Report written at Toa Payoh Vets: Feb 16, 2010. Chinese New Year (CNY) 3rd day. Still a holiday. I wrote the following since I was quite free.
CNY reviews of interesting cases.
During Chinese New Year, almost all Singapore small animal vets close. Feb 14, 2010 was Chinese New Year and also Valentine's Day. Toa Payoh Vets do open half days during Chinese New Year. During last Chinese New Year, I had no cases and so I thought the same would happen this time. However, there were a few cases. Vomiting and diarrhoea in dogs accounted for 3 cases. The following were some interesting cases for dog lovers.
Case 1. Hypersexuality in the male dog.
The career lady was in charge of a regional publishing operation and had no time to take leave. She planned one month ahead and took several days' leave to care for her Miniature Schnauzer after neutering as advised by me. Her dog had inflamed areas in his groin region due to humping and licking.
The dog was groomed first. Multiple rashes on his lower body. Treatment for 4 days. Then I neutered him and sent him home 4 hours after neutering. He would be given Tolfedine 60 mg at 1 tablet per day. I phoned the lady and she said that the dog felt no pain and was just normal. I told her that the urine analysis showed that the dog has no urinary crystals unlike the previous test in which some triple phosphate crystals were found. The dog had spermatozoa in the test, as in previous test. Why? This male dog had an anti-social habit of humping onto legs and pillows, injuring his groin area. I hope neutering would help as he is already 4 years old. Neutering before 1 year of age would be best. This owner slims her dog down now as she cooks for him. No more dry dog food. She takes good care of him and I expect this dog to live up to 20 years. He is only 4 years now and may outlive me as I am 15 times older than him.
"You can't shout at him," the gentle lady boss told me. When I commanded the Schnauzer in a firm voice to be still on the examination table, the dog suddenly turned around and opened his mouth to bite me. I just withdrew my fingers in time. No tough love for this dog. But no gentle kind words from me. I muzzle him instead.
Case 2. Medial Entropion. Shih Tzu, 7 kg, Male, Neutered, 1 year, 39deg C. Persistent eye tearing since puppyhood.
The Shih Tzu is well known for medial entropion causing life-long tearing and irritation but few owners are aware of a simple surgery to resolve the problem. Seldom does the owner bother to take the surgery. A case is recorded below for the benefit of vet undergraduates. Name of surgery: Nasal fold excision. I didn't know there is such a surgery.
Admitted: Feb 2, 2010
Surgery 1: Feb 5, 2010
Surgery 2 (left eyelid tearing on day 6, right eyelid has no tearing): Feb 11, 2010. Excised a bigger elliptical skin area below and lateral to the medial canthus. Rolled out the left eyelid more. Took out stitches of right eye area to review. Wound opens up as the area is under tension and has not healed firmly as it was 6 days only. Has not healed 100%. Re-stitch. Tolfedine 60 mg (1/2 tab/day) x 10 days
Baytril 50 mg (1/2 tab/day) x 6 day
e-collar, eye drops
Daily cleaning of eyelid area is necessary for the next 10 days
Nylon 5/0 stitches to be taken out on Feb 25, 2010
Goes home on Feb 17, 2010 (pictures taken on Feb 16, 2010. Phoned owner at 10.30 am wakening him up.)
Case 3. Anal sacculitis or circum-anal tumour.
Miniature Pinscher, male, 5 years with hard lump on left anal sac area. Anal sacculitis/circum-anal tumour surgery. Heals well. Goes home on Feb 16, 2010. Is this a circum-anal tumour? Still Alive And Kicking - Circum-anal tumours. Should the dog get a second anti-androgenic injection and be neutered? Many owners are against neutering deeming it to be a cruel act.
Anal sacculitis (left)
Anal sac and surrounding tumour excised. Neuter advised
Or in this case, the dog is deemed too old and a anaesthetic risk. So I do not pursue the matter further as the owner may think that I am soliciting business from her and from the owner's point of view - this is patently obvious. Update: 2004 tips for young and older dogs
Case 4. Torticollis (head tilt) in a rabbit.
CNY 1st day. Rabbit, female, 2 years, 1.7kg
Feb 14, 2010 (Chinese New Year).
Head tilt to the right. Rolling and rolling as the rabbit could not stand up. Sudden onset at 1 am (loud noises heard). Left eyelid wide open. Nystagmus. Right eyelid injured as rabbit lies on right face. Keeps rolling to try to get up. Ear canal - A bit of blood stain was seen in the cotton bud seen from deep inside the ear canal. No ear pain. Irrigated ears. Prednisolone, Meloxicalm oral, Biolapis, Fiberplex. SC dextrose saline and baytril.
Sent home the 2nd day as she could stand but with head tilted. Less Nystagmus. The lady owner to nurse and hand feed at home as economics was a big concern. Floor mat. No blood test or X-rays for the time being as this would increase vet costs. Possible causes are: trauma (cage too low), otitis media or externa (X-rays needed), encephalitozoonosis, neoplasia, toxicity and cerebro-vascular diseases. Antibiotics given.
Vestibular Disease is common dogs and cats. Rabbits too. Clinical signs are NOT dependent on the localisation of the lesion within the peripheral or central pat of the vestibular system. The peripheral system is the balance organ (semicircular canals) and distal Cranial Nerve 8. The central is vestibular nuclei and proximal CN8 and part of cerebellum (flocculonodular node).
1. Head tilt, falling and rolling: peripheral and central and sometimes cerebellum affected.
2. Circling: peripheral (ipsilateral). central affected. cerebellum: not affected.
3. Nystagmus: yes for peripheral and central. eye oscillations (tremor) if cerebellum affected.
4. Nystagmus changes direction: no for peripheral. yes for central. N/A for cerebellum.
5. Vertical nystagmus: no for peripheral. yes for central. N/A for cerebellum.
6. CP and postural deficits: no for peripheral. yes for central. no for cerebellum.
7. Paresis: no for peripheral. yes for central. no for cerebellum.
8. Horner's syndrome & CN7/5 signs: often for peripheral. rare for central. no for cerebellum.
Horner's syndrome is caused by disruption of the sympathetic innervaton from the hypothalamus to the eye and periorbital region and clinical signs are miosis, ptosis, enopthalmos and 3rd eyelid prolapse. Causes usually idiopathic but common ones are brainstem disease, cervical spinal cord disease (disc prolapse, embolism, trauma), C8-T2 brachial nerve root avulsion, C8-T2 spinal nerve or brachial plexus nerve sheath tumour, large anterior mediastinal lesions (thymoma, lymphoma), neck injuries or disease, otitis interna/media, skull fractures, trauma, retrobulbar neoplasia or infection.
CNY 2nd day.
Case 5. Suspected high fever in a hamster.
White dwarf hamster, Male, 14 m,
Eyelids closed. Not eating 2 days. Sleepy for 2 days
Young teenaged boy was upset that his pet became sick when he was in China for 9 days.
SC dextrose and Baytril and eye drops.
Day 2 - conjunctivitis and tearing esp. right eye (photography) and dehydration - will need electrolytes. Eating. Stools passed but only a few pieces. Not a good prognosis.
Owner to disinfect hamster cage, feed bowl and water bottle.
CNY 3rd day. Still a public holiday.
Case 6. Deep ulcerative keratitis in a Chihuahua.
Chihuahua, 2.6 kg, 38.8. adopted for 2 months. Abandoned. Eye cataracts. Possibly >8 years old. Male. 2.65 kg. Heart disease.
Right corneal eye ulcer very deep. Blood spots. Past 2 weeks. Why the delay? The owner thought it was a small matter.
Anaesthesia is high risk as dog has heart disease. Bad teeth. Eats only wet food. Big right flank abscess > 4cm x1 cm. 3rd eyelid flap on day 2 planned. As the dog has serious heart disease and would die under general anaesthesia in 90% of probability, I decided not to operate and let the dog go home later.
Case 7. Poodle, Male, 2 years. Dental scaling. I was surprised that the lady owner made an appointment for dental scaling for a young dog. Rarely do Singapore owners bother at this age. Grooming 3-monthly and regularly yes. The external beauty is a priority.
Tartar in the back teeth
Dental scaling removed tartar and plaques
But teeth check up once a year? No. This young dog eats home-cooked food and no dry food. So plaque and tartar form in the back teeth. Daily brushing will resolve all problems. Some dogs don't like teeth cleaning. This lady may be one of those more sophisticated ones who know the importance of dental health to enable her dog to live longer.
Case 8. A tele-conversation with a pet owner. One owner complained that his dog had been losing weight since being warded. His vet prescribed many types and sizes of capsules containing nutrients and vitamins for his old dog to "prolong his life". Yet the dog lost weight while he was warded. He said he was not given progress reports. The dog would not eat when brought home as he was force-fed. I don't make comments in this case as I only get one side of the story. Just provide a listening ear as I am sure that there will be owners with grievances against me as a vet.
