Well, welcome everybody to the Zuku Review, NAVLE® Prep Accelerator Hoot Camp session seven. We're at our penultimate session for the summer, and I'm looking forward to this talk. We've got a really interesting talk set up for you tonight, both the clinical and the strategic. 

As usual, we'll start out with the weekly warmup. We'll be doing some retrieval practice questions based on what we covered last week and maybe even a week before that. Our clinical topic tonight will be a canine and feline classic case scenario with Q&A available from the one and only Dr. Catherine Reiss. Study strategies, we're going to talk about activating prior knowledge. You know more than you think you do. And we're gonna try to help you establish a habit so you can access that information more reliably, even under the stress of test situations. As always, we always reinforce near the end of our talks with a low stakes quiz on tonight's topic. And then finally, there will be a short assignment. If you go to the top of the chat, you can also see it. But we'll be doing a turbo two note between now and the final session this summer, getting ready for a short mock exam. Don't panic. 

Okay, it's time, folks, once again, for the weekly warmup. Everybody probably knows by now, we always start to, we like to start a warmup session where we review a few questions from the previous talk or talks, which is always good practice. And what we're doing here is trying to model the same stuff you should do in your study, which is to say, when you study, you quiz yourself. And then you come back a day or so later, you re-review it and you quiz yourself again. Independent study is one of the foundations of good learning. We're reinforcing knowledge. 

Here we go right out the gate with question number one, which choice best describes the classical clinical presentation of avian influenza in a commercial poultry flock? Gradual onset of coughing and nasal discharge, exudative sinusitis and low mortality? Sudden high mortality, drop in egg production, neurologic signs, facial edema? Chronic weight loss, paralysis, and irregular iris pigmentation? Swollen joints, lameness, and caseous exudate in the air sacs? Yellow diarrhea, enlarged liver, and high hatchery mortality? So take a little time here. Look these over. If you have an answer you're happy with, pick it A, B, C, D, or E, and put it in the chat box. Excellent. Excellent. I see a nice diversity. And if you remember what we talked about in strategic guessing in one of the earlier sessions, it's common not to know the answer exactly. So if you don't know the answer, narrow it down. Cross out the choices that feel wrong to you. Narrow it down to two and take a wild guess. Even if you miss it, you're going to learn. That's why we call it practice. All right, folks, great job in the chat room. I see a lot of people picking choices like A or B, those are excellent choices. And in this case, the correct answer is B. With avian influenza, classic clinical presentation is gonna be sudden high mortality, that remember what Dr. Tracy said, suddenly dead chickens and no other signs is sometimes your best indicator of possible avian influenza outbreak. This is pretty current right now because we're dealing in the United States with a country-wide avian influenza outbreak, which is now spreading into other species. So high mortality, drop in egg production, neuro signs, facial edema. Take home message, severe. 

An outbreak of sudden high mortality and neurologic signs in a commercial flock raises suspicion for highly pathogenic avian influenza, HPAI. Which statement regarding the diagnosis or prevention of HPAI is most accurate? Any licensed vet diagnostic lab can make definitive diagnosis? The cloacal swabs are the preferred diagnostic sample for all birds? C. Vaccination against H5 and H7 subtypes is common in US and Canadian commercial poultry operations? Biosecurity measures, especially restricting wild bird contact, are critical for prevention? D, ELISA and AGID are preferred tests for detecting active viral shedding? So let us know your choices there in chat. Take your time. Remember, if you don't know, that's normal. It's okay not to know the answer. But cross out the stuff that feels wrong to you, narrow it down to two, and then strategically guess one out of those two choices. All right, and I'm watching the chat responses come in. I see a little wider of a spread of people choosing what they want to choose, which is totally fine. Okay folks, get your choices in. We're going to give it about 10 more seconds. It's good to commit. And the answer is... Biosecurity measures, especially restricting wild bird contact are critical for prevention, okay? Well done, everybody. Now remember, if you picked what was the wrong answer, remember, we call it practice testing for a reason, for the same reason we call a clinical practice. Nobody gets 100 in real life on the test, and nobody gets 100 real life in clinical practice. What we try to do is is learn from our mistakes and get better, okay? Nothing wrong with making a mistake, just try to learn from it, okay. In Zuku, the missed questions, they're gonna recycle and you're gonna see it again until you get it right. Good job, everybody. 

Question four, a young chicken presents with asymmetric leg paresis and mild head tremors. Necropsy reveals enlarged sciatic nerves and visceral lymphomas. Which choice best describes the pathophysiologic mechanism of Marek's disease? Here comes your options. Inhaled mycotoxins cause demyelination and immune suppression? Retrovirus integrates into host lymphocytes, triggering neoplasia and leukemia? Cell-associated herpesvirus causes immune cell apoptosis and T cell transformation? D, direct parasitic invasion of nerves results in lymphocytic infiltration and paralysis? I think there's not an E, but I'm not sure. Give me your choices out of these four guys, and then we'll see how we do. There might be an E. I don't remember. Okay, people are guessing around in there. That's good. Let's see if there's an E. Okay, there's not an E, good. All right, so I'm seeing a nice diversity of answers. Some people like B, some like C, some like some like D, and here is our answer. Oh, there is an E, okay, sorry. I don't know, does that change it for you? A bacterial toxin induces peripheral nerve inflammation and edema? I think most of you already guessed it. So the correct answer in the case of Marek's disease is cell-associated herpes virus causes immune cell apoptosis and T-cell transformation. Good job. Really good job. So remember herpes, just like retroviruses, has its own little tricks for hiding within the genome, causing problems there, or hiding within these cells, that is. 

Which choice is the most effective strategy to prevent Marek's disease outbreaks in a commercial poultry operation? So, we've already got an outbreak. No, the most effective strategy to prevent Marek's outbreaks? In OVO or day of hatch vaccination with strict hygiene? Routine antibiotic prophylaxis and vitamin supplementation? Delayed placement of chicks until two weeks of age? Isolation of infected birds and feather trimming to reduce dander? Use of coccidiostats in feed and minimizing humidity? So we're looking for the most effective strategy to prevent Marek's disease outbreaks in commercial poultry operations. Okay, a lot of quick answers on this one. People seem pretty sure about this one, so let's see how we did. And the correct answer is A, in ovo or day of hatch vaccination with strict hygiene. Yeah, that's always a pretty good answer for poultry. 

