The year of the veterinarian: a call to celebrate, and to collaborate

Dear reader,

This year has been declared to be the “Year of the Veterinarian”, in recognition and celebration of 250 years of veterinary education and the profession (Comité-Vet2011 2008–2011). Progress in veterinary science has paralleled that in human medical science, and appears to have increased logarithmically since the early days of servicing Napoleon's cavalry. Our understanding of companion animal diseases that are counterparts to diseases in humans has benefited from human medical literature, and human medical science has benefited from spontaneous disease models in animals.

Yet there are some exceptions to this scientific symbiosis. For instance, the long-held assumption that infection with the Feline Immuodeficiency Virus would lead to an immunodeficiency state that was synonomous with HIV-AIDS has not served our understanding of the disease in cats. That is despite the value that FIV research has brought to the understanding of human retroviral infections (Elder et al. 2010). Similarly, the assumption that the immunopathogenesis of lymphoplasmacytic enteritis is the same as Crohn's disease or ulcerative colitis has not been supported by recent studies (Cerquetella et al. 2010).

In comparison with human medicine, veterinary medicine is often limited by smaller case numbers, fewer researchers, limited research funding, and the fact that the profession is distributed over numerous small practices, rather than being condensed into large hospitals. Thus progress in veterinary science is best served through collaborative, often international efforts to focus research efforts and funding, and through pooling of resources, experience, and expertise.

In 1998, at the 8th Annual Congress of the European Society of Veterinary Internal Medicine in Vienna, Austria, a group of interested internists and researchers established the International Renal Interest Society (IRIS), which has been a lightning rod for international opinion and research efforts since. As a result of validation of the IRIS staging, there is now an international standardisation that has greatly improved prognostication (Boyd et al. 2008). Similar initiatives have emerged in attempts to standardise diagnosis (WSAVA International Gastrointestinal Standardization Group), to improve patient assessment (WSAVA Nutritional Assessment Guidelines Task Force), and encourage consensus in controversial areas (ACVM cencensus statements) (Freeman et al. 2011; Lees et al. 2005; Washabau et al. 2010).

At the AVMA annual conference in 1963, Lewis et al. presented a case series of 19 dogs with a combination of immune-mediated haemolytic anaemia and thrombocytopaenia (Lewis et al. 1963). Of those 19 dogs, the author later reported that only 8 survived for a prolonged time. Idiopathic immune-mediated haemolytic anaemia (IMHA) is much less common in humans than it is in dogs, and veterinarians do not have a large body of evidence of treatment efficacy in humans to refer to. However, although a high mortality might not be surprising in 1963, it is still concerning that the mortality in cases seen at large referral institutions remains high.

As with any idiopathic disease, the diagnosis can only be made in animals that present with the appropriate clinical signs, and following an exhaustive search for concurrent disease that might explain those signs. It is likely that prior to the discovery of Tritrichomonas foetus as a cause of chronic lymphocytic colitis in cats, pedigree cats in many countries were diagnosed with “idiopathic inflammatory bowel disease” (Yaeger and Gookin 2005). Similarly, granulomatous colitis in boxers had a poor prognosis until the association with intramucosal colonization by E. coli was reported (Simpson et al. 2006). So it may be that cases of IMHA currently diagnosed as idiopathic will, in time, come to be classified as secondary to an as yet unknown cause, whether that be a simple infectious cause, or a complex interaction between a genetic susceptibility and environmental risk factors.

Certainly there is considerable variation in the presenting history, severity, speed of progression, response to therapy, motbidity and mortality in canine IMHA (Holahan et al. 2010). In the vast majority of cases, the clinician is ignorant of the precise immunopathogenesis in that particular case, and routine diagnostic testing does not discriminate between immunoglobulin isotypes, the antigens involved, or the most important site or primary mechanism of erythrocyte destruction. Neither is the clinician capable of predicting the development of important co-morbidities such as thromboembolic disease or coagulopathies at the time of presentation.

In this edition, we publish a condensate of the literature on the clinical and clinicopathological features of canine IMHA, including a review of the risk factors for mortality (Piek 2011). The author emphasises that the prognosis of canine IMHA is poor, and may not have changed much in the last 40 years, despite the availability of immunosuppressive drugs that are more potent or more targeted than corticosteroids. Different conclusions could be reached from this sobering realisation. Once could conclude that canine IMHA is, simply, a “bad disease”, and that attempts to significantly alter the prognosis may be unwise, until radically different methods of immunosuppression are available. Alternatively, one could conclude that the increased use of unproven therapies should be encouraged, simply because they are new, and that there are no better alternatives. Refreshingly however, the author reaches a different, and more positive conclusion, namely that there should be a coordinated, international effort to standardise the clinical and clinicopathological definitions, and to develop a scoring system by which multi-institutional collaborative investigations can better evaluate novel therapies.

In a year when we should celebrate the progress that has occurred in veterinary medicine, it is prudent that we recognise the global nature of our profession, and temper our celebrations with a recognition of the progress that is still, sorely needed.