Canine Development Puppy Large Dog Dry Dog Food Homemade Diets or Toppers But my dog is picky... Now what?? My opening line during my consultation with a new dog owner is: “what does Luna like to eat?” I chose Luna because we have a LOT of Luna puppies! Anyway, it opens up the conversation of what Luna actually likes, and what Luna refuses. This client is offering a well-balanced puppy kibble diet, that they then top with something juicy like boiled chicken, which they then mention that Luna is picky, she noses around and eats the chicken and doesn’t eat the kibble. This is the equivalent of telling me that your child picks around the plate and doesn’t eat their vegetables and only eats the cheese or pasta. So what do you do for your child who doesn’t eat their veggies? They get a vitamin supplement. So guess what?? For those picky dogs who don’t want to eat that dehydrated kibble, and only eat that juicy chicken, they also need a vitamin supplement. If you are going to all this work to dress up your dog's kibble, and they just don't want to eat that kibble, or any kibble for that matter, then don't offer kibble! There is actually no reason (other than balancing a diet) that your dog needs kibble. You can feed your dog 100% canned dog food and maybe she will be happier! Or, you can spend some time in the kitchen, knowing exactly what your pup is eating with a homemade diet, but it still needs to be balanced! I have been leaning towards the website, because it is easy to use, pet owners can choose the protein, veggies, fat source and starches that their pet enjoys, then you click the DONE button, and you are provided with a pass or fail - and which vitamin and mineral supplement to use to balance the recipe. It's really good for pets who are allergic to things! Hilary's Blend is another. A newer one that our technician found is Just Food For Dogs. My Pet Has a Medical Condition, What Should I Feed? This will be very individualistic, and best to consult your veterinarian who knows your pet’s health condition the beat. I definitely have my go-to diets for health conditions, but each pet should be treated as an individual. Itchy skin? There are diets for food and environmental allergies. Intermittent diarrhea? There are diets for that too. Intermittent vomiting? Yup, that too! Kidney disease, pancreatitis, bladder stones, cystitis, the list goes on! There are a few conditions that you can try to make your own homemade diet, but the diet should be balanced and should pass the test. For example, kidney diets should be lower in phosphorus, because part of kidney disease is that the kidneys cannot excrete phosphorus well and this backs up in the body as waste. So consult with your veterinarian for your specific pet's needs. Grain-Free Diets The BEG (boutique, exotic and grain-free) diet debate is the most recent and most common client education topic that I discuss with dog owners when it comes to nutrition. There was a study published in 2018 that found that dogs who were offered a grain-free diet were developing dilated cardiomyopathy, a type of heart disease that was not common in certain breeds. It also seems that the bioavailability of the nutrients in each diet differs depending on the protein sources, even when the diet is formulated and balanced. Taurine has been known for decades to be important in the prevention of dilated cardiomyopathy. The golden retrievers that had dilated cardiomyopathy were treated with taurine and their heart disease improved. So part of the story includes taurine absorption or metabolism. Twenty-three of 24 dogs diagnosed with taurine deficiency and dilated cardiomyopathy were fed diets that were either grain-free, legume-rich, or a combination of these factors. None of these diets were feeding trial tested using Association of American Feed Control Officials (AAFCO) procedures. Twenty-three of 24 dogs had significant improvement in their echocardiographic parameters and normalization of taurine concentrations following diet change and taurine supplementation. So how do you know if a diet has gone through AAFCO trials? The Pet Nutrition Alliance helps us out with this. It's 2020 now, and I know from experience with publishing literature, it can take a long time from the completion of a study to publication of these studies, so what is new in the world of cardiology and diet? Many of the fad diets are replacing grains with pulses (lentils or peas). A few small clinical trials have been published, this one used Labrador retrievers, and found that the grain-free diet in their study did not decrease the dogs' taurine levels, though they did not do any cardiac ultrasounds in that study either. The Golden retriever still appears to be an at risk breed for diet associated dilated cardiomyopathy. I couldn't find anything about the cross-bred Golden Doodles that have been popular in the last decade, but I just inform owners to be cautious about what they are choosing to feed their dogs. The one thing that we all want is a healthy puppy! It's best to be wary, but be informed. Pet owners and veterinarians should always work as a team for what is best for the health of the pet.

