Surgery Report for ROY (11 Y/O mixed breed male dog)
PRE-OP
History:
Roy was presented with a malignant tumour on the Right cheek. Tumour was persistent, with ill-defined margins and had a rough 7cm circumference. It also had a history of dermatitis with multi-focal exudative pustules and papules located primarily on the proximal fore and hindlimbs, with severe scaly and crusted regions of epidermis on the caudal elbow and knee joints. Roy was otherwise eating normally.
Physical Exam (PRE-OP):
On physical examination, Roy displayed an obdunted attitude. Heart, respiratory rate and temperature were within normal limits at 102 bpm, 30bpm and 39.2degrees Celsius respectively. Peripheral perfusion seemed normal with mucous membranes being moist and pink and CRT < 2 secs. Breath was malodorous (possibility of bacterial / fungal overgrowth inside the mouth).
Treatment Plan:
Palliative and curative.
To surgically excise the malignant cheek tumour via electrocautery and check for observable metastasis to regional lymph nodes under general anaesthesia.
OPERATION
Surgical and Anaesthetic details:
Roy was not sedated prior to anaesthetic induction as there was sufficient restraint to hold him down.
Catheterization was performed via a 22G needle into his left cephalic vein for easy intravenous (IV) access before anaesthetic induction with Diazepam (0.4ml) and Ketamine (0.4ml) totaling 0.8ml IV. Roy was deemed sufficiently induced after 10minutes and surgery proceeded. Surgical site was prepped with chlorhexidine and alcohol and a transverse incision across the tumour was made via electrocautery.
The epidermis above the tumour site was undermined to relieve skin tension and provide easier excision of the tumour itself. Roy was also given an IV drip of 5% dextrose wit 0.45% NaCl to compensate for electrolyte losses and to prevent dehydration and hypovolaemia.
Care was taken not to sever the facial nerve although part of it might have been as the tumour margins were large and irregular and the base of the tumour was located deep within the facial cavity, thus requiring aggressive surgical therapy. Upon tumour excision, tumour was found to have metastasized to the bone as well as the upper gingiva. As the effects of the induction drugs weared off, gaseous anaesthesia for maintenance was administered. 5% isoflurane was administered initially and slowly decreased over the course of the surgery up to 0.2% during the muscle, subcutaneous and skin closure at the excision site. 0.1% zoletil was also administered IV during the course of the surgery as Roy was still deemed too light. After 40 minutes, tumour was partially resected and wound closure commenced so as to decrease anaesthetic risk and toxicity. Muscle, subcutaneous and skin closure was performed using 2-0 synthetic polysorb, absorbable suture for all layers. Muscle and subcutaneous layers were closed using a simple interrupted pattern while the skin layer was closed using a mattress suture pattern.
POST-OPERATION
Surgical site was washed and swiped clean with sterile saline to reduce risk of sepsis and 1ml of Tolfenamic Acid (Tolfedine) was administered IV as post-op analgesia. Roy was then placed back in his cage and equipped with an E-collar while he continued to receive the remainder of the 5% dextrose and 0.45% NaCl at maintenance rates followed by another 500ml of Hartmann’s after, also at maintenance flow rates to prevent dehydration, hypovolaemia and to maintain electrolyte balance. Blood sample was taken for CBC and biochemistry while a tumour sample was also submitted to QuestLabs for histopathology.
DRUGS USED AND PRECAUTIONS
Ketamine:
- Mode of action: Acts at the N-methyl-D-Aspartic (NMDA) receptors and blocks central sensitization. It is useful for patients with chronic pains and patients that fail to respond to conventional analgesic therapy. Can also be used (mostly in combination with other drugs such as Xylazine and Diazepam) for sedation and anaesthetic induction.
- Precautions: AVOID the use of ketamine in patients with traumatic head injury as it increases cerebral blood flow and may increase intra-cranial pressure.
Diazepam:
- Mode of action: Diazepam is a benzodiazepine that binds to a specific subunit on the gamma-aminobutyric acid (GABA) receptor at a site distinct from the binding site of the endogenous GABA molecule. Therefore it works as an allosteric modulator of GABA, enhancing its effects and provides good anxiolytic, anti-convulsant, hypnotic and amnestic properties. Used especially in the management of seizure cases.
- Precautions: IV administration of diazepam should be performed slowly, particularly when injected into the smaller veins such as the cephalic vein because of the potential of thrombophlebitis and cardiotoxicity due to the propylene glycol base.
Diazepam may cause weakness, drowsiness and loss of motor coordination. In rare cases, it may result in paradoxical excitement, unexpected aggression or unusual behavourial changes.
Zoletil
- Mode of action: Combination of 2 drugs, tiletamine and zolazepam. Tiletamine’s mode of action is similar to that of ketamine as it is a NMDA receptor antagonist and blocks central sensitization as well. Zolazepam’s mode of action is similar to diazepam as it is a pyrazolodiazepinone derivative that is structurally similar to the benzodiazepine drugs.
- Precautions: Contraindicated in animals with CNS signs, hyperthyroidism, cardiac disease, pancreatic or renal disease, pregnancy, glaucoma or penetrating eye injuries.
REFLECTIONS
As tumour was incompletely resected, the chance of recurrence is very high. Prognosis of this dog is very poor as well as it is old and there has already been evident local metastasis to bone and gingival. Distant metastasis has not been diagnosed but is possible, which will further decrease its prognosis for survival.
In my opinion, if cost is not an issue for the client, I would recommend palliative treatment with NSAIDs such as acetaminophen, aspirin, meloxicam as well as prophylactic broad spectrum antibiotics such as Trimethoprim Sulphate (TMS) or Amoxicillin Clavulanate (Amoxy-clav) along with neoplasia excision again when the tumour grows again to a clinically significant size.
As the surgery had to be aggressive, part of the facial nerve might have been severed in the process which might have resulted in the post-op excessive salivation, drooping of the lip and ear on the ipsilateral side of the lesion. Dog should also be examined for signs of nystagmus, head tilt, asymmetrical pupil size dropping of food and ataxia to further confirm the suspicion of facial nerve paresis or paralysis. Part of the sublingual and mandibular salivary glands and/or their ducts might have also been severed in the process, resulting in excessive salivation. Due to traumatic injury to the glands and/or ducts, in my opinion, I would expect the dog to develop a sialocele which would then require further surgical intervention. Diagosis of this could be confirmed with fine needle aspirate should a SOFT, palpable mass develop near the mouth region. Needle aspirate can also help differentiate a sialocele from a neoplastic process.
On a separate note, the dermatological processes should also be looked into if the client is willing. Punch biopsies should be done on the pustules and papules, centered in the middle of the biopsy specimen. Punch biopsies should also be obtained from the scaly and crusted areas AS WELL AS from the normal skin. This is to allow comparisons of the epidermis and stratum corneum of the 2 sites by the pathologist. This is done to diagnose the nature of the skin lesions and to determine an appropriate treatment plan for Roy with systemic treatment such as injectable or oral cephalosporins, enrofloxacin etc. Adjunctive therapy could include topical treatments such as Chlorhexidine gluconate (Pyohex Dermcare) shampoos as well as benzoyl peroxide (Pyoben Virbac)
Done by:
Geoffrey Yeo
COMMENTS FROM DR SING
A good report written by a 4th year Murdoch Univ student on first day of internship at Toa Payoh Vets. Interns are expected to write report of interesting cases to make them good vets as merely observing surgeries and anaesthesia during internship will not be effective in training of a vet student. In this way, veterinary surgery is brought alive to the student and hopefully, he or she will remember the case study during his final year examinations or after graduation.
The following is additional information for my record and to share my knowledge with other vets
HISTORY
Previous handling of the case including anaesthesia and surgery are documented at:
1. http://www.toapayohvets.com/surgery/20100618cheek_tumour_old_dog_electrosurgery_ToaPayohVets.htm
2. http://www.asiahomes.com/singaporetpvet/dogs/20100690emergency_anaesthetic_death_cheek_tumours_old_dog_excision_ToaPayohVets.htm
On this 4th surgery case study, the submandibular and popliteal lymph nodes of the dog are enlarged to around 1 cm in diameter. The mouth was very painful and the dog has poor appetite till painkillers are given. The owner gave rimadyrl tablet earlier and the dog did not feel any pain and therefore ate canned food.
PRE-OPERATION
The Miniature Schnauzer, male, 12 years old was operated 3 times. The cheek tumour was malignant and recurs within a month. It keeps growing bigger and has spread to the bones and gums now. The owner had declined cytotoxic drugs or euthanasia and expected the old dog not to die on the operating table. She was informed that this was a high risk anaesthetic case. She wanted the surgery to be postponed on Sunday as she felt that nursing would be better on Monday. So, the dog was operated on Monday.