Oh, look at this, folks. We have a blast from the past. We have question about a cow. This three-year-old Charolais bull, weighing 2,100 pounds, was found at pasture, walking in circles. He's been fed ensiled chicken litter in addition to winter pasture. We have our TPR here. I see temperature is 104.6 Fahrenheit, which is 40.3 Celsius. The normal range is below that. We have a cow with fever, a bull. Heart rate, basically normal. Respiratory rate, basically normal, so I've got fever, walking in circles, history of eating silage, and winter pasture. This animal is depressed, anorectic, drooling, head tilt to the right. The right ear and eyelid droop. So if you look over here, you can see the right ear is drooping, the right eyelid is drooping, that's ptosis. The bull is ataxic. Be very careful around any large animal that's ataxic. If you're around a cow or a horse and they go down, you can get hurt. So be mindful of that. The bull's ataxic with predominantly right-sided proprioceptive deficits. Now, I bet you most of you are guessing what you think we're looking at. What are we thinking here? Yeah. Everybody's saying it. So we're thinking Listeriosis, aren't we? Good job. So that's your diagnosis. Remember on the real test in NAVLE® and in the real world of clinical medicine, we're often going to ask not what is it, but what are we going to do about it? What test do we want? What treatment are we gonna do? What action are we're going to take? Let's just see what our options are here. So what test might help to confirm the clinical diagnosis? This is not multiple choice. So this is much like if you made for yourself flashcards. And maybe you don't remember from, we talked about this earlier in the month, maybe you don't remember the exact test, but you know you're looking at listeriosis, you know it's neurologic, if you had to come up with a reasonable guess. What test might you think of that we frequently think of with a neurologic problem which does appear to be central, either in the head or in the spinal column? And let's just see what chat room says. OK, I see let's see, we see some people say CSF, some people say ELISA, some people, say culture. Very good, excellent answers. I, I'm not positive. I'm pretty sure you do a CSF tap on this guy. I think this is one where culture is not rewarding, but let's find out. Yeah. So you do a CSF tap. You would do this on, you know, a valuable animal. Okay. You do it in the lumbosacral space. Normally it should have no color or turbidity, but if you've got a bonafide case of listeria, you'll see an increased mononuclear cell count and elevated protein concentration. Signs of a severe bacterial infection. And the fever goes along with that. Circling, silage history, you're certainly thinking Listeria. Oh shoot, I did that too soon. Treatment of choice, if you're going to treat, it's gonna be, you're gonna hit them hard with antibiotics and supportive care. If I recall, prognosis is not super on these guys, especially if they go down. Let's see what chat room says. Yeah, good job everybody. Yeah, now here's somebody, this is actually a pretty good answer based on my experience as well. When one of our doctors is saying, well really don't treat, cull the animal. If they're not a, if this is not a valuable animal, they would probably cull it before they hit it with antibiotics. If it's a Charolais bull, I assume it's still walking around because it's a valuable animal. But that's not a wrong answer to say I might cull it, unless you see something in the question that's really clear it's a valuable animal. Good job, everybody. Well done. At this point, I'm going to hand over the host hood to the one and only Dr. Katherine Reiss, and she is going to regale you with some amazing cases in small animal medicine. 

All right, so we're gonna go through a small animal case. We're gonna start on the canine side here. So we're going to start. I saw this little dog years ago. This is Georgia. She is a five-year-old female intact chihuahua. She was taken by a rescue group I work with up here in Virginia from a high kill shelter in rural Georgia. That is the Southeastern part of the United States. She had been part of a breeding facility that was maybe not doing a great job and the dogs were taken off of that property. They were kept in outdoor facilities and there was very unlikely any vet care given to these dogs prior to the shelter taking them out of that situation. The transporters from this dog on the way up here had noticed some frequent coughing. She went into foster care. And they also were worried about her coughing. She's not eating and drinking very well and she just seems lethargic to them. So she was in foster care a couple of days, came over to me, this is still Georgia. She's a lot fatter in this picture, but she was quite thin when I saw her. She's on the quiet side. Her lungs do sound a bit harsh, especially up in those dorsal regions. It's easy to note a cough with her. It's kind of a quiet or dry cough. And we notice a split second heart sound. We don't hear a murmur, but we do have a little concern for how her heart sounds. So everybody think about what your top differential might be. I will say, I think it's fair to have more than one on your list. There's definitely a top one for me. But if somebody comes up with one or two others, I will probably not argue with you. All right, so let's see what we think for Ms. Georgia here. And she has canine heartworm disease, okay. If you had mentioned some other infectious things, again, I would probably not argue with you as far as an initial list. So we are gonna start going through canine-heartworm disease though. 

All right and this is a really common, Steve mentioned this, really common really important disease. It is no longer just in the southeastern United States, although we certainly see the highest numbers there. It is absolutely in every state in the United States at this point. The pathophysiology of this disease is these gross little heartworms that you can see in that picture get into those pulmonary arteries. They cause inflammation, they damage the parenchyma and they will eventually cause fibrosis. So that will lead to several changes in the heart. One thing that we see really commonly with heartworm disease is pulmonary hypertension. Very, very common. That's from a couple different reasons. The worms themselves will actually obstruct blood flow. We'll get vessel thickening, especially the longer pronicity the worms have been in there, the more thickened vessels we might get. And we can even get PTEs, pulmonary thromboembolisms from the worms themselves, wedging in those pulmonary arteries. And all of that increases that blood pressure on that pulmonary side. We can also see right-sided hypertrophy with the most severe heartworm disease. We will get glomerulonephritis. Very common in these dogs. It's often reversible, but it's super common to get some glomerulonephritis with these guys. When we look at that urine, we're gonna see protein. And then ultimately, with most severe infections, we can get something called caval syndrome. That's when worms will move into the right side of the heart. We get acute and very severe tricuspid regurgitation that will cause a poor cardiac output. We get intervascular hemolysis. Basically, those red blood cells are essentially shredded as they're trying to go through those worms in that tricuspid valve. Those dogs become rapidly shocky, will get low blood pressure, and we can see congestive heart failure. So that is some of the worst sequelae and we'll talk a little bit more about caval syndrome. 

The life cycle in this disease is actually really important. You'll see as we go through both treatment and testing, why that is, this is actually a really important life cycle to know. We get mosquitoes as the intermediate host to these Diofilaria immitis. They are nematodes. So those mosquitoes will take the larvae from an infected, usually canine, and they are going to mature to an L3 and that mosquito bites another dog and infects them. Those larvae, though, travel through the body and don't reach the pulmonary arteries until about 70 to 120 days from that initial mosquito bite. They then are gonna mature in that pulmonary vasculature. By the time we get to microfilaria, by the time were producing those microfilaria from those adult breeding worms, that is seven to nine months from that initial mosquito bite. So that progression of timeframe there is actually really important. And we're also gonna go into the Wolbachia, which are bacteria that are intercellular gram negative bacteria in those heartworm worms. The worms actually cannot reproduce without the Wolbachia, but the Wolbachia bacteria are actually really important in post-inflammatory response. So very important life cycle for these guys to know. 

