The future?

RE: The future?

Anthony Todd — Sat, 13 Apr 2019 11:15:33 GMT

[quote user="bevs2251"]the corporate BS line of must have a definitive diagnosis with myriads of tests before any treatment. [/quote]

Not only the corporates, just follow the threads on here!

It seems almost mandatory in most clinical presentations to "diagnose" common conditions and not jump straight to the only or best [considering all the possibles] treatment.

This always seems to involve a test of some sort. [and a cost, of course]

See what your hit rate is for sarcoptes, to take an obvious example.

RE: The future?

Anthony Todd — Sat, 13 Apr 2019 11:08:28 GMT

[quote user="vs0u "] you most certainly should not measure cat urine on a different SG scale to dog urine.[/quote]

Did I miss something [only ever having one refractometer for every fluid from any source]

What is the variation, never mentioned as far as i can see, and does it change the ball-park value both as absolute and significance.

RE: The future?

Julian Earl — Sat, 13 Apr 2019 11:02:51 GMT

Why be so scared about NSAIDs? There are well-known die-effects but surely they are rare? In humans patients on long-term non-steroidals have blood tests every 2-3 months but not beforehand as far as I am aware. Defensive medicine is sometimes being silly I think.

RE: The future?

bevs2251 — Sat, 13 Apr 2019 01:18:09 GMT

[quote user="Glen McIntosh"]Some of these ideas (eg doing bloods before starting NSAIDS etc), are being driven - either consciously (which is certainly the case in some Australian states) or unconsciously (which might be the case in the UK) - by veterinary regulatory bodies such as the RCVS, such that their members, especially the younger ones, are under the impression (rightly or, more commonly, wrongly), that failure to follow these dogma will result in their striking off. This mindset filters down to teaching institutions and their students.[/quote]

Absolutely. Worked as a locum for a corporate (GreenCross, now bought out by American company TPG) some years ago. Was told off for giving NSAIDs to a lame dog and not doing bloods/radiographs first (weekend, one vet/one nurse and consults all day so no time for "gold standard" GA and radiographs !!). I do suggest a preGA profile for an older lame dogs but certainly not young dogs for a 1 week course !

There is a fear instilled about this + the corporate BS line of must have a definitive diagnosis with myriads of tests before any treatment.

RE: The future?

Julian Earl — Fri, 12 Apr 2019 23:14:13 GMT

Similarkly to Joyce, I rarely did sensitivity for ear swabs , nor for mastitis cases in fact. In ears the easiest and quickest test would be a Diff-Quik smear for rods or cocci or yeast and selection of antimicrobial based on that. Sensitivity or otherwise on a plate is largely unrelated to the response in vivo due to the massive concentration of antibacterial agent to which they are exposed in the ear compared to the miniscule, concentration on an agar plate. Similarly, sensitivity in milk is often not comparable to, or at least inconsistent with sensitivity on an agar-plate. Therefore for ears, antibiotic selection was based on the predominant bacteria seen on the Diff-Quik slide. Plus results can be obtained within, say, 20-30 minutes?

RE: The future?

vs0u — Fri, 12 Apr 2019 22:59:16 GMT

[quote user="Beats"]

[quote user="vs0u "]Never heard of this - what do you mean? [/quote]

https://www.refractometer.eu/rur5-atc-refractometer-for-urine-of-cats-dogs-and-large-animals

this thread isn't the place, so suffice to say that you were in a good place having never heard of this! For clarity of my opinion: you most certainly should not measure cat urine on a different SG scale to dog urine.

[/quote]

Phew!

RE: The future?

Beats — Fri, 12 Apr 2019 22:35:49 GMT

[quote user="vs0u "]Never heard of this - what do you mean? [/quote]

https://www.refractometer.eu/rur5-atc-refractometer-for-urine-of-cats-dogs-and-large-animals

RE: The future?

vs0u — Fri, 12 Apr 2019 21:23:03 GMT

[quote user="Beats"]

suggestion 1 from the floor :-)

cat urine needing measured on a different refractometer scale to dog urine

(I could start a whole forum on the topic, let alone a thread ;-)

[/quote]

Never heard of this - what do you mean?

RE: The future?

Beats — Fri, 12 Apr 2019 20:51:52 GMT

suggestion 1 from the floor :-)

cat urine needing measured on a different refractometer scale to dog urine

(I could start a whole forum on the topic, let alone a thread ;-)

RE: The future?

Judith Archbold — Fri, 12 Apr 2019 20:36:57 GMT

I completely agree with all the comments ( even from David Mills!) so far about OOH providers ... one in particular ....whose vets spend so long farting around with “ pre op “ bloods / minimum bloody data base and repeat bloods .... and repeat ultrasounds ...that the poor animal is left suffering / dying ( in my opinion) ....because they are too scared to just do a bloody ex-lap and take out the ruptured spleen! (Obviously I am referring to an actual case! )....

