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Hello, and welcome to the November
episode of Chattering with ISFM.

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I'm Nathalie Dowgray, Head of ISFM
and host of this month's podcast.

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Our spotlight this month is on
pain and pain management in cats.

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Kelly St.

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Denis is speaking with Mark
Epstein, our JFMS guest editor,

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for the pain special collection.

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But first up, Yaiza Gomez Mejias is
speaking with Sabrine Marangoni on

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her 2024 ISFM Congress award winning
abstract, Characterisation of Pain

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Behaviours in Kittens Undergoing
Ovariohysterectomy Using Video Assessment.

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So Sabrina Marongoni is a PhD candidate
at the University of Montreal, research

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assistant at the City University
of Hong Kong, and this year she won

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two ISFM awards at the conference
in Malta, so congratulations.

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Thank you very much, Yaiza.

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It's a real pleasure to be here.

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Thanks for having me.

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So, I believe you have done
some work on pain in kittens

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undergoing ovariohysterectomy.

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Could you talk a little bit
about the findings you find more

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relevant for general practitioners?

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Yes, of course.

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This experiment, it's part of a large
experiment divided into three segments.

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Unfortunately, we know that adequate
pain management in kittens under

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ovariohysterectomy sometimes is
not always provided due to lack of

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drug availability or training in
pain assessment in young kittens.

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Also early discharge maybe, or even
neglecting that kittens feel less

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pain or can cope better with pain
after such common procedures such as

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castration and ovariohysterectomys.

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So that's the reason that Dr Steagall
created this pain free kitten project.

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So, first, from this main study,
which was a prospective clinical

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trial with the objective of comparing
an opioid free protocol  with or

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without multimodal analgesia, right?

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So to evaluate if it's effective or not.

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So briefly, the results of this main
study was that the prevalence of

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rescue analgesia in control cats, which
received only ketamine, midazolam,

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and dexmedetomidine, was really
higher in comparison to the multimodal

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group that received the same injected
protocol, but with the addition of

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one single shot of NSAs, meloxicam,
and also intraperitoneal anaesthesia.

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So this protocol of injectable
anaesthesia with multimodal

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analgesia almost eliminates the
requirement of rescue analgesia in

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those patients, which is great and in
addition to that, we also evaluate in

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that study the food intake of those
kittens undergoing a ovariohysterectomy.

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And it was found out that the
control group, the painful

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kittens, has a reduced food intake.

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For the third  segment, which is the
study that I just presented in the last

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ISFM Congress, we look into the pain
related behaviours of those kittens.

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So from the video recordings that
we collected during the study pre

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and post op, we found out that pain
related behaviours that have been

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described already in adult cats, such as
lowered head position, no attention to

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surroundings, and eyes partially closed,
were also observed in painful kittens,

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and the administration of analgesia
changed the duration of these behaviours.

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So after giving the rescue analgesia,
those kittens were more attentive

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to surroundings, they were more
playful, they had the eyes fully open.

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The duration of playing was
significantly lower post op in

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painful kittens in comparison to
multimodal and pain free kittens.

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So we know that decreased
playfulness can be considered a

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behavioural  indicator of pain.

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Of course, it is very variable between
cats, but we know that kittens, it's

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intrinsically of their nature to play.

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So this study shows that play is
affected by pain in kittens, and

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may represent a behavioural positive
welfare status in the clinical setting.

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So one can infer that a playful kitten
after surgery is likely not painful.

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So we want to see our
kittens play in the practice.

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Exactly.

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That would be great.

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And now Kelly St Denis is going
to be talking about the evolution

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of pain and pain management in
veterinary medicine with Mark Epstein.

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You've seen a lot of changes.

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I graduated in 1999 and I've
seen a lot of changes in pain

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management in our feline species.

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What do you think are some of our best
changes and improvements over that time?

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The high-level answer is the recognition
of pain and the culture of pain

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management that had to be invented,
poor cats, we're trailing dogs.

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We didn't have products
for them for so many years.

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Cats are less accommodating, and we
didn't understand their nonverbal cues.

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That's the overarching change.

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And then of course we have a number
of therapeutics that are in the

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market now, specifically for cats.

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We've certainly learned a lot
about extra label use for cats.

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The recognition and assessment of
pain in cats is light years beyond

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what it was even just a few years ago.

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Where do you think we
still have room to grow?

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I think I'm going to answer
that by citing a paper.

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It was a comprehensive survey about
their perception about medicating

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their cats, among other things.

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But, news alert, shockingly, they
hate it, having to give oral meds.

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So as we move in the direction of
therapeutics, these are going to

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be some of the maybe longer acting
ones parenterally administered and

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transdermals, and things like that.

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Again, your listeners probably
know more than most is that when

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you're chasing after your cat,
you start to break the bond.

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So whatever we can do that's hands off
for them and not forcing oral meds is

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probably the direction we need to go.

