Showing posts with label feline medicine. Show all posts
Showing posts with label feline medicine. Show all posts

Tuesday, August 24, 2021

Veterinary bibliotherapy: All My Patients Are Under the Bed

 

"All My Patients Are Under the Bed" by Dr Louis J. Camuti, Marilyn Frankel and Haskel Frankel.

I’ve been delving into veterinary history for a couple of projects, and stumbled upon the veterinary biography of one Dr Louis J Camuti, written with support from his clients and friends Marilyn and Haskel Frankel. The book, AllMy Patients Are Under the Bed: Memoirs of a Cat Doctor provides a fascinating insight into veterinary practice in the 20th century.

Dr Camuti was born in 1893, and worked until his death – likely due to a fatal arrythmia when driving – in 1981. He was aged 87 and had been in practice for over 60 years.

The book is intended for a non-veterinary audience, focused mostly on anecdotes about quirky cat owners and their cats. But it contains some fascinating insights into veterinary practice in a different era.

Dr Camuti graduated from New York University in 1920. He lived through the great influenza pandemic in 1918, contracting the virus in 1919 when he was a second lieutenant in the New York Cavalry. When the flu struck his camp, over 100 men died. He made it home – with a fever – and married, but as a precaution didn’t kiss his new wife.

When the horses were struck by shipping fever, Dr Camuti was given the job of destroying all of the sick horses - one that caused significant distress.

"I told myself over and over again that the animal was sick and could not be saved. Wasn't I really sparing it pain? yes, but it was something I had to remind myself of everyday. I knew that bringing the peace of death to an animal was as much a part of being a veterinarian as helping a dog to give birth to its puppies, but still I suffered. I guess I was still a kid, and like all kids who think of becoming
doctors, the first thought is of life. It is only later on that you have to face death as part of the job" (p51).

We now know that killing animals can be a source of moral stress for veterinarians. And moral stress can indicate there are systemic animal welfare issues that need to be addressed. In Carmuti's case there was no alternative to killing the horses, he was a subordinate given the order. But he did endeavour to change the method of killing to ensure it was as humane as possible in the circumstances. Perhaps these traumatic early experiences drove him to focus on companion animals.

He later discussed a request for euthanasia of a seemingly healthy St Bernard. This didn't occur because Dr Camuti, who purchased a bottle of chloroform from the pharmacy on the way to the housecall, accidentally anaesthetised himself when he opened it in a poorly ventilated bathroom. Both the vet and the dog survived.

Early in his career, Dr Camuti established a few practices, but his penchant for feline patients became known and he performed house calls in New York City. In the latter two decades of his life he set up an exclusively house call practice. He would begin his evening rounds from about 4pm, sometimes until well after midnight, often getting to bed at 4am. His wife Alex would book appointments – before people had mobile phones or email. She also rode alongside him and waited in the car, ready to move it if the parking inspectors or police turnedup. He would attend up to 30 housecalls a week.

Many of Dr Camuti’s clients did not have cars or cat carriers. Getting to the vet was impossible. And Dr Camuti felt that his patients were more relaxed in their homes – though he did spend a lot of time trying to find his patients in their homes (that aspect of house calls remains unchanged).

He would ask clients to have his favourite hand-soap ready (Cashmere Bouquet), and boil syringes (they were glass then) on the stove tops of his clients. He practiced when there were no analgesics registered for use in companion animals, when Nembutal (pentobarbital) was used as a sedative, and when blood tests weren’t routinely performed. If a patient needed surgery, a spey for example, he would often perform this in the owner’s home, on the kitchen table or similar. Veterinary practice is very different now.

After he survived a cardiac arrest, Dr Camuti couldn’t climb the stairs to reach patients in apartments above the first floor. So he took to examining many cats in the hallways of huge apartment buildings in which they lived (I would have been terrified of a patient escaping). On the day he died, he was still seeing patients.

The book makes much of the “quirky” relationships people had with pets. It was written before anthrozoology was established as a field of scholarship, well before James Serpell’s book In the Company of Animals put the human-animal bond on the academic map.

When I read about practice, at a time when there was no pain relief for veterinary patients, when there was little awareness about animal welfare, when humane euthanasia could not be guaranteed, it reminds me how far our profession has come.

That is not a criticism of Dr Camuti. He was the first feline-only veterinarian in the USA. Despite limitations in practice, Dr Camuti was deeply concerned about animal welfare, expressing his views about declawing: 

"People who have cats declawed usually do so for one of two reasons: to prevent being scratched by an aggressive cat or to preserve their furniture. Such people are obviously thinking only of themselves, not of the pets they are supposed to love. For their own selfish reasons they put their cats through a surgical procedure which is severe, both physically and emotionally. Very often a cat is declawed without any attempt on the part of the owner to train the animal first to use a scratching post. The cat never had a chance. In fact, I've known of cases where a prospective owner demands a cat to be declawed before he'll adopt it. I certainly would never give a cat to such a person because the request itself is an indication that the household is not suitable to a cat". p91. 

And he goes on. This passage reminds me of important positionstatements on declawing in cats, published more recently by the American Association of Feline Practitioners and the International Society for Feline Medicine.