Prior to this 4th surgery, the dog was on 2 days of IV drips, baytril and metronidazole IV as the mouth was smelly due to the large infected cheek tumour. On the day of the surgery (Monday, Dec 6, 2010 at 2 pm), the bad breath was 90% absent.
PAIN-KILLERS
Sufficient pain must be given during surgery and post-operation. The dog was whining
1. during surgery at times when the IV general anaesthetic of ketamine 0.4 ml and diazepam 0.4 ml in one syringe, totally 0.8 ml. Initially at 0.4 ml of the mixture was given via the IV cathether. This was insufficient analgesia for this 10-kg dog.
2. Isoflurane gas 5% was given for less than one minute by mask when the dog whines during the surgery. "Intubation is not practical," I told my assistant who asked for an endotracheal tube. "The cheek tumour is too large and the tube would be obstructing the excision and view." I got a small mask (usually for cats) and supplied gas at the nose level. It was effective. The tongue remained pinkish, the intern practised on taking the heart rate which was normal. Maintenance dose varies from 5% to 0.2% to effect.
3. Zoletil 100 at 0.1 ml IV was given towards the 30th minute of surgery as the dog was whining when isoflurane gas was reduced considerably. The dog stopped whining within a few seconds.
4. Tolfedine 4% at 1.0 ml given IV towards the completion of surgery as the dog was whining in pain as he had waken up at the 45th minute when the last stitching was done. I supervised the intern to give the injection IV via the IV set. "Not direct injection," I stopped him. "Stop the IV flow first, inject and continue the IV drip".
Within 60 seconds, the dog stopped whining in pain and for the next 12 hours after surgery. This shows that Tolfedine acts effectively.
NOTES: The intern was told that the IV flow must be stopped by rolling down the control wheel before injection of the drug. He asked whether there was another solution to inject the remaining drug and was told there was none - in human IV anaesthesia, another syringe with saline of 2 ml would be injected to flush in the remaining small amount of drug in the needle of the first syringe which is removed first.
FACIAL NERVE
The intern was asked to identify the large 3-mm wide white nerve seen between the right eye and the commissure of the lips, above the cheek muscle. He said it would be the trigeminal nerve.
HISTOPATHOLOGY
The intern was asked to send the greyish white fatty-like tumour for histopathology.
BLOOD TEST 2 DAYS BEFORE SURGERY
TELEPHONE FROM THE OWNER. The young lady phoned me and was told the good news that the dog was OK. Another bottle of IV drip of Hartmann's solution would be given. Metronidazole and 0.1 ml of dexamethasone IV would be in the drip. The dog would be on immunosuppressive drug.
BLOOD TEST 2 DAYS BEFORE THE SURGERY. I asked the intern to comment on the report. The total WBC was 25 (very high). The platelet count was above normal.Why? I asked him to comment in his report.
CONCLUSION
It is too early to know whether this dog will survive post-operation as it is only 14 hours post-op. Dogs do die post-op too.
Tuesday, December 7, 2010
Saturday, December 4, 2010
Two stray cats - caterwaul, spay & nursing
HISTORY
2 stray cats along streets picked up by a young couple who has hamsters too.
Cat 1 - Black & White, Female, around 8 months, 2.6 kg. Vaccinated her as a kitten and so she would be at the correct age.
Cat 2 - Grey striped, Female, around 9 months, 2.9 kg. Signs of one birth based on changes in mammary gland area were seen.
"Both make a lot of noise (caterwaul) for 5 the past 5 days straight before I bring them to you. Want to go out of the apartment!" the young man said to me. "Neighbours do not complain as they have cats too." Bought into surgery on Thursday Dec 2, 2010 at night.
Friday Dec 3, 2010
Spayed by me from around 10 am. Cat 1 done first followed by Cat 2.
ANAESTHESIA by injection
Both given xylazine 2% at 0.15 ml mixed with ketamine 100 at 0.6 ml totalling 0.75 ml in one syringe IM. I noted that Cat 2 received around 0.70 ml IM due to some movement as my assistant did not gripe the scruff of the neck well. Cat 2 was more active.
SURGERY
5-10 minutes after anaesthetic injection.
Cat 1 - excellent surgical anaesthesia.
Cat 2 - was moving even at 10th minute. "She is heavier," my assistant said. Isoflurane gas for one minute by mask at 5% was sufficient to bring her down to surgical anaesthesia. I was able to spay.
UTERINE BODIES & FULL BLADDER
Cat 1 - peed before surgery onto surgical drape. Hooked out the left ovary at 2nd trial.
Cat 2 - bladder full but could not be expressed manually. I did not persist. Just hooked out the ovary. Took several trials as the bladder was obstructing. Uterine body 5 x larger and wider than that of Cat 1. Yellow corpus luteum seen prominently and larger. Why? Took pictures. Both cats not let out of apartment and so would not be pregnant.
GOES HOME AND HOME NURSING
Owner wanted to take the cats home one hour after surgery. I advised him to let the cat rest in the surgery as they may get choked and die during transport on the way home.
Went home at 8 pm Friday Dec 3, 2010. Both cats at home vomited when they tried to eat. Cat 1 was more groggy. Both were not so active.
Saturday Dec 4, 2010. 11 am. Owner phoned me.
1. Cat 2 was back to normal, but Cat 1 was not so active. Running here and there.
Cat 2 had licked off her plaster. I advised putting on another one or wrap a bandage round her.
2. 2/0 absorbable suture will dissolve. No need to return for stitch removal. Only one skin horizontal mattress suture. Cat 2 may lick it off but owner says she does not bother with the stitch. She started to eat at 11 a.m, but not Cat 1.
FOOD - Dry food from Royal Canin
Wet food from Whiskas
WATER - freely available.
3. Post op antibiotics. Baytril PO x 1 tablet each at 1/4 tab per day for 4 days. I don't advise e-collars in cat spays. Plaster usually sufficient. I use only one suture pack of 2/0 per cat. The muscle cut was closed with just 2 interrupted sutures at 5 mm apart. The skin incision was approx 1.2 cm from umbilical scar. The incision of skin was around 1 cm. I asked the assistant to untie the front legs and lift up front lower half of Cat 1 if I could not hook out the right uterine horn after ligating left ovary. In Cat 2, there was no problem.
DURATION OF SURGERY
I had my assistant record the start and end of surgery. For Cat 1, it was 7 minutes. Smooth and easy. For Cat 2, it took much longer due to full bladder, abdominal fat which I cut off a piece and extra large uterine bodies.
MY ADVICE TO VETS
There is no need to insert another layer of subcutaneous stitching in my over 20 years of spaying cats. However, some vets deem that necessary as the university professors teach this method to close the dead space and prevent haematoma. However, they also stitch the skin incision.
Some cats and dogs do get irritated by this extra S/C layer of stitching and lick the wound vigorously. You will see a red inflamed area in some cases. Simple method is best. Less is best.
It saves time, money (some vets use 2 packets of sutures to spay a cat or a small breed dog) and less painful irritation to the pet. Each vet has his own style. It is hard to change mindsets esp. if University lecturers teach S/C layer to close a spay wound or "concealed" stitching.
As for injectable anaesthesia, xylazine 0.2 ml + ketamine 0.8 ml in one syringe IM is safe for cat spay at 3-5 kg bodyweight. At 2-3 kg, I use xylazine 0.15 ml + ketamine 0.6 ml as in the above two cats. The duration of surgical anaesthesia is sufficient if you start surgery 5-10 minutes after the IM injection and can complete your surgery in 10 minutes as in Cat 1.
Topping up can be done using isoflurane gas at 5% by mask for <60 seconds to effect or by injection of the combination. I don't use the latter method although I have seen it done using small doses e.g. 0.1 ml of the combination. The above applies to Singapore cats. Each country has its own cat sizes and climate and the dosage may vary.
UPDATES are at www.toapayohvets.com
2 stray cats along streets picked up by a young couple who has hamsters too.
Cat 1 - Black & White, Female, around 8 months, 2.6 kg. Vaccinated her as a kitten and so she would be at the correct age.
Cat 2 - Grey striped, Female, around 9 months, 2.9 kg. Signs of one birth based on changes in mammary gland area were seen.
"Both make a lot of noise (caterwaul) for 5 the past 5 days straight before I bring them to you. Want to go out of the apartment!" the young man said to me. "Neighbours do not complain as they have cats too." Bought into surgery on Thursday Dec 2, 2010 at night.
Friday Dec 3, 2010
Spayed by me from around 10 am. Cat 1 done first followed by Cat 2.
ANAESTHESIA by injection
Both given xylazine 2% at 0.15 ml mixed with ketamine 100 at 0.6 ml totalling 0.75 ml in one syringe IM. I noted that Cat 2 received around 0.70 ml IM due to some movement as my assistant did not gripe the scruff of the neck well. Cat 2 was more active.
