THE ART AND SCIENCE OF VETERINARY MEDICINE

16 Oct

Diagnosing illness in both human and veterinary medicine is both an art and a science. Some diseases present with very typical physical signs and laboratory results while others are much more subtle and require more involved diagnostics. In some cases no definitive diagnosis can be made with the available diagnostic techniques and a therapeutic trial, using appropriate medications, is performed to see if there is any response. Diagnosis is much more difficult in our animal patients because they cannot talk to us to explain their symptoms, and they are masters at hiding signs of illness until a disease process is more advanced. To help us make a diagnosis we rely heavily on a good history provided by the pet’s owner, a good physical examination and laboratory testing.  Additionally  we utilize diagnostic imaging such as radiographs (Xrays), ultrasound, and in some cases referral for CT or MRI. Further diagnostics include getting fluid or tissue samples through needle aspirates, endoscopy, laparoscopy and surgery. This is the science of medicine. The art of medicine is using this information to make a diagnosis and treatment plan. Sometimes laboratory tests and imaging studies are perfectly normal, yet we still have an ill patient. Sometimes there are abnormalities found that are not significant or have no bearing on the illness the patient is presented for. Most laboratory test results fall into a range of normals, but there are small percentages of patients where the values lie outside these ranges. These results  are normal for the particular patient. So we have to ask ourselves if the laboratory tests fit the disease condition and if the patient’s symptoms are compatible with these tests results. An example of this is testing for lyme disease. We know that a large percentage of dogs living in our area have a positive test result, indicting exposure to the lyme bacteria through a tick bite and an immune response which we measure. We also know that only about 5% of exposed  positive dogs ever develop symptoms of lyme disease- fever, lethargy, limping on  one or more legs. So you could test dogs with a wide variety of clinical symptoms- vomiting and diarrhea, skin problems, bladder infections- who all show up positive for lyme disease but this has nothing to do with their problem. We must correlate the correct clinical symptoms, correct lab test results and a correct response to treatment to make that diagnosis. If a dog comes in with fever, lethargy and limping and tests positive for lyme disease but does not show a clinical improvement after 2-3 days on appropriate antibiotic therapy, then we can say this is not lyme disease but another illness with similar symptoms (other joint infections, bone lesions, arthritis, immune disease of the joints), and further diagnostic testing is needed.

There are 2 statements that vets and medical doctors use when presented with an ill patient. One is : ” if you hear hoofbeats, don’t think of zebras”- this basically means that hoofbeats would likely be from horses in our area, not zebras, which are exceeding rare (unless you live in Africa). The second statement is similar: “common things occur commonly; uncommon things occur uncommonly. Basically we look for and try to rule out all the common illnesses that could present with the symptoms and diagnostics we have.Once we have ruled these out then we look for the zebras or the uncommon illnesses. This usually requires more and more specialized diagnostic testing.

Hopefully this gives you some insight into the thought processes entered into by you vet or MD when presented with an ill patient.

Martin G. Randell, DVM,DACVIM

Canine and Feline Nutrition

15 Mar

Nutrition is an important part of every pet’s health and well being. There are a wide variety of pet foods available on the marketplace and a wide variety of thoughts on the subject. I would like to discuss Somers Animal Hospital’s views on this matter.

Pet food companies spend millions of dollars on research and development of pet foods. The vast majority of pet foods available to the consumer are safe, balanced and healthy. Any commercial food has to satisfy nutritional requirements of AAFCO (the national organization that sets nutritional standards for pet foods). Virtually all brand name and lesser known companies have their dry and canned foods meeting these standards. It often says so on the label. This does not necessarily apply to raw food, freeze dried raw foods or generic pet foods. In general our pets are living longer due to better veterinary care and better nutrition.

