New Year's Resolutions for Cat Owners

Cat-owners (of which I am one), are a unique bunch. We love our cats (every bit as much as dog-owners love their dogs), but we tend to be more "hands-off" with their care. This is probably because cats don't complain much, especially if allowed to stay in their routine. They tell their humans, "You do your thing and I'll do mine. I'll let you know if I need anything." And they do, especially at 6:00 AM when they are ready for us to WAKE UP! However, cats are not necessarily keen on change, even if it's for their own good. They detest going to the vet, having their food changed, meeting new cats, etc... This is another reason we cat owners are hands-off: We don't want them ticked off at us. 

So cat-owners are a tough crowd for us veterinarians. When "what is best for the cat" doesn't jive with "what the cat wants", they are caught in the middle. "Do I really want to incur Garfield's wrath, just because this guy in the white coat says I should?" Trust me, I understand. But there are so many things that cat-owners could do better for their cats, that it really is worth it in the long run to make some changes. So here are my New Year's Resolutions for cat-owners:

1.Bring your cat to us at least once a year, no matter what! I know your cat hates it. I know she never goes outside. I know she seems perfectly healthy. But cats are the very best at hiding illness. It is very common for me to see an extremely sick cat, and have the owner swear that they brought her in as soon as they noticed a problem. Many of these problems have actually been chronic, and have pushed the cat to the breaking point, at which time my job becomes a lot tougher, and the outlook for the cat is much worse.

2.Put your cat on heartworm/intestinal parasite/flea medicine every month. Even indoor cats get parasites. Heartworm infection in cats is extremely difficult to diagnose, but can definitely shorten the cat's life by causing asthma-like symptoms, wasting disease, or even sudden death (I've seen it happen.) Cats can also carry intestinal worms, with no symptoms, which are contagious to her owners (gross!) Prevention is easy - there is a once-a-month topical product (no pills!) called Revolution which protects your cat against all these parasites.  

3.Give your cat canned food, at least once in a while. The more we learn about feline medicine, the more we discover the value in treating many chronic conditions with certain "prescription" canned foods. The dietary therapy is often more effective than drugs (really!), and soooo much easier....as long as the cat will eat it. Yes, some of these diets also come in a dry form, but the canned food is almost always more effective. The biggest obstacle is trying to get a cat that has always eaten dry food to switch to canned (did I mention that cats hate change?) So, get your cat used to eating canned food, at least once a week or so. It may pay off later.

4.Feed your spayed/neutered adult cat about 30% less than the label says. AAFCO feeding guidelines are based on studies done mostly on non-spayed, non-neutered cats. We know that a spayed or neutered cat has about a 30% lower metabolic rate, and so needs fewer calories. Having said that, every cat is different, so the nutritional plan for your cat should be discussed with your veterinarian!

5.Play! All cats need physical and mental stimulation. They are predators by nature and are physiologically healthier if allowed to "scratch" their predatory "itch." Strings, feather toys, and laser pointers all provide the stimulation needed to help keep a cat healthy. Here is a link to a terrific website regarding environmental enrichment for indoor cats: http://indoorpet.osu.edu/cats/.

My Dog Just Had A Seizure!

One of the most awful and disconcerting things a pet owner may suffer is watching their pet experience a grand mal seizure. These seizures are often violent, and the pet seems to be dying right in front of you. They usually fall over, their eyes roll back in their heads, and there are uncontrollable body movements. In addition, some will urinate and/or defecate on themselves. It is a terrible, terrible thing to see.

The good news is that a single seizure is rarely as serious as it appears. They usually last no more than a couple of minutes (although they seem to last forever), and after some recovery time, the dog returns to normal. As with most medical problems, there are some exceptions.

Some dogs who have a seizure, only have a single one, and then are fine. For this reason, I usually do not do a full work-up on a young adult dog who has had a single seizure, has no other symptoms, and has a normal physical exam. However, if a dog is less than a year old, older than five years old, has other symptoms, or has had more than one seizure; that dog will need a full work-up.

