1 00:00:05,280 --> 00:00:09,510 Hello, and welcome to the April episode of Chattering with International Cat Care. 2 00:00:10,190 --> 00:00:14,159 I'm Yaiza Gomez Mejias, iCatCare veterinary community coordinator 3 00:00:14,210 --> 00:00:15,600 and host of this month's podcast. 4 00:00:16,470 --> 00:00:19,620 Our clinical spotlight this month is focused on dermatology. 5 00:00:20,630 --> 00:00:25,550 Dr Kelly St Denis will be speaking with Dr Banovic about immune-mediated 6 00:00:25,550 --> 00:00:29,919 skin disease in cats, it's presentation, diagnosis and management. 7 00:00:30,659 --> 00:00:35,309 But first, I will be interviewing Dr Llibertat Real Sampietro on 8 00:00:35,309 --> 00:00:39,309 her JFMS Open report about fatal disseminated toxoplasmosis. 9 00:00:45,029 --> 00:00:48,580 What is toxoplasmosis and how does it affect cats? 10 00:00:49,929 --> 00:00:53,589 Toxoplasmosis is a disease caused by Toxoplasma gondii, which is 11 00:00:53,689 --> 00:00:57,609 an apicomplexan proteasome, and it has a worldwide distribution. 12 00:00:57,719 --> 00:01:03,229 Cats are pivotal in Toxoplasma persisting in the environment because they are 13 00:01:03,229 --> 00:01:10,539 the only mammal or the only being where Toxoplasma can sexually reproduce and 14 00:01:11,090 --> 00:01:14,829 so how it affects cats is usually it doesn't affect them at all actually. 15 00:01:15,660 --> 00:01:19,499 And then sometimes in some cats, it can cause disease, which can range 16 00:01:19,499 --> 00:01:22,280 from mild to acute fatal disease. 17 00:01:22,289 --> 00:01:26,079 So we can have a wide range of presentations, but most of the time 18 00:01:26,079 --> 00:01:31,090 we will have no disease at all because the relationship between toxoplasma 19 00:01:31,130 --> 00:01:36,810 and cats, and cats brains, which we can speak about later, it's very ancient. 20 00:01:36,810 --> 00:01:40,240 It's very old, and so they have adapted very well. 21 00:01:40,289 --> 00:01:42,720 It will usually not cause any disease in cats. 22 00:01:43,960 --> 00:01:45,720 How do cats catch the disease? 23 00:01:46,850 --> 00:01:52,060 Cats can catch the disease by mostly two ways, but there's a third one also. 24 00:01:52,060 --> 00:01:57,389 But basically they will catch it by hunting small prey, that can be rodents 25 00:01:57,389 --> 00:02:02,979 or birds, because toxoplasma can live in any warm blooded living being. 26 00:02:03,090 --> 00:02:08,390 But also if humans feed raw meat to cats, they can also catch it. 27 00:02:08,959 --> 00:02:13,249 And also sometimes they can become infected by their mom when 28 00:02:13,249 --> 00:02:16,749 they're in womb by their mom, and sometimes also through the milk. 29 00:02:16,839 --> 00:02:21,269 What are the typical signs of fatal disseminated toxoplasmosis in cats? 30 00:02:21,870 --> 00:02:28,180 We should suspect it when a cat becomes very ill, showing severe disease after 31 00:02:28,709 --> 00:02:33,500 exploring the cat and running the blood test, or the imaging test that 32 00:02:33,500 --> 00:02:38,960 we need to run, the disease mostly appears focused on the respiratory tract 33 00:02:39,000 --> 00:02:41,450 and liver, but also on the pancreas. 34 00:02:42,440 --> 00:02:46,230 Other cats may present with acute neurological disease. 35 00:02:46,360 --> 00:02:51,029 This would be the other way of presenting, but when it is acutely disseminated, 36 00:02:51,030 --> 00:02:54,160 usually it's not only the central nervous system that is affected, but 37 00:02:54,170 --> 00:02:55,940 also the liver and respiratory tract. 38 00:02:57,660 --> 00:03:02,209 The clinical science may come across as nonspecific, and on top of that, 39 00:03:02,230 --> 00:03:03,380 we have a rapid deterioration. 40 00:03:03,390 --> 00:03:05,390 So it's all quite challenging. 