SURGERY
5-10 minutes after anaesthetic injection.
Cat 1 - excellent surgical anaesthesia.
Cat 2 - was moving even at 10th minute. "She is heavier," my assistant said. Isoflurane gas for one minute by mask at 5% was sufficient to bring her down to surgical anaesthesia. I was able to spay.
UTERINE BODIES & FULL BLADDER
Cat 1 - peed before surgery onto surgical drape. Hooked out the left ovary at 2nd trial.
Cat 2 - bladder full but could not be expressed manually. I did not persist. Just hooked out the ovary. Took several trials as the bladder was obstructing. Uterine body 5 x larger and wider than that of Cat 1. Yellow corpus luteum seen prominently and larger. Why? Took pictures. Both cats not let out of apartment and so would not be pregnant.
GOES HOME AND HOME NURSING
Owner wanted to take the cats home one hour after surgery. I advised him to let the cat rest in the surgery as they may get choked and die during transport on the way home.
Went home at 8 pm Friday Dec 3, 2010. Both cats at home vomited when they tried to eat. Cat 1 was more groggy. Both were not so active.
Saturday Dec 4, 2010. 11 am. Owner phoned me.
1. Cat 2 was back to normal, but Cat 1 was not so active. Running here and there.
Cat 2 had licked off her plaster. I advised putting on another one or wrap a bandage round her.
2. 2/0 absorbable suture will dissolve. No need to return for stitch removal. Only one skin horizontal mattress suture. Cat 2 may lick it off but owner says she does not bother with the stitch. She started to eat at 11 a.m, but not Cat 1.
FOOD - Dry food from Royal Canin
Wet food from Whiskas
WATER - freely available.
3. Post op antibiotics. Baytril PO x 1 tablet each at 1/4 tab per day for 4 days. I don't advise e-collars in cat spays. Plaster usually sufficient. I use only one suture pack of 2/0 per cat. The muscle cut was closed with just 2 interrupted sutures at 5 mm apart. The skin incision was approx 1.2 cm from umbilical scar. The incision of skin was around 1 cm. I asked the assistant to untie the front legs and lift up front lower half of Cat 1 if I could not hook out the right uterine horn after ligating left ovary. In Cat 2, there was no problem.
DURATION OF SURGERY
I had my assistant record the start and end of surgery. For Cat 1, it was 7 minutes. Smooth and easy. For Cat 2, it took much longer due to full bladder, abdominal fat which I cut off a piece and extra large uterine bodies.
MY ADVICE TO VETS
There is no need to insert another layer of subcutaneous stitching in my over 20 years of spaying cats. However, some vets deem that necessary as the university professors teach this method to close the dead space and prevent haematoma. However, they also stitch the skin incision.
Some cats and dogs do get irritated by this extra S/C layer of stitching and lick the wound vigorously. You will see a red inflamed area in some cases. Simple method is best. Less is best.
It saves time, money (some vets use 2 packets of sutures to spay a cat or a small breed dog) and less painful irritation to the pet. Each vet has his own style. It is hard to change mindsets esp. if University lecturers teach S/C layer to close a spay wound or "concealed" stitching.
As for injectable anaesthesia, xylazine 0.2 ml + ketamine 0.8 ml in one syringe IM is safe for cat spay at 3-5 kg bodyweight. At 2-3 kg, I use xylazine 0.15 ml + ketamine 0.6 ml as in the above two cats. The duration of surgical anaesthesia is sufficient if you start surgery 5-10 minutes after the IM injection and can complete your surgery in 10 minutes as in Cat 1.
Topping up can be done using isoflurane gas at 5% by mask for <60 seconds to effect or by injection of the combination. I don't use the latter method although I have seen it done using small doses e.g. 0.1 ml of the combination. The above applies to Singapore cats. Each country has its own cat sizes and climate and the dosage may vary.
UPDATES are at www.toapayohvets.com
Do you have a muse for a "tai-tai" artist?
Over 30 years of practice, some clients do become good friends of the veterinarian. The "tai tai" artist is one of them. "Tai tai" is a Cantonese term for a woman of leisure and wealth; one who does need to work for a living.
Her children had grown up and are in their 30s and when I first saw them, they were teenagers studying in Secondary Schools. The mum has a natural talent. Her classmates would retain her drawings. She would present her favoured surgeon a present of her painting. She did present me a chalk drawing of a monitor lizard puffed up to fight off an attacking dog for me after I gave her a picture of the scene.
In her house, I always get attracted to a very large painting of a wealthy young girl with bright eyes and adorned with a webbed necklace in a solemn light brown dress and darker brown background. This painting is hung on the wall of the living room.
She had commissioned an experienced old Chinese painter to paint her daughter. To me, this painting appeared to be painted quite fast as her necklace of several connecting precious stones were all painted blurred. Maybe that was purposely so as not to distract the viewer from looking at her bright and distant somewhat sad eyes. I appreciate more realistic portraits of ladies with sharper focused jewellry or dogs as shown in some European paintings.
Mum said to me as I appreciated this painting on the rare occasions I visited her: "The painter drew her hands too long." I did not realise that the hands were unusually long but after her criticism, I improved my observations and knowledge of art appreciation.
Every time I visited, I would ask: "Have you sold any of your paintings?" She would paint many but would not complete many of the oil or acrylic paintings. She does not need to sell paintings for a living and would paint any theme whenever she wants to. That is why I call her a "tai tai" artist.
I approve of her Madonna and Child painting prominently displayed on one side of the living room and asked whether she was selling it.
"My pastor wants me to sell my painting of Madonna and Child," the artist said. "I paid $400 for the frame as it is a good type."
I teased her: "The frame costs more than the painting."
"No, no," she replied in her gentle voice. "I can get $4,000 to $5,000 for this painting if I sell it at the Church through the pastor. Religious paintings of this type are in great demand."
"Really?" I was surprised that a copied painting of the Virgin and Child cost this amount and be able to attract buyers. I am not into religious paintings. I appreciate market place paintings of less developed countries like Myanmar. I have one displayed at Toa Payoh Vets. It was a present from an old friend who bought it from the market in Yangon. It costs around S$100. I don't know whether the artist is well known or not. It seems to represent tribal women from the villages selling their farm produce at the market in the town.
"Your paintings are of no value," I said. "You don't sell them." If an artist does not sell his or her paintings, how does one valuate the worth of their production?
"The pastor said my painting of the Madonna and child can sell for $4,000 to the member of the congregation", she replied. "Of course, the church would expect me to donate some part of the sales proceeds. Such religious paintings sell very well, do you know?"
"If there is such a great demand as you said, why don't entrepreneurs in China and Vietnam have Madonna and Child copied and sell them to churches in Singapore?" I asked.
"Those are scanned copies and will not sell," she said. "They are flat computer scanned images. Paintings done by hand look different."
"There are talented painters in China and Vietnam who can really copy using computer software and then use the real paint to complete the paintings of Madonna and Child," I said. "Surely, they will sell very well in Singapore and make profits for the entrepreneurs."
She did not think so. Professional painters work every day but she might paint once in a blue moon.
"Why are your finger nails greyish?" I asked as I sipped the coffee and biscuits she prepared for me. I hope she was not in poor health as she looked pale. "Oh, these are due to the paint," she said.
Somebody phoned me to get back to the Surgery. I said goodbye. I always encourage her not to copy portraits from the other painters or photographers and use her imagination.
Before I left, we checked her website where painters meet and gave points to one another and commented and criticised each other's paintings.
"I have got 50 points," she showed me her painting image of 4 Indian village women with pots on their head.
"Click to enlarge the thumbnail image," I said.
"I have removed the enlarged image after I got the assessment and points," she said. "This is to prevent others from copying my painting."
I could not see much. It was surprising to me that she was worried that others might copy her painting and sell them. Imitation is the sincerest form of flattery.
Paintings are meant to be enjoyed by others and selling them is one way of growing an artist's reputation. "Famous painters in the past have patrons to support them and commission paintings," I said, after spending some time reading some arts magazines. "Maybe their assistants paint for them as it takes a long time to paint oil and acrylic paintings."
"Don't go into the sale of painting business," the artist advised me. I don't know why she thought I was going to be an arts gallery owner.
Since this artist does not produce many original portraiture and landscape paintings, her artistic talents are wasted. But then, she is a "tai tai" (woman with wealth) and so she can afford the luxury of painting whenever she is in the mood. What she needs is a muse. And muses seem to have flown the coop.
Updates will be at toapayohvets.com
Her children had grown up and are in their 30s and when I first saw them, they were teenagers studying in Secondary Schools. The mum has a natural talent. Her classmates would retain her drawings. She would present her favoured surgeon a present of her painting. She did present me a chalk drawing of a monitor lizard puffed up to fight off an attacking dog for me after I gave her a picture of the scene.