Acupuncture for Fertility and Supplements

I’m back again! Now that Toronto has entered phase 3 of reopening with COVID-19 restrictions, acupuncture is available again. I decided to switch to the naturopathic clinic that works with my fertility clinic, as they have an integrated system, allowing the naturopathic doctors to see when I’m coming in for fertility treatments and monitoring. After my initial consultation today, the ND also recommended to increase my Ubiquinol from 200mg to 600-800 mg prior to retrieval, to stick with the NAC I started recently, stick with the 4000iu vitamin D, and just to change my prenatal to one that has active folate (instead of the one with folic acid). So below is what I am currently taking, in addition to my medications for depression and anxiety. According to the ND, research has shown to have a higher chance of implantation of the embryo if you have pre and post implantation acupuncture. So let’s find the evidence! In a meta-analysis (in case you’re not a scientist - this is an analysis of all applicable studies), researchers found that receiving acupuncture prior to oocyte collection (egg retrieval) increased the clinical pregnancy rate, and live birth rate. However, in a side-by-side comparison of women receiving acupuncture versus "sham" acupuncture (control), before and after embryo transfer, there was no statistical difference in live birth rates. This suggests that the benefits may be a perceived psychological benefit, the time while you are resting during the acupuncture treatment gives you 20 to 30 minutes of down time, therefore the stress reduction can increase pregnancy rate. Women who received several acupuncture sessions (greater than one month) compared with one acupuncture session on the day of embryo transfer, had a perceived stress during their IVF treatments that was lower. So if all acupuncture does is lower your stress levels during IVF, then it's probably a good thing! On the off-chance that it works to improve oocyte quality, then we want to know that we have done everything that we can.

To Test or Not to Test: Prenatal Screening

I was having some second thoughts on our up-coming IVF. My husband was 100% for testing the embryos before implantation. But I am feeling eager and anxious, and just want to get pregnant as soon as we can, so I went ahead and asked if my doctor could change the protocol to have a fresh transfer. The difference between the fresh and frozen embryo transfer, as far as success goes these days, is that our fertility clinic has had a slightly higher success with frozen transfers. The problem with the fresh transfer is that if the fetus is abnormal it carries a higher risk of miscarriage. You can only do genetic testing of embryos that you freeze. From what I gather, the cells have to be sent to an external laboratory for DNA amplification and assessment of the chromosome numbers, taking about three weeks to get the results. We are planning a big move in the near future hence I don’t want to be waiting to transfer an embryo, so where would that leave us? Potentially transferring an embryo that may not make it to term. The majority of miscarriages occur due to some sort of genetic abnormality. So, if we have a fresh transfer, then we cannot do preimplantation genetic testing for aneuploidy (PGT-A), at least on the fresh transferred embryo. My husband does not want to take the risk having a baby that would not be born healthy. So we agreed that we would test in utero. There are a few different tests to screen for chromosomal abnormalities. The ones I have been reading about are non-invasive prenatal testing (NIPT), chorionic villus sampling (CVS), and amniocentesis. When I had my phone consultation with our genetic counsellor, she had mentioned that most couples who