41 00:03:05,990 --> 00:03:11,550 And also none very specific, but at the same time a bit strange because you don't 42 00:03:11,579 --> 00:03:18,750 tend to see many cats with respiratory and liver clinical signs and biochemical 43 00:03:18,750 --> 00:03:21,310 changes and it progresses really quick. 44 00:03:21,310 --> 00:03:26,219 So the first day you may think it's pancreatitis, or maybe I just have 45 00:03:26,220 --> 00:03:30,390 a cat with some degree of pneumonia and he's very ill because of the 46 00:03:30,390 --> 00:03:35,050 pneumonia, but then because of this very rapid progression, then you see 47 00:03:35,050 --> 00:03:38,850 that the liver goes really worse or the pancreatic disease will go really worse. 48 00:03:39,140 --> 00:03:43,460 But at the same time, you get all those respiratory changes and that 49 00:03:43,460 --> 00:03:47,790 doesn't make much sense with either liver or pancreatic disease by itself, 50 00:03:48,499 --> 00:03:52,850 not being by an infectious disease, so that makes you think about it more. 51 00:03:52,860 --> 00:03:57,089 I think we should think about it when it goes quick and affects these two organs. 52 00:03:57,089 --> 00:04:02,540 If they have ocular signs or central nervous system signs, that should put 53 00:04:02,540 --> 00:04:04,440 it from the differential list higher. 54 00:04:05,540 --> 00:04:06,989 It can be tricky, can't it? 55 00:04:07,440 --> 00:04:10,749 How do you diagnose toxoplasmosis In cats? 56 00:04:12,950 --> 00:04:18,080 You need clinical signs compatible with the disease for one thing, because you can 57 00:04:18,080 --> 00:04:25,319 have many cats that have become exposed to the toxoplasma because they ate that prey 58 00:04:25,360 --> 00:04:31,549 or that raw meat that had the cysts there, and then they contacted the parasite. 59 00:04:31,559 --> 00:04:35,030 It became disseminated and it became dormant and nothing happened. 60 00:04:35,629 --> 00:04:39,270 But because the big contact, the parasite, they will have produced 61 00:04:39,280 --> 00:04:43,219 some sort of immune reaction to it, and because many cats become 62 00:04:43,220 --> 00:04:49,109 exposed, you can have many cats being positive to toxoplasma not being ill. 63 00:04:49,109 --> 00:04:53,649 So you need to have compatible clinical signs, or at least some sort of clinical 64 00:04:53,650 --> 00:04:59,040 sign that you could put into toxoplasmas list of things that can cause, and then 65 00:04:59,040 --> 00:05:01,510 you need to prove the parasite is there. 66 00:05:01,859 --> 00:05:04,460 You can prove it with serology sometimes. 67 00:05:05,630 --> 00:05:09,700 With serology, you can do, you run immunoglobulins and you need to run 68 00:05:09,749 --> 00:05:15,919 IgGs and IgMs and you need to run both of them because IgGs will only show 69 00:05:15,929 --> 00:05:17,674 that the cat has been exposed to it. 70 00:05:17,849 --> 00:05:21,229 So you can have a very high titre in a completely healthy cat. 71 00:05:21,830 --> 00:05:25,030 Pregnant women can have the toxoplasma test and be healthy. 72 00:05:26,030 --> 00:05:30,780 Or it can be negative if it's been a recent exposure, but, and then you 73 00:05:30,780 --> 00:05:35,284 need to run the IgMs, and the IgM, it will show recent exposure and it 74 00:05:35,479 --> 00:05:37,239 will indicate an active infection. 75 00:05:37,729 --> 00:05:43,719 So, if your IgM titre is positive and is above 164, then that means that cat was 76 00:05:43,719 --> 00:05:46,189 exposed, recently exposed to toxoplasma. 77 00:05:46,190 --> 00:05:51,060 So if you get that positive titre and he shows clinical signs compatible 78 00:05:51,060 --> 00:05:55,820 with it, that could mean it does have toxoplasma, but you could also 79 00:05:55,820 --> 00:05:59,030 have a healthy cat with a positive IgM just because he was recently 80 00:05:59,030 --> 00:06:00,859 exposed, and it would only mean that. 81 00:06:00,859 --> 00:06:05,369 So as with all diseases, we only need to look when we have clinical 82 00:06:05,369 --> 00:06:06,920 signs compatible with the disease. 