And we see it most commonly in our younger adult dogs. They are adults because it does take so long to get a full mature heartworm. And we tend to see it in our outdoor medium to large breed sporting dogs. That's not because small breed dogs aren't as susceptible, it's because of exposure. The more our dogs are outside and exposed to those mosquitoes, obviously more in heavily endemic areas than other colder areas of the country, but it's exposure really contributing to who we see the most in. And then a lot of dogs will not show any clinical signs, but coughing is the most common clinical sign. So a coughing dog, should have heartworm disease on this list. We'll also see some exercise intolerance and weight loss. So there's a classification scheme to kind of describe the severity of heartworm disease in our dogs. We start with a class one being those dogs that have minimal to no signs. And that's actually a third of dogs, which is nice. We go to class two, which have more obvious signs probably going to be where Georgia's line, where we have pretty consistent coughing and we're definitely losing weight. We're really not feeling great, but we're maybe not in true respiratory distress. Once we get to true respiratory distress that becomes a class three where we really are all having obvious trouble breathing, not just coughing. We can get that from PTE, which is a very acute onset respiratory distress or with those dogs who've had some chronic pulmonary hypertension, just for all the other reasons we get pulmonary hypertension, they can come in with some pretty severe distress at that point, but it's more of a chronic buildup. And then third classification is that very, very severe caval syndrome. 

All right, so let's go back to Georgia for a second. We look at her and we want to do a lot of tests on her. I did truncate this a little bit, but we do a CBC, we see a mild regenerative anemia, thrombocytopenia, We do run that 4DX and she is a strong heartworm positive. She's actually Lyme positive as well. And then on a blood smear, we do not see microfilaria. Just a note on that CBC, she also has fleas and ticks and every GI parasite known to man that a regenerative anemia is actually not related to the heart disease and the thrombocytopenia is probably related to the Lyme disease. So just to kind of keep that in mind. But she has a bunch of problems. We do take some x-rays, because again, we're concerned how those lungs sound, we're concern how she's feeling. We see some mild pulmonary artery changes. They look a little dilated and blunted, but we do see a patchy interstitial pattern in those caudal lung fields. Her heart size looks normal, so we like that. But because we did not get a positive on the microfilaria, we want to confirm the heartworm disease with another test and we sent her to a cardiologist. This is an excellent rescue group and we'll go to whatever lengths they need to. And the cardiologist is able to see those worms on the echocardiogram, but they do also diagnose her with some very severe pulmonary hypertension at that point. 

All right. So when we're diagnosing these guys in general, Radiographs are really important. It's not, we're going to diagnose it solely off an X-ray, but we are going to get an idea of severity of this disease. So this X-Ray we have up here, there's a really pretty severe heartworm dog, where we can see, if you look at the kind of like oblong tracing, is showing those sort of enlarged pulmonary arteries, they're torturous, they're often kind of blunted, where you can see it kind of stops. And then we're gonna see that patchy, it's a mixed alveolar interstitial pattern. It's predominantly seen in those caudal lung lobes. Again, in this patient, you can see that there's some mild pattern in other places, but the caudodorsal is the most severe. We can see right-sided heart enlargement as well, so we need to keep an eye out for that. Blood work, again, often normal. You can see it an eosinophilia or basophilia, but they're not gonna be specific. Seeing elevated globulins and seeing proteinuria definitely is common with these guys, but again, not specific. And if we do have those caval syndrome dogs, that's where we're gonna get elevated bilirubin. We're gonna see the anemia and hemoglobinuria, but those dogs are gonna be critically ill. EKG is usually normal in these guys unless we've had some chronic right-sided heart enlargement that's gonna cause some of those more rare arrhythmias. 

And we're going to look at our echocardiogram ideally. We would love to get these guys to a cardiologist, especially for those class two or higher. So if we have truly symptomatic dogs, it'd be really nice for a cardiologist to take a look, especially assessing for pulmonary hypertension because it's so common and we wanna treat that. We can also visualize the worms as you can see in this picture. And I do mean with a boarded cardiologist. It's not the easiest thing to pick out and be definitive about. But that is a nice way to do that second test. Then if we're suspecting caval syndrome, then we're going to see those worms in the right atrium as well. So our antigen test, that's the one we're most familiar with, that bench side snap test is great for screening as well as confirmation. But important thing to remember with that test is it only detects adult female worms. Okay, so again, we think of our life cycle that we went through. It takes time to get to an adult worm, and we do have to have a female worm to have that antigen test be positive. So it takes like seven months post-infection. It is highly sensitive and specific. We do need to keep in mind those timeframes. So, and that microflaria test, that's where we look at a blood smear, and you're actually looking for these fun little wiggly microfilaria. When you actually get to see it, it's really cool. They're kind of moving among the red blood cells. But not every heartworm positive dog is gonna have microfilaria. But when you get a antigen positive dog, so that's our general screening test, we always wanna confirm it with a second test. So if we can see microfilaria, then we've said, okay, we confirm heartworm disease, or if we go get that echo, but it is important to confirm your antigen tests. 

Right. So back to Georgia one more time. Um, we diagnosed her with a heartworm disease. She's, you know, kind of a sick little puppy. We go ahead and start her on the doxycycline, um, that is for the heartworm disease and luckily covers our Lyme disease as well. Um, we get her started on a steroid to try to reduce some of that inflammation and we put her on very severe exercise restriction. She is now on crate rest. Um, and she starts a monthly heartworm preventative. She was actually so severe, the cardiologist referred her to try to do a worm retrieval where they actually get a snare in there, but that was actually unsuccessful. They could not get the worms out that way. We do start sildenafil to help control that pulmonary hypertension, help reduce her signs, and we opted to go at that point to the melarsomine protocol, which we will go through in a second. After we went through all that, she actually did great. Um, but recheck with a cardiologist showed ongoing, very severe pulmonary hypertension. They actually gave her about a two month survival, but because she is a very tough little chihuahua, we thought like chihuahua jackrat, um, she defied everybody and lived three more years. She had a great quality of life. Um, so she was a good success story, but she did ultimately succumb to heartworm or to heart disease secondary to heartworm infection. But, that is her living her best life in her foster home. 

So treatment for these guys, we're gonna break it down. We're gonna start with the acute treatment. So these are the dogs that come in with acute severe respiratory signs. Again, that PTE, pneumonitis. We wanna get them strictly like restricted cage oxygen. Same way we would treat almost any respiratory distress coming through the door, anti-anxiety medication. If there's heart failure present, we wanna go ahead and start treating that. So we might consider pimobendan, ACE inhibitors. And if we have enough fluid in the abdomen from the right sided congestive heart failure, because remember we put fluid in the abdomen, sometimes pleural effusion, with right-sided heart failure. We can do a tap to relieve some of that pressure, help them take a little bit deeper breath. If we have a caval syndrome dog, that is where we want to consider acute worm embolectomy, where again we get a retrieval scenario. It's ideally done under fluoroscopy. This is 110%, a cardiologist only. But if they can pull those worms out and relieve that severe tricuspid regurgitation, again, very high risk because these dogs are incredibly ill, PTE, anaphylaxis, but the prognosis for caval syndrome is pretty scary. So it's worth a try. 

