Transcript
Gianluca Bini: All right, so tonight we have our guest, Dr. Alvarez. She is a diplomate in sports medicine and rehabilitation. She's also certified in veterinary acupuncture, and she currently works at the Schwarzman Animal Medical Center in New York. Thank you so much for being here with us tonight. I think we have a few questions for you and you feel free to ask us any anesthesia related questions or guess, you know, analgesia as well.
Ryan Bailey: Oh
Gianluca Bini: Everybody forgets that we are like anesthesia and analgesia, but like, you know, people forget about that.
Leilani Alvarez: Yeah.
Ryan Bailey: yeah, for sure.
Leilani Alvarez: That's good. don't know. I could ask you questions. I like it.
Gianluca Bini: Oh, you can, yeah, this is free for all.
Gianluca Bini: So I have a first question for you. You know, a lot of what you guys do is, I think you guys do an amazing job with like, you know, the whole day rehab with, you know, for our small animal patients. I think it's kind of rare to have somebody that does, you know, do you have more people that do like small animal or large animal and do your college?
Gianluca Bini: Is it like,
Gianluca Bini: Yeah.
Leilani Alvarez: Well, it's one college, but it's similar to the ACVS that has large animal and small animal. We have canine and equine. And I will say that I definitely treat cats and other small species, but the college is specific for canine and the same for the equine.
Leilani Alvarez: I think a lot of my equine colleagues will treat you know, livestock and other large animals, but it's only equine. So unlike the surgery college, we don't treat all the small species and all the large species.
Leilani Alvarez: It's focused on canine and equine. And the reason for that is the college first formed to help performance athletes. And because, you know, cows and sheep are not athletes and because cats are not athletes, then that's why specific canine and equine.
Gianluca Bini: Okay, that's really cool. always feel like a lot of people that are not in good veterinary medicine, they don't even know that there is such specialization, right? And we have a few listeners that actually I think they're not into the VATMAT space at all.
Ryan Bailey: Yeah.
Leilani Alvarez: Yeah, and we could talk about that because it's a question that I get is like, so what, like what athletes are you treating like they don't realize that dogs are athletes and, and, you know, interestingly, when the college, the college was provisionally approved by the AVMA in 2012.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah.
Leilani Alvarez: And then we received the final approval in 2018. So the college has been approved accreditation from the aviomason to 2018. It's the newest specialty in veterinary medicine.
Leilani Alvarez: And yeah, so it's definitely emerging area of specialty. And I think a lot of veterinarians don't know what we do, and so certainly the public doesn't know what we do, especially because there are a lot of certification programs.
Leilani Alvarez: You mentioned that I'm certified in acupuncture. I see them as continuing education programs where you gain advanced training and something specific, but there's no requirement for that certification for ongoing training.
Leilani Alvarez: So I got certified in acupuncture, I think it was 2006 or 2007. And I don't need to do anything to still put the CVA after my name, which is different, of course, as you know, being board certified anesthesiologist than any other board specialty, you're required to complete training, whether that's giving lectures, publishing,
Gianluca Bini: That's it.
Leilani Alvarez: educational thing, we're actually sitting for the boards again in order to maintain your diplomat status. There are certifications in rehabilitation, which I think is confusing for the public and veterinarians because people will say that they're certified in canine rehabilitation, which I have that certification. I had that before the board specialty was available, but I don't even use those letters anymore because of course my board specialty is really, I think what what allows me to a specialist and of course do a lot to keep up that level of specialty.
Gianluca Bini: Amen. Amen.
Leilani Alvarez: Uh, the certification is fantastic. And there, I think there's a really great rehabilitation therapist who've completed that advanced training, but of course it's nothing in comparison to a three-year residency sitting for a board examination.
Leilani Alvarez: And to answer your listeners' questions about, you know, what athletes do I treat? You know, I liken it to maybe you, Gianluca, maybe, you know, you're not an athlete, but you could still injure your ACL and you will see a sports medicine specialist.
Gianluca Bini: Yeah, that's true.
Leilani Alvarez: So you don't have to be an athlete to see a sports medicine specialist. We specialize in the treatment of soft tissue injuries and for the most part pursue non-invasive therapies.
Leilani Alvarez: Of course, we work closely with surgeons. So if that musculoskeletal injury is such that it's not amenable to rehabilitation or we tried rehabilitation, we're not getting the results we want, we would of course send them to surgery.
Leilani Alvarez: But usually the first step is we do strengthening, a lot of pain management. You know, we can talk about that. I know that's your specialty.
Ryan Bailey: Thank you.
Leilani Alvarez: We do, we were just saying this, that anesthesia, everybody thinks of the anesthesiologist.
Gianluca Bini: Yeah.
Leilani Alvarez: You're in the operating room and you're giving a lot of advice how to manage the anesthesia. There's a pain aspect to that as well. We have anesthesiologist AMC and they manage acute pain in the OR and postoperative pain.
Leilani Alvarez: I don't hardly ever get that. I do chronic pain management, outpatient care, oral analgesics.
Gianluca Bini: Yeah. No, that's all really... I think it's really cool. And, you know, it's one of those things that, you know, again, you know, the public definitely is totally oblivious to, right? They don't know this. And we, you know, we get asked a lot of, like, sometimes we do get asked those chronic pain questions. And, you know, we definitely focus way more on the acute pain side, right? Like even the residency.
Gianluca Bini: Now we do have... think a fellowship in pain management or something like that that was recently established, but it's not something that a lot of people are into.
Leilani Alvarez: Oh, that's cool.
Ryan Bailey: Yeah. exactly.
Gianluca Bini: Most of us are more hired for peer-reparative management.
Leilani Alvarez: Yeah, injectable drugs.
Gianluca Bini: Yes.
Leilani Alvarez: Yeah. Yeah.
Gianluca Bini: Yeah.
Leilani Alvarez: Yeah. That's, I, I get afraid with the injectables.
Gianluca Bini: Yeah.
Leilani Alvarez: I'm all about oral drugs. So, you know, those would be my questions for you is like, what, you know, what do I do? And see a lot of senior dogs that we do procedures on.
Leilani Alvarez: So we, but besides the rehabilitation aspect of it, we will, we will do some minor interventions like joint injections. For example, do tendon injections as well, and we'll need to sedate patients and,
Leilani Alvarez: So at some point, maybe I can pick your brain about your favorite safe ways of sedating a patient.
Ryan Bailey: Ha, ha, ha, ha.
