4000. Educating the rabbit owner about his rabbit abscess

If a vet wants to build up his reputation and expertise, he has to review his cases, esp. challenging ones and must be able to communicate in the layman's language.

I heard a new graduate telling the owner he wants a "history" of the panting dog. To the owner, "history" means nothing.

It requires a lot of time to process the X-ray image so that the rabbit owner understands the pathology of the rabbit's impacted molar and bone infection as shown in the images below:

1075. KPI for a fat dog spay by Dr Sing. Sunday Sep 2, 2012's interesting cases

Sunday Sep 2, 2012. Sunny day, blue skies

Myths
Three dog owners told me today:
1. Dog at 5 years old, if neutered, will develop prostate cancer
2. Dog at 11 years old. Too old to neuter to prevent urine marking. I checked the health. Has heart disease now. So, anaesthesia not advised.
3. Dog, 4 years old. If spayed, will still get heat bleeding. "This is not possible," I said."Unless the vet leaves behind some ovarian tissue after spay."

I took over the spaying of this overweight Maltese X, at 9.15 kg,  as Sunday is a busy day and I can spay faster, due to more years of experience. Still, I pray not to get fat dogs.

A.  10am  Sedation with D + K at 50%. Dom = 0.18ml  Ketamine = 0.23ml IV.
B.  10.28 am  Isoflurane gas first given
C.  11 am Isoflurane gas stopped
D.  10.34 am First skin incision
E.  11.02 am  Completion of stitching

Lots of oily fat. Hooked 2nd attempt.
10.42 am Left ovary hooked out
10.48 am Right ovary hooked out.
10.51 am Uterine body pulled out
10.55  am  Uterine body ligated twice at 2 locations
10.56 am  Linea alba stitched
11.02 am End of stitching.

12 noon  Dog alert and goes home.

E-D = 28 minutes
E-A = 62 minutes (includes dental scaling before spaying). Therefore, excluding dental scaling, just for spay, E-A should be lesser.
SPAY TIPS FOR YOUNG VETS
1. The incision started 1.5 cm from the umbilical scar.
2. Ensure ovaries are exposed thoroughly including at least 5 mm of the ovarian suspensory ligament. Incise anteriorly 5mm more if you find difficulty in pulling out the ovary or can't access the suspensary ligament. In this dog, I was able to pull out the whole ovary and my finger could feel at least 5 mm of the suspensory ligament.

3. NICK INSTEAD OF RUPTURING THE SUSPENSORY LIGAMENT AS ADVISED BY THE PROFESSORS.
What to do with this suspensory ligament. I know the professors in the University may say "snap" it off with the finger by pulling hard to break it. The danger in fat dogs and small breed is that the force may break the whole ovarian ligament including the ovarian blood vessels, leading to profuse bleeding.
3.1 I use the scalpel blade and nick off the taut suspensory ligament on the dorsal side at around 2 mm depoth. A young vet asked me whether I would also nick off the ovarian blood vessels with the scalpel. My answer is no if you just nick at the taut ligament. You can feel it very tight when you pull out the ovary and at the tight area, use the scalpel to nick it. For big breeds, you can feel this tight ligament. I also nick it in big breeds.

4. TRANSFIXING SUTURE.  The professors advise transfixing the uterine body. Now, the theory is great but in practice, the uterine body of a small breed like the Maltese or even this fat Maltese X Silkie is less than 8 mm in width. Transfixing ligature may rupture this uterine body as there is not much space. In this dog, I ligate the uterine body 2 times at 2 locations.
5. PROFUSE BLEEDING SEEN.  If you incise the linea alba correctly and not the muscles, you seldom get profuse bleeding. I don't separate the omental fat surrounding the length of the uterine horn in this fat dog. Some vets will pull off the omental fat before ligating the uterine body and in big breeds, this may need to be done. In small breeds, I don't do it and ligate it together with the uterine body. Hence two ligatures at 2 locations. Profuse bleeding may come from omental blood vessels and it can be very alarming, as the body fills with flowing blood.

In cases where bleeding is non-stop, even when swabs are used, it is necessary to extend the incision to look for the bleeder and to save the dog from bleeding to death. There is no choice. Sometimes, the dog is on heat and the omental vessels are fragile and bleed easily. If the vet does NOT clamp the omental fat from the uterine horn area but just bursting it away with fingers before ligating the uterine body, there may be alarming profuse bleeding.