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If our listeners aren't totally
familiar with our special collections,

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about  once a year the journal will
put together a special collection.

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Last year it was on
accessible veterinary care.

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And essentially we are taking
maybe published articles

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that were already published.

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So in this case it's on
pain, pain management.

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But we're also reaching out to people
that maybe would contribute an article.

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In there already we have exciting
articles like a video based compilation

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of acute pain behaviour in cats.

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And I think that was out of
the Paulo Steagall's lab.

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We have a really nice article
on neuropathic pain in cats.

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We have our consensus guidelines on
NSAIDs and even the FGS for kittens.

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And they have something of the order
of, help me Kelly, maybe 20, 21 papers

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in this special collection so far?

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Yeah.

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There's over 10 so far already published,
what are some of the topics coming?

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We often focus on therapeutics, right?

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Drugs.

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Because it's easy to
wrap our minds around.

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But we have papers coming that
are going to be talking about

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physical rehab for the cat.

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These are non pharmacologic things.

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One for acupuncture.

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One for cannabinoids and
a few others like that.

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So, it's gonna be about as robust a
kind of collection I think may exist.

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I'm not aware of anything
else similar to this.

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It's a really nice collection of articles.

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Let's talk about therapeutics in
cats, multimodal pain management

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and where we're at with that with
cats in terms of the drugs that we

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can use even post operatively, but
acute pain or even chronic pain.

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Where do you see those
fitting in with our medicine?

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Not to put too fine a point on
it, but we should redefine them.

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I know your listeners know multimodal.

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We've been using that phrase for 20 years.

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It's probably worthy of a minute
to talk about why we're doing that.

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First, you are hitting the pain processing
pathway and receptors at different places.

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So if you're doing that
in multiple places, you're

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going to have more efficacy.

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Number two, is if you are doing a little
bit of a few things rather than leaning

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heavily into one thing, like just
opioids, the adverse effect profile drops.

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Use a little bit of several things
instead of a lot of any one thing.

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In the post  surgical domain, we try
to dial back on the opioids, not just

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because we had gone through a shortage of
opioids at one point and not too terribly

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long ago, although that may have passed.

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And not just because there is an
opioid epidemic on the human field,

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which has changed the face of the
way opioids have used on the human

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side, although we overlap with that
a little bit on the Venn diagram and

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we have our responsibilities too.

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So it's just trying to steer, not steer
away from, but mitigate the, particularly

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the use of the full new agonists,
because it can also, those particular

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opioids can have adverse effects.

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There's no ceiling effect on the
analgesia, but, some of those have no

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ceiling effect on the adverse effects.

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You can get more methadone or
morphine fentanyl to be fatal,

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it can pop the appetite and cause
dysphoria, constipation, other things.

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So for all those reasons together,
we  were trying to use multi modal

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balanced analgesic approaches so that
we don't have to use, in the kind of

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peri-surgical setting, quite so much
in the way these full new agonists.

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Lastly, is that there's a subset of
patients that either have or at risk

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for hypersensitisation, and your
listeners may know this a little better

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by its vernacular wind up, right?

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And it's where the pain gets exaggerated
in intensity, scope and duration.

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Even the field, like if, and not to put
too fine a point on it, but this was for

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those of you have been out in practice
long enough to have done declaws early

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in your career, there were always the
cats that would limp and hold up a paw.

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That was from amputating a
nerve, that is a classic example.

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These cats may not even
have pain just in the foot.

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That may be their whole arm for example.

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That's an example of an expanded field.

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So sensitisation and wind up is
unaddressed by the simple use of

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opioid or the simple use  of NSAIDs.

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And so there are other therapeutics and
other things we need to do to address

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that particular dimension of pain.

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Yes.

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And that's a scary part of pain.

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Like when we think about any
surgical procedure on a human or

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a cat or a dog where, not just
amputations, but we're always cutting

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nerves when we make a cut, right?

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I just wanted to say thank you.

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And I don't know if you have any last
words for us before we close off.

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No, I just want to thank you again
for the opportunity to be the special

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editor here and to call in some
favours from my friends and colleagues.

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And I'm looking forward
to the final product.

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It'll be very robust and fascinating.

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And I hope you're, you're listeners
and your readers will enjoy.

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Thank you.

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And don't forget everyone.

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You can see any article on the Journal
of Feline Medicine and Surgery and OR.

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at Open  Access.

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So, you don't need to be behind a paywall.

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All there for everyone to have a look at.

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Have a check our pain
management collection.

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Thank you for listening.

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If you're an ISFM member, don't forget
you can access the full version of

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the podcast and all the other ISFM
member benefits, including congress

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recordings, monthly webinars, the
clinical club, the discussion forum,

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and much, much more at icatcare.org.

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If you're looking for more free CPD from
ISFM in December, on the 5th we have a

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webinar on triditis with Fabio Procoli
and that's brought to you by IDEXX.

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We'll be back again next month
with more from the world of

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feline medicine and JFMS.