2019 Conference Pearls of Wisdom

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American Association of Feline Practitioners 2019 Conference
5th World Feline Veterinary Conference
October 31 – November 3, 2019
Complex Disease Management – Exploring Feline Comorbidities

Pre-conference Day
Thursday – October 31, 2019

Feline-Friendly Handling Workshop, Dr. Ilona Rodan

  1. Feline-friendly handling can be incorporated successfully into any type of practice, increasing feline welfare, client loyalty, job satisfaction, and human safety. Since tight restraint leads to distress, struggling, and increased incidence of human injuries, gentle and respectful handling techniques are critical. An environment, handling, and appointment flow that work best for the cat increase efficiency and decrease number of team members per patient.
  2. Cats that have not been socialized or that had previous negative experiences – including previous negative veterinary experiences – will demonstrate negative emotions, such as fear, anxiety, or pain to protect themselves. The associated behavior responses are survival mechanisms that may be challenging, but deserve understanding and respectful handing while still remaining safe. Anxiolytics given prior to veterinary visits and/or sedation at the practice help alleviate these negative experiences, and facilitate examination, diagnostics, and treatments.

Keeping Calm Under Pressure: Hypertension & Comorbidities in Cats, Dr. Andrew Sparkes

  1. In cats it is estimated that around 80% of cases of hypertension have an underlying disease that potentially causes the high blood pressure (secondary hypertension). Whenever hypertension is diagnosed it is important to search for (and manage) underlying diseases, and conversely when a disease known to predispose to hypertension is diagnosed, close monitoring of blood pressure is recommended.
  2. Amlodipine besylate is a calcium channel blocker that causes arteriolar dilation with minimal cardiac effects. This has proved to be a highly successful medication for the management of hypertension in cats and remains the first choice in most cases. It is very often successful as a monotherapy, but can be combined with other drugs if hypertension proves difficult to manage.

Mind & Body: How Emotions Can Impact Feline Health, Dr. Andrew Sparkes

  1. Cats as a species are highly susceptible to stress – anxiety, fear, frustration – in part because they remain only a semi-domesticated species and in part because of the way they are kept as household pets. Being a highly territorial and largely solitary species also means that visits to a veterinary clinic are highly challenging.
  2. Stress in cats is associated with various neurohormonal changes that can have physiological effects that complicate the detection, monitoring and/or management of disease – a classic example being the effect of stress hyperglycaemia on diagnosis and management of diabetes. However, stress can also have a direct impact on clinical disease too and there is increasing evidence of the role of stress as a causative or contributary factor in various diseases including feline idiopathic cystitis, infectious diseases, gastrointestinal disease and dermatological disease. While the role of stress may not always be obvious consideration should be given to environmental modification where stress might be a contributory factor.

Between a Rock & a Hard Place: Diagnosis & Management of Constipation, Drs. Jolle Kirpensteijn & Susan Little

  1. All therapies for relieving acute constipation in cats are more effective if dehydration and electrolyte abnormalities are corrected first. Most patients will also benefit from anti-emetic therapy (even if they are not vomiting) and possibly analgesia.
  2. Trickle-feeding polyethylene glycol 3350 via a nasogastric tube can be an effective and less invasive means for managing acute constipation. Based on a published study, median time to defecation is 8 hours.

Localizing Feline Dyspnea, Dr. Christopher Byers

  1. The physical examination begins before a clinician lay hands on a dyspneic feline patient. Breathe with one’s patient from a distance to help one localize a patient’s breathing disorder.
  2. Use minimal restraint with dyspneic cats as excessive handling can readily contribute to morbidity and mortality.

Update on IMHA, Dr. Christopher Byers

  1. A thorough diagnostic investigation is essential as secondary disorders are more than primary ones in cats.
  2. Be aware of bone marrow-directed immune-mediated attacks. Be prepared to sample the bone marrow!

Practical Approach to Feline Hypotension, Dr. Christopher Byers

  1. Be sure to assess preload, contractility, and systemic vascular resistance when treating hypotensive cats.
  2. Appropriately rewarm hypothermic and hypotensive cats before infusing large volumes of intravenous fluids. Vasomotor tone will return – thus improving systemic vascular resistance – once hypothermia has resolved.

Acute Pancreatitis: What Do We Really Know?, Dr. Christopher Byers

  1. Diagnosis is based on compatible clinical signs, as well as supportive clinical pathology and diagnostic imaging.
  2. Early enteral nutritional support is of paramount importance and patients should be fed as soon as possible. The use of temporary supplemental feeding tubes, including nasoesophageal/nasogastric and esophagostomy tubes, can be life-saving.

Friday, November 1, 2019

Why are Comorbidities the “New” Norm for Cats?, Dr. Margie Scherk

  1. It is very important that cats are able to express species-specific behaviors in order to be healthy. Therefore, it is important not just to examine the patient and perform diagnostic testing, but to consider the home life of the patient (e.g., indoor vs. outdoor access, resource suitability and availability, social interactions).
  2. Health problems may be identified early not just through serial examinations and diagnostic evaluations, but also by changes in body weight, body conditions core, muscle condition score. By educating clients to look for, and make note of, subtle changes from normal behaviors, problems may be detected and addressed earlier. These basic assessments often detect insipient illness before laboratory tests are able to.
  3. Complex disease may occur as a result of genetics, the experiences of the queen while the kitten is in utero, nutrition, exposure to substances (smoke, xenobiotics, etc.), that create susceptibility in an individual. Exposure of this individual to a provocative event (e.g., stress, infection, chronic inflammation, etc.), may predispose to disease. Through mechanisms, as yet not fully understood, additional stressors may result in one or more comorbidities occurring.

