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Welcome to Chattering With ISFM, the official monthly podcast of the International Society of Feline Medicine, hosted by Nathalie Dowgray (Head of ISFM). Each month, we chatter about cats and cat-friendly practices with industry experts and contributors to The Journal of Feline Medicine and Surgery. Each episode contains highlights from our longer discussions and interviews, which are accessible to ISFM members at portal.icatcare.org. If you would like access to our full episodes, would like to become an ISFM member, or find out more about our Cat-Friendly schemes, visit icatcare.org.
Nathalie Dowgray: Hello and
welcome to the November 2023
episode of Chattering with ISFM.
I'm Natalie Dalgrey, Head of ISFM
and host of this month's podcast.
First up this month, I'm speaking with Dr.
Kelly St Denis on her
latest publication in JFMS.
And that looks at the benefits of being
a cat friendly practice with regards
to laboratory testing and improved
diagnosis of common feline conditions.
We're also featuring our monthly JFMS
Clinical Spotlight interview, and this
month the focus is on surgical management
of biliary tract disease in cats.
I'll be speaking with Dr.
Daniel Low on his review article.
So we are talking about your paper
today, and the title is Cat Friendly
Practice Improves Feline Visits
Resulting in Increased Laboratory
Testing and Increased Diagnosis of
Certain Common Feline Conditions.
To start with, would you be
able to summarize the study
and the study design for us?
Kelly St. Denis: Sure.
So this is something that was put together
with collaboration between AAFP and IDEXX.
So we did look at a number of Cat
Friendly Practices versus non Cat Friendly
Practices in a retrospective manner.
And of course, those practices
had to have an IDEXX account and
a practice information management
system so that IDEXX could actually
monitor the data that was collected.
And they broke the analysis up
into two different sets of data.
So first was the financial and
then also a clinical findings.
Our hypotheses were that Cat Friendly
Practices were going to be getting
more income from laboratory testing,
but also doing more diagnostic testing
and also having increased results and
findings associated with disease in cats.
Nathalie Dowgray: As vets, we're often
very focused on the clinical side of
things, but sometimes people that are
more in the managerial side of things
want to see what the financial benefit is.
Kelly St. Denis: We have some
publications that have already
shown that, we know there's reduced
injury and reduced insurance claims.
We know from a Cat Friendly Clinic
study done in Spain by Pere Mercader
that again, they had shown increased
income associated with Cat Friendly
Clinics compared to non Cat Friendly.
So there is information out there,
but in this study, in the financial
analysis, we also found similar results.
They did look at two different
years in the financial cohort.
They wanted to look at pre pandemic.
So they looked at data from 2018 and
then also data from 2021, but they were
looking at things like visits per year.
And then the proportion of visits
that included diagnostic test results.
And they looked specifically in the
financial analysis, that blood testing,
imaging, faecal testing, and urine.
And then they looked at revenue
per visit type and yearly
revenue per feline patient.
And so when they looked at those two
different years, they found there
was not really any difference between
the two of them, so we didn't have to
worry about pandemic related factors.
And they did find, as was found in the
CFC study, that there was an increased
average per feline visit practice
revenue, and they also found a higher
annual revenue per feline patient for all
visits and also for diagnostic visits.
So where patients are actually
having diagnostic testing.
The other thing that they found, which was
part of our hypothesis and we confirmed,
was that there was a higher proportion
of cats in Cat Friendly Practices
that had diagnostic testing performed.
And that was at any
type of clinical visit.
And then they also specifically
looked at wellness visits.
So, I should clarify that one of the
things that they did with the financial
data and the clinical findings was
they took out non clinical visits.
So anytime someone was spending money
on things like prescription refills
or, um, picking up food, boarding or
anything like that, that those were
not included in the financial data.
And then finally, one of the other
findings that we had under the financial
analysis was that there was actually no
difference in the proportion of wellness
visits, but we did find an increased
clinical visit per feline patient.
We know that clients seem to have more.
trust and more comfort in dealing
with a cat friendly clinic
or a cat friendly practice.
One thing that really struck me
in the Spain studies was that 40
percent more caregivers were likely
to buy their food at the practice.
