Tuesday, August 8, 2017

Helping Your Veterinarian Make the Diagnosis

Helping Your Veterinarian Make the Diagnosis

A successful examination begins with the owner

            If you think about it, being a cat veterinarian is not very different from being a pediatrician. We can’t ask our patients what’s wrong. We just have to figure it out.
Nowhere is the role of a cat owner more important than at the veterinarian’s office, where a good history can sometimes mean the difference between life and death.

            Veterinarians are faced with a variety of diagnostic challenges on a daily basis. The ability for a veterinarian to obtain a detailed and complete history is our most important diagnostic tool. When accurately interpreted, this information lays the groundwork for a logical diagnostic and therapeutic plan, which may prevent unnecessary
diagnostic testing and needless discomfort to the patient and cost to the owner. After briefly discussing the primary complaint, veterinarians try to obtain both objective and subjective information when gathering the history. Examples of objective data include the signalment, the environment, diet and medical history.

            The signalment consists of the cat’s age, breed and gender, including the reproductive status, i.e. whether the cat is neutered or spayed. This is basic and important information. Certain illnesses tend to strike cats at certain age ranges. For example, hyperthyroidism is a glandular condition that causes cats to lose weight despite a ravenous appetite. It’s an old age disease, rarely striking cats under the age of eight. A 13-year old cat with weight loss and excellent appetite warrants a blood test to evaluate thyroid function. A four-year-old cat with the same signs would be more likely to have something else, such as inflammatory bowel disease or pancreatic insufficiency. Even if you’re not sure of the exact age, an accurate approximation can be very useful for a veterinarian. Certain breeds are predisposed to certain conditions and knowing the breed can help veterinarians choose proper diagnostic tests. Persians are prone to polycystic kidney disease; Ragdolls and Maine Coons are susceptible to hypertrophic cardiomyopathy. Veterinarians must not be misled by clients who tell their veterinarian that their cat is a Maine Coon, only to discover that it’s a domestic longhair that, “looks just like the Maine Coon in the magazine.” Gender provides important information as well. A female cat straining to urinate is likely to have cystitis. A male cat straining to urinate could have a urinary obstruction, something that can be life-threatening if not treated promptly. Unlike age or breed, there’s very little guesswork when it comes to determining gender. Just lift the tail and take a look!

            Gathering environmental history is a routine yet important part of a cat’s history. Free-roaming cats, or cats that stay outdoors, are at a much higher risk of getting into fights with other cats, which increases their risk of getting cat bite abscesses or acquiring feline leukemia or FIV. Free-roaming, or recently escaped, cats may have had access to toxins or have been subject to trauma, which is unlikely to occur with an indoor pet. Sometimes a travel history is important, although this is true more so with dogs than cats, because when cats travel with the owner to another part of the country, they are not usually let outdoors where they are at risk of running away or getting lost. Still, a travel history can be important, especially if the patient has been exposed to diseases endemic to certain regions but not prevalent in their normal environment.

            A dietary history is more than merely determining which type and brand of food you’re feeding your cat. Granted, knowing the type of diet (dry, moist, table food), the brand name, any types of snacks, the method of feeding (free-choice or individual meals) and the amount is important; but, veterinarians also want to know about your cat’s appetite and whether there has been any weight gain or loss. It’s helpful if you watch your cat eat. Complete or partial anorexia is a common reason that clients take their cat to the veterinarian. A client that notices that their cat only chews on one side of its mouth, or has stopped eating dry food and now will only eat canned food, is telling the veterinarian that oral pain or discomfort may be the source of the problem and that a thorough oral exam may be the only diagnostic test necessary to obtain the diagnosis.