Canines- dogs are omnivores, meaning they are adapted to eating both meat and plant  sources. In fact recent genetic research has shown that the long association of dogs and humans leading to domestication has led to  genetic mutations allowing them to properly digest starches. These genes are not found in wolves and they are less efficient in digesting starches. The majority of pet dogs eat dry kibbled dog food. There are also many varieties of canned food. Any good quality food purchased at the supermarket or pet store should be fine unless your dog has a medical condition requiring special foods. There are many new foods being offered and marketed as better for your dog because they are grain free, organic, natural, etc. Most of this is marketing and not based on any studies showing they are better than the major brand foods.  Grain free means no grains but there are other carbohydrates in the food. There is no difference in digestibility of grains versus other carbohydrates.  Many are touted as hypoallergenic but some dogs can develop food allergies on any food. We have to look for the offending food source that stimulates the allergic response. Most allergic responses are actually due to the protein source in the food, not the carbohydrate source. Actually, as pet food companies are coming out with more varieties of proteins in foods- venison, various fish, bison, turkey, etc.- it is getting more difficult for us to find truly novel protein sources to trial suspected food allergic dogs on. There is also no good correlation between food type and dental tartar build up and periodontal disease. We see dogs with minimal dental problems and dogs with marked dental problems on all different types of foods- canned and dry. The main underlying issue to the development of dental disease is underlying genetics and home dental care- tooth brushing, dental chews and dental rinses and gels. So if your dog is doing well on the diet it is presently on -good hair coat, good stools, good weight- then there is no need to switch foods.

Felines- unlike dogs, cats are considered strict carnivores. Their metabolism and physiology is adapted to eating prey species- rodents, birds, insects, reptiles. Nutritional analysis of prey species shows high protein, moderate fat and very low carbohydrate. although cats can digest carbohydrates they are less efficient at doing so. Canned cat foods are much more similar nutritionally to their natural diet. Dry foods are much higher in carbohydrates. No dry food can be made low enough in carbohydrates to be similar to canned food, although there are some lower carb dry foods becoming available. We find many cats eating all or primarily dry food have higher rates of obesity, diabetes, urinary problems and kidney problems. One of the aspects of treatment for these conditions is to switch to canned food. Also, unlike dogs who can be intermittent feeders, cats are adapted to eating multiple small meals daily. The majority of cats in this country do eat dry food because it is more convenient for the owners to leave it out and feed free choice. Of course this makes portion control difficult. It is best to feed 3 small meals of canned food daily. Alternatively, feeding canned twice daily and leaving a small amount of dry out may be easier for most cat owners. Being obligate carnivores cats have some very specific nutritional requirements- just a few differences from dogs include -the need for preformed taurine (an amino acid – deficiency leads to blindness and heart disease), the need for preformed vitamin D and A because they are unable to convert the plant forms into the active forms needed in the body, higher protein and fat requirements, and the need for certain types of fatty acids that only come from animal sources. In fact cats fed dog food will develop severe nutritional deficiencies. Again, the majority of commercial cat foods are complete and well balanced but we promote canned food over dry.

Over the last number of years there has been a movement toward feeding raw foods and bones to cats and dogs. This is based on the assumption that this is what their wild kin eat. The problem with this is that wild animals eat whole prey- including internal organs, bones and skin. When wild animals eat any bones they are usually covered with skin and muscle which protects against damage from the sharp edges on some bones. Dogs and cats fed bones from the grocery store or butcher shop do not have these protections and we see worn and broken teeth, gastrointestinal obstructions and occasionally perforations from the sharp edges. We do not recommend any raw food diet for several reasons- raw meats may contain a variety of harmful bacteria and parasites which are risks both for the pets and for the people preparing the food for them.  Salmonella, campylobacter,  and listeria are some of the bacteria isolated form raw food diets. Parasites such as toxoplasma, roundworms and tapeworms have been found in raw foods. There have been occasional outbreaks of salmonella in commercial dog foods, but also in peanut butter, salad greens and fruit that humans eat. This is a consequence of modern food production techniques. But the incidence in raw foods is significantly higher. The last issue concerning raw foods is nutritional value- veterinary nutritionists have analyzed a variety of raw and freeze dried raw foods and find almost all are nutritionally deficient in at least one nutrient, often several.