have a PGT-A tested embryo do not do amniocentesis, but do NIPT. Ok, so what are these? Non-invasive just means that they are taking a sample from your blood that can predict the genetic make up of the fetus, or at least somewhat. How does this work? So, we probably already know that the maternal endometrium meshes with the fetal placenta for the exchange of nutrients and waste from metabolism in the fetal cells, via the blood vessels within the blood placental barrier. During this exchange some of the fetal genetic materials are sent into the mother’s vascular system that doctors can access through a blood sample from the mother without damaging the fetus. Cool! Obviously, there are limitations of what information you can get from this, both false negative and false positive results, or no results at all. But, it is a simple test, so why wouldn’t you do this? I guess regardless of these results, if you want to be prepared for a baby with a disability or if you wish to terminate a pregnancy that would result in poor quality of life, however you personally define that, then you may go on to doing CVS or amniocentesis. Many women elect not to test, because the love for your child is not diminished by their disability, however from the father’s perspective things would be different, and I respect that, hence why we have agreed to test. This study compared CVS and amniocentesis demonstrating that there was no increase in miscarriage for CVS over amniocentesis - though previously it was more risky to sample during early pregnancy (prior to 15 weeks). An abortion of an abnormal embryo is legal in Canada, just a slight side note. A friend of a friend was pregnant, visibly, then suddenly wasn’t. There is no one in their right mind that would dare to ask what happened, because you risk causing the mother anguish. You still wonder though. What happened?? I thought they were pregnant? Did they miscarry? How sad! Only those women who are brave will be open about the cause of their miscarriage or abortion. I am on enough of these social media groups to understand the social judgement that women place on other women. Whatever your religious or social background is, it is your decision. In Canada, we are soooo fortunate that so many folks are pro-choice for the mother. It baffles me that still in 2020 the U.S. has state authority over whether a women can terminate a pregnancy! Abortion Laws in the U.S. I realize this is a complete aside, but I know that during the current U.S. presidential period, I would check which states were actually deemed illegal, a.k.a. a criminal offence where the mother can be charged or imprisoned. Yikes! Canadians, consider yourself lucky. In the early 1970’s, following the second wave of feminism or women's liberation, the U.S. Supreme Court decided during the conclusion of the Roe vs Wade trial that women in the U.S. have a right to choose whether or not to have an abortion, without excessive restrictions from their state government. Where the state gets involved is the rules by which a women can have an abortion. Of course, with COVID-19, our politicians have been busy, but you can see what the restrictions are for each state here. Interestingly enough, Harvard is offering a free course on the ethics of ART (assisted reproductive technologies). I'll keep you posted if I have time to take it! Back to Canada Saying back to Canada, is kind of like saying, ok, back to be logical and realistic. Oh I kid. Canada basically says that the woman has a right for personal freedom, and can terminate a pregnancy at any stage. So if the fetus is deemed genetically abnormal, i.e. trisomy 18 or 21, then a woman can elect to terminal the pregnancy, even after the first trimester has completed - would she want to? Well, that's up to her to decide.