Gianluca Bini: For sure. sure. So, you know, think when we go into the chronic pain, you know, because this is where we overlap a little bit, right? When we go into the chronic pain kind of things, I think there is a lot of new options that came into the market recently, right? Or at least in the last couple of years.
Gianluca Bini: You know, Do you, some people do this kind of like subcutaneous ketamine injection, right? Like every two weeks, every three weeks. Is that something that you guys do? What kind of results have you, and if you do, what kind of results have you been having with that?
Leilani Alvarez: Yeah, I love the pubic. I mean, so I do injectables.
Gianluca Bini: See?
Leilani Alvarez: I use it. I should preface by saying that it's not the first thing I reach for for a chronic bane. These would definitely be refractory cases. These are cases where we're worried about central sensitization and there's difficulty in managing the pet on the oral analgesics.
Leilani Alvarez: I love ketamine as a drug. I think it's quite safe. It's been around for such a long time. And I love the resurgence that we've seen And ketamine as a drug, in particular, the studies on the human side for managing refractory depression.
Leilani Alvarez: And, you know, it really, I think, has uses far beyond the perioperative thing that we before. And maybe the other thing was recreational, right?
Leilani Alvarez: That's the other thing I get clients are like, oh, you mean that ketamine?
Ryan Bailey: Yes.
Leilani Alvarez: from the 70s. But so I, yes, we've used sub-Q ketamine. I prefer to admit the patient for CRI of ketamine. I think that is important to have the best utility of then the less frequent injection.
Leilani Alvarez: Not always, sometimes patients are too anxious or for rare diseases, we can't do that CRI, which we'll just do for six, eight hours. It doesn't even have to be a full 24 hours.
Leilani Alvarez: And then I typically do twice weekly injections to begin and see they're responding to that and tape off to effect. Most of them they're getting about, I would say once weekly for a month. The goal is not that they stay on these sub-Q ketamine forever. It's more to control that refractory pain state that it's more manageable. So it's really, I think, to get them into a place where we can do maintenance more easily because I think it, it, it, it acts more quickly than, than some of our oral medications.
Leilani Alvarez: But yeah, especially for sensual sensitive eyes patient, we, we love subcademy.
Gianluca Bini: That's really cool. I think so. you know, looking online, you know, when people ask on forums or, you know, there is anesthesia Facebook groups and whatnot. I think a lot of people don't do, like they just do every two weeks, you know, without, you know, the protocol you described, quote unquote, sort of like looked something like you do a loading,
Gianluca Bini: dose quote unquote right of ketamine and then you just taper them off slowly and actually it's you know more don't want to say it's more aggressive but like it's you know there is a higher you know how we're frequency even you're right the beginning rather than know somebody that do you know
Leilani Alvarez: Yeah.
Ryan Bailey: Yeah.
Leilani Alvarez: Yeah.
Leilani Alvarez: Correct.
Leilani Alvarez: Yeah.
Gianluca Bini: So I think that the average practitioner or the average clinic out there, it's doing this extremely spaced out, very low dose,
Leilani Alvarez: Thank you.
Ryan Bailey: Yeah. Right.
Leilani Alvarez: don't know. I'd want to see a study to show that they have the same mechanism of action, but they're different drugs. So I don't know that... when you start to D if you then give subcute injection of, I mean, that somehow the amyntidine.
Leilani Alvarez: Yeah.
Ryan Bailey: I've been asked that exact same question and I've given the exact same answer. Like, why would you do that? I mean, guess, but they're different drugs.
Leilani Alvarez: Yeah. Like.
Ryan Bailey: One's an antiviral that also has an NDA and one is like, I'm like, I mean, it's probably not going to harm the patient, but like, I don't think it's going to work the way, like I did it.
Leilani Alvarez: Yeah.
Leilani Alvarez: Yeah, I think people think like, same target, like then, but I don't think they're the same.
Ryan Bailey: Yeah. Yep. Yeah. Yeah.
Leilani Alvarez: Well, we know they're not the same drug. So yeah, I use it, as I said, I think that's for the more severe refractory pain, you really need to interject in a big way.
Leilani Alvarez: You get the pain under control and then you can rely on your orals, which oftentimes does involve amantadine.
Gianluca Bini: Yeah. Yeah.
Leilani Alvarez: So amantadine is a drug for central sensitization. And it does take a bit of time to kick in, but I'm not using them interchangeably. It's that you need both actually.
Leilani Alvarez: And the amandadine would be more maintenance, whereas the injectable ketamine would be more for that intervention that needs to be a little bit more aggressive.
Gianluca Bini: I like your protocol and how you like I think it makes way more sense.
Leilani Alvarez: Well, thank you. I'm glad you approve. That means a lot coming from two anesthesiologists.
Leilani Alvarez: Yeah. Yeah.
Gianluca Bini: But yeah, and it's sad that there is no study on this, right? Like I wish there was some more literature out there, but, you know, it's,
Gianluca Bini: Everything that's pain-related in that med, it's really hard to study, right? Our patients don't speak. They can't really tell us how they feel. We have, unfortunately, a huge problem with that. Do you...
Gianluca Bini: Do you feel like one course is enough for these patients or do you think they, know, do you repeat the same protocol multiple times during the year? you, how do you do that?
Leilani Alvarez: Yeah, that's good question.
Ryan Bailey: Thank you.
Leilani Alvarez: I'm not doing it that often. would say majority of patients I've done it and we just did it the one time because these are usually new patients who we've been treating, say, for a month.
Leilani Alvarez: And then we do a recheck and they're still... I usually see the CVP, the K-MRI-FAM inventory. We do it with every initial consultation and we use that as a guidance of how effective our therapies are for pain intervention. And if we're not...
Leilani Alvarez: meeting our goals to reduce that pain severity score, the pain interference score, then that's usually well, was like, okay, well, I think we need to step it up. Let's do something else. I guess I did have one patient and it had a contracture.
Leilani Alvarez: And so ideally what we want to do is have that intervention that's more aggressive. And then you go to an oral maintenance that will manage that pain long-term.
Leilani Alvarez: But there are patients that have repeated inflicting pain, you may need to repeat the course. I would say that's a minority. If I think about, let's say an advanced OA case, they shouldn't need more than one intervention.
Leilani Alvarez: I think if you're doing a good job of your chronic pain management. So I would say it really depends on the individual. And the only cases where we would repeat a course of injectable ketamine is if there's continuing source of pain that we can't manage, which I would say is pretty
Gianluca Bini: That's cool. Do you do like And this came up because I was chatting with somebody else that does sports medicine. Do you ever do like steroids, lumbosacral injections, stuff like that?