Based on these findings we cannot recommend feeding raw foods. If you choose to do so we recommend cooking the food and consulting with a veterinary nutritionist to properly balance the diet. Also be sure to thoroughly clean and disinfect all cutting and cooking utensils, counter surfaces, food and water bowls. Wash your hands  after handling the raw food. These are sources of human exposure to bacteria and parasites.

Martin Randell, DVM,DACVIM

Why does my cat need a blood test? Part 2- Hyperthyroidism

11 Feb

In part 1 we discussed the common problem of kidney insufficiency. This month we will review feline hyperthyroidism, another common disease that is easily identified on a routine wellness blood test.

The thyroid is a gland with two lobes found in the neck. Cats with hyperthyroidism develop a tumor which produces excessive amounts of thyroid hormone. The thyroid regulates the metabolic rate, and in excess can cause problems in many different organs systems. This can lead to weight loss despite an increased appetite, hyperactivity, high blood pressure, and damage to the kidneys, liver, heart and eyes. If left untreated it can lead to heart and kidney failure and blindness. This tends to be a slowly progressive disease. When detected early there may be minimal clinical signs.

In cats, 95% of these thyroid tumors are benign but a few are malignant. The problem is due to the excess thyroid hormone alone. There are a number of different treatment options for these patients. Most agree, the best option is radioactive iodine treatment. This is done at a special facility. It generally involves 1 injection of radioactive iodine, is curative and has no side effects. Another treatment which can be curative is surgery. However, some tumor tissue can be missed and there are all the risks and complications that surgery involves. There is an oral medication that can be given twice daily that controls the level of thyroid hormone. This can be a very effective treatment. It does necessitate daily medications, blood monitoring and has a low risk of side effects. The last option is a new prescription diet. This diet controls thyroid hormone levels by restricting iodine. Iodine is required for the body to synthesize thyroid hormone. While on the surface this sounds like a great option, there are some serious concerns. First, these diets are by nature markedly deficient in iodine and we do not know what other effects this may have on the body. Iodine is found in many organs, such as the eye, and we do not know what years of deficiency will do. The diet is also a very poor source of protein which is very important in felines. The cat must eat only this diet with no treats or other foods. It is important to note that these last two options control but do not cure the disease. There is still a growing tumor which 5% of the time can be malignant.

Hyperthyroidism is a disease that when left unidentified and untreated will slowly rob a cat of their quality of life and is eventually fatal. However, it is very easily identified on routine blood tests. If your middle-aged or older cat gets their routine check-up then they are being screened for hyperthyroidism.

Tim Walker, DVM, DABVP

Alternative and Complimentary Medicine

21 Dec

Medical care and therapy of patients, both human and animal, can be quite involved and require a number of different medications and therapeutic modalities. At Somers Animal Hospital we primarily practice conventional, sometimes referred to as Western or allopathic, medicine. Alternative and complimentary medicine uses philosophies and treatments that differ from conventional medicine. Many of the treatments are based on Asian, especially Chinese, philosophies. alternative/complementary treatments include things like acupuncture, chiropractic care, massage therapy,  therapeutic laser therapy, herbal supplements and homeopathy. Some of these therapies have become fairly mainstream.  We do utilize some of these therapies to complement the traditional medicine we practice. Some of these complimentary treatments have sound scientific basis and some do not and this will be a discussion of these aspects.

