? peculiar cat fit

Re: ? peculiar cat fit

Moira Hamilton — Wed, 05 Sep 2012 22:07:07 GMT

Thankfully she is a very compliant cat, so should manage to do all these tests. The owner is compiling a fit diary including which side she falls over to, and is coming in to see me in a week, so will post an update on her after I've seen her, though the owner is giving me update on her by e-mail.

Thank you so much for your advice, neurology is not my strongest subject so the information is VERY useful.

Thanks very much everyone and will update you, including if I find anything on the bloods if the owner is happy to have these done. I suspect he will as he is a very loyal and switched on owner. To the extent of sending me update pictures of his other cat who was critically ill with intestinal problems when very young but is now doing very well.

Re: ? peculiar cat fit

Rajat — Wed, 05 Sep 2012 18:39:51 GMT

[quote user="Hannah Wynne Richards"]It is absolutely unforgivable for a veterinary surgeon to not offer the best treatment because of a misguided desire to save the owner money-which they might not want saved-and thereby put the animal's life at risk-it's the only life that animalwill ever have[/quote]

Re: ? peculiar cat fit

Hannah Wynne Richards — Wed, 05 Sep 2012 17:09:07 GMT

Re read your oath I remember mine as being "My constant endevour will be to ensure the WELFARE of animals committed to my care " That means doing my utmost best to cure them-which means alwayds initially advocating best practice If I'm forced to downgrade treatment and not blood test when there is a chance that the test will improve outcome, then , so be it-I've given the owner the best OPTION

I can't remeber swearing an oath to save the owner money-even if sometimes it is at the expense of the animal

It is absolutely unforgivable for a veterinary surgeon to not offer the best treatment because of a misguided desire to save the owner money-which they might not want saved-and thereby put the animal's life at risk-it's the only life that animalwill ever have

Wynne

Re: ? peculiar cat fit

David Mills — Wed, 05 Sep 2012 14:51:51 GMT

[quote user="Hannah Wynne Richards"]

Since David is in a minority of 1 thinking that blood samples aren't advisable-then RCVS might very well find someone who hadn't offered negligent

Wynne

[/quote]

1 out of at most 10 people. Out of ~15,000 practising vets in the UK. I'll think I'll continue to take my chances.

Re: ? peculiar cat fit

Hannah Wynne Richards — Wed, 05 Sep 2012 14:44:04 GMT

Since David is in a minority of 1 thinking that blood samples aren't advisable-then RCVS might very well find someone who hadn't offered negligent

Wynne

Re: ? peculiar cat fit

Kate Richardson — Wed, 05 Sep 2012 14:22:18 GMT

Cheers Mark, and very well put Alex

Re: ? peculiar cat fit

Mark Lowrie — Wed, 05 Sep 2012 14:02:39 GMT

[quote user="Kate Richardson"]

[quote user="Mark Lowrie"]Turn the cat on its back and check for spontaneous nystagmus – determines if there is vestibular disease[/quote]

So if spontaneous nystagmus is present would this indicate normal or abnormal vestibular function?

[/quote]

If there is spontaneous nystagmus this would indicate abnormal vestibular function, i.e. the presence of vestibular disease. All nystagmus is abnormal unless it is induced by moving the head from side to side/round and round (so-called physiological nystagmus).

Re: ? peculiar cat fit

Rob Loxley — Wed, 05 Sep 2012 13:41:27 GMT

[quote user="David Mills"]I have never seen a commercial biochemistry panel with enough parameters to be useful for less than £20 to the client, once mark up has been included[/quote]

No, but as the profit on not doing bloods is zero, the markup doesn't need to be excessive! Anyways, I think we'll have to agree to differ on this

