Hello, it's Anthony Chadwick from the webinarett welcoming you to another episode of Vet Chat, the number one UK veterinary podcast. And I'm very pleased to set today to have one of my very good friends and I would, I would really say teachers of dermatology, Trevor Whitbread, who, I think we've had a long association going back 2030 years, Trevor, of working with you in partnership on my dermatology cases and you always added. Something extra into those conversations.
The, the link with the pathologist and the dermatologist is such an important one, but perhaps before we go into that, just, can you give us a little potted history? I, I, you even were lucky enough to, I, I think, . Teach at Liverpool University.
Were you a graduate at Liverpool University as well, or where did you graduate from? Yeah, I, I did a, first of all, I did a biology degree in Bath and then went and did a veterinary degree in Liverpool. I went into practise for a bit and then went back as a lecturer for about 5 years.
Where about did you practise this Trevor? In Leicester, in Leicester, mixed practise, excellent. Yeah, I really enjoyed it.
And I think it's so important, probably for a pathologist to have had that experience in practise has been really important for you. When, when we started the lab here, I always took people on who had been in practise, it was one of the criteria really, er for a pathologists to have been in practise, cos we're serving the practises, we serve as practitioners. And I think it's useful to know.
Practitioners' problems. You know, they've they've they've got a client at their end, that is pestering for a result, for example, and we know that, we know the difficulties of practise if you've been in practise, and you also know what practitioners want from a report. So I, I think that's been quite important.
That's less common now, it's less common to find, pathologists who can do the pathology but who have been in practise. And it's mainly because the, the production line now is you get a degree, you do a residency, you come out the other end with your boards, you're a pathologist. Where about your, your labs were right down in in Devon, when did you actually start Abbeyvet services?
It was around about 1985, round about there, 18586. Right, so you left Liverpool about I came down I came down here, I came down here for a job with, Peter Bloxham who had Bloxham laboratories down here in Tymouth, which subsequently after very many, rebirths became Axum Laboratories. And I came down to set up histopathology for him, which we did, and then set up on my own.
And when did you leave Liverpool University? When did you finish as a lecturer there? That would have been 80.
5 probably. We just missed out on each other because I started at the university in '85, so. We, we just missed out, but of course you'll remember people like Don, Professor Don Black, Don Kelly.
Yeah. Yeah. Don Don's living down here now in Exmouth, about 15 miles away, not too far from you, fantastic.
Yeah. It's good to have been a clinician and a pathologist, and I think I, I learned fairly early in my career that I kind of looked up to pathologists and thought they were like mini gods. And then as I began to get reports back and I, I started reading more, I realised that pathologists, just like ordinary vets make mistakes as well, don't they?
Yeah. Oh yeah, absolutely. I mean, everybody makes mistakes at the end of the day.
But you know, as, as you know, as you know, you go through an algorithm in your head. It comes automatic in the end, but it's still nonetheless an algorithm when you're doing a diagnosis or looking at a a case. And if that algorithm isn't right or if you haven't got all of the information that you need for that algorithm, it sometimes won't work properly and you come out with a different conclusion.
And also, you know, our knowledge is increasing all the time, and you may be at a stage where you don't quite have, nobody has the knowledge to actually complete the algorithm in the, in the correct way. So that that, I mean, you know, every, every profession has that problem. And I think that's where the partnership between vets and pathologists is so important.
Do you think there's a danger in the busyness of life now that vets and pathologists don't talk enough to each other, because that's how the diagnosis comes, doesn't it, from the two of us. We used to have lots of chats about particular cases and I think for me they always added, you know, to my ability to make hopefully the right diagnosis. I'm obviously reluctant to suggest that, you know, to phone up with each case because that would just make life impossible.
And I think clinicians probably also, on the bane of their lives must be answering the phone calls. But yeah, I mean, you know, with difficult, most 90% of cases that you look at are fairly straightforward. It's the 10, the 5 or 10% that keeps you interested.
First of all, and maybe those ones that need some sort of discussion. And it is now so easy as the world digitalizes for us to be able to send photographs over from an iPhone, you know, via email to, to your account. Presumably seeing pictures of the animals, you know, particularly on dermatology lesions and cases is, is also very useful as well.
Yeah, yes, it's very, very useful. As I say, it's useful probably for the 5 or 10% that are. Not very straightforward, most things, as you know, as you as you get experience become fairly straightforward and routine, but it's the bits at the end, the 5 or 10% that are really.