Case 9. A tele-conversation with a new vet undergraduate. Young people prefer texting. I prefer phoning to thank Daphne for her help in producing 2 educational videos for vet students recently. Creating educational videos to bring veterinary surgery alive. She had been an intern at Toa Payoh Vets. I gave her my very best wishes for her new adventure as a veterinary undergraduate in Australia. She saw 5 beautiful Miniature Schnauzer puppies at a practice and was saying how cute they were. New-born puppies always tug's a lady's heart strings. I told her I did not perform the Caesarean section but was taking pictures. Oxytocin injection and wait or an elective Caesarean section?
This 2010 CNY was not a quiet day unlike 2009 CNY. My main lesson is from the feedback in Case 8. It is important that the vet does daily rounds of in-patients and check records of weight loss and appetite as a routine no matter how busy they are. Phone the owner to update and to phone the owner to visit the pet if the pet is dying. Before the pet dies so that the owner can pay the last visit. I wonder whether this is taught at veterinary schools for the 5th year students.
Friday, April 9, 2010
18. How to ace the surgical practical?
A team of 3 classmates from the 4th year will be assessed on their surgical skills. One will be the surgeon, one the anaesthetist and one the recorder for the forthcoming test. The students would have theoretical knowledge from lecture notes and a video of the surgery prior to the practical. For a student who wants to be in the top 2%, this test is very important as every mark counts.
The surgery. Anastomosis of the small intestines in a pig. None of the students had performed this surgery. I assume none have seen it done when they see practice as it is an uncommon surgery. It is not a simple surgery. Poor stitching will lead to leakage of the intestinal contents and septic peritonitis. The stress is extremely high if one wants to ace this first-time difficult surgery.
How to ace this practical test?.
1. Don't be the surgeon. Unfortunately, none of the 3 volunteered. A lucky draw picked out one girl to be the guinea pig. The other 2 can relax.
2. Get hands-on practice after knowing the theory and watching the video. This is what differentiates an "A" student from the rest of the pack. None of your classmates will bother. Why should they? They are not interested in being top 2%. This will be to your advantage as you will shine in the sea of mediocrity.
3. Know the competition. The 80:20 rule in life says that 80% of a cohort will not be interested in excellence. The 20% contributes to 80% of the production. So, in a team of 3, one may be interested in scoring the highest mark in surgery. The sample is too small for the 80:20 rule. I did a bit of research into the motivations of this group.
Surprisingly, the 80:20 rule does not apply to your group. I know there is another girl who wants to excel and is in the top 2%. I don't know about the 3rd person who may be influenced by the competitiveness of both of you. At least 2/3 wants to ace this practical. That exceeds the 20%.
4. Pass the buck to your competitor. "Let the other girl be the surgeon", I advised this girl. "She has had worked more in seeing practices and is older. "It is not fair," the prospective student-surgeon said. "But is life ever fair? My question is 'Will she rise to the challenge and accept this position?"
5. The competitive edge I doubt it. Why volunteer to be a pioneer to blaze the trail and suffer personal damage? "Is she agreeable to be the surgeon?" I asked again. "Not really." the girl replied. Well, this competitor is very smart. Very sharp. Yet she is magnanimous in giving this unlucky pioneer-surgeon some fishing line to practise surgery. She knows she has the advantage of seeing practice. I don't think she has had the practice of anastomosis. In any case, she is in an enviable position of not being required to perform the most stressful task of the group. Fate has had chosen you. Yet, Fate has given you a mentor if you have been able to read the stars accurately. That mentor is me.
6. Correct tools needed. Know your stuff. "Fishing lines are nylon. "No teacher is going to teach you to use nylon in the anastomosis of the jejunum," I asserted. I may be mistaken but I am quite sure that it is not the correct way to teach students in this particular type of surgery. Fishing lines are too thick if I am correct. Inserting a fishing line into a suture needle to stitch up the intestines should never be taught. This will lead to big holes in the intestine and seepage of intestinal fluids. The suture should continue from the end of the needle instead of being inserted as in a clothes sewing needle. So, you must understand and know the tools of the trade.
7. Where to get such tools? You just buy the absorbable suture packs from the practising veterinarian.
8. Where to get the pig intestines? "Don't they have the small butcher shops in Australia selling pig intestines?" I asked. I graduated from Glasgow University in 1974. There were small butcher shops selling such intestines. At that time, I never was given a similar task nor did I perform any practical surgery. It was almost 30 years ago and 4th year vet students didn't do practical surgery on live animals. There were no surgery videos nor the internet.
7. Practice, practice, practice. You just got to spare the time to stitch and stitch at least 100 anastomosed intestines if you want to be confident and get top grades. No easy way out.
8. Get a mentor A vet who had performed surgery for many years to monitor your surgical stitching. Not necessary pig intestines. Dog intestines will do if he or she is in small animal practice. Nothing beats having somebody to show you how it is done and then supervising you doing the anastomosis.
7. Seize the moment. I was available for the last 5 days and had advised that you buy the pig intestines and get on with the surgery practice. Today will be my second last day in Australia.
8. Be Proactive Overcome your inertia. Just go out to buy the intestines and practise, practise, practise on a hundred jejunums yourself. Devote time to it. On the day of the trial, you will just do it with two eyes closed and get 100% score. In countries like Taiwan and India, I hear that vet undergraduates have lots of surgical experiences, but in the Western education model, animal welfare prohibits such undertakings.
But there are other alternatives like the butcher shop. It is as easy as that, but the vast majority of the 4th year vet students will never do it. They have better things to do. They don't want academic excellence nor do they have great passion in veterinary medicine and surgery. All these factors work to giving you the competitive edge. Just be proactice and just do it. If you want to achieve something, plan ahead, research and work very hard by practising a lot. There is no short cut to academic excellence and a Medal of excellence from the University.
The surgery. Anastomosis of the small intestines in a pig. None of the students had performed this surgery. I assume none have seen it done when they see practice as it is an uncommon surgery. It is not a simple surgery. Poor stitching will lead to leakage of the intestinal contents and septic peritonitis. The stress is extremely high if one wants to ace this first-time difficult surgery.
How to ace this practical test?.
1. Don't be the surgeon. Unfortunately, none of the 3 volunteered. A lucky draw picked out one girl to be the guinea pig. The other 2 can relax.
2. Get hands-on practice after knowing the theory and watching the video. This is what differentiates an "A" student from the rest of the pack. None of your classmates will bother. Why should they? They are not interested in being top 2%. This will be to your advantage as you will shine in the sea of mediocrity.
3. Know the competition. The 80:20 rule in life says that 80% of a cohort will not be interested in excellence. The 20% contributes to 80% of the production. So, in a team of 3, one may be interested in scoring the highest mark in surgery. The sample is too small for the 80:20 rule. I did a bit of research into the motivations of this group.
Surprisingly, the 80:20 rule does not apply to your group. I know there is another girl who wants to excel and is in the top 2%. I don't know about the 3rd person who may be influenced by the competitiveness of both of you. At least 2/3 wants to ace this practical. That exceeds the 20%.
4. Pass the buck to your competitor. "Let the other girl be the surgeon", I advised this girl. "She has had worked more in seeing practices and is older. "It is not fair," the prospective student-surgeon said. "But is life ever fair? My question is 'Will she rise to the challenge and accept this position?"
5. The competitive edge I doubt it. Why volunteer to be a pioneer to blaze the trail and suffer personal damage? "Is she agreeable to be the surgeon?" I asked again. "Not really." the girl replied. Well, this competitor is very smart. Very sharp. Yet she is magnanimous in giving this unlucky pioneer-surgeon some fishing line to practise surgery. She knows she has the advantage of seeing practice. I don't think she has had the practice of anastomosis. In any case, she is in an enviable position of not being required to perform the most stressful task of the group. Fate has had chosen you. Yet, Fate has given you a mentor if you have been able to read the stars accurately. That mentor is me.
6. Correct tools needed. Know your stuff. "Fishing lines are nylon. "No teacher is going to teach you to use nylon in the anastomosis of the jejunum," I asserted. I may be mistaken but I am quite sure that it is not the correct way to teach students in this particular type of surgery. Fishing lines are too thick if I am correct. Inserting a fishing line into a suture needle to stitch up the intestines should never be taught. This will lead to big holes in the intestine and seepage of intestinal fluids. The suture should continue from the end of the needle instead of being inserted as in a clothes sewing needle. So, you must understand and know the tools of the trade.
7. Where to get such tools? You just buy the absorbable suture packs from the practising veterinarian.
8. Where to get the pig intestines? "Don't they have the small butcher shops in Australia selling pig intestines?" I asked. I graduated from Glasgow University in 1974. There were small butcher shops selling such intestines. At that time, I never was given a similar task nor did I perform any practical surgery. It was almost 30 years ago and 4th year vet students didn't do practical surgery on live animals. There were no surgery videos nor the internet.