By far, the most common cause of seizures is a disease called Idiopathic Epilepsy. Epilepsy usually first appears in dogs between the ages of one and five. There is no known cause, but certain breeds seem to be predisposed. There is no test for epilepsy, so the diagnosis is made by ruling out other causes of seizures. So, what are some other causes of seizures? The list is long, but includes: head trauma, toxins, metabolic disorders (low blood sugar, kidney disease, liver disease), congenital brain disorders (such as hydrocephalus), cancer, meningitis, heart disease, and "stroke." My typical work-up for a seizure dog includes an ECG, CBC, blood chemistries, blood pressure, and a thyroid test. If these tests are all normal, but the dog is showing other neurologic symptoms or is not responding to treatment, I refer the dog to a specialist who can do more advanced testing such as CT scan or MRI.

My first choice anti-seizure drug for epileptics is phenobarbital. Phenobarbital is very effective in most cases and is fairly inexpensive (the dog will be on medication for life). There are potential side-effects of phenobarbital which include transient sedation, increased appetite, and most significantly - liver toxicity. The liver problem is uncommon, but we closely monitor liver values on our patients who take phenobarbital. For those patients whose seizures are not adequately controlled with phenobarbital, I usually add potassium bromide. When combined with phenobarbital, potassium bromide is a very effective anti-seizure drug, and is also fairly inexpensive. Dogs on potassium bromide have an increased risk for pancreatitis.

There are newer anti-seizure drugs on the market, which are significantly more expensive. However, these drugs tend to have fewer side-effects, and are sometimes effective in patients not responding to (or who are having side-effects from), phenobarbital or potassium bromide.

A recent study showed that the sooner an epileptic dog is put on medication, the better the medication will work, and lower doses will be needed. Historically, veterinarians (including myself) tended to not start anti-seizure drugs until the patient was having seizures with unacceptable frequency ("unacceptable" was based on the owner's tolerance, but I often would suggest that more than every two months was "unacceptable.") Since the newer information has come out, I strongly urge that my epileptic patients start medication after the second seizure. Being able to use lower doses of anti-seizure drugs (lower-doses = less chance for side-effects) with better results is definitely in the best interest of the patient!

Well-Thought Complaints From a Client, And My Response

As the owner of a fairly large (4 DVMs, 35 support staff) suburban veterinary practice in the year 2013, I occasionally get complaints from disgruntled clients. Yesterday I received a well-written letter from a client which was clearly thought-through, and significantly, logical. I appreciated the feedback, and the opportunity to respond. Here is her letter, followed by my response and a comment or two.

Dear Horseshoe Lake Animal Hospital,

Thank you for the care that you provide my pet.  I appreciate the work that you have done in the past and currently, but I feel that I need to communicate my feelings as customer feedback.  When I first began bringing my pets to your clinic, I felt that the care was great and the price was also reasonable; however, in recent years I really dread bringing my pet to the clinic, because it’s difficult to leave without a $200+ bill and significant guilt for treatments may be as well.  I have several examples from my pets’ histories to call from. 

One day I brought my dog in for severe diarrhea.  She was examined and I was asked if I wanted a giardia test.  I said if you feel that the test is necessary, then give it to her.  The end result was that she was negative for giardia but she was given flagyl (Metronidazole) to take at home.  My frustration with this incident is that she was given the treatment for giardia even though she as negative.  I understand that the treatment for severe diarrhea with a protozoal or anaerobic bacterial etiology would be Metronidazole.  I do not understand why the giardia test is necessary if she is going to be given the treatment for it despite the test outcome.  It was a waste of your time and my money to do that test when she was going to receive the medicine regardless. 

Secondly, each time I visit for a well animal visit, there are many options for tests and extra vaccines that are presented to me.  Of course I want my dog to have good treatment and prevention of disease, but I feel that my pet is probably not at high risk for many of these diseases because she is indoors most of the time (example: Leptorspirosis vaccine).  I feel guilty for refusing each time I say no to a test or a treatment, but I suppose if I accepted everything that is offered or recommended, I would leave with a $300-400 bill.  This is more than I typically spend on my family of 4 per year for healthcare clinic/hospital charges. 