Practice Management: Work Life Balance & Making Time for Yourself, Ms. Melissa Tompkins

  1. It is very important for everyone to make time to take care of themselves. Recognizing what gets in the way of that time is important.
  2. Learning how to say no is important. You cannot say yes to everything because you could easily get burned out. You will also not be able to perform as well with your own job if you are constantly doing other team members job.

Comorbidities in Retrovirus Infected Cats, Dr. Michael Lappin

  1. Results of retrovirus tests generally do not prove the presence of immunodeficiency. Thus, if treatable co-infections exist, the best way to determine prognosis is to treat the coinfection.
  2. While the evidence suggests that feline retroviruses do not infect humans, clinically ill cats may be shedding other zoonotic agents. However, once the clinical signs have resolved, most cats are not zoonotic risks to their owners.

Practice Management: What Do You Do When a Client Says No?, Ms. Melissa Tompkins

  1. Creating trust and building a relationship with each client is essential for the client to feel comfortable when saying yes to our recommendations. It is important for doctors and managers to understand that the entire team should be trained on effective communication. Every person that meets a client can impact client compliance.
  2. Each hospital needs to determine what clients are commonly saying “no” to in their hospital and create written scripts on how to respond so that they can convert the “no” into a “yes.” Each team member should be trained with this information and taught how to effectively communicate with the client.

Managing Feline Endocrine Diseases: Easier Said Than Done, Dr. Audra Fenimore

  1. Mistakes can happen when owners administer insulin to their pets. Go back to the basics if there appears to be lack of diabetic control which includes verifying the type of insulin administered, verifying what insulin syringes are being used, and having the owners demonstrate how the insulin is administered.
  2. Screen the unassuming cat for hyperthyroidism and hypertension. Early detection and treatment for these conditions can prevent future problems (anesthetic complications, target organ damage, etc.) while improving quality of life.

What Makes a FI Pathogen, Pathogenic?, Dr. Michael Lappin

  1. All of the GI pathogens we encounter in feline practice can be detected in both healthy cats and those with clinical signs of disease. If routine treatments fail for a suspected infectious disease agent, remember to go back to the diagnostic workup to see if co-infections or other potentiating problems exist.
  2. Most causes of feline diarrhea have now been associated with changes to the fecal microbiome. Data continues to be published supporting the use of probiotics in the management of acute or chronic diarrhea. Make sure to prescribe probiotics that meet the label claim and have been shown to be effective in clinical trials.

Practice Management: Impact of Environmental Design & Choices on the Cat, Dr. Ragen McGowan

  1. Clinic environments should be optimized to reduce stress for cats, owners and veterinary care staff alike. Cats perceive the world differently than humans and it is important to consider their unique perspective in clinic design and ways of working to create an environment that is emotionally supportive for cats. Small changes to both the micro-environment (e.g., carrier, enclosure, exam table) and macro-environment (e.g., noise, lights, odors, general routine) can go a long way to promote a positive experience at the veterinary clinic.
  2. Humans are key to the equation for creating a cat friendly clinic environment. Fostering a strong cat-owner bond and promoting a bond between cat and veterinary care staff can lead to significant improvements in both cat wellbeing and overall care. Providing information to cat owners regarding ways to prepare their cats for success at the clinic and calling out the efforts of the clinic towards creating a cat friendly environment will improve perception and drive owner compliance in ensuring proper medical care for their cats.

Lunch & Learn #1– Feline Infectious Respiratory Disease: What Every Veterinarian Should Know, Dr. Annette Litster

  1. Doxycycline is a good first-line empiric choice for cats with suspected acute bacterial upper respiratory tract infection, since it is likely to be effective against the most commonly identified isolates – Mycoplasma spp., Bordetella bronchiseptica and Chlamydia felis. Clinical trials of L-lysine supplementation in cats with FHV-1 have produced conflicting results, but a recent systematic review of the evidence for L-lysine supplementation concluded that clinical trials with cats had failed to show efficacy and that in vitro experiments did not demonstrate that excess L-lysine inhibited viral replication (Bol and Bunnick, 2015).
  2. Pain relief should be considered on an individual cat basis, especially if there is evidence of oral or corneal ulceration. Appropriate analgesic protocols should be initiated promptly by a veterinarian and cats should be monitored often to ensure that therapeutic efficacy is achieved. Non-steroidal anti-inflammatory drugs can also be used to treat fever and oral or ocular pain (Radford et al., 2009), but caution should be exercised in cats with evidence of clinical or subclinical dehydration, renal, hepatic or gastrointestinal disease or clotting abnormalities Griffin et al., 2016).

Lunch & Learn #2– It’s a New World: Update on Feline Retrovirus Testing, Dr. Susan Little

  1. Long term studies of retrovirus testing in kittens are revealing new information that may change interpretation of test results for FeLV, especially for identification of regressively infected cats. Regressively infected cats can be identified using a combination of p27 antigen and provirus PCR tests. Due to differences in tests, regressive infection in Europe is typically characterized by a negative or transiently positive antigen test and positive proviral PCR while in North America, regressive infection is more likely to be an antigen positive, PCR negative pattern. Cats that initially test positive by both p27 antigen and PCR can transition to a regressive infection pattern, usually within 16 weeks post-infection.
  2. It may not be possible to determine FeLV or FIV status based on the results of a single test performed at a single point in time. In some cases, repeat testing combining the results of different test methodologies may be required.

