Wednesday, September 16, 2020

3151. Liver disease. Therapeutic diet (Hills L/D)


Thur 17 Sep 2020.  Follow up on last Thursday case.
See:
 https://2010vets.blogspot.com/2020/09/3146-chronic-haematuria-in-14-year-old.html


The dog came for blood in the urine again some 2 weeks ago. Blood and liver test on 6 Sep 20 show bacteraemia and liver disease indicated by high liver enzymes and ketones in the urine.

BLOOD TEST on 6 Sep 2020

1. Liver disorders.
SGPT/ ALT   788 U/L  (less than 59)
SGOT/ AST   259 U/L  (less than 81)

2.  Bacteraemia.
Total white cell count   29.0 x 10*9/L  (6-17)
Neutrophils  96.1%   (60-70%)    Absolute  27.9 x 10*9/L (3-11.5)

3.  Urea and creatinine within normal units. No kidney failure.

URINE TEST on 6 Sep 2020

pH = 7 (5-8)
SG  1.020  (1.005-1.030)

Protein 4+ (Negative)
Ketones 2+ (Negative)
Blood  4+ (Negative)

White blood cells over 900 (/uL)
Red blood cells over 1800 (/uL)
Bacteria +
No casts or crystals.

DIAGNOSIS
1.  Bacteraemia. No vomiting or polydipsia and polyuria.
Fever due to bacteraemia. Infections could be from the liver and urinary tract infections.


CONCLUSION

The 14-year-old labrador retriever has high liver enzymes. No jaundice. Vet prescribed Zentonil and antibiotics for haematuria.  Sent the dog home with antibiotics and Zentonil. Is this sufficient for the dog? 

Is this a cause for concern for this old dog?
What can be done to help the dog? X rays and ultrasound test of the liver to check for liver tumours can be done if the owner consents.

In the meantime, the owner must be educated to give a therapeutic diet for liver disease. Based on the dog's weight of around 27 kg, the daily intake should be at least 313g. Switch over to new food by the 7th day and do not give other food or treats for 3 months. A blood test and urine test in 3 months. 






Monday, September 14, 2020

3150. An 8-month-old Shih Tzu has an ocular dermoid electro-surgery - superficial keratectomy

15 Sep 2020. Script for Intern to create a BKTP video


(HOOK)
Eyes are the first objects we see in a person or an animal. 
Pretty big clear eyes are attractive.



Eyes and a chrysanthemum-hair cut face make the Shih Tzu the top 3 small dog breeds as pets in Singapore. 



 From my Toa Payoh Vets case files over the past 40 years, the Shih Tzu breed has the most incidence of ocular dermoid.  










Dermoids are non-cancerous masses with skin, hairs and fat. They can be found in people as well as dogs and cats.

There are two types. They are the
limbal dermoid, being located in the limbus (sclera and corneal junction) 






and the lipodermoid which is sited in the temporal area (where the eyelids meet in the corner towards the ear - lateral canthus). 




THIS IS A BE KIND TO PETS VETERINARY EDUCATIONAL VIDEO: 




This video shows surgical procedures. Viewer discretion is advised. 





SINGAPORE is a city state with more than 80% of the residents living in apartments. Small dog breeds such as the Shih Tzus are most popular as apartment pets. 







The Shih Tzus appear to be the breed that is most affected by ocular dermoids, in cases seen at Toa Payoh Vets. 






ELECTRO-SURGERY - EXCISION OF AN OCULAR DERMOID IN A DOG
Dr Sing Kong Yuen, BVMS (Glasgow), Toa Payoh Vets 

I do not know whether other use electro-surgery to remove ocular dermoids from the cornea. This video shows the electro-surgical procedure to excise the limbal dermoid using electricity


SURGICAL PROCEDURES ARE AS FOLLOWS:



This is a normal left eye of the Shih Tzu. It has no dermoids




A limbal dermoid is at the junction of 
the sclera (eye white) and the cornea as in this case




Sedation is by IV ketamine and ketamine
General anaesthesia using isoflurane gas 




The dermoid is excised using electricity




3/4 of the dermoid has been excised.