Re: ? peculiar cat fit

Alex Gough — Wed, 05 Sep 2012 11:10:38 GMT

I get your point David, I think you are right that every case needs to be looked at as an individual, and that some tests have low yield in comparison to financial costs (MRI) and invasiveness (CSF). So a dog between the age of 6 months and 6 years when it has its first generalised seizure, that has a normal interictal neurological examination, and a normal physical examination, with no other abnormal historical signs, is likely to have idiopathic epilepsy. The cost/risk of an MRI scan and CSF sample in those cases is questionable, although I think it is reasonable to discuss with the owner, and if they are keen to rule out other conditions prior to starting lifelong treatment, as long as they understand the low diagnostic yield, I dont have a problem with that. I have certainly picked up brain tumours in dogs 3 years old and younger, and previously undiagnosed congenital brain deformities in dogs as old as 3, so there is no safe age to say something definitely has not structural brain disease.

However, when it comes to blood tests, the financial cost (especially in comparison to lifelong treatment) and the invasiveness (especially compared to drug side effects) strongly tip the risk/cost:benefit ratio in favour of a benefit of doing blood tests, and for this reason I think it would be hard to defend against a negligence claim if you started any dog with seizures on phenobarbitone without at least offering blood tests. The definition of negligence applied is whether a reasonable body of your peers would do the same as you have done. It's debatable whether vetsurgeon forum posters are reasonable (insert whatever the smiley is for ironic grin here) but most people seem to agree that blood tests should be offered.

Cheers

Alex

Re: ? peculiar cat fit

David Mills — Wed, 05 Sep 2012 10:49:36 GMT

[quote user="Kate Richardson"]

What if no bloods had been run and dog started on treatment with phenobarbitone, then went into status epilepticus and died? Negligence?

[/quote]

I'm unsure whether there is wilfull misconstruction or not here, but anyways. My objection is to 'screening bloods' for any seizure activity in any animal, which is advocated in textbooks and by many (majority?) practitioners. If there is specific indication for bloods - suspicion of systemic disease as dictated by presentation, examination or history, this includes age and unusual pattern - then fine, do bloods; but I object to the blanket application of bloods to any case to 'rule many things out' - it is dogmatic, and, by the absence of anything other than anecdote on here, not supported by clinical audit of those peoples' clinical behvaiour. It is a bit like sending a cat for an echo with vomiting - just to 'rule out' cardaic causes, where you might pick up 1 in 1000 vascular causes.

Negligence by definition is jusged against what a reasonable veterinary surgeon would have done in the same position. In the case you mention, sudden onset seizuring in a middle aged dog, there is an argument - but not a concrete case - to be made for running bloods. But this cannot be transmorgified into a 'best to run bloods' policy

Re: ? peculiar cat fit

Alex Gough — Wed, 05 Sep 2012 09:51:34 GMT

That's interesting. A lot of people say that hypoT4 doesn't cause seizures any more, but I still check T4/TSH in most cases, as it can affect treatment, and it's hard to diagnose hypoT4 after you have started phenobarb.

Alex

Re: ? peculiar cat fit

Mark Holmes — Wed, 05 Sep 2012 09:39:26 GMT

I've got one, 11 year old dog, seizuring, bloods hypercholesterolaemia which prompted T4 check. HypoT4 seizuring stopped when treated.

Re: ? peculiar cat fit

Mark Holmes — Wed, 05 Sep 2012 09:36:44 GMT

I've got one, 11 year old dog, seizuring, bloods hypercholesterolaemia which prompted T4 check. HypoT4 seizuring stopped when treated.

Re: ? peculiar cat fit

Kate Richardson — Wed, 05 Sep 2012 09:25:36 GMT

[quote user="Mark Lowrie"]Turn the cat on its back and check for spontaneous nystagmus – determines if there is vestibular disease[/quote]

So if spontaneous nystagmus is present would this indicate normal or abnormal vestibular function?