7. Practice, practice, practice. You just got to spare the time to stitch and stitch at least 100 anastomosed intestines if you want to be confident and get top grades. No easy way out.
8. Get a mentor A vet who had performed surgery for many years to monitor your surgical stitching. Not necessary pig intestines. Dog intestines will do if he or she is in small animal practice. Nothing beats having somebody to show you how it is done and then supervising you doing the anastomosis.
7. Seize the moment. I was available for the last 5 days and had advised that you buy the pig intestines and get on with the surgery practice. Today will be my second last day in Australia.
8. Be Proactive Overcome your inertia. Just go out to buy the intestines and practise, practise, practise on a hundred jejunums yourself. Devote time to it. On the day of the trial, you will just do it with two eyes closed and get 100% score. In countries like Taiwan and India, I hear that vet undergraduates have lots of surgical experiences, but in the Western education model, animal welfare prohibits such undertakings.
But there are other alternatives like the butcher shop. It is as easy as that, but the vast majority of the 4th year vet students will never do it. They have better things to do. They don't want academic excellence nor do they have great passion in veterinary medicine and surgery. All these factors work to giving you the competitive edge. Just be proactice and just do it. If you want to achieve something, plan ahead, research and work very hard by practising a lot. There is no short cut to academic excellence and a Medal of excellence from the University.
17. Biosecurity in poultry farm
Poultry Assignment 2010
The implementation of a well planned biosecurity program is important in maintaining bird health on poultry farms. The four potential sources of diseases are from people, poultry, contaminated premises or equipment and vectors, though there are other possibilities that will not be covered. Measures must be taken to prevent or control the introduction and spread of infectious agents to a flock (Commonwealth of Australia, 2010).
People are considered to be the most common source of carrying poultry diseases into poultry farms and measures must be taken to minimize these risks (PoultryHub, 2009). Firstly, using signage and gates prevents unauthorized people from entering the farm. Visitors and service providers must wear overalls and boots provided by the farmers and footwear must be disinfected before entering the sheds (PoultryHub, 2009). Lastly, movement of people should be scheduled such that the youngest flocks are visited first and the oldest last (PoultryHub, 2009). This measure is especially important in conventional cage systems as birds are confined to their cage and are susceptible to any infections.
Another common source of infection is from poultry. Routine vaccination should be done at specific ages to prevent diseases by creating immunity in the bird’s system. Daily inspection for dead or sick birds should be done and removed immediately to prevent the spread of bacteria or virus. Sick or newly purchased birds should be quarantined from the flock. Also, giving a nutritionally balanced diet, proper ventilation and minimizing fear and anxiety in the birds will help the birds’ natural protective mechanisms to function optimally (PoultryHub, 2009). This measure is important for all types of systems.
Contamination can also come from the air, water supply and feed. Especially for conventional cage or barn systems, ensure that good ventilation systems are installed to as air borne diseases spread very quickly. Water supply should be changed regularly to prevent contamination with faeces from contact with avian or other animal species (Commonwealth of Australia, 2010). Using good quality feed is particularly important as bacteria and mould may be present in poor quality feed. Feed can also be contaminated by the raw materials used, post production and during transport or by exposure to rodents and birds on the property (PoultryHub, 2009) if not kept properly.
Wild birds, rodents and insects can be carriers of diseases and this aspect is especially important in free range farms as they have easy access to the birds’ living quarters. Possible measures to be taken are to wire net the barns to make them bird proof (PoultryHub, 2009), to discourage wild birds from visiting by removing any spilled feed immediately (deGraft-Hanson, 2002) and by sanitizing water for bird consumption. Farmers should also ensure good fencing to prevent rodents from gaining access which can contaminate poultry feed and good parasite control programs should be implemented.
In conclusion, different production systems inclusive of the type (conventional cages, free range, barn layer, household), species (chicken, ratities, etc.), and product emphasis (meat or egg) have emphasis on different aspects of their biosecurity program. However, it is still important that all aspects are covered to maintain good bird health for greater production and economical value.
MY OPINION
Your article is very dull and boring to read.
If I write, I will give an introduction (hook), middle (main answer) and a conclusion as follows:
1. A Hook - Some current concerns of biosecurity in the poultry industry leading to massive economic losses in poultry farms e.g. H1N1 viral infections in hong kong? Some references.
2. Answer the question directly --- What aspects of the biosecurity program would I put in place to protect my poultry farm against the 4 potential sources of diseases?
This depends on what type of poultry farm I am operating. Free range or indoor housing?
Free range
Caged indoor housing
Some disease prevention procedures will apply to both. Some will be particular to free ranging birds.
1. Quarantine of new arrivals or sick birds
2. Visitors hygienic measures - procedures
3. Vaccinations. Give some examples of commercial vaccines used.
4. Good nutrition.
5. Anti-stress measures.
6. Rodent control, parasite control, wild bird control etc.
7. I have not included all you had mentioned.
You have all the facts in your report. It is just that you are not answering the question directly as a farm operator. Re-write and good luck.
P.S. The question is as follows:
Assignment question for 2010
On poultry farms, to maintain bird health the emphasis is ‘Prevention is better than cure’. Prevention involves having a well planned and implemented biosecurity program.
Diseases can be introduced to your poultry farm by
People
Poultry
Contaminated premises or equipment
Vectors
What aspects of a biosecurity program would you put in place to protect against these four potential sources of disease.
The implementation of a well planned biosecurity program is important in maintaining bird health on poultry farms. The four potential sources of diseases are from people, poultry, contaminated premises or equipment and vectors, though there are other possibilities that will not be covered. Measures must be taken to prevent or control the introduction and spread of infectious agents to a flock (Commonwealth of Australia, 2010).
People are considered to be the most common source of carrying poultry diseases into poultry farms and measures must be taken to minimize these risks (PoultryHub, 2009). Firstly, using signage and gates prevents unauthorized people from entering the farm. Visitors and service providers must wear overalls and boots provided by the farmers and footwear must be disinfected before entering the sheds (PoultryHub, 2009). Lastly, movement of people should be scheduled such that the youngest flocks are visited first and the oldest last (PoultryHub, 2009). This measure is especially important in conventional cage systems as birds are confined to their cage and are susceptible to any infections.
Another common source of infection is from poultry. Routine vaccination should be done at specific ages to prevent diseases by creating immunity in the bird’s system. Daily inspection for dead or sick birds should be done and removed immediately to prevent the spread of bacteria or virus. Sick or newly purchased birds should be quarantined from the flock. Also, giving a nutritionally balanced diet, proper ventilation and minimizing fear and anxiety in the birds will help the birds’ natural protective mechanisms to function optimally (PoultryHub, 2009). This measure is important for all types of systems.
Contamination can also come from the air, water supply and feed. Especially for conventional cage or barn systems, ensure that good ventilation systems are installed to as air borne diseases spread very quickly. Water supply should be changed regularly to prevent contamination with faeces from contact with avian or other animal species (Commonwealth of Australia, 2010). Using good quality feed is particularly important as bacteria and mould may be present in poor quality feed. Feed can also be contaminated by the raw materials used, post production and during transport or by exposure to rodents and birds on the property (PoultryHub, 2009) if not kept properly.
Wild birds, rodents and insects can be carriers of diseases and this aspect is especially important in free range farms as they have easy access to the birds’ living quarters. Possible measures to be taken are to wire net the barns to make them bird proof (PoultryHub, 2009), to discourage wild birds from visiting by removing any spilled feed immediately (deGraft-Hanson, 2002) and by sanitizing water for bird consumption. Farmers should also ensure good fencing to prevent rodents from gaining access which can contaminate poultry feed and good parasite control programs should be implemented.
In conclusion, different production systems inclusive of the type (conventional cages, free range, barn layer, household), species (chicken, ratities, etc.), and product emphasis (meat or egg) have emphasis on different aspects of their biosecurity program. However, it is still important that all aspects are covered to maintain good bird health for greater production and economical value.
MY OPINION
Your article is very dull and boring to read.
If I write, I will give an introduction (hook), middle (main answer) and a conclusion as follows:
1. A Hook - Some current concerns of biosecurity in the poultry industry leading to massive economic losses in poultry farms e.g. H1N1 viral infections in hong kong? Some references.
2. Answer the question directly --- What aspects of the biosecurity program would I put in place to protect my poultry farm against the 4 potential sources of diseases?
This depends on what type of poultry farm I am operating. Free range or indoor housing?
Free range
Caged indoor housing
Some disease prevention procedures will apply to both. Some will be particular to free ranging birds.