Leilani Alvarez: Yeah, we were just, we had a patient today that has lumbar sacral disease and has had chronic IVDD.
Ryan Bailey: Thank you.
Leilani Alvarez: And it's an older patient. And so this came up about sedation and how do we do that safely in a 14-year-old dog who is already ataxic. But yes, we've actually had great success with epidurals.
Leilani Alvarez: We typically do, we combine usually a an opioid steroid and a local anesthetic and it can be it could be like game changer for some of these dogs i mean they just go from they can't they can't get up on anything owners complain like they can't get up on the bed anymore they can't get into the car and the epidural and the next day they're you know they're just like brand new uh you can get
Ryan Bailey: Thank
Leilani Alvarez: really lovely efficacy. And I find it's a very straightforward procedure. It really doesn't take long at all. Very well tolerated. Again, it's not the first thing that I reach for. These are, again, cases where, okay, we did, for those for the LS cases, I really like a combination of acupuncture. I love shockwave therapy. That's given us really nice results together with strengthening.
Leilani Alvarez: And if that combination would, what most of my patients will respond to, if I'm not getting the efficacy that we expect, then I do offer epidural. That would be the next phase.
Gianluca Bini: That's cool. So actually the conversation I was having was about lumbar sacral injections, but they were asking about the specific needle, right?
Gianluca Bini: So like some, and don't know if, you know, they're aware of this or not, but there is several different like epidural needles or spinal needles, right?
Ryan Bailey: Mm-hmm.
Gianluca Bini: And so somebody, they were asking about like the different like epidural needles and, you know, I think, what kind of needle do you use?
Gianluca Bini: Do you use a normal spinal needle or?
Leilani Alvarez: I typically do, but it's interesting. The last one we had, the anesthesiologist was like, there's this other kind of needle and you don't do the hanging drop because we usually do the hanging drop technique, but they had another one that I don't even remember, but it was, it was a different kind of needle and it's not a hanging drop.
Leilani Alvarez: She liked it better, but that's, I, you know, I'm a little traditional, you know, I'm just the standard epidural needle.
Gianluca Bini: Okay.
Leilani Alvarez: Yeah.
Gianluca Bini: So what do you use for your epidurals, Ryan? Do you use a spinal or a two-way needle? Okay.
Ryan Bailey: I actually converted to nerve simulator.
Leilani Alvarez: Yeah, that's what you use, the nerve stimulator.
Ryan Bailey: Yeah, because it just with where I was practicing, it just gave everyone in the room the ability to kind of witness success or failure.
Leilani Alvarez: Yeah.
Ryan Bailey: And like there's reasons the hanging drop doesn't work. Like if you go through your needle track too many times, you can get like a false positive and then...
Leilani Alvarez: You don't get the negative pressure. Yeah.
Ryan Bailey: it becomes like, there can just sometimes be,
Ryan Bailey: like to not put it bluntly, like ego that gets in the way and then people say, oh, I'm in, I'm in, I'm in. It's like, yeah, they're paying $300 for this and we're relying on this to be the like main analgesic and I'm not gonna like, I don't want to, like I want people to learn and I want them to grow and gain confidence, but I also want the patient to receive what,
Leilani Alvarez: I do know.
Ryan Bailey: they're supposed to receive. So I switched to the nerve simulator and never looked back. And there are a couple issues. A, you don't get the hanging drop. So if that is a skill you learn, it probably does get rusty. And then if you ever place an epidural catheter, you definitely cannot place it through the nerve simulator needle. So then you're trying with a 2E, which is a little bit different. Yeah, that's like the big disadvantage to that.
Ryan Bailey: But for like, I've placed one epidural catheter in my lifetime, and I suspect that's probably going to stay pretty low, you know, no matter what I end up doing in my life.
Gianluca Bini: Yeah.
Ryan Bailey: So yeah, they're just not even that common.
Gianluca Bini: Yeah, definitely you're not placing one with us.
Ryan Bailey: And I don't know about AMC, but like in the places I've practiced, they're one a year, maybe like in clinical practice, like
Leilani Alvarez: No, we don't do catheters, no.
Ryan Bailey: Yeah. So.
Gianluca Bini: Yeah, they're kind of rare. Yeah, I'm more used to that tool.
Leilani Alvarez: The only time I would think is there was a spinal tumor where you have ongoing pain where you would want to have access.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah, maybe, yeah.
Ryan Bailey: In humans, it's like the way to, it's like so many of them are done epidurally, like, or like catheterized. Like that's the way they do a lot of epidurals nowadays.
Ryan Bailey: Like they don't, they, it's single shots are rarer for them than the catheter placement.
Leilani Alvarez: Oh, interesting. Okay.
Ryan Bailey: Yeah, it's a weird world.
Leilani Alvarez: Yeah.
Gianluca Bini: Yeah. Yeah.
Leilani Alvarez: Yeah.
Gianluca Bini: Even when you're, you know, impregnating women, that's, that's, they're all categorized, you know, so that they continuous, they give a continuous infusion through the.
Ryan Bailey: Yep. Yep.
Leilani Alvarez: Yes.
Leilani Alvarez: You know what?
Gianluca Bini: Yeah.
Leilani Alvarez: Now I'm like, mean, my youngest child is 13 years old. So I was 13 years ago. But no, that's right. I remember that they would like continue to give you as needed.
Leilani Alvarez: yeah, yeah.
Gianluca Bini: Yeah. Yeah. And so for those, you need to use a two needle. I usually use a two way just because I learned that way. And I'm like, You know, has a curved tip, which, you know, it gives you a little bit better feeling of, yep, just put it in like this.
Ryan Bailey: You gotta hold it.
Gianluca Bini: It's just pretty cool. But, yeah, I mean, it's interesting. Some people use ultrasound nowadays, but I, you know, don't
Ryan Bailey: Yep.
Ryan Bailey: For like the Frenchies maybe, like the patients have really abnormal spines, I think that does have its place just to help you locate, you know?
Leilani Alvarez: Yeah, if you have like a bridging spondylosis or something, yeah.
Ryan Bailey: Yeah.
Leilani Alvarez: Mm-hmm.
Gianluca Bini: Yeah, those patients probably then it makes more sense.
Leilani Alvarez: Yeah.
Gianluca Bini: But sometimes it's cumbersome, right?
Leilani Alvarez: Mm-hmm.
Gianluca Bini: Like, you know, having the... Yeah. Okay, that's...
Leilani Alvarez: I also think that veterinarians are not as good about sterility. And when there's an ultrasound probe there, I just think it dirties access. So, yeah.
