So, hello again. First of all, thank you very much to Kirsty, Ingrid, Catherine, Boas, and obviously to Cavet for fantastic, block of presentations before the break. So a lot of Practical information that is just of so much use.

So it's, it's brilliant. I, I will rewatch the whole thing again because I just couldn't keep up with the information coming in. So absolutely brilliant, and thank you very much to you guys for, for helping with this event.

Talking about rich. Donations have come, have come in really fast. I mean, last night we were at 25,000.

Now we are close to 30,000 pounds, and the donations are still coming in. Included in these 30,000 are three big donations from our, big donors, Labole, Eichemeyer, and, the, Hill Company. So thank you very much to Elizabeth Mueller, to Christoph and Alexander Sprung, and to Eric Reinhart from these companies.

Your support is much appreciated. Talking about some German companies, so, we have another German speaker, Ariana Neuber. Hello, Ariana, are you around?

Of course I am. Hello. Oh hi yeah.

So just for as an explanation, Ariana is one of these magical people who used to be in the area of my own practise and all my difficult skin cases. Ah, it was so nice having her close by to ask for advice or to refer cases, and I tell you I had to refer a lot of cases. But unfortunately, Ariana moved away from the UK .

But obviously, to the benefit of a lot of German dogs and cats. So she runs now a dermatology referral clinic in Bahone near Cologne or near Bonn. And, so, but nevertheless, she stays, very much in contact with us over here on the island and it's even better that she agreed to give a presentation on An earful.

She wants to give us an earful. So Ariana, I hand over to you, OK. Thank you very much, Botham for this lovely introduction.

Let me just Share my screen with you. OK. Can you see properly?

Yeah, can you, can you see the presentation OK? No, at the moment we see you and a dog's nose behind you. Oh, OK.

So let's have a look what we can do with the screen sharing. You press on share screen? Yes, I did.

That's bizarre. Let me check. Amy, if I can't fix this, are you ready in the wings to share my presentation?

Let's have a look. I get here a yes from Amy and her team. So that means I think it should come on shortly.

You might, yeah, you might have to instruct them then also when to change the flight. So I, I think that they, that they will be, oh yeah, looking good, looking good. Sorry about that.

So I'm gonna give you an earful as Wolfgang said, and thank you ever so much for inviting me to be part of this. It's such an amazing day and . Yeah, I'm, I'm just, you know, we all feel a bit powerless nowadays in this situation, and at least there's is one thing we can do and help and yeah, raise some money for pets and, and vets in Ukraine.

So fantastic for everyone being part of this and, and participating and watching. Right, can you put on the next slide, please? So, cases of titis, I guess you see those a lot in practise, as I do.

I, I love ears, and, I was just, quite surprised, pleasantly surprised and amazed how, how, how, similar ears and eyes actually are. You know, doing cytology is basically my bread and butter. And getting topical medication in ears, just like Katherine said about eyes.

Basically, there seem to be a lot of a lot of similarities, and, in the past, I have worked with ophthalmologists together, together, and there's so much overlap and it's fantastic. So what we're gonna talk about today is, about the PSPP system, which is really important for everything in dermatology, really, and particularly in ears. And PSPP stands for primary, secondary, predisposing, and perpetuate perpetuating factors that are really important, to, you know, identify and correct in these dogs with really horrible ears.

. The dog in the picture here, or the ear in the picture was one of those that you can smell before you can actually see the patient in your waiting room. It was absolutely horrendous. And the dog, understandably was quite sore and therefore a bit aggressive as well.

And nowadays, the ears are sorted and it's the loveliest little dog ever. But when the ears were really painful, he really wasn't. So after discussing the PSPP system, I'll, discuss the approach to the ear with you and what do you do for therapy.

So can I have the next slide, please? So, as I said, PSPP stands for primary, secondary predisposing, and perpetuating factors. And in the picture on the right, you can see the model of an ear and basically you should always have the kind of the anatomy in the back of your head and also discuss this with owners because they're not really aware of what the ear canal looks like and You know, the, the, this knowledge is very important and they, in order to be able to treat them effectively because of that, that kink in the ear, the horizontal and vertical canal.

Obviously owners can't see right to the bottom of the ear canal and also cleaning is quite Difficult and, you know, gravity is against us, really. So what we need to do when we clean the air is completely fill the air whilst most owners would just, you know, get their their tissues out and maybe wipe the wipe the outside of the ear, which is nowhere near enough. Can we have the next slide, please?

Now, in terms of primary, factors that cause heottitis, and there's always a primary, underlying factor that, that is present that needs to be identified. The most common ones I see are allergies. I guess in practise you probably more, see more foreign bodies.

Fortunately, I hardly see them because you're so good at catching them and And basically getting the foreign bodies out. Endocrine diseases can also be a reason for, for dogs or cats to develop ear problems or parasites. And again, that's something I, that I don't really see that much.

But ear mites in, in young kittens or or puppies, demodex can, can involve the ears as well. And when the ear margin is involved, psychoptic mange is also, something. But that wouldn't necessarily cause ortitis as such.

And then much rarer other diseases like pemphigus foliatcious or sebaceous adenitis, they can also cause ear disease. And on the right here you see me with, a bit of brown waxy discharge, bit of erythema, and that's kind of your typical allergic dog with, probably a seruminous titis, maybe with maesthesia. We have the next slide, please?

Now, the secondary factors are the things like either bacteria or yeast. So the thing, so the things that happen or the overgrowth that happens because the primary disease, so the, the underlying allergy in, in many cases, is kind of driving the infection. So basically the normal flora.

Manages to overgrow in a way that then because of the, the, the huge numbers that are present, that then cause problems themselves. And that's actually when you notice the otitis and that's when the owners come to, to seek our help. So it's not an infection, not like corona, not something you catch, but it's basically overgrowth of the normal flora.

A very important distinction is between cockey and rods and between bacteria and yeast organisms. And, that's why cytology is really, really important, and I was so happy to see ophthalmologist do this as well. Now, on the normal, slides, you do, on in-house cytology, normally you can't distinguish gram-posit, and gram-negative organisms because most of us have diff quick, or rapid diff or something like that, or modified, Romanovsky type stain in the practise.

But, very often Rodha bacteria. Are gramme negative and very often rounds or cocci are Gram-posit. And when we're talking yeast organisms, it's mostly malahesia, but Candida can also play a role in, in certain cases.

And on the picture on the right, you see neutrophils, and you see cocci, and then there are some intracellular cocci as well. Can we have the next slide, please? So again, cytology, as I say, it definitely is my bread and butter.

Not many people leave my consulting room without having had a sample taken from the ear or from the skin. And, as I said, it's quite easy to do, so, a bit similar to what, Catherine did with the eyes. I use a cotton swab, and then I will, try and get into the ear canal into the depth of the ear canal to get a decent sample out and then I'll roll it out on the slide.

Usually what I do is I, I use frosted slides and I put the contents from the right ear, right next to the frosted bit and the contents from the left ear on the other side. So I only use 11 side for both ears. That makes it a bit quicker to examine.

And with ears, really what you're looking for is, are they inflammatory cells? Yes or no, which would mostly be neutrophils, and are there any organisms such as bacteria or yeast. So in most instances, for this situation at least, just using the methylene blue, so the last stain of your staining system will be enough to give you that information.

Now, some dogs, like the one I showed you in the first picture, can be a bit aggressive, just because of the pain. And therefore, what I'll do in those cases, I'll wear gloves, normal gloves, examining gloves, and then I will massage the ear canal and just slip my index finger into the ear. And most dogs, even when they're really aggressive, will tolerate that.

Because having their ears massaged is normally something that, you know, soothes their ears and that they quite enjoy. And I've had so many people, who came into the practise and said, Oh, you cannot examine my dog. They're so aggressive, they're so painful.

And then, I would just do it with that method, and very often I'll still get a very meaningful sample with that method. Can we have the next slide, please? Now, rods are a very specific situation, as I said before.

They are often gram-negative and gram-negative organisms are much more, much less predictable in their resistance pattern. And therefore, that's the, one situation where I will take a culture, a sample for culture straight away. The exception for the gramme negativity is corona bacteria.

They, they are, rod-shaped, but they are actually gram-posit. And often, rods such as pseudomonas can be multi-drug resistant. So, therefore, culture is, is quite important.

However, and I think that's on the next slide, so if we can advance one more, culture and sensitivity, because we're talking, a topical application of medication, and what you're comparing, your culture or sensitivity data with this break points that are based on serum levels. So culture and sensitivity or sensitivity is not really that reliable for topical preparations. However, it is very important still.

To identify your organism because your prognosis will be very different for a pseudomonas case versus coinobacteria, for example. So, although I know that I can't rely on the sensitivity pattern as much, I will still culture these diseases. Can I have the next slide, please?

Now, one thing that complicates matters very often, and that's the case, particularly with pseudomonas again, but it can also happen with malathhesia, so sorry, malathhesia or Tits, they can form a biofilm. So, what happens if you is you have, you know, your individual organisms and they're planktonic, and Then they're attached to the surface, and then they form a monolayer. They produce a matrix, and the cells kind of specialise in their different drops.

And then you get a microcolony formation, multi-layer, and then you get this big blob of biofilm with, the bacteria or yeast or organisms kind of protected in the slime. And that makes them really hard to, to get to with your medication. So this situation, is, is very difficult to deal with and therefore, doing, an ear flush, a deep ear flush under general anaesthetic is usually indicated in these cases.

Can we have the next slide, please? Now, predisposing factors are all the factors that were present prior to the beginning of the otitis, so that have not been caused by the inflammation and the craicity of the disease. And they're very often breed related.

For example, in the springer spaniel, those pendulous ears. Or sharpes unfortunately come with many things that, make us dermatologists happy, if not rich, probably not rich, but definitely, well, not happy. But give us some work at least.

So very often they have stenotic ear canals congenitally without ever having had any otitis at all. Other, situations are hairy ear canals, like in poodles, for example. I mean, sometimes you can't see anything down there, just the hair, and the floppy pin there, as I said.

Next slide, please. Now, perpetuating factors are those that actually develop because of the otitis that's there. So when the ear is inflamed because The canal is surrounded by a cartilage.

So when tissue is inflamed, it obviously swells up and swelling up means because of the cartilage surrounding it, that the only way it can go is to stenos the ear canal. And when that happens quite chronically, you can also get seruminal gland hyperplasia. In some instances, the tympanic membrane can break and then you can get otitis media.

And that can be quite tricky to deal with as well. And the other thing is normally the ear canal is self-cleaning. So, what happens is that the, cells that, the, the, the keratinocytes down in the ear canal, they kind of grow outwards from the tympanic membrane.

And almost like an elevator, they take with them on their, on their way out, they take with them any debris, and the earwax, any any bits of allergens, and so forth. However, when there's massive inflammation and massive ear wax production, then This mechanism just breaks down, it's completely overwhelmed and quite often, particularly when this has been a chronic state, the self-cleaning mechanism also breaks down kind of long term and you have to help it along, and that's where air cleaners come in. And the next slide, please?

So what do you do when faced with a, a dog or cat with otitiss? So as with any case, any, any skin case, you take a very thorough history and that has to be a general history and also dermatological and Outtic history. And then you perform a clinical exam and that can give you quite a few good hints as well.

For example, as I mentioned before, Demodex can manifest in the ear, but usually you have other skin disease as well. . Allergies and, in particular, you usually have port dermatitis, you can have axillary region, erysema, ventral abdomen is usually affected.

So all those, areas on the body, the, the pattern of distribution can be very helpful. And then you check the, the general health, you check the skin, and then obviously you check the ear. And that includes palpation of the ear canal as well.

When there's very chronic inflammation in the ear canal, the, the canal feels really thickened and obviously you can feel whether they're painful as well because of their reaction. And then you perform autoscopy if possible. In some patients, that's not so easy because they're so painful.

But when you do perform otoscopy, always warm up the, the cone because, having something really cold thrust in, in your ear is not very pleasant, so most animals, even if they're not that painful, will resist that. And do it gently and also make sure that somebody pulls the nose down and you pull the pinna up because that will straighten out the canal for you a bit and make it easier for you to get to the bottom of things and also for the animal because of that kink, you don't want to hurt them. Next stage definitely to do cytology, on, and then, culture and sensitivity if indicated, so if there's a rod, shaped bacteria present.

In some cases, imaging such as an MRI or CT might be a good idea if it's a very chronic infection. And as I say, for some instances, particularly again, when there's biofilm or when there are rods, and ear flush might be indicated, and then you want to use targeted ear cleaners and drops and develop a long-term plan. Next slide.

So the aims of your treatment are you want to treat the current otitis that's there. So remove the discharge, restore the microbial balance, provide analgesia because as I said, they're very painful reverse inflammatory changes. But then also you need to work towards your PSPP system and In doing so, hopefully you can prevent recurrence.

Next slide. So, what kind of treatments do you need then? Do you need analgesia?

Do you need something that's anti-inflammatory and steroids are often very helpful in this situation. Most drops that proprietary drops are a triple combination of an antimicrobial, of an anti-inflammatory, and antimicrobial is usually an antibiotic and an anti anti yeast preparation. And you want to use a cleaner to remove the discharge to avoid, you know, that biofilm building up and protecting the bacteria.

Some, some antibiotics are also, kind of, inactivated by pus and you want to prevent recurrence so often you use cleaners long term and the aim is to restore the aortic microbiomes in the normal flora down the canal. Next slide. And as I said, analgesia, these are very, very painful, so often I will use systemic steroids and quite often, particularly after ear flushing, I will use gabapentin, which seems to work very, very well.

Next slide. Now, ear cleaners, these are dependent on what kind of discharge you have, and what you want out of your cleaner. You want drying agents, and that can be something like isopropyl alcohol, acetic acid, boric acid, benzoic acid.

These might be irritating. They might cause a burning sensation, particularly if it's an ulcerated ear. So don't use these in a very severe case of pseudomonocytitis because it will be quite painful.

