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.