Guest Author

Expectations vs. Intentions

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In our previous blog (which you can find here), we introduced the concept that acceptance is the first step to making positive change. This can apply to many aspects of life and to many situations. In the words of Eckhart Tolle, author of The Power of Now, ‘whatever we accept, we go beyond’.

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‘Going beyond’ introduces another important issue. One that is strongly associated with subjective wellbeing. Expectations.

Mo Gawdat discusses this topic at length in his book Solve for Happy, which he wrote based largely on his own experiences and how he found happiness again following the tragic loss of his son. He refers to a simple equation which he and his son devised.

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But how can we have goals, desires, dreams and ambitions without creating unhelpful expectations?

If we draw on some of the concepts from our previous blogs, hopefully we are able to take time to pause and observe how we are feeling, following which we can consciously acknowledge these feelings and choose an inner dialogue which allows us to give ourselves permission to accept things as they are, whatever that might be.

But what if we have noticed, acknowledged and accepted that we are feeling frustrated with ourselves because it’s 4pm and this is the third time this week that we realise that we have not eaten or drunk anything since breakfast. What next?

One option might be to set a rigorous routine and create a strict process of reminders and alarms that make sure we don’t do this again. And have a strict word with ourselves. An internal chat that is peppered with phrases such as ‘I should not have let that happen’ and ‘I must/will do it differently’. But the problem with words such as ‘should’ and ‘shouldn’t’ is that they infer a harsh judgement upon ourselves. Equally words such as ‘must’ and ‘will’ are demanding a certain behaviour.

Together these dialogues can create expectations, which may lead to a change in behaviour. But we also know that human behaviour is often not this easy or predictable, especially when it comes to changing habits.

And so, as demonstrated in Mo Gawdat’s equation, if we fail to meet our expectations, it can have negative impacts on our wellbeing.

So, what’s the alternative? Does this mean we should no longer have aims, set goals or be ambitious? Not at all! However once again it all comes back to how we frame it in our minds and the mindset we bring to the process.

Mindfulness is a great example of how carefully considered words and phrases can make a huge difference to how the brain engages with any particular activity. Phrases that feature commonly within mindfulness training are ‘we invite you to…’ or ‘build an intention to…’ Using these much kinder phrases with ourselves can have a big impact and may help us approach our actions and self-thoughts with self-compassion, above all else.

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So, let’s use the example we discussed previously. Having noticed, acknowledged and accepted our frustration at not looking after our physiological needs as well as we would have liked, it’s absolutely fine to come up with practical ideas to improve the situation (we are great fans of Shawn Achor and he has some great ideas on changing habits). However, the words we choose to approach these solutions can have profound effects on how we subsequently feel about ourselves. Approaching this example with the phrase ‘it is my intention to follow this plan as best I can most days’ will not only help us to be kinder to ourselves if it doesn’t go exactly to plan, but will also make us more likely to stick to the plan in the first place.

About VetLed

VetLed was founded to provide support to veterinary professionals who are faced with significant challenges every day. The VetLed team believe that creating a compassionate and professional workplace culture that puts people wellbeing and patient safety at the core of everything we do, will in turn, improve animal and people welfare. The VetLed performance approach supports veterinary professionals to maximise their own wellbeing and to fully utilise their skills to deliver optimal patient care. You can contact VetLed by emailing info@vetled.co.uk

Hypoadrenocorticism Refresher

By Lisa Murphy DACVECC

Primary hypoadrenocorticism (HA) is an uncommon disease in dogs and rare in cats.

Adrenal gland physiology

First, we’ll go over some basic adrenal gland physiology.

The adrenal cortex is primarily responsible for secreting several important hormones including cortisol and aldosterone. Cortisol has several functions including carbohydrate, lipid and protein metabolism, immune system modulation and proper catecholamine function. The amount of cortisol being released is determined by a negative feedback system:

  • The hypothalamus produces corticotropin releasing hormone (CRH) which stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH).

  • ACTH stimulates the zona fasiculata and reticularis of the adrenal cortex to produce and release cortisol.

  • Increased serum cortisol inhibits the release of CRH and ACTH.

Aldosterone is also released from the cortex; however its release is stimulated by hypovolaemia which is recognised by the kidney. In times of hypovolaemia.

  • Angiotensin II is released via a hormonal cascade and stimulates the zona glomerulosa to release aldosterone.

  • Aldosterone stimulates cells in the renal collecting duct to resorb sodium (leading to secondary water retention and restoration of the effective circulating volume) and excrete potassium.

Causes of HA

Primary HA is caused by adrenal gland dysfunction. Although much more rare, secondary HA can also occur; this is caused by hypothalamic or pituitary dysfunction. Most cases of primary HA involve concurrent cortisol and aldosterone deficiency although atypical HA can also occur where only cortisol is deficient.