Lunch & Learn #3: Maintain Muscle Mass While Feeding Feline Renal Therapeutic Diets, Dr. Amy Farcas

  1. There appears to be two camps of nutritional management of chronic kidney disease (CKD) in cats-one with primary consideration of dietary protein contributing to uremia, and the other with primary consideration for maintenance of lean body mass. These are not mutually exclusive; with consideration and nutritional assessment, concerns for uremia (not too much protein) can be managed without sacrificing lean body mass (not too little protein).
  2. Muscle wasting in cats with CKD fed renal diets likely occurs because of a lapse in follow up. Failure to detect that the cat is not eating enough of a lower-protein diet to meet its protein needs will result in protein malnutrition and muscle wasting. The solution is diligent follow up and careful matching of both calorie and protein requirements to a diet with the ideal (for that patient) ratio of protein and calories.

Chronic Enteropathy in Cats With Triaditis: Optimization of Diagnosis & Management, Dr. Stanley Marks

  1. Measurement of serum cobalamin should be performed in all cats with chronic enteropathy given that cobalamin deficiency can produce similar signs to those associated with IBD, and response to IBD therapy will be suboptimal unless cobalamin concentrations are replete.
  2. The main limitation of endoscopic biopsies for the diagnosis of IBD or intestinal lymphoma is the working length of the endoscope and not the inability to collect full-thickness biopsies. Partial thickness biopsies will not be able to diagnose transmural lymphoma, however, lymphoma manifests in the intestinal mucosa long before transmural progression, which may not even occur during the full duration of the disease process.

Setting the Stage: Managing CKD, Dr. Jessica Quimby

  1. Suboptimal weight and poor body condition score are associated with a poorer prognosis in CKD. Ensuring adequate caloric intake and maintaining body weight is therefore an important part of CKD management.
  2. Hypoxia is a driver of fibrosis. Strategies to optimize tissue oxygenation such as maintaining hydration and addressing anemia potentially help to mitigate renal hypoxia.

Practice Management: Feline Professional Liability Risk Management, Dr. Linda Ellis

  1. Dental related claims involving cats are fairly common. Some of the more common complications seen that may lead to a claim include tracheal tears, retained roots, and thermal injuries in long dental procedures. Being aware of these common claims can help you avoid them.
  2. If the client is bitten or injured by their cat during treatment, that typically will be determined to be a Professional Liability claim. Personal injury professional liability claims are some of the most difficult to defend and have higher average settlement costs. Having well trained staff assist and low stress feline practices, as well as doing what you can to keep owners out of harm’s way can help reduce the risk.

New Insights in Hepatic Disease Associated With Triaditis, Dr. Stanley Marks

  1. Antibiotic therapy for acute neutrophilic cholangitis should be optimally based on culture and sensitivity testing of bile or parenchyma; however, antibiotic recommendations for empiric therapy include a combination of amoxicillin/clavulanic acid and a fluoroquinolone, with or without metronidazole.
  2. Injectable vitamin K1 (3 doses of 0.5-1.5 mg/kg q 12 hrs SC or IM) should be proactively administered in all jaundiced cats with hepatic disease prior to intravenous catheterization, placement of an E-tube, or prior to liver aspiration or liver biopsy.

The Cushingoid Diabetic: Recognition, Diagnosis, & Management, Dr. Audrey Cook

  1. Concurrent hyperadrenocorticism is an uncommon cause of insulin resistance in cats; other possibilities should be considered first unless the physical examination (abdominal adiposity, hair loss, thinning of the skin) is suggestive of this condition.
  2. Practitioners should familiarize themselves with the particulars of adrenal function testing in cats, as protocols differ from their canine counterparts.

Practice Management: Does Cat Friendly Practice Impact Your Team’s Risk of Injury?, Mr. Scott Simpson

  1. The AVMA PLIT finds that the average cost for a single claim is over $3,200, with the average cost of a claim that involves contact or exposure to an animal at $1,600. Preventing injuries related to feline bites and scratches in a cat friendly environment will assist practices in controlling their Worker’s Compensation Modification Factor.
  2. In most states, a Worker’s Compensation Modification Factor is determined by the National Council on Compensation Insurance (NCCI) to analyze the cost of losses from a practice which establishes a comparison to the rest of the industry. This modification factor directly affects how much practices pay for Worker’s Compensation insurance, and practices with a high mod factor may pay anywhere from 10% to double that of their industry peers with lower mod rates.

Lessons Learned: Diagnosis & Management of Exocrine Pancreatic Disorders in Cats With Triaditis, Dr. Stanley Marks

  1. There is increasing evidence that acute pancreatic inflammation occurs secondary to intestinal inflammation (IBD) that promotes dysbiosis and translocation of enteric bacteria to the pancreas and liver across the inflamed intestines or pancreatico-biliary duct.
  2. Dietary fat restriction is not warranted for the nutritional management of feline pancreatitis.

Managing IBD in the Diabetic Cat – Part 1: Challenges, Drs. Audrey Cook & Amy Farcas

  1. Consider concurrent IBD in any diabetic with a poor appetite, vomiting and diarrhea, but also in those with polyphagia and weight loss despite acceptable glycemic control.
  2. Detailed nutritional assessment provides often-overlooked data useful to evaluating a patient and determining the appropriate nutritional strategies, thus facilitating development of a customized feeding plan.

Practice Management: Incorporating Feline-Friendly Techniques into Practice Management Decisions, Ms. Melissa Tompkins

  1. Managers have the ability help make becoming a Cat Friendly Practice® more successful by utilizing the marketing tools the AAFP as and focusing on training the team.
  2. There is opportunity to grow the hospital’s revenue by becoming a CFP. Staff injuries as a result of feline handling can also go down.

How Chronic Disease Affects Pain Perception & Management, Dr. Elizabeth Colleran

  1. As the feline population ages, along with the North American human population, a central focus of health care is to understand and beneficially intervene upon, the factors that place older cats at elevated risk of precipitous decline. The syndrome commonly called frailty has been hypothesized to represent such a risk, in particular the increased vulnerability to stressors that characterize many older cats.
  2. The value of assessing cats’ frailty is to evaluate its predictive value as a risk factor for adverse health outcomes. Measures of frailty are outside the measures of disease, disability and comorbidity. Measuring frailty may be helpful in assessing risk for other health events and assist in intervening in individualized creative ways to limit this risk. Understanding the neurological alterations, for example, that take place as a result of chronic pain can lead to interventions that more successfully ameliorate it.