For actual heartworm treatment, so when we're treating the heartworm itself, not the respiratory distress secondary to heartworm, I strongly recommend everybody check out the American Heartworm Society. They are the beginning and end of this treatment. They are phenomenal. They have so much information on the website. And my favorite part of the website is they have a PDF protocol that goes through this melarsone three injection protocol. So this is the adulticide, rapid kill protocol that is recommended in most canine cases. They go through day zero, day one. I actually will print this out every time I have one with the dog's weight and doses and dates on there. It's so helpful. But this three-injection protocol actually starts with two months of treatment prior to that medication, trying to make the patient a little bit safer, less risk of reaction to that melarsomine. So we do the doxycycline that kills those Wolbachia, which are, again, going to prevent reproduction of the heartworm, but we're also going to reduce some of that inflammation that the body is responding to, less risk of anaphylaxis, prednisone to decrease the inflammation that tapers down. And we start our monthly heartworm preventative, and we're actually going to do two doses of that monthly heartworn preventative. So our first marlarso, I always say this word poorly, melarsomine injection actually starts after that two months of treatment. We give that injection, we restart the steroids and then a month after that is our second injection and one day after that is our third injection. We restart the steroids for that second and third injection and they are on extreme exercise restriction through this entire protocol and for six to eight weeks after. Um, a little clinical pearl here is that these are deep, deep intramuscular injections. We usually go apaxial. You want to clip and clean the space. We use like a long needle for bigger dogs. You want it very deep intermuscular and it hurts. We pre-med them with pain medication. I will give them injectable pain medication for the whole day after. You want be really cognizant of this protocol. So it does have some risks and side effects we're watching for. 

There is a slow kill method, and that's giving macrolides monthly, but it's not actually recommended in most cases. There are times we wanna consider that, and that's in dogs that maybe can't tolerate the melarsomine or that have other diseases that make giving those injections a little either more risky or we're not gonna get that same benefit and, for instance, if the dog has like terminal cancer or other things where we're not going to send them through that whole protocol, we can give the macrolides monthly. We still give that doxycycline and we're going to come back and test these guys regardless. And so when we're looking at testing, we do for the rapid kill as well, we're gonna test for microfilaria four months post-treatment. And we're gonna do an antigen test at six months post-treatment for the rapid kill. We're gonna make sure that we have cleared all of those heartworms. As far as prevention, if you ever need to convince your owners of why they're giving a yearly heartworm prevention, go through what we just talked about. That is not a fun disease to treat. And there is a lot of risk, both to the heartworm as well as the treatment. So we do recommend everywhere year round prophylaxis with a macrocyclic lactone. So that's ivermectin. I mean, you guys know there's so many different preventatives out there at this point. They're all very effective preventatives. We want to begin those at six to eight weeks. If you have a dog who's starting heartworm prevention after seven months, we do need to screen ahead of time and then repeat screening in six to seven months. Cause again, if we think about our life cycle, if the mosquito, you know, bit the dog the day before it saw you, you're gonna have a negative initial antigen test. We need to retest later, okay? 

So outcome with these guys. The prognosis in those mild to moderate cases really is very good. Once we get to the more severe cases, we start to talk about more guarded prognosis, those respiratory distress cases. And then when we get the caval syndrome or severe PTEs, congestive heart failures, those have a pretty grave prognosis at that point. The severity of disease is determined by the number of worms, the larger the worm burden, the more severe disease, but also the host's immune response comes into play, how long they've had that infection, the more active the dog, the more damage we're getting to the heart just because the work on the heart during that heartworm infection. There's multiple things that come into play. Exercise restriction is truly key in these therapies. The more quiet we can keep these dogs, the better we're going to have, um, outcome wise and the less risk of anaphylaxis and PTE and all those unfun sequelae. 

All right. So we will go through questions, I promise, because it's a lot for these, this disease, but it's really important. I'm checking my time. Um, but first we have to remember that dogs are not the only ones that get heartworm disease. Okay. And in so many other instances, cats are not small dogs. Okay, so they get the disease. But their response, their treatment really is a little bit different. I am going to try to go through this relatively quickly for you guys. Okay. The pathophysiology and the life cycle are the same, but remembering that cats are atypical hosts. So they do have some inherent resistance. Canines, both domestic and wild, are our typical hosts. Ferrets and cats are atypical. But any age cat, indoor and outdoor, the studies were showing pretty similar levels, like mosquitoes can come inside. Then same breakdown really as the dogs, where we have our asymptomatic cats, that is again about one-third of cats will be asymptomatic, and we have also our acute and chronic cats. Acute distress in these cats can be pretty severe. They can have a PTE from the worm itself. They get really severe pneumonitis, a little bit more severe pulmonary reactions in cats, again, as the atypical host. We can even get acute respiratory distress syndrome in these cats. And then there is something that's referred to as hard H-A-R-D, which is heartworm associated respiratory distress. And that's actually a inflammatory response to the juvenile worms entering the pulmonary vasculature, but those cats can be pretty severe. For chronic cases, we'll see a cough, dyspnea, weight loss. Biggest thing to remember as far as signs in feline heartworm, when we talk about not our severe cases, not our PTEs, is that cats don't cough commonly for a lot of different, dogs cough all the time. Cats are not big coughers, even asthma cats aren't big coughers. So if you have a cat who's truly coughing, heartworm should really be on your list. That should be something we look for. 

Diagnostically though, unfortunately, not as easy as dogs. X-rays would show similar patterns, but are more often kind of less significant or normal than dogs. Blood work, again, often normal. Echo, we might see some dilated pulmonary arteries. We may see some worms, but again, as atypical hosts, they're having far lower worm burdens and seeing literally one or two worms on an echo is not easy. There is antibody tests. It indicates exposure. It increases our suspicion, but it can't confirm it. And there are antigen tests for cats. It's very similar to the dog. But again, if we think about what gets us a positive antigen test, it is an adult female worm. And so a lot of these cats are having clinical signs before we have adult worms. You know, we have those juvenile syndromes, the risk of PTE. And with our very low worm burdens in our cats, we might not have a female worm in there to give us an antigen test. So if you have a positive in a cat, that is really specific, but there's a good risk of false negatives as well. 

Treatment wise, again, pretty similar to the dog. We have our acute treatment. We want to give them rest, oxygen, steroids, bronchodilators. Worm extractions really not done in cats. The risk is just too high. With those heartworm associated respiratory distress cats, we're gonna do a tapering dose of steroid and bronchodilators, so they're gonna stay on those medications for a while. And then big thing to know in cats is there's no adulticide. When we talk about treating heartworm, specifically treating the worms in cats, we are stuck with the heartworm preventatives that do a slow kill. We also still give doxycycline, but it's a little bit different with kitties. 