He was also against ear cropping and tail docking in dogs, and raised concerns about the neglect of long-haired cats, the impact of inbreeding, failure of many people to recognise (and control) their cat's reproductive potential, and the hoarding of animals. He treated a range of exotic pets, back at a time when people could acquire a primate on a whim without any sort of license, permit or clue as to how to meet the animal's welfare needs.

Veterinary biographies like these are such important historic records, often for the minor, seemingly routine details they capture about past veterinarian’s daily routines and habits. This biography is worth a read. Especially if you do appreciate cats. 

On another note, if you are tempted to write your own veterinary (or non-veterinary) biography, the Vet Cookbook is hosting a writing workshop on narrative non-fiction with award winning author Brendan James Murray. Check it out here 


Monday, March 27, 2017

Free symposium for cat lovers and a question about graphic medicine

Cats, cat on bookshelf, three legged cat
Do you want to know more about infectious diseases in cats? Hero was adopted from the Cat Protection Society almost five years ago. 

If you’re into cats, the Cat Protection Society (NSW) is hosting a symposium this weekend which is free for those who RSVP.

The symposium, on Saturday April 1 from 10am-12.30pm, will aim to address important questions like can we vaccinate against cancer? Is there hope for cats with FIV? Why did we see an outbreak of Feline panleukopaenia Virus in Sydney and what can we do about it?

The details are:
Feline Research Symposium
10am – 12.30pm, Saturday 1 April 2017
Centre for Veterinary Education
University of Sydney
Parramatta Road – entry via Western Avenue gates (opposite Ross St/Officeworks)

RSVP: 9519 7201 or email 
info@catprotection.org.au

If you’re into graphic medicine – comics about health, illness and medicine, this is a fantastic article discussing the use of comics to articulate the “hidden curriculum”. It shocks me that there remain people out there who treat interns and residents as lowly slaves yet turn around and exercise compassion to patients. It’s not something I’ve experienced as a veterinarian but I’ve heard the odd horror story and we have our own “hidden curriculum”.

The concept of an elective dedicated to studying graphic medicine and the human (or non-human as it were) side of veterinary science really appeals.

I’d love to know from any SAT readers, are you aware of any good “pathographies” of the veterinary or other kind?


Are you aware of veterinarians contributing to graphic medicine? Drop us a line!

Declaration: I am a supporter of the Cat Protection Society and do some veterinary work for them.

Monday, March 14, 2016

Diagnosing and treating infectious diseases in cats - an interview with Dr Steven Holloway

cat flu signs
Cats tend to hind signs of infectious disease.

Diagnosing and treating infectious diseases in feline patients can be tricky for a range of reasons. Dr Steven Holloway is a Melbourne-based veterinary specialist who knows a thing or two about infectious diseases. He has worked in Australia and the US, and became a diplomate of the American College of Veterinary Internal Medicine in Small Animal Medicine. He undertook a PhD in virology and has taught in veterinary faculties in Sydney and Melbourne. His research interests include clinical and genetic aspects of disease and the interaction between infectious diseases and the host immune response. I think it is fair to say we have mutual feelings about feline infectious peritonitis. He took some time out of his hectic day to chat to us about infectious diseases in feline patients.


Dr Steven Holloway with Alfie.
What is your day job? 

My day job is as a specialist veterinarian at Advanced Vetcare in Melbourne.  I am a registered specialist in Internal Medicine, I see a lot of cats.  Sadly many have cancer but we see a number with infectious diseases.  

What are the most common infectious diseases you see in feline patients?

The most common infectious diseases I see in cats would be chronic herpesvirus infections, cryptococcus, FIP (feline infectious peritonitis) and FIV (feline immunodeficiency virus).

What are the most severe infectious diseases you see in feline patients and why?

Feline herpesvirus is probably the most difficult one in terms of chronicity and overall morbidity.  It is under-rated in terms of impact on feline health with so many cats suffering from chronic nasal disease and eye diseases.  

Why do infectious diseases in cats often present a diagnostic challenge?

The biggest challenge is carrier status of so many of the important diseases.  This poses particular problems with diagnosis and defining if the agent is actually causing the disease you are trying to treat/diagnose.

How can veterinarians improve their approach to infectious diseases in feline patients?

The most important thing for veterinarians to know about infectious diseases relates to how to identify them as part of a differential diagnosis, In cats, think infectious disease as part of every differential.  Learn to interpret test results correctly in light of the carrier status that may exist and how to control infection once a patient with a suspected infectious disease enters your hospital.  Know the factors that make a particular infectious disease spread in the feline population, how it is transferred, carried, and eliminated from the environment.  
What improvements have you seen in the management of infectious diseases in cats in the last decade?

Diagnostics have improved greatly in the last two decades with PCR and improved cage side serology tests.  Treatment has not improved much for most of the diseases, particularly the viral ones.   I hope to live long enough to see FIP become a treatable disease [Ed: me too].   We made great progress in FeLV prevention due to improved tests and management awareness.   I think most veterinary graduates are much more aware of husbandry practices and the importance of infection control in hospitals and animal shelters/catteries.  

Where do we go from here?

I feel that we need to be aware of the growing problem with antibiotic resistance and take precautions to make sure we don't add to this in our hospitals.  I feel more research into antiviral therapies would help a lot in our practice.  In particular, new anti-coronavirus drugs might lead to a treatment for cats with FIP.  Every FIP case is a tragedy in small animal practice.  