5. NO. OF SUTURE PACKETS
I used one packet of PDS 2/0. The last bit was to suture one horizontal mattress suture on the skin.     

In conclusion, for the young vet, keep spaying simple by:
1. Making a large skin incision of over 4 mm. It is unlikely you can do a 2 cm incision and so don't try till you know the best location.    
2. Try not to use fanciful stitching. Simple interrupted stitches x 3 (in this dog where the linea alba is around 2.5 cm long) and one horizontal mattress suture for the skin. No subcuticular or hidden sutures to impress the owner. Efficiency (short surgery, accuracy, speed and completion) rather than take your sweet time to do a spay.

1074. Young couple cares for old dog

I showed the young couple, 20-30 years old, my writing on the case card cover: "young couple cares for old dog" - written on Nov 25, 2009. Happy, black and white Shih Tzu, female, was adopted as a 13-year-old by them. R eye had deep white ulcer and black pigment 99% covering the cornea. Loose teeth. Heart OK. These were recorded in my case sheet.
3rd eyelid flap and dental work was done.
R eye had pus


Dog very lethargic this afternoon, came to consult me. Last time I saw them was 2009. Now the couple thought left eye (being closed) had ulcers too. Did fluourescein tests. Both eyes had ulcers but they were old ones.
"Lack of grooming," I said. The dog sat quietly on the table. "But the dog would move here and there at home," the wife said.  

This couple really cared for an old abandoned dog. 13 years old. Now she is 16 years old and they thought she had eye ulcer. I checked the temperature. 40.3 C. "Fever, that's why the dog was not standing up," I said. "The left eye has no tears and may be painful. The right eye was tearing and the tears matted the hairs at the medial side. I wipe off the matted hair. The dog wrinkled and wanted to bite me.

1073. Uncontrolled fever in a Samoyed

Today, Friday, Aug 31, 2012, an old friend visited me. "How's the Samoyed?" he asked. "I came to visit this dog as Vet 2 could not control the fever but the fever went down when treated by you."

"How long was the Samoyed having fever in Vet 2?" I asked. "Was it 3 days?"
"I think it is 2 days. The vet sponged it and injected it, but the fevcr appeared again the next day! Vet 2 told me that the dog was sent to my good friend at Toa Payoh Vets and the fever came down the next day!"

"When the dog came in, it was having of a very high fever of 41.2 degree, panting non-stop and unable to stand," I got the dog from the transport couple who said there was a traffic jam. "I told Dr Daniel that this dog would die as the fever was so high and had been at 41 degrees in Vet 2 for the last 2 days. No hope as the internal organs must be burnt out!"

"Is the dog still alive?' my friend asked. "I don't see him in the Surgery."
"Yes," I said. "According to Dr Daniel who was in charge of the case as I was in Hong Kong, thedog is now normal and walking!"

My friend smiled at the strange situation: "Vet 1 knew the dog had high fever and quickly referred to Vet 2! So Vet 2 was landed with a "hot" dog with uncontrolled high fever and being unable to stand on the back legs.

"Actually the dog had fever again the next day!" I said to my friend. "My anti-fever injection could only bring down the fever for a few hours." So this Samoyed had uncontrolled fever. What was the cause? I was very worried. In my younger days, like Vet 1, I would have referred the case away to others.  

But in this case, Dr Daniel had accepted the dog as it was one of the two neutered by Dr Jason Teo earlier. Also I am more experienced in knowing what to do. Yet, this dog's fever could not come down. Was it a viral fever? A tick fever? Blood test by Vet 2 showed negative Babesia which caused tick fever. My test showed E.canis negative.

"It could still be tick fever," I said to Dr Jason Teo on that Saturday, the 2nd day of admission. He said Vet 2 tested negative Babesia. I gave instructions for treatment of Babesia canis using the imidazole injection and E. canis using oral vibravet. Dr Daniel had proposed clipping off the coat and I got it completely shaved down on Saturday. Anti-fever and antibiotics and IV drips were given.

Surprisingly, on Sunday, the fever was no longer above 40.5. No more heavy panting.