Fear Free: Sliding Base Cat Carrier

I saw this video on FaceBook and thought this is amazing! It is a cat carrier that slides out, with the base keeping the cat feeling secure in it’s box. When a cat does not willing long come out of its carrier, I usually take the top off the carrier and perform the majority of my exam with the cat in the bottom of the box. They feel a lot better, and are less fearful when you are touching them. I have not seen any yet with this feature, but already I would recommend it! Calm Carrier Check it out here on the Van Ness Pet Products site.

The Culture of [Veterinary] Medicine

I was listening to the As a Woman podcast while driving to work. Dr. Crawford was talking about how your workplace cannot support you if you don’t ask for or tell them what you need. She was talking about the context of discrimination against women who are trying to be a mom. Whether it’s time off because you’re going through a miscarriage, or not getting the promotion because you’re a mom and suffer the “mom tax”. Meanwhile, my workplace is quite supportive, but I had no idea when I would need time off for all these fertility diagnostics and treatments, that itself creates a lot of anxiety for me. In all honesty, I was trying to get pregnant right when I started my current position. While they cannot legally ask you if you are going to have children in the next little bit, I felt guilty not being transparent about my goals. I spoke about it with the regional director, and then turned out that my hospital manager was pregnant. So, I eventually was open about trying to conceive with most of my working crew, the women anyway. At the time, I didn't know that we would struggle to get pregnant, and so given that information I don't want to count the proverbial chickens before they hatch. So what is this Culture in Veterinary Medicine? Remember the post I did a while back on the Women of the Round Table? Well, I attended the following year, when I was in my fourth and final year of vet school. The question came up about how to balance building a career with building a family - again - as I am sure it always does. Women going through veterinary medicine in the 70's and 80's in Canada struggled a LOT more than those of us going through it now. What I mean by this is, the boy's club mentality. You all know what I mean. Ok, maybe you don't. But think about the show 'Mad Men' - a workplace where the executives or high-ranking individuals in the office are all men, and the women hold the servant role of secretary or housewife. If you take a look at medical doctors, up until recently, men out number women in the graduating classes in medicine, while women out number men as nurses, a role that does not hold as much power. Things for women in Canada in veterinary medicine were slightly ahead of their human medical counterparts. I say the 1970's because this is when women were trickling into veterinary colleges in the U.S., demonstrating approximately 11% of the graduating classes in 1970. A far stretch from 50:50; this occurred in the U.S. in 2009! That's a little over a decade ago. Statistics published in 2007 by the American College of Veterinary Medicine (AVMA) demonstrated that in veterinary medicine, women's average income in the U.S. was approximately $79k while their male counterparts were earning $109k. (See the history of women in veterinary medicine for more.) So again, what is this culture? The Culture of Medicine, and Veterinary Medicine, is to show up, no matter what. You have to earn your place in this male-dominated space. If you're sick, if you're 8 and 1/2 months pregnant, if your child is ill and you are without daycare, you feel guilty. Either way, you are going to have to make a choice! It's not good! So who is going to advocate for you? We do not feel like we are given a choice. If we are sick, we come to work. We are told we have to make up the time if we go off for a personal reason. We also feel like we are going to be judged for trying to get pregnant. Guess what? Men are not the problem. Women judge other women. It is so true! The women who graduated from veterinary medicine in the 1980's from my college who were seated at the Round Table during this year were part of the problem. I didn't take time off for my pregnancies. I didn't take time off to raise the child, they just came on calls with me. I sucked it up, so you should too! I was taken aback with these attitudes. Do not presume that you have no choices. Dr. Crawford says, we must change this culture when we get to the top! If you are a women in power, the head of your department, you need to help others out. Everyone has a different set of priorities in their life. As veterinarians, we commonly believe that we can have it all. We can have our career, and become a mom, however, there will always be sacrifices. You are the one who needs to prioritize what you feel is important. Plan ahead. When is the school play? I want to be able to go and watch, let's book that time off work now. If your child's birthday, or Christmas is really important for your family, then advocate for yourself, prioritize these, ask for the time off. If you do this in advance, it's much easier to plan that time off around these events, whether you have to make up the time or not. Women in veterinary medicine. If you are a large animal practitioner, and you want to get pregnant, you need to be realistic about what your body will be able to do. Not every female veterinarian is going to be able to safely go out to preg check the cattle in 40 below while 8.5 months pregnant. Yes, there have been women who have done this! Also note that, in some countries, there are high risk infectious agents, for example Brucellosis in developing or undeveloped nations, increasing your risk of abortion. Or if you are a small animal practitioner, what's your risk of Toxoplasmosis? Then, we could even start discussing the influence that the mother's stress levels have on the hypothalamic-pituitary-adrenal axis, called epigenetics - how the fetus' environment (the placenta, in utero environment) influences the fetus' gene expression - which I find super interesting, so maybe there will be an entire blog post about it. I could go on and on. One of the main factors when looking for a job is will you have a decent work-life balance. Arguably, I had a much better work-life balance at my previous job. I got to the point where almost all of my medical records were completed during the work day, and then I wouldn't have to take work home with me. In my current workplace, from the pressures of the manager, she didn't want me typing in the exam room, taking away from the face-to-face conversations with the client. So, I would write it all down, history, physical exam findings, etc - and darn, I write a lot slower than I can type! But, then, after writing the notes down on paper, I then had to go and transpose allll this writing into the electronic medical record! It was extremely inefficient. I started to voice my concerns, and my colleague, now medical director said that she always types in her appointments. Ahhhh... Ok, it gave me permission to do so. But for months I was torturing myself with this! Once you have a workplace that puts value on having a balance between working and life, you will feel more comfortable with asking for time off when necessary. My manager sat down with us during a doctor's meeting and she said, No working on Sundays! Don't check your email. Don't be doing your medical records. Take one day in the week to do things for yourself, or with your family. I can't say that I have taken this 100% to heart, but I definitely coached myself to say, is it really that important to log into the work computer at this moment. The answer is always no. Listen to the podcast As a Woman for more great information!

