Pet peeve: quotation marks around names

"Ripley" "jumps" out of a "box". 

This week I received a referral letter from a specialist about a procedure performed on one of my patients. The work-up on this patient was nothing short of the gold standard, and the care was excellent. But the letter repeatedly referred to the patient (let's call her Fluffy) as "Fluffy". Not Fluffy. Not Fluff-miester. "Fluffy". In quotation marks. In every instance.

They didn't address me as "Dr Anne" or "Anne", not was it signed by the "specialist". So why this unnecessary quotation marks around the animal's name?

During my undergraduate years I worked in at a major supermarket chain. Someone who worked in the signage department was quotation mark obsessed. Thus we never had a sale on bread, it was always a "sale" on "bread". Makes you wonder - why the need for quotation marks? Is it really a sale? And is that really bread they are selling? I saw customers laugh as they read signs drawing their attention to the  "Fresh" mince or "Meat" pies.

Used appropriately, quotation marks indicate dialogue or speech, or indeed to distinguish a quotation from the rest of the text. Over time, quotation marks have been used to denote "irony, emphasis and exception", according to this article from The Guardian.

Let's say I send you an email including the comment, that you are my best friend, you might feel chuffed (or not as the case may be). That changes if I write that you are my "best" friend. Or "best" "friend". The internet is full of examples of misused quotation marks (e.g. here or here).

To refer to a patient's name, such as "Phil", adds a bizarre emphasis, a pause, that makes you wonder - is the letter-writer really thinking that the patient is worthy of a name, or do they think they are simply humouring the owners by treating it as a real pet? I'm not suggesting in this case that the author of the referral letter was of the view that pet names are silly or frivolous. I got the very strong impression that the quotation marks were automated by whatever software she was using. 

Maybe it seems like a minor, niggly point to some - but I actually think its worth a mention. Would someone who read this letter take note and question the specialist's beliefs about the status of animals? Maybe they would. 

So here is our statement: SAT takes the position that proper names (of non-humans and humans alike) do not require quotation marks - unless we want to suggest they are an alias or pseudonym, and even then that is questionable.

What are your thoughts? Is this petty or does it have profound implications? Has someone ever referred to your "loved one" thus? And how did you interpret it?

Collecting a urine sample from your cat

Michael (who was wearing a moustache long before hipsters made it cool) is getting older.

Its hard to believe, but my beautiful cat Michael turns 14 this year. She's well any truly a senior though the way she jumps around at times you would hardly believe it. 

Michael has been with me since a good samaritan found her attempting to cross Parramatta Road as a kitten. She was around when I qualified as a vet, sat on my keyboard for pretty much my entire masters degree, and even thwarted a burglary by alerting me to the presence of an intruder. If I sleep in she gently pokes me in the eye until I wake up. 

But lately she seems a bit stiffer and tentative at times, most likely due to oesteoarthritis. 

I want her to be as comfortable as possible so wanted to commence treatment with some non-steroidal anti-inflammatory drugs. Ideally, one runs a complete blood count, biochemistry panel and urinalysis to detect any underlying disease before commencing treatment. She let me take a blood sample and the results returned pretty normal, much to my relief.

There are two good ways to collect a urine sample in cats. Neither of them involves asking your cat to urinate in a specimen jar, although I have known a few clients over the years who have hidden beside the litter tray, waited til the cat was mid-stream through a morning pee and dived underneath them with a jar. This doesn't always do great things for human-cat relations and may end in the cat bolting, mid-stream, through the house. 

A much more reliable method of urine collection is known as cystocentesis. This is not one to try at home, but if your cat presents to the vet clinic with a reasonably full bladder the easiest way to obtain a nice sample is to pass a needle through the abdominal wall and into the bladder. This technique IS also used in people though less commonly. Its the best way to obtain a sterile sample as you bypass all of the colourful flora dwelling in the distal urethra. And most cats don't get too worked up about this - they don't have the psychological fear of needles that is so prevalent among humans.

