1
00:00:05,230 --> 00:00:07,740
Nathalie Dowgray: Hello and
welcome to the November 2023

2
00:00:07,770 --> 00:00:09,780
episode of Chattering with ISFM.

3
00:00:10,410 --> 00:00:15,120
I'm Natalie Dalgrey, Head of ISFM
and host of this month's podcast.

4
00:00:15,120 --> 00:00:16,759
First up this month, I'm speaking with Dr.

5
00:00:16,759 --> 00:00:20,060
Kelly St Denis on her
latest publication in JFMS.

6
00:00:20,590 --> 00:00:25,220
And that looks at the benefits of being
a cat friendly practice with regards

7
00:00:25,220 --> 00:00:28,390
to laboratory testing and improved
diagnosis of common feline conditions.

8
00:00:29,370 --> 00:00:33,230
We're also featuring our monthly JFMS
Clinical Spotlight interview, and this

9
00:00:33,230 --> 00:00:37,200
month the focus is on surgical management
of biliary tract disease in cats.

10
00:00:37,770 --> 00:00:38,780
I'll be speaking with Dr.

11
00:00:38,780 --> 00:00:40,709
Daniel Low on his review article.

12
00:00:46,549 --> 00:00:50,309
So we are talking about your paper
today, and the title is Cat Friendly

13
00:00:50,309 --> 00:00:54,699
Practice Improves Feline Visits
Resulting in Increased Laboratory

14
00:00:54,879 --> 00:00:58,869
Testing and Increased Diagnosis of
Certain Common Feline Conditions.

15
00:00:59,209 --> 00:01:02,129
To start with, would you be
able to summarize the study

16
00:01:02,129 --> 00:01:03,779
and the study design for us?

17
00:01:04,690 --> 00:01:05,050
Kelly St. Denis: Sure.

18
00:01:05,060 --> 00:01:09,220
So this is something that was put together
with collaboration between AAFP and IDEXX.

19
00:01:09,240 --> 00:01:13,269
So we did look at a number of Cat
Friendly Practices versus non Cat Friendly

20
00:01:13,269 --> 00:01:15,630
Practices in a retrospective manner.

21
00:01:16,020 --> 00:01:19,370
And of course, those practices
had to have an IDEXX account and

22
00:01:19,370 --> 00:01:22,429
a practice information management
system so that IDEXX could actually

23
00:01:22,449 --> 00:01:24,290
monitor the data that was collected.

24
00:01:24,380 --> 00:01:27,630
And they broke the analysis up
into two different sets of data.

25
00:01:27,630 --> 00:01:31,370
So first was the financial and
then also a clinical findings.

26
00:01:31,830 --> 00:01:37,150
Our hypotheses were that Cat Friendly
Practices were going to be getting

27
00:01:37,160 --> 00:01:42,160
more income from laboratory testing,
but also doing more diagnostic testing

28
00:01:42,160 --> 00:01:46,860
and also having increased results and
findings associated with disease in cats.

29
00:01:47,730 --> 00:01:50,529
Nathalie Dowgray: As vets, we're often
very focused on the clinical side of

30
00:01:50,529 --> 00:01:54,799
things, but sometimes people that are
more in the managerial side of things

31
00:01:54,799 --> 00:01:57,859
want to see what the financial benefit is.

32
00:01:57,859 --> 00:01:59,509
Kelly St. Denis: We have some
publications that have already

33
00:01:59,509 --> 00:02:03,020
shown that, we know there's reduced
injury and reduced insurance claims.

34
00:02:03,050 --> 00:02:07,369
We know from a Cat Friendly Clinic
study done in Spain by Pere Mercader

35
00:02:07,389 --> 00:02:11,070
that again, they had shown increased
income associated with Cat Friendly

36
00:02:11,070 --> 00:02:12,889
Clinics compared to non Cat Friendly.

37
00:02:13,270 --> 00:02:16,990
So there is information out there,
but in this study, in the financial

38
00:02:16,990 --> 00:02:19,240
analysis, we also found similar results.

39
00:02:19,300 --> 00:02:22,609
They did look at two different
years in the financial cohort.

40
00:02:23,070 --> 00:02:24,760
They wanted to look at pre pandemic.