More challenging and keep you interested in what you're doing. And talking particularly about dermatology, cos that's obviously my area of expertise. I think it's knowing when is the right time to biopsy and how to biopsy and how to prepare samples, because a, a 6 millimetre punch from one piece of skin is a lot more challenging for you to come back with a meaningful report than getting 5 or 6 pieces from different areas of the body, isn't it?
Yeah, yeah. I mean, most dermatologists send 3 or more punch biopsies of a condition. Yeah.
And that's probably OK. We, we, we're we're comfortable with that. Sending one is.
Often not very helpful. For example, if you're looking at follicles, for example, if you take 16 millimetre punch biopsy, you may get 3 or 4 follicles in there. Not very many, if you're looking for some problem with follicle growth, hair growth.
So the more the merrier. I think most pathologists will say, give me the body and we'll tell you what's going on, but that's obviously not feasible. So yeah, 3 punch biopsies or more is great.
And things like sebaceous adenitis depend on having 3 biopsies at least. To be able to make the diagnosis anyway, or definite as definite as you can be for space adenitis, a definite diagnosis. The other thing is that obviously choice, choice of choice of biopsies as well is important.
In that getting different stages of a disease process is excellent. Different areas within a lesion, if it's just a single lesion. With alopecia, the centre of the lesion is probably the most important part.
Than the periphery, but with inflammatory processes and particularly ulceration, the periphery is more important than the centre, so it needs to be . You need to choose exactly where, where to take the biopsy to get the maximum results. Sending something that's just an erosion, you'll get a diagnosis which is this is an erosive lesion, won't you?
Yeah, the other thing is that there are some conditions that affect the epidermis, for example, viral infections. They, most of them only affect the epidermal tissue. So if you have an ulcer, the epidermis is gone.
Yeah. So the actual definitive like looking for viral inclusions, for example, in herpes in cats or. Or pox virus to a lesser extent, but if the epidermis is gone.
It takes all of the telltale signs away, the diagnostic features away. And this is another reason why we dermatologists can be classed as being a bit dirty because of course we, we really don't want to surgically prep a a biopsy lesion either, do we? No No, that's right.
And, and if you, I mean, well, you, you'll know, you might need one stitch with a 6 millimetre punch. So and I mean how many times have you had an infection in something like a punch biopsy? I don't think I ever had one, not that I was aware of, or if there was an infection, the dog was able to sort it out or cat sort it out itself.
Yeah, yeah. And obviously, you know, as you as you're saying, as you're alluding to, if you, if you prep the surface, it takes away keratin, it takes away eggsudate, it takes away a lot of diagnostic features, potential diagnostic features. Nationwide laboratories believe in the power of veterinary education and offers a wide range of CPD on various platforms.
Their online learning hub, brought to you in partnership with the webinar vet, is a great multimedia resource full of bite-sized pieces of valuable content coming in various formats to make your learning easy and engaging, and you will get a CPD certificate straight into your webinar vet account. Obviously, just if, if you're doing more of a lump excision and it's a larger area, then of course probably would advise prepping that. But for skin biopsy, punch biopsies, then prepping is, is actually not only not necessary, but it can really confuse and mean that you lose a diagnosis, can't it?
Yeah, yeah, definitely. Do you feel, Trevor, and this was a conversation we used to have a lot, there are too many diagnoses that or pattern diagnoses at the end that come back as perivascular dermatitis. Do we send too many of those into you?
Does that get a bit boring, or, or are we learning? Skin's never boring, I have to say. But yeah, and actually I have to say I get far fewer now than I used to, and I think practitioners.
Are better at dermatology as a whole. We get fewer biopsies with just a hypoplastic dermatitis reaction, which I always have to say is non-specific. Like 95% of them are probably allergies, but, you know, there's a small proportion that aren't, and the inflammation itself is not particularly diagnostic.
If you get a lot of Eosinophils, then, you know, you may, it may push you in one direction for a for a suggestion as cause. But most dermatitis reactions have lymphocytes, some mast cells, perhaps a few macrophages, not many granulocytes. And that's the same thing that you would get beneath the pustule for ephagus folia, for example.
And if you rub the if you rub the pustule off by prepping, hm, you're gonna end up with a diagnosis of hyperplastic dermatitis. So it is actually non-specific, but most of them are allergies. Mhm.