83 00:06:06,959 --> 00:06:13,080 And if you find some lesion or some area where you think it's focused, 84 00:06:13,239 --> 00:06:16,300 your disease, for instance, in our case it was the lung and the liver, 85 00:06:16,300 --> 00:06:21,229 but you could have skin nodules, or you could have cholecystitis and a 86 00:06:21,650 --> 00:06:26,109 bile infection, enlarged abdominal lymph node, pneumonia, you could do 87 00:06:26,109 --> 00:06:27,769 a bronchoalveolar lavage as well. 88 00:06:28,299 --> 00:06:32,540 When you have localised where your problem is, if it's a place where you 89 00:06:32,540 --> 00:06:37,659 could take a sample with a fine needle aspirate or with pathology, you could 90 00:06:37,659 --> 00:06:42,960 run a PCR and if it was positive, that would show that the parasite it is there. 91 00:06:47,139 --> 00:06:50,780 And now Dr Kelly St Denis will be interviewing Dr Banovic 92 00:06:51,000 --> 00:06:55,500 about his JFMS article on immune mediated skin disease in cats. 93 00:06:56,030 --> 00:06:59,680 This is the first of two parts, and you will be able to access the 94 00:06:59,680 --> 00:07:01,589 second part of the interview in June. 95 00:07:03,099 --> 00:07:07,650 Today we are meeting with Dr Frane Banovich, to discuss the 96 00:07:07,650 --> 00:07:10,590 clinical spotlight articles that he's written for the Journal of 97 00:07:10,590 --> 00:07:14,789 Feline Medicine and Surgery, feline Immune Mediated Skin Disorders. 98 00:07:14,839 --> 00:07:17,690 There are so many immune mediated skin disorders in cats, that 99 00:07:17,690 --> 00:07:20,769 we decided to break it into two different clinical spotlight articles. 100 00:07:20,799 --> 00:07:24,539 From a general perspective, Dr Banovic, I was wondering if you could just 101 00:07:24,539 --> 00:07:28,020 discuss with us like how common are immune mediated diseases in cats? 102 00:07:29,190 --> 00:07:30,120 Very good question. 103 00:07:30,120 --> 00:07:36,140 So in general rule, there is always debate about using terminology of autoimmune 104 00:07:36,619 --> 00:07:39,849 and immune mediated as disease processes. 105 00:07:40,349 --> 00:07:44,370 In general sense, we prefer to use autoimmune when we can really show 106 00:07:44,700 --> 00:07:49,580 that there is a direct immune response against its own tissue, against its own 107 00:07:49,590 --> 00:07:53,359 antigen, which we would call auto antigen. 108 00:07:53,359 --> 00:07:57,739 Unfortunately, in veterinary diseases or veterinary medicine, 109 00:07:57,749 --> 00:08:01,189 the advancements of techniques generally lacks the human field. 110 00:08:01,489 --> 00:08:05,719 So in many instances we have a high suspicion that there is an auto antigen, 111 00:08:06,059 --> 00:08:11,819 but we generally lack techniques or studies to prove that so many times 112 00:08:11,839 --> 00:08:16,369 the, we like to use the terminology immune mediated diseases, which shows 113 00:08:16,369 --> 00:08:18,579 that there is an inflammatory process. 114 00:08:18,770 --> 00:08:24,109 Highly likely it's autoimmune in many of these cases, but unfortunately, due to the 115 00:08:24,109 --> 00:08:28,219 lack of studies, we cannot really come and say, oh, this is an autoimmune disease. 116 00:08:28,260 --> 00:08:32,799 We show that this is an auto antigen, and if you look at the dogs and cats, 117 00:08:33,020 --> 00:08:36,609 we have far more evidence in dogs than we would have in cats because 118 00:08:36,620 --> 00:08:40,689 in general sense, I would also say as a clinician scientist, we tend to 119 00:08:40,689 --> 00:08:43,380 research less cats than we do dogs. 120 00:08:44,270 --> 00:08:44,839 That's so true. 121 00:08:45,400 --> 00:08:49,509 And also, to be honest, I would also say that it's not as easy to collect samples 122 00:08:49,510 --> 00:08:53,500 from cats as it is from dogs, which also contributes to the problem I think. 