Managing IBD in the Diabetic Cat – Part 2: Strategies, Drs. Audrey Cook & Amy Farcas

  1. At-home blood glucose monitoring supports effective glycemic control in the face of changes in food type and intake, along with compromised insulin sensitivity secondary to immunomodulatory therapy.
  2. While not fully “ideal” in terms of dietary carbohydrate content for a diabetic cat, some (not all) of the canned limited-ingredient therapeutic diet category are close to diabetic-recommended carbohydrate content and are often practical choices for the diabetic cat with IBD for several reasons; check product guides, this data changes frequently.

Practice Management: Team Building: Create Stronger Practice Teams, Ms. Melissa Tompkins

  1. Creating core values and a vision statement can impact the hospital significantly. Use your team to help create the vision so that they will have more incentive to follow it.
  2. Hold team meetings at least monthly and by incorporating team building activities you can see positive results in your hospital’s culture.

Saturday, November 2, 2019

CKD & Chronic Enteropathy: Clinical Implications of Gut-Renal Syndrome, Dr. Jessica Quimby

  1. Cats with both chronic enteropathy and CKD may be more prone to anemia exacerbated by hypocobalaminemia and functional iron deficiency, urinary tract infections secondary to diarrhea, and may struggle even more to maintain nutritional adequacy due to poor utilization of food consumed.
  2. Alterations to the gut microbiome occur in cats with CKD. This results in increased production of uremic toxins that may have multiple negative effects. The gut microbiome is a potential therapeutic target.

Cardiomyopathy & Thromboembolic Disease, Drs. Ronald Li & Joshua Stern

  1. Feline aortic thromboembolism is not a death sentence. Sensible prognostication can aid clinicians in directing clients towards pursuing therapy in cats with the best chance of a favorable outcome.
  2. The study and availability of novel anticoagulant therapies in cats is changing the way that clinicians treat this disease. In particular, multi-modal targeting of the coagulation system is a mechanism to combat the known resistance to some antiplatelet drugs in the feline population.

Technician/Nurse: Veterinary Technician’s Role in the Feline Healthy Wellness Visit, Ms. Rachel Poulin

  1. Client’s frequently believe that the stress of an office exam is too much for a cat to endure if they are not sick. The veterinary team, specifically the technician can help dispel those myths by educating clients on the value, but moreover, demonstrating the value. Low stress visits and expert feline handling will help our clients realize not only the importance of annual exams but also develop an appreciation for the clinic’s expertise, patience and handling of their fur baby.
  2. Age-based testing allows the veterinary team to keep an eye on the aging feline patient. We know that felines are masters as disguising injuries and sickness until it is more advanced. Annual exams and age-based testing gives us the awareness of the aging physical state of a patient. This also allows an opportunity to educate the client on when we should start performing certain tests and why.

Cardio-Renal Syndrome, Drs. Jessica Quimby & Joshua Stern

  1. A critical step in managing a patient with cardiorenal syndrome is to identify both diseases exist by encouraging a complete diagnostic workup to better understand the degree of organ compromise in each system. Knowledge is power and awareness should result in heightened scrutiny that will catch complications before they are too advanced.
  2. Far and away the most important systemic condition afflicting cats and resulting in cardiovascular change is systemic hypertension. Systemic hypertension is most commonly secondary to kidney disease in the cat and leads to downstream cardiovascular effects attributable to a pressure overload physiology.

Diagnosis of Comorbidities on a Budget: Practical Diagnostic Options Can Help, Dr. Elizabeth Colleran

  1. Recognizing that financial and other conditions may limit an owner’s ability to choose the best possible diagnostics or therapy, a clinician, in honest conversation with clients, can learn to think deeply about the best path forward. The alternative in some minds when the best is not possible cannot be euthanasia.
  2. The textbook is not always the best resource for daily practice where the challenges of family life intersect with feline medicine. The goal in this case-based approach is to help clinicians imagine themselves in the shoes of a client who loves their cat and is compelled to make hard choices.

Technician/Nurse: Diabetes & the Role of the Technician in Disease Management, Ms. Rachel Poulin

  1. Feline diabetic remission is possible and probable with proper insulin and proper nutrition. Proper nutrition when trying to achieve feline insulin remission is to focus on a well-balanced carbohydrate low/free diet. While clinic regulation is possible without a low carbohydrate diet, remission is not likely without it.
  2. Cats can be extremely sensitive to stress which can result in a stress hyperglycemia. Cats that are having their blood sugar evaluated while in an extremely stressful state may have a falsely elevated blood glucose reading. A thorough history, physical exam and secondary confirmations such as a fructosamine level will aid to determine the correct information. This also offers an opportunity for the technician to provide a peaceful, stress-free environment for feline diabetic patients and/or educating clients on the importance of performing blood glucose curves at home, when appropriate.

Hyperthyroidism & CKD: Now What?, Dr. Jessica Quimby

  1. A combination of creatinine, urine specific gravity and SDMA are more powerful than one test alone in determining whether underlying CKD is present.
  2. In order to minimize sudden changes in GFR and prevent clinical decompensation, cats with both CKD and hyperthyroidism may need lower starting doses of methimazole and more supportive care as medical management is initiated.