Do you live with any cats yourself?

We have no cats at our house L  My youngest daughter is very allergic sadly.  We have Mabel the Russian Blue and Dusty our neighbour’s cat who visit each night.  Mabel in particular seem keen to get inside with my second daughter Sammy.  We call Sammy the cat whisperer cause cats seem to follow her home.  We also have our two AVC practice cats Basil and Alfie, so I get my cat fix.   Alfie in particular seems glued to my Mac keyboard!

Any advice for veterinarians and vet students about how to best treat their feline patients?

Get a nurse who is an expert cat handler! Our nurse Lauren is absolutely the best cat holder I ever met.  Cats seem to respond to vets/nurses who have good karma with them.  I always think over restraining cats is worse than no restraint at all.   Patience will pay off with feline patients.  

Thank you Dr Holloway for sharing your thoughts. Dr Holloway will be talking about immune mediated and infectious diseases, among other topics, at the Centre for Veterinary Education’s Valentine Charlton Feline Conference in July. Check out event details on Facebook here Or visit the webpage here


Friday, March 4, 2016

New guidelines for treating chronic kidney disease in cats

chronic renal disease cat
Michael has chronic kidney disease, and one of her key symptoms is polydipsia or drinking a lot.

Did you know there have been some new developments in treatment of feline chronic kidney disease? This week the International Society for Feline Medicine released its new Consensus Guidelines on the Diagnosis andManagement of Feline Chronic Kidney Disease (CKD). 

Unfortunately this is directly relevant to our household as Michael is suffering from CKD.

Living with a cat with CKD can be challenging. Symptoms include increased drinking (polydipsia) – most cats don’t make a big deal out of drinking. These days if I pour a glass of water, Mike comes chasing me and paws at me to let her drink from it. I caught her drinking tea the other day. Other signs are increased urination (yep), reduced appetite (aha), vomiting (check) and weight loss (this has been significant).

I’ve been very proactive in managing her but it’s nice to see these new guidelines which you can download for free. The great thing about these are that they stress the variation in individual patients which can sometimes be really puzzling. They also discuss new parameters like symmetric dimethylarginine (SDMA) and how these fit into a work-up, the aims of which are to confirm a diagnosis of CKD, identify specific causes that can be treated (e.g. pyelonephritis), identify complications and diagnose concurrent disease. The main aim of treatment is of course to improve the patient's quality of life.


For those of you to whom this does not apply (i.e. those who don’t live with or treat cats with CKD), you might enjoy this series ofphotos that have been digitally altered so that the dog looks gigantic. By someone with a bit of time on his hands!).

Reference
Sparkes AH, Caney S, Chalhoub S, Elliot J, Finch N, Gajanayake I, Langston C, Lefebvre H, White J and Quimby J (2016) ISFM Consensus Guidelines on the Diagnosis and Management of Feline Chronic Kidney Disease. Journal of Feline Medicine and Surgery Clinical Practice 18:219-239.

Monday, February 29, 2016

25 Signs of Pain in Cats

Hero kept open-mouth breathing when he had urolithiasis (even though he also had bouts of chasing a toilet-paper roll around the bath).

Cats are experts at masking pain. We discussed this recently when we spoke to Dr Susan Little about signs of pain in cats, and now there is more research to add to the discussion.

Isabella Merola and Daniel Mills, from the University ofLincoln, set out to determine whether feline experts could achieve a consensus on the signs of pain in cats. They found over 80 per cent agreement that 25 signs were considered sufficient to indicate pain (i.e. sufficient to indicate pain when they occur, but not necessarily present in all cats with painful conditions).

They begin by acknowledging that there is now general agreement that pain – in humans and non-humans – is a multidimensional experience. It’s not just a matter of a physical sensation – the sensory aspect of pain relates to its intensity, location and duration. Pain also involves thoughts and feelings (what scientists call the affective-motivational domain) – this encompasses the emotional and unpleasant aspects. Put it this way, without emotions we wouldn’t have negative associations with pain. It would be just another physical experience.

Feline better on pain medication, post-operatively.
The authors reviewed the literature on feline pain and identified 67 signs that a 
cat might be in pain.

The study involved several rounds, the first to ascertain what conditions experts associated with pain in cats, also to find out if there were any other signs of pain in cats. There were: the list grew from 67 to 91.

Conditions the experts considered painful included orthopaedic conditions (conditions like arthritis, fractures); cancer (especially bone cancer); urinary tract disease (cystitis, urinary tract obstruction), pancreatitis, ophthalmic conditions (like uveitis), dental disease (tooth fractures, stomatitis, gingivitis), trauma, surgical pain, peritonitis, diabetes, bowel disease, foreign body ingestion, vertebral disc disease, thromboembolism, neuropathic pain, skin damage, dermatological conditions (burns, wounds, ear infections), visceral inflammation, oro-facial pain and cat fights. One might rate some of these conditions as more painful than others.