In addition, I feel that some of the medications are overpriced and that, since you have your own pharmacy, the option to have the meds filled elsewhere is taken away.  For example, some antibiotics and generic medications at Schnucks pharmacy and many other pharmacies are free or next to nothing in price, yet I pay a premium to have them filled by the pharmacy at the clinic.  I know some veterinary medications are not carried at standard pharmacies, but some are.  In those cases, I would appreciate your recommendation to have the script filled elsewhere.

Most recently, my pet came in with a limp.  I thought I established before the appointment that the cost of treatment is an issue for me.  Two to three weeks prior to the appointment, my dog hurt herself while chasing a rabbit (or other creature).  The injury happened acutely.  After examining my dog and feeling an effusion around the knee, the veterinarian order 2 films- one of the knee, and one of the pelvis area.  Understandably, he was trying to rule out a hip; and given the acute onset of the injury the knee was the most likely culprit.  To save cost, it seems prudent to only order 1 x-ray, and if that comes back negative, to order an additional film if necessary.  When patients don’t have insurance to help offset the cost (and even when insurance is available), prudent management of diagnostic tests and films is necessary.  Maybe ordering 2 x-ray views in this situation was the same cost of ordering 1 (I could not tell definitively from my bill); but coming away from the appointment, I felt that maybe this could have been an unnecessary cost and I find myself frustrated at myself for agreeing to x-rays at all.  At this visit, I also had to reject two of the three therapies that may help my animal based on cost and this also made me feel terrible.

Please understand, I don’t question the excellence of care given to animal at your clinic.  The veterinarians and the techs are amazing with the animals.  However, to keep coming to the clinic I need to feel that you are also considering the cost to the “parents” of the patient.  Sometimes I feel like I’m being taken advantage of by the number of tests and preventative treatments that are strongly encouraged.  I feel like there might be a money making aspect to some of the recommendations. I would just like to feel the vets are doing their best to keep the cost of care down for the “parents”.

Thank you for your consideration.

Sincerely,

(Name Withheld By Dr Hall)

My response:

Dear (Name Withheld),

Thanks so much for your letter.  I am always appreciative when clients have the courage to voice their opinions to us, even if they are unhappy.  I would like to address your specific concerns as much as possible, and also speak to the “big-picture”.  By the way, thank you for your nice words about the care that your pets have received at Horseshoe Lake Animal Hospital.

I will start with the occasion that you mentioned when (name withheld) was tested for giardia, and then given Metronidazole anyway.  My guess would be that the Metronidazole was prescribed for its anti-inflammatory effects on the large and small intestine, and not anti-protozoal.  If (name withheld) would have tested positive for giardia, this would have changed things in two; and possibly three ways.  First, a follow up giardia test would have been indicated to make sure the infection was cleared.  In our experience, giardia is probably the most difficult parasite to clear from the body.  Second, giardia is potentially contagious to people.  We always have a conversation with our clients about zoonotic risk when their pets have giardia.  And lastly, Metronidazole is no longer considered the treatment of choice for giardiasis in dogs.  Had (name withheld) tested positive, the doctor probably would have prescribed fenbendazole.  I hope this explains why we would not consider the giardia test to be unnecessary.

Your second concern involved the tests and extra vaccines that are presented to you at annual wellness visits.  You specifically mentioned leptospirosis.  There is a national advisory commission that meets every few years to determine the best vaccine recommendations for companion animals.  This commission has currently determined that there are four “core” vaccines (vaccines that all patients should receive) for dogs, four “non-core” vaccines (vaccines that should be administered to at-risk patients), and numerous non-recommended vaccines.  “Lepto” is considered non-core by the commission, and therefore by us. However, lepto has become so pervasive that the Veterinary colleges at the University of Missouri and Purdue University (among many others), consider it “core”.  The fact is, just about any dog that goes outside faces some risk, and dogs that travel away from their homes (like going for runs/jogs) are at increased risk.  I hope you understand that preventable diseases such as leptospirosis can be devastating to a dog’s health, and like giardia, lepto is contagious to people.  Our focus is always going to be putting the best interest of the pet and family first. 