123 00:08:54,050 --> 00:08:58,730 Now, regarding these diseases, how common they are, it's a very good point. 124 00:08:58,800 --> 00:09:03,630 I would say that in my clinic, the most common disease we tend to see is some kind 125 00:09:03,630 --> 00:09:08,100 of an allergic dermatitis disease, whether that's a feline atopic skin syndrome 126 00:09:08,110 --> 00:09:10,940 or atopic skin syndrome due to food. 127 00:09:11,249 --> 00:09:12,569 I would say that's rare. 128 00:09:12,790 --> 00:09:17,699 And then we do see these weird immune mediated diseases come 129 00:09:17,699 --> 00:09:19,740 to us on a regular basis. 130 00:09:19,750 --> 00:09:24,229 Some of them come through ER because the cats have undiagnosed pemphigus 131 00:09:24,600 --> 00:09:27,850 that is not an allergic skin disease, but gets treated like that. 132 00:09:27,850 --> 00:09:31,390 And then they unfortunately come through emergency service because 133 00:09:31,430 --> 00:09:32,960 the patient is not doing well. 134 00:09:33,240 --> 00:09:37,650 Some diseases are not that dramatic and it's just a foot pad and 135 00:09:37,650 --> 00:09:40,910 therefore can wait a month or two months to get a referral in. 136 00:09:41,329 --> 00:09:42,749 So it just depends on a patient. 137 00:09:42,780 --> 00:09:43,550 But do we see them? 138 00:09:43,589 --> 00:09:44,169 Absolutely. 139 00:09:44,169 --> 00:09:44,579 Yes. 140 00:09:44,919 --> 00:09:48,770 As a matter of fact, to give you a fun story, one of my PhD students last week 141 00:09:48,770 --> 00:09:54,540 emailed me foot pad lesions from her roommate's cat, and the cat has a, what 142 00:09:54,540 --> 00:09:55,770 we would call plasma cell pododermatitis. 143 00:09:56,760 --> 00:10:01,759 It's in, in the part two, but classic example of it, all four 144 00:10:02,060 --> 00:10:04,239 feet, all four central pads. 145 00:10:04,620 --> 00:10:08,700 And of course, so they do, they are there, but maybe they are not diagnosed. 146 00:10:08,750 --> 00:10:12,179 Maybe sometimes they're, there's not such morbidity that people 147 00:10:12,319 --> 00:10:15,990 are gonna investigate more in depth and multiple factors. 148 00:10:16,510 --> 00:10:16,880 Yeah. 149 00:10:17,170 --> 00:10:17,250 Yeah. 150 00:10:17,379 --> 00:10:20,420 And so as clinicians, like someone for myself in general practice, 151 00:10:20,879 --> 00:10:24,389 obviously there's some pretty classic things that we may see that say immune 152 00:10:24,389 --> 00:10:28,280 mediated derma dermatologic issues or autoimmune dermatologic issues. 153 00:10:28,640 --> 00:10:31,280 But when I'm looking at a cat with skin disease, would you say there's 154 00:10:31,280 --> 00:10:35,820 a short list of things you would say, we should put that autoimmune 155 00:10:35,820 --> 00:10:39,209 disease on our differential list as soon as possible, or right away? 156 00:10:39,790 --> 00:10:42,380 There are some clues like in the paper. 157 00:10:42,380 --> 00:10:46,850 That is the reason why we decided to go into the paper project because 158 00:10:46,860 --> 00:10:51,680 some diseases definitely have a very relatively unique clinical phenotype. 159 00:10:52,199 --> 00:10:56,309 So, for  pemphigus that would be, for instance, there are not many diseases 160 00:10:56,470 --> 00:11:01,349 that will cause very uniquely the nail fold production of puss in there 161 00:11:01,510 --> 00:11:05,990 and when you squeeze the nail folds out, you basically see pus coming out. 162 00:11:06,000 --> 00:11:09,800 That's very unique for pemphigus foliaceus in cats, there are not 163 00:11:09,839 --> 00:11:11,559 many differentials that will do that. 164 00:11:11,560 --> 00:11:14,239 Same thing with, for instance, plasma cell pododermatitis. 165 00:11:15,850 --> 00:11:19,620 Very unique to affect the central foot pads of multiple legs, so there are 166 00:11:19,620 --> 00:11:21,449 not many diseases that will do that. 167 00:11:21,839 --> 00:11:24,989 So they do have some uniqueness sometimes. 