            Reviewing the patient’s prior medical record can give valuable information to the veterinarian. If this is your first visit to this particular veterinarian, it is very helpful if you know your cat’s vaccination history as well as feline leukemia virus and feline immunodeficiency virus status. Medical records detailing the diagnosis or treatment of any prior or ongoing health problems are helpful, as the primary complaint may be a consequence of a prior medical condition. Once the above information is obtained, the veterinarian is ready to delve deeper into the primary complaint. The history surrounding the primary complaint tends to be more subjective and this information, obtained from observant, conscientious owners, can be a tremendous asset. Veterinarians know that some owners aren’t as observant as others. Our job is to encourage our clients to describe the cat’s problem from its onset so that an orderly chronology is obtained. Some of the things we’ll want to know are when the cat last seemed normal, whether the onset of the clinical signs was sudden (acute) or if it developed slowly over time (chronic) and whether or not the illness has responded to previous treatment. For example, an itchy cat that was treated with steroids and did not respond in the past is more likely to have food allergy (poorly responsive to steroids) rather then flea-allergic dermatitis (responds rapidly to steroids).

            Depending on what the primary complaint is, a veterinarian may delve even deeper, to further help characterize the problem and better formulate a diagnostic plan. As an example, if a client reports that their cat has diarrhea, the veterinarian may then ask whether there’s any blood or mucus in the stool, whether the cat has been straining in the litter box or whether the cat has had any accidents in the house. The more the client answers “yes,” the more likely that the diarrhea has originated from the large intestine. This narrows down the list of possible causes for diarrhea and helps the veterinarian formulate a diagnostic and therapeutic plan.

            Behavioral changes can be difficult for veterinarians to interpret. I’ve had many clients bring in their cat because he or she was acting differently, although upon further questioning, it became apparent that the cat wasn’t actually ill despite the difference in behavior. Cats who suddenly stop sleeping on the bed, even though it’s been their favorite sleeping spot for years, or normally vocal cats that have lately become more quiet, may indeed be acting differently, but these are more likely to be benign behavioral changes. Lethargy, hyperactivity, aggression, growling and urinating or defecating in inappropriate places, however, are behavioral changes that may indicate an underlying medical problem. When in doubt as to whether any apparently new behaviors are medically significant or not, it’s best to be on the cautious side and report everything to your veterinarian. With the advent of cell phones and the ability to quickly take a photo or a video, clients are encouraged to photograph or videotape any unusual behaviors or symptoms, as a video of a seizure, for example, or other odd behaviors can often serve as a valuable supplement to the client’s verbal description.

            Because our patients cannot talk, veterinarians must rely on you, the client, to speak for them. The more observant you are, the more information you can give us. This information can go a long way toward obtaining the proper diagnosis, allowing us to tailor a treatment plan to put your companion quickly on the road to recovery.

Friday, July 28, 2017

Inhaled Medications: Another Option for Medicating Your Cat

            Cats can be tricky to medicate.  Veterinarians know that it is difficult to medicate a cat consistently with a medication that is required twice daily, and almost impossible to administer a medication reliably and unfailingly three times daily.  Most veterinarians, when dealing with cats, try to strike a balance between efficacy and ease of administration, prescribing the most effective drug that can be given with the least frequency. 

Medications that come in pill or capsule form are especially challenging, as many cats actively resist having pills put down their throats. Uniquely designed treats, such as “Pill Pockets” are available in some pet stores and veterinary offices. These are soft treats with a hole cut out of the center. Pills are placed in the center of the treat, and are then sealed inside by gently squeezing the sides. Some cats can be tricked into taking pills this way for months, although many catch on to the ruse and will eventually refuse to eat the treat.

Cat owners often find liquid medications easier to administer. Fortunately, a number of pharmacies now offer compounding services - they can convert medications traditionally available only in capsule or tablet form into other formulations, such as a liquid form, often adding chicken, liver, beef, and tuna flavoring if requested. While most cats do not like having any medication forced upon them, many find a tuna or chicken flavored liquid less objectionable and a few will take a flavored medication voluntarily.

A number of pill-hating cats will also resist liquid medication, regardless of the flavor. Transdermal medication (delivering drugs into the bloodstream via application of gels or skin patches) offers another option of medicating cats that simply refuse to take any medication orally. Some medications can be compounded into a gel, a small amount of which can be spread on the inner surface of the ear.  The medication is then absorbed through the skin, into the bloodstream, allowing owners of stubborn cats to bypass their mouths completely.  While transdermal drug administration is becoming more commonplace in veterinary medicine, there are only a few drugs for which efficacy has been proven with this method.  Just because a drug can be formulated into a transdermal gel doesn’t mean that therapeutic blood levels of the drug can be achieved. 