And that's something like clean oral or malaitictic, for example, for those of you listening in from the UK, then in many cases, you want antiseptic action action and for example, cleaners, with triDTA or clohexidine in very low concentrations, or acetic acids are, kind of antiseptic, and preparations that you might want to choose, EDTA, tricloidine, and they are also very good at dissolving the biofilm to some degree. If you've got quite waxy ears, you want seruminolytics, and these can be used in combination with a drying agent, for example, and one serummonolytic, that's very good, and that's also quite useful if you're not sure about the integrity of the eardrum is squale, so something like Oteract for example. And then very often these are combination products and you need to basically make sure you choose it depending on what kind of discharge you have and what kind of organisms you have.

And another ulcer present that might make it very painful. So if you clean an ear with very severe ulceration with a cleaner that contains acetic acid, you're probably gonna clean that ear once and never again because the dog is so painful. Next slide.

Antimicrobials. So, do you use topicals or do you use systemic? And again, just like in ophthalmology, very, very, we're very lucky as dermatologists that topical medication is a very, very good option.

And in fact, I can't remember the last time I used systemic an antibiotics for a case of whattitis. With just topical medication, you can reach such high concentrations, 100 or 1 thousandfold compared. That to what you can with your serum levels that you can even overcome resistance in many instances.

As I say, the proprietary drops are usually combination products. You need to make sure you use them frequently enough, and you also need to make sure you, you use a large amount enough amount to actually coat the whole lining of the e canal, and that will vary from, you know, a tiny chihuahu to a Newfoundland. The choice of antibiotic, antifungal, anti-inflammatory, needs to be made dependent on what bugs you have.

For example, for, bloodshed bacteria, very often I will use a fluoroquinolone, but I would never use that for, for coccoid bacteria. And it depends on whether you, have an an intact tympanic membrane or not because that also alters your choice of, of topicals because some antibiotics can be autotoxic. And particularly with these long acting gel preparations, they're very convenient and also they ensure very good compliance because the owners don't have to do anything.

It's very easy to be compliant with those, but you need to make sure that your tympanic membrane is intact and if you want to use this. Next slide. So in summary, make sure with every ear or with every case of otitiss you see, you work towards the PSPP system.

And if it's just a foreign body, you've already got your primary disease, and you'll probably see lots of those. But if not, at least tell the illness about it. You don't have to, you know, do an allergy test every time, a dog with otitiss comes in.

But I would warn them that this could be the first time that they've got an ear problem, but it's very possible that it will recur and that then you want to look a bit further. Use topicals. You don't need antibiotics, systemic antibiotics for these cases.

You can achieve such high concentrations topically and choose the right cleaner and the right drops. And the other thing that's really important. Do very frequent rechecks.

Don't just send them home with a bottle, maybe the 100 mL bottle of Canorol. Make sure you see them again and make sure that the infection isn't changing and that you've treated and it's all fine at the end of your treatment before you, you know, send them home as, as healed and, and fine. And next slide.

Thank you again, everyone for being here today and thank you both for putting together this today and inviting me. And if there are any questions, I'm more than happy to answer them. Absolutely.

Thank you so much, Ariana, for this presentation. I mean, Ear problems, one of the things in first opinion practise, we always see them. I always think, OK, I know enough about it, but no, no, no, no, no.

You never, you never know enough about it. And there's always something new that's coming. And as it shows, sort of, I mean, for example, warming the autoscope, for example, it's, yeah, brilliant idea.

So, Alexandra is asking a question, how you do it. How you warm it up. I basically hold it in my hand.

OK. In winter, I rub my hands first and then I warm it up in my hand, or I hold it in my pocket, you know. And I'll tell owners the same about air cleaners.

Make sure you warm it up, because again, it's not nice to have really cold ear cleaner, down your ear, and you get far better compliance if you, if you treat them gently, you know. And also not, not having it in a, some sort of sterilising solution or something like that and put it then wet into the ear or something like that. So that's not, not a good idea.

Jennifer is asking, if I understand you right, with dogs with a lot of pain, you use your finger with gloves as a cotton swab. Do you do a print smear with your own finger on the side then? So basically, I have them like this.

I go in. And then I dab them on the slide. And again, right finger, right ear, right side, right next to the frosted bit on my slide.

Mhm. Yeah, yeah, yeah. What else I, Daniella is asking.

Hi, I just heard a lecture. No, so that's sorry, this, this is ophthalmology, I think we don't asking Catherine. No, we are now at Ariana.

OK. Yeah, after flushing the ear, gabapentin, at what dose and how long? OK.

So after GI flush, so for these really severe cases, I will send them home with 3 days' worth, and I'll give. A relatively high dose, 20 mg per cake, up to 3 times a day. And I'll tell owners if the animal is very, very tired, quite sedated, then reduce the dose, but I'll let them kind of determine what dose exactly they give because it varies a lot.

Some, some animals are quite sensitive and some just need it because they're really, really painful. Gabapentin I think you have quite a wide therapeutic sort of range, one more question is, what is the safest air cleaner if unsure, if the, sympanic membrane is in. as if there's just too much discharge in the ear, or if the ear canal is too long, too narrow if you don't know.

Yeah. So, as a rule of thumb, things like pseudomonas are more likely to break the eardrum. And if you've got lots of neutrophils on your cytology, that's an indication that there might be a rupture in the eardrum.

And what's safe in the middle ear are cleaners with squale, that's for seruminous ears and cleaners with Tri EDTA for purulent ears. Yeah. It's a typical thing.

When, when I started my, my own clinic, it was so that I, because I'm, I'm more surgically minded, sort of, I thought, oh, yeah, great. Start my own practise so that will all the sort of orthopaedic cases and all the soft tissue surgery stuff will come in. What did I get?

Skin, skin, skin. And it shows. I mean also here with the question, there are several more questions.

It just keeps us so busy and I think it's also the most common reason why clients move from one vet to the next actually because skin is just you have to be so patient and you have to lower the expectations so. No, it's just, I mean, I always the expectations if somebody comes in, never say, oh yeah, it's an easy case to you know it's always that can be chronic. And I think, as you say, I think people change practises a lot with with ear and skin cases because it's quite frustrating.

And I have to say, I think, people are happier to stick with their practise if they're being referred. I have to make a bit of advertising here for dermatologists. No, because I think it, it helps foster a, a, a bond.

And, and, and trust, if you say, OK, like you, I, I mean, I think you're actually quite good in dermatology, but if someone is actually, you know, only orthopedically or surgically minded, and they, they are, they're not that interested in, in dermatology, which is, you know, It's not everybody's cup of tea. And if it's not, send them to somewhere who is, because I think that's the better approach rather than just trying a bit. And I've seen so many ears that I've been looked after, not very well for years and years, and they've been practise hopping, and it's quite frustrating for everyone.

Ariana, there are a few more questions, but if you could be kind enough maybe to have a look at them if you have the time to, to answer some of them in writing. So, thank you very much, and I have the great pleasure to introduce the next speaker. It's Xavier Levy.

Hi, Xavier. There you go, there we are. There we are.

So, Savia is, European College, of, Animal reproduction specialist. He's also, the cava, the French representative at VIAA. he, is a veterinarian since 2003.

And he's also an elected national director for AFAC, the French Small Animal Veterinary Association. And Xavier is talking about another subject that I think where teamwork is really just super important. He's talking about the caesarean sections.

And so this is something sort of when I do caesarean sections, sort of, I actually, I like to time it actually, so that that I say here. From the moment when the patient is going under anaesthesia, let's have a look how quick we are. And then really it, it makes a huge difference if you have a well working team.

But I'm sure there's always something that can be improved, and I think I leave it to you, Saria, to explain to us how to do that. OK, thank you very much. Thank you for this invitation.

Thank you to be part of it. I was supposed in one month to go in Kiev to give a lecture and to speak also about C-section. So, I'm nearly pleased to speak about C-section nowadays that we can collectively, help them.

So, I will try to focus on some specific things that are very crucial and makes the difference at the time of C-section and how to schedule the C-section and to prepare. To perform, I could say the perfect one. But scheduling the C-section, the difference between emergency and scheduling is that we know that the parttuition cannot happen correctly and we have to decide to plan a C-section before parttuition starts.

There are many reasons for that. I will go very briefly because that's not the really the topic. So you can have a beach with a history of full primary uterine inertia, some breed of course.

As English bulldog. You can find some anatomical abnormality, as you can see here with the vaginal septum that sometimes does not prevent a mating, but of course we prevent a normal btuation. You may have some dumb distress because of eclampsia, and you could have a single syndrome, some very uncommonly malpresentation before patuation time, as you can see here with Bcor neural.

That is seen a few days before patuation time. So of course you will not be able to go out by normal delivery, so you will need to do a C-section. You can sometimes discover a time of foetal counting by x-ray, a foetal death.

You may have very uncommonly this proportion of foetal maternal canal birth. So all of that you will have to schedule a C-section. The first thing when you want to schedule it is to define the perfect date.

So you have different ways to practise it. I don't say that one way is better than, than the other. It depends on your own practise and what is your favourite, for you.

You can wait until, as it has been historically done since decades, wait until the drop of progesterone below 2 nanograms per millimetre in most of analyzer and sometimes a little bit over it. The problem when you do so is that you cannot really schedule it many hours or one day before, and you will do the progesterone daily at the end of the year. Just, just a very brief interruption.

We get a few messages in that the slides are not changing. Have you changed the slides or are you still on the first slide? Because I'm also still on the first.

No, I changed the many slides. Oops, I'm on the 5th 1. OK, so, team, team, shall we go over to, the presentation that you that you run the presentation?

So not the talking, obviously, just the, just the slides. My dad, I yeah, something is happening in the background. I think we have to move a few slides on.

So, maybe don't, go from the first just before, so it, it was here to show the vaginal septum so you can go on the next slide. On the next slide, you can see on the X-ray, the neural that comes, go from the left side to the right side. You can see the head on the right side.

So of course you will not have a normal batuition. You can go to the next slide. To the next, really site.

OK, so how to schedule C-section so you can go to the next. Thank you. So you can, as I just said, wait, wait until the drop of progesterone next, and most of the time you will wait until the progesterone drop below 2 nanograms per litre or 8 n per litre.

The problem when you do so is that you need to wait, most of the time to, you're not really scheduling it. You are like doing the progesterone daily and for instance, on Thursday, you will see that. Progesterone drop and you will have to decide for the C-section immediately.

So sometimes in private practise, it can be a little bit boring when you have already a full schedule. So another way to perform really a planned C-section is to first do an ovulation date determination by heat follow up. So for instance, if you know that you will do a C-section, an English bulldog, and you do the heat follow up.

You will know the exact day of ovulation, and you know that you can do the C-section 62 days later without any risk. Of course, among follow-ups, sometimes you may have a slight mistake in the window of the. Day.

So, you don't really know if you are at 61 days or 63 days. So you may decide, around 61 days and you will do some, you will do some control. You will see if you have some milk production.

It may be important because if you have a beach that is coming at 62 days after ovulation or 61 days after ovulation, and you'll see that she doesn't have any milk, you may wait until the next day if the progesterone remains high. If you have milk, you should do the measurements of the parietal diameter what I show you on the picture below. You take the size of the head and you see if you have a minimum size that is enough to go for C-section.

For instance, if I don't haveI follow up, I will still be at 30 days of pregnancy, and I will consider, I will do the date determination. We know that she should work around 32 days later. I will ask the owner to come 31 days later, and I will do a new measurement to see if I'm I'm right.

And if really everything is fine, I can do the C-section even if the progesterone didn't grow and in my. In my private practise, we are doing around 150 C-sections a year and I never wait until the progesterone is dropping when I from the C-section. I always do the C-section one day before normal contribution, and it works very well, but the date determination is crucial.

You can go to the next slide. So as soon as you decided to go for C-section, you have many things that remain important. The anaesthesia and analgesia are the key factors are really the key points to have a good success for the dam and for the neonate resuscitation.

Next, please. For some reminds, quickly for the respiratory point of view, you know that you have a reduction of the lungs volume on the FC. You have an increase of the oxygen need and alveolar ventilation.

That means that you have a higher risk of hypoxemia and overdose. Anaesthesia. In the other hand, from the cardiovascular point of view, you have an increase of the cardiac output and the blood volume, and you have a reduction of compulsator reflexes.

That means that you will have a higher risk of acidosis and poxia and a higher risk of hyperfusion of the uteery. This next. From the nervous system point of view, you have increase of the sensitivity to the anaesthetic agents, so you have to be careful about the drugs you are using and of course the the the dosage.

Next please. And from the digestive system point of view, that's really crucial points. You have a reduction of the gastric time viange and you have an increase of the gastric acidity.

That means that you have a higher risk of regurgitation at time of induction before the intubation. And that's very important in practise for the breeds as French bulldog, English bulldog, and so on, because most of the time it takes for them more than 10 hours to empty the stomach. So if they ate a few hours before, you will still have some food in the stomach, and that can be a very dangerous situation is next.

So all of the drugs will cross the placenta very fast very quickly and also all the drug, the drugs may accumulate in the cholesterol and milk. So the first thing that is very important is to prepare the female in a quiet room. Next please, in the quiet room, you can go through the site with in a quiet room without any sedation, and most of the time, as you can see on the video, we will ask the owner to stay until the beach is really ready to.

To have the induction. Most of the time for brachycephalic breeds, we will use anti vomiting drugs as metoclopramide. Metoclopramide has one other interest that it can promote lactation.

So sometimes injection is not enough, but it may promote, lactation. You can of course also use marropitan that is even more efficient. Very it's crucial.

You are very stressed. The team most of the time is a little bit stressed when you are not very still, but you need to be relaxed. Most of the time you don't have it on the video here, but I put music.

I put Bob Marley, things like that that are really quiet, promise. I don't give anything to the dog and the clients, but still, we, we need to be very relaxed. We will put the beach, lie down, with a slide.

Inclination of the table to reduce the compression of the diaphragm and most of the time if the pitch is really fully pregnant with a very high number of foetus, we will put in a little bit lateral recuerancy but very slight, just to reduce also the compression on the beta cover. Then we will clip and clean the white line without any sedation. Next please.

