scott@vtx-cpd.com
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Replying to Lucy Bennett 02/05/2026 - 13:48
Hi Lucy 🙂
It’s really nice to meet you and congratulations on William that’s such a special time even if returning to clinical work in small steps can feel a bit strange at first. It sounds like you’ve already done a huge amount with your imaging certificate so the instinct to revisit and strengthen those disease pattern links makes a lot of sense and will pay off quickly once you’re back seeing cases regularly.
That Frenchie sounds like a genuinely frustrating case and honestly the kind that tests everyone especially when you inherit it partway through and finances are tight. You’re thinking about it in exactly the right way though. The vomiting versus regurgitation distinction is key but can get very blurred in real life particularly once a case has been going on for a week. Owners often describe a mix because repeated vomiting can lead to oesophageal irritation and secondary regurgitation or vice versa. The timing clue you mentioned is helpful but not absolute as regurgitation is often soon after eating or drinking but not always especially if there is oesophageal dysfunction or intermittent obstruction.
I think Frenchies in particular are always really challenging in this space. Even when you are specifically looking for something like a hiatal hernia it can be very frustrating because you will not always see it on standard imaging and even on CT it can be missed if it is intermittent. Sometimes you do need something dynamic like a fluoroscopic swallow study to really demonstrate what is happening in real time. Alongside that I think it is always important to step back and assess how much the BOAS component is contributing because the upper airway and reflux cycle in these dogs can be a big driver of ongoing clinical signs.
In terms of differentials I would still keep things broad. Gastrointestinal causes like partial foreign body pyloric outflow obstruction or severe gastritis remain possible even with previous imaging as these can be subtle or evolving. Pancreatitis is always worth keeping in mind in this breed. Oesophageal disease becomes more relevant with the regurgitation component so reflux esophagitis intermittent hiatal hernia or other functional oesophageal disorders all fit within the picture.
From a practical standpoint I tend to approach these cases like other chronic GI patients as well. A GI panel including cobalamin and folate can be useful to build a bigger picture and endoscopy is often indicated if things are not resolving. A lot of these dogs will have some degree of inflammatory disease within the stomach or intestines so if nothing structural is identified and they are not improving then a steroid trial can be reasonable alongside the fundamentals like dietary modification and good supportive care. At the same time I would still continue antiemetic support if vomiting is part of the picture and tailor that based on response.
The lack of response to maropitant and supportive care does make me lean a bit more toward an ongoing structural or functional issue rather than simple gastritis but cases like this often end up being multifactorial which is why they can feel so difficult.
Really glad to have you on the course and I hope the first KIT day back felt like a good step rather than an overwhelming one.
Keep the questions coming!
Scott 🙂
Replying to Lucy Bennett 02/05/2026 - 16:08
That sounds like a great journal club paper, Lucy. It is one of those studies that is immediately practice-relevant because it challenges a rule many of us have probably carried for years: sharp object equals no emesis. I still think there needs to be a lot of case selection here, especially witnessed ingestion, asymptomatic dog, likely gastric location and a sensible discussion with the owner about uncertainty, but it is reassuring to see that emesis was successful in a good proportion of cases and no complications were recorded in that group. I’d be really interested to hear what your team makes of it after journal club.
Scott 🙂
Replying to Sophie L. 03/05/2026 - 15:07
Hi Sophie,
In general, placing a urinary catheter with a closed collection system can be helpful from an infection control perspective in suspected or confirmed leptospirosis cases, particularly in dogs that are polyuric or difficult to manage in terms of urine containment. It allows you to minimise environmental contamination and reduces the risk of staff exposure, which is especially relevant in busy hospital settings where maintaining control of urine can be challenging.
That said, it would not be inappropriate to place a catheter, but I would not do this routinely. If the patient is stable and manageable, good barrier nursing with appropriate PPE and cleaning protocols is usually sufficient. I would often prioritise taking these patients outside more frequently so they are not urinating throughout the hospital environment, which can be a simple and effective way to reduce contamination risk.