The experts whittled this down, agreeing on 25 signs and behaviours sufficient to indicate pain.
These were:
  • Lameness
  • Difficulty to jump
  • Abnormal gait
  • Reluctance to move
  • Reaction to palpation
  • Withdraw/hiding
  • Absence of grooming
  • Playing less
  • Appetite decrease
  • Overall activity decrease
  • Less rubbing toward people
  • General mood
  • Temperament
  • Hunched up posture
  • Shifting of weight
  • Licking a particular body region
  • Lower head posture
  • Blepharospasm
  • Change in form of feeding behaviour
  • Avoiding bright areas
  • Growling
  • Groaning
  • Eyes closed
  • Straining to urinate
  • Tail flitching

In addition, a number of other behaviours were considered unreliable for inferring pain but were present in cats with high or low level pain. These included signs like sitting more often (a very difficult parameter to evaluate in a species that sits even more than we do); panting (also associated with fear/stress); seeking contact with a person (some cats are people-cats, others most definitely are not); hissing (again, depends on the temperament); house soiling (can be due to feline politics); ear position; eye position; tension in the body and so on.

Of course there are some limitations. For example, signs must be interpreted in context – some of the listed behaviours might be related to the animal’s mood or temperament, or may occur due to a non-painful condition (for example, an abnormal gait can occur due to a non-painful neurological condition; a scared cat may freeze or withdraw or react explosively to palpation). The experts disagreed on things like the intensity of pain associated with certain behaviours, and no signs could be reliably linked to chronic conditions. Because it is so insidious and may not be associated with an initial, acute phase, chronic pain is more difficult to detect in cats. Sometimes we really don’t know until we trial pain relief.

As with people, cats are individuals and their expression of pain may vary significantly with personality, temperament and mood. The authors conclude that much work needs to be done to validate an observational instrument for assessing pain in cats, but the list itself is an excellent tool for vets and owners in considering whether a particular cat’s behaviour and signs are consistent with being in pain.

Reference

Merola I, Mills DS (2016) Behavioural Signs of Pain in Cats: An Expert Consensus. PLoS ONE11(2):e0150040.doi:10.1371/journal.pone.0150040


http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150040#abstract0

Monday, February 1, 2016

How can you tell if a cat is in pain? and other important feline questions answered by Dr Susan Little

Dr Susan Little with Zanzibar.

When it comes to all things feline, Dr Susan Little is one of the big players on the international field. She is the owner of Bytown and Merivale Cat Hospitals inOttawa, Canada. She serves on the board of the American Association of Feline Practitioners and the National Board of VeterinaryMedical Examiners.

She is also am the editor and co-author for two textbooks: The Cat – Clinical Medicine and Management (2012) and August’sConsultations in Feline Internal Medicine volume 7 (2016)  . She is visiting Australia later this year to talk at the Centre forVeterinary Education’s Feline Medicine conference. Two topics she will be discussing in detail include feline pain and feeding the anorexic feline patient. Despite her hectic travel schedule, she took some time out to share her thoughts with SAT.

What motivated you to become a feline specialist?

I’ve always been primarily interested in cats, and entered feline-only practice not long after graduation. It was a logical step to pursue board certification in feline medicine to help develop my skills and my career.

Why is feline pain challenging to recognise?

Cats are skilled at hiding their signs of illness and pain as part of their survival mechanism. Their signs of pain are therefore different and often subtler than those seen in dogs and people. In addition, pet owners have a different relationship with their cat than with their dog; it’s often less interactive especially in terms of exercise and feeding, so that lethargy and decreased appetite are not noticed as quickly in a sick cat as they are in a sick dog.

Cats and kittens can be very hard to read.
How do you identify/quantify feline pain in your practice?

Unfortunately, there are few validated pain scoring systems available for cats. For musculoskeletal pain, I recommend the Feline Musculoskeletal Pain Index from Dr. Duncan Lascelles at North Caroline State. For acute pain scoring, I recommend the Glasgow Composite Measure Pain Scale for cats.

How can we do better in terms of recognising pain?

I think it’s important for veterinary practices to adopt a pain scoring system and to train all staff that are involved in patient care to recognize pain in cats and use the scoring systems.

Do you believe vets treat feline pain adequately?

Studies in different countries have consistently shown that cats receive less analgesic treatment than dogs and veterinarians view analgesia for cats differently. We have a long way to go to improve the delivery of analgesia for cats!

Currently in Australia we have an increased range of analgesia options for cats, the most commonly used being non-steroidal anti-inflammatory drugs and opioids. What range of analgesics do you use?

While we have a limited range of licensed products available for cats in most countries, pain management should always be multi-modal. Drugs from different classes can be combined (such as NSAIDs and opioids) and other options, such as local or regional analgesia can be used in many cases. There is no ‘one size fits all’ when it comes to pain management – it should be individualized to the patient and the procedure or disease.

How has your management of feline pain evolved?

The introduction of pain scoring systems as well as improved knowledge about analgesic drug (and non-drug) options for cats has changed the face of feline medicine for the better.

Why is anorexia such a common problem in feline patients?

Many cats are fed free choice so that owners actually do not know how much their pet eats each day. Therefore, it can take some time before decreased appetite is noticed by the owner. In most veterinary hospitals, the actual food/caloric intake of hospitalized patients is not measured.

What underlying conditions are most frequently associated with anorexia?