Gianluca Bini: Yeah, yeah.
Ryan Bailey: And no matter when I went, the whole place was slammed. The human rehab centers were slammed. And you had who's just
Leilani Alvarez: Yeah.
Leilani Alvarez: Yeah.
Ryan Bailey: He randomly, he showed up and was like, why are you here? And he was like, oh, he tore his Achilles and had surgery.
Leilani Alvarez: Surgery.
Leilani Alvarez: Yeah.
Gianluca Bini: Thank
Ryan Bailey: There were people who were like pre-habbing, I guess, like,
Ryan Bailey: pre-habilitating before they go to surgery or to like potentially try to avoid surgery, even though it's probably in the cards.
Ryan Bailey: And feel like just personally, and that's why I wanna ask you the question is like, I feel like that is an underutilized, like the whole rehabilitation arm is just underutilized compared to the way I see it in human medicine.
Ryan Bailey: Like when I did my rotations
Leilani Alvarez: Oh, you're reaching to the choir. I couldn't agree more.
Ryan Bailey: Yeah. Like when I went to the human hospitals, you know, they, they did blocks for the humans, but they wanted you to be up and mobile so that they could start rehabilitating you within the next day of, of anesthesia.
Ryan Bailey: That was their goal for their ortho stuff.
Leilani Alvarez: including spinal surgery you know you have spinal surgery and you have the PT working on you and you have to be up and moving but we put ours in a cage like don't move for four weeks yeah very different approach yeah I think it's an evolution and yeah
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah, so I guess my question is, like, should we be doing more?
Gianluca Bini: Yeah.
Ryan Bailey: Is there more advocacy? Like, you know, because we're the ones in there right away getting the pain management going.
Leilani Alvarez: yeah
Ryan Bailey: But then I think, I feel like there's a, I don't know, there's a slow adopting of the, of getting these patients to you guys sooner, you know.
Leilani Alvarez: Mm-hmm.
Leilani Alvarez: Yes. Yeah, I absolutely agree. It is very underutilized. The other thing, I could just speak from my own experience at AMC, our TPLOs, they're coming out of the OR and we are working on them immediately.
Leilani Alvarez: So we do intervene with the TPLOs. It's actually included in their surgery package. The rehabilitation is included.
Ryan Bailey: Oh, nice.
Leilani Alvarez: Yeah. And then the next day we work with them again. And then we generate a home discharge instruction that has exercises that they should begin right away. And then two weeks post-operative, they can begin a formal rehabilitation program. I wish every patient was like that. That's the one that I think we tackled correctly because...
Leilani Alvarez: you know, other, let's say orthopedic fractures, they don't have that plan. So then we rely on that, the surgeon to make the recommendation, then the owner has to approve it.
Ryan Bailey: Yeah.
Leilani Alvarez: And then there's a conversation, well, is it necessary? And they're like, well, it's not necessary. And I want to say it's necessary, but, and then it becomes about costs.
Ryan Bailey: Yeah.
Leilani Alvarez: And that's why we just bundled it for the TPLOs, because I don't want people to have that conversation.
Ryan Bailey: Yeah.
Leilani Alvarez: Like, yes, it's important. Like, you know, It's not necessary, but it's important and it should help your recovery.
Ryan Bailey: Yeah.
Leilani Alvarez: But you know how it is in veterinary medicine. Everything is about the estimate and the money and you end up, you know, it's like, I feel like a used car salesman when you're like, well, you know, you could do this.
Ryan Bailey: That's true. That's
Gianluca Bini: Thank you.
Ryan Bailey: true.
Leilani Alvarez: We could do that.
Ryan Bailey: Yeah.
Leilani Alvarez: Whereas in human medicine, you don't have a choice. This is what the doctor recommends and that's what you do. But yeah, I love pre-habbing.
Ryan Bailey: Yeah. Oh.
Leilani Alvarez: We definitely have that for a lot of our patellar luxations. That's a common patient for pre-hab where the owners will come and they'll say they saw their vet and they're recommending surgery, but then maybe you can try rehab first.
Leilani Alvarez: And a lot of them, I will say, really, I've been even surprised. Usually I think about the grade three patellar luxations. They don't you know, they're really, you're lucky if they're going to get better with rehab because they're already wanting to be out.
Leilani Alvarez: And those are the ones where I don't give owners the greatest hopes that we can stay out of the OR. But I've been pleasantly surprised.
Ryan Bailey: Thank you.
Leilani Alvarez: We had some grade threes that we got to stabilize to grade two and were able to avoid surgery. And definitely a lot, I would say probably a majority of the grade twos that come to us, we can keep them out of the OR.
Leilani Alvarez: And it's just simple anatomy, the quadriceps ends in the patellar tendon. If you can do really good quadriceps strengthening, you can keep that patella in place. It works. It's a really very straightforward rehabilitation approach of strengthening that really works to stabilize that patella.
Leilani Alvarez: And we've had it also for hips where they're potential candidate for total hip replacement. And the surgeon will say, well, why don't we try rehab first? And then if that's not bringing the results that you want, then we can do the total hip replacement.
Leilani Alvarez: We've had several patients again where they did so well. The surgeon, actually, it's funny, I was the one that was asking for surgery because the hips were so horrible. And, but then the surgeon said, well, you know, they look so good.
Leilani Alvarez: I don't need to it anymore. I'm like, no, I can make them look worse. Like, please replace their hips, you know, because the hips were in such bad shape.
Leilani Alvarez: But, Yeah, it's wonderful to do that. But then the other thing I will say is I think a lot of people don't realize that rehab touches practically every other specialty.
Leilani Alvarez: There is, because the focus that we have is twofold.
Ryan Bailey: Oh, yeah.
Leilani Alvarez: One is pain management, definitely, but the other is improving function. And when you broaden it like that and you think about, well, what is, you know, what patients have decreased function?
Leilani Alvarez: Well, it's like every sick patient. I mean, everybody that has been hospitalized for, it doesn't have to be musculoskeletal. We treat a lot of patients that are internal medicines patients or critical care patients.
Leilani Alvarez: that because of a severe illness develop difficulty moving or have pain management issues from their severe illness. But yeah, we interact with internal medicine.
Leilani Alvarez: We interact with exotics, definitely critical care, as well as dermatology, even oncology, for sure.
Gianluca Bini: All right.
Leilani Alvarez: The oncology patients, I will say the one specialty we don't interact with is ophthalmology. We don't rehab the eye.
Ryan Bailey: Oh.