The other method is to collect urine using inert litter beads. Normal litter soaks up the urine before you can collect it, but products like Catrine Litter Beads are designed to feel and sound like litter (so your cat will pee on them) without soaking up the urine. So you can collect a sample. Here are the beads (or pearls, as they like to call them) that I used:

Litter beads for urine collection. 

Knowing your cat's routine helps. For example, I know the order in which Michael performs her morning ablutions. Thus I only make the beads available when I know she is going to urinate, as opposed to doing something else. I also know how to distract the other cat in the house, so that Michael has the bathroom to herself and I know the sample is from her (collecting a urine sample from Hero, much as he is willing to oblige, isn't going to tell me much about Mike's renal function).

[If you have a multi-cat household or know you won't be home when the magic happens, or you just really don't want to touch cat urine, an alternative is to board your cat at a vet clinic and get them to collect the sample when it appears].

The process was easy. I waited for the right time, filled the tray with the beads and showed Michael. She was so excited about the sound they made as she stood on them that she provided a sample immediately. Sorry Mike, but for the benefit of readers this is how it went down.

Michael provides a urine sample.

You can see that unlike normal litter, these beads don't soak up the urine.

The sample. On the left of the tray is a pipette provided in the pack to collect the sample after, and on the right is the sample. If you look at this side on, or flip it anti-clockwise, you can see that Michael's sample has created an "M" pattern in the litter. She IS a very talented cat, but peeing your initials Michael? Well, that's just being an overachiever. Really.

Using the pipette one collects the sample into a test tube.

The instrctions on the label say it all really.

And here is our magnificent sample:

Liquid gold. A generous urine sample from a cat, collected painlessly and rapidly.

The whole process took around five minutes. The good news is that her urine looks great - concentrating off the scale, and no sign of glucose, ketones, blood and so on. 

We've started a course of non-steroidals (Meloxicam for cats) and will report back on her mobility and comfort. Meanwhile please give Michael a round of appaws for sharing her tips. Hopefully this will help others collect a urine sample from their cat when the need arises.

Michael demonstates that you're never too old to appreciate a good cardboard box.

Things I learned about ectopic ureters in dogs and cats

Louis doesn't have ectopic ureters. But he is a handsome devil.

Here at SAT we have something of a soft spot for the urinary tract. It is deceptively simple in design. Urine travels from the upper urinary tract (the kidneys and ureters) into the lower urinary tract (the bladder and urethra). This one-way flow [everytime I type that word I think about Shaggy singing "Hey sexy lady, I like your flow" and can't help wondering if he too is enamoured with the design of the urinary tract?] helps get rid of waste and ensure bacteria is flushed out (imagine E.coli and other pathogens arming itself with crampons and climbing up the distal urethra like a determined mountaineer, only to be washed out by a waterfall of healthy urine).

But it doesn’t always happen that way.

Last week we attended a fascinating talk by University of Sydney surgeon Mark Newman about ectopic ureters. This is a congenital abnormality of the distal ureter – normally they enter the bladder in a “J” curve” (except in a dog or cat, just turn the J on its side), and enter at an angle such that as the bladder fills it closes the ureters and prevents reflux (backflow).

(Interesting fact – the internal diameter of the dog ureters is around 2-2.5mm in diameter, and in cats it’s just 0.4mm).

Instead of J-curving, extramural ectopic ureters course right on past the bladder and empty into the urethra. This is the most common type of ectopic ureter found in cats (you can see some diagrams here).

In dogs, the most common form is intramural ectopic ureters – they enter the bladder wall but can course along through the wall with the opening more distal (or closer to the trigone of the bladder) than usual. In fact sometimes they can open into the urethra or seminal vesicles in males, while in females they can open into the urethra, vagina or vestibule.

Females are more commonly affected than males, and some breeds are more likely to be affected than others (Skye terriers, Labradors, huskies, bulldogs, Newfoundlands, West Highland White Terriers, fox terriers and poodles.

Animals with intramural ectopic ureters often have abnormalities of the trigone of the bladder or the internal urethral sphincter as well.