If the patient is oliguric or anuric, then catheter placement becomes more appropriate from a monitoring perspective, as you want to accurately assess urine output. It can also be useful in more critical or recumbent patients where containment is otherwise difficult.
One important consideration is that urinary catheter placement does carry a risk of increasing urinary tract infections, particularly if left in place for longer periods, so that risk has to be balanced against the infection control benefits.
So overall, catheterisation is a reasonable option in selected cases, but not something I would consider routine if you are able to manage the patient safely with good nursing care and hygiene practices.
Glad you are enjoying the course, and keep the questions coming.
Scott 🙂
Replying to Mirja S. 21/04/2026 - 15:41
No problem!
Let me know if you have any other questions. I hope you are having a lovely weekend.
Scott 🙂
Replying to Felipe M. 23/04/2026 - 22:22
Felipe!
This is so interesting, thank you for sharing.
Scott 🙂
Hey Rosie!
So lovely to hear from you. I hope all is well with you. Great question!
I will make sure Felipe sees this question and we will get back to you.
Schnauzer by any chance?!
Scott 🙂
Replying to Mirja S. 16/04/2026 - 14:34
Hi Mirja,
These are great questions!
I think the “sneezy, snotty” geriatric cats are cases I certainly see a lot. It’s often that cycle of an initial infectious trigger—something bacterial or viral like herpesvirus—which then leads into this ongoing cycle of inflammation that just perpetuates itself.
At the root of many of these cases, there’s an underlying inflammatory process, often something like a chronic lymphoplasmacytic rhinitis. Because of that, many of them are actually steroid responsive.
If you’re reluctant to use steroids (which is completely reasonable, especially with CKD and age in the background), I’m also not a huge fan of repeated antibiotic trials—but a short course (e.g. a couple of weeks of doxycycline) can be reasonable if you’re concerned about secondary bacterial involvement.
That said, I think in most of these cats, any infection at this stage is secondary rather than primary, and the main issue is inflammatory/immune dysregulation within the nasal passages.
If you want to avoid steroids, the main alternative I’d consider would be cyclosporine, targeting that underlying inflammatory component.
In terms of other options and diagnostics:
Lysine: no longer strongly recommended based on current evidence, though still sometimes used
I’m generally not a fan of superficial nasal swabs in these casesYou could consider a deeper nasal or nasopharyngeal swab for a full respiratory PCR panel (including herpesvirus) if you felt it would change management
From an investigation standpoint, more definitive options would include advanced imaging and guided nasal biopsies, although in many of these patients that’s not pursued.
In terms of maropitant:
Systemically, it can help with appetite and nausea, but it’s not really a primary respiratory treatment
There has been some more recent evidence suggesting intranasal maropitant may not be as effective as previously thought, which is a bit disappointing (though studied in a slightly different population).Anecdotally, some cats seem to benefit—but that may partly be due to the act of instilling something into the nose, giving mild topical or flushing relief.
Supportive care still plays a role:
Nebulisation is a good option.
You could consider topical/intranasal steroids if trying to avoid systemic effects
That said, systemic steroids are generally more reliably effective when needed.So practically, I’d approach these as chronic, manageable inflammatory conditions, using trial-based therapy depending on what the owner is comfortable with.
On Cartrophen (pentosan polysulfate) and tracheal collapse:
I’ve never used it for this indication, and I’m not aware of any good evidence supporting it. The rationale is likely extrapolated from cartilage support, but this would be considered anecdotal rather than established.
It’s not something I would describe as a recognised or evidence-based treatment for tracheal collapse.
Thank you so much for your questions and thank you for joining the course and supporting vtx!
Scott 🙂
Replying to Laura S. 14/04/2026 - 19:41
Hi Laura,
That all makes complete sense, and I think what you’re describing is probably a very common driver for why people are reaching for Libres early, that understandable concern about missing hypoglycaemia at home, especially if there has been a bad prior experience in the practice. Those cases do tend to shape behaviour quite strongly.