41
00:02:24,780 --> 00:02:29,570
So they looked at data from 2018 and
then also data from 2021, but they were

42
00:02:29,570 --> 00:02:31,410
looking at things like visits per year.

43
00:02:31,440 --> 00:02:34,560
And then the proportion of visits
that included diagnostic test results.

44
00:02:34,639 --> 00:02:38,209
And they looked specifically in the
financial analysis, that blood testing,

45
00:02:38,589 --> 00:02:40,624
imaging, faecal testing, and urine.

46
00:02:40,984 --> 00:02:43,905
And then they looked at revenue
per visit type and yearly

47
00:02:43,905 --> 00:02:45,375
revenue per feline patient.

48
00:02:46,265 --> 00:02:49,934
And so when they looked at those two
different years, they found there

49
00:02:49,934 --> 00:02:52,824
was not really any difference between
the two of them, so we didn't have to

50
00:02:52,824 --> 00:02:55,065
worry about pandemic related factors.

51
00:02:55,714 --> 00:02:59,945
And they did find, as was found in the
CFC study, that there was an increased

52
00:03:00,005 --> 00:03:04,034
average per feline visit practice
revenue, and they also found a higher

53
00:03:04,055 --> 00:03:09,089
annual revenue per feline patient for all
visits and also for diagnostic visits.

54
00:03:09,250 --> 00:03:12,089
So where patients are actually
having diagnostic testing.

55
00:03:13,559 --> 00:03:17,019
The other thing that they found, which was
part of our hypothesis and we confirmed,

56
00:03:17,019 --> 00:03:20,390
was that there was a higher proportion
of cats in Cat Friendly Practices

57
00:03:20,390 --> 00:03:22,540
that had diagnostic testing performed.

58
00:03:22,899 --> 00:03:24,809
And that was at any
type of clinical visit.

59
00:03:24,889 --> 00:03:27,579
And then they also specifically
looked at wellness visits.

60
00:03:28,535 --> 00:03:31,734
So, I should clarify that one of the
things that they did with the financial

61
00:03:31,744 --> 00:03:35,285
data and the clinical findings was
they took out non clinical visits.

62
00:03:35,285 --> 00:03:38,744
So anytime someone was spending money
on things like prescription refills

63
00:03:38,744 --> 00:03:42,605
or, um, picking up food, boarding or
anything like that, that those were

64
00:03:42,605 --> 00:03:44,575
not included in the financial data.

65
00:03:45,504 --> 00:03:48,415
And then finally, one of the other
findings that we had under the financial

66
00:03:48,415 --> 00:03:51,715
analysis was that there was actually no
difference in the proportion of wellness

67
00:03:51,745 --> 00:03:56,005
visits, but we did find an increased
clinical visit per feline patient.

68
00:03:56,174 --> 00:03:58,405
We know that clients seem to have more.

69
00:03:58,930 --> 00:04:01,950
trust and more comfort in dealing
with a cat friendly clinic

70
00:04:01,950 --> 00:04:02,890
or a cat friendly practice.

71
00:04:02,920 --> 00:04:05,820
One thing that really struck me
in the Spain studies was that 40

72
00:04:05,820 --> 00:04:08,969
percent more caregivers were likely
to buy their food at the practice.

73
00:04:09,690 --> 00:04:14,220
So that to me signals that caregivers
are trusting us more and more

74
00:04:14,220 --> 00:04:15,879
willing to take our recommendations.

75
00:04:15,889 --> 00:04:19,059
And so when we make a recommendation
for diagnostics, they're

76
00:04:19,060 --> 00:04:20,650
more likely to agree to it.

77
00:04:20,955 --> 00:04:24,725
And again, this is all correlation
and not causation, but certainly

78
00:04:24,725 --> 00:04:25,935
that would be the suspicion.

79
00:04:26,595 --> 00:04:26,895
Nathalie Dowgray: Yeah.

80
00:04:26,895 --> 00:04:30,295
And that was definitely my thoughts
as well, that taking the time

81
00:04:30,325 --> 00:04:33,685
to communicate what you're doing
builds that trust, doesn't it?

82
00:04:33,685 --> 00:04:37,064
Kelly St. Denis: And the caregivers can
see in front of them what we're doing

83
00:04:37,065 --> 00:04:38,584
with their cats and that it's different.