Having said that, we never recommend vaccines from the non-recommended list , and we do not recommend a non-core vaccine for a pet with no risk factors, but we will have the conversation to determine risk. 

You may also be referring to the “wellness testing” recommended at each annual visit.  We do believe in the value of wellness testing for our patients, and have hundreds of experiences where early disease detection has benefited them.  My personal physician orders labwork on me every year, even though I perceive myself to be healthy.  Since many patients age so much faster than humans, and they can’t talk to us, I believe that wellness testing is even more important for them.  I do understand that many pet owners cannot or choose not to spend their dollars on wellness tests, which is why these things are optional.  But we at least owe it to you to make you aware of the benefits so you can make an informed decision. 

There is a mention of writing prescriptions for our clients to take to human pharmacies in order to save money.  We do write or call in prescriptions for our patients on a daily basis.  However, there is even some concern on our part about this practice.  Dogs are not small people, and in many cases the biological activity and dosing of drugs is dramatically different between people and pets.  You may be aware of the pharmacist in Tacoma who talked this client out of giving the dosage of medication the veterinarian prescribed for her dog, telling her it could kill the dog.  The dog suffered needlessly because the owner was afraid to give the medication. 

Lastly, regarding your recent visit with (name withheld), you are correct that I suspected a problem in her knee.  But after practicing for almost 30 years and seeing some really awful things from missed diagnoses (usually pathologic fractures from undiagnosed bone tumors), I want to make sure not to miss something obvious.  I do not always order x-rays for limping dogs (although I probably should), especially if I think it’s just an arthritic issue or a soft-tissue injury based on history and physical exam.  (Name withheld)’s history of acute onset single-leg lameness with minimal improvement in over two weeks suggested something other than arthritis or soft-tissue.  

Any radiologist will tell you that when radiographing any body part, two views should always be taken.  In (name withheld)’s case, I wanted the V-D view to also include the hips (pelvis) since that could easily be incorporated into the V-D view of the knee.  This is standard procedure and gives us “more bang for our buck”.

In summary, I am truly sorry that you are frustrated with the costs involved in the care of your pets at our hospital.  I hope that this helps you understand that every decision that we make is driven by what is in the best interest of our patient.  I assure you that surgical correction of (name withheld)’s knee is reasonable therapy (and may become imperative at some point), but I felt that conservative treatment also had a good chance at helping her, and I always prefer that over surgery, when feasible.  If my recommendations are based on what makes the most money, I would have chosen to recommend surgery.

I do very much appreciate your feedback, and I hope we can do a better job of explaining your options, and why we are recommending (or just discussing) them moving forward.  It is my true and sincere hope that (name withheld)’s knee will do well, and that she will be running around normally in the future.

God Bless,

Dr. David Hall

The only thing I would add is that she mentions that she has the potential to spend more for her vet visits than on her family's healthcare in a year. This conveniently overlooks the THOUSANDS of dollars that she or her employers are spending annually on health insurance, which then pays most of their medical bills. I've seen my health insurance premiums, and I've seen the medical bills before insurance. No one can reasonably assert that veterinary care is anywhere close to the cost of human health care. I assure you, no one at my practice (including me) is getting rich. And by the way, I'm not complaining: I make a good living, and I don't mean to suggest that veterinary care should cost as much as human health care.

When The World Gets Crooked

It won't happen to too many pets, but if it happens to yours, it will have you thinking that it's finally time to "put her to sleep." Your dog (or cat) will suddenly (as within a few hours) become extremely disoriented - probably to the point where she is running into things and falling over. There's a good chance she'll vomit, and for sure she will refuse to eat. You may or may not notice that her head is tilted, and her eyes are doing crazy things! You will see these symptoms and fear the worst. And who can blame you? This almost always happens to older pets: the ones that we are waiting and fearing something terrible is going to happen to anyway. And this certainly is something terrible.

