Chattering With ISFM

This month Yaiza Gomez-Meijas is joined by Dr Ryane Englar who has published two articles on 'Recasting the gold standard' that were published in the JFMS special collection on Accessible veterinary care. We also continue our discussion about the treatment of invasive fungal infections with Nathalie Dowgray and Prof. Vanessa Barrs.

Our first conversation between Yaiza and Ryane features a discussion on the continuum of care in veterinary medicine, emphasizing a shift from the gold standard approach to more tailored and patient-centred care. Additionally, it delves into strategies for initiating conversations with clients about healthcare options and case management decisions.

The conversation on contextualised care also continues into the discussion on the treatment of invasive fungal infections where Prof. Barrs discusses drug selection and how to best approach these discussions with owners where the treatment options are often prolonged. Make sure you check out part one of our interview with Prof. Barrs in our January episode (entitled: ‘FCoV-23: Is it driving the Cyprus FIP Outbreak?’) in which we discuss the diagnosis of invasive fungal infections.

For further reading material please visit:

https://journals.sagepub.com/doi/epub/10.1177/1098612X231209855

https://journals.sagepub.com/doi/epub/10.1177/1098612X231215639

https://journals.sagepub.com/doi/full/10.1177/1098612X231219696

https://journals.sagepub.com/doi/full/10.1177/1098612X231220047

For ISFM members, full recordings of each episode of the podcast is available for you to listen to at portal.icatcare.org. To become an ISFM member, or find out more about our Cat Friendly schemes, visit icatcare.org


Host:
Nathalie Dowgray, BVSc, MANZCVS, PgDip, MRCVS, PhD, Head of ISFM, International Society of Feline Medicine, International Cat Care, Tisbury, Wiltshire, UK

Speakers:
Yaiza Gomez-Mejias, LdaVet MANZCVS (Medicine of Cats) CertAP (SAM-F) Acr AVEPA, ISFM Community Coordinator and Small Animal Clinician

Ryane Englar, DVM, DABVP (Canine and Feline Practice), Executive Director of Clinical and Professional Skills, Associate Professor of Practice, and member of the founding faculty at the University of Arizona College of Veterinary Medicine.

Vanessa Barrs, BVSc (Hons), PhD, MVetClinStud, FANZCVS (Feline Medicine), Registered specialist in Feline Medicine, Dean of Hong Kong Veterinary School and past president of the International Society of Companion Animal Infectious Diseases.

Creators & Guests

Host
Nathalie Dowgray

What is Chattering With ISFM?

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, welcome to the
March episode of Chattering with ISFM.

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

First up this month, Yaiza Gomez
Mejias is speaking with Dr Ryane

Englar on the continuum of care.

And that's following her two articles
on recasting the gold standard that

were recently published in the JFMS
special collection on accessible care.

We're also featuring our monthly
JFMS Clinical Spotlight interview.

Following on from January's
eepisode, I'm speaking again

with Professor Vanessa Barrs.

And this month, the focus is on the
treatment of invasive fungal infections.

Yaiza Gomez Mejias: Thank
you for your time today.

Congratulations, by the way,
on these amazing articles you

recently published in the Journal
of Feline Medicine and Surgery.

So, what inspired you
to write these articles?

Ryane Englar: Yeah, thank you so much.

They're really two of my passion
projects that I was really

grateful to see come to fruition.

They stemmed from this feeling that
we need to really broaden the lens

through which we see veterinary
care, not just on a community

level, but nationally and globally.

There's been this transition in the
veterinary profession as a whole from

gold standard care to beyond that.

The reality is that's a bit of an
antiquated approach to medicine.

It really implies a medical monotheism,
in a way it's saying, you have a

pet that comes to you or a patient,
there's one approach, right?

And if you're not doing that approach
to diagnostics, or if you're not doing

that approach to treatment options,
that you're giving lesser care.

It's an all or none approach, either or.

And I think that what really bothers
me about that is, when you get

into practice, we realized very
quickly there's very rarely the time

that you can apply that approach.

Then you discover that, in fact, some
of the other approaches for whatever

reason, in context, can actually be
quite beneficial for that patient.

And so, I really play a role as that
general practitioner mindset of trying

to think about how do we help ourselves
and our patients and our clients

embrace that contextualized care.

It's not lesser care.

It's care that is actually
tailored to that patient.

And in a way, that's the optimal care.

Yaiza Gomez Mejias: why do you think terms
such as contextualization of veterinary

care, spectrum of care, and patient
centred medicine have become so popular

just over the last couple of years?

Ryane Englar: I think it's something
that was always under the surface.

And it's things that we didn't always
talk about because when I was trained

to think it was subpar medicine to
think about doing something other

than gold standards, CBC chem, UA,
fecal, T4, full thyroid panel imaging

for everything that came in the door.

That I was almost embarrassed sometimes
to admit, I have a dog that's vomiting and

we're just going to do supportive care.

And I didn't really want to
feel like I was not offering

to the best of my ability.