Heart Disease & Respiratory Disease in the Cat, Drs. Ronald Li & Joshua Stern

  1. Cats in respiratory distress are fragile and require careful handling to avoid worsening of their condition. Tests that minimize stress such as cage-side ultrasound perform well in differentiating cardiac versus respiratory disease and are initially preferable to radiographs in a distressed feline patient.
  2. Cardiac biomarkers have a role in the differentiation of cardiac versus respiratory disease. At this time the performance of the NTproBNP bedside test appears to be the most reliable and can be used on blood or even pleural fluid.

The Role of Coinfections in Select Feline Clinical Disease Syndromes, Dr. Michael Lappin

  1. Infectious disease diagnostic test results are becoming even more widely available in many countries and panels are available for many syndromes like respiratory disease, gastrointestinal disease, and blood borne infections. Panels can be beneficial for diagnosing co-infections. However, sometime infections by agents that are just incidental can detected, leading to clinical confusion. Always remember to interpret infectious disease agent test results with the signalment, history and physical examination.
  2. If coinfections are detected, select a therapeutic agent that is likely to be effective for both agents. If the agents have treatments that vary, I general select the product that should be effective for the agent that is highest on my differential list first, with the option to add additional therapies depending on the response to the first treatment.

Hypertrophic Cardiomyopathy & Co-Managing Hypertension or Hyperthyroidism, Dr. Joshua Stern

  1. Hypertrophic Cardiomyopathy is extremely common in the cat population, however it is important to recognize that other causes of left ventricular hypertrophy exist and may warrant treatment. Screening for systemic hypertension in all cats with an HCM diagnosis is warranted. Screening for hyperthyroidism in all cats with an HCM diagnosis over the age of 6 is warranted.
  2. Hypertrophic cardiomyopathy may be exacerbated by the comcomitant complications of hypertension or hyperthyroidism. Treating these conditions requires multimodal management with strict attention to renal function.

Technician/Nurse: Nutritional Management of Patients With Vomiting & Diarrhea, Ms. Ann Wortinger

  1. Vomiting and diarrhea are not diseases themselves, but rather signs of disease. Not all of these diseases are related specifically to the GI tract.
  2. Evidence suggests that the prokinetic effect of feeding may actually decreased the vomiting response in some patients.
  3. There is little evidence to support the recommendation of feeding a “bland” diet, and this term is poorly defined and vague, and can mean many different things to different people.

Lunch & Learn #1: Weight Loss in CKD: Is it the Protein or the Calories? Dr. Angela Rollins

  1. When assessing the protein content of a diet, it is important to remember that animals actually require amino acids, rather than protein. By feeding protein sources with well-balanced ratios of essential amino acids that are readily digested and absorbed, one can lower the overall protein content of the diet while preventing protein malnutrition.
  2. Cats have a median weight loss of approximately 10% of their body weight in the 12 months prior to diagnosis of CKD. When consuming adequate calories, cats with early CKD maintain muscle mass on the moderately low protein concentrations typical of most therapeutic renal diets. Maintaining adequate calorie intake may play an even more important role in maintaining body composition than dietary protein intake.

Lunch & Learn #2: It’s so HARD! Feline Heartworm Case Management & Diagnostic Updates, Dr. Byron Blagburn

  1. Feline heartworm disease (FHD) is caused by both immature (HARD) and mature heartworms. Because the clinical presentation of FHD in both of its forms is similar to other cardiopulmonary diseases of cats, it is a difficult disease to diagnose.
  2. At present, symptomatic treatment is the only option in cats with HARD and disease caused by adult heartworms. Longer lasting broad spectrum products could encourage more clients to adopt heartworm prevention and broad spectrum parasite control for cats, and would improve compliance and pet protection.

Lunch & Learn #3: Controlled Substances 101: How & Why You Must Comply!, Ms. Jan Woods

  1. Controlled substances are one of the biggest risks in your practice. Not knowing the controlled substance regulations that apply to you and practice is not acceptable to the DEA. You must be familiar with and actively follow the most stringent Federal, State and/or Veterinary Board controlled substance regulations.
  2. All Practitioners who administer, dispense and/or prescribe controlled substances must be registered with the DEA and have a current DEA number, unless the Hospital has a written exemption from the DEA. Exemptions are usually granted to federal organizations such as Teaching Universities, Teaching Hospitals and Prisons, etc.
  3. Controlled Substance Logs must be current, complete and accurate at all times. Therefore, all controlled substance logs should be reconciled daily for a day practice and at every shift for 24×7 facility.

Feeding Senior Cats for Life-Managing Common Concurrent Needs, Dr. Julie Churchill

  1. There is no established ‘senior diet’ nutrient profile. Although there are plentiful senior cat diets on the market senior cat foods can vary widely even within one manufacturer’s products, making food choices confusing to cat owners.
  2. Aging is not a disease, yet it increases the risk for ongoing physiologic and functional changes in elder cats. Because aging changes will vary by individual, every senior cat should have a nutritional assessment at every visit to identify nutritional risk factors that would prompt a more in-depth evaluation and allow a proactive individualized nutritional plan.

Layers of Complexity: The Feline Imperative for Integrating Pharma & Non-Pharma, Dr. Bonnie Wright

  1. Physical medicine at it most simple, is interacting with the analgesic systems provided by an organism modifying homeostasis. This occurs along the entire pain sensing system: from skin to brain, and involves muscle, tendon, fascia, periosteum, etc. Physiology provides a complex, multi-faceted tapestry for both pain sensing and modification of the transmitted signal that is robust for treating pain and overlaps with other body systems.
  2. Non-pharmaceutical additions include machine based systems that use waves (such as shockwave therapy or therapeutic ultrasound), photons (such as laser and light therapy), electrical currents (such as electrical stimulation, NMES and TENS), Thermal changes (ice, heat); as well as manual or mechanical therapies that create changes such as: mechanotransduction (fascial release, acupuncture, stretching, exercise), neuromodulation (acupuncture, laser, touch, vibration). All of these have a scientific basis for understanding, despite limited clinical proof of efficacy in the feline.