But when I tried to raise my concerns about the negligent vet on call at the OOH centre I was confronted by a patronising area manager vet who said to me “ so you don’t think it’s important to stabilise a dog before surgery.”....

well not for 3 hours while it’s pumping out half it’s blood volume into its abdomen you daft cow,....(I said in my head....probably ....might have spoken it?)

I qualified from Cambridge in 1994 ...back in the days when we were taught medicine and surgery and just told to get on with it ....my year churned out great vets...not wet lettuces!

Mind you human doctors are also absolutely shit nowadays and can’t diagnose a thing without Google or a referral...( in my opinion).

RE: The future?

Rob Loxley — Fri, 12 Apr 2019 19:17:06 GMT

[quote user="Julie Innes"]

[quote user="robloxley"]It's interesting to see how the 'new' universities of Nottingham and Surrey have taken very different approaches to their final year roations regarding 1st opinion vs referral-based placements[/quote]

What approach have they taken, Rob?

[/quote]

Nottingham have partnered with referral centres, Surrey do al lot of their final year electives in partner 1st-opinion practices

RE: The future?

Arlo Guthrie — Fri, 12 Apr 2019 19:06:56 GMT

[quote user="David Mills"]I'm game.[/quote]

Fantastic. I'm really excited about this.

[quote user="David Mills"]One of the issues with RCVS Knowledge and BestBets is the need for peer review. But this forum is made for it.[/quote]

I was thinking the same.

What's the starting point? How shall we structure things?

I've been inviting some experts from a variety of disciplines to come and get stuck into the forums recently, in the context of the special interest groups, and it might make sense to see if they would like to be involved on a panel.

We need a list of things / bullshit statements which have become accepted as fact. I'm sure you've got a good supply, David Mills, but should we invite suggestions from the floor, so to speak. ie i email everyone and invite them to suggest statements for which they would like to know whether there is any evidence?

RE: The future?

David Mills — Fri, 12 Apr 2019 18:20:14 GMT

[quote user="Arlo Guthrie"]David Mills - an idea sparked by vs0u 's question and Michael Woodhouse's reply. How about putting together a small expert group, led by you, which considers some of the:[/quote]

Yes I think it's a great idea. I have plenty of statements that need debunking.

One of the issues with RCVS Knowledge and BestBets is the need for peer review. But this forum is made for it. And we could look at some of the mundane, simple bullshit statements. I'm game.

RE: The future?

Iain Richards — Fri, 12 Apr 2019 17:46:48 GMT

It's a good idea Arlo, some of what Best Bets and RCVS knowledge are looking at.

RE: The future?

Evelyn Barbour-Hill — Fri, 12 Apr 2019 13:23:20 GMT

[quote user="Glen McIntosh"]But it is the fear (almost certainly unfounded) of the RCVS[/quote]

Totally unfounded! Negligence is NOT the preserve of the RCVS DC. I have to say, I think RCVS have rather (deliberately?) muddied the waters about this in the last five, ten, years or so.

I'd be interested to hear from recent graduates on this forum whether they had a lecture from RCVS in the final year, as we did, and if the distinction between negligence and misconduct was made properly clear.

RE: The future?

Glen McIntosh — Fri, 12 Apr 2019 13:05:17 GMT

[quote user="Richard Carter"]

[quote user="Glen McIntosh"]doing bloods before starting NSAIDS etc)[/quote] actually it is the drug manufacturers that have devised every a.se covering statement in data sheets to make sure nothing sticks when the side effects happen

[/quote]

True.

But it is the fear (almost certainly unfounded) of the RCVS that is the main driver for many vets taking some aspects of drug company arse covering data sheets too seriously.

RE: The future?

Richard Carter — Fri, 12 Apr 2019 12:43:52 GMT

RE: The future?

Anthony Todd — Fri, 12 Apr 2019 12:21:03 GMT

[quote user="Glen McIntosh"]doing bloods before starting[/quote]

Like doing a blood K+ before unblocking a cat......

RE: The future?

Glen McIntosh — Fri, 12 Apr 2019 12:04:42 GMT

[quote user="Arlo Guthrie"]

David Mills - an idea sparked by vs0u 's question and Michael Woodhouse's reply. How about putting together a small expert group, led by you, which considers some of the:

[quote user="David Mills"]shite [which] gets post rationalised as gold standard. Tack a specialist onto it, paid handsomely, and we have the new "best practice". Not based on evidence. Not based on experience. But a sordid, financially gainful exploitation of good owner intentions and guilt. The young dogs refused nsaids without a blood test. The vomiting cat with slightly raised alt given liver biopsies. CT scans on a 14yo dog BCS 1/v with a bleeding splenic mass. Ooh providers who market themselves as sepcialists in ECC, yet fill their ranks with barely qualified locums. Council increasingly filled with these people who propagate this nonsense. [/quote]

... and then prepares a series of guidelines showing the evidence, or lack thereof, for some of this stuff that has been post-rationalised.