IVF Funded List

This week, we found out that our funded cycle for IVF would occur in October. The original plan, since I was told that the waitlist was 9-12 months, was to pay for one IVF cycle, and bank those embryos. We have always wanted to have two children, but as luck, and age, would have it, we may not be able to. IF, with a big I-F, we get several embryos that are genetically normal, that would be a fluke. So what does this mean? We had completed our karyotype testing and were waiting for results. We got these results a few weeks ago. Everything was normal - yay! My period had already started, so there goes another moon cycle of time. So the next period wasn't due until the beginning of September. As everyone who has gone through IVF or IUI knows, you call or email in to the fertility clinic with your Day 1 - day 1 is the first day of full flow of your period, not spotting, but enough that you would need to wear a tampon (or menstrual cup in my case). This changed our plans a bit. We had sort of discussed, what is waiting another month to get going with IVF, in the grand scheme of things. Well, for us, that is saving $13k - which is a substantial chunk of our savings. So, coming October now, we will email in our day 1. If everything aligns, this would be Oct 1st, but chances are that it won't happen until the 3rd week of October. Waiting is exhausting in and of itself. While we have decided that since TTC naturally actually messes with my natural cycle - making it even harder to track, and with every late period I get hopeful, then disappointed, we plan to put a hold on TTC naturally so that I can manage my cycle better leading up to IVF. But, it has been over a year since we started to try, and six months since I found out that I have diminished ovarian reserve (low AMH). For those of you who don't know, we are currently in Toronto, Ontario, Canada. Ontario is one of the only provinces where the provincial government provides for their residents the ability to fund a cycle of IVF. Take a look at the information below. So, for every woman living in the province of Ontario, holding an OHIP card, you get one IVF cycle covered if you are under 43 years of age. What the OHIP covers is the cost of the egg retrieval, the laboratory fees of fertilization, whether it is through ICSI or more natural fertilization of putting the egg and sperm together in a petri dish, they will cover the blood work and ultrasounds for monitoring prior to the egg retrieval and the embryo transfer, whether fresh or frozen. They do not cover the medications for stimulation, if you decide you want to have genetic testing of the embryos (PGT-A), if you wish to have fancier laboratory equipment like embryoscope or spindle view of the oocytes prior to ICSI, and if you are using a donor or third party for your IVF. So overall, for our OHIP funded cycle, we will be looking at $7-8k versus $20k. There have been these extra costs that pop up here and there. Like the karyotyping, sperm banking prior to IVF, getting blood work or DNA fragmentation testing, and I am sure there will be others. But what we keep telling ourselves is that it will be worth it if we get to build our family... that this is just coming out of any inheritance our children may get. I am a very patient person, but this TTC journey has been the greatest test of my patience! Good luck to all of you out there who are also on this journey with me. Acronyms: IVF = in vitro fertilization OHIP = Ontario Health Insurance Plan ICSI = intracytoplasmic sperm injection IUI = intrauterine insemination TTC = trying to conceive PGT-A = preimplantation genetic testing for aneuploidy AMH = anti-Mullerian hormone

New Puppy

Who doesn’t want to see a new puppy?? One of our assistants got a new puppy! She got weaned early, they think because the dam may have had mastitis. She definitely brightens my day! So why not yours??

Supernumerary Teeth

Today’s dental case was a 4 year old male neutered Burmese cat. He is a very sweet patient that I saw recently for his wellness and booster vaccines. The biggest abnormality that I saw was some crowding of the teeth and gingivitis, with mild dental calculus. I can’t say he was very compliant for his oral examination, but I discussed with the owner about the crowded teeth and had recommended a dental, thinking it was his breed and smooshy face. Today, we anesthetized, and the veterinary technician took dental x-rays. When it came time to chart his teeth after the x-rays were taken, I realized that the teeth were not poorly erupted adult teeth with retained deciduous teeth, but supernumerary teeth. My assistant who was writing my chart for me said, ummm... I’m not sure how to spell that. Right... then comes the decision of what to do with all the extra teeth! My patient had supernumerary bilateral last premolars on the mandibular arcades, similar to this photo. Fortunately, we did catch it early, prior to there being severe periodontal disease. The molar wasn’t smooth either, which was suspicious for a cervical resorptive lesion in the enamel of the tooth. After discussing the x-rays and chart with the owner, we agreed to remove the rotated premolar and the molar with the neck lesion, but leave the other side how it was. There was also a supernumerary 109? I actually could not really make out what tooth it was, but it was an extra tooth. It didn’t seem to be rotated or causing any trouble, so it got to stay. The extractions went fairly smooth, though my drill was not having the best of days, so two cross burrs broke. But no roots were broken, and the patient had a smooth recovery. I’d say that’s a good dental! I thought I would share the DVM360 post on supernumerary teeth, just in case you come across it too!