Leilani Alvarez: But other than that, like I've done rehab for jaws, like from dentistry. We've had a lot of, you know, they had like a partial mandibulectomy or, you know, had other chewing problems. And we need to strengthen like the muscle. And anyway, we really can rehab it.
Leilani Alvarez: practically anything in the body. And of course we see it on the human side and they're specialized. So we're, it's also, you know, the history of veterinary medicine is suspect over time we'll get more specialized, but right now rehab everything.
Leilani Alvarez: It's just not specific. You know, they have, for example, they have respiratory rehab in the ICU for humans, like if you're having trouble and there's all these techniques that help with moving fluid so that you can evacuate that fluid.
Leilani Alvarez: And they've shown that the hospitalization of those respiratory patients is shortened if they're doing respiratory rehab. So it's really fascinating.
Gianluca Bini: That's cool.
Leilani Alvarez: Never ending the opportunities. I'm so excited to be in this specialty because I see so many opportunities. We have to study a lot. There's a big, big gap in knowledge. There's a lot of things that I would like to contribute to, including in the area of pain management. There's a couple of drugs that I don't know how you guys feel about this, but I think ever since tramadol fell out of favor, gabapentin became like its instant replacement.
Ryan Bailey: Yeah.
Leilani Alvarez: And I'm like, well, what's the evidence for gabapentin, you know, especially for OA pain. I personally don't think it works great, but that's what every GP is putting the dog on gabapentin for their And I think, you know, those are the ones that end up getting ketamine because the pain is not well managed.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah.
Leilani Alvarez: But, and I, yeah.
Gianluca Bini: Yeah, Debra Pending is the new drama though, for sure.
Leilani Alvarez: Yeah.
Ryan Bailey: Yep.
Gianluca Bini: People dispense it like candy, right? They just give it to Debra Pending.
Leilani Alvarez: Yes. Yes. And for the older dogs, a lot of these older dogs, they get knocked out on gabapentin.
Gianluca Bini: Yeah.
Leilani Alvarez: The other one that I would love, that I suspect I think could be have good utility is acetaminophen. I think that's a drug that's been underutilized in veterinary medicine for pain management.
Leilani Alvarez: But, you know, we don't have that. There was a one paper that was acetaminophen with codeine was not very efficacious, don't think oral opioids are efficacious anyway.
Gianluca Bini: Yeah.
Ryan Bailey: I hear.
Leilani Alvarez: But it'd be nice to see more studies to see if that might be an option for an oral analgesic.
Gianluca Bini: Yeah.
Gianluca Bini: Yeah.
Leilani Alvarez: I certainly have used it for patients that can't tolerate an NSAID, like let's say a patient that has a renal contraindication and, you know, liver function as normal, then we'll reach for acetaminophen.
Leilani Alvarez: But, yeah, those, those, those are.
Gianluca Bini: Yeah, I think they do the same, you know.
Leilani Alvarez: Yeah.
Ryan Bailey: I hear a rumor there may more evidence for acetaminophen coming out soon. I was actually, was asking questions about acetaminophen because it is like, it is a total deficit of knowledge for me because where I, where I trained, we weren't using it.
Leilani Alvarez: Yeah.
Ryan Bailey: And then finished training and then acetaminophen kind of took off a little bit from, and a lot of those things. residents started disseminating and so it became, think it became back in vogue.
Ryan Bailey: And so I just, it's just like a big knowledge gap and someone asked me a question.
Leilani Alvarez: Yeah.
Ryan Bailey: So I was asking around and then one of my colleagues said they're working on a review paper of acetaminophen in dogs. So I'm not sure what time, what the ETA on that is, but you know, fingers crossed.
Leilani Alvarez: Oh, great.
Leilani Alvarez: Okay. Hopefully a publication out soon.
Ryan Bailey: Yeah.
Leilani Alvarez: Good. Yeah.
Ryan Bailey: Yeah.
Leilani Alvarez: Yeah.
Gianluca Bini: That's cool. That's cool.
Leilani Alvarez: Yeah, I'll tell you what I reach for more for my, that does have evidence that I think is an underutilized, maybe because it had a bad stigma when it first came out as cannabinoids.
Leilani Alvarez: There's a wealth of evidence for both anti-inflammatory and even neuropathic pain management for cannabinoids. And in particular, Ellivet, they've had multiple studies out of Cornell And that's the drug that reach for if I can't use an NSAID.
Leilani Alvarez: NSAID would be the first thing that I would use if I can. But if there's a contradiction, did my sound, did it change?
Gianluca Bini: And now you're fine.
Ryan Bailey: Oh, still good. Yeah, you're still good.
Leilani Alvarez: Oh, okay. The sound sounds different for me since my AirPod dropped out. But yeah, if I have, we treat a large population of our patients are senior or geriatric patients.
Leilani Alvarez: And I definitely shy away from the NSAIDs in my older patients, but we need anti-inflammatory pain management. And I find the cannabinoids are really effective for getting that anti-inflammatory effect with, you know, would say some side effects, but not nearly as large as the side effects we see with gabapentin in the older population.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: Speaking like anti-inflammatories that kind of not anti-inflammatories, what are your thoughts? Just because this is not an area I have a ton of experience with and people are not fans when it first came out was like Galloprant and Grappoprant, like,
Ryan Bailey: What do you like? I'd heard like to me, the science suggests it would be great for chronic pain. I heard clinically that wasn't actually true and it seemed better for like acute pain.
Ryan Bailey: It's like theoretically this great drug because maybe we can use it in those kidney and liver patients or patients who do see side effects with NSAIDs.
Gianluca Bini: Yeah.
Ryan Bailey: But yeah, what are your thoughts?
Leilani Alvarez: I'll tell you a story on that. When Galaprant first came out, I was very excited because, again, big, big population of my patients are senior.
Ryan Bailey: Yeah.
Leilani Alvarez: And that seemed to be like, oh, you know, this is just only an EP4 receptor antagonist. You're just much, much safer drug. So I had this. I'll never forget.
Leilani Alvarez: It was a Maltese. It actually had MPLs and it also had a Cruciotare. Dog was doing great on Remedil, but it was an older dog.
Gianluca Bini: Thank you.
Leilani Alvarez: I had cardiac disease too. So, you know, it's just like, I felt like, oh, this could be kind of a frail patient. You know, don't want to. Anyway, I called out the owner and I like, this great new drug is on board. I'd like to switch from the Remedil to the Galopran.
Leilani Alvarez: And like, I'll tell you about a month later, that lady called me up like yelling at me. She's like, you ruined my dog. My dog was doing so great. And then you put it on this shit drug and now my dog's limping again.