In her house, I always get attracted to a very large painting of a wealthy young girl with bright eyes and adorned with a webbed necklace in a solemn light brown dress and darker brown background. This painting is hung on the wall of the living room.
She had commissioned an experienced old Chinese painter to paint her daughter. To me, this painting appeared to be painted quite fast as her necklace of several connecting precious stones were all painted blurred. Maybe that was purposely so as not to distract the viewer from looking at her bright and distant somewhat sad eyes. I appreciate more realistic portraits of ladies with sharper focused jewellry or dogs as shown in some European paintings.
Mum said to me as I appreciated this painting on the rare occasions I visited her: "The painter drew her hands too long." I did not realise that the hands were unusually long but after her criticism, I improved my observations and knowledge of art appreciation.
Every time I visited, I would ask: "Have you sold any of your paintings?" She would paint many but would not complete many of the oil or acrylic paintings. She does not need to sell paintings for a living and would paint any theme whenever she wants to. That is why I call her a "tai tai" artist.
I approve of her Madonna and Child painting prominently displayed on one side of the living room and asked whether she was selling it.
"My pastor wants me to sell my painting of Madonna and Child," the artist said. "I paid $400 for the frame as it is a good type."
I teased her: "The frame costs more than the painting."
"No, no," she replied in her gentle voice. "I can get $4,000 to $5,000 for this painting if I sell it at the Church through the pastor. Religious paintings of this type are in great demand."
"Really?" I was surprised that a copied painting of the Virgin and Child cost this amount and be able to attract buyers. I am not into religious paintings. I appreciate market place paintings of less developed countries like Myanmar. I have one displayed at Toa Payoh Vets. It was a present from an old friend who bought it from the market in Yangon. It costs around S$100. I don't know whether the artist is well known or not. It seems to represent tribal women from the villages selling their farm produce at the market in the town.
"Your paintings are of no value," I said. "You don't sell them." If an artist does not sell his or her paintings, how does one valuate the worth of their production?
"The pastor said my painting of the Madonna and child can sell for $4,000 to the member of the congregation", she replied. "Of course, the church would expect me to donate some part of the sales proceeds. Such religious paintings sell very well, do you know?"
"If there is such a great demand as you said, why don't entrepreneurs in China and Vietnam have Madonna and Child copied and sell them to churches in Singapore?" I asked.
"Those are scanned copies and will not sell," she said. "They are flat computer scanned images. Paintings done by hand look different."
"There are talented painters in China and Vietnam who can really copy using computer software and then use the real paint to complete the paintings of Madonna and Child," I said. "Surely, they will sell very well in Singapore and make profits for the entrepreneurs."
She did not think so. Professional painters work every day but she might paint once in a blue moon.
"Why are your finger nails greyish?" I asked as I sipped the coffee and biscuits she prepared for me. I hope she was not in poor health as she looked pale. "Oh, these are due to the paint," she said.
Somebody phoned me to get back to the Surgery. I said goodbye. I always encourage her not to copy portraits from the other painters or photographers and use her imagination.
Before I left, we checked her website where painters meet and gave points to one another and commented and criticised each other's paintings.
"I have got 50 points," she showed me her painting image of 4 Indian village women with pots on their head.
"Click to enlarge the thumbnail image," I said.
"I have removed the enlarged image after I got the assessment and points," she said. "This is to prevent others from copying my painting."
I could not see much. It was surprising to me that she was worried that others might copy her painting and sell them. Imitation is the sincerest form of flattery.
Paintings are meant to be enjoyed by others and selling them is one way of growing an artist's reputation. "Famous painters in the past have patrons to support them and commission paintings," I said, after spending some time reading some arts magazines. "Maybe their assistants paint for them as it takes a long time to paint oil and acrylic paintings."
"Don't go into the sale of painting business," the artist advised me. I don't know why she thought I was going to be an arts gallery owner.
Since this artist does not produce many original portraiture and landscape paintings, her artistic talents are wasted. But then, she is a "tai tai" (woman with wealth) and so she can afford the luxury of painting whenever she is in the mood. What she needs is a muse. And muses seem to have flown the coop.
Updates will be at toapayohvets.com
Friday, December 3, 2010
Vomiting and diarrhoea
Vomiting and diarrhoea in dogs may not be a one or two-day cure. Prevention of dehydration using IV saline and treatment with IV antibiotics and drugs are the ideal way to treat such cases. Blood tests were taken in this case. The dog was hospitalised for 3 days. My associate sent the dog home as he had recovered. The next day the distressed owner came back to say that the dog was vomiting. The stools were soft and had white specks (medicine tablets probably). A few spots of blood. So, I got the dog hospitalised and x-rayed. X-ray revealed no big foreign bodies. "Better to hospitalise more than 2 days," I advised my associate vet. "I will bear the responsibility of complaints if the dog dies." Defensive medicine is sometimes necessary.
An X-ray would have to be taken if the dog continues vomiting after 2 days.
If the dog dies and x-rays were not taken, there may be a case of negligence or incompetence. We try to save money for the young lady who was cost-conscious, but sometimes, vomiting can be longer than 3 days and sending the dog home to save on costs may be of good intentions. But in a complaint or litigation, it counts for nothing if the dog has had died and no x-rays had been taken. Blood test did reveal a low platelet count and this could be toxaemia.
An X-ray would have to be taken if the dog continues vomiting after 2 days.
If the dog dies and x-rays were not taken, there may be a case of negligence or incompetence. We try to save money for the young lady who was cost-conscious, but sometimes, vomiting can be longer than 3 days and sending the dog home to save on costs may be of good intentions. But in a complaint or litigation, it counts for nothing if the dog has had died and no x-rays had been taken. Blood test did reveal a low platelet count and this could be toxaemia.
259. Dog biting groomer
A young lady groomer was hospitalised because the Alsatian cross bit her face during grooming. The dog had a history of biting people but the groomer had groomed him before with no problems.
Why do some older dogs start biting people? Recently some young men ganged up to kill a young man in a staring incident in Singapore. This murder and attack was not the first case in Singapore. So what happened? Why are males involved?
Something abnormal had happened to change their behaviour to become anti-social. As for the groomer, who would be paying for her medical and surgical bills? The employer or the dog owner?
The dog owner did not want to put the dog to sleep. "She wants to protect the dog," the groomer's employer said to me yesterday. Nobody can go near this caged dog. Not even the owner whose children had been bitten. What is the solution?
Why do some older dogs start biting people? Recently some young men ganged up to kill a young man in a staring incident in Singapore. This murder and attack was not the first case in Singapore. So what happened? Why are males involved?
Something abnormal had happened to change their behaviour to become anti-social. As for the groomer, who would be paying for her medical and surgical bills? The employer or the dog owner?
The dog owner did not want to put the dog to sleep. "She wants to protect the dog," the groomer's employer said to me yesterday. Nobody can go near this caged dog. Not even the owner whose children had been bitten. What is the solution?
Monday, November 29, 2010
258. How to succeed in business: The 72-year-old man
To succeed in life and in business, one has to know what to do and to work hard. There is no short cut to success. I will illustrate this interesting case.
Mr Oh - A prospective Buyer's Agent - The 30-year-old man
Mr Lee - A prospective Seller's Agent - The 72-year-old man
Goods in demand in Myanmar - a brand-name multi-vitamins
What Mr Oh wanted from Mr Lee was a large number of multi-vitamins without the box, an analysis certificate and quotation. He said: "I could get the vitamins from a Singapore importer but his prices are high."
What Mr Lee wanted from Mr Oh was his quoted buying price and method of payment. He did now want to waste time providing quotes so that Mr Oh can use to underprice or force another Seller to bid lower. He would not provide an analysis certificate at his own expense. He would not provide the vitamins without a box as there would be damages and then claim from Mr Oh. He wanted full payment but Mr Oh offered to pay 50% deposit and 50% on delivery.
I could see that there was no point in doing business. "It is not easy to do this business," Mr Lee reiterated to me several times. I was not doing this business as I knew that a lot of time would be wasted wheeling and dealing. So I dropped the contacts. Then Mr Oh phoned me to follow up. I arranged for a meeting with Mr Lee at the last minute and asked Mr Lee to meet at Peninsula Plaza at 4 pm.
BE FLEXIBLE
1. Last-minute meetings are irritating to my friend Khin Khin when she has better things to do. She blasted me once when I arranged for her to meet the 72-year-old man (who has extensive trading contacts in China and Indonesia). She gave me a piece of her mind. For me, this is OK if I have the time.
2. The 72-year-old man asked me to drive him to the meeting. I obliged. There is no point saying to him that "you want the business, you go yourself." This is being inflexible.