84
00:04:38,635 --> 00:04:42,005
Nathalie Dowgray: And then the second part
of the study was where you were comparing

85
00:04:42,245 --> 00:04:47,525
Cat Friendly versus non Cat Friendly based
on geographical and other data as well.

86
00:04:47,545 --> 00:04:50,900
So you're trying to compare like
for like as much as possible.

87
00:04:51,160 --> 00:04:54,240
Would you be able to sort of summarize
the findings from that part of the study?

88
00:04:54,320 --> 00:04:55,200
Kelly St. Denis: Absolutely.

89
00:04:55,210 --> 00:04:55,280
Yes.

90
00:04:55,340 --> 00:04:58,680
They looked during one whole
year from June of 2021 to 2022.

91
00:04:59,110 --> 00:05:02,059
And as you noted, it was matching
for every one Cat Friendly

92
00:05:02,059 --> 00:05:05,120
Practice that was IDEXX with the
practice information management.

93
00:05:05,410 --> 00:05:07,930
They looked at seven non
Cat Friendly Practices.

94
00:05:08,610 --> 00:05:11,760
And we weren't necessarily looking
at the data from the geographical

95
00:05:11,760 --> 00:05:15,379
perspective, although that was a bit of
a sub study, just looking at regions in

96
00:05:15,380 --> 00:05:19,130
the US and if there were any differences
there that might suggest a bias.

97
00:05:19,389 --> 00:05:22,200
So again, they were looking at
testing categories, but in this case

98
00:05:22,229 --> 00:05:26,599
it was biochemistry, complete blood
count, thyroid where appropriate

99
00:05:26,599 --> 00:05:30,699
based on age, and then urinalysis
or some portion of a urinalysis.

100
00:05:31,369 --> 00:05:34,625
And they took the other couple of
things out, the radiographs and the

101
00:05:34,625 --> 00:05:37,785
faecal, because those were harder
to follow because they weren't

102
00:05:37,865 --> 00:05:41,634
necessarily directly associated with
that practice information system.

103
00:05:42,165 --> 00:05:44,294
So when they were looking at
those, they were trying to find

104
00:05:44,295 --> 00:05:45,755
proportionate clinical visits.

105
00:05:46,045 --> 00:05:50,344
In which each finding was observed how
much volume of testing categories as a

106
00:05:50,344 --> 00:05:52,134
proportion of clinical visits occurred.

107
00:05:52,165 --> 00:05:56,215
And then the proportion of
diagnostic visits with 1, 2,

108
00:05:56,215 --> 00:05:57,635
3, or 4 testing categories.

109
00:05:57,655 --> 00:06:00,895
So, did they just do biochem,
biochem and CBC, biochem and a

110
00:06:00,945 --> 00:06:03,155
urinalysis for example, or all 4.

111
00:06:04,015 --> 00:06:07,814
So, in the clinical findings,
the visits per cat and higher

112
00:06:07,835 --> 00:06:11,724
diagnostic inclusion reflected what
we found in the financial analysis.

113
00:06:12,315 --> 00:06:15,265
And then what they found was that
the Cat Friendly Practices were more

114
00:06:15,325 --> 00:06:18,895
likely to include testing across
multiple testing categories, so

115
00:06:19,234 --> 00:06:24,495
biochem, CBC, thyroid urinalysis,
and Significantly lower odds of

116
00:06:24,495 --> 00:06:26,665
performing testing in only one category.

117
00:06:27,525 --> 00:06:30,934
And then when they looked at that in
more detail, they had significantly

118
00:06:30,934 --> 00:06:34,325
higher odds of performing testing
for more than one category.

119
00:06:34,625 --> 00:06:37,314
So the Cat Friendly Practices
were more likely to do more

120
00:06:37,314 --> 00:06:39,215
testing in multiple categories.

121
00:06:40,165 --> 00:06:43,765
And then when we look at actually
findings that they had, when we look

122
00:06:43,765 --> 00:06:46,985
at Cat Friendly Practices, we're more
likely to have a result within the

123
00:06:46,985 --> 00:06:48,815
reference interval for most analytes.