So as you can see on the video here, as you could see on the video, most of the time in the clinic, you don't have a lot of vets that can, be in the C-section time. So you have a lot of nerves, but most of the time I will prepare myself, have two wearers of gloves, and, I'm doing the intubation by myself to have no mistake, and then after I remove this first glove and I'm ready to open it. For the preparation, very uncommonly sedation may be necessary, but really, to be honest, I use sedation on beach maybe once every 3 years.

So maybe one beach for 500 C-section. So it's very, it's something that is most of the time unnecessary, but if you need. You may use diazepam if you have most of the time the antagonist asazinil.

You could use alpha agonist as meatomidine or dexedatomidine. It is possible to use it if you use very, very low dose. It's just for sedation, of course it's not for induction.

But you should avoid acepromazine or atropine acepromazine may increase the hypotension and the atropine may lead to tachy arrhythmia and arrhythmia in neonates. Next please. You, you can stop the fission of the beach with lacto reactate solution.

It will reduce the effect of vasodilation and it may have induction fast. Most of the time you can see the literature that we will recommend mask oxygenation on the beach group to promote super oxidation, oxygenation before induction. But I have to say that in practise it's not really convenient because it may excite excite the bitch a little bit of the queen and so it's not something that in, in practise we are doing, we are doing routinely, but you could do it by mask or by nose oxygenation next please.

For the induction the drug must be rapid, short life action, and rapid and eliminate it quickly. I have a preference for alfaxolon, alfaxone propofol. For decades we used propofol as the gold standard, but I have to say that since around 10 years now I use Alpha alfaxolon, and I think it's much more convenient, mainly for dogs, maybe not for cats.

For cats, the alpaxolon maybe have a too long live action effect, a little bit longer than propofol, so I prefer still propofol for queen, but for dogs, I prefer alpaxolon. You have . A little bit longer effect action that is very convenient because most of the time when you use propofol, you need sometimes maybe mostly on nervous beach to reinject propofol before externalisation of all foetuses because it really short time of action.

When you use alphasone, it has a little bit longer effect and it's much more convenient for the stabilisation of the beach before giving a lot of gas. The gas mass induction is really to avoid most of the time, but it may be an option on white cats. I have to say that because I have this experience of Bengal breeds.

Some queen are very cool, very relaxed, some. Are very nervous and it's it is sometimes very difficult even to put a catheter and I don't want to fight with the queen at the time of C-section and sometimes I will do a very quiet mask induction and then after it will go very quickly. What you should avoid for induction is of course the ketamine.

That will have a prolonged neonatal resistation and also the medeomidine in the 1920s, you had a publication showing that meatomidine could be used as the induction and even sometimes maintenance for C-section, but it's really something that you should avoid because you have a very strong periphery vasocon. That leads to hypoxia to the foetuses and when you see in a big, when you look at the core of neonates, you have a higher percentage of neonates that are, are dying before before before 3 weeks of, of life than if you didn't use me domini. Next please.

Intubation is an obligation. Of course I spoke about regurgitation, so really you have to intubate the bitch or the queen all the time. You may use for dogs, a normal tube.

For cats, what you could use is a vagal tube made market from axions. It's very useful because it's very easy to put and you have no. Inflammation of the trachea.

So that's something that I will recommend and it's also very important even if you don't have gas anaesthesia in your practise, it's that you need to do intubation. Next piece for the maintenance of the anaesthesia, next piece. We always recommend to use gas maintenance anaesthesia.

So when you start just after the induction, some people will recommend you not to put any gas. I don't think so. It's a good idea because most of the time you will have a bit that will awake again before the full expression of foetuses.

So we always put between 1 to 1.5 of a percentage of. It's run with the oxygen and when you do so, I even did a C-section this morning again.

The foetus are really alive on a scheduled C-section because you have no supper before the C-section, no distress of the foetuses, and they are really awake without even with this gas injectable can be used, but only if you don't have gas and. It's not something that is really recommended and always you have to think to put perfusion. That's also one of the key points of the C-section is the perfusion of the beach.

It is something very crucial, even more if it's a giant, if it's a very high number of foetuses, if it's a brachiceal breed, and if you need to do an over hysterectomy at this time. It will reduce the vasoplegia, reduce the brain hypoxia, and we recommend most of the time to use react that more than hypochlorate because you have a metabolic acidosis at time of late at the end of pregnancy, so it may reduce this metabolic acidosis. Next, please.

For the pain management, for decades, nothing, nothing was given to the beach for pain because we were afraid to deliver to the neonates, the drugs, but of course we know that we need to give pain therapy, . Pain drugs to to, to fight against the pain because you have many sources of pain, the intubation, the incisions, the uterine contraction. Don't forget about the uterine contraction that can be really painful.

All the women that have baby know that in the audience. So it's very crucial because the pain, of course, it's not something ethical that we can accept even more if it's an elective C-section, but also the pain will lead to reduction of milk, may lead to a rejection of the neonates and even cannibalism. So please give any source of drugs is next.

You can use, buprenorphine, you can use tanol. Some are less effective than others, so we prefer buprenorphine to tanol. You may also use dexamethasone.

That's something interesting, mainly in brachycephalbreeds. Next please. Me on English bulldog, French Google, I always use dexamethasone.

Local anaesthesia is something that is really useful, so you may use lidocaine, pivacaine. You have many drugs that can be used locally. You don't, overdose, so be careful about the dose.

If it's a small dog, I put you here the the the paologypolidocaine, the vivacaine, or the Vivacaine, and that's something very efficient to reduce the pain, after C-section. Next, please. You can use methadone.

A lot of people are using non-steroid anti-inflammatory drugs. I don't like so much to use these drugs during C-section, but that's something that is quite effective and seems to have very low risk of nephrotoxicity on neonates. Next, please.

I will not speak so much about epidural and C-section because to be honest, it's something very nice but very unuseful. And when I have colleagues that used to do epidural C-section, and they came to our clinic in internship and they saw how The beach was going at time and after C-section, they realised that it was a waste of time and something really unnecessary, but of course, if you are skilled to epidural and you want to go for, you can do it. Next please.

So the procedure, I will go quickly through the procedure to promote the ne neonatal rate survival. It's stupid, but the opening is important. So the localization of the opening on the white line is also important.

If you do it too craally, you will have some big bloods. That most of the time will bleed and you will waste time. If you go to Kodai, it's something unuseful and you will have a bladder that can be uncomfortable.

So I show you here on the right picture where where you should open and please next one. And when you open, don't try to open too big. You don't need to do a too big opening on the beach, even if you have a lot of foetuses or if they are quite big, of course, you need to open enough to be able to extract them, but not too huge.

Don't try to put out of the abdomen, the uterus. Before externalisation of the foetuses, it's sometimes going to do a hypoten shock to the participal breeds and so it's unusful and you need to open very largely. So as you can see on the video on the right screen on the on the screen, I will do most of the time I will open with a scissor so to try.

To reduce the bleeding because it will limit my bleeding at time of dissection and as you see here on the video, I don't try to remove to put out all the uterus. I just put a little bit of the foetus. I do a slight opening.

I open with the scissor to avoid to cut the skin of the neonate and then. I put out the first, the first status, the first neonate, and I will show you later, what I do, next. But so if you have to remember that, please don't try to open everything.

Next one. The time after induction for foetus extraction, I will, I will go very briefly, but you can see in the literature that some people recommend to wait until 20 to 30 minutes after propofol induction to remove the foetus because you still have a high concentration of propofol through the placenta if you deliver the. It is very quickly, but I have to say that in my own experience, if you don't put too high volume of propofol for induction of the pitch, the foetus are really awake even 2 or 3 minutes after the induction, so I don't think so.

It's most of the time important to wait this time, this next time. You have to adapt to the situation. If it's an emergency C-section or if you see that the foetus are very awake most of the time you can see that that they move in the uterus.

They are dancing in the uterus, don't wait. You removed briefly. If of course you had the need to reinject a lot of propofol because they became very nervous or You awake during your procedure.

If he seems to be completely asleep for the first neonate, you see, when you remove the first one, you see that he's fully asleep. You didn't remove the placenta at this time. Wait a few minutes and most of the time you will see that they will awake again.

It was related to your induction. Next please. When you put out the uterine, so you will see on the video and it's the same, the same video that just before it's the the follow up and so you cut the uterus, you remove the, the neonates.

The first thing to perform is to open the amniotic site on the mouth of the neonate. So really with my finger, I, I, I cut the amniotic site on the head of the neonates and then I will put the neonate. I will, I will inclinate the neonate a little bit as if here is the head.

I will inclinate the neonate a little bit, so you will immediately have the drip of the fluid from the nose and the mouth, and I will keep the placenta connected with the umbilical cord to the foetus. I will not cut the placenta. I will go very gently and it will be very, it's very important to do.

Very smooth placental separation to the uterus because sometimes when you want to go too fast, you go, you will remove, you extract the placenta to to briefly from the uterus and that's leading to a severe bleeding of the beach. But if you go very gently, very smooth, you are not in really an emergency. You can take 1020 seconds if it's necessary.

You don't need to rush so much. You will see that the bleeding of the beach will be really reduced. The, the metrohagia, event will be very uncommon and, the foetus will awake very quickly.

Next slide please. It is something that, since few years seems to be very obvious, it's better not to clamp the umbilical cord immediately at time of externalisation of the foetus than to clamp it. At time of birth, you have the umbilical arteries that contract in a minute while the umbilical vein remains visible.

What is next. That have next one that has very important consequences. When you clamp immediately the umbilical cord from the neonates, you will block the blood flow immediately from the umbilical vein that will reduce to a preload that will reduce the preload of the herbs.

When you blockage the umbilical arteries by planting in the same time, you reduce the cardiac output. Next one, please. So not clamping the umbilical cords, it's better to stabilise the the neonate circulation, increase the perfusion, and reduce the hypoxia of the neonates.

And that has been published in a human, since many years and if you have recent publication in a small animal, practise that shown that you have a better resuscitation of neonates when you keep the placental in, in connection with the bal code for a few minutes. Next one, please. In human, you have really a reduction, if you, keep, the, you use the, the, the blood flow from the placenta through the umbilical cord after birth.

You reduce, the, the, the, the babies that need a transfusion, you reduce the problems of enterocolitis, . Reduce the number of sepsis in neonates and you improve the card, the cardiovascular function, the cerebral perfusion, and the Ada score. And I, I do that since maybe 868 years now, and that's funny because I have some colleagues from other countries that do, do so, and they did a very interesting study.

Next one, please. That's shown the same shown that in, in in neonates in puppies, if you keep the umbilical cord connected for a few minutes, you have a better resuscitation. Some, small things to know at the end of C-section, sometimes you may have quite a severe hemorrhagia of the uterus, what we call a merhagia.

So you need to know that you may use oxytocin intrauterine inside the uterus lumen. Most at the end of C-section, I would always. A little bit of oxytocin into the lumen of the uterus.

It promotes contraction of the uterus. It's important for me if you have an inertia to see if the uterus is available to contract well, and most of the time you will have a reduction of hemorrhagia. If the bleeding is too strong, you may use metre or hemoset that can be bought that you can have at your clinic, and that will help to reduce the bleeding.

Next one, please. If you still have a persistent bleeding after C-section, when the beach will go back home, you can give orally the treatment of amo, the tampilla, and you can complete it with tranexamic acid that will reduce the bleeding and that's sometimes very efficient to stop a maorrhagia in a beach. Next one, please.

When you want to reduce the adherence for an exotuation in a beach that maybe you will have nexttuation, please try to do a cushing or a lumbar surgery at the end of when you close the uterus. You don't need to do a. A cashing or er closure, but it will reduce the adherence between the epilant to the uterus opening.

So, as I show you on the picture, you can see the picture at the end of the surgery, on the slide. Next one, please. It's possible to do hemioarectomy at time of C-section if you have specific problems.

It's possible to do a partial hysterectomy. I had sometimes uterine rupture at time of paltuation we had sometimes . An abnormal bleeding, it's possible to cut a part of the uterus and to close it again.

The recovery is really impressive and most of the time if you do a surgery in the years next, you even don't see that you did the surgery and you cut a part of the uterus home. Next one, please. As you can see here, it was in, in, in small dog, so we had to, to, it's like an anterectomy, but it's much easier than ectomy.

It goes very fast to perform. Next one, please. Like Next one, please.

And so don't forget to do the local anaesthesia if you didn't do it before C-section to reduce the pain of the abdominal wall at time of recovery. And I will suggest you to do intradermal contious suture because you have no. You have nothing outside, so it's much easier for the milking and most of the time I will recover my closure with rela, what we call a super ugly 3, because it will do a protective, protection barrier over my closure, so it's something very efficient.

Next one please. So, I think I try to give you all my, my tools, to do a perfect C-section, a scheduled C-section, and I think if you follow up. With your own practise, but if you follow up my slight advice, I'm sure most of you already did the same.

You will do a C-section very easily and you will have a very nice recovery of the beach. And most of the time after a C-section, the beach is, is able to go back home, 2025 minutes after the surgery by walking by herself. That's really impressive.

And if people have A long way to do when to go back home. Don't forget to milk the neonate before awaking the beach. So most of the time on the surgery table, I will put the neonate to milk the beach, and then after I would stop the gas anaesthesia so they will milk a little bit before departure.

Thank you for your support for this really great. Event. Thank you, Vorgan for this invitation.

You do an amazing job, and I have to say that I'm a little bit, yeah, it's emotion because it's something we, we don't, we don't like to do lecture for this kind of reason, but I'm very happy to do this lecture today to help, but I would have preferred to do it in Kiev in a month. Thank you so much, Xavier, for this presentation. There are quite a few questions, but we are also quite a bit over time, so.

I'm afraid these questions, Xavier, if you kindly could answer them, by writing and, now I, the, there are two things. First, just to let you know, we just went through the 30,000 pounds donation barrier, 5000 pounds more just since last night. So this is an amazing result, but Don't stop there.