3. The old man said he had to eat something as he was diabetic. The meeting was 4 p.m and we were late by 15 minutes. So I phoned Khin Khin and her contacts to explain the situation of delay and suggested a meeting at Funan Shopping Centre Food Court which is just a 5-minute walk from Peninsula Plaza. "No," Khin Khin said. "We meet at Peninsula Plaza. How long will you and the old man take to come?"
"It will be 2 hours later," I slammed down the phone. I had driven Mr Lee all the way from Clementi and here, Khin Khin and her contacts were not keen to meet nearby and have some drinks. Making a business contact is 90% entertainment rather than just straight talking about business.
BE RESPECTFUL
1. I really dislike Khin Khin saying "old man" when she could say Mr Lee. It is disrespectful in stating the obvious. Even "young man" may be condescending to somebody who is insecure and just starting out in business. Just address the business contact by his name. It is so simple and yet Khin Khin and her friend would not do it since they are younger. But not as young as spring chickens.
BE CLEVER WHEN ENCOUNTERING OLD DOGS IN BUSINESS
1. When Mr Lee had his roti prata, he told me that since he had come all the way, he should contact Mr Oh. I said: "Phone yourself, as I don't see any future in this business with the behaviour of the Sellers' agents." He phoned Khin Khin's friend, May Thet whom I had first introduced earlier. She was the one who knew Khin Khin and Mr Oh. May Thet said OK to meet at Peninsula Plaza. When Mr Lee and I arrived, May Thet pulled up a chair and said: "Welcome boss..."
This is where I said one has to be clever when encountering old dogs in business. The 72-year-old man replied: "If I am the boss, why do I have to come all the way with my goods to see you? You even refused to meet me at Funan Centre..."
LEAVE THE MEETING WHICH WILL NOT BE SUCCESSFUL
I left Mr Lee at Peninsula Plaza with the Seller's Agent and contacts. It would be an acrimonious meeting with no results. The old man would be brutally frank to teach these young people how to do business. I went to a shop that sells paintings. The proprietor cannot converse well with me in English but she has new paintings on sale. It would be such a pleasant time to spend looking at the work of the craftsmen selling their artwork.
Later, Mr Lee told me that he told Mr Oh to put $100 cash down while he would write a cheque for $1,000 since Mr Oh said he had a Singapore importer and would not really need Mr Lee's services. Mr Lee said that the "importer" was just a distributor or post man. Mr Oh declined the bet and left in an unhappy manner. That was what I predicted. No need brains to do it. As for Mr Lee, he told me he felt invigorated sparring with the Seller's agents as they knew nothing about the vitamin business.
I learnt some business tips such as "dumping" from the 72-year-old man by being hands on and though this business meeting was acrimonious, I was not involved in the unpleasant encounters. No business university can beat being hands on and meeting a brutally frank 72-year-old general trader with considerable experience. You just need to spend time with him and if he respects you, he will share his experiences and extensive network. You just have to read the situation and act wisely.
APPLICATION TO VETERINARY MEDICINE.
"Dumping" applies to veterinary medicine too. For example, pet shops in veterinary surgeries sell a brand of food at just cost-price by ordering in large quantities.
The importer has given the seller a 40% discount and recommends a 20% discount to consumers. If the pet shop operator sells at 35% discount, he gets many sales and in theory he will ask for more supplies. However, this is dumping and the importer will never supply him more as dumping is not sustainable in business in the long term for the manufacturer and importer.
Mr Oh - A prospective Buyer's Agent - The 30-year-old man
Mr Lee - A prospective Seller's Agent - The 72-year-old man
Goods in demand in Myanmar - a brand-name multi-vitamins
What Mr Oh wanted from Mr Lee was a large number of multi-vitamins without the box, an analysis certificate and quotation. He said: "I could get the vitamins from a Singapore importer but his prices are high."
What Mr Lee wanted from Mr Oh was his quoted buying price and method of payment. He did now want to waste time providing quotes so that Mr Oh can use to underprice or force another Seller to bid lower. He would not provide an analysis certificate at his own expense. He would not provide the vitamins without a box as there would be damages and then claim from Mr Oh. He wanted full payment but Mr Oh offered to pay 50% deposit and 50% on delivery.
I could see that there was no point in doing business. "It is not easy to do this business," Mr Lee reiterated to me several times. I was not doing this business as I knew that a lot of time would be wasted wheeling and dealing. So I dropped the contacts. Then Mr Oh phoned me to follow up. I arranged for a meeting with Mr Lee at the last minute and asked Mr Lee to meet at Peninsula Plaza at 4 pm.
BE FLEXIBLE
1. Last-minute meetings are irritating to my friend Khin Khin when she has better things to do. She blasted me once when I arranged for her to meet the 72-year-old man (who has extensive trading contacts in China and Indonesia). She gave me a piece of her mind. For me, this is OK if I have the time.
2. The 72-year-old man asked me to drive him to the meeting. I obliged. There is no point saying to him that "you want the business, you go yourself." This is being inflexible.
3. The old man said he had to eat something as he was diabetic. The meeting was 4 p.m and we were late by 15 minutes. So I phoned Khin Khin and her contacts to explain the situation of delay and suggested a meeting at Funan Shopping Centre Food Court which is just a 5-minute walk from Peninsula Plaza. "No," Khin Khin said. "We meet at Peninsula Plaza. How long will you and the old man take to come?"
"It will be 2 hours later," I slammed down the phone. I had driven Mr Lee all the way from Clementi and here, Khin Khin and her contacts were not keen to meet nearby and have some drinks. Making a business contact is 90% entertainment rather than just straight talking about business.
BE RESPECTFUL
1. I really dislike Khin Khin saying "old man" when she could say Mr Lee. It is disrespectful in stating the obvious. Even "young man" may be condescending to somebody who is insecure and just starting out in business. Just address the business contact by his name. It is so simple and yet Khin Khin and her friend would not do it since they are younger. But not as young as spring chickens.
BE CLEVER WHEN ENCOUNTERING OLD DOGS IN BUSINESS
1. When Mr Lee had his roti prata, he told me that since he had come all the way, he should contact Mr Oh. I said: "Phone yourself, as I don't see any future in this business with the behaviour of the Sellers' agents." He phoned Khin Khin's friend, May Thet whom I had first introduced earlier. She was the one who knew Khin Khin and Mr Oh. May Thet said OK to meet at Peninsula Plaza. When Mr Lee and I arrived, May Thet pulled up a chair and said: "Welcome boss..."
This is where I said one has to be clever when encountering old dogs in business. The 72-year-old man replied: "If I am the boss, why do I have to come all the way with my goods to see you? You even refused to meet me at Funan Centre..."
LEAVE THE MEETING WHICH WILL NOT BE SUCCESSFUL
I left Mr Lee at Peninsula Plaza with the Seller's Agent and contacts. It would be an acrimonious meeting with no results. The old man would be brutally frank to teach these young people how to do business. I went to a shop that sells paintings. The proprietor cannot converse well with me in English but she has new paintings on sale. It would be such a pleasant time to spend looking at the work of the craftsmen selling their artwork.
Later, Mr Lee told me that he told Mr Oh to put $100 cash down while he would write a cheque for $1,000 since Mr Oh said he had a Singapore importer and would not really need Mr Lee's services. Mr Lee said that the "importer" was just a distributor or post man. Mr Oh declined the bet and left in an unhappy manner. That was what I predicted. No need brains to do it. As for Mr Lee, he told me he felt invigorated sparring with the Seller's agents as they knew nothing about the vitamin business.
I learnt some business tips such as "dumping" from the 72-year-old man by being hands on and though this business meeting was acrimonious, I was not involved in the unpleasant encounters. No business university can beat being hands on and meeting a brutally frank 72-year-old general trader with considerable experience. You just need to spend time with him and if he respects you, he will share his experiences and extensive network. You just have to read the situation and act wisely.
APPLICATION TO VETERINARY MEDICINE.
"Dumping" applies to veterinary medicine too. For example, pet shops in veterinary surgeries sell a brand of food at just cost-price by ordering in large quantities.
The importer has given the seller a 40% discount and recommends a 20% discount to consumers. If the pet shop operator sells at 35% discount, he gets many sales and in theory he will ask for more supplies. However, this is dumping and the importer will never supply him more as dumping is not sustainable in business in the long term for the manufacturer and importer.
257. The dog with white gums - continued
Low red blood cells, low haemoglobin and very low platelet count are life-threatening situations to the dog with the white gums. I followed up by phone call for the next 2 weeks for 3 occasions. The owner was quite happy that the dog was eating 4 times a day and her gums were pinker and would come in for another blood test on the 14th day after the first consultation.
Then on the 14th day (Friday), the dog vomited and so the owner texted me to cancel the appointment. Vomiting is a serious sign. The owner brought in the dog on a Saturday afternoon and she was given the IV drips and treatment. Blood and urine tests were done. "The dog bites me when I carry her," the owner said. I palpated the T/L spinal area and the dog wanted to bite me. The dog had normal rectal temperature and the gums had become pale. She was not eating.