So what does this mean clinically? Affected animals often present with incontinence – it can be continual urine leakage, or it can be intermittent. But some can void (pee) normally. These animals are prone to urinary tract infections and development of uroliths (bladder stones). That’s more than a mere inconvenience – patients can develop multi-drug resistant bacterial infections and succumb to these before there’s a chance to repair the underlying defect.

Queue for the loo: whilst neither Phil or Bosca have ectopic ureters, affected dogs can still appear to void normally.

The other problem is that often these animals have concurrent abnormalities such as urethral sphincter mechanism incompetence, a hypoplastic bladder, renal aplasia or hypoplasia and so forth. Thus just fixing the ectopic ureters doesn’t eliminate the incontinence or predisposition to infection.

It doesn’t end there. Affected animals can acquire secondary conditions – hydroureter, hydronephrosis or pyelonephritis (makes sense right – if urine can reflux or travel retrograde from the lower to the upper urinary tract, problems will occur upstream). This can lead to irreversible damage to the ureters or kidneys.

Ectopic ureters can be tricky to diagnose but these days contrast CT and cystourethroscopy (essentially passing a scope into the urethra and bladder) are the methods of choice, though work up should include urine culture and sensitivity (usually more than once) and abdominal ultrasound.

Surgical treatment involves re-implantation of the ureters into the bladder wall. In vetland, this is typically a specialist procedure and with good reason. It takes a delicate, experienced surgeon to maintain the patency of tiny dog and cat ureters (it can be performed in general practice, although less commonly now that specialists abound). 

Dr Newman cited studies reporting surgical cure rates of 22-67% - that’s a big range but depends on the type of ectopic ureter, presence of concurrent conditions and complications. Obviously a very good argument for early detection.

If you've read this far down here is a pic taken on Saturday night. I'd just been nerding it up at a meeting at the airport, of all places, because it was my only opportunity to pin-down the co-author of a paper who lives interstate. I dropped into a housewarming party afterwards and blow me down, Louis the chihuaua was wearing practically the SAME JUMPER. 

Nerdsville, Population 2?

Who wore it best?

Argyle is SOOOOO hot this season. I swear there was no collusion about outfits.

Superdeeds to help super dogs

Phil is embraced by a giant Batman balloon. (Thanks Hero for the photobomb).

Here at SAT HQ Phil and I have been flat out keeping up with commitments. My commitment to mark a lot of assignments, and Phil's committment to sleep as much as he can in every possible spot in my study (I think I got the wrong deal here).

The internet is full of distractions, and plenty of cries for help (some from unworthy scammers I might add) but it also provides opportunities to help animals from your desktop. We wanted to take this opportunity to give a shout out to two excellent organisations that do very important work.

This month Animals Fiji has launched a huge appeal to find land for a new clinic - or it faces closure. So if you are keen to help animals in our region and you have some dough, click here.

If you would prefer to help animals a little closer to home, I cannot recommend AMRRIC enough. The organisation, which supports Animal Management in Rural and Remote Indigenous Communities, does vital work in our own backyard. Having volunteered on several programs over the last five years I can personally vouch for them. So click here to find out more. Vets and vet students should consider attending AMRRIC's 10th Anniversary Conference in Darwin in September this year. Visit here for details and registration.

Weekend links

Phil and Coco beat the winter chill in their beds.

Hurrah...its the weekend again! Although here at SAT we know all too well that lots of you will be working, studying or cramming. (What evil mastermind made May the month of intense exam preparation anyway?) Even so, exam prepartion inevitably leads to some procrastination. So we can thank our readers for these links! 

Have you ever considered training a reptile? Australian scientists have taken on that challenge, reporting early success at training goannas to avoid cane toads which if eaten will kill them. Read more about this incredible project here.

If you have not yet seen the video of a brave cat who took on a dog that was attacking a kid, you need to see it (click here). Tara, a former stray who followed the family home, took on a lab x chow. The boy, Jeremy, sustained some nasty bites but is now doing well. 