Clients now want
individualized care, right?

It's not, I want vaccines
for my dog, that's a cookie

cutter vaccine protocol, right?

Clients are more well read, they go
to the internet, they find sources,

they find evidence, they find
journals and they say, does my cat

really need that leukaemia vaccine?

This is the lifestyle,
let's talk about that.

Could we add it in later
if we need to, right?

So, I think that customization
can serve us well.

By virtue of embracing it, start to
rrealize there's lots of different ways

to practice and there's not one right way.

It's about what does that
patient, veterinary team and

client need as a trilogy.

And if we can embrace that, we can
really create power in our ability

to serve individuals and communities.

Yaiza Gomez Mejias: Your second
article introduces strategies

for initiating conversations with
clients about healthcare options

and case management decisions.

Would you like to expand on any
of those communication strategies

we can use to navigate a spectrum
of care clinical conversation?

Ryane Englar: Yeah, I think
transparency is huge, we don't

have a crystal ball in front of us.

We can't predict everything.

We wish we could.

Here's what I know.

Here's what I don't know.

Let's talk about that.

And let's figure out
where's our comfort level.

Where does that fall in that spectrum?

We need to do a lot more eliciting
the client's perspective.

What would be helpful is to stop
and pause and just say to the

client, what concerns you most?

What do you need from
today to make a choice?

And if we can ask those
questions, our clients are

going to feel more apt to share.

Perspective is everything, and I need
to start asking, what do you need?

What can you do?

What's your capacity?

And we often think about capacity in
terms of economics, that's really true.

But what is their emotional capacity
to navigate this next steps, right,

what's their physical capacity?

And all of those things that go in.

So I think those are the biggest ones.

The third one would be regard
for the choice that they make.

It's tough because I've been in
situations where we may not agree

with the choice that was made.

But if you offer it as a choice
option, then we can't be wrong

when our clients choose that.

If we're offering it as a viable
option, then we need to believe

in it and have partnership.

Let's just take off that doctor
uniform and have a conversation with

someone else about what they need
to know and how we can help them.

Yaiza Gomez Mejias: Do you think
we talk about that enough and

that we assess quality of life
enough in our clinical work?

Ryane Englar: I think we're improving
with the publications of more

quality of life scales and that we're
starting to realize again, there's

not one scale, there's multiple ones.

we're recognizing there's more ways
to identify suffering, pain, quality.

We're realizing the importance
of subjectivity, having

different people to assess.

We're realizing to be focused on
subtle cues that we never thought

before, like the face grimace
scales and things like that.

I think where we need to sometimes be more
proactive is helping the client understand

how they can use these tools and that
they're not always the end all be all,

but which one resonates with you, right?

Yaiza Gomez Mejias: Do you think we
talk enough about ethical dilemmas

with our colleagues as well?

Because we been talking a lot about
the communication between vets and

owners, but I think communication
between vets is also important.

So what's your view on that?

Ryane Englar: We often ended up with
euthanasia and then no one talked

about their emotions and we tended
to just shove it down and not talk.

I think there's been more awareness
now of the impact of those cases.

There's caregiver burden, yes,
but there's also provider burden.

The healthcare burnout, compassion
fatigue, all of those have made it

more okay to start that conversation.

I think that we don't always know how
to hear each other and I think where we

still need room to develop is recognizing
that we each have different stop points.

Our colleague may have a
different line in the sand, and

we need to support each other.

We need to acknowledge why
does something trigger us?

Why does something make us react?

Can we talk about it so that I can still
feel okay with the choice I made, but

I need the support from my colleague.

I also need to support them
when they make a choice that

I might not have agreed with.

We just need to be kinder
to each other, I think.

Yaiza Gomez Mejias: That's great.

It's always good not to
forget our human side.

Yeah.

Nathalie Dowgray: And now I'm speaking
with Professor Vanessa Barrs on invasive

fungal infections and oomycosis in
cats, part two, antifungal therapy.

These cases really require
quite prolonged treatment.

So 3, 6, 12 months.

How do you frame that
discussion with the owner?

Are there factors that maybe need
to be agreed or discussed before you

decide to proceed with the treatment?

Vanessa Barrs: I suppose one of the
first things that I'll talk to the

owner about is say, I've got good news
in that this disease can be curable.

Obviously, some of them have got better
prognosis than others, but if we talk

about fungal infections in general,
yeah, I'm going to say it's good news.

This can be cured, but then I've really
got to let them know that it can't

be cured by a course of antibiotics.

And there's a few things
that need to be considered.

One is you need to be able to
medicate your cat, you need to have

the time to be able to do that.

You need to bring the animal,
your cat, back in for regular

rechecks and also, understand the
costs associated with treatment.

I try and let the owner know upfront
as much as possible so that they

can make an informed decision.

Nathalie Dowgray: Giving long term
medication, I know it's been talked

about especially with some of the
mycobacterial cases where actually in

some cases they place an esophagostomy
tube to facilitate medication.