Blood tests indicated that the red cells and haemogolbin levels were back to the low range of normal but would be considered normal. The platelet count was still low but not at 1. It was 120 (normal is 200 -500). A very high white cell count of 27,000 indicated a bacterial infection. The liver enzymes were very high too indicating hepatitis. Serum urea was high but creatinine was below normal. White cells and bacteria and blood were present in the urine tests. A few crystals of calcium oxalate.
Palpation: Spleen enlarged and could be felt like a long rectangular tongue transversing the abdomen. A large painful mass on left side behind the rib, of around 10cm x 4 cm would be the left kidney. Liver enlarged.
The owner visited the dog on Saturday afternoon. The dog seemed OK. No rectal temperature increase. Then on Saturday evening, the dog just passed away quietly at 7p.m. I phoned the owner who came.
"What's the cause of death?" her 2 friends asked me. "It is likely to be septicaemia from bacterial infection. The dog could have inhaled toxic dusts from the neighbour's ongoing renovation (acid and cement dust) for the past weeks." The dog's tongue was cyanotic and white. The spleen and left kidney were enlarged.
The dog had tumours based on ultrasound and these tumours could have spread to all over the body. It is hard to say without a post mortem. Direct Coomb's test was negative but this does not rule out autoimmune haemolytic anaemia. Thyroid function tests were done.
It was hard to save this old dog when she has internal tumours and a toxic dusty environment. Both could result in an autoimmune haemolytic anaemia and thrombocytopaenia.
The owner said good bye to the dog after arranging for cremation. There was not much I could say. She shook my hands and thanked me. This was one of my saddest cases in veterinary medicine as I could not prevent a second recent bereavement in her family.
Then on the 14th day (Friday), the dog vomited and so the owner texted me to cancel the appointment. Vomiting is a serious sign. The owner brought in the dog on a Saturday afternoon and she was given the IV drips and treatment. Blood and urine tests were done. "The dog bites me when I carry her," the owner said. I palpated the T/L spinal area and the dog wanted to bite me. The dog had normal rectal temperature and the gums had become pale. She was not eating.
Blood tests indicated that the red cells and haemogolbin levels were back to the low range of normal but would be considered normal. The platelet count was still low but not at 1. It was 120 (normal is 200 -500). A very high white cell count of 27,000 indicated a bacterial infection. The liver enzymes were very high too indicating hepatitis. Serum urea was high but creatinine was below normal. White cells and bacteria and blood were present in the urine tests. A few crystals of calcium oxalate.
Palpation: Spleen enlarged and could be felt like a long rectangular tongue transversing the abdomen. A large painful mass on left side behind the rib, of around 10cm x 4 cm would be the left kidney. Liver enlarged.
The owner visited the dog on Saturday afternoon. The dog seemed OK. No rectal temperature increase. Then on Saturday evening, the dog just passed away quietly at 7p.m. I phoned the owner who came.
"What's the cause of death?" her 2 friends asked me. "It is likely to be septicaemia from bacterial infection. The dog could have inhaled toxic dusts from the neighbour's ongoing renovation (acid and cement dust) for the past weeks." The dog's tongue was cyanotic and white. The spleen and left kidney were enlarged.
The dog had tumours based on ultrasound and these tumours could have spread to all over the body. It is hard to say without a post mortem. Direct Coomb's test was negative but this does not rule out autoimmune haemolytic anaemia. Thyroid function tests were done.
It was hard to save this old dog when she has internal tumours and a toxic dusty environment. Both could result in an autoimmune haemolytic anaemia and thrombocytopaenia.
The owner said good bye to the dog after arranging for cremation. There was not much I could say. She shook my hands and thanked me. This was one of my saddest cases in veterinary medicine as I could not prevent a second recent bereavement in her family.
Thursday, November 25, 2010
256. Autoimmune Haemolytic Anaemia (AIHA) in Dogs
Today, Thursday at 9.30 am, the lady owner will be bringing the Miniature Schnauzer with white gums, 2 weeks after treatment. It is 4.36 am now and I am reviewing the case of this dog. A case of the dog with white gums. The first report is at:
http://www.kongyuensing.com/folder5/201006220very-low-platelet-count-Schnauzer-10years_anorexic-ToaPayohVets.htm
So far, the lady said that the dog's gums had become pinker. The dog is eating and drinking and passes normal stools and urine. Her only complaint was that the dog had this panting throughout the day during the past 2 weeks. She said: "She may be feeling some pain."
Well, the dog did have a very painful slipped disc when I first checked her. She also had a painful bladder area on palpation.
What is the cause of this panting? Is the old dog with white gums suffering from a form of an autoimmune haemolytic anaemia (AHA)? In AHA, the dog's red blood cells are produced normally but its abnormal antibodies which are needed to destroy bacteria or viruses, start destroying the red blood cells. So, the dog has low red blood cells and suffers from anemia.
In AHA, the dog also has low numbers of platelets and suffers from thrombocytopenia. The platelets in the blood form clots when blood vessels are cut or broken. If the dog has low platelet count, there will be uncontrolled bleeding. AHA in dogs is similar to haemopilia in people.
SYMPTOMS
Anaemia. Pale or white gums, conjunctiva and later yellow instead of normal pink to red colour. So the dog is lethargic as it has low levels of oxygen in the tissues and brain.
Jaundice. The liver removes the damaged red cells. The breakdown products causes a yellow colour of gums, conjunctiva and skin.
Bleeding from the nose or blood in the stools due to low platelet count. Takes a longer time for bleeding to stop.
Heart beats faster to bring oxygen to the tissues and brain.
DIAGNOSIS
1. COOMBS TEST is used to check for antiglobulins (autoantibodies). Nearly 98% of human patients with AIHA have a positive direct Coombs test (also known as direct antiglobulin test or DAT). A positive DAT means that the red blood cells are coated with the red blood cell autoantibodies. Patients may only have a positive direct Coombs test during disease flares and not at all times. There is also the Coombs Negative AIHA as a result of vaccinations or other medical conditions and the patient is mis-diagnosed as having other types of anemia or non-immune haemolytic anemia.
2. BONE MARROW BIOPSY
AIHA may be either regenerative or non-regenerative as determined by a lab examination of a blood sample and/or bone marrow biopsy. Regenerative anaemia - increased numbers of large immature red blood cells (reticuloycytes). Non-regenerative anaemia - anaemia lasting >5 days with low reticulocytes; the immature red cells are made but are destroyed in the bone marrow by the dog's own immune system.
As Vet 1's blood results did not include platelets (IDDEX machine had advised another blood test), so there was no earlier blood test history in relation to RBC, HB and platelets.
Dogs with chronic AIHA take many weeks to show clinical signs as in this case.
A bone marrow biopsy is used to distinguished between non-regenerative AIHA and cancer or other causes of non-regenerative haemolytic anaemia. But few vets do this bone marrow biopsy and diagnose the dog with chronic non-regenerative AIHA as suffering from blood cancer.
IN THE CASE OF THE DOG WITH WHITE GUMS, it was difficult to collect the urine for analysis of the presence of haemoglobin in the urine. The dog was in great pain and I stopped catherisation of the urethra for urine. She peed the normal yellow urine instead of the dark red urine in AHA.
CAUSES
Genetic or environmental factors. The latter include infections, drugs, poisons, bee stings and vaccines. Various neoplasms, systemic lupus erythematosus and canine hypothyroidism.
The dog had not been vaccinated for the past few years and so vaccination would not be the cause. The dog was recently taken outdoors after living in the apartment for most of her life. Infections could be the cause.
Some indications of infections include ulcers at the back of the tongue on the left side. (I took a picture 24 hours after IV treatment when I examined the tongue and tonsills). At the first consultation, the dog wanted to bite me when I palpated the enlarged left submandibular and popliteal lymph nodes.
Tumours. Since the dog had been losing weight of 25% for the past 4 weeks (from 5kg to 4kg), it could be suffering from internal tumours, e.g. in the spleen, pancreas or liver as "diagnosed by ultrasound" by Vet 1 earlier.
Gender. Females of all breeds, even when spayed, have a higher risk for AHA than males.
Genetic predispostion. Some dogs have changes in their immune system, a deficiency of pyruvate kinaese enzymes or abnormal red blood cell structure.
Breeds at higher risk. American Cocker Spaniels, Beagles, Old English Sheepdog, Westies, Shih Tzus, Alaskan Malamute, Lhasa Apso, Poodles, Basenjis, Daschunds. The case being reviewed is a Miniature Schnauzer, female, spayed.
TWO BLOOD TESTS WITHIN 24 HOURS.