The General Practitioner's Approach to Cytology

I love cytology. But I'm not a specialist in the area. I always tell my clients that my goal is to acquire a diagnostic sample. A sample that, with the clinical picture, a clinical pathologist can make a diagnosis, or at least a best guess answer to the problem. There are some that are quick and easy, and in fact, I tend not to stain them or send them now because they wash off the slide. These would be lipomas. But some of the suspected lipomas will have something cellular on the slide, and if I can't recognize the cells, it gets sent away. Many folks take a wait and see approach, and some will sample everything. I am somewhere in the middle. A fine needle aspiration (FNA) is a non-invasive way to get a few answers, that does not require any sedation or anesthesia, and well, if it can save a life, it is worth it. I personally use a 25g hypodermic needle, and depending on the feel of the mass, I may redirect the needle 20 times. If the mass is cystic, has a fluid pocket, then I will aspirate with the syringe attached, but otherwise, I don't attach the syringe until the sample is in the needle. I learnt that technique from an intern in my 4th year, as she had an interest in oncology and has since gone on to be an oncologist. But no one really taught me how to collect an FNA sample! I collect enough samples that I have multiple slides per site. I like to stain some in clinic for various reasons including my own curiosity and learning. Some of the pathology labs take photos of the cells and send them back to you, others do not. So I have gotten into a habit now of staining a slide with diff quik and cruising around the slide and taking a few of my own photos through the microscope using my cellphone camera, nothing fancy. This helps me build a library of slide examples. But the pathologist will prefer if you also send unstained slides, as then they can use their own stains to identify cells. So, once I have redirected the needle multiple times and I am ready to put the sample on a slide, I use a 3 cc lure lock syringe, fill it with a couple mls of air, attach the needle, and give the plunger a squeeze to push the contents into the slide. I say lure lock syringe, as I have accidentally used a non-lure lock and fired a needle across the room. Not good! Also note, when you are putting sample into the slide, try to figure out where the frosted side is first, otherwise, it will be confusing for the person staining and interpreting the slide. Just a few little tips as I have made these mistakes myself. After staining, when you are looking at a slide, you want to be able to determine if this is an inflammatory, is it septic, or is it neoplasia. Many times I get hemodilution, a little bit of peripheral blood in the sample, so then you need to decipher if this is peripheral blood contamination in your sample, or is the sample from the mass itself. One of the best resources for cytology is the Clinical Pathology from Cornell. Here's the information on Sample Collection. My least favourite diagnosis is no diagnosis at all. The infamous "inconclusive" result. I hate that! There are some cells that are easily recognizable, and others that are not. Below, you see some cells without nuclei, and occasionally a cell with a nuclei. The cells have distinct borders. Cells that do not have a nuclei are essentially dead cells - flattened, flaky cells that are typical of superficial skin - keratinized epithelial cells. Just a normal finding on skin, in this case we were checking to see if the skin was also infected. These cells below are a little bit more difficult to recognize, likely because of the smear. The nuclei appear to have multiple lobes. These were neutrophils - called suppurative inflammation. But you can also see bacteria if you zoom in. This was an abscess on the back of a dog. Then there are going to be cells that you can't really recognize. So you have to discern, if this from an epithelial, mesenchymal or round cell origin? For description of these, head over the the EClinPath site! The cells on the left are difficult to assess because the cell borders are missing, but the cells on the right are closely adhered, which I put in the category of epithelial. After that, I defer to the clinical pathologist for my answers! This one came back as a perianal adenoma. After you have a diagnosis, in order to help with determining if you need wide margins, its good to have a biopsy. Some of them you can do excisional biopsies on. If it fits in a skin biopsy punch, go for it, it is a very quick procedure. But in the case of the perianal adenoma, it is much larger than the skin biopsy. Some pathologist will prefer a tru-cut biopsy, as you can get a core sample, but similar to doing your fine needle aspirates, you will want to take several samples, otherwise, they may not make the diagnosis. Then you are left cursing, having to call the owner with the "inconclusive" results. Bummer. A few years ago, I did a tru-cut biopsy on a firm mass within a large lipoma that came back as a mast cell tumor, so you really don't know what you're getting into if you don't have a biopsy. While I prefer a biopsy before removing a mass, you do not always get the option. Sometimes you're asked to remove a lump while the pet is anesthetized for another reason, like a dental cleaning. Obviously, be mindful of what you are comfortable with. I have said, this is a great time for a biopsy, while they are sleeping, but you will gain confidence as time goes on. Don't forget that you can always offer owners a referral. If you let the owners have a choice, say hey, this could be really scary, and there is a possibility that I may not remove it all, did you want to see a specialist? Then they understand that there are always limitations to what the naked eye can see. If they don't wish to be referred, likely due to costs, then at least they have been informed. A Lesson Learned Too Late There is one mass in particular that I had wished I had aspirated. Lesson learned too late. I was a new graduate as the second doctor in a two doctor practice. I had a patient come in with a interdigital cyst. Typically these are furunculosis, a reaction of the skin cells to the keratin, I usually explain it to owners like an ingrown hair. It's an inflammatory process, which usually responds to anti-inflammatory medication. This cyst was about the width of my thumb nail. I had my mentor have a look at it, I spoke about doing an FNA on it, and he said it likely wouldn't be useful, and I could poke it, but it was going to bleed everywhere. I spoke to the owner and mentioned this, and we decided to try a topical anti-inflammatory gel. A few weeks later, the dog has come back because the cyst still had not resolved, and now it was bigger. This time we tried an oral anti-inflammatory. A few weeks later, and this cyst still hadn't resolved, but this time it had burst and the owner described it like a piece of pepperoni. Eventually, we took a cell sample, and found out it was a mast cell tumor. The patient required a toe amputation to have this tumor removed. So in hindsight, I wish I had aspirated this cyst sooner! By the time we had removed the toe, it had already spread to the draining lymph nodes, and eventually to the lungs. I tell this story because I want you, the new graduate, to stick to your schooling, aspirate anything you want to aspirate. You never know who you will end up saving.