The typical signalment for HA is young-to-middle aged dogs with females more likely to be affected. Average age of onset is 4 years old.

The most commonly affected breeds include Portuguese water dogs, Great Danes, Westies, Standard Poodle, Wheaton Terrier and Rottweilers.

In cats there is no known sex or breed predisposition.

The exact cause of primary HA is unknown but is believed to be immune-mediated destruction of the adrenal cortex. Less common causes of primary HA include trauma, infiltrative disease or iatrogenic destruction due to mitotane or trilostane therapy for hyperadrenocorticism. In one study evaluating 156 dogs on chronic trilostane treatment for hyperadrenocorticism, the relative risk of developing HA was 15% at 2 years and 26% by 4 years.

Clinical presentation

The clinical presentation of typical HA can be vague and non-specific. We will focus on the emergent Addisonian crisis:

Common clinical signs of a crisis include lethargy or collapse, hypothermia, hypovolaemic shock and bradycardia. Much of these signs occur secondary to the electrolyte changes induced by this disease (mainly hyperkalaemia and hyponatraemia).

On blood work, common findings include hyponatraemia, hyperkalaemia, azotaemia with a concurrent inappropriately low urine specific gravity (typically < 1.030) and possible lack of a stress leucogram.

Most of these patients (> 90% in some studies) will also have a low sodium/potassium ratio, typically less than 28. Other differentials of this include any disease which leads to severe dehydration including renal failure, severe gastrointestinal disease, and body cavity effusions among others.

Other less common blood work findings include hypoglycaemia and hypercalcaemia. Cortisol promotes gluconeogenesis and glucogenolysis and calciuresis leading to these respective electrolyte derangements.

In cases of severe hyperkalaemia, patients can experience significant bradycardia and/or dysrhythmias. Common ECG changes noted include:

  • Bradycardia

  • Diminished/absent P waves

  • Tented T waves

  • Wide/bizarre QRS complexes

  • Ventricular tachycardia/fibrillation

Diagnosis

There are several ways to evaluate if a dog may have HA:

1. A screening test evaluating the resting cortisol can be performed initially with values less than 1 mcg/dl having excellent sensitivity (100%) and good specificity (98%) for HA in dogs.

Values < 2 mcg/dl were also 100% sensitive but only 78% specific for HA.

Dogs with values > 2 mcg/dl are very unlikely to have HA

2. A confirmatory ACTH stimulation test should be performed in all cases of suspected HA. This test is considered the gold standard.

The drug used in this test (cortisyn) is very expensive and recent studies have shown that the low dose ACTH (5 mcg/kg) stimulation test is as effective as the standard dose (using a 250 mcg vial in a dog or 125 mcg vial in a cat).

3. In cases where primary vs. secondary HA needs to be differentiated or to diagnose atypical HA, endogenous ACTH levels can be measured.

Animals with atypical HA (cortisol deficiency without concurrent aldosterone deficiency), should have normal electrolyte values and an elevated endogenous ACTH level.

4. Evaluation of a dog’s cortisol/ACTH ratio: in one study, all dogs with HA had ratios < 0.17 vs. healthy dogs who had values > 0.79 (reference range 1-1.26).

5. Urine sodium levels: in a recent study dogs with HA had significantly higher urine sodium levels when compared to dogs with non-adrenal illness

While there are several tests that may increase suspicion for HA, the ACTH stimulation is the gold standard confirmatory test.

It is important to note that most exogenous glucocorticoids can interfere with adrenal function tests; therefore tests should be delayed if the patient has recently received steroids. Of all types of glucocorticoids dexamethasone has the least effect on testing. In a true Addisonian crisis, fluid resuscitation is the most important first step so delaying steroid administration until after the ACTH stimulation test likely does not have a significant impact on survival.

Treatment

Volume resuscitation:

Intravenous fluids are the mainstay of therapy in a crisis. Despite their potassium content, a balanced electrolyte solution is recommended over 0.9% sodium chloride solution. This is because the latter could increase the patient’s blood sodium levels too quickly which can cause neurological complications. Once the effective circulating volume is restored, kidney function and GFR will increase leading to kaliuresis; this negates the risk of using fluids with low potassium levels in a hyperkalaemic patient.

Hyperkalaemia:

Patients who have life-threatening hyperkalaemia require rapid intervention.

In animals that are experiencing significant cardiotoxic effects, calcium gluconate can be administered. This will not lower potassium levels and its cardioprotectant effects last approximately 15-20 minutes so more definitive treatments need to be instituted following calcium administration.