So that to me signals that caregivers
are trusting us more and more
willing to take our recommendations.
And so when we make a recommendation
for diagnostics, they're
more likely to agree to it.
And again, this is all correlation
and not causation, but certainly
that would be the suspicion.
Nathalie Dowgray: Yeah.
And that was definitely my thoughts
as well, that taking the time
to communicate what you're doing
builds that trust, doesn't it?
Kelly St. Denis: And the caregivers can
see in front of them what we're doing
with their cats and that it's different.
Nathalie Dowgray: And then the second part
of the study was where you were comparing
Cat Friendly versus non Cat Friendly based
on geographical and other data as well.
So you're trying to compare like
for like as much as possible.
Would you be able to sort of summarize
the findings from that part of the study?
Kelly St. Denis: Absolutely.
Yes.
They looked during one whole
year from June of 2021 to 2022.
And as you noted, it was matching
for every one Cat Friendly
Practice that was IDEXX with the
practice information management.
They looked at seven non
Cat Friendly Practices.
And we weren't necessarily looking
at the data from the geographical
perspective, although that was a bit of
a sub study, just looking at regions in
the US and if there were any differences
there that might suggest a bias.
So again, they were looking at
testing categories, but in this case
it was biochemistry, complete blood
count, thyroid where appropriate
based on age, and then urinalysis
or some portion of a urinalysis.
And they took the other couple of
things out, the radiographs and the
faecal, because those were harder
to follow because they weren't
necessarily directly associated with
that practice information system.
So when they were looking at
those, they were trying to find
proportionate clinical visits.
In which each finding was observed how
much volume of testing categories as a
proportion of clinical visits occurred.
And then the proportion of
diagnostic visits with 1, 2,
3, or 4 testing categories.
So, did they just do biochem,
biochem and CBC, biochem and a
urinalysis for example, or all 4.
So, in the clinical findings,
the visits per cat and higher
diagnostic inclusion reflected what
we found in the financial analysis.
And then what they found was that
the Cat Friendly Practices were more
likely to include testing across
multiple testing categories, so
biochem, CBC, thyroid urinalysis,
and Significantly lower odds of
performing testing in only one category.
And then when they looked at that in
more detail, they had significantly
higher odds of performing testing
for more than one category.
So the Cat Friendly Practices
were more likely to do more
testing in multiple categories.
And then when we look at actually
findings that they had, when we look
at Cat Friendly Practices, we're more
likely to have a result within the
reference interval for most analytes.
When there were abnormalities
found, they were more likely
associated with endocrine thyroid.
For example, kidney and electrolyte
system categories, which reflect those
common problems that cats get as they age.
So those were kind of like
key findings for that section.
In my own practice, if I'm seeing senior
cats, I want to start testing them early,
even before they're showing any history
or clinical signs of disease on physical
exam, because I can get baseline values
for those patients and then trend them.
And so when we're finding more values
in the reference interval, that means
we're probably having more opportunity to
trend our patients, which is proactive.
Nathalie Dowgray: Thank you
so much for your time today.
Hopefully the people listening will find
the links to the full paper in the show
notes and dive in and read it in full.
Kelly St. Denis: Yes, please do.
Thanks, Nat.
Nathalie Dowgray: Thank you, Kelly..
And now we're speaking with Dr.
Daniel Low on his JFMS Clinical
Spotlight article on the surgical
management of feline biliary tract
disease, decision making and techniques.
So just to get started, Daniel, I
was wondering if you have a preferred
diagnostic approach to deciding if surgery
is indicated in cases of especially
extrahepatic biliary obstruction.
Daniel Low: First off, every
case is unique and should be
approached on an individual basis.
Although a general
approach can be discussed.
First, you'd suspect hepatobiliary
disease on the basis of its
presenting clinical signs.
You'd narrow down your differential list
after doing hematology and biochemistry.
Certain abnormalities on your routine
clinical pathology would lead you to
suspect biliary tract disease in a cat.
Then you'd normally proceed to
imaging to diagnose extrahepatic
biliary tract obstruction, I'll
abbreviate this as EHBO from now on.