These photos of a girl and her bulldog are stunning, albeit concerning in part (am thinking about baby's face too close to dog's face...I know some readers will say "come on, don't be so risk-averse" - but you have to remember just one bite changes everything. And animals - like us - aren't always predictable). Still, I can appreciate some beautifully composed photos, and Rebecca Leimbach has captured something special about Lola and Harper in this series.

Worried about what would happen if rabies were to arrive on our shores? Professor Michael Ward, Chair of Veterinary Public Health and Food Safety at the Faculty of Veterinary Science will talk about the impact of Rabies on our Northern communities at the uni on Thursday May 22 at 1pm in the Veterinary Science Conference Centre. All are welcome.

Finally, most news publications can't resist stories about animals with prostheses. The Huffington Post has put together this collection of the most well-known cases in recent times.

Is it time for greyhound racing to retire?

A retired racing greyhound goes to the beach.

The Animal Welfare League of Australia has just released a policy on greyhound racing, which clearly calls for the end of the sport (see here). It is interesting that in the US, 43 out of 50 states have reportedly implemented a ban on greyhound racing.

Will Australia follows suit? The biggest concerns about the greyhound industry from an animal welfare point of view are a) the overall husbandry of the dogs involved and b) the huge "waste" - not really an appropriate term but all of those dogs deemed not fit for racing, or those that are retired that no one wants.

As a companion animal vet who treats a number of rescued greyhounds that are then kept as pets (really the tip of the iceberg of the numbers affected), I see conditions commonly in these dogs that reflect poor husbandry. For example, more often than not they require extensive dental work or teeth extractions, secondary to a poor diet or biting of cages, at a reasonably early age. Some suffer chronic gastrointestinal upsets. Numberous greyhounds that I currently treat require fluoxetine (aka Prozac) to reduce anxiety. Many have separation anxiety, some are hypervigilant, some have noise phobias.

Of course there will always be trainers who do really look after their animals, but there can be no doubt that there is a systematic failure to protect the welfare of racing greyhounds in Australia and overseas. Just look at the current parliamentary inquiry into greyhound racing in NSW: animal welfare is included within the terms of reference - well and truly AFTER financial matters are discussed (i.e. it is listed from item "j"). Little wonder that some animal welfare groups see no alternative but to call for a ban of the entire industry.

The Animal Welfare League's statement reads:

AWLA does not support the exploitation of dogs for sport, gambling or entertainment purposes. Racing greyhounds face negative welfare outcomes during training, transportation and racing. An unacceptably high number of healthy greyhounds are injured, discarded and euthanased annually across Australia. Also, the industry has proven incapable of safeguarding the welfare of the vast majority of dogs considered unviable for racing.

Because of these issues, we advocate for an end to greyhound racing in Australia. While greyhound racing remains active, we support:

• revision of the current regulatory regime to ensure effective and transparent control of all aspects of the industry
• the introduction of mandatory and enforceable welfare standards for the breeding, sale and post-racing treatment of greyhound
• registration and identification requirements applying to other breeds of dogs also applying to greyhounds
• consistent and rigorous enforcement of the Rules of Racing

Things I learned about minimally invasive desexing

If dogs could be vets...

WARNING: Surgical images in today's post. Some readers might be grossed out so please scroll carefully.

Last night the University of Sydney’s veterinary surgical team put on a wonderful series of talks themed around urogenital surgery. Sure, it’s not everyone’s idea of the perfect Wednesday night, but if like many vets you spend much time examining and operating on these areas, they are fascinating. And listening to surgical specialists talk is a beautiful thing. Anyone who can throw phrases like prostatic avulsion and intramural ectopic ureters into sentences that make perfect sense to non-specialists is very talented indeed.

The audience sat transfixed last night as Dr Laurencie Brunel described laparoscopic ovariectomy and ovariohysterectomy (OHE) (keyhole desexing of female animals). Again, maybe not a big deal to some but in companion animal medicine, reproductive surgery is common, it can be life-saving, and if there's a better way to do it we all want to know about it.