Stress and pain are common causes of decreased appetite in cats that is often overlooked. Disease in almost any body system can affect appetite, including dental or oral disease, gastrointestinal disease, urinary system, etc.

Is there a place for using appetite stimulants in cats and when do you usually use these?

Appetite stimulants tend to work best for cats that are hyporexic (versus anorexic) and that have not been off their food for very long. Food intake should always be measured in patients treated with appetite stimulants so that the next level of intervention can be employed (such as a feeding tube) if they are not successful.

Is there a problem with the types of foods being offered to cats in veterinary hospitals?

Cats that are sick or stressed will benefit from being fed familiar foods so it is often useful to ask the owner to bring food from home.

What can vets and vet nurses do to stimulate cats to eat or increase the chances that they will eat?

A calm and quiet environment can be very helpful as well as hand-feeding or coaxing. Pain prevents many cats from eating, so it should be addressed. It’s also important to recognize and treat nausea before trying to feed a cat to avoid food aversion. Providing an optimal cage environment including a place to hide may encourage shy cats to eat.

Thank you, Dr Little, for sharing your feline wisdom. If you want to catch Dr Little while she is Down Under, she will be speaking at the Valentine Charlton Feline Conference in Melbourne from June 20 to 23. Register here.



Monday, November 23, 2015

How do you get your cat to eat a prescription diet for kidney disease?

When cats have kidney disease, they prefer larger vessels (like baths) to drink from. This is what greets me every time I walk into the bathroom/

Just in case vets ever get too lofty a view of ourselves, the companion animals we live with are here to ground us. I thought I was pretty good at advising clients how to care for cats with chronic renal insufficiency and renal failure, but my cat Michael reckons I need a bit of a challenge.

She has developed azotaemia. I knew it was coming. The polydipsia (excessive drinking) is a bit hard to ignore: we’ve reached a stage where I get in the bath and she jumps in with me so she can drink. Not exactly typical feline behaviour. I estimate she is putting away 500-750ml per day. That and the fact that she has had a number of blood and urine tests in the past few months, in addition to repeat abdominal ultrasounds.

One of the other obvious changes in her behaviour is a marked reduction in appetite. In her salad days (though she ate anything but), Mike was a rather large cat, a subscriber to the “seefood” (see food and eat it) diet. Now, no matter what I offer her, she wants to lick the gravy off everything and walk away, causing me no end of despair and frustration- especially when dietary management is the key to managing chronic renal disease in cats.

The big challenge is trying to introduce a prescription diet, which is designed to reduce the secondary metabolic effects of renal insufficiency. To modify a phrase, you can lead a cat to a bowl of a prescription diet, but (sometimes) you can’t make her eat.

So what are the options? Apart from keeping cats properly hydrated, which may require intravenous fluids or subcutaneous fluids (yes, EVEN when they are drinking that much), there are a few things the experts recommend.
  • Make sure there is nothing else going on. Living with a vet, Mike has been checked out for concurrent gastrointestinal disease, pancreatitis, thyroid disease, diabetes and just about anything else under the sun that might cause her to be off food.
  • Make sure you treat for nausea. Azotaemia makes cats feel nauseous and they may not eat. Anti-emetics can be helpful. Feeding cats something when they are nauseous risks creating a food aversion. Plus it also risks your cat vomiting and Mike always seems to be pointing at a rug when she vomits. (My theory is that cats do this to avoid splashback).
  • Try multiple brands of prescription diet. If one doesn’t work, offer another as they clearly taste different. Now some brands offer more than one flavour (e.g. chicken, seafood) and different forms (wet vs dry, casserole style vs pate style).
  • Use food fresh from the packet, i.e. at room temperature, or warm slightly for a few seconds in the microwave (let it stand to avoid burns). Like some other cats, Mike will never eat anything that comes from a fridge.
  • Add some flavour. One paper suggests low sodium chicken broth, tuna juice (not an option for Mike who loves seefood, but hates sea food), oregano, brewer’s yeast or a small amount of regular food.
  • Use appetite stimulants like cyproheptadine or mirtazapine, but when nausea is treated. According to feline specialist Andrea Harvey, they can also develop a food aversion if given appetite stimulants when nausea has not been addressed.
  • Pretend you aren’t actually feeding your cat. I did have some (limited) success placing the prescription diet on the coffee table when visitors were over, and pretending it was some sort of fancy dish. We then chatted amongst ourselves and, predictably, Mike snuck up on the table for a taste of the forbidden food. You just need to ensure your visitors know that the dish being served is not for human consumption!

Reference


Roudebush P, Polzin DJ, Ross SJ, Towell TL, Adams LG, Forrester SD (2009) Therapies for feline chronic kidney disease: what is the evidence? Journal of Feline Medicine and Surgery 11(3): DOI 10.1016/j.jfms.2009.01.004

Friday, September 18, 2015

Should we be treating crystalluria in cats?

Cats with signs of lower urinary tract disease should also be encouraged to drink fresh water. Even if, like Hero, they insist on being served filtered water from a glass vessel on the kitchen bench only.

What should you do if a cat has crystals in its urine? (Crystalluria, as it is known in the business). While crystalluria sounds like the sort of affliction that unicorns might suffer from, it’s a real phenomenon in many animal species and a common finding on urinalysis in cats. Often the recommendation is not to do much at all. But a new paper challenges that thinking.

