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

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.

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?

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.

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.

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.

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.