The trend in traditional medical and surgical care is to use evidence-based medicine to decide whether a diagnostic procedure or treatment is worthwhile. The evidence comes in different levels- the lowest levels of evidence are based on clinical experience, followed by clinical and therapeutic trials. The most significant evidence is based on double blind clinical trials. This means neither the subjects taking the medications or treatments nor the people administering them know if they are getting an actual medication or a placebo. It is not until the trials are finished and all the information is collated is it known if the treatment is effective and better than the placebo effect. All clinical trials have a placebo effect. Even trials using animals have placebo effects- not necessarily in the animals but in the humans caring for them. If you are expecting something to work, it may have some type of positive effect. This is mostly psychological, but still can have noticeable physical effects. Most, but not all , of the drugs and therapies we use have gone through some level of clinical trials. So we have fairly good evidence  for the efficacy and safety. Responses and possible side effects are fairly predictable. Drugs and pharmaceuticals  we use are all controlled by the FDA. They must adhere to strict definitions of purity, efficacy and safety. The chemical make-up and dosage must be what is listed on the label. Any medication can have adverse side effects and individual patients respond differently.

What about alternative and complimentary therapies?  Some have been well studied and have good scientific evidence for their use and efficacy.  Acupuncture has become an almost mainstream therapy over the last 20-30 years, even though it has been part of Chinese medicine for hundreds of years. Scientists have studied how it works on the nervous system. One of the mechanisms  of effect is that the needles placed in specific parts of the body cause release of endorphins- the body’s own morphine-like (opioid) pain relievers. The pain relief effects can be blocked by  opioid blockers. This indicates a real, not a placebo, effect. Therapeutic (cold ) laser therapy, which we have been using for the last 2 years, has many studies showing the physiological effects of the laser on blood flow, stimulation of anti-inflammatory substances in the body and other effects. It seems useful in arthritis and many other painful conditions.

Other alternative therapies have far less evidence and successful responses are often based on anecdotal reports. This is basically the statement by a patient or pet owner about the responses they are getting. There is often a major placebo effect involved. There are very few controlled clinical trials for any of these modalities. In addition, herbal supplements, nutritional supplements and nutraceuticals (nutritional supplements used for therapeutic purposes) are not controlled by the FDA. Therefore you cannot be guaranteed of purity, safety and efficacy. When independent organizations randomly test these supplements they find levels of things listed on the label vary very widely. They also find many contaminating substances. This is especially a problem with herbal remedies from China. This is why they must put a statement on the label to the effect that claims for efficacy have not been scientifically studied.

That being said, we know that a substantial proportion of standard pharmaceuticals are derived from natural substances. Antibiotics from molds and fungi; digitalis from the foxglove plant; taxol, a chemotherapy agent, from the pacific yew tree are all examples. The difference is that the active ingredients have been isolated, purified and standardized. Natural and herbal supplements are extracted from their natural sources but not necessarily purified and standardized. This can and should be a concern. There are supplement companies that do adhere to strict manufacturing guidelines and many others do not so it can be difficult to know what you are actually getting.

There is also  the feeling that many people have that because it is natural or herbal it is non-toxic and safer than traditional pharmaceuticals. This is not necessarily true. Many natural substances are highly toxic. These substances evolved in plants  to inhibit consumption by insects and other creatures and in animals to protect against predators and can be quite toxic. Several herbal supplements have been removed from the market because they caused severe side effects, including liver failure.

We do use a fair number of nutraceuticals and herbally derived supplements.  For example, Denamarin contains silymarin, a chemical derived form the milk thistle plant, that has been shown to have beneficial effects on inflammation of the liver. Glycoflex, an anti-arthritic supplement, has many ingredients but one is derived from the shells of the New Zealand green-lipped muscle. We try to obtain our supplements from very reputable companies with known histories of accurate preparation of their supplements. Most adhere to and have labels for the NASC (National Animal Supplement Council) that has strict standards for purity and manufacturing standards. They also regularly inspect the facilities. So we feel confident that the products we dispense are good ones.