            Inhaled medications present another option for medicating cats, however, the use of inhaled medications is limited to cats with respiratory ailments, most notably asthma.  Interestingly, veterinarians seldom prescribe inhaled medications because of the difficulty of administering oral medications to a cat.  Rather, inhaled medications are often given because of the reduced risk of side effects when using inhaled medications. 

Veterinary Technician/Cat Whisperer Gill Nunes demonstrates
how to administer inhaled meds to little Trinity.
            Asthma is the most common reason for prescribing inhaled medication in cats. The most effective long-term treatment consists of high doses of oral steroids.  Steroids attenuate the inflammatory response, reducing the severity of signs.  Steroids are given twice daily for several days.  Most newly diagnosed asthmatic cats will feel and act much better, at which point, the steroid dose is tapered slowly over several weeks.  Unlike dogs, cats are fairly resistant to the undesirable side effects of steroids.  A few cats, however, exhibit adverse effects from steroids, making treatment challenging.  Oral steroids cause water retention, which increases a cat’s blood volume.  Cats with heart disease may not be able to withstand the increase in blood volume, putting a strain on an already compromised heart and triggering congestive heart failure.  Oral steroids also oppose the action of insulin, and can cause a well-regulated diabetic to become poorly manageable.  Some cats may be pre-diabetic, and giving oral steroids can tip them over the edge into overt diabetes.  Inhaled steroids, when administered, exert their effects almost exclusively in the lungs.  Very little of the drug crosses beyond the lungs into the bloodstream, so systemic side effects are minimized. 

Be warned: not all cats will be as cooperative as Trinity. 
            Bronchodilators are drugs that reverse airway constriction, allowing the air passages to open.  Although most asthmatic cats can be managed with steroids alone, some require a bronchodilator in addition to the steroid.  Bronchodilators can be given orally, although an advantage of inhaled bronchodilators is their rapid effect, which may be lifesaving in severely asthmatic cats that are prone to acute asthma attacks.

            Both types of drugs are available for humans, as metered dose inhalers (MDIs).  Human adults quickly learn to coordinate the inhaling of the medication with the actuation (pressing) of the device, although this is much more difficult for children, and impossible for infants or cats.  An alternative was developed to allow children, infants, and cats to use the MDIs without having to coordinate their breathing.  A spacer – a plastic chamber roughly the size of the cardboard inner tube of a roll of toilet paper – is attached to the MDI, and a facemask is attached to the other end.   The spacer acts as a temporary storage area for the misted medication to sit, until the individual breathes it in. Cat owners are taught to attach the MDI and the facemask to the spacer, and then to actuate the MDI twice, filling the spacer with the mist.  The facemask is gently placed over the cat’s mouth and nose, and the cat is allowed to inhale and exhale 7 – 10 times with the mask in place.  The most popular device for inhaled medications in cats is the Aerokat (see pictures above)

             Inhaled steroids are the most potent inhaled anti-inflammatory drugs available.  Fluticasone (Flovent) is the most commonly used inhaled steroid.  As for bronchodilators, Albuterol (Proventil) or Ventolin) is the one most commonly used for asthmatic cats.

            Inhaled steroids and bronchodilators have been the standard of care for the treatment of asthma in humans, and while oral medications are still the initial method of treatment for asthmatic cats, inhaled medications offer another option for cats at risk for or experiencing side effects of oral medications, or for cats who refuse to allow oral administration of medication.


Wednesday, July 12, 2017

Cat Man Adieu

It’s been a little over a month since I retired.  I’m still finding it hard to get used to.  I overhear other people say, “I’m not working the rest of this week” or “I’m off for the rest of this month”, and I realize that hey, I’m off for the rest of my life. 