Except, it often isn't as bad as it looks. I just described to you the symptoms that animals with vestibular disease often present with. Vestibular disease is a generic term which simply means there is a problem with the pet's equilibrium. The problem can be located in the inner ear, or more often in the brain. What the pet is experiencing is akin to someone spinning us around at a high rate of speed and then asking us to walk across the room. We will stumble, stagger, and maybe even vomit if we were spinning fast enough.

The various causes of vestibular disease in pets are still pretty mysterious to us. The most common maladies are "old dog vestibular disease" and "feline vestibular disease." The bad news is that we don't know what causes either one of these syndromes. The current thinking is that they are some form of vascular accident (think "stroke"). The happy news is that the prognosis is usually pretty good. Usually time, antivertigo drugs, and maybe some steroids work wonders for these patients.

Vestibular symptoms can less-often be caused by inner ear infections, trauma, or tumors. The prognosis varies in these cases.

My typical workup for a dog or cat with vestibular symptoms is to check the blood pressure (hypertension makes me suspicious of a vascular accident), and thyroid levels (hypothyroid dogs seem to be at increased risk for neurologic problems). I also do a thorough physical exam with special emphasis on the ears. The typical patient will improve over the next 2-4 weeks. If there is no improvement, I will do a more complete blood workup and skull radiographs to look for changes deep in the ear canals. If these tests are normal (which they usually are) and my patient isn't improving, the prognosis is less favorable and I am sending her to a veterinary neurologist for a second opinion and possible MRI.

I am happy to say that in my personal experience, about 80% of these pets do remarkably well, and the owners are REALLY glad I talked them out of euthanasia.

Aspirin in Pets - Bad Idea

Last night I had a patient who was in a really bad way. He had a serious arthritic condition which had gotten progressively worse over the past several months to the point where the dog could no longer stand on his back legs. In an effort to help, someone in the house had given the dog aspirin. Ugh. 

First of all, I could have done a whole lot more for this poor dog had he been brought to me months ago. Arthritis is a relentlessly progressive condition in dogs, and once it occurs, arthritic destruction of cartilage and remodeling of bone cannot be reversed. However, the progression of the disease and the pain that accompanies it can be dramatically reduced in most cases IF TREATED EARLY. Okay, that's not the topic of this blog, so...about that aspirin...

Aspirin in dogs is an effective pain-reliever at the proper dose. In fact, I would prescribe it for some of my patients 20-25 years ago. You can still buy "doggie aspirin" with the dose listed on the bottle. But unfortunately, aspirin has a very high potential to cause more problems than it helps. The number-one risk is gastric ulceration, which can cause death from hemorrhage or stomach perforation. I have seen it happen. Aspirin can also cause kidney failure, especially in older pets (which are the ones most likely to receive it).

Now we have newer drugs which are similar to aspirin, but much safer and more effective. These drugs can also cause serious side-effects, but their risk-profile is muuuuuch safer! The problem is, if our patient has been given aspirin for any recent length of time, it changes the dog's ability to handle the safer drugs. What this means is, if you give your dog more than one dose of aspirin before bringing him to see me, you have effectively tied my hands from giving him something much better and safer. 

Dogs who have received previous aspirin therapy should go through a 5-7 day "washout" period of no medication, before we can give the good stuff. During this time, the dog has to suffer with the pain that we could be treating had the dog not been given aspirin. 

As a side-note, aspirin is quite toxic in cats, except at super-low doses and prolonged intervals. Never give aspirin (or Tylenol) to a cat without specific instructions from a veterinarian. You know what? Let's just not give any medication to our pets without first checking with the vet. DVMs know what is safe, and at what dose. Use us! That's what we're here for.

The Difficult Decision

Five minutes ago, I ended the life of an older, but not "ancient" cat on a soft towel in a quiet room in the back of my office. She went to sleep peacefully and painlessly. This cat belonged to some nice folks that my family has been acquaintances with for a long time. The husband spoke to me yesterday about their cat. I was not at work, and we had been talking about something else (probably sports), when he abruptly mentioned that his cat had started urinating and vomiting all over the house. She had ruined several pieces of furniture as well as the carpet in the basement. He said, "I think it's time to put her down, don't you?"