Then I wonder whether it might slot in under the banner of the 'Campaign For Rational Veterinary Medicine' (originally set up to challenge quackery, but I think could/should broaden to other forms of unsubstantiated rubbish).

[/quote]

This is a great idea. This is a debate that the profession desperately needs to have and a strong evidence base needs to be developed. I suspect that both sides of the debate would end up learning something.

Some of these ideas (eg doing bloods before starting NSAIDS etc), are being driven - either consciously (which is certainly the case in some Australian states) or unconsciously (which might be the case in the UK) - by veterinary regulatory bodies such as the RCVS, such that their members, especially the younger ones, are under the impression (rightly or, more commonly, wrongly), that failure to follow these dogma will result in their striking off. This mindset filters down to teaching institutions and their students.

So the RCVS also needs to play a more proactive role than it does now in correcting these misconceptions that seem to have developed, and by doing so they will be going a long way to improving the reputation of the profession within the wider community. Maybe the RCVS would be willing to back this idea financially?

RE: The future?

Anthony Todd — Fri, 12 Apr 2019 11:44:35 GMT

Are there any records etc. of serial bloods showing how values of some parameters vary with food/diet, mealtimes exercise, time of day etc.?

I imagine some vary a lot??

The RVC used to diagnose "liver disease" if the ALP/ALT[??] was raised if I referred a skin that had had a C'steroid injection......

RE: The future?

Arlo Guthrie — Fri, 12 Apr 2019 09:14:40 GMT

David Mills - an idea sparked by vs0u 's question and Michael Woodhouse's reply. How about putting together a small expert group, led by you, which considers some of the:

... and then prepares a series of guidelines showing the evidence, or lack thereof, for some of this stuff that has been post-rationalised.

David Mills I applied to become an ambassador for the charity Sense about Science a few weeks ago, and it is exactly the sort of thing you talk about in your post that drove me to do it. If you thought the idea has any legs, I would support wholeheartedly - help with publication of guidelines etc.

RE: The future?

Robert Lowe — Thu, 11 Apr 2019 23:19:25 GMT

[quote user="David Mills"]Build in a requirement for residencies to have not an internship, but 5 years in general practice.[/quote]

Absolutely agree with the thrust of this. Our last three (and still current residents) all have 5 years plus of GP work. I would argue that there are disadvantages in this as well in terms of relearning learning techniques and things like reducing access to residency training for vets with young children or plans for.

RE: The future?

Anthony Todd — Thu, 11 Apr 2019 23:02:48 GMT

Just to enter a [most?] dinovet's views and thoughts:

Regular bloods for dogs/cats on long term nsaids (e.g. q. 6 m)

There weren't any BITD, but need evidence of significant incidence in the lack of any signalment. Not continuous dosage though, as and when needed.

Xray probable arthritis cases before starting nsaids

Never unless suspect fracture or significant pathology ie palpable or movement restriction or no response to drugs

Regular Liver bloods for dogs on phenobarbitone

Never, but only just adequate dosage always.

Regular phenobarbitone levels for dogs on pheno

A joke, never, unless proving dose was not inside animal. Levels are just ball-park values anyway.Possibly if poor control??

Regular full bloods for cats on felimazole/similar drugs

Never, unless signs of need.

Cardiology work up for elderly cavalier with chf (before starting meds)

Never; just monitored response to meds.

Regular monitoring of same dog using echo

Not invented!

Urine culture for female dog with one off cystitis

Never, unless cellular signs of infection [bacteria presence per se not a sign of cystitis!!] c/f faeces!!

Ear swabs for animal with one off OE

Never, as most are normal flora just increased due to increase in sebum etc production from irritation via mites or allergy. C'steroids always.

Fluorescein in every animal with conjunctivitis

Always, if non-purulent or very irritant, often anyway; positives frequent!

Regular glucose curve and/or fructosamine for diabetics.

Hardly ever if water consumption normal on insulin. Owners got adept at noticing change. checked urine.

Some of the drugs and/or equipment weren't available eg anti arthritics, echo.

[Still, await brickbats or worse]

RE: The future?

Sara Ramsey — Thu, 11 Apr 2019 23:02:18 GMT

X-ray before C-section: I do this also.

Once opened up a cat because it was straining and convinced I could feel a kitten. Uterus was empty :(

RE: The future?

Iain Richards — Thu, 11 Apr 2019 21:58:12 GMT

[quote user="David Mills"]2yo cat with no co-morbidities, sudden onset swelling around femur, lame.[/quote]

None of this is justfied without treating the abvious first. Sadly I've seen similar even up here.