In cats, crystalluria can be an incidental finding, but it is also often associated with signs of lower urinary tract disease.

Male cats in particular are vulnerable to life-threatening obstruction of the urinary tract. I know, I live with a victim of this terrible condition and last year’s Christmas/New Year break was a blurof surgery and hospitalisation.

Crystals are often implicated in lower urinary tract obstruction, e.g. by forming a matrix or little plug which blocks the urethra. But what do you do about crystals when you find them in a cat without obstruction? It would be nice if they weren’t there at all. Urethral mucosa is sensitive tissue, and the penile urethra of male cats is a treacherously narrow passage which can become occluded or obstructed readily.

Crystalluria is much more common in cats consuming exclusively dry food diets – also a risk factor for obstructive urinary tract disease. And one might imagine the capacity for a large load of crystals to irritate the bladder wall.

One of the treatments of cats with lower urinary tract disease is to use a therapeutic diet designed to alter urine pH and dissolve crystals. But one doesn’t want to use these willy-nilly and they tend to use more for cats that have had an obstruction or even uroliths.

A recent case report in the Australian Veterinary Journal describes one cat with marked crystalluria and lower urinary tract signs who responded to treatment with a therapeutic diet. The authors performed repeat bladder ultrasounds. Initially the bladder looked like a veritable treasure trove of crystals, while these disappeared following treatment. This happened on several occasions and each time the crystals disappeared once the therapeutic diet was instated.

Two lessons for me here. One is, in addition to performing a radiograph to ensure there are no nasty stones bouncing around in the bladder, we really need to ultrasound the bladders of cats with lower urinary tract signs to look for this sludge (you can find crystals in a urine sample but the amount does not necessarily correlate to the number in the bladder as it is affected by urine sample handling/processing).

The second is that we probably need to be much more proactive at treating crystalluria per se (which we can do if we look for it first).

Reference


Bell ET, Lulich JP (2015) Marked struvite crystalluria and its association with lower urinary tract signs in a cat with feline idiopathic cystitis. Australian Veterinary Journal 93:332-335. Doi 10.1111/avj.12353

Monday, June 22, 2015

Managing diabetes in cats: new ISFM consensus guidelines

Being plus-sized predisposes cats to diabetes mellitus.
The International Society for Feline Medicine (ISFM) has just released guidelines on management of diabetes mellitus in cats, published in the Journal of Feline Medicine andSurgery.

The full text document is available for free and if you are an owner of a diabetic cat, or a veterinarian or student, these are worth downloading and reading in full.

Like all consensus statements this was put together by a panel of specialists who review the available literature and make recommendations based on current knowledge. Therefore the recommendations may change as further evidence becomes available. But these are definitely very helpful guidelines for those who need to make decisions around the management of diabetic cats.
Feline diabetes is on the rise, possibly due to an increase in the incidence of obesity, which is likely a result of ad lib access to premium diets and reduced outdoor access without associated reduction in calories.

The average age of survival of a diabetic cat is 13-29 months after diagnosis, however they tend to live longer if their diabetes is well controlled. I have certainly treated some cats that have lived for five years and over with diabetes.

Most cats with diabetes have a type of diabetes similar to type 2 diabetes mellitus (DM) in humans = due to pancreatic beta cell dysfunction and insulin resistance (fat increases insulin resistance, hence obesity is a factor). Aside from obesity, other risk factors include: being over 7 years old, being Burmese, being indoors and inactive, being male and desexed, and being on drugs that impact insulin metabolism, e.g. corticosteroids.

Living solely indoors, being a dude, being desexed and being Burmese are all potential risk factors for developing diabetes mellitus - but of course these risk factors can be managed by providing an appropriate diet, opportunities for activity and play.
The classic clinical signs of diabetes are polyuria (urinating a lot), polydipsia (drinking a lot), polyphagia (eating a lot), fatigue, and weight loss. Some cats also appear weak, wobbly or flat, and those with diabetic ketoacidosis or pancreatitis – or other concurrent disease like renal disease or hyperthyroidism - may be inappetent and vomiting.

Diagnosis is based on persistent high blood and high urine glucose (hyperglycaemia and glucosuria respectively). But the panel recommend performing a complete physical examination, complete blood count, serum biochemistry panel, serum fructosamine (this gives an indication of the average blood glucose over the previous week), serum thyroxine concentration and feline pancreatic lipase tests due to the high prevalence of concurrent disease like hyperthyroidism and pancreatitis (your pancreas is where those insulin producing beta cells live so it’s important in the aetiology of DM).

According to the panel, there are two key aims of treating cats with insulin:
  • To control blood glucose by keeping it under 14mmol/L (252mg/dl for our Northern hemisphere counterparts) for as much of a 24 hour period as possible;
  • To avoid clinically significant hypoglycaemia as this can be life-threatening.

Currently there is very little evidence supporting the use of oral hypoglycaemic agents to treat DM in cats. Use of a long-acting (e.g. glargine or detemir) injectable insulin is preferred. Two daily injections twelve hours apart may be very hard for owners to comply with. While this is ideal, the panel recommend allowing some flexibility with doses given 12 hrs +/- 2 hours apart, and missing doses outside of this window if occasional.