Continue donating, please. And now the moderation of this event will be put one level up because da da da da. I announced the arrival of Julian and Mike, from veterinary ramblings.

If you haven't come across them before, then. Well, you are in for a real treat. Hello Mike.

Mike, you're in Prague at the moment, is that right? Yeah, that's right. OK.

Julian, where are you? Are you hiding? Julian Julian.

Yeah I'm not, I'm not hiding, but I think for some reason people don't want to see me. No, he's shy. He's shy but yeah here we go, there we go.

Oh, just, just got my coffee. These, these, these two guys are not only really good veterinary surgeons, they also run this very successful podcast, Veterinary ramblings, and I think I, well, you, you will find out sort of what the what just a recipe for success is. And, I, I'm really envious because you, you can introduce some amazing people now, and I think I hand over to you guys and do what you do best.

So, thank you very much for helping out. Have a nice afternoon and evening. I'll see you guys later.

Thank you ever so much, Wolfgang. That's a fabulous introduction. Hey, Julian, I'm a veterinary surgeon.

Hey, congratulations. I never knew that. All these years I've known you.

I know you as a as a. A physiologist and as as the introducer of apostles imagery to to to the vehe but not as a vet that's great, another string to your vote. Yeah thank you very much for that.

Thank you, Wolfgang. So that's amazing. Hello Julian, how are you?

I'm fine, Mike. Absolutely bubbling over with excitement to be on this, confidence for the day. What a, what a great cause and what a load of fantastic guests we've had on already and we've absolutely introduced some even better ones.

We we have, we have, who are we starting with? So we're starting with Sina Marsidio. Now Seena is, is, is a German vet.

She qualified in Hanover. And she did her PhD in Texas A&M University, and is now assistant professor at UC Davis. Now her most recent, one of her most recent articles was on investigating the proteome of of cats, the gastrointest.

Protein of cats with inflammatory bowel disease and comparing them to er to to cats with with lymphoma. And I think I'm probably not alone in wanting to ask her what I think is the most important question here today, which is, Seena, what's your favourite bread? What's my favourite cat breed?

No bread. Oh, my favourite bread, oh, like definitely rye bread, but like I haven't had it in a very long time, so I'm, I can't wait to go over to Europe and have it again. I'll cook you someone when you come over.

But you're gonna be talking to us today on feline enteropathies. Correct. And now, is this going to be, I don't want to spoil any surprises, cos I know you've.

Invented a test just recently, haven't you, which, distinguishes two very important canine enteropathies. So yeah, it's not yet commercially available, but we are working on that. Right, well, will that be part of your presentation today?

Sadly, no. I, I kept it a little lighter. I'm going to go over a few fun cases where I actually need the audience, so I hope that everyone uses their chat box and help me out here with some tricky cases that I saw.

I, I'm sure they will. Well I think Julian, you and I had better shut up and hand over to C. I'm gonna shut up and drink my coffee.

I'll do the same. See, take it away. Can you all see my screen?

Is that OK? Excellent. So I'll just assume that you can see my screen and I'm taking it away.

thank you so much for the kind introduction. Again, I'm talking about feline chronic neuropathy today, and thank you so much, Wolfgang and everyone for this fantastic conference. I'm really honoured to be a part of it, even though it's a, a sad occasion, but I think it's still for a fantastic course.

So thank you so much for having me. Oh, so feline chronic neuropathy, many of you are familiar with that. It's extremely common in elderly cats and the prevalence seemed to be going through the roof in the past couple of years.

Not entirely sure why that is. It could be either because we are seeing a lot more fe patients with urbanisation, people having more cats in cities, or whether there's a true increase in prevalence is currently a little uncertain, but I think all of us can agree that we see a tonne of these kitties in our private or in our practise. When I say feline chronic neuropathy, what do I mean by that?

It's generally an umbrella term, for lots of different diseases. One would be food responsive neuropathy, which usually presents as diarrhoea, and one can even argue that that is probably an umbrella term for different types of underlying etiologies. Then, of course, idiopathic inflammatory bowel disease.

As we call it. And then I also summarise on the intestinal small cell lymphoma under that umbrella, just because it is a very common cause for chronic GI signs in cats. And also, for all we know, it might actually be on the spectrum of disease.

So where we have inflammatory bowel disease and small cell lymphoma are just more so representing two extremes of a spectrum. Rather than two different entities, it's not entirely clear yet. We haven't had the longitudinal studies that will be necessary to follow up on that.

But there's a lot of data, including my data on the microbiome and the metaboloum, data from France, from Valerie Freisch, all of which point towards that this might be a spectrum of disease rather than two different entities. The clinical sciences and the phenotype is quite different from that of dogs, and I think that is extremely important to realise because we all know that if a dog, dogs present usually with diarrhoea, and so if anyone had a dog with diarrhoea, like me, I know that very easily because either I see accidents in the house, which is quite very unpleasant, or my dog asked me to go out, 4 times a night. And so, usually clients show up in our veterinary office, very soon after the onset of that clinical time.

In contrast, cats often lose weight over months, before clients even realised, and some even then don't realise, that they lose weight, and that might also be because the The client, the the the human animal bond between dogs and cats and between dogs and humans and cats and humans is quite different. Where treats and the feeding plays a much higher role in our bond to dogs, versus cats are more grazers, and, you know, they, they just eat whenever they like, and so a lot of owners actually don't realise that the cat is losing a lot of weight until it's very, very obvious. vomiting is the second most common clinical sign followed by hypoorexia or even polyphagia.

I see a lot of caddies that show up with polyphagia. And then diarrhoea dependent a little bit on the study that you read, only in 12 to 75% of cases present. So quite a different phenotype from that in dogs.

And I'm so glad. I think Ingrid already talked about workup of cases for GII disease and so I really don't have to dive too much into that. I just wanna remind the audience that we have to think about extra GI diseases, first, especially in chronic patients before we kind of dive into the gastrointestinal diseases.

And that is not because internists are complicated. People, but it is because if we think about it, the extraintestinal diseases like hyperthyroidism, like liver or kidney disease, pancreatitis, or other systemic inflammations, they're usually easily to be picked up through non-invasive diagnostic testing that helps us not to overlook things. And so we shouldn't immediately be drawn to working up the GI tract when in fact we have a kitty in front of us that has Severe chronic kidney disease, which would be really a mess.

On the other hand, if we look into GI diseases, the diagnostics and the treatments can be often elaborate. I'm just always saying good luck placing a, a 13 year old inhabitant cat on ZD diet, right? It's, this is kind of, a very, difficult endeavour because cats are very fixed on their diet, so it can be extremely difficult to switch diets.

It can be expensive. I don't know, ultrasound and, here at UC Davis is quite expensive. And it can also be invasive because ultimately, we need biopsies or and or treatment with, immunosuppressive drugs.

And so, just working up the extraintestinal side of things first, really is helpful. But again, I don't want to delve too much into that because I believe Ingrid has already, excellently covered all of that. And so I, to shake things up a little bit, I brought some of my cases that I saw in the past couple of years, and I just want to share them with you and kind of see what we can all learn from these cases.

At least I learned a lot. So first case I wanna bring here is Sasha. Sasha was a 10 year old female spayed Manx cat.

She was a single pet in the household and she only lived indoors. And when Sasha presented, the owners repeated, reported that she had severe weight loss, about 1 kilogramme over the past 4 months, which if you think about the weight of a cat that is a substantial weight loss that she had, the owners described her as having an excellent appetite, . And then we're not quite sure.

They said she was drinking great, which took Me Always indicates that they are probably drinking too much, and she was on a herbal control diet at the time. On physical exam, she was bright and responsive, but she was kind of a skinny girl, had a CBC BTS of 2 out of 9, and she was kind of borderline hypertensive, but everything else really was within normal limits. On a, baseline, CBC she had just a mild, stress leukogram, so quite boring, and on her chemistry panel, she had a mild elevation in her ALT and hos activities, urinalysis showed a slightly decreased USG, but otherwise, everything was within normal limits.

And so this is now where I want to hear what the audience would have done. I want first to present the problem list. So my problem list was that she had weight loss, a low BCS, and polyphagia.

At least that's what I got from the history. So I kind of like summarised all of that into one problem. She had POPD and she was borderline hypertensive.

So now, I would like to see the audience and and see what you guys would have done. Would you just run a total before or would you just jump right to an ultrasound and I'll just wait a few seconds to the, let's see, to observe the . The chat I see most people, most people choose A, which is great, that's exactly what I did, .

There you go. So, I did also totally 4 and tada. She was massively hyperthyroid.

I also, did not tell you that I felt a thyroid slip, so a total D4 was totally indicated. We diagnosed with her with hyperthyroidism. And we, plan to start her on methimazole, recheck in 2 weeks, and I told the owners that they really should consider I-131 treatment.

So this is a case where we really, what really drives home that, even though this cat had severe gastrointestinal signs, we should really, especially in older kitties, exclude that there is anything extra GI going on, that can cause very similar signs to GI disease. So the next fellow that I saw was Lucky. Lucky was a 6 year old male domestic short hair.

He was an in and outdoors cat and he was the only cat in the household. He had chronic diarrhoea for now, like, probably more than 6 weeks, you know, like when owners have outdoor cats, it's often very difficult to say. But he picked it up at least 6 weeks ago.

Lucky was also occasionally vomiting and he was quite itchy. On physical exam, he was brightly responsive. He was a little bit on the chunky side.

He had a BCS of 6 out of 9. I was lucky to have some history from him from 6 months ago, where he was 5.1 kicks.

Now he was 5.4 kicks. So if anything, he gained a little weight in the past 6 months.

I also found some abdominal alopecia. His pinny was slightly red, and he had quite a few scratch marks on his chin. He, CBC chemistry panel, UA, faecal flotation, FIV F ELV testing, all very boring, all within normal limits, great for the cat, but a little boring for the internist.

So now again, I want to hear what you would have done with Lucky, and I've asked that my students all the time, so I'm kind of curious if there's a difference between my students and the audience here. So, I would say I feel comfortable sending Lucky home with the wormers, a flea treatment and a hypoallergenic diet. So, either, yes, totally, so A or B, no, I want to do some more workup.

OK, so this is a little more mixed than the previous response. So most people, I think, say that they would feel comfortable, some want to do a little more workup. Let's just go back to the slide previously.

We did quite a little bit of workup, right? We did a CBC, we did a chemistry panel, UA, a faecal flotation, all of which came back negative. And, this kitty, basically had, was, was clinically really well, didn't lose weight, if anything, gained a little weight in the past 6 months.

So personally, I felt really comfortable sending him home on some empirical therapy. I dewormed him. I asked the owners to do regular fleet flea treatments, and I put him on a hypoallergenic diet.

And so the owners gave me a two-week update and they told me the diarrhoea had resolved. Yeah, no vomiting since the treatment was started. He was still a little itchy, but it seemed to be improving.

So I made here a a preliminary diagnosis of food responsive and neuropathy in this kitty. And what I usually do with these guys is because they can progress to more advanced stages, I always ask the owners to give me regular updates and to buy a baby scale for at home because as I initially mentioned, weight loss is one of the most common, but also sadly most overlooked clinical signs in these kitties. And so, I asked them to buy a baby scale to really monitor the weight, and give me a haul if they lose weight because that is usually a sign of a more, severe disease.

And if signs recur, I would, have opted for imaging, plus minus biopsies. And so then the last guy I wanna present here is Pete. Pete was a 14 year old male neutered domestic short haired cat.

He was indoor and he lived with a doggy friend. He was vomiting for about a month or so, said the owner had diarrhoea for about 2 weeks, and the owner reported a possible weight loss. And on physical exam, he was bright alert responsive.

He was also skinny with a body condition score of 3 out of 9. Historically, he had a 6, he was weighing 6.4 kicks, which I kind of, found out, while delving through his records, and now he was 4.2 kicks.

So a substantial weight loss, in fact. And that is driving the point home that a lot of clients really do not realise how much weight their cats lose because it is a gradual problem. And oftentimes in my, my experience also.

They will misinterpret the, the fat pad that we all see on the, on the kitties' bellies as being fat when the whole other, the rest of the cat is completely gone. This, this fat pad will often not disappear even in the most skinny of cats. While the muscle conditions who and the they develop significant sarcopenia over time and so that is a really the telltale sign to look out for.

He also had quite thickened intestinal loops that felt quite ropey up on palpation. So my problem list for him was that he had a severe weight loss, sarcopenia, vomiting, and diarrhoea. Again, because this was a chronically ill kitty that had quite a substantial clinical signs, I wanted to do more workup in terms of the CBC which which, which was quite boring, had a mild nongenerative anaemia, probably of chronic disease.

On his chemistry panel, he had a hypophosphateemia, which is was possibly GI related. It is. One of the markers on the feline chronic neuropathy activity index and hypophosphatemia can be mediated through two factors, malabsorption and also a hypovitamiosis D which has been reported for those kitties.

And he also had some evidence for dehydration, which is also very common in cats. Everything else, urinalysis totally for FIVFLV all within normal limits, faecal flotation negative and because that kidney was in Texas, I did a histoplasma antigen test which was also negative. For this kitty, I, because it was quite sick, I did some more testing for the GI tract, and I want to talk a little bit about cobalamine in this kitty, or for, for general speaking, cobalamine is, or vitamin B12, is a B vitamin that is present in dietary proteins and is basically, Absorbed here, through, or digested in the, in the stomach.

And then in the small intestinal tract, it is bound to, intrinsic factor, which is, secreted by the pancreas in cats exclusively and, by the pancreas and the stomachs, is the stomach in dogs. And cobalamin then travels to the Entire GI tract and we can see, we can see that in the distal GI tract and the ileum specifically, we have receptors for cobalamin which bind the cobalamin that is bound on intrinsic factor. And then cobalamine is absorbed into general circulation.

And so, The deficiency of cobalamine is quite telling and it's kind of fun to work up because really there's not many differentials that we have to consider. One would be a receptor defect which never has been described in kitties, and has been described in a few dog breeds, like the bee. The border collie or the Commodore, but really usually in young animals, and very, very rare.