Technician/Nurse: Refeeding Syndrome: Does it Really Exist?, Ms. Ann Wortinger

  1. This is not a new phenomenon, but has been noted in historic texts for both people and animals.
  2. Reintroduction of food causes a shift form a catabolic state to an anabolic state, this causes an increase in insulin requirements, and allows electrolyte shifts into the cells.
  3. This can be prevented by diligent monitoring, acknowledging it does exist, and supplementing aggressively as required.

Feeding Outside the Box: Nutritional Triage to Manage Comorbidities, Dr. Julie Churchill

  1. Patients with comorbidities require triaging nutritional goals to help prioritize problems to optimize quality of life and improve the cat’s prognosis. Consider the following factors in setting priorities; the impact of each disease condition on the patient’s quality of life and the degree or severity, acute or chronic nature of the condition, the prognosis or progressive nature of each disease.
  2. A patient’s comorbidities present nutritional challenges to try and meet a cat’s unique requirements while modifying nutrients to manage conflicting needs. Triage nutritional goals for patients with comorbidities to develop a nutritional ‘wish list’ to meet the species and life stage needs, nutrients of concern for each condition while considering contraindications or intolerances to find a balance or compromised nutrient profile and select the best therapeutic foods. Use pet food products guides as a nutritional formulary to match a product with your nutrient goals.

Managing the Peri-Operative Cat With Renal Disease from Start to Finish, Dr. Bonnie Wright

  1. Elective procedures should always be scheduled at time where a stable IRIS stage has been established. Emergency procedures have considerations that can help to reduce the incidence of post-anesthesia declines in renal function. Anesthesia can be done safely in renal compromised patients and should not be blamed as a reason for not treating systemic diseases that result in greater renal compromise (like dental disease).
  2. Massive IV fluids used to be the mainstay of treating renal diseased patients during anesthesia. This is no longer the case, as fluid extravasation from excessive isotonic fluid use has been linked to glomerular damage. Colloids have also fallen out of failure as a method to support blood volume and pressure, as colloid use has been closely linked to worse renal outcomes in human studies.

Technician/Nurse: Counseling Clients in Crisis, Ms. Ann Wortinger

  1. There is a vast continuum along the human-animal bond with varying degrees of attachment seen. Not everyone may feel the same way as you do about their pet.
  2. It is the team’s job to communicate with the client before beginning the treatment and to make sure that the clients understand not only the procedures involved, including any risk to the pet, the cost, but also the presumptive diagnosis that the tests are being done to confirm.
  3. Behind most conflict is a client who has had their feeling hurt either because they feel that their needs were ignored, their problems or concerns were trivialized of their emotions were ridiculed.

Sunday – November 3, 2019

Refining Diagnostic Skills in the Aging Cat: The Sense of Touch, Dr. Bonnie Wright

  1. A myofascial exam utilizing gentle but inquisitive touch accomplishes trust-building concurrent with exposing regions of interest for assessing and treating chronic conditions, especially pain. Done correctly, the exam can inform simultaneously with providing comfort.
  2. The muscle and fascia live alongside and intertwining one another, and they are the connection from the head to the foot. Their structure can report patterns of disease across the body. Myofascial restrictions can provide a type of roadmap to help discern pain patterns, as well as the contribution of other chronic conditions that create pain or inflammation in deeper, visceral structures.

Comorbidities: Changing the Way We Use NSAIDs, Dr. Dawn Boothe

  1. Nonsteroidal anti-inflammatory drugs should be reserved, as much as possible, for patients with minimal co-morbidities. Of potential comorbidities, cardiovascular and renal may be of biggest concern.
  2. Among the NSAIDs used in cats, robenocoxib appears to be the least likely to be associated with renal disease. However, if used properly (allowing the kidneys sufficient time to “rebound”), meloxicam might be used safely.
  3. Attention must be paid to feline specifics in drug metabolizing enzymes and transport proteins as both are likely to impact the disposition of the drugs.

Technician/Nurse: Hepatic Lipidosis, Ms. Ann Wortinger

  1. Hepatic lipidosis is the most common hepatobiliary disorder affecting cats.
  2. Hepatic lipidosis can develop with hyporexia, not total anorexia, and can seen in cats from 6 months on up.
  3. A veterinary recovery diet is recommended for use, usually through a feeding tube. Syringe feedings are stressful to the cat and the owner, and seldom meet the nutritional requirements for the cat.

Tools for Treating OA Pain in Cats Including Concurrent Renal or Cardiac Diseases, Dr. Bonnie Wright

  1. Non-steroidal anti-inflammatory drugs are highly efficacious for both the experience of pain from OA, and the progression of damage from OA. New evidence improves our comfort using chronic NSAIDs in cats with concurrent OA and CKD.
  2. Opioids are typically not favored for use in chronic pain, but cats may be a significant exception to this rule. Tramadol has been shown to be an effective analgesic in the cat, and may even reduce pain amplification as measured by DNIC (diffuse noxious inhibitory control). However, opioids have many notable side-effects, and there is a large list of other, albeit less proven, therapies that have shown clinical efficacy for reducing OA pain in cats.

Antimicrobial Risk: Changing Your Approach to Therapy When Comorbidities Exist, Dr. Dawn Boothe

  1. The ability to predict not only the organisms, but most specifically the susceptibility of that organism to commonly used drugs is limited in today’s state of antimicrobial resistance and comorbidities reduce that ability further.
  2. The cat is not likely to be any different than any other species in regards to paying attention to the dosing regimen, with the primary goal being to achieve sufficient concentrations of the proper antimicrobial at the site of infection.
  3. The most effective means of decreasing the advent of antimicrobial resistance, which is impacting our feline isolates, is to stop indiscriminant use.