And then prognosis-wise, we can have a pretty fair prognosis with asymptomatic. You can't have cat self-cure, because again, if they have one worm that kind of slowly dies off and they don't have some of that big reactive disease while that worm is there, then they can do okay. But as soon as we get a truly symptomatic cat, we move pretty quickly to a guarded prognosis. Once we're in our ARDS category, we have grave prognosis. And there was one study that looked at about 10% of cats with heartworm disease just having sudden death. So I actually think this is a nice thing about this disease is that feline heartworm disease is often mistaken for asthma. So that doesn't seem like a nice thing, but the nice thing is that we really treat them the same at least initially. So luckily we can give steroids and bronchodilators and be correct. That's because those x-ray patterns and the presenting signs will often look like asthma. So at least we get to treat them both the same way, but we still want to be working towards those diagnoses so we can start that preventative and know what we're dealing with. Then we look at the percent of heartworms in cats, if you look at a comparison to unprotected, so not on monthly heartworm dogs in an endemic area compared to un-protected cats, we have somewhere between a five to 15% infection rate. So if you have a hundred dogs in that area and of that same population, you might have five to fifteen cats as a positive comparatively. So it's out there enough to really be talking to your owners about year round preventative in cats, particularly because if we get this disease, we just don't have as many good options in dogs and we can have really fatal outcomes. So something to remember in cats. So that's really quick and dirty feline heartworm disease, and we can totally stop for questions. I will also try to answer in the Q and A portion as well. 

Alright everybody. So here we go. We're going to be talking now about activating prior knowledge and connecting the dots. This is your study strategy session for Hoot Camp session number seven. And basically I would say the gist of this talk will be you do know more than you think you do. And you will not go into your exam, whatever it is, expecting to get 100. Nobody really does that. And so what good test takers do is they find ways to at least activate what they already do know and then they try to make some reasonable guesses and assumptions based on that when it comes time to perform on an exam. Okay? So that's our topic for today. 

So you really do know more than you think you do. You did not survive three or four years of veterinary school without absorbing something, okay? And a big part of our topic today is finding ways to connect what you do know to what you don't know. What that literally means is we're trying to help you learn some habits to help you access what's in your head so you can use it when you're confronted with a question you're not so sure about. Okay. This is a very useful thing to learn how to do better. And like a muscle, you can strengthen your ability to access that prior knowledge with retrieval practice. But instead of doing it with practice questions, we're going to now do that with independent study. Literally, if you just practice pulling bite-sized pieces of information out of your brain over and over, then by test day it's going to be easier and more familiar so that when you're confronted with a question you're not so sure about, maybe it's about pigs, maybe it is about chickens, you may be able to access some things in your head in bite sized pieces, connected in some way that are relevant, that help you cross out the choices you think might be wrong, narrow it down to two and take a good strategic guess, okay? So that's what we're here to do today, to help you get to the place that when test day comes and you see a question you're not so sure about, you can at least not panic and you can say, well, I don't know what that is, but I do know this and I I do know that. And let me see if I can compare them and then eliminate some choices, narrow it down to two and take a good guess. 

So you may remember this slide, I believe this was from our second session. We talked about working memory and how we really learn and this idea that the way we really learned is not study, study, study really hard all weekend, one weekend and then never think about that topic again. And then you have this wrong expectation that you can always access that information you studied four months ago, right at the top of your brain. That's wrong. It's not how our brains work. The way our brains works is a thing called working memory. If your brain is a giant computer memory holding all this information, working memory is the little pieces that we take away from our brain and we use on a daily basis. Working memory is something we improve by learning to go and get information out of our head on a regular basis. And the way that works is pretty simple. You spend about two-thirds of your time in any given week doing practice tests and time tests, getting more comfortable with that whole format of pulling information out of your brain. And you spend about one-third of your time in a given week doing independent study on the big topics. You'll study a thing and then you'll quiz yourself about it. It's all about pulling information out, it's not so much about cramming it in. And that is the secret of success. So I want to put a new idea in your head. Imagine that facts about veterinary medicine, about some disease are Lego bricks. So it's little plastic bricks kids use to make things. And your brain is full of these Lego bricks, okay? Just a mountain of Lego bricks. How do you get the information out, and how do you get it out in a way that makes sense, that's relevant to either a real clinical case, a real animal in front of you, or some question that's been put in front of you? Well, how do you get it out? You don't get it out by pulling out every single Lego and looking at it. That's not what you do. We pull information out of the data bank in our brain one Lego at a time, one piece at a time, one chunk. And I want to encourage you to think in small bite-size chunks of information. Okay, you may not know everything, but you might know enough of those small bite size chunks to put together a good answer. That'll help you in real clinics and it'll help on the test. 

So what does one brick at a time mean? Well, studies of adult learning have shown very clearly that we can only recall and hold a small number of ideas in our head at any given moment. That's our working memory. Working memory is a small bucket that we carry a few ideas in, okay? It's not that massive mountain of Legos that's sitting in our heads, that massive pile of facts. Working memory is getting those small individual pieces of information out of our heads and then putting it together with a couple other small pieces of information to come up with a good choice. So start with your one brick and a really good thing that would be a simple piece of information to pull out about the things you wanna know would be what does a classic case look like? Could I describe a classic of canine heartworm? Could I described a classic a feline heartworm? Connect that brick to another brick, and you say, huh, okay, I think I know what a classic case of canine heartworm looks like. What is my test of choice? And if I recall, I was busy getting this stuff ready here for this presentation, but if I recall, it's usually an antigen test, plus or minus looking for microfilaria in the blood, okay? And then, let's add another brick and say, well, okay, I got my, I know what a classic case in a dog looks like. I think I know with the test of choice is. And then what's my treatment of choice? That's three really useful bricks of bite-sized information you can pull out of your memory banks and put together to make one useful foundation to stand on. And now we're getting somewhere. You put those three bricks together and even if you don't know everything about heartworm, now you're standing on a solid foundation, okay, to help improve and strengthen your mental muscles for the day the test comes or for your next clinical case. 

So we're going to now talk about something we've covered a little bit in previous talks, but from a different direction. And basically we're gonna talk about, well, how do I get in good mental shape to access prior knowledge. How do I get that information to be available to me at my fingertips when I'm faced with a test? Well, it is a habit you can practice. And the way you set yourself up for success is literally organize your key diseases in those small bite-size pieces. And then write it down. Physically get a pen or a pencil, get a piece of paper and on half a sheet of paper write down the three things you always want to know about a case and then stick a picture in there. It's not sexy, it's not exciting, it is not modern, and it works. There's no shortcut. I wish I could tell you I had a magic trick that you could avoid all this because this takes a little time, but this works. So find a way to include it in when you prepare. Doesn't have to be everything, but it should be part. 