And this is where perhaps we should switch from somebody who takes a big chunk of skin out to somebody who is, has much more finesse and just pricks the top of a pustule and looks at that under cytology, cos that definitely can also add something to the diagnosis, particularly with something like, Penthigus foliaceous, if you've got a really nice pustule and you know how to to look at that and put that under the microscope cytologically. That can be a really good way of differentiating between infectious and sterile diseases like pemphigus folia, can't it? Yeah, I had a PF case very recently that had quite a lot of bacteria in it, so it can be a bit.
Yes, not definitive. Yeah, and I did a I did a talk. A two-hander with a clinician who was very keen on cytology of pustules.
And said that basically you get a canolytic keratinocytes. In pustules with bacteria and. Pathologists don't often see that, I have to say.
And it does depend on the number of 8 cancer sites that are present, but I think there's. The reason why we don't necessarily see it very often and clinicians do, may be a question of volume because we're cutting 4 micron sections. There's a very limited amount of volume in that pustule in a 4 micron section, so we may not get the acanthocytes that you see when there's just a straightforward pyoderma.
And the diagnosis of PF depends on how many acanthocytes there are there really. I remember seeing a cat though there's a bit of discrepancy between what you see cytologically. Yeah, I remember seeing a cat with panthecus foliacious that had tonnes of bacteria in that was.
You know, quite a shock for me because I, I just didn't expect it and then obviously we sent, but it looked more like a sort of enhagus case, grossly and obviously when we sent some samples off, this was. Where it's important, I suppose if you only have one pustule on a dog or a cat and you think it might be pemphigus, you're actually better to take a punch, well, not a punch biopsy, but excise that because punch biopsies can actually tear the pustule, can't they? So we should take a little mini sort of elliptical excision with a scalpel blade.
So would you agree with that, if you've got oneus you'll get pathology on it rather than cytology? Or histopath should I say . Personally, I would, I'm a pathologist, so yes, but yes, I, I think that would be the best approach.
It's the two hander that I did was with Peter Forsyth, who's very obviously very, very experienced, so. His view was that you get a canocytes with pus with bacterial pustules, yeah. And also with Demadiosis as well.
Yeah, the theosis is a funny one, we always used to, way back, I mean, many years ago when I graduated, it was, you know, you. You get pyoderma with it. Yes, used to be used, we used to be told.
And I'm not sure that's the case in the majority of ones that I see, but then I probably only see ones that have been, and I have to say first of all. Most of the biopsies I receive have been scraped for Demodex if they are suspicious of Demodex. So, and they've been scraped and shown to be negative.
So scraping in general practise for Demodex, I think you get quite a lot of false negative results. So I, I don't know whether it's because they're not deep enough. You squeeze it or what.
I think that, as you said, the squeezing of the skin is really important, scraping until you see blood, but even in those cases where I used to miss Demodex. And you know, you would find them for me, Trevor, was on feet with a potodermadiosis, or in some of these thick skinned dogs like Sharpe's. More difficult to scrape.
Properly, yes, as well, no interdigital. In digital, sometimes it was nice to take a plucking. I usually found much more success plucking hers from there.
And putting them under the microscope and looking at the, you know, at the root of the hair, and I would often find demodex in those rather than from a scraping. Yeah, I don't know whether Demodex now is a big problem with the new. Products that you have like proveto or what or other drugs are available.
But that's, they seem to be very efficient at, getting rid of demodex, and I don't know whether practitioners and practitioners will treat anyway before they do any testing. I don't know what happens in practise in that respect. If you remember Trevor, I mean, to treat Demodex would cost hundreds and hundreds and hundreds of pounds and if it was a big dog even more than that, whether you were using, you know, milbamycin or if you were really old amateurs and things.
And I wasn't always that effective, whereas a one dose of Breveto has or one of the other isolazines. Given on a couple of occasions, it usually sorts the dog out, doesn't it? Yeah, yeah.
My worry with that is how we maybe affect the microbiome and also I remember seeing a case at ESPD of a lady, a Polish lady who'd seen many hundreds of Demodex cases and was then saying, We can now breed them mum and dad together again because we know that the pups produced will not have demodex and that seemed to me. Not the right approach rather than spaying those mums and dads. I think that's there'll be pressure to do that, won't there?
Yeah, exactly. 11 thing that you know, we've sort of talked about therapy, . There's a debate amongst pathologists as to whether you should mention therapy as a pathologist.
I quite often get phone calls saying, what shall I do with this now? So My view has always been that the pathologist's job is actually the prime reason for pathology is to give the clinician the next step. Not necessarily a definite diagnosis, although that's ideal.
But to give the clinician the next step, and that's particularly so I think with skin stuff, cos we often get biopsies late in the course of the disease process. The condition's been treated one way or another or many ways up until then, and we get the end product after all the treatment that's gone on. So, I always try and give the next step either in investigation or.