Technician/Nurse: Feeding Tube Management & Complications, Ms. Ann Wortinger

  1. One of the most common mechanical complications include tube obstruction, which can be prevents, in most cases, by proper maintenance through flushing with water after every feeding.
  2. Gastrointestinal complications can be caused by liquid enteral diets with very low residue. Only veterinary specific enteral diets should be used, human diets are too low in protein, and deficient in some essential vitamins and minerals.
  3. Infectious complications can be caused by setting up too much food to be fed at a time, and leaving food at room temperature too long. Food should not be a room temperature for longer than 6 hours.

Feline Anesthesia: HCM & Other Diseases, Dr. Bonnie Wright

  1. The art of anesthesia addresses the entire patient- behavior, socialization, pain and comfort in addition to disease and procedure. A less stressed patient is a more stable patient. This can and should be addressed as early as possible- even prior to arriving at the hospital in planned events.
  2. Anesthesia is about small details. In cats with complex disease combinations- such as kidney with chronic pain from OA or the mouth; or cardiac and renal- the small details can mitigate expected side-effects of the complex milleau of drugs being combined. A solid understanding of the drugs, the physiology of the patient, and specific pathophysiology is integral to making these decisions.

Managing Gastrointestinal Lymphoma in the Diabetic Cat, Dr. Barbara Kitchell

  1. Gastrointestinal lymphoma in cats can be high grade or low grade, and each type should be recognized and treated accordingly. High grade lymphoma is managed with surgical resection of intestinal masses followed by systemic chemotherapy with a high-grade CHOP-based protocols. Low grade lymphoma merits a low-grade protocol using chlorambucil and glucocorticoids.
  2. Geriatric cats are most often affected by low-grade alimentary T-Cell lymphoma. These cats present with anorexia, vomiting and diarrhea, and thus must be evaluated carefully to distinguish between this diagnosis and other morbidities of geriatric cats, such as inflammatory bowel disease, hyperthyroidism and other endocrinopathies, liver and kidney disorders. These cats may have co-morbid conditions that all merit independent assessment and management to return cats to good clinical health.

Technician/Nurse: Nutritional Management of the Feline CKD Patient, Mr. Ed Carlson

  1. Therapeutic renal diets have restricted protein, phosphorus and sodium levels when compared to maintenance diets. The quality of the protein is extremely important. Diets containing highly digestible protein with the correct balance of amino acids minimize nitrogenous waste. “…based on published evidence, feeding a dietetic renal food is the single most effective management option for improving survival and quality of life in dogs and cats with CKD.” (Jessica Quimby, DVM, Ph.D., DACVIM).
  2. Do not underestimate the importance of the client’s quality of life and their perception of their pets’ quality of life. Owners are more likely to euthanize or to consider euthanasia when their pet is not eating or has obvious muscle and weight loss. Consider pharmacological intervention to prevent and manage weight loss early in the disease process. Place esophageal feeding tube in anorexic patients. A multi-modal approach including E-tubes and pharmacologic intervention can extend a patient’s life and improve not only the quality of life of the patient, but also the quality of life of the owner.

Managing Skin Disease in Cats When Corticosteroids Are Contraindicated, Dr. Catherine Outerbridge

  1. Cats can have concurrent systemic diseases that make corticosteroids contraindicated as antipruritic therapy or for treating immune mediated skin disease.
  2. In these cases when treating an itchy cat it becomes even more critical to follow a multi-modal approach to allergic dermatitis and be sure to evaluate for secondary infections and concomitant allergies. This requires evaluating for degree of pruritus attributable to flea saliva hypersensitivity vs cutaneous adverse food reaction vs non-flea, non-food hypersensitivity dermatitis (feline atopic dermatitis) and performing serial cytology to always be assessing for secondary bacterial or yeast skin infections.
  3. Alternative drugs to corticosteroids include cyclosporine and off label use of oclacitinib. The future potential for feline specific biologics in the management of pruritus in the cat would be advantageous in cats with concurrent systemic disease where corticosteroids are contraindicated. Alternative drugs for managing immune mediated skin disease include cyclosporine, chlorambucil.

Managing Concurrent Lymphoma & Heart Disease, Dr. Barbara Kitchell

  1. Budesonide is a locally active oral corticosteroid that is more potent than prednisolone in cats. However, systemic absorption is possible in cats with severe inflammatory bowel disease or GI lymphoma, so care should be taken when it is being used to limit steroid exposure to cats with diabetes mellitus or cardiac disease. It is metabolized rapidly (first pass effect) in the liver, but systemic exposure may be greater in cats with severe liver disease so toxicity might be observed.

Technician/Nurse: Nutrition for the Hospitalized Veterinary Patient, Mr. Ed Carlson

  1. Avoid force feeding patients. This practice is not well tolerated and is not effective to meet patient energy requirements. Clients often object to their pet being force feed if they understand the process or witness the procedure. Force feeding, especially in nauseous cats, has been shown to cause food aversions.
  2. Nasogastric or nasoesphageal feeding tubes are ideal to provide anorexic hospitalized patients with enteral nutrition. Several liquid diet options are available specifically for the veterinary patient. These feeding tubes are easily placed, do not require anesthesia, and are well tolerated by veterinary patients. Additional therapies such as medications to manage unintended weight loss can also be considered in these patients.