For imaging, most likely this
will be abdominal ultrasonography.
Most practices should have access to this
imaging modality, but it has to be said
that you need an experienced operator
to be able to look at the biliary tract.
Once you've performed all that and you've
diagnosed extrahepatic biliary tract
obstruction, you should also be diagnosing
the underlying cause and further
decisions will be made on this basis.
For example, inflammatory and
neoplastic biliary tract disease
will be approached very differently.
But broadly speaking, the practitioner
after diagnosis will need to
decide whether to proceed with
medical or surgical management.
Surgery would be indicated
if you have tried medical
management and it has failed.
Or if you think that medical management
is very likely to fail, but this
goes back to the underlying cause.
And finally, the surgeon is not the sole
decision maker in these cases, as usually
collaboration with other colleagues
from other services would be required.
So you wouldn't necessarily
be working by yourself.
Nathalie Dowgray: Brilliant.
And I was quite interested in the
paper and reading about this sort
of stenting procedure as well.
And in the case where you're having
to place a stent, how long does that
stent generally remain in place?
Daniel Low: Biliary stenting is
not the same as cannulization
of the biliary tract.
Cannulization performs intraoperatively
and you remove the cannula once
you've confirmed the patency.
Stenting provides
temporary relief of EHBO.
A stent is placed with the intent to
maintain a lumen within the common
bowel duct on a temporary basis until
the swelling and obstruction resolves.
So the stent is placed and anchored
with monofilament absorbable suture
material, PDS or monocryl for example,
and what this does is as it's absorbed
by the body, the stent will pass into
the gastrointestinal tract once the
suture has lost its tensile strength.
PDS would probably last
longer than monocryl.
So the choice of suture material would
be at the discretion of the surgeon,
depending on how aggressive you think
the disease is and how long you think
you need to maintain that stent in place.
Nathalie Dowgray: Okay, brilliant.
The article also mentioned
cholecystotomy tube placement.
So would you be able to tell us a little
bit more about what they are and what
the indications for their placement are?
Daniel Low: A cholecystotomy tube
would be a tube that's placed into
the gallbladder and exiting the
body, creating an exit for bowel.
This works similarly to a biliary
stent, in that it provides a temporary
biliary diversion, and it is not a
definitive treatment for any disease,
but just provides temporary relief
for whatever the underlying cause is.
Cats are limited by their size.
Briefly, a step incision is created in
the gallbladder, and you place a pigtail
catheter around a purse string suture and
then you exit it through the body wall.
So it's very much like a
gastrostomy feeding tube, just
in a different luminal organ.
And what you do is you can use
this tube to remove bowel from the
gallbladder so that you don't have
any further progression of the
EHBO while you are treating the
underlying disease by another means.
And these tubes are normally
pulled after three to four weeks,
and you can remove them just like
any other ostomy tube, esophageal
ostomy tube or gastrostomy tube.
Nathalie Dowgray: Should this type of
biliary track surgery really always be
left to the specialists or are there
some procedures that you think could be
suitable for potentially more advanced
or experienced general practitioner vets?
Daniel Low: I think cholecystectomy and
treatment of bowel peritonitis may be
performed by advanced practitioners who
are familiar with the procedures and with
prior experience of soft tissue surgery.
As a lot of the soft tissue surgical
principles can be extrapolated to these
procedures, other procedures such as
biliary diversion or choledocotomies,
they are much more advanced and should
only be performed if you have prior
training or mentoring in these procedures.
If that's not something that you
have any experience with, then it's
probably best to refer these cases.
It's also useful to refer because these
cases always require multidisciplinary
approach and the surgeon is not
the one working in isolation.
You are going to need intensive
perioperative care and if your facilities
aren't adequate, then best to refer again.
Nathalie Dowgray: Brilliant.
Thank you very much for
your time today, Daniel.
I've definitely enjoyed
reading the article.
I think for most of us in general
practice, there's some really
useful bits of information in there.
So thank you so much.
Daniel Low: Yes.
And thank you for having me.
And if listeners have any, any
further questions or wondering about
biliary tract surgery, then please
do take a look at the article.
Nathalie Dowgray: Thank you for listening.
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