Have you ever wondered why vets don’t perform keyhole surgery? Is this something we should move towards? Well, if you look at the size of incision made for a routine spey (especially in cats), one could argue that this is practically keyhole surgery. [NB the pic below is NOT a cat so this is not illustrating my point!]

Reproductive tract of a German shepherd dog. Note the "Y" shaped uterus - the ovaries are at the top of the Y near the haemostats or clamps, the arms join at the bifurcation, the uterine body, and the cervix is below.

But good vets always look at viable alternatives. The advantages of laparoscopic desexing are that one has beautiful surgical field magnification – one can see the ovary in situ, as we did in Dr Brunel’s magnificent videos last night (seriously, I could have watched these over and over), and the associated vessels. Other advantages include (debatably) a smaller incision, reduced tissue trauma (i.e. less overall tissue handling, more precision), diminished pain and faster patient recovery.

Laparoscopic desexing is contraindicated in some animals: those with a congenital or traumatic diaphragmatic hernia where insufflation of the abdomen with CO₂ would leak into the thorax and inhibit ventilation; animals in oestrus; and where pyometra (pus in the uterus) is present as the uterus is very friable and the incision is tiny. One would have to be a magician to get a pyo out of a keyhole incision.

This is also a uterus - but the dog (in this case a chihuahua) has pyometra. The arms of the uterus are distended with pus. The uterine body is just below the crease in the uterus at the top of the photo. The ovaries are still intra-abdominal in this pic, at the ends of the arms which are at the bottom of the pic. Not a uterus I would want to be pulling through a keyhole incision.

Obviously another down side is the need for specialist equipment which requires some outlay of cashola. Medical equipment ain't cheap. Not to mention training. Initially one would be much slower at desexing – increasing the anaesthetic duration – and be a bit awkward. Is that a reason not to explore this technology?

Anaesthetic-wise, as with all patients we should be making sure that the patient is ventilating and oxygenating well – and remember that abdominal insufflation can increase pressure and reduce cardiac output (insufflation pressure should be <15mmghg be="" may="" o:p="" positive="" pressure="" required.="" ventilation="">

Also…all patients are clipped as if for an exploratory laparotomy (that’s the opposite of keyhole – where we open the patient from the bottom of the rib cage down to the pelvis, enabling full exposure). Why? In case of complications we don't want to have to prep the patient again. We also want the patient to have an empty bladder, as laparoscopy involves inserting trochars into the abdomen and a full bladder could be easily perforated.

So laparoscopic desexing, depending on which instruments one has available, involves palpating the abdomen carefully to avoid the spleen, insufflating the abdomen, inserting the instruments (through a single or multiple ports), visualise the ovaries, grasping them, severing the vessels using electrocautery and removing them through the hole. 

Potential complication include trauma to the spleen, reduced visualisation of the ovary due to haemorrhage (tilting the table so the patient’s head is elevated can be helpful), dropping of the ovary back into the abdomen once removed (this necessitates converting the laparoscopy to an exploratory laparotomy), burning of the peritoneum with bipolar electrocautery/vessel sealing device, haematoma at site of placement of a spey hook if used (this is avoided by using a taper-cut needle to suspend the ovary), and leakage CO² from the operating cannula incision, causing the abdomen to deflate like a tired old balloon and making visualisation really hard.

Discovery of pyometra or a diaphragmatic hernia are both very good reasons for converting to a laparotomy.

So there you have it. In general practice within Australia, the standard technique is OHE via a small laparotomy incision. Partly because most vets are trained in this technique, they can do it quickly, if there are complications the incision can be extended and that’s how it has always been done. 

But skilled practitioners can use laparoscopy to perform the procedure in the same time. It can also be used to perform prophylactic gastropexy, removal of bladder stones, biopsies and insertion of some feeding tubes. It will be interesting to see the uptake of this technology, used already for decades in the human field, in veterinary practice. (But if anyone offers you the opportunity to watch a video of a laparoscopic spey, I recommend it).