The dermoid inside the cornea is being excised




More dermoid is excised using the circular loop




Be careful not to enter the eye
causing rupture of the globe. No more excision
after over 90% of the dermoid has been cut out.

Care must be taken not to enter the eye when excising the dermoid. In this case, the site where the dermoid lay was not covered by a piece of transplanted cornea.  

A 3rd eyelid flap for 14 days facilitates healing of the exposed corneal epithelium. Antibiotic eye drops are applied daily for 14 days. An Elizabeth collar for 14 days prevents scratching of the eye.  In young puppies and kittens of less than 2 months, anti-inflammatory eye drops must not be used to prevent swelling and scarring. 


POST-SURGERY.
The owner did not permit me to ward the patient for 14 days after surgery. He wanted the dog back by Day 4. So, I took out the eyelid stitches sewing the eyelids together to facilitate corneal healing on Day 4 instead of Day 14. 

On Day 9 after surgery, I followed up and saw the corneal healing taking place. 



As to whether there will be corneal scarring later, I was unable to follow up. I electro-excised over 90% of the dermoid but not 100% as I did not want to risk the corneal laceration, rupturing the globe. 


CONCLUSION. 
SUPERFICIAL KERATECTOMY USING SURGICAL BLADE NO. 11 is the other option is to excise the limbal dermoid.

A stay suture to elevate the eyeball can be placed on the conjunctiva at the medial canthus area for easier surgery. 

Sunday, September 13, 2020

3149. Puppies with splayed legs (Swimming puppy syndrome)

A figure-of-eight rope around both hind legs --- help the puppy to walk normally.
Non-slippery floor. 
Lots of patience and love.
 
Hard to succeed as most breeders put the puppy to sleep.

---------------------

See:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743573/#:~:text=Swimmers%20syndrome%2C%20also%20known%20as,an%20inability%20to%20stand%20or

article reproduced below:

. 2013 Sep; 54(9): 869–872.

PMCID: PMC3743573
PMID: 24155492

Language: English | French

Home-care treatment of swimmer syndrome in a miniature schnauzer dog

Swimmers syndrome, also known as swimming-puppy syndrome, flat-puppy syndrome, swimmer puppy syndrome, flat-pup syndrome, twisted legs, or turtle pup, is an uncommon developmental deformity of newborn dogs and cats whereby the limbs, primarily the hind limbs, are splayed laterally resulting in an inability to stand or walk. Forward movement with this affliction is only accomplished by lateral pedaling motions (). Swimmers syndrome has generally been considered to be untreatable; therefore, animals that present with symptoms of the syndrome have tended to be euthanized (,). However, there have been several notable cases in which clinicians successfully treated animals — (1 kitten and 3 puppies) suffering from the syndrome with a combination of intensive physiotherapy, bandaging, external splinting, and hospitalization (,). In the present case, this miniature puppy with swimmers syndrome demonstrates that owners can provide satisfactory home-care and physiotherapy. Also, this case has been followed for over 10 y, and the dog is still alive, thus providng information about the prognosis.

This study presents the case of a dog that was born with swimmers syndrome; the original veterinarian had advised euthanization, but the owner chose to donate the dog to a teaching hospital. One of the authors adopted the dog and has been caring for it for the past 10 y. As a result of the home-care treatment, the dog recovered from the syndrome and continues to live a healthy life.

Case description

A 50-day-old, female miniature schnauzer was presented with astasia, dorsoventral flattening of the thorax, stiffness of hind-limb joints, hypoplasia of hind-limb muscles, paddling leg motion, and panting (Figure 1). A severe exorotation of both hind paws and a pronounced hyperextension of both tarsal joints were present. In addition, there was an inability to adduct the hind limbs and zero range of motion in the hind-limb joints was observed. Neither of the hind legs could be placed in a normal standing position even with manual support. At rest, the dog remained in sternal recumbency; if positioned in dorsal recumbency the dog was unable to right herself.