Lunch & Learn #1: Feline Hypertension: New Developments on a Pressing Topic, Dr. Bianca Lourenco

  1. Systemic hypertension is common in cats with chronic kidney disease and/or hyperthyroidism, and may also occur in absence of an identifiable primary disease, particularly in geriatric cats. Often silent in nature, the diagnosis of hypertension requires reliable measurements of blood pressure, in most cases, repeated on separate occasions.
  2. Chronically sustained hypertension promotes damage of the four “target organs”: kidneys, heart, eyes, and brain. Successful antihypertensive therapy, using medications such as amlodipine or telmisartan, may prevent irreversible damage to these organs and improve the quality of life of affected cats.

Lunch & Learn #2: Artificial Intelligence Takes the Surprise Out of Chronic Kidney Disease, Dr. Dennis Chew

  1. CKD is commonly diagnosed in cats of all ages when examined closely, but especially in geriatric cats. CKD cats do not exhibit obvious clinical signs or changes on physical examination during early stages of CKD.
  2. Trends in serial laboratory evaluation can be used to become aware of an impending diagnosis of CKD. AI/ML tools (such as RenalTechTM) have the potential to detect subtle changes in data points and trends in patient status that often escape routine detection by busy practitioners. RenalTechTM has the ability to help determine which cats will, and which cats will not develop CKD within the next two years. Predicting disease may allow treatments designed to prevent or slow the emergence of CKD in the future, but this has not yet been proven.
  3. Even a mild increase in UPC has the ability to predict survival of CKD cats. Increased blood pressure increases UPC in CKD cats, but does not directly predict survival.
  4. Safe upper limits for dietary phosphorus content need reappraisal, since it has recently been discovered that normal cats can develop renal injury and decreases in GFR during the feeding of foods with higher phosphate content.

Skin Manifestations of Underlying Systemic Disease, Dr. Catherine Outerbridge

  1. Skin disease is not always skin deep and recognizing that certain systemic diseases can have associated characteristic skin lesions can help increase the clinical suspicion for some diseases and help guide selection of diagnostic tests. Ventral alopecia with a marked shiny quality to the skin in an older cat should alert the clinician to recommend a minimally invasive abdominal ultrasound to look for evidence of pancreatic neoplasia.
  2. Cutaneous clues can help in the diagnosis of endocrine, metabolic and nutritional disease as well as certain infectious diseases, some types of neoplasia and systemic immune mediated diseases. Sometimes sampling the skin in these cases can provide critical information to make a timely diagnosis.

Managing Renal Lymphoma in the Azotemic Cat, Dr. Barbara Kitchell

  1. Renal lymphoma represents a true emergency in cats and time is of the essence. Start with drugs that require little to no renal excretion (L-asparaginase, vincristine) to kill lymphoma cells and allow renal perfusion to improve.
  2. Fluid diuresis is critical to supporting cats with renal lymphoma and azotemia. The often suffer free water loss and require diuresis to allow them to both reduce their azotemia and transit a period of reperfusion injury to the kidney.
  3. Cats with renal lymphoma can survive and can have long periods of remission, and even potentially cures, but the early phases of management are absolutely critical.

Technician/Nurse: Feline Pain Management: Using Physical Rehabilitation Treatments & Modalitites, Ms. Kristen Hagler

  1. Recognition of pain in a non-verbal species such as the feline patient can be challenging but through understanding the role behavior plays in pain the pain response treatment becomes easier. Veterinary hospitals are encouraged to utilize standardized scoring systems to create a customized system that all team members are familiar with.
  2. Therapeutic exercises for the feline patient can be cost effective and easy to implement with creativity. Exercise session times should be short with a minimally distracting environment. Equipment can include common household items like wooden dowels, garden hoses, broom handles or cardboard boxes.

Optimal Feline Hydration, Dr. Deborah Greco

  1. Cats evolved to eat a diet that is replete in moisture and wet foods approximate the water content of prey. Fearfulness (of being attacked by other animals, noisy water fountains) combined with physiologic attributes, such as eyes designed for focusing at a distance and reduced thirst drive contribute to reduced water intake in cats consuming all dry diets.
  2. Addition of wet food to a dry food diet will increase water intake; however, the only significant effect of increasing water intake is observed when the cat switches from an entirely dry diet to an entirely wet diet. Therefore, addition of liquid supplements or high moisture soups or gravies is the only way to increase water intake in cats receiving a dry diet only

High Grade GI Tumor With Intestinal Perforation, Spectacular Dysbiosis, & Small Cell Lymphoma, Dr. Barbara Kitchell

  1. Gastrointestinal lymphoma in cats can be high grade or low grade, and each type should be recognized and treated accordingly. High grade lymphoma is managed with surgical resection of intestinal masses followed by systemic chemotherapy with a high-grade CHOP-based protocols. Low grade lymphoma merits a low-grade protocol using chlorambucil and glucocorticoids.
  2. Geriatric cats are most often affected by low-grade alimentary T-Cell lymphoma. These cats present with anorexia, vomiting and diarrhea, and thus must be evaluated carefully to distinguish between this diagnosis and other morbidities of geriatric cats, such as inflammatory bowel disease, hyperthyroidism and other endocrinopathies, liver and kidney disorders. These cats may have co-morbid conditions that all merit independent assessment and management to return cats to good clinical health.

Technician/Nurse: Lights, Camera, Action: Using & Understanding Therapeutic Laser for Pain Management, Ms. Kristen Hagler

  1. Laser power, measured in a unit of time expressed in watts (W) or milliwatts (mW), and is emitted from a laser aperture. Power determines the dose or energy density and is measured by the number of Joules (J) delivered per surface area, measured in cm2 (1 W = 1 J/sec), to tissues. Calculation of time is required for treatment delivery and can only be determined if output power of the laser and desired total dose for the condition are known.
  2. For joints and muscles, new recommendations are being made to deliver therapeutic laser with the region in an open, stretched or extended position to maximize delivery to affected sections and mimic positions which may be incorporating additional areas causing pain.