1. Quarantine of new arrivals or sick birds
2. Visitors hygienic measures - procedures
3. Vaccinations. Give some examples of commercial vaccines used.
4. Good nutrition.
5. Anti-stress measures.
6. Rodent control, parasite control, wild bird control etc.
7. I have not included all you had mentioned.
You have all the facts in your report. It is just that you are not answering the question directly as a farm operator. Re-write and good luck.
P.S. The question is as follows:
Assignment question for 2010
On poultry farms, to maintain bird health the emphasis is ‘Prevention is better than cure’. Prevention involves having a well planned and implemented biosecurity program.
Diseases can be introduced to your poultry farm by
People
Poultry
Contaminated premises or equipment
Vectors
What aspects of a biosecurity program would you put in place to protect against these four potential sources of disease.
Thursday, April 8, 2010
16. urinary stones in dogs
The Death Sentence for Producing Urinary Stones - How to prevent recurrences in struvite and other urinary stone formation
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Updated: 08 April, 2010
Many times, it is a death sentence when the pet dog produces urinary stones again as the average Singaporean dog owner feels that the diagnosis by clinical signs and diagnostic imaging, the surgical treatment, hospitalisation, nursing care and medication from around S$800 to over $2,500 are "expensive". Unfortunately, urinary stones do recur in some dogs such as the Miniature Schnauzer.
Stones are usually found in the bladder and urethra. Less than 4% of urolithiasis cases are found in the kidneys or ureter (hydronephrosis, acute renal failure).
TREATMENT AND PREVENTION
1. Accurate analysis. Stone analysis by Hills Pet Nutrition using optical crystallography or infra-red spectrometry or a laboratory able to analyse stones. Crystalluria or urine analysis may not be accurate. Characteristic shapes on radiographs and by visual examination is not a reliable guide to their composition. Oxalates are said to be highly radiodense and silica are radiodense with jackstone shape. Struvites are moderately to highly radiodense but is associated with urinary tract infection (urease production) and alkaline pH. Calcium oxalates are associated with hypercalcaemia.
2. Treat UTI e.g. struvite stones.
3. Surgical removal by cystotomy (calcium uroliths) or medical dissolution by dietary manipulation of the urine pH (applies only to struvites, urate and cystine). Ureteroliths and urethroliths cannot be dissolved and should be surgically or manually removed. All uroliths dissolve at the same rate, so it is not the number. But largest stones dissolve slower than smaller ones. The owner may not want to pay for the regular X-rays to monitor dissolution of the stones in real life. The owner must be warned that it is possible that bladder stones may obstruct the urethra when they get dissolved to smaller size. In practice, I have a case where a vet suggested feeding home cooked food but the female Miniature Schnauzer had a stone as large as a quail's egg. The stone did not dissolve. I suspected that the vet just advised home-cooked food and gave antibiotics. I don't think the owner gave the acidification tablets after some days or were not given any. In any case, the dog kept peeing blood. I had it surgically removed and the dog was OK for the past years. It is said that it takes as long as 7 months to get the large struvite stones dissolved. When you see the large quail egg stone (in one of my case studies), you will wonder whether it can be dissolved medically at that size.
4. Lithotripsy or sonic dissolution. Not available in Singapore.
5. Prevent or reduce recurrence by getting the dog to pee less concentrated urine (target at USG <1.020).
How to do it? No dry food. Add water into food. Pet fountain, multiple water bowls around the house, ice cubes in water, add something inside water to encourage drinking. I would advise milk if the dog is lactose tolerant.
6. Monitor by regular imaging. Few Singapore owners spare the time or money to get this done. They just seem to have no time.
Some of my tips to prevent recurrences of struvite stones are:
1. BREED. Breeds like the Miniature Schnauzer are prone to producing urinary stones. Urinary examination at least 3-monthly will be ideal. If not, during the half yearly wellness examination or yearly vaccination, ask your vet to do a urinary analysis.
2. DIET. No dry dog food definitely. No canned foods or treats. Special low stone prescription diet or home-cooked food.
3. URINE pH to be acidic if struvite stones have formed. USG to be less than 1.020. Red and White Blood Cells measured weekly using dipsticks in collaboration with your vet.
4. WATER INTAKE. Measure diligently and scientifically 24-hourly water drunk in collaboration with your vet. Some sedentary dogs need to be encouraged to drink by more exercise or supervision.
5. ACIDIFICATION OF THE URINE if the urine pH is 7.0 and higher in collaboration with your vet.
6. BLADDER PALPATION. If stones or a crackling gassy sound are felt, it is bad news. Consult your vet promptly.
2 female dogs with blood in the urine. Both had dry dog food. The Schnauzer, peeing out stones, was fed home-cooked food at the same time as another dog (Golden Retriever) was fed dry food by the maid 8 months ago after consulting me about "no surgery". She was given acidification tablets and C/D diet for 1 month and had no longer produced stones. She might have eaten some dry food and produced stones 8 months after my consultation.
The Cocker Spaniel had fish-based dry dog food for 8 years and was observed to have haematuria 2 months ago. A vet advised medication to dissolve the stones in view of the high anaesthetic risk of operating on a senior dog.
The objective is to prevent struvite crystal formation by ensuring that the bladder is free from bacterial infections and that the urine pH is alkaline. The dog owner has to be educated in prevention and to take good care post-surgery in collaboration with their vet keeping proper records. Unfortunately, few owners bother. A recurrence means a death sentence usually during times of recession. The guidelines apply to the prevention of struvite (triple phosphate) urinary stones only.
INCIDENTAL FINDINGS OF A CALCULUS. Many Singapore owners are not interested in medical management by regular abdominal radiographs or surgical removal as the dog seems not to have any urinary problems after antibiotic treatment.
URINE pH required to form struvite stones is alkaline. Calcium oxalate and ammonium urate or urates (Acid to Normal). Cystine, silica and xanthine (acidic).
Struvite (magnesium ammonium phosphate) are most amenable to medical dissolution. Calculolytic diets have low protein, phosphorus and magnesium but high sodium content to produce diuresis and they acidify urine. Antibiotics based on bacterial culture. Dissolution may take 4 months or as long as 7 months. Surgical removal if urethral obstruction not relieved by retropulsion.
Calcium oxalate. Increased urinary calcium excretion may be due to increased GI calcium absorption, renal-leak hypercalciuria (tubular defect), hypercalcaemia or hyperadrenocortiicism. Surgical removal only. Correct hypercalcaemia, reduced protein, calcium and oxalae diet for absorptive hypercalciuria. urinary alklisation with potassium citrate. thiazide diuretics in dogs with recurrent cases eg. hydrochlorothiazide 2mg/k q 12 hr PO). No treatment for renal-leak hypercalciuria.
Ammonium urate. 96% Dalmatians. Dogs with liver disease of portosystemic shunts 4%. Calculoytic diets by urinary alkalisation e.g. Hills u/d but this takes many months. Allopurinol 30 mg/kg q 24 hr PO to reduce urate production by inhibiting enzyme xanthine oxidase WITH protein restricted food. Prolonged allopurinol treatment may result in xanthine crystalluria and urolithiasis.
Cystine
acid urine. renal tubular disorder. surgical removal. medical management said to work. Alkalisation and protein restriction diet e.g. u/d. PLUS N-(2-mercaptopropionyl)-glycine (2-MPG) at 15-20mg/kg, 12 hr with diet for dissolution, then 15 mg/kg q 12 hr for prevention.
References:
Bladder Stone case studies
The Vet's Best Is Not Good Enough
webpage: www.toapayohvets.com
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Updated: 08 April, 2010
Many times, it is a death sentence when the pet dog produces urinary stones again as the average Singaporean dog owner feels that the diagnosis by clinical signs and diagnostic imaging, the surgical treatment, hospitalisation, nursing care and medication from around S$800 to over $2,500 are "expensive". Unfortunately, urinary stones do recur in some dogs such as the Miniature Schnauzer.
Stones are usually found in the bladder and urethra. Less than 4% of urolithiasis cases are found in the kidneys or ureter (hydronephrosis, acute renal failure).
TREATMENT AND PREVENTION
1. Accurate analysis. Stone analysis by Hills Pet Nutrition using optical crystallography or infra-red spectrometry or a laboratory able to analyse stones. Crystalluria or urine analysis may not be accurate. Characteristic shapes on radiographs and by visual examination is not a reliable guide to their composition. Oxalates are said to be highly radiodense and silica are radiodense with jackstone shape. Struvites are moderately to highly radiodense but is associated with urinary tract infection (urease production) and alkaline pH. Calcium oxalates are associated with hypercalcaemia.