There are many things to adjust to.  I suppose the most noticeable thing for me is the silence.  As a veterinarian, I used to spend my day talking to clients during appointments.  If I wasn’t in an appointment, I was likely talking to a client on the phone.   If there were surgeries or procedures to perform, I’d be chatting with my staff in the treatment room before, during, and after the procedure.  My entire day was spent in some type of conversation.  In retirement now, I go through the day barely speaking a word to anyone.  Most days, the extent of my conversation is, “I’ll have the chicken salad club and an iced tea”, or “Can I have the venti green tea frappuccino?” (I’ve been saying that one a lot lately) I’m a social, outgoing person, and the curtailment of my conversation is the most striking difference in my day.

The lack of a set routine is probably the next most noticeable change.   My day was used to be pretty much the same: wake up, shave, shower, feed the cats, have breakfast, do a few household chores (laundry, dishes, litter box), and then descend into the hellish subway to work (thankfully only 5 stops), and then see appointments all day.  That routine is now gone, but being a creature of habit, a new pattern is starting to emerge to my mornings.  Sadly, I’m still getting up very early, because Mark (the hubby) still has to wake up at the ungodly hour of 5:20 a.m.   While he hops in the shower, I feed the cats and make breakfast for us both. (I’m getting very skillful and creative with omelets.) I complete a few more chores, and then I accompany him out the door at 6:30.  He walks to 14th Street to catch the van that takes him to work, and I peel away when we approach 27th Street and hit Planet Fitness.  Yes, I’m going to the gym for nearly 2 hours every single morning. 

Twice a week, I do a little grocery shopping at Fairway after the gym.  Otherwise, I come home, do a few more chores, shave and shower, read the New York Times headlines (delivered to my inbox every morning.  I’ve figured out how to work around their ten-article-a-month firewall), answer a few e-mails, and then confront the agonizing decision about where I’m going to have lunch.   As for my afternoons, they’re open.  Some days, I go to the mid-Manhattan library and either borrow some books, browse their books, or read a book that I’ve brought with me.  At least once a week, and sometimes twice, I catch the 1:30 movie at MoMA.  I’m a member, and so the movies are free for me.  These are usually old movies from the 30’s, 40’s, and 50’s, being shown as part of some actor/actress/director retrospective.  After the movie, I usually hang around and read in the sculpture garden.  Most of my afternoons are spent reading (and occasionally napping) in a park.   Some days (usually if I’m feeling a bit lonely or isolated) it’s Bryant Park.  Other days, it’s Madison Square Park (usually on days when I eat lunch at Eisenberg’s Sandwich Shop, because it’s close by).  Mostly, I head down to Tompkins Square Park.  It’s a little out of the way, but on weekdays it’s really peaceful and quiet, and I have a particular bench in a perfect, shady spot that is ideal for people-watching.  Rough life I lead, eh? 

I suppose the other major change since retirement is a so-called “lack of sense of purpose” that I’ve been warned about.  Two retirement books that I’ve read have mentioned this potential issue.   And yes, I can see how this can be an issue, and may end up being one for me in the future, given how strong a sense of purpose my career as a veterinarian had given me.   It so happens, this lack of a sense of “purpose” that I’m currently experiencing has actually turned out to be the most liberating and calming part of my retirement.  For 29 years, my purpose was to help sick animals become well, and help clients deal with all issues regarding their pets’ health, while mentoring students, interns and technicians along the way.  It was a huge responsibility (more on that in a future post).  Being free of all of that, for the moment, is a huge (we’re talking ginormous) weight off my shoulders.   Of course, at some point, the urge to do something more meaningful will be upon me, and I will pursue it wherever it leads (although I have a strong hunch that veterinary medicine won’t be involved), but for now, I really want to harken back to the days when I was a kid in Brooklyn and had the summers off.  I spent those summers playing stickball and stoop ball, riding my bike, and hanging out in the neighborhood park with my friends.  Forty-something years later, there won’t be any stickball or stoop ball, but I’m definitely on a mission to check out every little park in Manhattan.

Wednesday, May 10, 2017

Panleukopenia - a very bad viral disease of kitties

            Cats are uniquely susceptible to a variety of viral villains, and one of the most challenging culprits is the virus that causes feline panleukopenia.         

            Panleukopenia (pronounced “pan-luke-oh-pee-nee-a”) is a highly contagious viral disease caused by a parvovirus.  Most people mistakenly consider parvovirus to be a dog disease only, but this not the case.  All felids, as well as raccoons, mink, and foxes are also susceptible.