So, in reality, this Samoyed's fever went down after 4 days. "It could be that I was the lucky vet to cure this dog as medication needs time to act," I said to my friend. He was quite happy to know that the Samoyed was alive and walking. As to the cause of uncontrolled fever, it is still a mystery. Blood tests did reveal high white cell count. Was it tick fever? Possibly since the medication was "effective" but many pyrexias of unknown origin (PUOs) are not easy to get the cause.  

  
  

1027. Standard Operating Procedure for rabbit cheek abscess at Toa Payoh Vets

The following will be the Standard Operating Procedure (SOP) for rabbits with cheek abscesses with effect from Sep 1, 2012

1. Examination of the mouth for overgrown incisors and molars. Record of size of abscess

2. Advise X-rays or record AMA (Against Medical Advice) if the owner does not want it. Record which cheek tooth is affected and whether there is osteomyelitis of the jaw bone.

3. Sedation and clipping away the hairs

4. General anaesthesia gas using isoflurane gas via mask

5. Open the mouth to check for overgrown molars
 
6. Make a long skin incision in the ventral part

7. Lance the abscess

8. Irrigate the abscess

9. Post-op stay and treatment to express more pus, for 3 days

10. Review in 3 weeks 

11. Take images of pre and post-surgery if possible (see example below).

It is important that the vet advises X-rays as part of provision of a high standard of care. If the owner rejects the advice, this should be recorded in the case sheet.

			Updates and webpage is at: http://www.sinpets.com/rabbits/20120831rabbit_cheek_abscess_treatment_toapayohvets.htm

1071. Birth certificates from the vet?

EMAIL TO DR SING DATED AUG 30, 2012

On Thu, Aug 30, 2012 at 4:40 PM, Christine Park ..gmail.com> wrote:
He is a male schnauzer and the vet surgeon's name was Dr sing kong yuen

Thanks so much!
Sent from my iPhone



EMAIL FROM DR SING DATED AUG 30, 2012
Hello

BIRTH CERTIFICATE FOR MINIATURE SCHNAUZERS

I am Dr Sing Kong Yuen who answered your phone call and did not understand what you wanted before you sent this email.

I am a vet at Toa Payoh Vets. The birth certificate is never kept by the vet because the breeder or seller is the one who is responsible for the registration of the puppy. The vet just vaccinate the puppy and that is the vaccination certificate issued by the vet (as you have emailed the image).

As it costs money to register the dog with the Singapore Kennel Club, nearly 99% of Singapore's dog breeders and sellers do NOT phone the SKC to send its people to go to the kennels, examine the puppy and previous pedigree certificates if any. After that, the SKC may issue a "birth certificate". This birth certificate costs the breeder and sellers money and 99% of the buyers usually does NOT want to pay this amount of money to buy the puppy with the birth certificate. Therefore, most puppy Sellers (except professional dog show champion breeders or those specialists in breeding certain breeds at premium prices) don't register the birth of the puppy and the vaccination certificate is the document which will show the date of birth and details of the puppy.   

I hope this information helps you to understand the industry practice of selling puppies in Singapore. You can phone me 9668 6468 or email if you wish to know more info.

The pet shop operator's point of view

Yesterday, Aug 29, 2012, I phoned an old client cum pet shop owner as I reviewed his 2009 case records. He had sold off his share of consultancy business which included clientele like the Singapore Tourism Board. He had a pet shop which he now manages.
"How's business?" I asked. "Will you be interested in selling hermit crabs>"
"You've have the source?" he asked me.
"Yes, I have a supplier," I told him I was doing a survey.
"The AVA does not even allow me to sell a fish," he said.
"Why? Is your pet shop next door to a coffeeshop?"
"No, 3 shops away." he replied.
"That's strange," I said. "AVA allows pet shops to be opened elsewhere.
"I cannot sell any pets within 2 km of this food production factory," he enlightened me. "In case, disease goes to the food production factory." So, here, he wanted to increase his scope of services. The authorities put up 2km range to prohibit entrepreneurship.
"Business in pet shops in Jurong is very bad," he said the suppliers told him.
"Why? Is it because the public prefers to go to big operators where there is a diverse range of products and maybe cheaper?" I asked. This seems to be the trend. "This big operator (name given) kills all small operators. It does provide dog grooming too! People go for the cheapest prices."
So, there seems to be no hope for small pet shop operators as Landlords keep increasing the rentals. Singapore is just like Hong Kong. Only the Landlords and those tenants with deep pockets can benefit from intense competition. Kill all small operators in no time.