So take a classic case like heartworm. I want to know what it looks like. I want to learn what my test of choice is. And I want to know my treatment is. Then just add a really cool, memorable image. Something you'll never forget. You all know what this is, even though it's rare. It's such a good picture. That's Marek's, right? That's the lymphocytic infiltration of the pupil there, or the iris. That's your magic trick, that's all it is. When you do it is now, okay? This is not something you wait to do to the home stretch when you've got seven days and counting before your test. Remember, the basic recipe to prepare for a big test like NAVLE® is day in, day out, week in, week out, try to give two thirds of your study time that week to a routine of practice testing, whether it's the regular practice test where you see the answers as you go. Or the timed tests in the homestretch. But about two-thirds of your time goes there. One-third of your time though is independent study. That is where you are training your brain to access the main things you wanna know about the top, let's say 20 diseases in dog, cat, horse, and cow, and the top maybe five or eight diseases in pigs and the five or eight diseases in small ruminants. That's where the magic happens. You can't skip it. I wish I could tell you there's a shortcut. There is no shortcut. You need to do this work, okay? This is part of the process. Now, you can make it work in a way that makes sense to you, but you have to invest some time in retrieval practice with notes and books and images of real cases. That's about a third of your time in any given week. 

Now this is another thing we've covered before, so I'll briefly cover it. What does that look like? How do I start? Literally write the name of a disease at the top of a half page of paper. Find one good image that really speaks to you about what that disease is, slap it on your notes. And then with a pen or pencil, physically write down in language that makes sense to you what are the signs of a classic case? What does it look like. What's my key test of choice? How do I treat it? And then review that and quiz yourself over and over. That's what works. It's a big part of your independent study. And it's not so much just staring at a piece of paper passively and then throwing it down and moving on. That's not what it's about. You're making it yours and you're making active. 

So let's try another one. You may remember this one. We've talked about this before. Parelaphostrongylus tenuis, P. Tenuis. And who gets sick with it? Llamas get sick with. Who does not get sick with it? That would be white-tailed deer in the United States, okay? Or in North America, okay. So they're basically the carriers, but llamas can get sick with it. I think horses can also get a problem with this. What's a classic case look like? Llama, sheep, or goat with ataxia, pelvic limb weakness, stiffness, circling, lameness, very ain't doing right type neuro signs, maybe scoliosis, paralysis, and sometimes some temporary remission, okay? So that's not a very easy thing to diagnose, but I think I'd be worried about it if I knew I had P. tenuis in the part of the country I lived in and I was on a llama farm and I saw these neurologic signs of ataxia. Test of choice, you know what? There is not one. Short of a post-mortem necropsy and histopath, there isn't a really good anti-mortem diagnosis. Just like Listeria, you might consider clinical signs plus a CSF, and we're looking for abnormalities in the CSF. Treatment? No definitive treatment, okay? Sometimes Fenbendazol or Ivermectin has been used. There are problems with anti-helminthic resistance. This is probably easier to prevent invaluable llamas than it is to treat. So you need deer-proof fencing, which means a very tall fence, like 10 feet tall, and a pretty forward-thinking anti-helminthic program. Bonus point, if they go down, not a good prognosis, okay? So boom, that's what your notes could look like, right? And you can say, oh, I don't have time, that just takes too long, I dunno. I'm sorry that it takes too long. But if you can do this for the biggest diseases of the biggest species, and then you use that as a way to re-review and quiz yourself, it can really help on the day of the test, okay. It's not everything. But it's an important component. Okay? 

Who's aberrant? Who's the aberrant host for P. tenuis? Just tell me in chat. So we're doing what you should do. You write the notes and then you quiz yourself. Aberrant host should be Llamas, sheep, goats, things like that. Good job. Camelids, sheep and goats. Good job, five clinical signs of P. tenuis in an affected llama? Basically a grab bag of neurologic problems, ataxia, circling, weakness, paralysis, intermittency, things that. Scoliosis. Our treatment of choice? What's easy about this is, unfortunately there isn't any. Probably easier to prevent this one than treat it. Boom. That's all it is, it's not rocket science, okay? But if you can make a habit of piling up a nice pile of notes that you can quiz yourself on and go back and just kind of remind yourself from time to time, you'll be glad you did that when it gets into the home stretch and time is short. 

Here's another one, had to go back to that Listeria cow. Remember him, the listeria bull? So classic animals, you already know it. They may have a head tilt, they may be circling. You know, asymmetric sensation loss in the face, you gotta get pretty close to a bull to pull that off. But you know, you might be looking at a goat or something like that. You're often thinking of adult animals kept indoors in the winter, and you got this history of feeding silage. Test of choice. Just like P tenuis, we're thinking clinical signs and a CSF tap. Culture is difficult, usually not successful. Treatment, as you guys well knew already when we did the question earlier, it's antibiotics. If they're bloating, like a neurologic bloat, you've got to address that because a bloat will kill an animal. And supportive care. You probably want to think hard about hitting a food animal with heavy duty antibiotics before you do it. You probably wouldn't do that unless it's a really valuable animal. Bonus fact, once again, kind of a poor prognosis once they're symptomatic. Once again, if you learn these three things about the top 20 diseases for dog, cat, horse, and cow, that's fantastic. That's a great foundation. Do five or eight for pigs, five or eight for small ruminants, and you're in business. Maybe do four or five for chickens, off you go. 

So what we're really doing here is firming up our foundation, increasing our comfort level, with reaching into our own brains and pulling out those little Lego bricks to put together three or four Lego bricks of basic information about the really big diseases so that we can figure out quickly, here's what I do know, and this thing I'm reading about in a pig, this is nothing like that. And so I'm either just gonna cross out some stuff based on a whim, narrow it down to two and take a guess, or pulling that information out of my head really helped me. You know, I think I might know what to do here. What you might do on a real test too is, you know, you've got a whiteboard to scribble on during the test. You can scribble down what you think you do know, pick as good of an answer as you can and move on, but mark it. And if you still got time in the clock at the end of those 60 questions, go back and look at the one you marked and see if something, you now, during that marination made sense to you. There's another powerful exercise. We all kind of already do it. We're trained to do it in our school. And that's simply take something you do know from one species and see if there's any sort of transferable knowledge with the animal in front of you. Okay, so let's just say you are an expert on cats. You really are gonna be the best cat vet that ever existed. And you know everything there is to know about feline leukemia. But on a farm question, you are completely lost. And so you get confronted with a question about a cow with possible bovine leukosis, BLV. Well, you might use what you already know about the way the retrovirus feline leukemia acts in cats to maybe inform what you might say about a cow. The fact that it's typically adult animals that might have a problem. They're not necessarily only symptomatic. This is a retrovirus, so it's intercalating itself into the DNA or the RNA, things like that. Maybe you don't know everything about cows, but you know enough about adjacent diseases you can hopefully make some connections. 