So I think we can safely say that this is, nothing that, would, be of any relevance for Pete in our case. It can be, mediated through EPI, so exocrine pancreatic insufficiency, if we have an intrinsic factor deficiency due to a deficiency of the entire pancreas. So what I usually do if I see a hypocobiuminemia and kitties or dogs for that matter, I measure a TLI.

Or it can be mediated through a diffuse infiltrative distal small intestinal disease. And why do I say diffused? Because if we think about the GI tract is an incredibly large organ with a very high compensatory capacity.

So if I see a hypocobolainemia, that means that the substantial part of the small intestinal tract has to be affected by something. And so a local tumour usually doesn't do that. So it needs to be something diffused and it needs to be something infiltrative in the distal small intestinal disease.

And what can infiltrate the GI tract? Well, it could be inflammatory cells, so we are going down the route of either in IBD or food response neuropathy. It could be.

Plastic, and if we think about neoplastic, it needs to be diffused. If we think diffused, it's probably around cell tumour and then we land on lymphoma. And then, in, you know, the southern states, or Midwest, we definitely have to think about infectious causes such as histoplasma, which is less relevant, of course, for, European countries generally speaking.

Folate is another B vitamin that is extremely important, and we'll just talk about the pacifist, in a little while. It's, again, present in the food, and in contrast to cobalamine, folate is actually absorbed in the proximal small intestinal tract. So measuring folate and cobalamine gives me not only an, an idea on the function of the small intestinal tract, but also on the location of the lesions.

So if I find a Normal folate, but a decreased cobalaine, I'm thinking about distal small intestinal disease, and in these kidneys, I usually push for, an ileoscopy or, if I go for surgical biopsies, I definitely wanna take ileal biopsies versus if I see a normal cobalaine but a decreased folate, which is a lot less common, this, this combination is a lot less common. I know that the disease is probably more so in this, in the proximal small intestinal tract. Having said all of that, I think what is really important also to drive home is that these, I, I personally see and they are more so surrogate markers of a problem in the small intestinal tract.

So while B vitamins are extremely important in, in cell cycle metabolism and We think about it, crypt epithelial cells in the intestinal tract are amongst the most common, most most rapidly dividing cells in the bodies. So they are important for regeneration of the GI epithelium, and so it is beneficial to supplement those. And it has in fact been shown to alleviate some of the clinical signs of cats with chronic anduropathy.

They are really more so a surrogate marker of a much deeper underlying problem that we have and that we have to get on the bottom of, because if you, if you wouldn't, if you were to measure like me, untargeted metabolomics where you Measure thousands of metabolites, would find hundreds of metabolites decreased, and we can't just supplement all of those. So it is critical to realise that yes, we can, we can measure those, we can supplement those. They might have a beneficial effect, but they are not the solution to the problem.

They are just a symptom, much like creatinine for kidney disease. And so that's what I kind of did with this little guy. I wanted to know more about the GI function given this severe weight loss that's Pete sustained.

And so I did a full GI panel with a cobalamine, a folate, a TLI and an FPLI. And as we can see the cobalamine was actually below the detection limit. Folate was very, very low, so we have a problem here in the distal small intestinal tract, in the proximal small intestinal tract, and then we have a high TLI and a high FPLI, which to me indicates that this this kitty also has some pancreatitis.

And if I think about pancreatitis and cats, especially chronic pancreatitis, that is most commonly associated with a chronic neuropathy. Often seen as what we call triaditis, where we have an inflammation of the intestinal tract of the liver, and also the pancreas. And that is probably because of ascending inflammation, inflammation in the GI tract that just transcends into the local area and possibly also dysbiosis.

So, my interpretation of this kitty was that there's probably some intrinsic GI disease going on, and we did some imaging and found severely Thickened GI walls, and I scoped this kitty eventually and I brought you here like a normal scope, how a normal scope and a kitty looks like it's like a nice and pink, like, and the little vili here are very fine versus Pete looked very ugly here. The, the mucosa was very cobblestony, whitish, the, the vili here are very thick, and, ugly looking. Another, example here.

And when we then go and biopsy here, you can see my biopsy forceps. It started bleeding pretty rapidly, which indicates to me that there is some fragility going on. So after we got our diagnosis back from the pathologist, Pete was diagnosed with an epitheliotropic small cell lymphoma.

And what, what I did, I will just come and talk to you about it in just a 2nd. 1st, I wanna bring Sasha back because Sasha, meanwhile, came back to me as a recheck. And if you remember, Sasha was the kitty that was hypothyroid, she was coming, currently on methimazole.

The owner reported it decreased PUPD, but now, Sasha started to have some loose stools, and she started vomiting more. And then I was like, wait a second, what do you mean vomiting more? Like you have never reported vomiting, right?

Like if you go back to her initial complaint, it was a weight loss, she had an excellent appetite, but what I could have picked up in the first place was that this monk scan was on a hair or controlled diet. And this is another extremely common thing that we see all the time, that owners misinterpret vomiting as hair ball disease. And so if a cat cat is on a hair ball control diet, especially if it's a short haired cat, I start, you know, like, my, my antennas, start going up.

And I really question the owner, the owner. About that because it turns out that in a lot of cases, this is vomiting. And I'm sure you have noticed that with your clients as well, that often clients with kids, cats with chronic and neuropathy, they will not, they will even think that this is normal and normal behaviour that cats just vomit, like even a couple of weeks, a couple of times a weeks, and they will not realise that it is abnormal.

So that's something that really to look out for in our cat owners. On her physical exam, she was bright a responsive. She has lost even more weight since the last visit, but her blood pressure was now within normal limits.

So we did, ran like a baseline again, and of course, I checked her T4 because I was thinking maybe she's just not controlled very well, but, her total T4 at the time was actually completely within normal limits. So in terms of her hyperthyroidism, she was really well controlled. Her chemistry panel improved her liver enzymes were completely within normal limits at the time.

And so I was thinking, does this cat have something else? Let's check her folate, cabalmen and the rest of the GI tract. And there we go.

So we have here again a cobaltine undetectable, a folate that is very low, and that shows me that there is a distal as well as proximal small intestinal disease going on. Her TLI is normal, which excludes that she has an underlying EPI and her FPLI was also normal. And so this kitty showed me that every patient has the right to have more than one disease and we actually see hypocoallainemia and hyperthyroid kits quite commonly, and it actually has even been published on and it is probably because not because hyperthyroidism causes hypocobilainemia, but it is probably because these kitties are all old and they probably have two different diseases going on.

Eventually, we, performed, an endoscopy, like after we, we did some ultrasound imaging, which all pointed to a GI disease and her, we did, we did regular histopath, we did immunotochemistry because from the pathologist had some concerns. We also did a clonal clonality analysis and her final diagnosis eventually was idiopathic IBD. So every patient can have more than one disease.

So we saw 23 different friends today, Lucky, Sasha and Pete, which represents 3 different aspects of chronic neuropathy. Full responsive neuropathy, generally speaking, more common in younger animals versus IBD and small cell lymphoma, more happening in middle aged cats and small cell lymphoma cats really are usually 9 years or older. Food responsive neuropathy cats often have diarrhoea, which is often large cell large intestinal diarrhoea.

And they often also have cutaneous signs, as itchiness, very similar to dogs, that have usually skin disease, on top of it. Cats with IBD and small cell lymphoma can have exactly the same signs. Sadly, there is no differentiation that we can draw from that.

Cats with food responsive neuropathy will often have stable clinical signs, however, versus cats with IBD and small cell lymphoma, they often are progressive, or cyclical in IBD cases, or they can be very slowly progressive in small cell lymphoma. The physical exam in cats with feline feline food responsive neuropathy is often normal versus here in IBD and small cell lymphoma, the physical exam can be normal or abnormal. And so it's important that a cat, even with a small cell lymphoma in the GI tract, can have an entirely normal physical exam.

Just a few words to the treatment. So if we suspect a food responsive and neuropathy, we can go for different kinds of diets and the response rate actually, especially in young animals is quite remarkable with the response rate of sometimes over 60%. So we can go for either novel protein, which has some benefits, usually is well palatable, and, especially if my clients want to give cats a treat, which is sometimes even more important for dogs, but some cat owners are really dependent on treats for their cats.

This makes, makes it possible, for example, if I give a venison. And a green pea-based diet, I can ask them to buy some venison and either freeze dry it or cook it as a treat. But I have limited options if the, the patient has an extensive dietary history, which, at least in the US, a lot of, cats have.

If they have a, extensive dietary history, or the owners cannot recall, I often start a hydrolyzed diet. The problem with that is that sometimes these diets tend to be not as well palatable. I think the, pet food companies have made a lot of strides for that now, but, limited options for limited options for treats are certainly a problem in cats that are dependent on that.

Or I go for home cooked diet, which can be time consuming, but often empirically, I feel I have a very good response and I can also have treats. And of course, you can consult your, the nutritionist that you trust, or there's a really nice website that any vet can subscribe to that it's called Balance it. And I just give you a screenshot here where you can pick from a variety of different underlying diseases, and they will, you can pick what, what protein you want, what carbohydrate you want, what fibre you want, and they will, assemble you a diet in seconds, and, that is a completely balanced diet, which is can be helpful, for clients.

If we go for steroids, in, in IBD patients or even in patients with, small cell lymphoma, they often respond to, corticosteroids alone. usually prednisolone is very well tolerated in kitties. I go for, 2 weeks per cake per day divided in two doses if possible.

Of course, kitties don't often like to be pilled as much, so I try not, if, if that's not possible, we can give this. In one dose and you taper to the lowest possible dose. In kitties that have side effects or that develop diabetes, budesonide can be an excellent alternative, which is do on a square metre base or on a per cat base, and it's the dose is much lower.

And then, lastly, treatment for a small cell lymphoma or refractory IBD can be with Clombucil, and Clolambucil, you can give it a total dose of 2 milligrammes, so not per per kilogramme, but per cat, either every 2 or 3 days. I usually go for a Monday, Wednesday, Friday regime. In cats that really do not want to be pilled, I often opt for what we call post dose therapy where clients can bring them into the hospital and, one of my amazing technicians can pill them.

And, that is 20m per square metre every 2 weeks. Most common side effects are mild suppression hepatotoxicity, but Generally speaking, the, this drug is extremely well tolerated in cats. And, it's also illustrating the reason why we don't go full, cytotoxic chemotherapy with those guys, because if we think about it, a small cell low grade lymphoma consists of these small cells, that are very mature and have like the population that is in a cell cycle at any given point in time is very low.

So if we were to go with the COP protocol, that would mean that we have a lot of side effects for very little effect on the CAT, which is why we go for what we call a metronomic chemotherapy here with lambil, so we go for small doses, but more frequently. Other considerations that I can't talk today about because it's just like we are out of time. But I like probiotics, such as this biome, which now comes also as a vet formula, that has actually been, is one of the only probiotics that has been shown to have great effects in people with chronic neuropathies, even, it, it has, is the same efficacy to keep People in remission with ulcerative colitis then azathioprine, for example.

So it's a great drug, additional drug. It's not for by in and of itself. You can give some prebiotics, for example, psyllium.

If you go with Metamucil or something like that, you should be careful with artificial flavours or artificial sweeteners. And then lastly, my, another passion of mine now is the faecal microbiome transplantation. Just, this is my last slide, we'll just talk about the prognosis, because I know if we take, if we use the cancer word with, with clients, often they will opt for, euthanasia.

Having said that, I think it is important to drive home the fact that even for a small cell lymphoma, actually, the prognosis is excellent. There is nothing to be said, it is excellent. The, as, as I mentioned before, the chance of a diet responsiveness can be over 60%, if you, if you look into especially younger populations of cats, and the median survival time for small cell lymphoma, depending on the study you read is about 1.5 to 3 years.

And if we think about the population that we diagnose with small cell lymphoma. Which is usually cats that are 1214 years old, 3 years, they, you know, brings us to 17 now and they can die from something completely different, chronic kidney disease or whatever it might be, before they actually die from their small cell lymphoma. So with that, I'm done and I'm happy to answer any questions.

Thank you very, very much, Tina. Unfortunately, we, we are out of time, so, there are, there are no questions available, but if you could answer any in the chat afterwards, that would be very much appreciated. What an absolutely fantastic presentation.

In fact, one of the questions I was going to ask was about faecal microbiome transfers, so you've, you actually answered that, but we're gonna have to say goodbye reluctantly, and I hope that you come over and we can share some rye bread soon. Thanks so much for your, presentation and for attendance today, and we'll see you in on. Thank you very much, Tina.

Thank you. So, so Mike, who, who do we have next? Oh, you're not gonna believe this.

We've got one of the 13 our CVS specialist feline medics who works in the UK. I'm running through the reporters. Is it the one, yeah, Sarah Kaney, she's here.

Look, you could see her smiling next to us. Hey, Sarah, listen, great to see you, Sarah. Thank you very much for joining us on this, this amazing day.

It's gonna be really, really good. I understand you're gonna talk to us about top tips for anorexic cats. So that's correct, yes, excellent.

So Julie and I can take notes on this because we're both anorexic, I think, aren't we? We are wasting away. Yeah, that's what I think that's that's the same word as obese, isn't it?

I think so. OK, yeah, OK, well, let's get some tips from Sarah then. Sarah, take it away, looking forward to this.

Thank you very much indeed. Thank you very, very much, and I will just share hopefully the right thing. So, it's, it's absolute pleasure to be here with such a wonderful community of vets and non-vets in the terms of Mike and others who are, contributing to today.

And I just feel extremely honoured to be part of this initiative and would like to thank all of those who've made today possible, all of you that have donated. So much. It's just phenomenal what has been achieved.

And I hope very much that my presentation is going to be of use to you when it comes to dealing with your feline patients. The reason I chose the the topic of anorexic cats was because pretty much, in my clinical work, not today goes by when I don't see at least one, if not several cats that have problems with their appetite. So very much, thought it was an important topic to cover.

And the key things really I wanted to cover in this short presentation where, why is this something that we need to worry about? When do we need to worry, and what should we do about it? So that's really what I'm gonna hope to, achieve in the next 20 minutes.