"What about the vet business?" he asked me.
"I am OK as I have been established over 40 years," I said. "That does not mean I will be OK in the near future as there are around 50 vet clinics being set up. If the management is poor or the standard of vet care is not up to excpectations or the Landlord closes me down, that is the end." I need to buy my own premises.

"There are many owners complaining about vets," the ex-management consultant said.
"What type of complaints?" I asked.
"Over-charging and being too young."
"Well, the vet costs to start up a clinic are very high as the younger vets with good financing installed all kinds of equipment and pay high rentals or buy the premises at over $2 million. Usually some have a business manager and several lay staff increasing overhead cost.  It is hard to price lower. May as well be an employee if the practise loses money on every case handled. Furthermore, new clinics have less clientele and therefore, the vet may need to charge higher. That gives the perception of over-charging. "

"imes will be rough for vets in private practice," I said. "Even some specialists leaving the government hospitals are not all having lots of patients."

    

1069. Update: Perineal hernias (bilateral).

Did the maid do it?

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

First written: 30 November, 2008

Update: 30 August, 2012 TOA PAYOH VETS

Be Kind To Pets

Veterinary Education

Project 2010-0129

Friday, August 3, 2012

1023. Did the maid cause the perineal hernias?



Today Saturday, I came to work at 9 am. Reviewed the case of the Jack Russell who had passed away on the op table yesterday.



This was a case of a very poor prognosis because



1. The bladder was twisted. During surgery, this bladder was dark red and bleeding when seen from the hernia side, only a small portion of the neck of the bladder was the normal pink.



2. The associate vet was not able to catherise and lots of dark red blood inside the swollen bladder leaked out).



3. In addition, fresh blood leaked out from the anus.



An emergency surgery to reduce the bladder size was done but the dog passed away after the repair of the right perineal hernia. The owner said that around 4 weeks ago, the dog gave a loud cry as the maid had hit him. He was frightened of the maid since then. "Did the backside swelling disappear after some time?" I asked the father. "Yes," he said. "I could feel some water inside the swelling. It disappears but now it comes back again and grows much bigger."



So, was the maid's hitting cause the perineal hernias (left and right) to develop? It is a possibility but I don't think so. Old male, not sterilised dogs do develop perineal hernias and this Jack Russell fitted the picture. He was around 10 years old, not neutered and had a large perineal swelling that could reduce. I diagnosed perineal hernia.



The associate vet (Vet 1) diagnosed tumour e.g prostate tumour as there was too much bleeding from the penis. "Are you sure?" Vet 1 asked me. "Yes, I am 100% sure. I based this on the history of the backside swelling increasing in size and disappearing when pressed some 4 weeks ago. Look at the big swellings on the backside." As the dog came in recumbent and not able to stand up, the perineal hernia swellings were NOT obvious. The profuse bleeding from the anus and the penis distracted from the not so obvious perineal hernial swelling especially when the dog was so ill and lying on his die panting. Therefore, I would not expect Vet 1 to miss the diagnosis of perineal hernia which was the main problem. All associate vet cases are monitored by me to ensure a high standard of care and all vets have to learn from experiences of "challenging" cases presented. A normal standing dog will show the perineal hernia swelling but this dog was down and out and therefore its bilateral backside swellings were not obvious.



The father requested an X-ray to confirm the diagnosis of tumour. "Normally, no X-ray will be done if it is a perineal hernia," I said to the vet. "However, the owner had requested X-ray to confirm. It should be done. In any case, this dog would die soon as he could not stand up and was in great pain, passing blood in the urine and stools. This is serious and the owner has been told. I had shown the owner past case images of perineal hernia from www.toapayohvets.com and he understood what the problem was."



X-RAY

Showed a large swollen bladder trapped on the right perineal side while the left side was swollen with intestines filled with stools



Blood test - the owner did not want a blood test.



SURGERY. The dog passed away on the operating table after the bladder was emptied of over 30 ml of fresh blood and pushed back into the abdomen and the skin stitched. The owners knew that the chances of survival was practically low but wanted to take the chance.