124
00:06:48,895 --> 00:06:52,075
When there were abnormalities
found, they were more likely

125
00:06:52,075 --> 00:06:54,374
associated with endocrine thyroid.

126
00:06:54,454 --> 00:06:58,345
For example, kidney and electrolyte
system categories, which reflect those

127
00:06:58,385 --> 00:07:01,094
common problems that cats get as they age.

128
00:07:01,134 --> 00:07:04,275
So those were kind of like
key findings for that section.

129
00:07:04,515 --> 00:07:08,435
In my own practice, if I'm seeing senior
cats, I want to start testing them early,

130
00:07:08,435 --> 00:07:12,615
even before they're showing any history
or clinical signs of disease on physical

131
00:07:12,615 --> 00:07:17,175
exam, because I can get baseline values
for those patients and then trend them.

132
00:07:17,545 --> 00:07:21,315
And so when we're finding more values
in the reference interval,  that means

133
00:07:21,315 --> 00:07:25,865
we're probably having more opportunity to
trend our patients, which is proactive.

134
00:07:25,915 --> 00:07:27,845
Nathalie Dowgray: Thank you
so much for your time today.

135
00:07:27,945 --> 00:07:31,645
Hopefully the people listening will find
the links to the full paper in the show

136
00:07:31,645 --> 00:07:34,075
notes and dive in and read it in full.

137
00:07:34,504 --> 00:07:35,304
Kelly St. Denis: Yes, please do.

138
00:07:35,995 --> 00:07:36,584
Thanks, Nat.

139
00:07:36,645 --> 00:07:37,495
Nathalie Dowgray: Thank you, Kelly..

140
00:07:40,734 --> 00:07:41,984
And now we're speaking with Dr.

141
00:07:41,984 --> 00:07:46,145
Daniel Low on his JFMS Clinical
Spotlight article on the surgical

142
00:07:46,145 --> 00:07:50,344
management of feline biliary tract
disease, decision making and techniques.

143
00:07:52,200 --> 00:07:55,850
So just to get started, Daniel, I
was wondering if you have a preferred

144
00:07:55,900 --> 00:08:01,659
diagnostic approach to deciding if surgery
is indicated in cases of especially

145
00:08:01,659 --> 00:08:03,730
extrahepatic biliary obstruction.

146
00:08:04,980 --> 00:08:07,470
Daniel Low: First off, every
case is unique and should be

147
00:08:07,470 --> 00:08:09,380
approached on an individual basis.

148
00:08:09,610 --> 00:08:12,059
Although a general
approach can be discussed.

149
00:08:12,369 --> 00:08:15,799
First, you'd suspect hepatobiliary
disease on the basis of its

150
00:08:15,809 --> 00:08:17,090
presenting clinical signs.

151
00:08:17,490 --> 00:08:21,810
You'd narrow down your differential list
after doing hematology and biochemistry.

152
00:08:21,980 --> 00:08:25,910
Certain abnormalities on your routine
clinical pathology would lead you to

153
00:08:25,910 --> 00:08:28,299
suspect biliary tract disease in a cat.

154
00:08:28,650 --> 00:08:33,219
Then you'd normally proceed to
imaging to diagnose extrahepatic

155
00:08:33,280 --> 00:08:37,939
biliary tract obstruction, I'll
abbreviate this as EHBO from now on.

156
00:08:38,429 --> 00:08:42,510
For imaging, most likely this
will be abdominal ultrasonography.

157
00:08:42,850 --> 00:08:48,365
Most practices should have access to this
imaging modality, but it has to be said

158
00:08:48,365 --> 00:08:51,625
that you need an experienced operator
to be able to look at the biliary tract.

159
00:08:51,765 --> 00:08:55,855
Once you've performed all that and you've
diagnosed extrahepatic biliary tract

160
00:08:55,895 --> 00:09:00,745
obstruction, you should also be diagnosing
the underlying cause and further

161
00:09:00,745 --> 00:09:03,104
decisions will be made on this basis.

162
00:09:03,375 --> 00:09:07,115
For example, inflammatory and
neoplastic biliary tract disease

163
00:09:07,115 --> 00:09:08,464
will be approached very differently.

164
00:09:08,735 --> 00:09:12,584
But broadly speaking, the practitioner
after diagnosis will need to

165
00:09:12,584 --> 00:09:16,649
decide whether to proceed with
medical or surgical management.