I think the intention behind it is absolutely reasonable, but I’m not sure the Libre fully solves that problem in the early phase. In a newly diagnosed patient starting insulin, the variability is so high and the physiology is still settling, so even if you have continuous data, it does not necessarily translate into safer or more actionable decision making in those first few days. You can end up with a lot of data that looks reassuring or concerning without it actually reflecting what is truly happening in real time, particularly given the lag and early inaccuracy we talked about.
The scenario you describe with the ketotic but otherwise stable cat is a really interesting one. In that context, I do think a Libre can have some value in terms of trend monitoring and reducing handling, but I completely agree with you that it can feel like quite a significant expense for what is essentially additional reassurance rather than something that is clearly changing management. Especially if the patient is otherwise stable, on fluids, and you are already monitoring clinically and with intermittent blood glucose checks.
What you said about how you used to manage these cases is also really important, because that approach was always based on identifying general trends rather than exact numbers, and I think that principle still holds. Once you have seen a nadir and a rise, you have a reasonable sense of how that patient is responding in that moment, but as you pointed out, the day to day variability is substantial. The Fleeman and Rand paper really highlights that nicely, with quite a high proportion of cases where you would make a completely different dosing decision the next day despite identical conditions. So even what we consider structured curves are only ever a snapshot of a very dynamic system.
I think where that leaves us is that both curves and Libres have limitations, and neither should be over interpreted in isolation. In those early stages, particularly in newly diagnosed diabetics, I still think the priority is cautious insulin initiation, some targeted blood glucose monitoring, and close attention to the clinical picture rather than trying to achieve precision through dense data collection.
Where I do think Libres come into their own is a bit later, once things are more stable and you are trying to fine tune control or understand patterns in the home environment. That is where the additional data becomes much more meaningful and can genuinely guide decision making.
So overall I don’t think your instinct is off at all. Using a Libre for reassurance in those early cases is understandable, but it is probably not adding as much clinical value as it feels like it should, and in some cases may give a false sense of precision.
Never straightforward!
Scott 🙂
Replying to Silvana S. 13/04/2026 - 21:06
No problem!
Thank you for all of the brilliant interaction and questions.
I hope you are having a brilliant week.
Scott 🙂
Replying to Silvana S. 12/04/2026 - 10:00
Hi Silvana, great questions!
With active bleeding into the thorax, the CRT is not always increased. It can be, particularly if the dog is hypovolaemic and progressing toward shock, but early on it may still be normal. Remember that CRT is quite a crude parameter and can be influenced by stress, peripheral vasoconstriction, and examiner variation. In some dogs with haemothorax, especially if the bleeding is slower or partially contained, you may just see mild tachycardia and vague signs rather than obvious shock. So I would interpret CRT alongside heart rate, pulse quality, mentation, and lactate if available, rather than relying on it in isolation.
For rodenticide or other coagulopathies, you might see petechiae or ecchymoses, but not always. Petechiae are more typically associated with platelet disorders, whereas rodenticide toxicity tends to cause deficiencies in clotting factors, so you are often dealing with larger volume bleeding rather than pinpoint haemorrhages. In practice, dogs with rodenticide toxicity may present with cavitary bleeding such as haemothorax or heamoabdomen, and sometimes you will see external signs like bruising, bleeding from venipuncture sites, or epistaxis, but the oral exam can be completely unremarkable.
In a busy consult, the most useful clinical clues tend to be a combination of nonspecific signs like lethargy and hyporexia, plus cardiorespiratory changes such as tachypnea, increased effort, or muffled heart sounds. If something feels off, a quick point of care ultrasound is probably the highest yield next step, as it will very quickly tell you if there is pleural fluid present and help guide your next decisions.
I hope that helps!
Scott 🙂
Hi Laura,
Great question!