CONCLUSION. If the perineal hernias were discovered much earlier, chances of survival are good. Male dogs are prone to getting perineal hernias and one prevention is to get the male dogs neutered early in his life. This may appear "cruel" to the internet generation. Therefore perineal hernias and anal tumours do present in the some of the older non-sterilised males in old age.





tpvets_logo.jpg (2726 bytes)5558 - 5565. Bilateral perineal hernias. Twisted bladder (right side) and twisted intestines (left side) trapped inside the perineal hernias     webpage:
http://www.sinpets.com/dogs/20120829bilateral_perineal_hernias_jack_russell_toapayohvets.htm

1068. Update on closed pyometra in 2009

Closed Pyometra In A Miniature Schnauzer

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

Article written on: 15 March 2009. Updated: 30 August, 2012 toapayohvets.com

Be Kind To Pets

Veterinary Education

Project 2010-0129

Old Miniature Schnauzer, Not Spayed. Closed Pyometra. Toa Payoh Vets



Closed Pyometra. Spayed 12 hours ago. Miniature Schnauzer 10 years vomit next 2 days. Toa Payoh Vets.

Closed Pyometra



All owners do not want a dog to die on the operating table. This dog was at death's door. Surgery could not be delayed.



When to operate and how much IV fluids must be given to maximise the dog's chances of survival during surgery will depend on the veterinarian's judgment and experience.



A dead dog on the operating table is never forgiven by the owner and bad mouthing of the veterinary competence might be the consequence.

The risks and options are explained clearly to the owner and recorded. An informed consent form must be signed in case of litigation as Singapore is becoming a litigious society as the country develops into a "first world".



During litigation, the medical notes will be referred to and if there are no records of informing the owner of the risks and alternative treatments, the medical negligence suit will not be in the doctor's favour.



UPDATE ON AUGUST 30, 2012:

In 2012, I have implemented a work process in which all vets performing operations at Toa Payoh Vets have to be responsible for recording in their own book of anaesthesia and surgical templates the details of their anaesthetic dosages and times taken as well as surgical procedures. This book of records will be their defence in cases of litigation and investigations.

TIPS FOR VETS



Each vet has his or her own judgment as to the use of IV drips during surgeries.



I notice one vet inserting an IV catheter without attachment to any IV drip set during surgeries.



I will advise all vets to connect an IV drip to the IV catheter when performing spays and surgeries rather than just inserting an IV catheter into the cephalic vein by itself.



This is because, during emergencies, the IV catheter will be clogged by the blood clot while an IV drip will give instant IV access to emergency drugs during the surgery. In some cases, I give antibiotics and pain-killers prior to the start of surgery as the dog is not well and needs prompt surgery. In some pyometra cases, I run the IV drip overnight first to re-hydrate the dog and give her the antibiotics and pain-killers. This gives her a better chance of survival rather than rushing into surgery immediately.



In the above case, about 100 ml of glucose is given IV, not the whole bottle! Know your IV infusion well. 


Webpage and images are at:
http://www.sinpets.com/F5/20110438close-pyometra-schnauzer-iv-glucose-drips-catheter-toapayohvets-singapore.htm

1067. Pyometra in 3 Miniature Schnauzers reviewed

Yesterday, I reviewed 3 cases of Miniature Schnauzers with closed pyometra.

CASE 1. This was operated by me in 2009. The father prohibited surgery as the first dog died when given by an injection by Vet 1. However, the dog continued vomiting and so there was no choice. The surgery was a success but the dog continued vomiting. I had already told the young lady that the blood tests revealed kidney failure before I operated. The dog did survive but since the kidneys had failed, she vomited for the next 10 days. Euthanasia was done. This was a case whether the older baby-boomer generation has not much knowledge of the high fatality of procrastination in seeking surgery early.


CASE 2. In this case, operated by my associate vet recently, the older baby-boomer generation was the 60-year-old mother who did not want any surgery in case her vomiting dog died on the operating table. vomit and so why not wait. My associate vet warded her for 3 days with treatment given. One sister (Sister 1) took the dog back as the dog did not vomit. Conclusion was that the dog had some stomach infection. Then on the next evening, she brought the dog back and told me she was vomiting again. I was on reception duty and that is the best place to pick up complaints and feedback from clients. Three days had passed and the mis-diagnosis was gastritis. I examined the dog in the presence of the associate vet (Vet 1).

"A history of heat somewhere around Christmas" Sister 2 meant that this dog had heat around June. Now it was August, 2 months after the end of heat and so it was possible that pus had accumulated in the Schnauzer and caused vomiting.  Abdominal swelling and pain on the lower 1/3 of the abdomen.