166
00:09:16,979 --> 00:09:20,560
Surgery would be indicated
if you have tried medical

167
00:09:20,560 --> 00:09:21,969
management and it has failed.

168
00:09:22,199 --> 00:09:26,059
Or if you think that medical management
is very likely to fail, but this

169
00:09:26,059 --> 00:09:27,719
goes back to the underlying cause.

170
00:09:28,019 --> 00:09:32,890
And finally, the surgeon is not the sole
decision maker in these cases, as usually

171
00:09:33,300 --> 00:09:36,989
collaboration with other colleagues
from other services would be required.

172
00:09:37,310 --> 00:09:40,020
So you wouldn't necessarily
be working by yourself.

173
00:09:40,865 --> 00:09:41,285
Nathalie Dowgray: Brilliant.

174
00:09:41,295 --> 00:09:43,995
And I was quite interested in the
paper and reading about this sort

175
00:09:43,995 --> 00:09:46,245
of stenting procedure as well.

176
00:09:46,694 --> 00:09:50,135
And in the case where you're having
to place a stent, how long does that

177
00:09:50,215 --> 00:09:51,955
stent generally remain in place?

178
00:09:51,965 --> 00:09:54,824
Daniel Low: Biliary stenting is
not the same as cannulization

179
00:09:54,845 --> 00:09:55,924
of the biliary tract.

180
00:09:55,924 --> 00:10:00,605
Cannulization performs intraoperatively
and you remove the cannula once

181
00:10:00,615 --> 00:10:01,945
you've confirmed the patency.

182
00:10:02,345 --> 00:10:05,825
Stenting provides
temporary relief of EHBO.

183
00:10:05,825 --> 00:10:09,845
A stent is placed with the intent to
maintain a lumen within the common

184
00:10:09,845 --> 00:10:14,045
bowel duct on a temporary basis until
the swelling and obstruction resolves.

185
00:10:14,375 --> 00:10:18,365
So the stent is placed and anchored
with monofilament absorbable suture

186
00:10:18,365 --> 00:10:20,900
material, PDS or monocryl for example,

187
00:10:21,270 --> 00:10:25,949
and what this does is as it's absorbed
by the body, the stent will pass into

188
00:10:25,949 --> 00:10:29,920
the gastrointestinal tract once the
suture has lost its tensile strength.

189
00:10:29,969 --> 00:10:32,329
PDS would probably last
longer than monocryl.

190
00:10:32,560 --> 00:10:37,310
So the choice of suture material would
be at the discretion of the surgeon,

191
00:10:37,370 --> 00:10:41,170
depending on how aggressive you think
the disease is and how long you think

192
00:10:41,170 --> 00:10:43,230
you need to maintain that stent in place.

193
00:10:44,000 --> 00:10:45,010
Nathalie Dowgray: Okay, brilliant.

194
00:10:45,020 --> 00:10:48,540
The article also mentioned
cholecystotomy tube placement.

195
00:10:48,990 --> 00:10:52,540
So would you be able to tell us a little
bit more about what they are and what

196
00:10:52,569 --> 00:10:54,630
the indications for their placement are?

197
00:10:54,730 --> 00:10:57,870
Daniel Low: A cholecystotomy tube
would be a tube that's placed into

198
00:10:57,870 --> 00:11:01,509
the gallbladder and exiting the
body, creating an exit for bowel.

199
00:11:02,105 --> 00:11:07,035
This works similarly to a biliary
stent, in that it provides a temporary

200
00:11:07,105 --> 00:11:11,155
biliary diversion, and it is not a
definitive treatment for any disease,

201
00:11:11,155 --> 00:11:15,825
but just provides temporary relief
for whatever the underlying cause is.

202
00:11:16,085 --> 00:11:17,835
Cats are limited by their size.

203
00:11:18,244 --> 00:11:23,350
Briefly, a step incision is created in
the gallbladder, and you place a pigtail

204
00:11:23,380 --> 00:11:27,980
catheter around a purse string suture and
then you exit it through the body wall.

205
00:11:28,010 --> 00:11:31,260
So it's very much like a
gastrostomy feeding tube, just

206
00:11:31,260 --> 00:11:32,840
in a different luminal organ.