The last issue is homeopathy. This was developed about 150 years ago by a physician who had a philosophy that like cures like. So he made extremely dilute  solutions of a substance that in higher doses would cause significant symptoms. The problem with homeopathy is that there is absolutely no science behind the philosophy and virtually no studies on efficacy. When homeopathic substances are tested,  they are diluted so much that often no evidence of the supposed active ingredient can be measured. Often it is just water or alcohol that the substances are diluted in. This is one alternative therapy that we cannot recommend.

A couple of last points. People often take these supplements on their own and do not tell their doctor, or vet if they are giving them to their pet. It is very important to let us  or your physician know as there are many adverse reactions between these supplements and conventional drugs, and please listen to your doctor or vet about proper treatment with known and tested medications. Often a treatable disease can progress when these supplements are used instead of  conventional and tested treatments. Many of these things can be used along with, but not instead of, more proven therapies.

Martin Randell, DVM, DACVIM

Why does my cat need a blood test? Part 1- Kidney Insufficiency.

28 Nov

In May, Dr. Randell discussed the importance of semiannual exams for all pets as they get older. As mentioned, one of the reasons for these exams is to do a routine wellness blood test and urinalysis. As cats get older owners sometimes feel that a trip to the veterinarian is stressful, and may not be necessary if all seems well. However, these exams and laboratory tests are a wonderful way to identify problems early and start treatment to avoid a sick visit later. There are two very common diseases that if caught early are treatable, but if left unchecked can cause very serious illness. This month we will discuss chronic kidney insufficiency.

The kidney’s function is to filter the blood and to collect and remove waste products through the urine. As cats reach middle and later stages of life it is very common for them to slowly lose kidney function. This is a degenerative process that involves chronic inflammation in the kidneys. Early on there are no clinical signs for an owner to see. The first indication we find is dilute, or watery, urine. Once the cat loses 75% of their normal kidney function we begin to see changes in the blood tests. However, the patient still may show no symptoms, or may drink and urinate a little more than in the past. This is a very important time for us to identify the problem. Through the implementation of appropriate diet changes, supplements, and some times medications, we can greatly lengthen the amount of time before the cat starts to feel sick. As the disease progresses it leads to dehydration, lethargy, vomiting, poor appetite and weight loss.

Monitoring for progression of kidney insufficiency is very important.  We want to identify the common complications, such as silent urinary tract infections and high blood pressure, early and treat them. Thus avoiding further kidney damage and keeping the patient feeling good. We all want to help our pets when they are acting sick. Just remember, by treating them while they still feel well we may avoid them becoming sick.

Kidney insufficiency is a progressive disease. However, with good care and appropriate medical management cats can live happily for years. Just don’t tell them they’re sick! Look for Part 2- Feline Hyperthyroidism in a future blog.

Tim Walker, DVM, DABVP

The Other Side of the Fence

26 Sep

They say doctors and nurses don’t make good patients. They put off going to the doctor themselves, they ignore symptoms they have and they’re not always compliant with instructions. I think a lot of it has to do with the fact that they don’t like to be on the other side of the fence. Doctors and nurses know more and tend to gravitate towards the worst case scenario much more quickly because of all the knowledge they have. They lose control of being in the role of caregiver and provider and become one who is vulnerable and exposed, seeking advice and help in a potentially scary, unknown situation.

In the last 7 months, I have experienced this personally. As a veterinarian, my own dog was diagnosed with cancer in February. All of a sudden, I went from being the caregiver and provider to feeling helpless and terrified about the well being of my dog. I went through the gamut of emotions from grief and sadness to anger and disbelief. My dog is only 9, healthy as a horse and we had been doing some routine senior screening tests when we found a tumor on his spleen. After a successful surgery, performed by Dr. Walker to remove his spleen, we anxiously awaited results. Unfortunately, he fell into the 50% category of malignancy. My husband and I decided to pursue a number of conventional and alternative treatments to give him the best chance for a good fight, knowing we were dealing with a guarded prognosis. Again, I found myself in uncharted territory. Discussing chemotherapy with clients is very different than having to make a decision to do it on my own dog. Also, becoming acquainted with the world of integrative medicine was another education. We were able to come up with a complimentary balance between the therapies that he has tolerated very well. He has thrived, showing me that a little ammunition and a lot of education can go a long way and make a big difference. Other than a scare with a nearly fatal kidney infection, which he recovered from, he has lived life to the fullest and shown us that you don’t ever give up.