168 00:11:25,520 --> 00:11:29,909 It may be a little bit tricky, but if the patient is not responding after 169 00:11:29,990 --> 00:11:33,979 multiple weeks of treatment, whatever the clinician thinks, it is advisable 170 00:11:34,020 --> 00:11:38,460 to obtain good quality images and consult with a veterinary dermatologist. 171 00:11:38,839 --> 00:11:42,070 I was wondering about diagnosis because this is something that with Pemphigus, 172 00:11:42,170 --> 00:11:43,035 they used to always tell us, and again, I'm dating myself here in terms of 173 00:11:43,035 --> 00:11:44,980 when I graduated from vet college, but it was always about waiting for the 174 00:11:44,980 --> 00:11:47,539 pustules and only biopsying pustules. 175 00:11:47,569 --> 00:11:51,520 But I really like in this article that you guys discuss cytology that 176 00:11:51,520 --> 00:11:54,819 can be done and it isn't always just about sampling from pustules. 177 00:11:54,819 --> 00:11:57,360 And I wondered if you could tell us a little bit about that from a 178 00:11:57,370 --> 00:11:59,239 practical perspective in clinic? 179 00:11:59,980 --> 00:12:00,580 Absolutely. 180 00:12:00,589 --> 00:12:04,749 So there is a little bit of debate even among the dermatologists here, how we 181 00:12:04,749 --> 00:12:08,480 should approach this largely because we are dermatologists, so we just see the 182 00:12:08,480 --> 00:12:14,240 skin cases and for us to diagnose our cat with pemphigus is to some point, if we see 183 00:12:14,240 --> 00:12:16,710 these cases all the time, relatively easy. 184 00:12:17,199 --> 00:12:20,560 The problem becomes is that we have to provide advice to clinicians who 185 00:12:20,560 --> 00:12:24,439 are not dermatologists, that they get to see all the organs and all 186 00:12:24,439 --> 00:12:26,459 the diseases associated with that. 187 00:12:26,879 --> 00:12:31,530 So in these instances, we are always troubled how to make a recommendation. 188 00:12:31,560 --> 00:12:32,610 Why do I say this? 189 00:12:32,610 --> 00:12:36,760 We utilise skin cytology a lot to diagnose pemphigus because we can see 190 00:12:36,760 --> 00:12:41,079 the Acantholytic keratinocytes, which are very unique for the disease and with the 191 00:12:41,079 --> 00:12:46,030 clinical presentation of the nasal bridge and the ear pinna and the nail fold. 192 00:12:46,559 --> 00:12:50,030 We generally don't tend to see many differentials for that, such 193 00:12:50,030 --> 00:12:53,239 as potentially like a pyoderma staph [ylococcus] infections with 194 00:12:53,240 --> 00:12:57,769 exfoliative toxins that can also cause Acantholytic keratinocytes. 195 00:12:57,999 --> 00:13:00,720 We rarely see that presentation of pyoderma in cats. 196 00:13:01,199 --> 00:13:04,319 So therefore, when we see a patient like that, and if you do a cytology 197 00:13:04,319 --> 00:13:08,099 and we can see this Acantholytic keratinocytes surrounded by neutrophils, 198 00:13:08,470 --> 00:13:14,439 we are very much probably, I would say above 99% certain that we are dealing 199 00:13:14,449 --> 00:13:16,319 with pemphigus foliaceus in a cat. 200 00:13:16,740 --> 00:13:20,839 Now, ideally we would go ahead and biopsy that, but then it 201 00:13:20,839 --> 00:13:22,300 depends where the lesions are. 202 00:13:22,639 --> 00:13:25,750 And for instance, some lesions, some cats with pemphigus uniquely 203 00:13:25,750 --> 00:13:27,800 have only lesions in the nail fold. 204 00:13:28,069 --> 00:13:30,010 So there are different phenotypes of the disease. 205 00:13:30,020 --> 00:13:31,480 Not everyone is generalised. 206 00:13:31,750 --> 00:13:35,609 So in that case, you will have to remove the whole toe and that's 207 00:13:35,609 --> 00:13:37,079 where it gets a bit tricky. 208 00:13:37,319 --> 00:13:42,269 I would say that the vast majority of us tends to then call the Pemphigus 209 00:13:42,589 --> 00:13:46,070 based on a clinical presentation, history and cytology findings. 