2. Treat UTI e.g. struvite stones.
3. Surgical removal by cystotomy (calcium uroliths) or medical dissolution by dietary manipulation of the urine pH (applies only to struvites, urate and cystine). Ureteroliths and urethroliths cannot be dissolved and should be surgically or manually removed. All uroliths dissolve at the same rate, so it is not the number. But largest stones dissolve slower than smaller ones. The owner may not want to pay for the regular X-rays to monitor dissolution of the stones in real life. The owner must be warned that it is possible that bladder stones may obstruct the urethra when they get dissolved to smaller size. In practice, I have a case where a vet suggested feeding home cooked food but the female Miniature Schnauzer had a stone as large as a quail's egg. The stone did not dissolve. I suspected that the vet just advised home-cooked food and gave antibiotics. I don't think the owner gave the acidification tablets after some days or were not given any. In any case, the dog kept peeing blood. I had it surgically removed and the dog was OK for the past years. It is said that it takes as long as 7 months to get the large struvite stones dissolved. When you see the large quail egg stone (in one of my case studies), you will wonder whether it can be dissolved medically at that size.
4. Lithotripsy or sonic dissolution. Not available in Singapore.
5. Prevent or reduce recurrence by getting the dog to pee less concentrated urine (target at USG <1.020).
How to do it? No dry food. Add water into food. Pet fountain, multiple water bowls around the house, ice cubes in water, add something inside water to encourage drinking. I would advise milk if the dog is lactose tolerant.
6. Monitor by regular imaging. Few Singapore owners spare the time or money to get this done. They just seem to have no time.
Some of my tips to prevent recurrences of struvite stones are:
1. BREED. Breeds like the Miniature Schnauzer are prone to producing urinary stones. Urinary examination at least 3-monthly will be ideal. If not, during the half yearly wellness examination or yearly vaccination, ask your vet to do a urinary analysis.
2. DIET. No dry dog food definitely. No canned foods or treats. Special low stone prescription diet or home-cooked food.
3. URINE pH to be acidic if struvite stones have formed. USG to be less than 1.020. Red and White Blood Cells measured weekly using dipsticks in collaboration with your vet.
4. WATER INTAKE. Measure diligently and scientifically 24-hourly water drunk in collaboration with your vet. Some sedentary dogs need to be encouraged to drink by more exercise or supervision.
5. ACIDIFICATION OF THE URINE if the urine pH is 7.0 and higher in collaboration with your vet.
6. BLADDER PALPATION. If stones or a crackling gassy sound are felt, it is bad news. Consult your vet promptly.
2 female dogs with blood in the urine. Both had dry dog food. The Schnauzer, peeing out stones, was fed home-cooked food at the same time as another dog (Golden Retriever) was fed dry food by the maid 8 months ago after consulting me about "no surgery". She was given acidification tablets and C/D diet for 1 month and had no longer produced stones. She might have eaten some dry food and produced stones 8 months after my consultation.
The Cocker Spaniel had fish-based dry dog food for 8 years and was observed to have haematuria 2 months ago. A vet advised medication to dissolve the stones in view of the high anaesthetic risk of operating on a senior dog.
The objective is to prevent struvite crystal formation by ensuring that the bladder is free from bacterial infections and that the urine pH is alkaline. The dog owner has to be educated in prevention and to take good care post-surgery in collaboration with their vet keeping proper records. Unfortunately, few owners bother. A recurrence means a death sentence usually during times of recession. The guidelines apply to the prevention of struvite (triple phosphate) urinary stones only.
INCIDENTAL FINDINGS OF A CALCULUS. Many Singapore owners are not interested in medical management by regular abdominal radiographs or surgical removal as the dog seems not to have any urinary problems after antibiotic treatment.
URINE pH required to form struvite stones is alkaline. Calcium oxalate and ammonium urate or urates (Acid to Normal). Cystine, silica and xanthine (acidic).
Struvite (magnesium ammonium phosphate) are most amenable to medical dissolution. Calculolytic diets have low protein, phosphorus and magnesium but high sodium content to produce diuresis and they acidify urine. Antibiotics based on bacterial culture. Dissolution may take 4 months or as long as 7 months. Surgical removal if urethral obstruction not relieved by retropulsion.
Calcium oxalate. Increased urinary calcium excretion may be due to increased GI calcium absorption, renal-leak hypercalciuria (tubular defect), hypercalcaemia or hyperadrenocortiicism. Surgical removal only. Correct hypercalcaemia, reduced protein, calcium and oxalae diet for absorptive hypercalciuria. urinary alklisation with potassium citrate. thiazide diuretics in dogs with recurrent cases eg. hydrochlorothiazide 2mg/k q 12 hr PO). No treatment for renal-leak hypercalciuria.
Ammonium urate. 96% Dalmatians. Dogs with liver disease of portosystemic shunts 4%. Calculoytic diets by urinary alkalisation e.g. Hills u/d but this takes many months. Allopurinol 30 mg/kg q 24 hr PO to reduce urate production by inhibiting enzyme xanthine oxidase WITH protein restricted food. Prolonged allopurinol treatment may result in xanthine crystalluria and urolithiasis.
Cystine
acid urine. renal tubular disorder. surgical removal. medical management said to work. Alkalisation and protein restriction diet e.g. u/d. PLUS N-(2-mercaptopropionyl)-glycine (2-MPG) at 15-20mg/kg, 12 hr with diet for dissolution, then 15 mg/kg q 12 hr for prevention.
References:
Bladder Stone case studies
The Vet's Best Is Not Good Enough
webpage: www.toapayohvets.com
15. How I was appointed a Godfather
The mum informed me that her daughter got top 2% in Murdoch University examinations. What does it mean? Top 2% of the cohort or top 2% of the veterinary faculty of 100 students? Well, I was happy for the single mother. How did she motivate her child to excel academically? There is no simple answer.
Academic excellence opens doors to top professional practices all over the world. But male classmates in general don't seem to care two hoots about being top dog in the veterinary faculty, from my survey. Straight As mean nothing to many of them. If vet professors want to be stringent and permit only one repeat re-examination, I suspect many males will need to repeat the year and that the graduates produced will be reduced by some 30%, assuming the male:female ratio is 50:50.
How to be a straight A student?
1. Hard work mainly as there is a lot to memorise. Time must be spent in the actual studies.
2. Hands-on experiences by seeing practice with vets during the spare time or live-in.
3. Sacrificing time with family and friends. You can't have the cake and eat it.
The mum was very worried when the daughter was offered a vet practice accommodation. She would save money on her accommodation which can be as much as A$700 as month in Australia. The practice would benefit its employees who need not be present overnight at the practice. The mum was so worried that she wanted to fly over to see the practice and Quantas Airways was offering cheap S$700 return fare for Easter.
"No," the daughter said. "I would be busy moving and besides, I needed to entertain my friends during this time." There seems to me to be not the right thing to do and I told the young girl accordingly. I found that the friends stayed in her place since they did not want to pay for hotel accommodation at A$90.00 a night. I mean, what is an additional person who loves you very much - the mum since you got to entertain friends for 3 days?
I guess the daughter was worried that the mum might embarass her. After all, she was an adult. But to mums, 20+ year girl is still a baby. So, she asked me to check out the vet practice. "What will I say about my relationship to this young girl if the principal ask me?" I said to the worrier. "Just tell him you are the Godfather."
That's how I became a Godfather although I am not Catholic. I have yet to meet the principal vet and have only 2 days left in Perth. I had seen the location of the vet practice some 3 days ago only at night. The impressive practice is a bungalow, located off the main road, at a corner of a side street. The street lights were bright and the road was clean. The neighbourhood of low rise houses and one apartment block appeared serene, with warm yellow lights in the apartment at 9 pm. It looked safe as there were no drug addicts or gangs roaming about. There was a brightly lit liquor shop across the road with no drunkards lurking about. I better not say anything about this store to the mum as it would cause her unnecessary worries. Maybe I should take a taxi and go and see the place in daylight myself. It is not as easy to take a cab as in Singapore. I should drive as most students have a car and I can borrow one. Time is short. The real Godfather with the actor Marlon Brando acting as the Godfather would just send in the lieutenants to check the place inside out. I need to be proactive.
Academic excellence opens doors to top professional practices all over the world. But male classmates in general don't seem to care two hoots about being top dog in the veterinary faculty, from my survey. Straight As mean nothing to many of them. If vet professors want to be stringent and permit only one repeat re-examination, I suspect many males will need to repeat the year and that the graduates produced will be reduced by some 30%, assuming the male:female ratio is 50:50.
How to be a straight A student?
1. Hard work mainly as there is a lot to memorise. Time must be spent in the actual studies.
2. Hands-on experiences by seeing practice with vets during the spare time or live-in.
3. Sacrificing time with family and friends. You can't have the cake and eat it.
The mum was very worried when the daughter was offered a vet practice accommodation. She would save money on her accommodation which can be as much as A$700 as month in Australia. The practice would benefit its employees who need not be present overnight at the practice. The mum was so worried that she wanted to fly over to see the practice and Quantas Airways was offering cheap S$700 return fare for Easter.