Leilani Alvarez: And like, I just want it back on the Remedil. And I was like, oh my gosh. But that really, that story is like, I mean, not that severe, but that's been my experience with Gallopran.
Ryan Bailey: Yeah.
Leilani Alvarez: It doesn't work as well as your traditional nonsteroidals.
Ryan Bailey: Yeah. Okay.
Leilani Alvarez: And, you know, the other thing think, to be fair, if you're going to a true scientist about it, if you read about the drug, it'll say right on the label is contraindicated for renal disease and liver disease.
Ryan Bailey: Right.
Leilani Alvarez: So you shouldn't be using it in those patients anyway.
Ryan Bailey: Yeah, exactly. Sure.
Leilani Alvarez: And that's where I see that in Arians, the patient will come to me on Gallopramp because they have chronic renal disease.
Leilani Alvarez: And I'm like, well, you shouldn't be on Gallopramp.
Ryan Bailey: Yeah.
Gianluca Bini: Thank you.
Ryan Bailey: Yeah.
Leilani Alvarez: And my theory for why it's less efficacious is because it is such a narrow target. You know, it's your EP4 receptor antagonists for PGE2.
Ryan Bailey: Yeah.
Leilani Alvarez: And osteoarthritic pain is a lot more complex than that. You need a multimodal approach.
Ryan Bailey: Oh, yeah.
Leilani Alvarez: And it makes sense to me that it's just not enough. So I think, you know, if I have a patient, I don't, I don't prescribe it anymore, but if a patient comes to me, they're on Gallopret and they're happy with it, I'll keep them on fine.
Leilani Alvarez: If, you know, if they're well controlled, that's fine, but it makes a lot of sense to me, know, the patient
Ryan Bailey: Oh, God. Yeah.
Ryan Bailey: Yeah.
Leilani Alvarez: Yeah, for that reason, and also that I personally don't reach for it when there is a contraindication, and I wouldn't use that drug anyway.
Ryan Bailey: Yeah, for sure. For sure. Yeah.
Leilani Alvarez: So yeah, I stopped. I was very excited when it first came out. And then my patients were very disappointed with the results.
Gianluca Bini: Yeah.
Leilani Alvarez: And so I really, if you're on it and you like it, fine. Otherwise, I'm not using it.
Leilani Alvarez: Yeah.
Ryan Bailey: And so it's nice to get, you know, someone who's seen a little bit more, more of the long term kind of patients on it. So it's nice to know.
Leilani Alvarez: Yeah. And that's interesting. I hadn't heard it that it's better for acute pain management. I, that's not the type of pain I manage, so I wouldn't know, interesting.
Ryan Bailey: Yeah, that was what someone had told me about their experience with it when I, because, you know, I say this is an option, but like, you know, we didn't stock it.
Gianluca Bini: Yeah.
Leilani Alvarez: Hmm.
Ryan Bailey: And so it was always something I could tell, you know, the clinicians I was working with for their patients. But then, you know, we weren't, we didn't have an ability to send it home with an owner to have that follow up.
Ryan Bailey: So I would always ask RDVMs in the area about their experience just to try and like improve my knowledge about it.
Leilani Alvarez: Right.
Leilani Alvarez: Yeah.
Gianluca Bini: What do you, so now probably we need to get to the hot topic.
Leilani Alvarez: Oh, I knew it was coming.
Gianluca Bini: So what do you think about, know, lot of veterinarians have been probably overprescribing this Andai, NGF drugs like Librella and Solenzia and whatnot. And so now we have more evidence of the side effects associated with them. Some of them are, you know,
Gianluca Bini: from expanding from, you know,
Gianluca Bini: you most musculoskeletal issues to like cognitive dysfunction and stuff like that.
Leilani Alvarez: Yeah.
Gianluca Bini: Like, what's your thought on that? Like, do they have a space in what you normally do? Or is it patients that, you know, the GPs are trying not to ship to rehab? Yeah.
Gianluca Bini: and then, and then they just,
Leilani Alvarez: That's probably the case. Yeah. I'll tell you. I'm I'm sorry.
Gianluca Bini: yeah, don't know if they just put them on these drugs and, you know, hope for the best, or I don't know what's,
Leilani Alvarez: Go ahead.
Leilani Alvarez: Yeah.
Gianluca Bini: I've seen like clinics that like everything that was limbing, they would just get the bro. I mean,
Leilani Alvarez: LaBrella. That's right. That's right. I think there's been quite an evolution since the drug came out. Certainly. in our hands, always confirmed OA. Of course, similar to Galapramp, we were very excited to use it. We used right away when the drug came out. Actually, we had a list of patients we wrote down. I'm like, these are who we want to try it on because they had advanced OA. And we were managing them, but we thought, wow, this drug is going to be such a wonderful tool to improve their pain management.
Leilani Alvarez: Since then, would say even before things were out in the public, within the rehab community, we were starting to share with each other. first adverse side effects we saw was neurologic decline, acute neurologic decline. especially in our senior patients.
Leilani Alvarez: And then it was sometime after that, that it started to come out in Facebook and other forums and things like that. And then of course, last year we had that paper come out in Frontiers. I thought it was a well-written paper by other specialists. I did have a case of rapidly progressive osteoarthritis. We had it documented before the start of Librella. And I mean, it's just, I it can't be anything else.
Leilani Alvarez: I think that the biggest knowledge gap that was not shared with general practitioners is that nerve growth factor, you know, I think the story at least that we heard was nerve growth factor plays an essential role during development for the development of the nervous system.
Gianluca Bini: Thank you.
Leilani Alvarez: But then in adult states, it's, you know, it's only negative. It's like, you know, hyperalgesic states.
Ryan Bailey: Thank you.
Leilani Alvarez: and particularly regulated patients with OA. But that's not the full story. And of course, it's not the full story for any growth factor. And we know that in adult states, nerve growth factor plays an essential role for maintenance of the nervous system.
Leilani Alvarez: So we know for peripheral nerve function, also for repair of nerves. So if you think about your senior patient in particular has degenerating nerves, that nerve growth factor would play an essential role.
Leilani Alvarez: Also, we know it's important in angiogenesis, it's important in tissue healing, particularly corneal epithelial tissue healing. So it plays, it has constitutive role in adult states.
Leilani Alvarez: And I think that's really the gap in knowledge that I don't think was shared. And I don't think it was from a lack of that knowledge because it seems that that has been studied.
Gianluca Bini: Thank you.