Low red cell counts, low haemoglobin and lower platelet count.
In theory, the haemoglobin should be high if there is AHA. This is because the destroyed red cells will lead to an increase in haemoglobin and not to a decrease.
However total white cells were in the normal range. I noted that the % of neutrophils was over 90% (normal dog is usually around 75%). The dog responded to baytril IV, metronidazole IV, Vit K1 IV and dexamethasone 0.2 ml IV, iron SC and Vit B complex SC on day 1 as the gums became pink 24 hours later.
TREATMENT
1. Most dogs with AHA respond to steroid therapy which may be required for years. Prednisolone suppresses the immune system to prevent red blood cell destruction. Bacterial, viral and fungal infections must be treated if present.
Oral prednisolone in high doses e.g. 2-4mg/kg q 24hr divided into 2X/day, starting at 2 mg and increasing dosage if response is poor. Give for 2- weeks, then gradually taper off dosage. Decrease to mg/kg/24 hours for 2-4 weeks, then 1 mg/kg/48 hours for 2-4 weeks, then taper off.
*If anaemia (one author in a dog's forum uses PCV as below 12% as unstable, PCV 35-55% as stable). If unstable, go back to previous dosage that works.
2. A gastroprotecant e.g. sucralfate (0.5-1g) given when the dog is on high doses of steroids.
3. IMMUNOSUPPRESSANT medications like cyclophosphamide together with lower dosage of steroids for severe AIHA, for several months and reassess 2-4 weekly. Most dogs respond to prednisolone and immunosuppressant. If there is a relapse, a longer course of medication may be required.
Cyclophosphamide (50mg/Ma p/o q 24 hr) or 2 mg/kg q 24hr for the first 4 days of each week for 6-8 weeks. Re-assess.
Azathioprine (50mg/Ma q 24hr) (2mg/kg p o q 24 hr) for 1-2 weeks, then every other day
Cyclosporin (15mg/kg po q 24hr) has been used to treat refractory AIHA.
Danazol (synthetic androgen, 5 mg/kg po q 12 hr). Expensive. Reserved for dogs that have are refractory to pred + cyclophosphamide or azathioprine or intolerant drug side effects. Contraindicated in dogs with heart, liver or kidney problems.
3. For severe cases, blood transfusions, splenectomy (last resort in life-threatening refractory anaemia if medical treatment is not controlling the disease after 4-6 weeks of therapy).) and intravenous immunoglubulin therapy. Blood transfusion may be needed in the very severe anaemic dog to buy time for the drugs to act.
http://www.kongyuensing.com/folder5/201006220very-low-platelet-count-Schnauzer-10years_anorexic-ToaPayohVets.htm
So far, the lady said that the dog's gums had become pinker. The dog is eating and drinking and passes normal stools and urine. Her only complaint was that the dog had this panting throughout the day during the past 2 weeks. She said: "She may be feeling some pain."
Well, the dog did have a very painful slipped disc when I first checked her. She also had a painful bladder area on palpation.
What is the cause of this panting? Is the old dog with white gums suffering from a form of an autoimmune haemolytic anaemia (AHA)? In AHA, the dog's red blood cells are produced normally but its abnormal antibodies which are needed to destroy bacteria or viruses, start destroying the red blood cells. So, the dog has low red blood cells and suffers from anemia.
In AHA, the dog also has low numbers of platelets and suffers from thrombocytopenia. The platelets in the blood form clots when blood vessels are cut or broken. If the dog has low platelet count, there will be uncontrolled bleeding. AHA in dogs is similar to haemopilia in people.
SYMPTOMS
Anaemia. Pale or white gums, conjunctiva and later yellow instead of normal pink to red colour. So the dog is lethargic as it has low levels of oxygen in the tissues and brain.
Jaundice. The liver removes the damaged red cells. The breakdown products causes a yellow colour of gums, conjunctiva and skin.
Bleeding from the nose or blood in the stools due to low platelet count. Takes a longer time for bleeding to stop.
Heart beats faster to bring oxygen to the tissues and brain.
DIAGNOSIS
1. COOMBS TEST is used to check for antiglobulins (autoantibodies). Nearly 98% of human patients with AIHA have a positive direct Coombs test (also known as direct antiglobulin test or DAT). A positive DAT means that the red blood cells are coated with the red blood cell autoantibodies. Patients may only have a positive direct Coombs test during disease flares and not at all times. There is also the Coombs Negative AIHA as a result of vaccinations or other medical conditions and the patient is mis-diagnosed as having other types of anemia or non-immune haemolytic anemia.
2. BONE MARROW BIOPSY
AIHA may be either regenerative or non-regenerative as determined by a lab examination of a blood sample and/or bone marrow biopsy. Regenerative anaemia - increased numbers of large immature red blood cells (reticuloycytes). Non-regenerative anaemia - anaemia lasting >5 days with low reticulocytes; the immature red cells are made but are destroyed in the bone marrow by the dog's own immune system.
As Vet 1's blood results did not include platelets (IDDEX machine had advised another blood test), so there was no earlier blood test history in relation to RBC, HB and platelets.
Dogs with chronic AIHA take many weeks to show clinical signs as in this case.
A bone marrow biopsy is used to distinguished between non-regenerative AIHA and cancer or other causes of non-regenerative haemolytic anaemia. But few vets do this bone marrow biopsy and diagnose the dog with chronic non-regenerative AIHA as suffering from blood cancer.
IN THE CASE OF THE DOG WITH WHITE GUMS, it was difficult to collect the urine for analysis of the presence of haemoglobin in the urine. The dog was in great pain and I stopped catherisation of the urethra for urine. She peed the normal yellow urine instead of the dark red urine in AHA.
CAUSES
Genetic or environmental factors. The latter include infections, drugs, poisons, bee stings and vaccines. Various neoplasms, systemic lupus erythematosus and canine hypothyroidism.
The dog had not been vaccinated for the past few years and so vaccination would not be the cause. The dog was recently taken outdoors after living in the apartment for most of her life. Infections could be the cause.
Some indications of infections include ulcers at the back of the tongue on the left side. (I took a picture 24 hours after IV treatment when I examined the tongue and tonsills). At the first consultation, the dog wanted to bite me when I palpated the enlarged left submandibular and popliteal lymph nodes.
Tumours. Since the dog had been losing weight of 25% for the past 4 weeks (from 5kg to 4kg), it could be suffering from internal tumours, e.g. in the spleen, pancreas or liver as "diagnosed by ultrasound" by Vet 1 earlier.
Gender. Females of all breeds, even when spayed, have a higher risk for AHA than males.
Genetic predispostion. Some dogs have changes in their immune system, a deficiency of pyruvate kinaese enzymes or abnormal red blood cell structure.
Breeds at higher risk. American Cocker Spaniels, Beagles, Old English Sheepdog, Westies, Shih Tzus, Alaskan Malamute, Lhasa Apso, Poodles, Basenjis, Daschunds. The case being reviewed is a Miniature Schnauzer, female, spayed.
TWO BLOOD TESTS WITHIN 24 HOURS.
Low red cell counts, low haemoglobin and lower platelet count.
In theory, the haemoglobin should be high if there is AHA. This is because the destroyed red cells will lead to an increase in haemoglobin and not to a decrease.
However total white cells were in the normal range. I noted that the % of neutrophils was over 90% (normal dog is usually around 75%). The dog responded to baytril IV, metronidazole IV, Vit K1 IV and dexamethasone 0.2 ml IV, iron SC and Vit B complex SC on day 1 as the gums became pink 24 hours later.
TREATMENT
1. Most dogs with AHA respond to steroid therapy which may be required for years. Prednisolone suppresses the immune system to prevent red blood cell destruction. Bacterial, viral and fungal infections must be treated if present.
Oral prednisolone in high doses e.g. 2-4mg/kg q 24hr divided into 2X/day, starting at 2 mg and increasing dosage if response is poor. Give for 2- weeks, then gradually taper off dosage. Decrease to mg/kg/24 hours for 2-4 weeks, then 1 mg/kg/48 hours for 2-4 weeks, then taper off.
*If anaemia (one author in a dog's forum uses PCV as below 12% as unstable, PCV 35-55% as stable). If unstable, go back to previous dosage that works.
2. A gastroprotecant e.g. sucralfate (0.5-1g) given when the dog is on high doses of steroids.
3. IMMUNOSUPPRESSANT medications like cyclophosphamide together with lower dosage of steroids for severe AIHA, for several months and reassess 2-4 weekly. Most dogs respond to prednisolone and immunosuppressant. If there is a relapse, a longer course of medication may be required.
Cyclophosphamide (50mg/Ma p/o q 24 hr) or 2 mg/kg q 24hr for the first 4 days of each week for 6-8 weeks. Re-assess.