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Swimmer puppy. A — Before treatment — note the outward projection of the hind limbs, the flat thorax, and the rough hair coat. B — After treatment — note the resemblance to a normal puppy.

The owner brought the dog to the hospital and described its situation and signs. The owner explained that the dog was smaller than its littermates and that this, combined with its immobility, meant it had difficulty feeding. Moreover, the owner noted that the dog regurgitated its food after every feed. The regurgitation contributed to the dog’s low weight (the puppy weighed only 850 g when she arrived at the hospital).

In addition, the dog’s ventrum was covered with erosive lesions from urine and fecal scalding. A neurological examination identified no abnormalities. Thoracic radiographs revealed dorsoventral thoracic compression and displacement of the heart and lungs (Figure 2). A complete blood (cell) count (CBC) was normal. The level of blood urea nitrogen (BUN) (0.83 mmol/L, reference range: 2.14 to 7.83 mmol/L) was low and other serum chemistry panels (including albumin, alkaline phosphatase, aspartate aminotransferase, calcium, creatine phosphokinase, creatinine, glucose, lactic dehydrogenase, magnesium, and total protein) were within the reference ranges.

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Survey thoracic radiographs of the dog before treatment. Dorsal deviation of the sternum and left deviation of the cardiac silhouette were found. A — Right lateral view, B — Ventrodorsal view.

Environmental modification, nutritional support, and physiotherapy were recommended as treatment. As an environmental modification, a non-slippery floor was constructed with a cotton carpet, and an absorbent pad, which was frequently changed, was placed on the bed. In addition, the ventrum was wiped regularly with a wet cloth, and baby powder was applied regularly to prevent further erosions. A mixture of 2 pet foods — Science Diet Prescription p/d canned (Hill’s Pet Nutrition, Topeka, Kansas, USA) and Science Diet Prescription a/d canned (Hill’s Pet Nutrition), 10 g each — was fed to the dog every 2 h, 9 times a day. The dog consumed 15 to 20 g at each feeding. The total calorie intake for the dog was 173.2 to 230.94 kcal per day, an appropriate amount for a young dog weighing 850 g. After feeding, the dog was lifted upward and massaged gently from head to tail for 5 min to prevent regurgitation.

A standardized physiotherapy routine was performed every 2 h for 40 d following admission. The dog was placed in dorsal recumbency, and the physiotherapy session began with a gentle stroking massage from the head to the hind limbs for 20 s. Then, for the flat thorax, both lateral sides of the thorax were gently pressed and released using the palms of the hands, every 5 s for 1 min. For the hind limbs, an effleurage massage was applied from the hip to the digits for 20 s, followed by a kneading massage that was applied from the digits to the hip for 20 s.

After the massage session, each of the hind-limb joints was put through a series of passive range of motion exercises in the sequence outlined. First, to improve digit flexion and extension, the practitioner gently flexed and extended the dog’s digits for 10 s, while supporting the carpus with 1 hand and the digits with the other. Second, to improve the stifle flexion and extension, the practitioner gently flexed and extended the dog’s stifle for 10 s, while supporting the distal femur with 1 hand and the tibia with the other. Third, to improve hip flexion and extension, the practitioner gently flexed and extended the dog’s hip for 10 s, while supporting the proximal femur in 1 hand and the pelvis in the other. Fourth, to improve movement in the hip joints, the practitioner applied a gentle stroking massage with the fingers to both the dog’s hip joints for 20 s. To improve rotation in the joints, gentle pressure was applied medially, and excessive pressure was avoided during all massages and passive range of movements. In future cases, it is recommended that, as in this case, the passive range of motion on each joint be performed separately to prevent applying excessive stress on the joints. Finally, the dog was held in a normal standing position with all 4 limbs touching the ground for 1 min. After 40 d of treatment, the puppy was able to ambulate normally but experienced bilateral grade I medial patella luxation up to 1 y of age, after which the condition spontaneously resolved. Survey thoracic radiographs of the dog after treatment are shown in Figure 3.

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Survey thoracic radiographs of the dog after treatment. A — Right lateral view, B — Ventrodorsal view.