Its or so. And I think the answers to many of these questions, you will already have, I'm sure a great deal of knowledge, but just to start with a reminder of the many, many negative consequences of poor appetite that our poor cats can suffer from as listed on this slide. And some of these complications are very reversible and very treatable, but others of them are potentially life-threatening.

Hepatic lipiddosis would be a great example of unfortunately, a very serious complication of anorexia in cats, which Ultimately can be fatal. So clearly there's a lot for us to worry about, both in terms of those acute and chronic cases where whether it's a chronic reduced appetite or an acute complete loss of appetite, a huge number of things for us to be aware of in our patients. So that's the, the first question answered.

Why should we worry? It's definitely lots of negative things that can happen. When should we worry?

Well, I would say if a cat hasn't eaten for 24 hours or longer, then that definitely concerns me. And indeed, the, the, reminders on this slide are geared towards when we absolutely need to intervene. So 3 days or more of loss of appetite is really a medical.

Urgency in my view. And that's the time when this cat is likely to benefit from assisted feeding. So, really, we're, we're not going to hang around.

We're going to be instantly wanting to throw the textbook, as it were, at that poor cat. But certainly, for, for those of you like myself who are seeing, general practise cases, we quite often will see cats where the history is just, well, my cat hasn't eaten for 24 hours. And that's still, in my view, is definitely a medical emergency.

We worry more, especially though, if there is evidence of severe weight loss, so that's greater than 10% weight loss in two weeks. If the cat chronically is eating less than 85% of its resting energy requirements, and I'll come on to RER reminders in just a moment. If There is evidence of severe protein losing conditions, things like pyothorax, severe, generalised executive skin conditions, for example, then we would worry about our patient's nutritional status and also those caketic patients that we see coming through our clinic door as well.

So I mentioned RER resting energy requirements, and just a reminder really of what this is, you'll be familiar with, if, if not more recently, your vet school days when we were told how to calculate energy requirements for our patients. And the resting energy requirements of those requirements of an animal resting in a thermo neutral environment. So the, the cat just sitting there in a thermo neutral environment.

And there are a number of different equations that we can use, but actually, I find it really helpful to remember that the RER is approximately 50 kilocalories per kg per day. So the third or the bottom of those bullet points rather. And the reason that I often have that in my mind is because it's such an easy calculation.

To make. So then we know our 4 kg cat needs approximately 200 kilocalories per day as a starting point. Obviously, if it's a very active cat, it's going to need more than that.

But as, as shown for for completeness, the, the more correct, more sort of scientifically correct calculations, also available. And for those cats that have chronic illnesses, a good example would be chronic kidney disease. Often their appetite is reduced, doesn't completely stop.

So perhaps these patients are not seen as as the medical emergencies that the completely anorexic cat is. But if their voluntary food intake, that's the the VFI is persistently less than 85% of their resting energy requirements, then that really should be justification for us to take steps to intervene and improve that. And of course, in, in the very young and the very elderly and the very sick, then intervening more quickly is also indicated.

So having said now that we, we worry about poor appetites, and the sort of, situations when we're particularly concerned, what are we actually gonna do about this? Well, the starting point always is that thorough history. And often it's looking for those little clues that give us an idea as to what may be behind that loss of appetite, that are going to Help us because clearly the best prognosis for a cat that's lost its appetite is to understand, well, what has caused that?

What can we do about it? So this is really, I, I can't underestimate the importance of the history, really, in terms of asking those detailed questions. Are there, for example, preexisting conditions or preexisting medications that The cat is receiving that may have an impact on their appetite.

What subtle clinical signs is the owner noticing at home, for example, the cat that licks its lips and is gulping a little is often nauseous. The cat that's drooling a little bit, or of course cats that are actually vomiting again, or consistent with with signs of nausea. Is the cat interested in its food?

But perhaps having difficulty eating or pain associated with eating, all these clues can help us. And the bottom line is we, we just want to find out to the best of our ability, what exactly is going on. The thorough physical examination obviously goes next, and again, we want to look at everything really in these sort of patients, but the mouth is certainly an important area to focus on when it comes to appetite, because oral discomfort, oral pain often is involved in many of these cases, and, and we may be lucky in the sense of actually Being able to see a quick and easy reason for for that perhaps change in appetite in the cat.

Perhaps it is an oral mass or severe dental disease, which, which we can address, for example. But we're also going to get other clues from our oral examination in terms of mucous membrane colour, hydration status, a little bit of information there. And the rest of our physical examination is again really important to give us additional clues.

So is this cat pyrexic? Is there abdominal pain? Is there an abdominal mass?

What, what other clues can we find? And a big tip that I would also share as a referral clinician is that in some of these particularly tricky cases, and often cats can be very tricky, and anorexic cats in particular, can be tricky cases to solve. Just remember to keep coming back to that history and Physical examination, because things often change with time, new clues emerge.

And so just go back to the beginning, every time you see that cat, has anything changed? What new little pieces of information are going to help me solve this particular case situation? Sometimes it can be helpful to get some information on the cat's ability to eat, whether there is evidence of dysphagia, oral pain.

This cat, actually was very keen to eat as you can see, but then having some dysphagia and some gagging associated. With eating, which actually was a nice, nice diagnosis to make because it was due to a bit of grass at the back of the pharynx that was causing a lot of irritation, easily removed, problems solved. That's the sort of happy, straightforward, easy cases that we might see in our clinic.

But of course, for, for many of the cats that we see, presenting with anorexia, it's perhaps not that obvious in the consulting room, and we may complete our physical examination, complete our history, and then we have some difficult decisions to make really, which are how sick is this cat today? Does it need emergency support? Is this a cat that needs admitting for Fluid therapy and urgent investigations, or is this a catch where, we think some symptomatic and supportive treatment, is likely to be of assistance and perhaps the, the, the mysterious illness will, will get better on its own.

So they often, I think are some, judgments to be made at the end of that consultation. And what I'll share with you next, really, is my general approach in these cases, and some things that that I do find helpful. Certainly, if I'm finding that my history of physical examination is not as illuminating as I would like, then the sorts of starting investigations that typically I would do would be blood and urine profiles.

So haematology, serum biochemistry, if you do have access to a spec FPL, for example, that could be useful for pancreatitis assessment, particularly in those cats with cranial abdominal discomfort, nausea, and signs consistent with pancreatitis. Diagnostic imaging, certainly, if they're No other clues, then some survey radiographs, some abdominal ultrasound also can be helpful. But on the first day that the cats presented with poor appetite, perhaps it might seem that that's a bit of an extreme approach.

So next, we'll talk about the sort of general supportive options, particularly initially with outpatient approach. And one of the, the most helpful, I think, quite straightforward things to do with those outpatients that come in, and they're just not quite right, and they've, and they've not eaten, and perhaps there's not a lot to find on physical examination. Well, a little bit of subcutaneous fluids is, is not going to go amiss.

And, that can be administered through, a giving set of attack. To a drip bag or as in this example here, a little winged catheter attached to a syringe, something along the lines of 80 to 100 mLs of lactated ringers or Hartman's solution, subcutaneously very well tolerated in the consulting room, you can see just a couple of examples shown here. Also, many cats, will get a little potassium deficient, a bit hypokalemic if they lose their appetite.

They're very dependent on potassium in their food, so it can be helpful to spike the fluids just with maintenance amounts of potassium chloride, to provide a little bit of extra potassium via that route as well. And certainly, if I'm suspicious about nausea or if there's a history of vomiting, then Meropotent is, I, I think a very helpful treatment to use alongside this, or, or indeed on its own, if the patient is not dehydrated, perhaps a younger cat that we're less worried about. Dehydration in as well.

And, if I am using fluids, so, I will administer it actually into that fluid bleb because, those of you that have used, more potent injectables will know it can be a little bit, irritant, a little bit stingy by injection. In the UK and certainly in a number of other countries, we're very lucky in that we now also have a mirtazapine licenced as a transdermal medication, licenced for appetite support in cats, but also does have some anti-emetic effect in cats. And this can be really helpful from a symptomatic and supportive perspective.

So having a tube of Miritass if you're in a country where the licenced form of mirtazapine is available for outpatient use. Your clinic can be helpful, and the box has a line on it, which you can hold next to your finger next to it and put the transdermal preparation onto your gloved finger, and then it's applied to the inner surface of the ear, where it's absorbed through the skin. And often very, very effective in stimulating appetites.

And that perhaps combined with some, some tempting food, sometimes is, is all that's needed to get things back on track. If pain is a consideration, then analgesic, management, of course, is indicated. Again, think of those cats that maybe we're worried about pancreatitis, or perhaps there are other, Defined issues that we know are causing some discomfort, then analgesia is appropriate.

And, and the choice of analgesic will depend according to the patient. Younger cats, cats where we're not worried about, or there's no evidence of dehydration, and we're comfortable with their renal function, and non-steroidal anti-inflammatories, I think are a perfectly appropriate choice, but perhaps the older, more fragile cats, and certainly if dehydration is a component. Then often I would use buprenorphine, and that can be given by the oral trans mucosal route, and indeed can be supplied for, home administration by the owner, by that route as well as a way of providing some analgesia with the cat at home.

And if there's no, specific clues really as to why the cat has lost its appetite, then I think there's, there's nothing wrong with an analgesic treatment trial. Often also with these patients, I will talk about the sorts of foods that they can offer the cats. Cats often do get very bonded to certain foods, but there are also certain foods that are quite good for tempting them.

So things like cooked chicken or perhaps some sensitivity control if you want to provide something from, from your vet clinic or your AD, other convalescent foods, and, a little bit of, of hand feeding and, and nursing support. So from a carer's perspective, Talk through these sorts of tactics with the anorexic cat at home, they're offering food little and often, but also resist that temptation to do what I call the buffet, which is where either in the hospital or at home, all available cat food, is opened, and the cat is surrounded by, an array of bowls of, you know, tuna in one, chicken in another, whiskers in another, etc. Etc.

And it can all be very Overwhelming and counterproductive. So, so really resist the temptation to do that, but try little and often, offering the cat a little bit of perhaps gently warmed, food, so it's a little bit more aromatic. Try hand feeding, for the older cat that perhaps has dental disease, maybe try mashing the food a little bit, elevating the food bowl as well.

If the cat has arthritis, that makes it painful for it to adopt the normal crouching posture. And, tempting tempt. In food, some cats, catnip, the, the plants in the garden, neetaria, can encourage appetite.

Anecdotally, 40 flora as well, the probiotic made by Purina, a lot of owners feel encourages appetites. So all sorts of little tactics that can be tried with the carer at home. And undoubtedly, from a stress perspective, if the cat can be managed at home, it's going to be much less stressful than admitting the cat to the hospital for, for care there.

I mentioned already mirtazapine as an appetite stimulant, which we have licenced in the UK as Miritas available from DeA. And that is my most frequently used, appetite stimulant in cats. But, I know that this is, this, conference is, is a sort of global phenomenon, so it may not be something that's available.

In every country. So I wanted to just mention that there are, an array of other medications which have been used for appetite support in cats, some of which I would consider using, and some of which I would not, as you can see on here. I'll talk a little bit more in a moment about cyproheptadine and Capromin, the one at the bottom of the list.

But, you can See, I've got a few crosses next to some things that historically have been used, diazepam being one of those tends not to be very effective, which is a main reason for not using it. You end up with the very floppy cats that hasn't actually really eaten very much. But also some historic reports of idiosyncratic hepatotoxicity have also deterred people from using that.

In recent years, Prednisolone and progestogens, the main reason not to use those is potential for side effects, particularly in the case of progestogens, but also, in the case of steroids and also masking whatever disease process is there and perhaps influencing future treatment outcome. B vitamins and anabolic steroids, historically, lots of kidney cats certainly in the UK would have received those quite frequently and lots of owners really swore by them. I think relatively poor impact on appetite, but perhaps some impact.

So if you don't have other products available to you, perhaps those are worth some consideration. Cyproheptadine, which was second on my list. I did use quite frequently in the 1990s and, and 100s, before we discovered mirtazapine was so good for cats.

And this is an antihistamine, which is a less effective than mirtazapine and stimulating appetite. It's more of a gentle nudge to get the cat to eat, but it can be well tolerated and and effective. So if you do have that available, you might find it helpful, a dose of 1 or 2 milligrammes per cat every 12 to 24 hours as needed to stimulate and support appetites.

And, it, it, it often, as I say, is, is, helpful and well tolerated, but not as effective as mirtazapine. So it's not my, definitely not my first choice. Capri Morellin is not available in the UK to my knowledge, but it's licenced in the United States for appetite supporting dogs.

It has a lovely name, in terms of the brand name tights, which I think is, you know, very appropriate name. And it's a greeling agonist. Ghreeling is the hunger hormone, stimulates, appetite.

So that is the the mechanism of action for this particular medication. And it has been used in cats. There may well be people tuned in who have some experience of it.

I sadly don't have any direct experience. But it has been used with some efficacy in cats with poor appetite for a variety of reasons, including kidney disease, pancreatitis. And, so if that is available to you and other options are not, then it, it may well be something that also is, is worth some consideration.

Owners often ask me about syringe feeding, and, indeed volunteer that they would like to syringe feed their cats. Usually, my response to this is, very negative in that it's extremely rare to have a cat that genuinely tolerates syringe feeding. But also it's generally impossible to actually give an adequate amount of nutrition by this route.

And again, if we remember that resting energy requirements of 50 kilocalories per kilo, 4 kg cat needs about 200 calories per day, and most of the liquid foods available are around about 1 calorie per mL. So that's going to be 200. Syringed into the cat.

Well, that's, you know, generally impossible. And, the main risk is, potential aspiration by the cat, but also often a lot of negativity, potentially food aversion, and a lot of stress and distress. So, definitely something that I, I generally avoid, if at all possible.

If my other strategies at this point, have not been effective, so I've, I've, addressed the dehydration that might be present. I've addressed any electrolyte disturbances such as hypokalemia, that may be present. I've treated the nausea, I've treated the, the, any pain.