Leilani Alvarez: It just wasn't shared. And
Leilani Alvarez: I do know some, the patients that come to me now is because they received a series of Librella injections and now they're not doing well. So then they come to me. And then what do we do? Do we keep them on Librella or to end? like, okay, well, first thing we do is we take them off Librella.
Leilani Alvarez: But yeah, and so yeah, veterinarians are still using it. Sadly, I think there are still many veterinarians who are not confirming a diagnosis of OA and using Librella. I will say in fairness that I have had patients that came to us that had been receiving labrella and they thought it made a huge difference. They weren't experiencing side effects from it, but they wanted to come to us for strengthening or other additional things. I've seen so many negative side effects that my intuition wants to say, take them off, even if you're not seeing side effects, just because I'm worried for them, the longer they're on it, that we might see some ill side effects. But But to be fair, you know, think we need to learn more about the drug. In particular, I think patient selection is really, really important.
Leilani Alvarez: I will say that the most common patient that I think Librella has been prescribed to is your older arthritic patient. And I worry that that's not great patient selection because the older patient is more frail.
Ryan Bailey: Thank you.
Leilani Alvarez: and has other comorbidities. And I think those are the ones that are particularly at risk for adverse side effects from a NGF monoclonal antibody.
Leilani Alvarez: worry in that case would be what's the long-term side effects of an anti-NGF growth factor, but I don't use it in my complicated cases.
Ryan Bailey: Yeah.
Leilani Alvarez: I don't use it in the frail patient, certainly with any neurologic disease I would not reach for it. If you read, were told that the rapidly progressive osteoarthritis was a human condition.
Leilani Alvarez: This is not a canine thing. But if you look at the human data, it's pretty clear why it was not FDA approved for humans. And it was because of the severe adverse effects. And here we are, the same types of things are being reported now that it's been widely used.
Leilani Alvarez: So kind of part of me either, need like a big black label warning saying like, this is who you don't ever use it on.
Ryan Bailey: Yeah. Yeah.
Leilani Alvarez: or take it off the market because I just worry that it is continuing to be misused, unfortunately.
Gianluca Bini: Yeah. Yeah. And, you know, yeah, I've seen a lot of that, unfortunately, it's kind sad. I think that there is an issue with, you know, the misinformation that's out there, right? Like we, I think as a professional, we do a really bad job at keeping up with CEs, right? And unfortunately, I think that, fact that you can pick which CEs you go to,
Gianluca Bini: I think, I strongly believe it's an issue. Like, I think you, you know, like you have the two hours of mandated opioid CE, right?
Leilani Alvarez: Oh, that's an interesting point.
Gianluca Bini: Like in some states you do. I think there should be two hours of anesthesia mandated CE, two hours of cardiology mandated CE, two hours of internal medicine.
Ryan Bailey: Yeah.
Gianluca Bini: You know, I think...
Leilani Alvarez: Especially if that's what you do in your clinic, right? Like if you are anesthetizing patients, you're doing, you know, things. Yeah, I hadn't thought about that, but I agree.
Gianluca Bini: Versus like...
Leilani Alvarez: Like about growing your business.
Gianluca Bini: Yeah, and that's part of it. That's fine. But, like, it cannot be, know, the sole source of your C, right?
Leilani Alvarez: The only thing.
Gianluca Bini: Like, the fact that you can spend 20 hours on one single topic when you're not a specialist, you know, think that that's a little bit of an issue.
Leilani Alvarez: The other thing I noticed, too, because I was just at VMX, the most highly attended CEs are the ones where they provide free food, which are always sponsored.
Ryan Bailey: Yeah.
Leilani Alvarez: And of course, there's a degree of bias there.
Gianluca Bini: Yep.
Leilani Alvarez: So, you know, maybe you should be required to do non-sponsored CEs. So you get, you know, little list.
Gianluca Bini: Yep.
Leilani Alvarez: Yeah, it's a really good point.
Gianluca Bini: Yeah. And sometimes, you know, when they sponsor those, Some of the people that speak are not actually experts, right?
Leilani Alvarez: Correct. Yes. Yeah. I mean, sometimes they're great.
Gianluca Bini: Those are...
Leilani Alvarez: Like I've had I've been to sponsored lectures where it's a university DVM who's, I would say, actually very unbiased. And, you know, I think we've all been to great sponsored lectures that I think is very, very informative.
Leilani Alvarez: But then there's the ones where they're actually an employee of the company and they're not even DVMs.
Gianluca Bini: Yep.
Leilani Alvarez: And they're giving CE to veterinarians is very biased. I think, yeah, you can see that the full spectrum of that possibility.
Gianluca Bini: Yep. It's scary. And then there is the race approval thing, right? Where... you know, they say it's race approved, but in reality, nobody actually checks who that person worked for, who's like, you know, what the connection is, how much money they get paid, you know, if they get to the free flights and the free hotel and like, you know, double your pay for a sponsor.
Leilani Alvarez: Mm-hmm.
Gianluca Bini: You know what mean? Like that's, you're definitely not going to shit on that drug.
Leilani Alvarez: Yeah.
Gianluca Bini: You know what mean? So like, so, you know, it's,
Leilani Alvarez: No, that's right.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: I don't know. I have a lot of issues with that stuff and like, you know, actually getting proper.
Leilani Alvarez: Yeah. Well, and I think that's, that's what, you know, just thinking that the paper that was published, you know, these were obviously non, these are specialists who are not involved with Zoetis that are publishing this and, and,
Leilani Alvarez: I think that's really what we should do specialists is speak to each other, publish, learn from each other, and then disseminate that information. Because, you know, for example, I was at VMX and I do feel that's my role is that
Gianluca Bini: Yeah.
Leilani Alvarez: because they're not going to be reading the publications. And so I see that as our role as specialists when we speak is to educate the general practitioner about what's the latest information we have on this topic.
Ryan Bailey: Yeah.
Leilani Alvarez: We'll summarize it for you and give you the key findings. But that's the, I think that the, I think majority your general veterinarians are getting information from the conferences that they attend. I don't know how many of them are reading journal articles.
Gianluca Bini: Oh, nobody.
Leilani Alvarez: Yeah.
Gianluca Bini: And, you know, unfortunately, the other side of things is that, like, you they don't really have time, right? Like, when they, people, like,
Leilani Alvarez: I would say that's, yeah. For me, I mean, I read it because we cover it in journal gloves, so I have to read it.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Yeah, and some of them don't even have access to journal, right? That's the other big problem, right?
Leilani Alvarez: Oh, that's a big...
Gianluca Bini: Like if you look at the...