You’re absolutely right that Libres are less reliable in the first 24–72 hours after placement, and this becomes even more relevant in hospitalised or systemically unwell patients. The lag between interstitial and blood glucose is more pronounced when glucose is changing quickly, which is exactly what’s happening when we start insulin, and then you’ve got sensor equilibration on top of that, plus factors like reduced peripheral perfusion in sick patients. So early readings can be noisy, delayed, or just not that trustworthy from a decision-making standpoint.
I think it depends a little bit on the context. There are definitely situations in hospital where using a Libre makes a lot of sense. For example, in DKA patients where you’re otherwise sampling blood very frequently, or in a diabetic patient hospitalised for another reason, like surgery, it can be really helpful as an adjunct, reducing handling, giving you trends, and adding another layer of monitoring. There’s actually some evidence to support that approach too, CGMS systems in DKA patients have been shown to correlate well with blood glucose overall, with the vast majority of readings falling within clinically acceptable error ranges, although individual variability still exists and they’re best used alongside, rather than instead of, blood glucose measurements.
But my biggest question would be why we’re placing one right at the point of starting insulin. For me, that’s probably the situation where it makes the least sense. Newly diagnosed diabetics are inherently unstable, values are all over the place, insulin sensitivity is evolving, and you’re making relatively big-picture decisions early on. In that setting, the first few days of Libre data often aren’t that helpful and can even be misleading if taken too literally. So I’d usually prefer to start insulin, get a sense of response with traditional monitoring, with at least some blood glucose checks, especially around nadir, and then place a Libre a bit later when you’re moving into that fine-tuning phase.
I suppose it also depends what we mean by “sick patients.” In DKA cases it can absolutely be useful, but in newly diagnosed diabetics, the early data just isn’t that actionable from a clinical decision-making perspective.
The other piece I think is worth keeping in mind is that even our “gold standard” curves aren’t as robust as we sometimes assume. The Fleeman and Rand paper showed really nicely that there is significant day-to-day variability in glucose curves even when insulin dose and feeding are standardised, with opposite dosing recommendations occurring in up to 27% of cases, and even higher, around 40%, in well-controlled dogs. So whether we’re using curves or Libres, there’s always a layer of biological variability that needs to be interpreted in the context of the patient, not just the numbers.
In practice, I think the sweet spot is using Libres as an adjunct rather than a replacement early on, Libre plus strategic blood glucose checks at the start, then transitioning to more Libre-led management once things are more stable. And as always, if the clinical picture doesn’t fit the Libre, I’d trust the patient over the sensor.
I’m completely with you on Diabeasy as well, anything that shifts us away from rigid curves toward more clinically integrated monitoring is a big step forward!
Would be interesting to understand a bit more about how your colleges are using them.
Scott 🙂
Replying to Silvana S. 06/04/2026 - 09:56
Hey.
At my hospital I still see a lot of enrofloxacin being used as a first line antibiotic for many liver cases, which is interesting given what we are seeing in the data. I think part of it comes from a perception that these are “serious” infections and therefore need a “stronger” antibiotic up front, but this paper really challenges that idea. When you look at the actual isolates, with E. coli and Enterococcus dominating, and the relatively low resistance rates to amoxicillin clavulanate, it makes a good case for starting more simply and more rationally.
I completely agree with your point about ascending infections and the overlap with enteric flora, and we see the same variability in dogs as well, including the occasional unexpected isolate. But in most cases, starting with amoxiclav while you wait for culture seems both clinically appropriate and a better stewardship decision.
Scott 🙂
Replying to Silvana S. 06/04/2026 - 10:07
We are now looking in to the practicalities of getting one of these systems in to try.
Looking quite expensive so far! I will keep you posted. This is the system we are looking at:
Scott 🙂
Replying to Silvana S. 06/04/2026 - 10:14
I agree!
I must admit, I don’t have a huge amount of knowledge or experience with radiation therapy.
I am also surprised by what can be achieved with one dose!
Scott 🙂
Replying to Liz Bode 03/04/2026 - 18:15
Thanks Liz.
Really helpful!
Scott 🙂
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