I've tried appetite stimulants, and I'm still not getting, my poor little cat to eat. Then this is a time when assisted feeding tube feeding is indicated, and the tubes I place most frequently are nasal esophageal and esophagostomy tubes, the latter being better tolerated and a larger diametic so you can get much better feeding for the for the cats, but you do need to anaesthetize it to place it. The nasal esophageal feeding tube has the advantage of being easy to place in a conscious cat, although I think you'll all agree that Hobbs here is absolutely giving me the death stare because he was not happy to have a tube down his nose, which is not unusual.

So they're good for short term support, but most cats don't really like them. And sadly, I don't have time to talk about the, the procedures involved, but I have got some webinars on my website, which are free to access, vetprofessionals.com.

If you look at the helpful info top menu, video tutorials, and then look for the 10 minute tips for vets, you'll find one on placing those esophageal tubes, one on esophagostomy tubes, and one on calculating tube feeding, nutritional requirements that hopefully will answer any questions you might have on those. So finally, really, the summary is, there are, as we know, an infinite number of causes of poor appetite in cats. The best outcome obviously comes from understanding what has caused this cat's poor appetite, fixing anything we can, like those hydration problems, the nausea, etc.

Don't expect your appetite stimulants to work in the cat that's still dehydrated and hypokalemic. Avoid syringe feeding, if at all possible. And, if you do find that you need, more support, go for a tube feeding, assisted feeding.

But mirtazapine is certainly great medication to have licenced and available, and makes a big difference here. Much more resources on my website as well and you can email for the PDF of my presentation if that's of any use at all as well, info at vetprofessionals.com or through the contact on my website.

And I will just finish by saying another huge thank you to everybody who's been involved in today, whatever part you've played, whether it's, donating, attending, hosting, comparing, etc. It's really an honour to be involved and if there is any time for questions, I'll be happy to answer them, but if not, I'm happy to type replies, afterwards. Thank you.

That's, that's fabulous, Sarah. Thank you very much indeed. If you could, there's a couple of questions if you could pick them up off the Q&A, that'd be, that'd be brilliant, because unfortunately, we are getting pushed for time.

I do have a quick question for you though. I, I, we've been talking about anorexia and, and cats not eating. Do you think there's any conflict of interest in your homemade sushi habit and you taking the fish home?

And preventing the cat from eating it with, with this problem? Happy to say my cats, they've been very badly brought up and, and, they, they love their cat food, but they actually don't like human food, so I don't have any problems with them stealing the sushi. Yeah, you keep telling yourself that, Sarah, that's.

Absolutely, we, we'll, we'll talk later about sushi and sashimi. However, thank you so much, Sarah, an amazing presentation, as, as always. It only remains for me to thank you again and to introduce our next guest, in fact, I'm not going to introduce our next guest because he's not here, but his presentation is.

So we're going to introduce his presentation, and he is Rio ***. Many of you know him. He qualified in Switzerland and did his, internship and residency in internal medicine in Bern.

He then spent a a very, very short while, only, only 4 years at the RBC, and then, went on to to spend the next, I think, 12 or 13 years in the small internal medicine department at the University of Glassen in Germany, and he is now the country medical director of IVC Evidencia in Germany. He gets around a bit, doesn't he? The most interesting fact I found out about him is that he has two dogs, two little border terriers called Emeys and nausea, and it's just a shame we can't have him on to to chat to him about that.

But what we can do is put his presentation on, which is all about, acute diarrhoea in dogs and cats. So sit back and relax, but relax that sphincter if you've got acute diarrhoea. Yeah.

Yeah, keep that tight. Hello, everybody, and I'm very happy to be part of this Ukrainian help do and the topic I want to talk to you today is about acute diarrhoea, an internal medicine topic which is something that an internist and basically every veterinarian sees on a daily basis. And I've brought to you, two patients, which I'll show you here.

First one is a German Shepherd dog. He's quite young, with 8 months old, male. His name is Willis, and, he had acute diary.

For two days, watery diarrhoea, but otherwise, the appetite is normal and, he is kind of a normal dog. While the other case, that's Jackie, a Jack Russell terrier, 3 years old, female, and she has bloody diarrhoea for the last 24 hours and she's lethargic and anorectic. So, how do we work up cases with acute diarrhoea?

Firstly, diarrhoea is generally a clinical sign of gastrointestinal diseases. Now, many gastrointestinal diseases also show some other signs such as vomiting, maybe weight loss if it's It's not acute, maybe anorexia, mainly in cats, and on physical exam, they may also show some abdominal pain. However, diarrhoea is by no means only a problem of intestinal, diseases.

Especially if it's a chronic problem. With acute diarrhoea, it's much more commonly a true intestinal disease, and we have to think about gastrointestinal problems. So when we think back to our physiology, the intestine is really a mucosal barrier, which you see here on the left-hand side, basically blocks the Normal, the physiology from the abnormal to pathology.

So, the, the normal is we have the, normal local immunity. We have a normal blood flow, and epithelial cell turnover. There is a lot of mucus production, and of course, there is per peristalsis, which transports the intestinal.

Further down the line. And on the pathological side, you can see that there are various problems that can arise. Firstly, we can have infections, and then when you talk about acute problems, that's mainly viruses, but that could also be parasites and extremely rarely an invasive bacteria.

But I'll talk more about that bacterial problem later on. Then, of course, we can have some dietary abnormalities, dietary allergies, dietary intolerance, which is a very common problem. It's mainly in younger patients.

Obstruction can result in, problems with the mucosa, whether that's from a foreign body, whether that's from a tumour, whether that's from an interception or something like that. Next is, of course, a major problem with the normal microbiome. We'll call that dysbiosis, where our normal intestinal microbiome is getting, screwed up.

And, that could be due to mainly antibiotic, administration, but that can also be due to a Normal dietary content, garbageitis, something, something like that. Finally, you can see toxins, foreign substances, physical factors with hypersmolarity or other problems which can result in intestinal, fluid accumulation and therefore, in diarrhoea and a change in the normal mucosal barrier. So, going back to our two cases, I start with the first one, with Villa.

How do you proceed in a patient which has an acute diarrhoea? And when we talk about acute diarrhoea first, we need to really, take a very good history like we should do with all our patients. So, we asked the owner, what is the animal eating?

Does he get any treats, table scraps? If it's possible that the animal is eating something outside, or is it a, a purely indoor cat, for example, then, of course, we take a very good dietary history. What type of diet?

Is it dry food? Is it cans? Who is the producer?

Is it mainly table scraps? We, of course, also ask what kind of proteins the animal has been receiving. Is that proteins from beef, from pork, from poultry, from, horse, whatever, proteins, and maybe also carbohydrates are in that diet.

Then, next, anti-parasitic therapy. When, what dose? How often is the animal treated against anti Parasitics.

Animals do tend to have parasitic drugs, especially, animals which, which are scavenging, animals which go outside by themselves, tend to have parasites intermittently. And that's something which can result in a acute diarrhoea. Of course, we ask about, is, are there animal, other animals sick in the household, which could be either an infectious problem, which could be a dietary abnormality.

We ask about some travel history, depending on where that patient is living. And when has travel happened, how, what is the, contact with other, with other patients. We ask about other symptoms, for example, vomiting, which leads us more to an intestinal problem.

We ask about lethargy and anorexia, which could be just secondary problems to an intestinal or another disease, other, organ disease. And of course, if there is also polyuria and polydipsia, that could point much more towards a Systemic abnormality to an infection abnormality. And finally, drug history is important, and we should also ask about ear medication, eye medication, any medication that the animal has been receiving, or even toxins, when the animal is freely outside.

And next, after the first steps of history, it's the first step of clinical exam. Like, Willis, who has been eating fine, has no abnormality on the clinical exam, but nevertheless, is there abnormal behaviour? Is there lethargy?

What are the mucous membranes? Is, what's the colour? What's the dryness?

What's the capillary refill time? Because we want to see if the animal might be hypovolemic or dehydrated. What about the, the chest?

If possible, we do an auscultation. But sometimes when that's Possible because we, have the patient not in front of us, but we have only FaceTime with a patient that is on telemedicine, then at least we may be able to look at the patient via, the FaceTime or any other means. Pulse frequency is something, of course, we can easily do, ourselves when the patient's in front of us.

And then also, of course, pulse quality. Otherwise, maybe again, with, telemedicine, it's something that we tell the owners how to measure the pulse frequency. It's not really good to tell them how to, assess the quality because that's the only patient they have.

Abdominal palpation, once again, only if the patient is with us, but that's a very important question. Is it tense? Is it painful?

Can we feel abnormalities, increased, organs? Is there a lot of air in there? Or is it just a very normal abdominal palpation with nothing.

Abnormal, which of course could also be the case. Maybe some squashy intestines, which is not uncommonly found in diarrhoea. Lymph nodes, all the peripheral lymph nodes, and I think we should do that last is the temperature, see whether the animal has a normal temperature that's somewhere between around 37.5 to about 39.5, whether that's dogs or cats, or is it, if it's hypothermic, which is below 37.5 °C.

If it's hyperthermic, then it's above 39.5 °C. So all of these first steps really don't need a lot, huh?

You need, your hands, your eyes, you need a thermometer, you, you need your stethoscope when the patient is in front of us. And with that, we can also do quite a lot in patients which, in general, are otherwise quite healthy. Therefore, we have two major forms of acute diarrhoea.

The first one, that's what Willis is showing, it's A otherwise clinically well patient. Clinical exam is normal. There is no dehydration, no signs of hypovolemia.

The, animal has diarrhoea, yes, but there is no blood in it. Appetite seems normal, or at least the animal is still eating, and, a temperature, is normal as well as the palpation. We can't really find anything abnormal.

And in these clinically well patients, we have to think what are potential causes. And by far most problem, abnormality or most problem causing the acute diary with clinical well patients is that we have a dietary abnormality. Either that the animal has an acute dietary change, has eaten something which is not really healthy for that, or has what we consider garbageitis.

So he went into the garbage and he ate some bad stuff. Other abnormalities that we may think about are parasites, and here it really depends. Of when the patient has had its last antiparasitic drug, what kind, and that's why you, you need to investigate that.

Maybe some viral problems. There are many viruses that can result in acute diarrhoea from rotavirus to astrovirus to other viruses, which are in generally not really further investigated. And then, of course, and that's also part of your history, maybe some drugs for other problems that the animal has received.

Overall, acute diarrhoea with a healthy patient really is not a bacterial disease. That's always something we should remember. We have a normal microbiome in our patient that is absolutely always there from birth on.

The animal produces a microbiome which has billions and billions of bacteria, and that is normal, but bacteria resulting in a clinically well acute diarrhoea just does not exist in dogs or in cats. And therefore, our diagnostic tests in clinically well patients with an acute diarrhoea really are potentially a faecal analysis depending on when the last antiparasitic drug was, was, given for parasites. I'll talk a little bit more about that.

Maybe some, looking at hematocrit or, or PCD maybe looking at total protein or total solids, depending on what you think the patient has, that might not be even necessary. In general, you just do a dietary therapy and therefore, you get a dietary diagnosis, meaning that you change the diet to a well, digest the. Easy digestible diet, which is often commercial, maybe for a few days, home-cooked diet, and that does all the trick for that patient.

And if you think that the patient might need deworming, depending on the antiparasitic drugs, depending maybe on your faecal analysis, then you, deworm, that patient according to the SCAP guidelines. So, as I said, deworming is important. Many, many patients have parasites.

In, dogs and cats, the most common in gastrointestinal parasites are either roundworms, tapeworms, or protozoas. And here you've got again the list that you all know, ads, whipworms, hookworms for the round worms. For the tapeworms, we have the Titania, we have the Diylidia, the the difilobotria, and the, two echinococcus species.

Echinococcus luckily, very rarely. And of course, then we have Protozoa such as Guardia, Cryptosporidia, or maybe Chichi Comona's foetus in the cat. To investigate intestinal parasites, we have several means.

Firstly, we can do a faecal flotation, but don't forget, a single faecal flotation for roundworms is probably successful in Only about 70 to 75% of the cases that do have roundworms. You need 3 faecal samples to get a, sensitivity of around, 90 to 95%. And for tapeworms, faecal flotation is really, really bad.

Actually, for tapeworms, everything is bad. It's very difficult to find tapeworms because they have a very intermittent shedding. And therefore, if animals do, eat, some, mice or, or others or scavenging other, outside, or if the animal had fleas recently, then it's a very likely scenario that tapeworms are there, even if they might be negative and you foetal flotation and treating tapeworms at regular intervals in these patients is absolutely indicated.

Another possibility is that you can do a copper antigen test. Now, don't forget they are extremely sensitive. For example, for, Guardia, for example, for cryptosporidia, and especially for Jaardia.

Copro antigen tests are really not a good means of, testing if the patient has become negative after a treatment because there are long-term positive after therapy. So if you have animals with guardia, which often is a secondary problem, and there is an underlying disease and the guardia are just on top of that, then, you treat that patient with fendendazole. And you do not repeat your, copper antigen testing because, as I said, it could be positive for another 23 months post-treatment.

That does not mean that the animal still has G Giardia. It's just that it is falsely positive after the therapy. So do not test with copper antigen test for Giardia, effectiveness treatment.

And finally, we have PCR, but PCR is not. A very good test for faecal material because it's often negative due to negative impact from the faeces, but you can use, of course, PCR mainly for Tricommona's foetus in the cat or maybe for echinococcus if you have that suspicion when, because you cannot differentiate between tenia and Echinococcus based on light microscopy. And if you have tenia, proglotids, then doing a PCR is definitely indicated.

So, there is another means of antigen testing, and that's from IDEX, the pet check. And I really, think that it's a very positive way of looking for, for faecal roundworms. It does not look for tapeworms.

It only looks for roundworms. But you know, what you can see here is that it becomes positive quite much quicker, about half the time from the prep. Period, when you look at foetal examination.

So the first LISA positive test is around 1 month after the infection, while with, a normal, EX programme, is, positive only after about 70 days. And, what's also positive, was it also advantage is, once it's positive, it remains positive. It doesn't show, it, it, it's not as fluctuating with Yes, no, as with a, egg count that you may have with faecal flotation.