Leilani Alvarez: I mean, even for AMC, we lost access to some journals. Yeah. Hopefully, a lot of journals have now moved to open access, which is great because, yeah, that's a big issue is like, I think VCOD is still not open and there's some...
Gianluca Bini: Yeah.
Leilani Alvarez: That's the Veterinary Compendium of Orthopedic Trauma. You may not know that one, but there's some really... I would say reputable journals that are not publishing on open access. So a very big population doesn't have access.
Gianluca Bini: Yeah. Yeah. Which is an issue, right? Like, you know, those subscriptions are extremely expensive. if you want to buy an article, I think, you know, ranges from like 20 to 50, sometimes even 70 bucks, right? Like, which is insane, right? Like, it For somebody that's like one or two days of groceries, right?
Gianluca Bini: And they have to pay for one article, which is insane.
Ryan Bailey: Yeah.
Leilani Alvarez: Yeah.
Leilani Alvarez: Yeah. Yeah.
Gianluca Bini: It's not...
Leilani Alvarez: So it's not happening.
Gianluca Bini: Yeah, it's not happening. And so I can't really blame them for not reading. can't really blame them. So...
Gianluca Bini: you know, I get it, but, but, you know, we need to do a better job. Like I think even us as specialists to like, you know, disseminate that information, right? Like, and have a bigger reach, out there.
Leilani Alvarez: Yeah. Yeah.
Leilani Alvarez: Yeah. Yeah. Yeah. Mm-hmm.
Gianluca Bini: And, you know, it's not against any drug, you know, we, I think every drug has its place, right? Like Librella has its place in some patients, you know, Galliprin has its place in some patients for sure.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: And so does, you know, Gabapentin, but, you know, you need to be aware of what the risks are and you need to present the rest to the owners and, if they're fine with it, it's fine.
Gianluca Bini: It's just, you need to be aware of it though. You can be, you know, totally blindsided and, and,
Leilani Alvarez: Yeah.
Leilani Alvarez: Yeah, no, that's exactly right.
Leilani Alvarez: I distinctly remember when I learned about the side effects of Librella, I had clients that were making appointments, the presenting complaint was, wants to start Librella.
Leilani Alvarez: And I had open conversations with them. I said, these are the risks. And some of them, they wanted to try it. It was like the big hype. And I think people, they hoping to see that miracle change. And yeah, I think that's right. I think our role is to educate, to present the potential adverse effects, and client hopefully makes an educated decision based on that information.
Gianluca Bini: And some patients, they do see an improvement. I've heard plenty of stories out there that say the dog's completely changed.
Ryan Bailey: Yeah.
Leilani Alvarez: Oh, of course. Yeah.
Leilani Alvarez: Yeah.
Leilani Alvarez: Yeah.
Gianluca Bini: Maybe we do see, or at least you guys see more of the ones that didn't go well because that's when they were getting referred.
Leilani Alvarez: No, exactly. We have, I would say, more biased population, definitely.
Leilani Alvarez: We see the more complicated cases.
Ryan Bailey: Yeah.
Leilani Alvarez: That's why they come to us in a tertiary institution.
Gianluca Bini: Yeah. So I don't know what the percentage is of how many of them get those kinds of set effects, but like, you know,
Leilani Alvarez: Absolutely.
Gianluca Bini: I see clinics prescribe it left and right. And, you know, I don't know how many side effects they see, but, you know, if every clinic is doing that, that means that, you know, probably there is very few of them that actually do have the side effects.
Leilani Alvarez: Okay.
Leilani Alvarez: Yeah,
Gianluca Bini: You know, it's just sad when people weren't educated on the potential side effects. That's where the
Leilani Alvarez: that's right.
Gianluca Bini: Now that we got to the end of the hour, so we always ask this question our guests. What's your favorite hot dog?
Leilani Alvarez: I don't eat hot dogs. I'm vegetarian.
Ryan Bailey: You know, like a vegetarian hot dog?
Leilani Alvarez: No, it's gross.
Ryan Bailey: Wow.
Gianluca Bini: Oh, my God, Ryan.
Ryan Bailey: That, I mean, it's okay. Like, everyone has their own thing.
Gianluca Bini: Ryan.
Ryan Bailey: I think with hot dogs, I am like, huge hot dog lover and fan.
Leilani Alvarez: That's funny.
Ryan Bailey: In fact, I wore my hat that recently got.
Leilani Alvarez: Oh, well, you know, have you been to the Nathan's hot dog?
Ryan Bailey: It said, it's a bad day to get hot dogs. I've had Nathan's, but I've never, I lived in New Jersey and I never made it out to Nathan's.
Leilani Alvarez: That's.
Ryan Bailey: Like I did my internship in Red Bank.
Leilani Alvarez: Oh, okay.
Ryan Bailey: So was in Jersey for a year and never made it out to Nathan's.
Leilani Alvarez: Oh, nice.
Leilani Alvarez: Oh, I mean, think it's really fun to watch the hot dog eating contest, you know.
Ryan Bailey: That's like a big,
Ryan Bailey: oh my God, of course.
Leilani Alvarez: They're like, it's like professional thing. Now, if you really want to know my answer to that, probably the closest thing is Trader Joe's makes a really yummy vegetarian chorizo. And I love that.
Ryan Bailey: Oh, I'm always, my brother's a vegetarian and I obviously love hot dogs.
Gianluca Bini: Yeah.
Ryan Bailey: I'm always looking to try and like bring something that's not just like the, like some of the grocery options are like honestly terrible and just like so sad.
Leilani Alvarez: Yeah. See, I, as a vegetarian, I don't like the imitation things because, you know, I'd rather have, there's like wonderful vegetarian meals that are just delicious.
Ryan Bailey: Yeah. Oh
Ryan Bailey: yeah.
Leilani Alvarez: Like they don't need to taste like a hot dog, but, but that, I will say that that chorizo is really yummy.
Ryan Bailey: Yeah.
Ryan Bailey: Okay.
Leilani Alvarez: So you could bring that for your brother.
Ryan Bailey: All right. Yeah.
Gianluca Bini: I need to try it.
Ryan Bailey: Well, that's good know. Thanks.
Gianluca Bini: I need to try that.
Gianluca Bini: Well, thank you so much, guys, for being here. Thank you so much for joining us tonight. I guess we'll see you next time.
Leilani Alvarez: All right.
Gianluca Bini: Thanks, guys.
Leilani Alvarez: Thank you so much for having me.
Ryan Bailey: Bye.
Gianluca Bini: Thank you. Bye.