The guidelines go into detail on initial and long-term management of cats with DM, but one of the things strongly recommended is home monitoring of cats. While previously there have been mixed reports about home blood glucose monitoring, the panel supports this, along with assessment of daily wellbeing, daily water intake, daily urine production, weekly body weight and body condition score, urine glucose (using urine dipsticks) and where possible blood glucose.

They also recommend very regular in clinic monitoring. After initial diagnosis, 
cats should be re-evaluated in weeks 1,2-3, 6-8, 10-12 and 14-16 and then every 1-4 months (a good reason to invest in pet insurance).

There are now excellent resources for cat owners that can aid in monitoring diabetics via the iCatCare YouTube channel, so you can check out these very helpful links below.





Reference

Sparkes AH, Cannon M, Church D, Fleeman L, Harvey A, Hoenig M, Peterson ME, Reusch CE, Taylor S & Rosenberg D (2015) ISFM consensus guidelines on the practical management of diabetes mellitus in cats. Journal of Feline Medicine and Surgery 17(3):235-50. Doi: 10.1177/1098612X15571880

Wednesday, May 13, 2015

Australia's biggest dog walk and free webinars for veterinary nurses

Phil puts in some serious training for the RSPCA Million Paws Walk on Sunday May 17.
What are you up to this weekend? The RSPCA’s annual Million Paws Walk is upon us. Philpers and I are volunteering at our local event on Sunday May 17. If you’ve got a dog, odds are you’d be spending some time with them anyway – so why not spend it and help a good cause at the same time? You can meet hundreds, if not thousands of other dogs and dog owners in your community and do something positive for animals.

Anyone can register, and all fees raised go to the RSPCA.

To register for the MPW in your state, visit the site and click on relevant piece of Australia. There are events happening in most major centres and capital cities.

Free membership of ISFM for veterinary nurses!

Everyone who works with cats knows that these creatures have special needs, and feline nursing brings its own unique challenges.

The International Society of Feline Medicine(ISFM) is offering free membership for vet nurses. There are already 4000 members. ISFM provides monthly webinars and a journal. They’re a fantastic international community, well-resourced and unwaveringly committed to feline welfare.

Nurses and technicians can go to their website to sign up. Next month's webinar in on acute pain management by anaesthetist Dr Jo Murrell.  

Tuesday, January 20, 2015

Complication

Hero experienced complications following his surgery. You wouldn't know it now.
Feline urinary tract disease can be challenging and frustrating to treat. Recurrence of obstruction is common, although the reasons can vary. When I treated my cat Hero for urethraland bladder stones over Christmas he seemed to be recovering well. But he experienced a complication.

I want to discuss it here because a) complications are a normal part of medicine and surgery and I think we need to discuss them more; b) turns out this one is a lot more common than I thought and c) I’ll feel more like Hero didn’t suffer the experience in vain if others can learn from it. And suffer he did. Suffer everyone around him did. Many sleepless nights were had over the festive season and none of them were the celebratory sleepless kind!

It was day four post-op. Hero had been eating, drinking and becoming more active. He seemed bright and happy. His surgical wound looked beautiful. Then I watched him go to the litter tray. Not once to pass a nice stream, but twice. And he passed a few drops. And cried. My heart sank.

I palpated his bladder. It was large, despite the fact that he’d just “voided”. He reacted when I touched his tummy. There had to be a stone obstructing that little urethra of his. It sent my mind my mind into a vortex of retrospectoscopy…
At the time of surgery we counted the stones on radiographs and those we retrieved, and thought there may be a discrepancy. His first wee post-op had contained more blood than I’d hoped. The patches of urine in the litter tray were getting subtlely smaller.  I’m not going to lie. I did not like what this was telling me and did the whole “oh Anne, you’re just being a paranoid hyperchondriac by proxy”. It’s easy to do. But a little voice inside me said “or is this a complication?”.

Potential complications of cystotomy including uroabdomen (urine leaks into the abdominal cavity), urinary tract infection, surgical site infection, recurrence of stones (usually secondary to infection), lower urinary tract obstruction (mechanical or functional) and incomplete removal of uroliths (Appel et al 2012). I was concerned about the latter.

When it comes to uroliths that hang around post-cystotomy, MOST of these can be prevented by passing a urinary catheter and flushing stones back into the bladder intra-operatively, or - as US veterinary surgeon Howie Seim does in his fantastic video on urinary tract surgery – performing the “urogenital floss”.

In addition, post-operative radiographs of the entire urethra following surgery can identify stones that are left. A review of literature on veterinary cystotomies found that radiographically detectable uroliths remained in 14 to 20 per cent of dogs (Grant et al 2010).

BUT not all uroliths are radiographically detectable. Even if they show up on the rads, if they’re hiding behind the pelvis or beside a catheter in the lateral view, or below the spine on the ventrodorsal view, you won’t see them. How can they escape a catheter? Well, if they’re narrow enough a catheter can slip past them. You can urogenital floss all you like but there’s a chance they won’t be dislodged.

In a Canadian study of 106 veterinarians who performed cystotomies, 42 per cent reported that patients had recurrent uroliths, although it’s hard to know how many of these were true recurrences as opposed to those not removed at surgery. When I did the ring-around, lots of colleagues had experienced the pain (indirectly, of course – it’s the patient who feels it first-hand) of a retained stone.