Is that something that you've
considered with some of these

fungal treatment sort of cases?

Vanessa Barrs: Look, I think
it's not needed in most cases.

I mean, you know, it can make
the management a little bit more

complicated than you want it to be.

I think the good news is that a lot of the
fungal medications come in oral solutions.

So it's not necessarily always going
to be a capsule or a tablet and some

of those things like posaconazole
is generally very palatable.

I used to have one cat that would
stand up on his back legs and beg

for the stuff out of the syringe.

Nathalie Dowgray: Brilliant.

And that's good to know.

With the sort of long term nature
of the treatments, are there any

circumstances where you might consider
giving antifungals without having done

that sort of susceptibility testing?

Vanessa Barrs: That is a great question,
and I know in the article that I talk

a lot about antifungal susceptibility
testing, but the reality is that

probably the majority of Invasive
fungal infections are treated in

practice without having done that.

So, in the treatment section of the
article, we've indicated which drugs

can be used for first line and second
line therapy and these can be given

regardless of whether susceptibility
testing has being done or not.

Nathalie Dowgray: Okay.

Now that's really interesting.

And we talked obviously about oral
drugs, probably being the majority

of them, but definitely for some
cases, IV infusions are required.

How do you approach that
to get the best outcome?

Vanessa Barrs: Yeah.

So it's going to depend on the type of
fungal infection that you're treating.

So if, for example, you're treating
cryptococcus and you've got really severe

disease or you've got CNS disease, you
need to be able to give perhaps something

like Amphotericin B and you can give
Amphotericin B as outpatient therapy

by giving the subcutaneous infusion
three times a week and that's great.

IIt makes it much more accessible to
people and more affordable as well.

But, there are some situations
where you need to use an IV drug

and probably the best example
would be with the echinocandins.

So they're a newer class of
antifungal therapy that haven't been

used much in veterinary medicine.

But occasionally, you might get
a mould infection that is really

got low MICs for caspofungin a nd
you can really only give that drug

intravenously as a once daily infusion,

but fortunately, the number of times
that you're going to be confronted

with that situation is pretty rare.

Subcutaneous infusions of amphotericin
being for severe infections is something

that can be readily done in GP practice.

You need to be able to monitor for
azotemia and also, you've got to

think about whether they've got any
underlying heart disease as well.

Because if you've got a cat that's got
a quite a severe heart murmur, it might

have an underlying cardiomyopathy,
you don't want to be giving it 300mls

of subcut fluid three times a week
because it might tip into heart failure.

Nathalie Dowgray: That's a really
interesting point, isn't it?

Because you were saying the
risk of overload is less with

subcutaneous compared to IV.

But yeah, I can see on that
volume on a regular basis.

Yeah.

Are there any circumstances where you
wouldn't necessarily advise treatment?

Vanessa Barrs: There's one
situation where you might think

about sporotrichosis, for example.

So sporotrichosis is polyzoimotic.

If you've got an immunosuppressed
family member, you might be having a

different conversation about whether the
owner's really concerned about zoonotic

infection, and that's problematic,

then, if they can't treat the cat
somewhere else, they may not be able

to manage that risk appropriately.

I think with each of these invasive
fungal infections, it's a matter

of looking at, okay, first of all,
what type of fungal infection is it?

And then how bad is it?

How severe is it?

How advanced is it?

That's also probably going to help
advise whether to treat or not.

I tend to be an optimist and I always
think it's worthwhile trying to treat

fungal infections because I think that
you can have a really good result.

Nathalie Dowgray: What would be
your top tips for successful long

term management of these cases?

Vanessa Barrs: Yeah, I think
I've got four top tips.

The first one is focus on getting
a definitive diagnosis with an

accurate identification of the
fungus to guide your treatment.

So remember it's not to
just only to do histo.

If you're taking a sample for
histo, always stop and think,

should I do culture on this as well?

Should I do a double culture on this?

And if you're not sure, remember to
keep that little bit of tissue in the

freezer for PCR in case you forgot, or
in case your fungal culture was negative.

The third thing I would say, remember that
antifungal drugs can have adverse effects.

So do your baseline
monitoring of liver enzymes.

And finally, get your patients back
regularly so you can follow up and

see if your treatment's working
and if not, use some of those

newer tools that we spoke about.

Nathalie Dowgray: Thank you for listening.

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

the podcast or the other ISFM member
benefits, including congress recordings,

monthly webinars, the clinical
club, the discussion forum and much,

much more at portal.icatcare.org.

If you're looking for more free CPD from
ISFM on the 16th of April, please do join

the Open Access webinar from Royal Canin.

Toilet Trouble, Diagnosis and Management
of Feline Idiopathic Cystitis.

And that's with Doctors Sam
Taylor and Cecilia Villaverde.

We'll be back again next
month with another episode.

If you don't want to miss it, do make
sure you sign up to Chattering with

ISFM on your preferred podcast platform.