Re: ? peculiar cat fit

Mark Lowrie — Wed, 05 Sep 2012 09:17:12 GMT

[quote user="Moira Hamilton"]

I don't know if she always falls to the left but does seem to lose awareness albeit for a second or to, and yes she does have facial twitching for a couple of minutes afterwards. In between episodes she is completely normal. Though her bloods were normal a couple of months ago, I will see if the owner will agree to re-testing them, neurological exam when not doing this, (she's only done it once in 3 double consults) reveals no obvious abnormalities, to me anyway but I'm not a neurologist but tested all the normal things. I haven't done urine analysis yet as she isn't litter trained and haven't yet persuaded the owner to have cystocentesis, also haven't done BP as machine isn't the easiest to get readings from! (Yes a slight cop out! I will definitely check if it is always to the left or not, no incontinence, inappropriate urination. I am pretty sure MRI would be beyond available funds which is a shame, but as long as nothing shows up in new bloods, (will try BP) and urinanalysis am thinking of probably doing a phenobarb trial first. Thanks for the advice, would it be significant if it was always a left sided fall? Other than possibly establishing it could be a right brain problem???

[/quote]

The only real reason for asking about falling is to determine whether we are looking at forebrain or vestibular signs and in turn determine the more likely causes for the signs (both locations have different differential diagnoses). If these are forebrain signs then it is unusual, though not impossible, for the cat to fall to the same side continually and we would expect more circling/seizures. However, if they are vestibular signs then falling to one side is more indicative of a lesion in the brainstem/ear on the same side.

Specific tests I would do (if the cat is compliant):

· Check menace response in both eyes – commonly decreased in forebrain disease

· Hop the cat on both forelimbs to see if it falls over on either side – a normal cat should not fall over when ‘hopped’, doesn’t distinguish forebrain vs brainstem disease but helps to know if a structural lesion is present

· Turn the cat on its back and check for spontaneous nystagmus – determines if there is vestibular disease

Let us know how you get on.

Re: ? peculiar cat fit

Alex Gough — Wed, 05 Sep 2012 09:13:48 GMT

Bear in mind that screening bloods may not reveal a shunt, although you may get some secondary evidence of one. Bile acid stim test is worth doing in all cases before starting phenobarb, both to confirm it isn't HE as a cause, and to make sure the liver is in good enough shape for the phenobarb.

Re: ? peculiar cat fit

Kate Richardson — Wed, 05 Sep 2012 09:09:29 GMT

Another case that springs to mind is a middle aged seizuring dog in which "screening" bloods revealed hypocalcaemia. IV diazepam did not control the fits, calcium surprisingly did. Eventual diagnosis primary hypoparathyroidism, lifelong treatment Vit D supplement.

What if no bloods had been run and dog started on treatment with phenobarbitone, then went into status epilepticus and died? Negligence?

Re: ? peculiar cat fit

Moira Hamilton — Wed, 05 Sep 2012 00:10:08 GMT

Will definately do bloods before comensing a trial of phenobarb

Re: ? peculiar cat fit

Utlendigur — Tue, 04 Sep 2012 23:55:20 GMT

[quote user="David Mills"]To expect every owner to come to a balanced decision is too much when even the 'expert' in the client relationship - the vet - cannot necessarily concur with other experts[/quote]

The consensus amongst the majority of people on here seems to be that it is sensible to at least offer bloods. You seem to be the only "expert" that doesn't concur. In any statistical distribution there are always "outliers" - they tend to get ignored

[quote user="David Mills"]what would you say if he asked 'what are the chances of picking something up this this blood test'[/quote]

I would, and HAVE, said that it is low (ie it will probably come back normal) but it is sensible to exclude metabolic problems and make sure there is no contraindication to phenobard before starting treatment. And for £20-30 most clients are happy to accept that advice.£30 is a lot less money than lifelong phenobarb treatment even without any monitoring tests, or the cost of resurrecting a dog with a shunt or liver diease pushed over the edge by anti-epileptics. Once the animal is on phenobarb and still seizuring, how do you differentiate between the rise in liver enzymes you quite often get with seizure meds and underlying liver disease if you haven't done bloods beforehand. Personally there's nothing I hate more than being presented with a case that has been tried on this medication and that medication without an attempt at work up and isn't responding, and you have to try to unpick side effects from symptoms, or explain to the owner why you are taking the animal off all treament,waiting weeks and starting from scratch - and even worse explain why it actually hasn't got the problem it was "diagnosed" with, but has something entirely different.