Treatments to lower plasma potassium levels include fluid resuscitation as well as administration of substances which shift potassium from the extracellular compartment into the intracellular compartment:

  • The most commonly used is 50% glucose solution and regular (neutral, soluble) insulin (0.1 u/kg with concurrent glucose supplementation to avoid hypoglycaemia)

  • Sodium bicarbonate is used less commonly as this drug carries significant risks due to several possible side effects and should only be considered a last resort.

Following adrenal function testing, patients with typical HA can be started on mineralocorticoid and glucocorticoid supplementation:

  • Mineralocorticoids can be given daily in tablet form or as an injection given approximately every 25-30 days.

  • Glucocorticoids are typically administered intravenously to begin with and then per os. They are usually weaned off over time.

  • The timeline for clinical recovery is different for every patient although it can be anywhere from hours following supplementation to 3-5 days.

  • Animals with atypical HA (singular glucocorticoid deficiency) only require glucocorticoid supplementation.

  • Cats typically take longer to respond than dogs.

The prognosis for this disease is quite good, especially in those who survive the initial crisis. However they do require lifelong monitoring and treatment. This is typically long-term mineralocorticoid administration with intermittent glucocorticoid administration at times of physiological stress or illness.

Pause, notice...and accept

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In our previous blogs we have discussed how wellbeing can be seen as a foundation on which we can build; a strong basis to help us to move towards fulfilment and achievement. 

By prioritising our physical and emotional wellbeing, as well as our happiness, we establish a springboard from which we can learn to thrive and succeed. As the first stage in this process, we have previously discussed the importance of ‘being’ and how we can overcome our ‘automatic pilot’ by simply pausing and consciously observing how we feel. This allows us to notice and acknowledge our physical and mental state in any given moment. 

Acknowledgement alone can be a great tool and can have an immediate effect on how we feel. But more significantly, it is an essential first step towards acceptance.

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Acceptance may be something that we try to avoid. Because sometimes, to accept can feel as though we have somehow given up and any hope of change has ceased to exist. But the reality is quite the opposite. Acceptance is actually the precursor for change and helps to reduce anxiety and improve self-esteem by appreciating ‘what is’ without judgement, especially of ourselves.  

Acceptance in this way can apply to many moments within our lives – both the big and the small. Seemingly small day-to-day issues such as irritation towards another road user as you navigate your journey to work or frustration as a result of running late might seem like just ‘one of those things’. You may not give it another thought.  But what could the alternative look like? Noticing, acknowledging and accepting feelings such as these is an opportunity to better understand our reaction in these moments. This helps to prevent any resulting feelings from negatively impacting our health and wellbeing. 

Acceptance can also apply to bigger issues that might be affecting us. For example, if we believe that we haven’t been looking after our body (we haven’t been paying attention to our diet, not exercising, relying on alcohol or substances for example), we may find ourselves either holding onto the judgemental feelings we have about ourselves, or repressing them altogether. However, by consciously acknowledging the issue, addressing it with kindness and allowing ourselves to accept the situation, we are far better placed to move forwards.

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And so, the big question is how do we help ourselves to be more accepting? Would it seem too simple if we said you begin by simply giving yourself permission? Whilst this might sound obvious, how often do we really take a moment to notice how we are feeling and (either silently or aloud) acknowledge that feeling along with a confirmation that it’s OK to feel that way. This conscious process is the starting point. It is fundamental to helping us to be OK in the present moment. 

And there are additional techniques which can further complement the practice. Emotional Freedom Technique (see here for more information), mindfulness training and guided meditation are good examples of other ways which can provide a basis for non-striving, non-judging acceptance. For further information on any of these and for further advise, please contact any of the VetLed team using the details below.

The great news is that improving your ability to notice, acknowledge and accept can better your sense of peace and wellbeing. The even better news is that it doesn’t end there. With acceptance comes a clarity and sense of freedom from which we can form an intention and a motivation to make change. This might mean, for example, that we become better able to accept former lifestyle habits and can now more objectively understand what we can change that might improve our health, without the burden of judgement or regret. An acceptance for ‘what is’ allows you to approach the next steps with kindness, curiosity and optimism. 

And anything done with kindness, curiosity and optimism is always good medicine for the mind, body and soul. 

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About VetLed

VetLed was founded to provide support to veterinary professionals who are faced with significant challenges every day. The VetLed team believe that creating a compassionate and professional workplace culture that puts people wellbeing and patient safety at the core of everything we do, will in turn, improve animal and people welfare. The VetLed performance approach supports veterinary professionals to maximise their own wellbeing and to fully utilise their skills to deliver optimal patient care. You can contact VetLed by emailing info@vetled.co.uk