            The symptoms of panleukopenia are similar to those seen in dogs with parvovirus: fever, vomiting, diarrhea (possibly bloody), and poor appetite.  The symptoms are explained by the propensity of the virus to attack cells in the body that are rapidly dividing, namely cells of the digestive system and the bone marrow.  Virally induced damage to the intestinal tract leads to vomiting, diarrhea, and poor appetite.  Infection of the bone marrow with this virus impairs the ability of the marrow to produce white blood cells, leading to a low white blood cell count.  This explains the name of the disorder: in Latin, “pan” means all; “leuko” means white, and “penia” means “decreased amount”. Cats with panleukopenia have low numbers of all white blood cell types.  Panleukopenia is sometimes referred to as “feline distemper”, however, this is a misnomer.  It probably started because some of the symptoms of panleukopenia are similar to those of dogs with distemper.  Veterinarians don’t like to use that term because the virus that causes canine distemper is a completely different virus that is in no way related to the parvovirus that causes feline panleukopenia.

            The panleukopenia virus is most commonly transmitted when a vulnerable cat comes into contact with the feces, urine, blood, or nasal secretions of an infected cat.  Contaminated objects, such as bedding, cages, shoes, clothing, hands, and food bowls can harbor and transmit the virus.   It can also be transmitted from the mother to the developing kittens in her uterus.

            Although the panleukopenia virus can infect cats at any age, kittens aged three to five months are particularly susceptible.  These poor kittens often experience severe clinical signs, such as profuse diarrhea, frequent vomiting, abdominal pain, high fevers, and marked lethargy.  Owners of affected cats often report finding their cats with their heads hanging over their water dish. With their small body size, kittens may rapidly become dehydrated.  There are no medications that kill the virus itself.  Treatment consists of aggressive supportive care with intravenous fluids, antibiotics, anti-nausea drugs, and nutritional sustenance.  Severely affected kittens or cat may require plasma or blood transfusions. The prognosis for recovery is guarded.  The mortality rates for panleukopenia are high, and most kittens less than eight weeks old succumb to the disease.  Older kittens, if they survive the first 48 hours of hospitalization, may pull through.  Kittens that contract the virus in utero, if they survive, may be born with a brain disorder called cerebellar hypoplasia.   The cerebellum is responsible for balance and coordination.  Because these kittens have an underdeveloped cerebellum, they go through life a little clumsy and ungraceful, but are otherwise fine.  Due to the contagious nature of the disease, hospitalized cats should be strictly isolated from other cats. Cats that recover from panleukopenia are believed to be immune from the disease for the remainder of their lives.
            A presumptive diagnosis is usually made based on the age and vaccination status of the cat and the clinical symptoms.  Because panleukopenia is caused by a parvovirus, the rapid in-house parvovirus tests for dogs will also detect the virus in feline feces.  Although the test has some limitations in cats, it does allow immediate, in-house detection of the virus in just a few minutes, confirming the diagnosis.

            The best way to treat any problem is to prevent it from occurring in the first place, and this certainly holds true for feline viral diseases.  Fortunately, vaccination offers safe and effective protection.  Initially, kittens receive immunity from the antibodies in the mother’s milk.  This immunity is temporary, however, lasting only a few weeks. As the kittens’ antibody level drops, they become very vulnerable to infection. To best protect kittens, they should be vaccinated against the virus.  The initial vaccine is given between six and eight weeks of age, and then every two to four weeks thereafter until about 16 weeks of age.  Panleukopenia can be a major cause of mortality in cats in shelters and rescue homes.  With rare exceptions, all kittens and cats in a cattery or shelter over 6 weeks of age should be vaccinated, regardless of their physical condition and pregnancy status.

            The parvovirus that causes panleukopenia in cats is highly resistant to some disinfectants and may survive in the environment for several months.  This has significant implications in shelters and catteries trying to limit the spread of the disease.  Disinfectants containing sodium hypochlorite (bleach) have been shown to be effective in killing the virus in the environment. 

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