Veterinary medicine is just full of connections. Think about gastric dilatation volvulus in dogs versus bovine bloat in cattle, okay? They both are literally blowing up in their stomach full of gas. Here on the left-hand side, we've got a nice picture of the double bubble, you're in trouble. This is a great big dog with a true gastric dilitation of volvulus. If you can't get that relieved fast, what are you gonna do? You're gonna put a trocar in it and relieve the pressure fast to give you a little breathing room to get this fixed. It's a surgical fix. We look at these cattle, not one, but two of these cattle, they both have bloat. You've got this enormous distension on the left side, okay? The left side is where the rumen is. The rumen is just this giant 55 gallon drum full of gas. If it gets too big, it will squash the entrance where the esophagus and the carotid artery and the vena cava are all coming down the neck and it'll kill the cow. They can asphyxiate. They can just collapse from the blood being cut off to their head. So maybe you want to put a trocar in that. Where you're going to put it, you're gonna put it where it's biggest, just like in the GDV dog. Now, sometimes putting a trocar in isn't going to help an animal with frothy bloat, but presumably you've passed a tube already and tried to find out if you can relieve gas that way. So, look for connections. 

Here's some more connections. Think about parvovirus. You know, many of the diseases we look at have counterpart viruses in other species. Think of caliciviruses in cats, just for one example. And think about COVID. So think about parvo in puppies versus parvo in pigs versus parvo in cats. In cats, that would be feline panleukopenia. Pop quiz, everybody. What's a key lab finding in a parvo puppy? Tell me in chat. We're looking for a clinpath finding you might see in a Parvo puppy. There we go, Alison Lynn, good job. Dr. Burkhardt, nice, very good. Dr. Smith, very Good. Dr. Aburaya, good. Dr. Maloof, very, good, good Job. Yeah, Leukopenia, we're gonna be looking for depressed white blood cells, okay. So look, we think of parvo puppies and diarrhea and then you get these panleukopenic cats or in pigs, you can see things like abortion in the mothers, okay? So we're just looking for ways to make connections. There are more connections than not. It's a rare disease that doesn't have a connection to something you might already know. Remember avian influenza, it's famous for being a zoonotic disease, so we also are seeing avian influenza passing over into cattle, they're finding it in milk samples. Pigs can carry a form of influenza and when the influenza virus in the pig promiscuously shares its genetic material with an avian influenza virus in the same animal, like a pig, sometimes the Resulting progeny virus that comes out of that sharing is even more virulent than the two individual pig or avian viruses. That's a real problem. And of course, we think of influenza in people. Another classic example, think about foot and mouth disease versus say vesicular stomatitis. That's an absolutely classic comparison you pretty much can expect to see on NAVLE®. And finally... Couldn't help but with the picture, we think about, they call it psittacosis chlamydophila in birds, but people can get chlamydophila as well, and in humans, we call it ornithosis. So if you come in and somebody's presenting you with a psittocene bird, and they got all these respiratory signs, you might wanna look at the owner and say, how's everybody doing at home? 

So let's just see this. Here's something we're just gonna do another retrieval practice question based on something you've seen a few weeks ago. I want you to make a connection. You may know nothing about zoo animals or exotics, but you do know some things about parasitology in other species that are more common, dogs, cats, horses, and cows. So let us take what we do know and see if we can come up with a reasonable choice for an animal we don't know. A snake is presented because the owner says it spends a lot of time in the water bowl. Gently rubbing the dry snake over white paper yields numerous tiny specks on the paper. Under a microscope, they look like the image below. And remember in Zuku, if you click on the image, whenever we have a high resolution image, it'll just go big for you. So I look at that and I go, Now that looks like a parasite to me. And it's on the skin, I'm assuming it's a mite, or a louse, or a tick, or something like that. Doesn't look like a tick. I think that might be a mite. Um, and the question is not, what is it, the question as usual in NAVLE® and in real life is they expect you to be in the ballpark of what it might be and they're asking you, what do you do? What tests you want? What action will you take? So what's your action on this situation? Is it oral praziquantel? Is it topical permethrin? Is it that no treatments necessary for this? Is it hyperimmune bovine colostrum? Or is it improved sanitation? Now, if you know the answer, just you tell us in chat and you're done. If you don't know the answer, look at that and say, huh, what am I looking at? I'm looking at what appears to be an external parasite. If this was a dog or a cat or a cow, how would I treat this in an animal that I'm more familiar with. I also remember that praziquantel is something I treat tapeworms with, and this is nothing to do with tapeworm. So I think I'm going to hide that one. And you know, it does appear, according to the owner, that there's a problem here. It might not be likely that this is a no problem, okay? So I'm gonna hide that one. Topical permethrin, that might treat this. I think it might be a mite. I'm gonna hold on to that. I don't think it's no treatment. I have no idea why you would ever want to use hyperimmune bovine colostrum in a reptile, so I'm just going to hide that. Narrow it down to two choices. What do you guys like? Tell me in chat. Chat room says, a couple of different things. Some people say improve sanitation, some say the colostrum, some say permethrin. Remember, if you get it wrong, not a problem. Just learn from the ones you miss in Zuku. The ones you missed are going to recycle until you get them right. Nobody expects anyone to get 100 when they first start this. Even when you're the day before your test, you're probably not going to get a hundred on any test you take. Our goal, though, is just to pass. You don't need 100 to pass, so if you miss it, learn from it. So the question, in this case, the answer is permethrin. We've got these external mites. They're relatively common. You'll find these, they'll be around the eyes and the gluteal folds of the skin. Anywhere there's a skin indentation, they can transmit some diseases, and so you basically do want to treat it and try to take care of it. Because remember, it is bothering the snake. The snake's not acting normally so that's why you wouldn't pick oh it's normal don't treat it. Believe it or not they do treat cryptosporidiosis in reptiles with hyperimmune bovine colostrum. Who thought that up? I have no idea. Praziquantel, we do use that in reptile to treat pentasomes. And that's it. Good job, everybody. 

I think we've got one more. Oh, last thing. Um... We all perform better if we can manage our stress. Some stress is very normal in vet school. It is common and normal to have anxiety about getting ready for a big test like this. It is common and normal to have some anxiety and stress about just trying to be a good vet student, you know? So if you have some stress and some anxiety, I would say remember you're not alone. It is part of the experience, it's not necessarily fun, but it is part the experience and we grow by overcoming these challenges. And that can be a very important part of experience of vet school. However, it is hard to learn and it's hard to perform well if you are totally stressed out. If you are non-functional, if you're so stressed out, like so stressed, so depressed, so exhausted, you can barely function, then you can't study in those situations. That's not a good situation, okay? And if that's the case for you, it might be time to ask, do I need to do something different? Do I need dial this back? Maybe I need to, if it's really bad, maybe I need just step away for the rest of the semester and come back next year, okay? Nothing wrong with that, okay. But if you're so stressed out by the experience that you're not able to function, the test is not the most important thing at that moment. However, this is another indication that it is well worth your time to invest some positive energy in the things that have nothing to do with study but are healthy. Pardon me. That are healthy and make you feel better. Invest some positive energy in exercise, sleep, and breaks. We talked about this on the last talk. You can't study all the time. It won't help if you try to study all of the time, no one can concentrate all of time. You do need to make sure you get some rest. You do to need to exercise. It will help you cope better. And yeah, you're allowed to take some breaks, okay? Remember, you don't need a hundred. You don't need 100 to pass this test. Basically, on the day of your exam, if you can get 75% of the questions correct that count, you are likely to pass. You're very likely to pass. That means you can miss some and you'll be okay. Missing some and being okay is not permission to coast. It's permission to not freak out if you miss a few. We all miss a a few. 