How can YOU help your veterinarian?

The next time that you hear or see a bad review about a veterinarian, you should share this TED talk with them. “...every perceived failure, every time we have to euthanize a pet because we are unable to help, every time we have a negative client interaction, or if there is a bad review of us online, it slowly chips away at our humanity, and our love for this profession.” This TED talk really resonated with me tonight. I had just been lamenting with one of my veterinary assistants on an angry client. Said angry client left without paying for the consultation fee and told the assistant that we can expect a bad review. I get upset when people focus on the bad reviews online. There are always two sides of a story. What is it that they say, guilty until proven innocent? I have said this in the past, we as veterinarians are our own worst enemy. We feel bad about every mistake we make, regardless of the outcome, and then even when we don’t make any mistakes, and the outcome is poor, we also feel badly. In a previous job, I was being punished for making a mistake, and what I said to my confidants, no matter what punishment they give me, it will be much less than I do to punish myself. The constant self-deprecation that your mind’s voice repeats. Over and over. If only I had done this... I should have paid more attention to this... I was in a rush, so I made a mistake... If I had more staff, I wouldn’t have made these mistakes... Your mind’s voice doesn’t stop when you lay your head on your pillow at night. Yes, many professions have a lot of pressure on them, and a lot on their plate. No one is trapped between compassion and money as much as veterinarians are. Why? Because if we really loved animals, we would do it for free. Guess what? My time is my most valuable resource, and I give a LOT of time to my clients, that I am not compensated financially for. A lot of the time it is because of our own guilt, that we cannot sleep if we do not get to the tasks we need to do. A lot of the time we are under appreciated. So, I plead to you to grow your own compassion. Stop the cyber bashing of veterinarians. Stop your angry rants. And if you see a bad review, stand behind the fact that this is not the full story. Have compassion. Be human.

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