"No," the daughter said. "I would be busy moving and besides, I needed to entertain my friends during this time." There seems to me to be not the right thing to do and I told the young girl accordingly. I found that the friends stayed in her place since they did not want to pay for hotel accommodation at A$90.00 a night. I mean, what is an additional person who loves you very much - the mum since you got to entertain friends for 3 days?
I guess the daughter was worried that the mum might embarass her. After all, she was an adult. But to mums, 20+ year girl is still a baby. So, she asked me to check out the vet practice. "What will I say about my relationship to this young girl if the principal ask me?" I said to the worrier. "Just tell him you are the Godfather."
That's how I became a Godfather although I am not Catholic. I have yet to meet the principal vet and have only 2 days left in Perth. I had seen the location of the vet practice some 3 days ago only at night. The impressive practice is a bungalow, located off the main road, at a corner of a side street. The street lights were bright and the road was clean. The neighbourhood of low rise houses and one apartment block appeared serene, with warm yellow lights in the apartment at 9 pm. It looked safe as there were no drug addicts or gangs roaming about. There was a brightly lit liquor shop across the road with no drunkards lurking about. I better not say anything about this store to the mum as it would cause her unnecessary worries. Maybe I should take a taxi and go and see the place in daylight myself. It is not as easy to take a cab as in Singapore. I should drive as most students have a car and I can borrow one. Time is short. The real Godfather with the actor Marlon Brando acting as the Godfather would just send in the lieutenants to check the place inside out. I need to be proactive.
Wednesday, April 7, 2010
14. High BUN and creatine in a vomiting adult dog
April 7, 2010. Perth, 6 am. Writing from a Willeton house in Perth as I reflected on this "medical malpractice" case.
Vet 1 diagnosed kidney failure. The adult neutered male dog of a small breed, around 5 years had been vomiting for the past few days and occasionally over the years. Vet 1's blood test some 9 months ago showed a high BUN. So she advised another blood test. It showed high BUN and an extremely high creatine level. She suspected acute kidney failure and advised abdominal scanning at two other practices as she does not have the facility. Antibiotics were prescribed for the "skin disease" according to the owner.
Vet 2 (myself) advised monitoring. The worried owner phoned me wanting to fax me the blood tests and get a telephone diagnosis. I asked her to bring the dog down for an examination as blood test results need to be co-related with the history and physical examination of the dog.
She got the dog in for examination. She showed me the blood tests and asked whether her dog was dying soon. The dog was normal and had no polydipsia or polyuria. Therefore, I did not "run down" the other vet. I did not ask for another blood test to verify as it was taken 24 hours ago. I presumed that the owner would not want one as most owners of small breeds feel the pain of their dogs having their small vein punctured for blood taking. In any case, most vets in Singapore, including me, trusted the blood test results of our competitors and seldom asked for another test. This was a big mistake on my part.
As the dog was active and normal, except for vomiting, I said it was not dying soon. It could be having gastritis (stomach infection). I advised taking of the antibiotics I prescribed for 5 days. The important thing was to monitoring the water intake daily and to keep in touch by phone if vomiting persisted and the dog did not eat. I advised a prescription canned food for kidney disease. The owner phoned me the next day that the dog ate the canned food. However, it vomited after eating the canned food some 24 hours later.
Vet 3 diagnosed no kidney problems. The owner went to Vet 3 to get a scan. Vet 3 did a blood test and warded the dog which was given an IV drip. "It is a medical malpractice," the owner phoned me. "Vet 1 said that her blood test machine had broken down and did not even have the decency to phone me earlier." There was much anger. There was a meeting with Vet 1. Vet 1's mentor told the owner that I ought to have taken a blood test. Since I had not done it, I was also involved in "misdiagnosis".
Conclusion:
I should have taken a blood test and recommended a scan immediately. There was no point trying to save money for the owner. Practising defensive medicine would have been prudent on hindsight. I apologised for not having asked her to take a blood test. She said she would have objected anyway. I offered to take back the cans prescription renal diet.
"Well, Vet 3 says that the dog should be on a prescription liver diet!". The dog was no more vomiting. What was the diagnosis? Liver problems now? This case shows that the vet must get another blood test done and if the owner objects, to put it in writing. If the physical findings do not indicate kidney failure, be assertive and run down the competitor. No quarters given. However, running down the competitor just adversely affect the image of the veterinary profession in Singapore. I don't do it. Every vet will make mistakes and so I don't run down my competitors. I hope the 4th year vet students in Murdoch University will find this case alive and interesting for their "Polydipsia and Polyuria" lectures, well documented by Dr Peter Irwin,
1. Normal dogs drink about 50-60 ml/kg/day. Cats considerably less. I did ask the owner to monitor the water intake. Instead she syringe feed water to the dog. This may be one cause of "vomiting" after eating the canned food.
2. Polydipsia: >100ml/kg/day in dogs. >50ml/kg/day in cats on DRY food and >10ml/kg/day in cats on WET food.
3. Polyuria: increase in urine production >50ml/kg/day. general guide only. not possible to measure in clinic or home setting.
4. Urine Specific Gravity (USG) to assess renal concentrating ability. Measured on a refractometer (urine dipstick results unreliable).
No such thing as a "normal" USG. Most healthy animals USG 1.025 to 1.065. A sample with <1.025 may raise a diagnostic suspicion of polydipsia.
4.1 Hypersthenuria USG>1.012. Urine more concentrated than the patient's plasma
4.2 Isothenuria USG 1.008 - 1.012. Persistent isothenuria with azotaemia is consistent with tubular insufficiency or renal failure.
4.3 Hyposthenuria USG <1.008. Renal tubules can dilute but not concentrate urine. Unlikely to have renal failure or insufficiency. Usually caused by interference with the ADH receptors in the renal collecting ducts.
DDx of PU and PD in dogs and cats
COMMON CAUSES
DOGS
Chronic renal disease
pyometra
diabetes mellitus
hyperadrenocorticism
Iatrogenic (drug induced)
Medullary solute washout - a process as a consequence of marked polyuria of ANY CAUSE and can contribute to the severrity of the PU. E.g. relief of Urinary tract obstruction in FLUTD cat.
CATS
Chronic renal disease
Post-obstructive diuresis
Hyperthyroidism
Diabetes melllitus
Iatrogenic
Medullary solute washout
P.S. It is best to advocate ultra-scan of the kidneys to check for polycystic kidneys or tumours and not to ask the owner to wait a few days. In the above case, the owner said that Vet 1 should have made the necessary arrangements as she was told to wait 2 weeks at one practice. She managed to find one vet who did the scan.
LESSONS LEARNT FROM THIS CASE
1. PROVIDING EXCELLENT CUSTOMER SERVICES
The vet can make arrangements for scanning at other practices since he has none. The dog owner wants scanning and therefore, this service should create goodwill and loyalty if the vet does it. As for me, I did not advise immediate scanning as my clinical findings did not indicate acute renal failure and like vets from my baby-boomer generation, I was trying to lower the owner's total veterinary costs. I should make arrangements for scanning as that was what the owner wanted. In fact, she had the impression that I said scanning was unnecessary, according to Vet 1's mentor when I spoke to him to discuss the resoluion of the owner's conflicts in this case.
2. MINI-PROFILES NOT ADVISED
Always collect URINE and blood for health screening. This is because the vet cannot assess the dog's metabolic state without both samples. In this case, Vet 1 did a mini-profile to check only blood BUN and creatinine. The owner told me that the BUN was high but creatinine was normal some 9 months ago and the vet advised a mini-profile to check BUN and creatinine. The BUN has gone higher and the creatinine level was extremely high in the second mini-profile test.
FULL PROFILE means CBC (complete blood count) and FBE (full biochemical exam) AND elecrolytes (Na, Cl & K). Many Singapore pet owners will not want to pay for the full profile and so, permission must be given first. Otherwise, the owner may not pay!
3. HONESTY
The owner complained that Vet 1 should have had informed her when the vet knew that the blood test machine was malfunctioning instead of after she told them that Vet 3 had said that there was no kidney disorders from Vet 3's blood test. She had to take leave from work and suffered stresses. "Why didn't Vet 1 inform me earlier?" she said. "It is medical malpractice!"
4. REPEAT BLOOD SAMPLE.
I should have strongly advise a blood sample plus a urine sample when clinical findings did not indicate an acute renal failure. This was what the owner had the impression from Vet 1 and was worrying a lot. I was trying to save the owner some money. Younger vets in Singapore do not think twice about blood tests, X-rays, urine tests and histopathology (even for a hamster tumour). Times have changed and the Singapore pet owner must pay more for vet treatment.
5. POLYDIPSIA AND POLYURIA
Many Singapore dog owners know that their dogs drink a lot but don't know how much. The dog may not be polydipsic. Check Urine SG with a refractometer. A sample with less than 1.025 may indicate polydipsia.