I never quite know how to respond to those situations, because you see, we had not seen his cat in two years. I assumed that since he hadn't brought her for an exam (and possible testing), that he really wasn't interested in trying to find out why she was vomiting and urinating all over. He was really just wanting me to "sign off" on a decision that had already been made. The cat had originally belonged to his son, who had long since moved away.

I'm not judging him. There are often mitigating factors when people decide that it's best to end the life of a pet. We usually are not privy to these circumstances. I believe that sometimes the person making the decision isn't even aware of some of the psychological "baggage" that is influencing their choice. The gentleman in my story is an intelligent guy. He is smart enough to know that maybe I could have done something medically that would have helped his cat. He's also smart enough to know that it might have been expensive, unrewarding (ie ineffective), or labor-intensive (have you ever tried sticking pills down a cat every day?)

So he probably had his reasons for not seeking my medical assistance, but instead my reassurance that they were making the "right" decision. Was it the "right" decision? I am humble enough to admit that I don't know. There are simply too many factors that I am unaware of.

I do know this: His is a good family, and although the cat might not be high on their priority list, I think they provided a comfortable home for her. I also know that humane euthanasia results in no suffering for the pet. I was there to make sure she left this world in a painless manner (which is better than many of us will have.) For reasons of their own, they chose euthanasia over exploring medical options. It's not the decision I would have made, but that doesn't make it wrong.

Tularemia - An Emerging Threat To Cats and People

This just in from the Illinois State Veterinary Medical Association:

Cats Test Positive for Tularemia

Champaign-Urbana Public Health District Encourages Citizens to Keep Cats Indoors to Help Minimize Tularemia

Champaign, IL – The Champaign-Urbana Public Health District (CUPHD) is encouraging area residents to keep cats indoors to reduce the likelihood of contracting tularemia. The Champaign-Urbana Public Health District has identified two additional cats positive for tularemia in Champaign-Urbana. Previously, five cats were diagnosed with tularemia at the University of Illinois, College of Veterinary Medicine; one cat from Champaign and one from Urbana; and three cats from two households in Savoy. Tularemia is caused by the bacterium Francisella tularensis found in animals (especially rodents, rabbits and hares).

Cats may prey on rabbits and rodents and become infected or they may become infected through tick exposure. Cats may develop a variety of symptoms including high fever, mouth ulcers, depression, enlarged lymph nodes and behavioral changes including not eating. Persons whose cats have contact with the outdoors should take their pet into the veterinarian if they should develop these symptoms.

People may also contract tularemia developing sudden fever, chills, headaches, diarrhea, joint pain, muscle aches, cough and weakness. People can become infected by handling pets or wild animals with tularemia, being bitten by ticks or by inhaling the organism. If you develop symptoms of tularemia see your health care provider.

To reduce the chances that your cat will become infected:

• Do not allow your cat to hunt outdoors
• Consult with your veterinarian to make sure your cat is protected from tick bites
• Report any unexplained large die-offs of rodents or rabbits to your local animal control. • To reduce the chance that you or your family members will become infected:

• Wear tick protection when outdoors
• Do not mow over sick or dead animals
• Do not handle wild animals
• Cook wild game meat thoroughly before eating and use gloves when handling the animal and preparing the meat for cooking
• Take any pet with symptoms of tularemia to the veterinarian

If you have questions about tularemia in humans, please contact Rachella Thompson, Communicable Disease Investigator, with CUPHD at (217) 531-5361 or your health care provider. If you are a cat owner or have questions about tularemia in animals, please contact your veterinarian. Visit http://www.bt.cdc.gov/agent/tularemia/facts.asp orhttp://www.avma.org/public_health/biosecurity/tularemia_facts.asp for additional information.

Note from Dr Hall: There is no vaccine for Tularemia!