But the data illustrates that even in the best hands (ie world-class veterinary teaching and referral hospitals) some uroliths inevitably escape the surgeon. Post-op rads confirmed my worst nightmare. A urolith the size of Tasmania (almost) in his distal urethra. I won’t lie: I felt sick. But I couldn’t leave that stone in there.

Evil, evil urolith.
Flushed retrograde into the bladder to allow it to be retrieved via cystotomy (bladder surgery) rather than by traumatising the urethra further. Why do that? Trauma to the uretha may cause scarring which can cause major problems in cats and may require removal of the end of the urethra (and the penis with it) - a procedure called a perineal urethrostomy. Worth doing if you have to but worth avoiding if you can.
So I flushed it back into his bladder and performed the second cystotomy in four days on little Hero. Are there alternatives? In humans, cystotomy is rare these days. In the US, open-surgical removal of uroliths was described in only 0.3-4 per cent of human patients (Defarges et al 2013). But non-invasive alternatives aren’t well established in companion animals. Voiding urohydropulsion is contraindicated in male cats because of the high risk of obstruction (sorry to say it Hero, but male cats have a tiny penis with a narrow urethra that is easily blocked), lithotripsy is still experimental, and laparoscopy remains uncommon in first-opinion practice.

My concern was that he was in pain. His urine was full of blood and that stone was tearing his urethral mucosa. The surgery was straightforward. Cystotomies are beautiful surgeries and I’ve said before that the bladder and urethra have extraordinary healing capacity. When I opened him up there was Hero’s bladder looking quite healthy despite being opened four days earlier.

I incised once again, locating and removing the stone within minutes. Its removal was confirmed (as much as it could be) on radiographs. Again I used multimodal analgesia (multiple drugs) to minimise his pain and of course checked on him through the night.

The following morning I helped him into his litter tray (he had kept the drip on overnight this time) and his post-operative wee was like Niagra Falls compared to the first post-op wee.

MUCH BETTER.
A few lessons learned here…

  1. The first, which I didn’t realise, is that the incidence of uroliths leftover after surgery (even in the hands of a specialist) is higher than I thought.
  2. The urogenital floss is good – but doesn’t prevent sneaky uroliths from hiding out in the pelvic urethra. And a catheter can pass adjacent to a particularly recalcitrant urolith embedded in the urethral wall.
  3. Post-cystotomy radiographs are essential but don’t absolutely rule out uroliths. In retrospect I should have taken a post-op rad of Hero WITHOUT the urinary catheter in just to be sure there was nothing in the urethra hiding beside the catheter.
  4. Know your cat’s wee. I was celebrating about a post-op wee that wasn’t as voluminous as it should have been.
  5. Phone a friend. I called a specialist friend for a debrief after cystotomy number two. He was the one who suggested I look at the literature about incompletely removed uroliths, and I have to say that was both educational and therapeutic.

Of course, all of this fiddling with Hero’s urethra – all done as gently as possible – wasn’t unnoticed by his urethral mucosa. Predictably, he developed a functional urethral obstruction (essentially his urethra just threw a hissy and clamped shut). 

So he was readmitted, I placed an indwelling urinary catheter, and kept Hero in hospital. Then plan was 48 hours of catherisation. Despite the world’s biggest Elizabethan collar, Feliway, a private cat grass/mint/nip garden in his cage and drugs galore, he protested. He removed collars. He removed catheters (urinary and intravenous), he threw a rockstar rampage in his cage and misbehaved for colleagues. But he put in 36 hours before I caved and took him home.

The urolith analysis returned a result of 100 per cent calcium oxalate. These types of stones tend to be sharp and prickly, whereas struvite (the other very common stone in cats) produces very smooth stones. So I had an inkling.

The bummer about calcium oxalate uroliths is that they can return after months or years even with IDEAL management. So whilst modifying Hero’s diet will hopefully slow the rate of recurrence, we’ll need to be vigilant. Fortunately I’ve taught him to tolerate a daily bladder palpation session by convincing him it’s a weird new patting style.

Interestingly, a very close family member of the human variety has experienced the woe that is a kidney stone. The medical team didn’t bother with x-rays and instead performed a CT scan to detect the 3mm-diameter offender (but amazingly, didn't show him a picture of it). In twenty years we might all be doing pre-and post- or even intra-op CTs or cystoscopies (with tiny, tiny, tiny cat-penis sized scopes) and we will be laughing about “ye olde days” when people had to worry about sneaky uroliths evading detection.

References

Appel S, Otto SJ & Weese JS (2012) Cystotomy practices and complications among general small animal practitioners in Ontario, Canada. Canadian Veterinary Journal 53 (March):303-310.

Defarges A, Dunn M & Berent A (2013) New alternatives for minimally invasive management of uroliths: lower urinary tract uroliths. Compendium: Continuing Education for Veterinarians January 2013:E1-E7.


Grant DC, Harper TAM & Were SR (2010) Frequency of incomplete uroliths removal, complications, and diagnostic imaging following cystotomy for removal of uroliths from the lower urinary tract in dogs: 128 cases (1994-2006).