6. ACUTE RENAL FAILURE
is characterised by the sudden onset of oliguria/anuria, azotaemia or both.
6.1 Clinical Signs are: extreme lethargy (the dog was active in this case study), dehydration, oliguria or anuria and vomiting.
6.2 Lab findings include: renal azotaemia (very high increase in BUN and creatinine) with isothenuria. Urea >50mmol/L. creatinine >300mmol/L.
6.2.1 Urine analysis may show cause e.g. oxalate crystals, white cell cass, bacteriuria in acute pyelonephritis).
6.3 Electrolyte abnormalities (Na, K, Cl variable)
6.4 Metabolic acidosis
6.5 Hyperphospataemia
I hope this case study will be useful as they show the owner's points of view. In this case, assuming that the blood test machine was not "malfunctioning", it is possible that the vomiting dog had a bacterial infection of the kidneys resulting in a renal azotaemia (acute renal falure). With antibiotics, the dog took a few days to recover. When Vet 3 was consulted, there was no more bacterial infections (e.g. pyelonephritis) and therefore no more renal azotaemia. Acute renal failure at the beginning stage may just show azotaemia and not oliguria/anuria. So Vet 3 became the hero. A urine test by Vet 1 would have been very useful to support bacterial infection in the urinary tract, e.g. proteinuria, white cell casts, USG, pH, presence of uroliths but the owner might not want to pay initially and this is a common situation in Singapore in this period of recession.
CONCLUSION
4th year vet students who must study a lot of theories and memorise them to pass examinations can see that the complexities and and economics of practice are so much different from the class-room lectures.
Mini-profile blood tests rather than complete blood count and biochemistry may be done in practice as the owner may not want to pay for a comprehensive blood test. Do NOT assume that the owner would not want a repeat blood test. Get a second blood test done rather than try to save money for the owner and be liable for "medical malpractice" litigation. Get the owner's objection recorded if the owner does not want a second blood test.
Vet 1 diagnosed kidney failure. The adult neutered male dog of a small breed, around 5 years had been vomiting for the past few days and occasionally over the years. Vet 1's blood test some 9 months ago showed a high BUN. So she advised another blood test. It showed high BUN and an extremely high creatine level. She suspected acute kidney failure and advised abdominal scanning at two other practices as she does not have the facility. Antibiotics were prescribed for the "skin disease" according to the owner.
Vet 2 (myself) advised monitoring. The worried owner phoned me wanting to fax me the blood tests and get a telephone diagnosis. I asked her to bring the dog down for an examination as blood test results need to be co-related with the history and physical examination of the dog.
She got the dog in for examination. She showed me the blood tests and asked whether her dog was dying soon. The dog was normal and had no polydipsia or polyuria. Therefore, I did not "run down" the other vet. I did not ask for another blood test to verify as it was taken 24 hours ago. I presumed that the owner would not want one as most owners of small breeds feel the pain of their dogs having their small vein punctured for blood taking. In any case, most vets in Singapore, including me, trusted the blood test results of our competitors and seldom asked for another test. This was a big mistake on my part.
As the dog was active and normal, except for vomiting, I said it was not dying soon. It could be having gastritis (stomach infection). I advised taking of the antibiotics I prescribed for 5 days. The important thing was to monitoring the water intake daily and to keep in touch by phone if vomiting persisted and the dog did not eat. I advised a prescription canned food for kidney disease. The owner phoned me the next day that the dog ate the canned food. However, it vomited after eating the canned food some 24 hours later.
Vet 3 diagnosed no kidney problems. The owner went to Vet 3 to get a scan. Vet 3 did a blood test and warded the dog which was given an IV drip. "It is a medical malpractice," the owner phoned me. "Vet 1 said that her blood test machine had broken down and did not even have the decency to phone me earlier." There was much anger. There was a meeting with Vet 1. Vet 1's mentor told the owner that I ought to have taken a blood test. Since I had not done it, I was also involved in "misdiagnosis".
Conclusion:
I should have taken a blood test and recommended a scan immediately. There was no point trying to save money for the owner. Practising defensive medicine would have been prudent on hindsight. I apologised for not having asked her to take a blood test. She said she would have objected anyway. I offered to take back the cans prescription renal diet.
"Well, Vet 3 says that the dog should be on a prescription liver diet!". The dog was no more vomiting. What was the diagnosis? Liver problems now? This case shows that the vet must get another blood test done and if the owner objects, to put it in writing. If the physical findings do not indicate kidney failure, be assertive and run down the competitor. No quarters given. However, running down the competitor just adversely affect the image of the veterinary profession in Singapore. I don't do it. Every vet will make mistakes and so I don't run down my competitors. I hope the 4th year vet students in Murdoch University will find this case alive and interesting for their "Polydipsia and Polyuria" lectures, well documented by Dr Peter Irwin,
1. Normal dogs drink about 50-60 ml/kg/day. Cats considerably less. I did ask the owner to monitor the water intake. Instead she syringe feed water to the dog. This may be one cause of "vomiting" after eating the canned food.
2. Polydipsia: >100ml/kg/day in dogs. >50ml/kg/day in cats on DRY food and >10ml/kg/day in cats on WET food.
3. Polyuria: increase in urine production >50ml/kg/day. general guide only. not possible to measure in clinic or home setting.
4. Urine Specific Gravity (USG) to assess renal concentrating ability. Measured on a refractometer (urine dipstick results unreliable).
No such thing as a "normal" USG. Most healthy animals USG 1.025 to 1.065. A sample with <1.025 may raise a diagnostic suspicion of polydipsia.
4.1 Hypersthenuria USG>1.012. Urine more concentrated than the patient's plasma
4.2 Isothenuria USG 1.008 - 1.012. Persistent isothenuria with azotaemia is consistent with tubular insufficiency or renal failure.
4.3 Hyposthenuria USG <1.008. Renal tubules can dilute but not concentrate urine. Unlikely to have renal failure or insufficiency. Usually caused by interference with the ADH receptors in the renal collecting ducts.
DDx of PU and PD in dogs and cats
COMMON CAUSES
DOGS
Chronic renal disease
pyometra
diabetes mellitus
hyperadrenocorticism
Iatrogenic (drug induced)
Medullary solute washout - a process as a consequence of marked polyuria of ANY CAUSE and can contribute to the severrity of the PU. E.g. relief of Urinary tract obstruction in FLUTD cat.
CATS
Chronic renal disease
Post-obstructive diuresis
Hyperthyroidism
Diabetes melllitus
Iatrogenic
Medullary solute washout
P.S. It is best to advocate ultra-scan of the kidneys to check for polycystic kidneys or tumours and not to ask the owner to wait a few days. In the above case, the owner said that Vet 1 should have made the necessary arrangements as she was told to wait 2 weeks at one practice. She managed to find one vet who did the scan.
LESSONS LEARNT FROM THIS CASE
1. PROVIDING EXCELLENT CUSTOMER SERVICES
The vet can make arrangements for scanning at other practices since he has none. The dog owner wants scanning and therefore, this service should create goodwill and loyalty if the vet does it. As for me, I did not advise immediate scanning as my clinical findings did not indicate acute renal failure and like vets from my baby-boomer generation, I was trying to lower the owner's total veterinary costs. I should make arrangements for scanning as that was what the owner wanted. In fact, she had the impression that I said scanning was unnecessary, according to Vet 1's mentor when I spoke to him to discuss the resoluion of the owner's conflicts in this case.
2. MINI-PROFILES NOT ADVISED
Always collect URINE and blood for health screening. This is because the vet cannot assess the dog's metabolic state without both samples. In this case, Vet 1 did a mini-profile to check only blood BUN and creatinine. The owner told me that the BUN was high but creatinine was normal some 9 months ago and the vet advised a mini-profile to check BUN and creatinine. The BUN has gone higher and the creatinine level was extremely high in the second mini-profile test.
FULL PROFILE means CBC (complete blood count) and FBE (full biochemical exam) AND elecrolytes (Na, Cl & K). Many Singapore pet owners will not want to pay for the full profile and so, permission must be given first. Otherwise, the owner may not pay!
3. HONESTY
The owner complained that Vet 1 should have had informed her when the vet knew that the blood test machine was malfunctioning instead of after she told them that Vet 3 had said that there was no kidney disorders from Vet 3's blood test. She had to take leave from work and suffered stresses. "Why didn't Vet 1 inform me earlier?" she said. "It is medical malpractice!"
4. REPEAT BLOOD SAMPLE.
I should have strongly advise a blood sample plus a urine sample when clinical findings did not indicate an acute renal failure. This was what the owner had the impression from Vet 1 and was worrying a lot. I was trying to save the owner some money. Younger vets in Singapore do not think twice about blood tests, X-rays, urine tests and histopathology (even for a hamster tumour). Times have changed and the Singapore pet owner must pay more for vet treatment.