"It is closed pyometra," I based my diagnosis on the 3 factors mentioned above. "An X-ray will be useful but it is not necessary. The solution is to spay her soon." The sister did not believe me. Vet 1 stuck to the diagnosis of stomach infection (gastritis) as the history given was that the heat period was more than "3 months ago" or "unknown" and advised an X-ray of the abdomen. So there was a delay of one day. "How's the X-ray interpretation?" I asked the associate vet. "Is there closed pyometra?" Sister 1 came and requested that the operation be done the next day as Vet 1 was busy with cases till past 8 pm during her visit. and Sister 1 wanted a vet who would be not so tired doing surgery. This is the situation with multi-family interactions on the veterinary duties.  "This dog could still be operated after 8 pm," I said but since Sister 1 had said so, I did not object. This closed pyometra dog had already been over 6 days since the first consultatio by Vet 1 and delays in surgery are not good for the dog's health and prognosis.

Vet 1 did not think the X-ray showed closed pyometra although I disagreed with Vet 1.  "However the owner did not mind getting the dog spayed," Vet 1 said.

Spaying showed closed pyometra. The dog was standing and barking the day after the operation. However, post-op complications set in after 3 days of hospitalisation. Complications of wound breakdown do occur in surgeries for all vets. The dog became recumbent and the 3 sisters and mother were visiting her every day. "Why is the dog vomiting?" one sister asked me at one visit one evening. I told her that the dog would be operated by Vet 1 to close the stitch. Vet 1 operated late at night at around 10 pm on Aug 27, 2012. A drainage tube was inserted. As post-op complications do happen, I monitored this dog daily.

Yesterday, Aug 29, 2012, she started eating, wolfing down the steamed fish but ignoring the whole bowl of cut pears yesterday morning at 10 am. The mother had cooked the fish and came to give her the food. On Aug 28, 2012, this dog also wolfed down the fish given by the mother.

 "Since she eats the food fast, she has recovered from the operation," I said to Sister 2 who came yesterday evening to visit and asked me if the dog could go home. Vet 1 was busy consulting and could not spend time with multi-family visits.  "We have to wait and see the next few days," I said to Sister 2.        


CASE 3. Another Schnauzer with closed pyometra was operated by Vet 1 on Aug 28, 2012. The uterus was packed full with pus, much fuller than that of Case 2. In the evening, I could see that the dog post-op was not well. She was shaking in her body and then she pushed her head against the crate's bar, as if trying she had headache. "What's wrong with the Schnauzer? She looks very sick," one young lady who was visiting her vomiting Shih Tzu hospitalised asked me. I told her that the dog had an operation.

I had seen such head butting against the crate behaviour from distemper puppies with fits and it is not a good sign of health. The young lady owner came in the evening and wanted to take this dog back. "A dog that is not eating should be hospitalised and given drips," I said to her and Vet 1. "Why is the dog not on drips?" I asked Vet 1 who was preparing to send the dog back home as requested by the young lady who would not be in Singapore till the next Saturday (10 days later).

Vet 1 said, "The dog flung off the IV set." I said to Vet 1: "If the dog dies at home, all the family members will not only bad-mouth you, but also Toa Payoh Vets. This dog should not be allowed to go home (to give her a better chance of survival on IV drip. The lady owner had been shown the swollen pus in the uterus). I could not believe that the young lady wanted the dog back on the same day after surgery as most owners accept the vet's advice. Maybe it was economics, but here there was the dog successfully operated but could die a few days later due to the lack of IV drips.  "Get the owner to sign a letter stating the possiblity of death and that the dog was discharged against medical advice by you and I," I instructed Vet 1.

It is tough nowadays for vets as clients want their own way. But there must be a firm action to let the lady owner and her family members know that the dog could die due to the lack of post-op IV support. The vet has to be alert and mindful of the consequences of the failure of IV support since this dog was not in good health. The young lady phoned her family. I noted that the dog was hospitalised. In this case, it was likely economics.

In conclusion, in all 3 cases, had the dogs been spayed when they were younger and healthier, closed pyometra would never be present and much financial expenses and more worries would not be present. But many Singaporean owners think it is cruel to spay the dog. So, there are more cases of pyometra seen and it is not guaranteed that a dog that survived the operation would remain alive after surgery as you could see in Case 1.