210 00:13:46,240 --> 00:13:49,000 Of course, if we can, we will go ahead and do biopsy. 211 00:13:49,270 --> 00:13:53,969 Now we are dermatologists, so for us, this is what we do every day of the month. 212 00:13:53,999 --> 00:13:59,289 Now, if we take someone who sees this rarely as a private practitioner, 213 00:13:59,589 --> 00:14:04,770 they may lean more towards biopsy to make sure that we get what we need. 214 00:14:05,110 --> 00:14:09,939 Yes, ideally we would sample pustules, but they are relatively short lived on 215 00:14:09,939 --> 00:14:14,509 the patient's dogs and cats predominantly because of the rather thinner 216 00:14:14,560 --> 00:14:16,420 epidermis, so they don't tend to stay. 217 00:14:16,420 --> 00:14:19,180 So what you end up having is usually crusts. 218 00:14:19,890 --> 00:14:23,240 Now, if you see some erythema beneath, it tells you that probably 219 00:14:23,250 --> 00:14:24,800 it's still an active process. 220 00:14:25,100 --> 00:14:29,989 So we tend to go and try to get those most recent lesions that 221 00:14:29,999 --> 00:14:33,400 the owner can remember and that we see that there is still erythema. 222 00:14:33,809 --> 00:14:36,939 If the crust has no erythema and you can just pull it off, 223 00:14:36,970 --> 00:14:39,190 then likely it's already gone. 224 00:14:39,459 --> 00:14:42,310 What we never wanna do is scrub the crusts away. 225 00:14:42,319 --> 00:14:46,380 So we always wanna submit the crust because the are acantholytic keratinocytes 226 00:14:46,380 --> 00:14:48,249 are usually embedded in them. 227 00:14:48,560 --> 00:14:53,160 If you do any surgical scrubbing, you will lose that diagnostic sample 228 00:14:53,160 --> 00:14:57,990 and your biopsy will come back as inconclusive, meaning they don't know 229 00:14:57,990 --> 00:15:01,569 what, it's an inflammatory process, but they don't know exactly what's going on. 230 00:15:02,350 --> 00:15:05,009 And that's one of the key things that again, are pointed out in a box out 231 00:15:05,010 --> 00:15:09,980 in your article about taking biopsies and not prepping the skin or shaving 232 00:15:09,980 --> 00:15:13,350 or anything because you're taking away a lot of that diagnostic information. 233 00:15:13,380 --> 00:15:17,099 You rarely will ever need to scrub the skin, exceptionally rarely. 234 00:15:17,370 --> 00:15:21,069 So I would rather not to do that on, on any patient unless 235 00:15:21,069 --> 00:15:24,220 you want lose your diagnostics and the biopsies are expensive. 236 00:15:24,600 --> 00:15:28,050 You need a heavier sedation for a cat than a dog. 237 00:15:28,370 --> 00:15:31,810 Therefore, you do not wanna repeat these processes multiple times. 238 00:15:31,819 --> 00:15:35,490 So it's better when you do it that you do it the best way you can. 239 00:15:41,280 --> 00:15:42,060 Thank you for listening. 240 00:15:42,490 --> 00:15:46,790 If you are an iCatCare Veterinary Society Member, don’t forget you can access 241 00:15:46,819 --> 00:15:50,380 the full version of the podcast and all the other member benefits, including 242 00:15:50,420 --> 00:15:54,199 congress recordings, monthly webinars, the clinical clubs, the discussion forum 243 00:15:54,550 --> 00:15:57,719 and much more at portal.icatcare.org. 244 00:15:58,350 --> 00:16:02,680 If you’re looking for more free CPD from International Cat Care, on the 245 00:16:02,680 --> 00:16:07,140 6th of May Rachel Korman will host an open webinar sponsored by Hills. 246 00:16:07,630 --> 00:16:12,180 She will talk about the new guidelines on lower urinary tract disease in cats. 247 00:16:13,079 --> 00:16:17,774 On the 21st of May, Dr Stephanie Sorell will talk about diabetic ketosis in 248 00:16:17,890 --> 00:16:21,629 the feline patient in another open access webinar sponsored by IDEXX. 249 00:16:21,809 --> 00:16:25,949 We will be back again next month with more from the world 250 00:16:25,960 --> 00:16:26,930 of feline medicine and JFMS.