The dog, now 10 y old, has not suffered from any health issues, other than those seen in the first year of treatment; the dog has regular heartworm prevention medication and vaccinations.

Discussion

Swimmers syndrome is similar to myofibrillar hypoplasia syndrome, which is seen in piglets (); the cause of each syndrome is unknown (,,). However, it has been suggested that genetic and environmental factors may be responsible, including hard or slippery floors, weight gain exceeding skeletal development, dysfunction of synaptic or ventral horn cells, abnormal myelinization, delayed neuromuscular development, and obesity (,,). In addition, it has been proposed that in-utero viral or fungal infections may cause muscular dystrophy in the developing fetus of piglets (). In the disease of piglets, the histological appearance of affected muscles resembles that of experimentally induced glucocorticoid myopathy, suggesting that the condition could result from stress during pregnancy ().

Pectus excavatum is a malformation of the sternum and costocartilages that results in dorsoventral flattening and narrowing of the thorax (,,). Swimmers syndrome and pectus excavatum can occur independently or concurrently. Pectus excavatum is a congenital thoracic skeletal deformity, while the main symptoms of swimmers syndrome are the inability to stand or walk by the normal age of 3 wk, the limbs being splayed laterally; the inability to stand or ambulate; and forward movement being accomplished only by lateral pedaling motions (). In this case, the dog was unable to stand or walk, and it was diagnosed with swimmers syndrome.

Environmental modifications can help improve the health and hygiene of dogs suffering from swimmers syndrome. To help swimmer dogs in their efforts to stand, it is necessary to provide a non-slippery floor to prevent slippage and further injury. In addition, because swimmer puppies urinate and defecate where they rest, it is suggested that an absorbent pad be placed on or near the bed, baby powder be applied after each movement of the bowels or bladder, and that they be wiped regularly to prevent urine and fecal scalding.

The dog in this study had a low BUN. Possible causes for decreased BUN in a dog are malnutrition, liver dysfunction due to infectious diseases, toxins, and portosystemic shunts (). However, the latter factors were excluded because the liver enzyme and CBC values were within the reference ranges; thus, malnutrition due to competition among the littermates was regarded as most likely. To treat the malnutrition, we selected a canned diet rich in calories and protein and with a desirable texture, and fed small, frequent amounts to improve the dog’s nutritional status ().

These dogs may be at greater risk of inhalation pneumonia from regurgitation after feeding, as shown in a previous report of a German shepherd dog afflicted with swimmers syndrome ().The dog herein was therefore lifted regularly and massaged from head to tail to prevent regurgitation.

In a previous case, in which a 6-month-old swimmer dog was euthanized, the dog never gained weight, was undersized (18 kg), walked unsteadily, and tired easily after moderate exercise (). In the present case, while the dog was smaller than its littermates, weighing only 3.5 kg at 6 mo and 4.5 kg at 1 y, being undersized did not lead to any further health issues once the dog had recovered from swimmers syndrome. This indicates that, while swimming puppies may remain underweight, they can function normally, as long as the nutritional support is appropriate.

It has been suggested that hobbling, or tying the hind limbs of piglets suffering from myofibrillar hypoplasia syndrome together below the hocks with adhesive tape may accelerate recovery and help affected piglets to stand and move around more freely (). Some veterinarians have suggested hobbling the hind limbs together to prevent the splay-legged stance in dogs. However, while hobbling reduced the permanent dorsoventral flattening in swimming puppies, there was no effect on the speed of functional improvement (). In addition, care must be taken not to cause swelling, edema, or ischemia by hobbling ().

Physiotherapy is beneficial in increasing muscle tone and strength, activating limb coordination, and stimulating circulation of the tissues (,). Stroking, effleurage, and kneading massage techniques were applied. The stroking technique exerts a calming and soothing effect that helps animals become accustomed to being touched, reduces tension and anxiety, lowers muscle tone, and thus serves as a useful way to start and to finish massage sessions. The effleurage technique reduces swelling and edema, removes chemical by-products of inflammation, maintains mobility of soft tissues, and stretches the muscles. Kneading increases circulation and lymphatic flow, mobilizes soft tissues, removes chemical by-products of inflammation, increases sensory stimulation and invigoration, relaxes the animal, and lowers muscle tension (,).