Azathioprine (50mg/Ma q 24hr) (2mg/kg p o q 24 hr) for 1-2 weeks, then every other day
Cyclosporin (15mg/kg po q 24hr) has been used to treat refractory AIHA.
Danazol (synthetic androgen, 5 mg/kg po q 12 hr). Expensive. Reserved for dogs that have are refractory to pred + cyclophosphamide or azathioprine or intolerant drug side effects. Contraindicated in dogs with heart, liver or kidney problems.
3. For severe cases, blood transfusions, splenectomy (last resort in life-threatening refractory anaemia if medical treatment is not controlling the disease after 4-6 weeks of therapy).) and intravenous immunoglubulin therapy. Blood transfusion may be needed in the very severe anaemic dog to buy time for the drugs to act.
Wednesday, November 24, 2010
The Panting Old Schnauzer with low platelet count
It is almost two weeks since I saw the dog with the low platelet count. The case is recorded at:
http://www.kongyuensing.com/folder5/201006220very-low-platelet-count-Schnauzer-10years_anorexic-ToaPayohVets.htm
Yesterday I phoned the busy young lady as there was no news from her. No news means good news. The young lady said: "My dog has pinker gums. She is eating. I have given her the prednisolone half tablet two times per day. But she pants heavily the whole day. Could it be the pain? She may need an X-ray as you had advised. Or a blood test. Should I get her examined by you?"
It is hard to diagnose over the phone. I was glad that this dog had not died from internal bleeding due to such a low platelet count. I gave her an appointment to see her dog at 9.30 am on Thursday.
A follow-up in such a case is important but some owners may not have the time to do the follow up till the dog collapses.
http://www.kongyuensing.com/folder5/201006220very-low-platelet-count-Schnauzer-10years_anorexic-ToaPayohVets.htm
Yesterday I phoned the busy young lady as there was no news from her. No news means good news. The young lady said: "My dog has pinker gums. She is eating. I have given her the prednisolone half tablet two times per day. But she pants heavily the whole day. Could it be the pain? She may need an X-ray as you had advised. Or a blood test. Should I get her examined by you?"
It is hard to diagnose over the phone. I was glad that this dog had not died from internal bleeding due to such a low platelet count. I gave her an appointment to see her dog at 9.30 am on Thursday.
A follow-up in such a case is important but some owners may not have the time to do the follow up till the dog collapses.
253. Ticks in the apartment dog
Each dog owner has his or her own favourite vet and so I did not want to interfere in this case as this 70-year-old man may view me as soliciting for business. He is a general trader by profession and yesterday he invited me to his apartment to collect some multi-vitamins and calcium which he had bought at a discount from a China trade fair last week. "The company officers at the fair did not want to take the bottles back and sold them at huge discounts on the last day of the fair. If you don't want them, I will offer them to James. He will surely buy them."
I am personally not keen on taking multivitamins and calcium from unknown drug companies as there had been horror stories from one company in Australia producing poor quality multi-vitamins marketed by health shops in Singapore some years ago. There was no quality control but a desire to make money.
I accepted his invitation to visit him as a friend. He had two dogs. One 17-year-old cross had died recently and suddenly of a bloated stomach and he was still grieving over the loss.
"He killed the dog with too much vitamins and glucosamine," the wife told me.
"Based on the history of sudden swelling of the abdomen, I think the dog had a ruptured big blood vessel due to old age. The dog's abdomen started to swell as the bleeding filled the abdomen. The dog lives to a ripe old age of 17 years and it is inevitable that the big blood vessel would break down. The only way to find the definite cause of death is a post-mortem."
"No point in having a post-mortem," the husband said that the dog had been cremated.
"When I die, I have asked my children to scatter my ashes in the sea," the wife said. "That will save them the trouble of having them to maintain my grave or urn. The later generations may forget about doing any maintenance."
The husband shocked me by saying: "Your ashes in the sea will kill all the fishes!" What a surprising thing to say. This was the first time I met the wife, a silver-haired trim lady.
"Well," I said to the husband to defuse the awkwardness of his comments, "Your ashes in the sea will kill all the whales."
The wife kept picking out the ticks from her Silkie Terrier. "The ticks keep appearing on the dog. Small dotted ones."
"Did you use spot-on insecticides like Frontline?" I asked.
"Not effective."
So this 7-year-old Silkie had been biting her back area till they were almost bald. "This could be a tick-bite allergy," I said to the wife. The dog was on prednisolone tablets and anti-ringworm tablets for many weeks.
I had to intervene for the sake of this poor dog. "I cannot guarantee, but this dog may have a full coat of hair if you can get rid of the ticks in the apartment and on this dog."
"Really?" the wife was interested as to what she should do.
"I cannot guarantee anything," I said. "The first step is to get the dog clipped bald, de-ticked and given a different type of spot-on insecticide. De-contaminate the apartment area where the dog stays usually. Best of all, after de-ticking put the dog in another part of the apartment so that the baby ticks cannot jump onto her.
"Will the dog have a full coat during Christmas?"
"I cannot guarantee it. Do you have a good groomer who can clip the dog bald and de-ticked? Ask your vet for a different spot-on insecticide."
Ticks in a dog can be difficult to be rid of due to the re-infestation from the surroundings. Apparently this dog does not go outdoors and therefore the ticks must be from inside the apartment. "My vet advised Bagon spray onto the walls," the wife said. "It does not work."
"It is hard to get rid of ticks if you don't isolate the de-ticked dog from the contaminated area," I said. "In any case, there are so many cracks in the wall and you need to do it thoroughly. Some vets and pest control companies advise 'bombs'. You close all the windows. Release the gas from the bombs to fumigate and kill all the ticks. It does not work in practice for many reasons."
"You have two dogs. Get both of them clipped bald and de-ticked by your groomer or your vet."
Many owners have their preferred vets and so I just give some free advices.
I am personally not keen on taking multivitamins and calcium from unknown drug companies as there had been horror stories from one company in Australia producing poor quality multi-vitamins marketed by health shops in Singapore some years ago. There was no quality control but a desire to make money.
I accepted his invitation to visit him as a friend. He had two dogs. One 17-year-old cross had died recently and suddenly of a bloated stomach and he was still grieving over the loss.
"He killed the dog with too much vitamins and glucosamine," the wife told me.
"Based on the history of sudden swelling of the abdomen, I think the dog had a ruptured big blood vessel due to old age. The dog's abdomen started to swell as the bleeding filled the abdomen. The dog lives to a ripe old age of 17 years and it is inevitable that the big blood vessel would break down. The only way to find the definite cause of death is a post-mortem."
"No point in having a post-mortem," the husband said that the dog had been cremated.
"When I die, I have asked my children to scatter my ashes in the sea," the wife said. "That will save them the trouble of having them to maintain my grave or urn. The later generations may forget about doing any maintenance."
The husband shocked me by saying: "Your ashes in the sea will kill all the fishes!" What a surprising thing to say. This was the first time I met the wife, a silver-haired trim lady.
"Well," I said to the husband to defuse the awkwardness of his comments, "Your ashes in the sea will kill all the whales."
The wife kept picking out the ticks from her Silkie Terrier. "The ticks keep appearing on the dog. Small dotted ones."
"Did you use spot-on insecticides like Frontline?" I asked.
"Not effective."
So this 7-year-old Silkie had been biting her back area till they were almost bald. "This could be a tick-bite allergy," I said to the wife. The dog was on prednisolone tablets and anti-ringworm tablets for many weeks.
I had to intervene for the sake of this poor dog. "I cannot guarantee, but this dog may have a full coat of hair if you can get rid of the ticks in the apartment and on this dog."
"Really?" the wife was interested as to what she should do.
"I cannot guarantee anything," I said. "The first step is to get the dog clipped bald, de-ticked and given a different type of spot-on insecticide. De-contaminate the apartment area where the dog stays usually. Best of all, after de-ticking put the dog in another part of the apartment so that the baby ticks cannot jump onto her.
"Will the dog have a full coat during Christmas?"
"I cannot guarantee it. Do you have a good groomer who can clip the dog bald and de-ticked? Ask your vet for a different spot-on insecticide."
Ticks in a dog can be difficult to be rid of due to the re-infestation from the surroundings. Apparently this dog does not go outdoors and therefore the ticks must be from inside the apartment. "My vet advised Bagon spray onto the walls," the wife said. "It does not work."
"It is hard to get rid of ticks if you don't isolate the de-ticked dog from the contaminated area," I said. "In any case, there are so many cracks in the wall and you need to do it thoroughly. Some vets and pest control companies advise 'bombs'. You close all the windows. Release the gas from the bombs to fumigate and kill all the ticks. It does not work in practice for many reasons."
"You have two dogs. Get both of them clipped bald and de-ticked by your groomer or your vet."
Many owners have their preferred vets and so I just give some free advices.
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