So, I really advise that if you think that a roundworm infection could be there, instead of a faecal floatation that you give the patient a pet check, they, put the faeces themselves in there and the results are submitted to you and then you can advise the owner based on your SCAP guidelines, what you do with these patients. And here is a study looking at faecal flotation in a doctoral thesis here in Germany, and you can see the percentage of positives, so tenia in dogs was somewhere about 0.25% of, faecal analysis were tenia positive, capillaria tricures, hookworms, toxicaris, toxoar toxoara eggs, which are somewhere 4 to 5%.

And Guardia has actually actually been up to about a quarter of the dogs had Guardia. And a very recent study from IDEX looking at the positivity based on antigen testing all over Europe shows that, the, average, Toxocaraanis and Toxascaisatti is somewhere around 3 to 4. Overall, but it can be a little bit higher or a little bit low, depending on the country that, the animal is living in.

So, yes, you have roundworms. You definitely have a lot of guardia cases, but tapeworms luckily are quite rare. Nevertheless, if an animal has acute diarrhoea, you should contemplate that, faecal, parasites is a possibility and you need to treat for that.

Beside, antiparasitic drugs, of course, the most common problem really is dietary abnormality. And so you should give the patient a, a well-digestible protein, a well-digestible carbohydrate source. It's, it's a, a, a good means of giving a Commercial diet.

I've put here several commercial diets on here. It really doesn't matter which one you use. They are all, good commercial diets that I've put here on the, the slide.

You give them multiple feedings per day. Don't stop feeding, what has been done about 20 years ago. Nothing orally when the animal has gastrointestinal signs really is not indicate anymore.

So we continue to feed. And as I said, for Parasite GD worm, according to the SCAP guidelines, and as you can see here, they have been, published by the SSCAP in many, many different languages. And on the bottom right, you can see they have even been published in, Ukrainian, today we're having a, Ukrainian overall, positive, event.

You can even look it up there if that's something you want to do. In IBC Evidencia, where I'm country medical director, in the Dach region, Switzerland, Germany and Austria, we've also, published for our clinics a, guideline for which antiparasitic drug, works against which parasites, whether it's ectoparasites and endoparasites. We've even showed them, greed is what is, licenced and red is what it's not licenced for, but what works, never the.

Less. And you, and with this, the, nurses at the reception, potentially can, sell antiparasitic drugs depending on what the owners is, needing, or the, young veterinarians, if they don't know all the drugs that you have in your clinic, can, look up what they want to treat and which antiparasitic drug, whether it's an oral drug or whether it's a spot on drug, can be used, whether it's a dog or a cat. What about bacteria?

As I said, bacteria really are not a problem in a clinical well acute diarrhoea case. So, do not use antibiotics. They're never indicated in these patients.

Never ever. You may, of course, use probiotics, and there is a huge range of probiotics on the market, which is best. Unfortunately, I can't give you.

Any evidence, medicine and say this and this is better. But, probiotics is a good choice because it's better to do something for these owners than do nothing. So, dietary change, maybe, antiparasitic drug, depending on, when the last time the animal was, treated against parasites and a probiotic is your best bet in these patients.

Here is a study from the group from Janzo Khodolsky at Texas A&M where they looked at the faecal microbiome in dogs receiving metronidazole. They've made three groups. One group was a control group.

The second group was a group which received hydrolyzed diet and, subsequently metronidazole at the regular dose. And the last group was a group which only received metronidazole, but no, change in the diet. And on the left-hand side, you see the dysbiosis index on the on the Y axis.

And you see the, days of the dysbiosis index, after the animal has been treated, and that was always for 14 days with metronidazole. And you can see here, that's only group 2 and 3, so those animals which receive metronidalal, at this biosis index below 0 is normal, between 0 and 2 is borderline and above 2 is abnormal. And you can see that every single dog that received metronidazole during the metronidazole treatment, so on day 7 and then on day 14, had an abnormal dysbiosis index.

And what you can also see is that about half of the dogs still had an abnormal, microbiome. Therefore, had an abnormal dysbiosis index 42 days after Start of that study. So even when metronidazole was not, has not been given for about 28 days, there was still a abnormality.

Then, on the left hand side, on the right hand side, what you can see is the, secondary bile acid percentage and normally, what we have is a quite high percentage of bi secondary bile acid, as you can see. But, a lot of these dogs, about half of the dogs still had very, very low secondary bile assets, even 42 days after, the, start of the study or 28 days after the metronidazole was stopped. Therefore, metronidazole is really a very difficult drug in terms of microbiome, and I can only advise you very heavily against using Metronidazole in a lot of your patients, or actually, I have, have not used metronidazole for, I would say now, about 7 to 10 years, in any of my GI cases, because having seen all those data and changing in the dysbiosis index and see how long that is abnormal, I really don't advocate of using metronidazole.

And when you use an, an antibiotic, it has a huge effect on our microbiome. You, what you can see here on the left-hand side again, is the microbiome has positive effects on immune modulation, on vitamines, for example, B12 and folate, on short term fatty acids. It has a positive effect on the lymphocyte population producing a local IG.

So, overall, the anti and the pro-inflammatory, balance is very much in favour of the, anti-inflammatory balance. However, if you look on the right-hand side, when you give, antibiotics, it changes the species diversity. It changes the, the T lymphocyte receptor signalling.

It changes. The, immune regulation to a this regulation and overall, your normal balanced microbial community completely goes out of whack and therefore, antibiotic usage for the GI tract is a very, very difficult thing and in acute diarrhoea, it's extremely rarely to almost hardly ever indicate it. Let's go to the second case where you may say, well, he always talks about no antibiotic, and now we have a bloody diarrhoea for 24 hours.

The animal is lethargic and anorectic. Do we need to give an antibiotic now? Well, what are, animals in that form?

Well, they are lethargic, they are dehydrated. They may have bloody faeces, anorectic, and of course, abdominal palpation and maybe hypo or hypothermia or other clinical findings in. These patients where we have patients be, with acute diarrhoea and otherwise also sick.

What are causes in these? Well, firstly, it could be a viral disease, especially parro virus. Corona, well, maybe, but corona in general is, not really so severely, a problem as, as is parvo.

A very, very important part of animals with acute bloody diary. Is a disease which is called acute hemorrhagic diarrhoea syndrome. And that's a disease which occurs mainly in youngish, mainly small breed dogs, and they may be acutely sick with severe, bloody diarrhoea with dehydration, but no immunosuppression.

These patients, and we'll talk about it, do not need a. Antibiotic. So just because the animal has bloody diarrhoea means by no means that an antibiotic is vindicated.

And then you see, otherwise sick patients with acute diarrhoea could be a metabolic disease such as Addison's disease, diabetic ketoacidosis, systemic infection, sips. Well, of course, they eventually will need an antibiotic. Some toxins, maybe some, obstructions such as foreignbodies interception.

Some extraintestinal causes such as pancreatic diseases, liver diseases, kidney diseases, and so on. And extremely rarely also bacteria. Nevertheless, bacterial faecal exam, I'll show you that is hardly ever indicated.

So what do you do in patients with an acute diarrhoea and otherwise sick? Well, because of all the underlying problems, you should definitely do a complete haematology. You should do a biochemistry and depending on what you think, maybe also a a baseline.

Cortisol value in a youngish dog because an animal might also have a, atypical hypoadrenal corticism, and especially in ACTH stimulation test, if the animal is hypo natrimic and hyperkalemic. Then a faecal analysis, well, maybe you want to look for parvovirus. I'll show you a little bit more in a moment.

Again, parasites. I personally feel that faecal parasitol. A bacteriology, has no place in my armamentarium for any of my faecal, for, for my GI cases.

I haven't done a faecal bacterology over the last, I would say, 15 to 20 years, irrespective, whether that's acute or chronic problems, I never ever do faecal bacterrology, and it has not been any time a case where I really missed it. So, other, clinical examinations, depending on the, physical exam finding might be diagnostic imaging, X-rays, ultrasound, contrast X-rays. That really depends what you have available and how the patient looks like.

But haematology and biochemistry, and I would suggest that you do really not only 23 parameters, but you do a reasonable good profile, because underlying problems. Like I showed you might be there. And I said, I'll talk a little bit more about Parvo virus, testing.

We've done one a study looking at the, 3 quick tests, 3, in-house tests, and compared those to polymer chain reaction in animals with acute diarrhoea, animals with chronic diarrhoea, unhealthy dogs. And what we found is that all these tests have a really poor Sensitivity in general, less than 50% of a, but have an excellent specificity. So what does that mean?

That means if the test is negative, then you can be pretty much certain that the animal does not have a parvovirosis. But if the test is, sorry, wrong way round, if the animal, if the test is positive, you can be pretty much certain that the animal has Parvovirosis. But if the test is negative, then, you cannot be certain.

And about 50% of the negative tests, the animals still had parvovirosis. Therefore, a, quick test, an in-house test is really only to, kind of, prove the parrovirosis, but you cannot really rule it out. So, what do you do?

Well, if possible, you, of course, treat the underlying disease. Therefore, you need all the testing which I just showed you before. If the animal is dehydrated, you need to give it some infusion.

If the animal is hypoglycemic, you need to give it some glucose. If the animal is hypokalemic, which is not uncommon, in animals with acute diarrhoea, you need to give it some potassium substitution and you can guesstimate your dehydrate. Based on your physical exam, and that's what you have here.

Less than 5% dehydration is clinically not really, accessible. About 5% dehydration has some dry mucous membranes, and that's about it. 7% dehydration already has some mild to moderately skin tinting, and of course, also dry mucous membranes and maybe a mild tachycardia, still normal pulse.

And then when you get to 10% Dehydration, you, it really gets quite worse with skin tenting up to severe, still dry mucous membranes, tachycardia, sunken eyes, in general, weak pulses at above 12%, the animal becomes really shocky, lethargic, in lateral recumbency. And therefore, you need to give that patient sufficient amount of fluids with potassium. I'm not going into details about that.

Unless the patient really has some immunosuppression, meaning that it is really hypothermic, hypothermic. It has a neutropenia, it has a left shift or anything like that, and antibiotic is not indicated. Antibiotics really are only indicated in animals which have some signs of immunosuppression.

So an animal with acute hemorrhagic diarrhoea syndrome has been shown very many times that no antibiotics should be given. And on the bottom you See if we have a suspicion of a, or a diagnosis of pyrovirosis. When this animal has mild to moderate disease and symptoms, then giving only amoxicillin or ampicillin without anything else, so not the po potentiated, amino penicillin.

20 milligrammes per kilogramme, 3 times daily. Initially, you give it IV of course, it's sufficient and only if the animal has severe disease with severe leukopenia, less than 1500 micro, neutrophils per microliter. Then you can add androfloxacin.

We normally give it at quite a high dose, 10 milligrammes per kilogramme. Of course, unless you have a puppy dog, then, you, you need to think about something else, plus minus metronidazole. Besides that, what else can you do?

Well, if the animal has bloody diarrhoea and becomes anaemic, maybe you need to give a blood transfusion depending how bad that is. If the animal is also vomiting, you may need to give it some antiemetics. And, in dogs, really, meropetant is your drug of choice.

So, you can give that IV. You can give quite a high dose. So, generally, 1 milligramme per kilogramme, parental.

I, is, the, the normal dose, but you can easily go to 2 or 3 milligrammes per kilogramme if 1 milligramme per kilogramme is not sufficient and the animal continues to vomit. And if then still continues to vomit, you give it also, melo clopramide or another antiemetic on top. And finally, you should start feeding that patient.

You may need feeding tubes, but of course, initially, you give it some feeding support, such as, Warm the diet, hand feed, think about, put, off, often feeding, multiple feedings per day, maybe make it a blenderized food or a soup type of food, add something special that the animal is really, liking. And of course, tender loving care. Never is a, a, a mistake.

So, have a nurse, have an owner, really try to feed that patient. There are some drugs. To increase appetite.

Mirtazapine is, licenced for cats. It also works for dogs. Cyproheptadine is not licenced, but works quite well.

In the, United States, there is Caramorain or nia licenced in dogs, works really well, in a lot of dogs. And other drugs I've put on here is something that you can try diazepam, oxazepam, Stanoxolol. But generally, I really go for either.

My, my, my favourite drug is mirtazapine and, or ciproheptadine. These are my most favourite drugs to increase appetite. Or as I said, you, do tube feeding, either, basofacial tube feeding, and that's probably the one I would use in an acute case.

You can feed the patient for up to 10 days. There is no anaesthesia requirement. It's easy to place.

It's cheap and practical to give. There are some drawbacks. You can only li liquid feed, you have the risk of placing it into the in, the trachea.

And if chronic vomiting or i also acute vomiting is a, is a major problem, then, you, definitely also need to treat that vomiting. So the animal is not vomiting the tube up and then maybe, getting it into its trachea. So, what is the material?

You need a tube, you need some lidocaine, you need some gel, you need some other suture material or maybe even some glue, and of course, a buster collar, so the animal is not taking it out immediately. And there are feeding tubes available from all these companies I have here, depending on the size of the patient. Easy placement.

You measure the length up to about the 4th rib, put some local anaesthetic into the nose, pass it through the ventral myetus into the pharynx, and once it's there, you wait for swallowing, and then push it into the oesophagus. Then you control, of course, you first, try to aspirate air, you give some sodium chloride. And if you're still not certain, you, use an X-ray to make certain that it's in the oesophagus and not in the trachea.

And of course, you need to fix it, either with a Chinese finger trap or with super glue and, and put on a buster collar, as I said. And with this, I finished my lecture on acute, diarrhoea in the patients. And I've shown you hopefully sufficiently that, antibiotics is hardly, hardly ever indicated.

You need to deworm, you need to give it some, food. You may, you may want to feed it with a, nasal facial feeding tube if the animal is really sick, you may need to have to give it an infusion. And, I'm, very happy that I was part of this lecture here at today's meeting.

Thank you very much for your attention.