5. POLYDIPSIA AND POLYURIA
Many Singapore dog owners know that their dogs drink a lot but don't know how much. The dog may not be polydipsic. Check Urine SG with a refractometer. A sample with less than 1.025 may indicate polydipsia.
6. ACUTE RENAL FAILURE
is characterised by the sudden onset of oliguria/anuria, azotaemia or both.
6.1 Clinical Signs are: extreme lethargy (the dog was active in this case study), dehydration, oliguria or anuria and vomiting.
6.2 Lab findings include: renal azotaemia (very high increase in BUN and creatinine) with isothenuria. Urea >50mmol/L. creatinine >300mmol/L.
6.2.1 Urine analysis may show cause e.g. oxalate crystals, white cell cass, bacteriuria in acute pyelonephritis).
6.3 Electrolyte abnormalities (Na, K, Cl variable)
6.4 Metabolic acidosis
6.5 Hyperphospataemia
I hope this case study will be useful as they show the owner's points of view. In this case, assuming that the blood test machine was not "malfunctioning", it is possible that the vomiting dog had a bacterial infection of the kidneys resulting in a renal azotaemia (acute renal falure). With antibiotics, the dog took a few days to recover. When Vet 3 was consulted, there was no more bacterial infections (e.g. pyelonephritis) and therefore no more renal azotaemia. Acute renal failure at the beginning stage may just show azotaemia and not oliguria/anuria. So Vet 3 became the hero. A urine test by Vet 1 would have been very useful to support bacterial infection in the urinary tract, e.g. proteinuria, white cell casts, USG, pH, presence of uroliths but the owner might not want to pay initially and this is a common situation in Singapore in this period of recession.
CONCLUSION
4th year vet students who must study a lot of theories and memorise them to pass examinations can see that the complexities and and economics of practice are so much different from the class-room lectures.
Mini-profile blood tests rather than complete blood count and biochemistry may be done in practice as the owner may not want to pay for a comprehensive blood test. Do NOT assume that the owner would not want a repeat blood test. Get a second blood test done rather than try to save money for the owner and be liable for "medical malpractice" litigation. Get the owner's objection recorded if the owner does not want a second blood test.
Tuesday, April 6, 2010
13. 8-year-old male dog urine-marks indoors and outdoors. Is there a solution?
E-MAIL TO DR SING DATED APR 6, 2010
Subject: Serious Urine-marking Indoors
Hi,
I was referred by a friend to seek your advise regarding my maltese's serious urine-marking habits.
I'm not sure if it can still be corrected now as he is already 8 yrs old now but still quite active. These are the different scenarios:
1) In the daytime while me and my hubby are working, we kept him in the kitchen with the kitchen door closed and the toilet fenced up. We confine him to the kitchen because he tends to lift his legs everywhere on the furniture if we were to allow him to freely roam in the house. Sometimes, he also sits on the wet floor in the kitchen toilet so we had to fenced the toilet also. He usually pees on newspaper on the pee tray. However, he still marks the kitchen walls, fridges and cabinets.
2) If we are at home, he is free to roam in the house. He usually will go to the pee tray in the kitchen to pee and does his business. But again, he also leaves marks everywhere in the kitchen.
3) At night. This is where there is a major problem. He sleeps with us in the bedroom. We fenced up the bedroom door and puts a pee tray in the bedroom. He does pees in the pee tray but at the same time he marks every where in the bedroom, against the dustbin, bed legs, walls etc. We tried having a small light, it doesn't help. We've tried the commercial products as well, doesn't work.
4) When we bring him out for walks, he marks every single pole and trees he pass. After a while, he has no urine already but still he will lift his leg on every pole n tree.
You can see that my dog has a serious urine-marking problem and we have lived with it for so long. We have given up actually. I am writing to you not in the hope of correcting it totally but maybe you have advise for me to improve the situation. If I have no intention of neutering him, is there still other solutions to this problem?
Cheers,
Name of Owner
E-MAIL REPLY FROM DR SING DATED APR 6, 2010
Hello
Thank you for your email. I am Dr Sing from Toa Payoh Vets. Below are my comments and suggestions which may or may not be useful .
1. Neutering at this age may not be 100% effective although the urge to urine-mark may be reduced over time.
2. Neutralise all urine smells in the vertical surfaces and urine-marked areas with white vinegar:water at 1 part to 3 parts, using a rag to wash out the urine smells. This may prove impossible house is full of urine smell.
Start your trainingt in a small area. For example, do try with one room over several months by setting up this room as a "restricted zones (RZ)". For example, use the guest bedroom as a RZ. The room is closed when you are not able to monitor your dog.
3. In the RZ, you can use a mixture of Positive reinforcement training using food treat rewards and praises and Negative reinforcement training using loud and firm scoldings and a spanking on the floor with the newspapers just when your dog starts to urine-mark. Which approach you use or a mixture of both, depends on your personality and that of the dog.
4. Noise Distraction method. When the dog starts to urine-mark, distract him by dropping a can of coins. Give him food treats and praises.
5. Time-out method. When you catch your dog about to urine-mark, say "no marking" and put him inside a confined room for 10-15 minutes, for example. He may associate this punishment with urine-marking and may try to change.
6. Take him outdoors at fixed times e.g. morning and evening so that he urine-marks only downstairs.
7. In your bedroom, he is confined to a crate at night so that he does not urine-mark. This may sound cruel to you.
8. All the re-training takes lots of time and patience. If you have the time, the old dog will learn new tricks in 6 months. Success is not guaranteed.
9. You still need to neuter him as well as do re-training for the next 6 months, if you want some success.
I hope the above helps.
Subject: Serious Urine-marking Indoors
Hi,
I was referred by a friend to seek your advise regarding my maltese's serious urine-marking habits.
I'm not sure if it can still be corrected now as he is already 8 yrs old now but still quite active. These are the different scenarios:
1) In the daytime while me and my hubby are working, we kept him in the kitchen with the kitchen door closed and the toilet fenced up. We confine him to the kitchen because he tends to lift his legs everywhere on the furniture if we were to allow him to freely roam in the house. Sometimes, he also sits on the wet floor in the kitchen toilet so we had to fenced the toilet also. He usually pees on newspaper on the pee tray. However, he still marks the kitchen walls, fridges and cabinets.
2) If we are at home, he is free to roam in the house. He usually will go to the pee tray in the kitchen to pee and does his business. But again, he also leaves marks everywhere in the kitchen.
3) At night. This is where there is a major problem. He sleeps with us in the bedroom. We fenced up the bedroom door and puts a pee tray in the bedroom. He does pees in the pee tray but at the same time he marks every where in the bedroom, against the dustbin, bed legs, walls etc. We tried having a small light, it doesn't help. We've tried the commercial products as well, doesn't work.
4) When we bring him out for walks, he marks every single pole and trees he pass. After a while, he has no urine already but still he will lift his leg on every pole n tree.
You can see that my dog has a serious urine-marking problem and we have lived with it for so long. We have given up actually. I am writing to you not in the hope of correcting it totally but maybe you have advise for me to improve the situation. If I have no intention of neutering him, is there still other solutions to this problem?
Cheers,
Name of Owner
E-MAIL REPLY FROM DR SING DATED APR 6, 2010
Hello
Thank you for your email. I am Dr Sing from Toa Payoh Vets. Below are my comments and suggestions which may or may not be useful .
1. Neutering at this age may not be 100% effective although the urge to urine-mark may be reduced over time.
2. Neutralise all urine smells in the vertical surfaces and urine-marked areas with white vinegar:water at 1 part to 3 parts, using a rag to wash out the urine smells. This may prove impossible house is full of urine smell.
Start your trainingt in a small area. For example, do try with one room over several months by setting up this room as a "restricted zones (RZ)". For example, use the guest bedroom as a RZ. The room is closed when you are not able to monitor your dog.
3. In the RZ, you can use a mixture of Positive reinforcement training using food treat rewards and praises and Negative reinforcement training using loud and firm scoldings and a spanking on the floor with the newspapers just when your dog starts to urine-mark. Which approach you use or a mixture of both, depends on your personality and that of the dog.
4. Noise Distraction method. When the dog starts to urine-mark, distract him by dropping a can of coins. Give him food treats and praises.
5. Time-out method. When you catch your dog about to urine-mark, say "no marking" and put him inside a confined room for 10-15 minutes, for example. He may associate this punishment with urine-marking and may try to change.
6. Take him outdoors at fixed times e.g. morning and evening so that he urine-marks only downstairs.
7. In your bedroom, he is confined to a crate at night so that he does not urine-mark. This may sound cruel to you.
8. All the re-training takes lots of time and patience. If you have the time, the old dog will learn new tricks in 6 months. Success is not guaranteed.
9. You still need to neuter him as well as do re-training for the next 6 months, if you want some success.
I hope the above helps.
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