Being on the other side of the fence broadens one’s perspective. It gives you an appreciation for all the information your clients have to sift through and decisions they have to make based on information given to them by their veterinarian. (And of course, what they find on the internet:). In my case, it wasn’t a matter of ignoring clinical signs or not being compliant. It was not imagining that we would find a tumor in an apparently healthy dog that put me in a position that I hadn’t planned on being in- the client with the patient. I believe that things happen for a reason. It has been a valuable experience for me to become the client and be on the other side of the fence. Although cancer is a hard pill to swallow, my dog has taught me that we have a lot of resources out there and your veterinarian can help guide you to make the best choices for you and your pet.

 

Amy Williams Salman, DVM

The Costs of Veterinary Medicine

30 Aug

We are often asked why veterinary medicine is so expensive. The cost of veterinary medical care  is a significant concern for most pet owners, especially in difficult economic times. The reality is that veterinary medical care is actually fairly reasonable compared to many other things we pay for. Most people are not aware of the true costs of human medical care because they have health insurance and only pay deductibles and co-pays. The actual cost of health insurance premiums has to be added in to this equation. If you are able to see an actual bill from a human medical provider or hospital you will realize that fees for medical procedures, surgeries, hospital care and medications exceed those costs in veterinary medicine by several fold, sometimes 10-20 times for the same types of procedures. Only about 5-10 % of pet owners obtain pet health insurance so veterinary expenses come out of discretionary income.

The costs of veterinary care are determined by many things:

1)  A veterinary hospital is a business with all the expected costs- rent, taxes, utilities, property and liability insurance, health insurance for employees, costs of diagnostic and surgical equipment, outside laboratory fees, medication costs, staff salaries,etc.  Many of these costs are constantly increasing. Veterinary hospitals are full service facilities and have high overhead because of the  equipment and staffing needs.

2)  Veterinarians are professionals who spend 8 years going through undergraduate college and then veterinary college. Many also pursue post-graduate internships or residencies. Average veterinary incomes in the US are noticeably lower than professionals with similar training- MD’s, dentists and allied professions. Licensed veterinary technicians (who are comparable to nurses) get a 2 or 4 year degree but are paid far lower compensation than human nurses. The compensation is directly correlated with the high overhead and modest veterinary fees charged.

3)  Veterinary medicine, like human medicine, is a rapidly changing field with new and more complex diseases  developing. There are also new diagnostic and surgical techniques. To keep current veterinarians and staff must attend continuing education, purchase new equipment and supplies, and keep their facility up to date. All these things cost money. Veterinarians often have to perform a lot of laboratory testing and other diagnostics to evaluate our patients as they cannot talk to us and often hide symptoms.  This can, of course, increase the fees you have to pay.

4)  Many veterinarians (including Somers Animal Hospital) do pro bono and volunteer work caring for strays and orphaned animals. Our hospital also cares for injured and orphan wildlife working with wildlife rehabilitators as well as caring for the resident animals of several educational and environmental facilities.  These are significant out-of -pocket expenses.

5)  If veterinary fees  were compared to other things we commonly pay for- auto repair, plumbing, landscaping, home repair and improvement -it would seem that veterinary medical costs are quite reasonable.

So when you are faced with the costs of care for you beloved pet, who is a family member,  please keep these things in mind.  Most veterinarians will offer alternative treatments if the recommended treatment is unaffordable.

We are all in this profession because of our love of animals and we are all advocates for their proper care.

Martin Randell, DVM, DACVIM