207
00:11:33,210 --> 00:11:37,480
And what you do is you can use
this tube to remove bowel from the

208
00:11:37,490 --> 00:11:40,429
gallbladder so that you don't have
any further progression of the

209
00:11:40,429 --> 00:11:45,110
EHBO while you are treating the
underlying disease by another means.

210
00:11:45,550 --> 00:11:48,930
And these tubes are normally
pulled after three to four weeks,

211
00:11:48,989 --> 00:11:52,569
and you can remove them just like
any other ostomy tube, esophageal

212
00:11:52,630 --> 00:11:54,880
ostomy tube or gastrostomy tube.

213
00:11:55,140 --> 00:11:57,760
Nathalie Dowgray: Should this type of
biliary track surgery really always be

214
00:11:57,760 --> 00:12:02,349
left to the specialists or are there
some procedures that you think could be

215
00:12:02,780 --> 00:12:07,559
suitable for potentially more advanced
or experienced general practitioner vets?

216
00:12:07,999 --> 00:12:12,209
Daniel Low: I think cholecystectomy and
treatment of bowel peritonitis may be

217
00:12:12,209 --> 00:12:16,439
performed by advanced practitioners who
are familiar with the procedures and with

218
00:12:16,439 --> 00:12:18,520
prior experience of soft tissue surgery.

219
00:12:18,900 --> 00:12:23,420
As a lot of the soft tissue surgical
principles can be extrapolated to these

220
00:12:23,430 --> 00:12:29,379
procedures, other procedures such as
biliary diversion or choledocotomies,

221
00:12:29,400 --> 00:12:33,780
they are much more advanced and should
only be performed if you have prior

222
00:12:33,780 --> 00:12:36,199
training or mentoring in these procedures.

223
00:12:36,749 --> 00:12:40,050
If that's not something that you
have any experience with, then it's

224
00:12:40,069 --> 00:12:42,109
probably best to refer these cases.

225
00:12:42,489 --> 00:12:47,870
It's also useful to refer because these
cases always require multidisciplinary

226
00:12:47,870 --> 00:12:51,344
approach and the surgeon is not
the one working in isolation.

227
00:12:51,845 --> 00:12:56,015
You are going to need intensive
perioperative care and if your facilities

228
00:12:56,095 --> 00:12:58,805
aren't adequate, then best to refer again.

229
00:13:00,024 --> 00:13:00,564
Nathalie Dowgray: Brilliant.

230
00:13:00,705 --> 00:13:02,625
Thank you very much for
your time today, Daniel.

231
00:13:02,625 --> 00:13:04,495
I've definitely enjoyed
reading the article.

232
00:13:04,495 --> 00:13:07,145
I think for most of us in general
practice, there's some really

233
00:13:07,154 --> 00:13:09,015
useful bits of information in there.

234
00:13:09,015 --> 00:13:10,525
So thank you so much.

235
00:13:11,165 --> 00:13:11,375
Daniel Low: Yes.

236
00:13:11,375 --> 00:13:12,495
And thank you for having me.

237
00:13:12,564 --> 00:13:16,705
And if listeners have any, any
further questions or wondering about

238
00:13:16,814 --> 00:13:19,605
biliary tract surgery, then please
do take a look at the article.

239
00:13:25,605 --> 00:13:26,595
Nathalie Dowgray: Thank you for listening.

240
00:13:26,625 --> 00:13:30,004
If you're an ISFM member, don't forget
you can access the full version of

241
00:13:30,004 --> 00:13:34,065
the podcast and all the other ISFM
member benefits, including congress

242
00:13:34,065 --> 00:13:38,555
recordings, monthly webinars and clinical
clubs, the discussion forum, and much,

243
00:13:38,555 --> 00:13:41,324
much more at portal.icatcare.org.

244
00:13:41,985 --> 00:13:45,275
We'll be back again next month with
an additional bonus episode, as well

245
00:13:45,275 --> 00:13:46,905
as our regular monthly chatterings.

246
00:13:47,435 --> 00:13:50,305
If you don't want to miss out, do make
sure you've signed up to Chattering with

247
00:13:50,305 --> 00:13:53,115
ISFM on your preferred podcast platform.