Trials or whatever, trials, therapies or whatever, my attitude to. Talking about clinical work is. To preface it by saying I'm not a clinician, I'm a pathologist, you should ask a clinician, but.
As pathologists, we have to look at probably more journals and go to probably more meetings than most practitioners do. And we therefore have had, we have a quite a broad range of. Knowledge And if I think I've been to a meeting or I've seen something written, and I don't think that a lot of practitioners may, may have had that journal.
Or come across that particular bit of information, then I think I will probably. Say it, I will tell them it's up to the clinician then whether they want to take that on board or to go and look it up and go and look at it further. And also talking with experienced clinicians like yourself, I pick up information from you of what you've done and what's worked and what hasn't worked, and I can then pass that on.
But it's anecdotal, well, fine, but you know, prac practitioner maybe in a. Come to the end of the road of what they normally would do for a particular case. And it may just be helpful.
I don't know. But they can take it or leave it. So yes, I do, I do give clinical information sometimes.
It, it's so important when you're at an ESVD meeting or a World Congress of Veterinary Dermatology meeting and you see the dermatologists in the room, you know that they're. They're the people to be sending the biopsies to because they really understand dermatology, but also they're, they are picking up stuff on clinical which. The ordinary GP who's not at those meetings won't be picking up.
So I think it's, as you say, if you, as long as you preface it with, I'm not a clinician and I've not used this drug, but this drug has been seen to be helpful with other clinicians. I think this again is part of the partnership, isn't it? Go away and read up on it or find some more information.
Get all your dosing rates right, because of course that's really important, and then this is a product that you could use and quite often. The next stage is for the clinician to ring up the relevant company that makes that drug and says, I have heard that this drug can be used in this condition. Can your technical vet give me more information and that's often a good next step.
As you've said, you're, you're pointing the clinician to what their next step is, and I think that's obviously a logical way to go, isn't it? Yeah, my experience also has been that if you, if that clinician phones up a dermatology specialist, most of them are very happy to give some sort, you know, a a a nudge in the right direction. Exactly, yeah.
I mean, I did that a lot when I was in practise to help out my vets and sometimes that meant that they would, the dog or the cat would come to me, but you know, sometimes it didn't mean that, which was, which was fine. Trevor, perhaps to finish off, obviously, where do you see pathology going with digitalization, technology, maybe even AI do you think this is something that, Pathology is is moving towards with digital scanners and so on. There's quite a lot of work being done, particularly in Switzerland, in Zurich and one or two other places on the continent, especially when they're, where they're looking at AI.
Interpretation of digital pathology, and I think that's gonna, I mean, some of the AI stuff that you see now is just. Astounding actually what can be done, and I that's only going to get more sophisticated and I, I don't think at the end of the day. I like to think that they won't completely replace pathologists, but it may help pathologists in their interpretation.
It was another step in the algorithm that we talked about earlier. So I think that's gonna happen. And I know .
Nationwide Labs have have obviously just taken on a new piece of kit, a a a water immersive scanner as well. Tell us maybe a little bit about that. It's the state of the art.
It's the only one in the country, as I understand. It'll go up to about 80. Which which is very high, which is very high, .
And is suitable for cytology. The big problem with scanning up to now is that cytology has not been very good on on scans. But with this machine, I think it is, it is now coming to its own, digitised.
And that will also increase over the years, you know, digitise samples because people can then work for a laboratory but don't have to uproot their family and go and work at the laboratory. They can work wherever they like. They can sit on the beach and do it if they like, which I have thought about.
As long as the lighting isn't, isn't too strong, you'd, you'd have to be under an umbrella, shaded umbrella, wouldn't you, Trevor? Yeah, and a decent internet connection as well. So yeah, I think that's where we're going, we're going towards the AI stuff, I think.
Trevor, it's been so good to speak to you. I miss our, our more regular chats when I was doing more dermatology, but I have been back, you'll be pleased to hear in the clinic over the last couple of weeks, helping out with, with shortage of vets as we know it is post Brexit, etc. So it's been really enjoyable to do that, and who knows, I might even be giving you a ring at some point about a case.
OK. You'd be very welcome. Thanks so much, Trevor, and thank you also to Nationwide Laboratories for making this possible with their sponsorship of this podcast.
Thanks everybody for listening. This is Anthony Chadwick from the webinar vet, and this was Vet Chat. Take care, bye bye.