Excellent. Folks, we are now at the home stretch of today's talk. It is low stakes quiz time. These will be sample NAVLE® style questions based on today's topic from Dr. Reiss. Question number one. We have a five-year-old Labrador retriever presenting with chronic coughing and exercise intolerance. Thoracic radiographs reveal torturous pulmonary arteries and a mild interstitial lung pattern. Antigen testing is positive for heartworm. Which of the following most appropriately classifies this patient's heartworm disease? Class one, asymptomatic or mild? Class two, moderate disease with coughing, mild radiographic changes? Class three, Severe disease with right-sided heart failure? Class four, caval syndrome? Class 0, prepatent infection with false positive antigen? So what do you guys like here? What do you think? Excellent. We got a diversity of people making choices here. That's good to see. Remember If you miss it, learn from it, you will see it again. If you get it right and you guessed, try to learn from that. On the real test, on a typical time limit, you will have about one minute, well, you'll have one minute five seconds per question on average. Most people can answer a NAVLE® question in less than that by the time they take the test. If you have accommodations, you typically will have extra time to answer questions. Alright, here we go. Here comes your answer. For this dog, this is a class two moderate disease heartworm case with coughing and mild radiographic changes. 

Question two, which one of the following diagnostic findings is most specific for confirming a symptomatic heartworm infection in a dog? So we're looking for which one diagnostic finding is most specific to confirm a symptomic heartworm infection. Visualization of worms on echocardiogram? Presence of eosinophilia on a CBC? Enlargement of pulmonary arteries on radiographs? Hyperglobulinemia on serum biochemistry? Proteinuria on urinalysis? Okay, I see the chat answers piling up pretty quick here. Very good. Yeah, very good. Dr. Navar, excellent. Dr. Guerrero, Dr. DeLong, Dr Raymond. Good job, good job. Okay, Dr. Garcia, muy bien. Entonces. So here comes your answer. And the answer in this case to confirm symptomatic heartworm infection in a dog would be visualization of worms on echocardiogram. If you see adult worms in there, you know what you're looking at. 

Question three, which choice is most appropriate when initiating treatment for a dog with confirmed heartworm infection and mild clinical signs? So we're looking for the most appropriate initiating treatment. Begin melarsamine immediately and to eliminate the adult worms? Start the slow kill protocol with monthly ivermectin only? Perform surgical worm removal via the jugular vein? Administer prednisone and doxycycline before adulticide? Treat with diuretics and pimobendan until signs resolve, then begin heartworm preventative? All right, take your time and have a look at that everybody. And lots of answers coming in here. Excellent. Love to see this. Once again we have a little bit of diversity. Most people are choosing either b or d, that's great. If you don't know eliminate the choices that feel wrong to you narrow it down to two and take a good guess, okay? Remember practice testing is another form of learning. So, D is your correct choice in this case. You're initiating treatment with confirmed heartworm infection, mild clinical signs. We're gonna start them on prednisone and doxycycline before we give adulticide. Before you kill off those big, I mean, five, six inch long, 10 centimeter long adult worms and break up those bodies that's a lot of gunk in the blood vessels, before we do that, you want to calm the immune system and we want to wipe out the Wolbachia that are living inside the heartworms. That is, by the way, something that was discovered in humans, there's a human version of a dirophilaria that causes elephantiasis, and that's where they first saw the Wolbachia, or at least that's what they figured out that antibiotics would help with treatment. 

Question number four, a four-year-old indoor-outdoor cat in a heartworm endemic region presents with chronic coughing and intermittent dyspnea. Thoracic radiographs show a patchy interstitial alveolar pattern and no obvious heart enlargement. A heartworm antigen test is negative. What is the most appropriate next step in managing this patient? So this is a, what do you do next question? Is it, begin melarsomine injections to eliminate adult worms? Rule out heartworm disease, a negative antigen test is definitive in cats? Supportive care and heartworm prevention, consider antibody testing? Perform worm extraction via the right jugular access under fluoroscopy? Initiate lifelong corticosteroids to manage irreversible eosinophilic bronchopneumonia? Okay, excellent. So I see a nice diversity. Some people are choosing B, some E, some C. That's great. Remember, as Dr. Reiss said, cats are not small dogs, so the way we address this is a little different in that. And three, two, one, here's your answer. So the correct choice in this case, in a cat like this, is C, supportive care, heartworm prevention, consider antibody testing. 

Okay we have reached the end of session seven everybody. We have one more session this month that'll be happening this Sunday in the morning. Here's your assignment for Sunday. If you do this it'll take you just a little over one hour but if you can invest an hour and 20 minutes in this it will pay off on Sunday when we do the mock exam. Spend about 10 minutes per disease topic. And on paper, write down what does a classic case look like and find one good image. The Merck manual is a great source. What's my test of choice and what's my treatment? And what are our diseases? It's the seven diseases we've covered in the last four weeks. Displaced abomasum in cattle. Pregnancy toxemia in small ruminants. Feline urinary obstruction. Equine laminitis. Gastric dilatation volvulus, that's dogs. Avian influenza, and Marek's disease in poultry. And tonight's topic, heartworm disease, not just in dogs, also in cats. I'm going to now quickly see if I can paste that into chat for you guys. And if not, I will come out of the presentation and paste it, just give me one moment. So this is literally what you want to do before the test, before your test in October, November. You're also going to be re-reviewing all the stuff you've been studying this summer. So in a very small way, I want to encourage you to carve out about an hour and 20 minutes before Sunday's session and just give yourself a short tune up on those seven diseases. Scribble down on paper the three things you want to know. You're gonna do so much better on the mock exam if you do that, okay? Remember, we're not trying to stress anybody out. It's there to help you learn. Okay, and I think we're at our final slide. 

Excellent, thank you everybody for coming tonight. Really appreciate it. You guys have been hanging in there. A really strong performance this evening. I'm glad you were here for Dr. Reiss's heartworm talk. She's a star when it comes to communicating. We look forward to seeing you in a few days for our mock exam and then we're all going to go off and study hard for a couple of months before we come into that home stretch territory before the NAVLE®. I'll see you guys soon.