Passive movement is the movement of a joint by external forces and is generally used when a patient is incapable of moving the joint on its own or when active motion may be injurious to the patient (,). The ability to maintain or increase muscle length and flexibility is one benefit of passive movements. Other benefits include the prevention of adhesions in articular capsules and joints that helps maintain joint range; improvement of articular nutrition by increasing synovial fluid production and diffusion; and maintaining mobility between different tissues. Furthermore, producing or maintaining normal patterns of movement and stimulating mechanoreceptors in joints, muscles, skin, and other soft tissues help to improve proprioceptive awareness and increase circulatory and lymphatic return (,,). Thus, physiotherapy includes massages and passive range of motion exercises to develop and strengthen muscles and joint flexibility.

As muscles develop and are strengthened through therapy, animals will begin to self-correct their own walking. Therapy that commences before 3 to 4 wk of age has a better prognosis (,). In a previous report, an English bulldog puppy was treated by splinting and hospitalization for 14 d (). However, the present case shows that home care with intensive physiotherapy is an effective alternative to bandaging or external splinting. Home care reduces stress to patients and provides better protection from infectious diseases compared with hospitalization.

As our case shows, swimmers syndrome is treatable with appropriate home-care treatment that involves environmental and nutritional management along with intensive, diligent physiotherapy. This case has been followed for over 10 y, and is, therefore, an invaluable resource for information about the prognosis. Owner education for treatment is important, with emphasis on the importance of maintaining regular physiotherapy.












3148. Final Video: A Yangon cat has pyometra

13 Sep 2020 Final Video: A Yangon Cat has pyometra https://www.youtube.com/watch?time_continue=2&v=eKheu1XulUg&feature=emb_logo

Saturday, September 12, 2020

3147. An 11-year-old female Silkie Terrier has a large elbow tumour.







This video is part of Dr Sing Kong Yuen's training programme for veterinary students Chloe and Stefanie on a case of pre-surgery assessment of a dog with a large tumour near the left elbow. The owner consulted Toa Payoh Vets as she discovered a large subcutaneous tumour near the left elbow one month ago. A pre-surgery blood test showed that the dog was unfit for anaesthesia and surgery owing to: 1. low total white cell count, low lymphocytes, low neutrophil 2. liver disorder - high liver enzymes 3. high cholesterol level. The dog was prescribed Hills' low fat I/D (7.4% fat) which is less fattening compared to the old diet (12%). She was deprived of dog treats. Today, the owner came for a review and a second blood test. The dog had lost a lot of weight of weight as the dog disliked the new diet and was not given dog treats. ADVICES FOR TODAY 1. High total cholesterol levels. The dog was given around 20 grams of dog treats per day since she was one year old. Now she is 11 years old. For the past month, she was not given dog treats. Strict dieting using Hills' low fat ID was advised by Dr Daniel. The owner is again taught how to mix the slimming diet slowly to get the dog to eat it. NO dog will eat a new diet which is given 100% immediately. Exercise is recommended. 2. Liver disorder. High liver enzymes is usually due to a fatty liver disease. Reduce fatty food and feed liver supplements like Zentonil. The commercial food had 12% fat while Hills low fat diet has 7.4%. The owner needs to give an appropriate amount to reduce the dog's weight but not to underfeed her. There is a food amount for desired bodyweight guidelines on the bag. 3. Left forelimb tumour is large. It was noticed only last month and hence may be cancerous. However the blood test showed a high risk of anaesthetic death as the total white cell count was low. A second blood test will be done today.

 


 4. The owner has to decide whether to get the surgery done or not if the 2nd blood test is not normal. 

 

TRAINING VIDEO - CONSULTATION -- DR SING KONG YUEN\\\A veterinary educational video for pre-veterinary students Chloe and Stefanie.

A large tumour near the left elbow. See consultation video at:
https://www.youtube.com/watch?v=cUXqD-ZsdS0