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Nathalie Dowgray: Hello, welcome to the
March episode of Chattering with ISFM.

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

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

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Englar on the continuum of care.

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

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

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

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

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with Professor Vanessa Barrs.

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

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Yaiza Gomez Mejias: Thank
you for your time today.

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Congratulations, by the way,
on these amazing articles you

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recently published in the Journal
of Feline Medicine and Surgery.

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So, what inspired you
to write these articles?

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Ryane Englar: Yeah, thank you so much.

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

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grateful to see come to fruition.

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

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

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level, but nationally and globally.

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

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gold standard care to beyond that.

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

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

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

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

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

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

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

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

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that you can apply that approach.

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

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

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

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

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embrace that contextualized care.

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It's not lesser care.

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

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

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

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

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just over the last couple of years?

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

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

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

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

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for everything that came in the door.

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

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we're just going to do supportive care.

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

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to the best of my ability.

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Clients now want
individualized care, right?

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

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cutter vaccine protocol, right?

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

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

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really need that leukaemia vaccine?

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

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

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So, I think that customization
can serve us well.

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

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to practice and there's not one right way.

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

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client need as a trilogy.

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

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to serve individuals and communities.

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Yaiza Gomez Mejias: Your second
article introduces strategies

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for initiating conversations with
clients about healthcare options

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and case management decisions.

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Would you like to expand on any
of those communication strategies

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

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

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have a crystal ball in front of us.

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We can't predict everything.

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We wish we could.

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Here's what I know.

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Here's what I don't know.

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Let's talk about that.

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

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Where does that fall in that spectrum?

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

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

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client, what concerns you most?

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What do you need from
today to make a choice?

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And if we can ask those
questions, our clients are

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going to feel more apt to share.

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

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What can you do?

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What's your capacity?

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

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

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what's their physical capacity?

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And all of those things that go in.

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So I think those are the biggest ones.

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

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

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with the choice that was made.

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

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when our clients choose that.

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

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in it and have partnership.

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

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

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

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

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

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

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not one scale, there's multiple ones.

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

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We're realizing the importance
of subjectivity, having

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different people to assess.

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

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

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

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

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but which one resonates with you, right?

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

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with our colleagues as well?

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

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

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So what's your view on that?

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

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

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

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

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

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more okay to start that conversation.

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

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

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

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we need to support each other.

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We need to acknowledge why
does something trigger us?

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Why does something make us react?

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

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I need the support from my colleague.

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

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I might not have agreed with.

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

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Yaiza Gomez Mejias: That's great.

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

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Yeah.

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

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

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These cases really require
quite prolonged treatment.

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So 3, 6, 12 months.

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How do you frame that
discussion with the owner?

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

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decide to proceed with the treatment?

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

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

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

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

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

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be cured by a course of antibiotics.

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

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

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the time to be able to do that.

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

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rechecks and also, understand the
costs associated with treatment.

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

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can make an informed decision.

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

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about especially with some of the
mycobacterial cases where actually in

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some cases they place an esophagostomy
tube to facilitate medication.

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

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fungal treatment sort of cases?

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

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

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complicated than you want it to be.

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

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

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of those things like posaconazole
is generally very palatable.

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

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for the stuff out of the syringe.

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Nathalie Dowgray: Brilliant.

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And that's good to know.

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

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circumstances where you might consider
giving antifungals without having done

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that sort of susceptibility testing?

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

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

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probably the majority of Invasive
fungal infections are treated in

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practice without having done that.

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

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

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regardless of whether susceptibility
testing has being done or not.

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Nathalie Dowgray: Okay.

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Now that's really interesting.

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

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

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How do you approach that
to get the best outcome?

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Vanessa Barrs: Yeah.

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

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

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

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

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

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

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

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and probably the best example
would be with the echinocandins.

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

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used much in veterinary medicine.

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

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

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intravenously as a once daily infusion,

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

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with that situation is pretty rare.

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Subcutaneous infusions of amphotericin
being for severe infections is something

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that can be readily done in GP practice.

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

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

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

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

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

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

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Because you were saying the
risk of overload is less with

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subcutaneous compared to IV.

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

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Yeah.

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

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

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about sporotrichosis, for example.

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So sporotrichosis is polyzoimotic.

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

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

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infection, and that's problematic,

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

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to manage that risk appropriately.

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

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

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And then how bad is it?

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How severe is it?

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How advanced is it?

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

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

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

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

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term management of these cases?

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

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

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accurate identification of the
fungus to guide your treatment.

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

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

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should I do culture on this as well?

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Should I do a double culture on this?

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

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

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

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So do your baseline
monitoring of liver enzymes.

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

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

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newer tools that we spoke about.

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Nathalie Dowgray: Thank you for listening.

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If you're an ISFM member, don't forget
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00:14:22,600 --> 00:14:27,189
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much more at portal.icatcare.org.

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00:14:35,110 --> 00:14:40,060
If you're looking for more free CPD from
ISFM on the 16th of April, please do join

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00:14:40,090 --> 00:14:43,320
the Open Access webinar from Royal Canin.

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00:14:43,340 --> 00:14:47,720
Toilet Trouble, Diagnosis and Management
of Feline Idiopathic Cystitis.

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00:14:48,140 --> 00:14:51,660
And that's with Doctors Sam
Taylor and Cecilia Villaverde.

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00:14:53,180 --> 00:14:55,580
We'll be back again next
month with another episode.

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