More of those anecdotes that you hate but the last but one insulinoma I diagnosed was in a dog coming in for a phenobarb blood test. No pre-treatment bloods had been done before putting it on phenobarb for its "funny turns"

Re: ? peculiar cat fit

Utlendigur — Tue, 04 Sep 2012 23:34:20 GMT

Couldn't view the video (old computer) but it sounds like my geriatric cat. Anecdotal so limited usefulness. She was about 17-18yrs old, hyperthyroid (on vidalta for quite a while), suspected hypertensive and on istin although she was too feisty to check BP and I doubt it would have been reliable on a hissing, spitting ball of fury, plus occasional metacam. She suddenly started having short seizures one day (about 6 in a day) - facial twitching, then falling to one side, occasionally becoming full seizure - normal in between. Recent bloods were normal. I suspected probably a CVA. Started on phenobarb which controlled them fairly well, then weaned her off over about 3-4wks. They didn't recur and she lived another couple of years. I was tempted to not start the phenobarb since the fits only lasted a few seconds but the problem was my two dogs got very distressed each time she had one - my collie would run to get me while my jack russell stood over the cat nudging her with her nose

Re: ? peculiar cat fit

David Mills — Tue, 04 Sep 2012 23:28:01 GMT

[quote user="Hannah Wynne Richards"]

David If I ran 99 uninformative blood tests,and on the 100th picked up something that enabled me to save an animals life-the only precious life that animal has , then I think the tests are worth while Please don't say it's a waste of money My reply would be MYOB You're working in a charity situation,so it's different for you You have a moral responsibility to use scarce charity resources so as to benefit the maximum number of animals The moral situation in private practice is totally different We have a moral duty to OFFER the highest possible standard of care It is then up to the owners whether they will pay for this, or negotiate for an inferior level We have absolutely no moral or legal right to only offer an inferior level because we think doing things properly is too expensive It's not our money, therefore not our business

Wynne

[/quote]

We have to agree to differ. To my mind, the 100 blood tests to pick up 1 is phenomenally low value and you're simply playing a numbers game - with owners money - whereby the one success is offset by 99 normals.

I agree that all the options should be presented. However, an owner also requires guidance. To expect every owner to come to a balanced decision is too much when even the 'expert' in the client relationship - the vet - cannot necessarily concur with other experts - what would you say if he asked 'what are the chances of picking something up this this blood test' if all people can show on here is isolated anecdote, without their own internal clinical audits? - not guiding the client is an abdication of your responsibility to the animal. It is in many ways a tough path to tread - the vet as both salesman and animal advocate, but that doesn't mean it shouldn't be tread successfully. It may be their money but it very much is a vet's business to advise - they are not simply a reference tool.

As for the reports of picking things up on bloods, they are illuminating - but they are exceptions that prove my rule more than anything else. I have never seen a commercial biochemistry panel with enough parameters to be useful for less than £20 to the client, once mark up has been included. So not dirt cheap and, I believe, like most 'screening bloods' often a waste of the client's money. An instructive exercise is mentally trying to restrict yourself to 3 parameters per blood test - somewhat focuses the mind on what you actually might be testing for.

Re: ? peculiar cat fit

Moira Hamilton — Tue, 04 Sep 2012 23:04:47 GMT

Re: ? peculiar cat fit

Rob Loxley — Tue, 04 Sep 2012 18:42:44 GMT

[quote user="David Mills"]And the 'dirt cheap' isn't a clinical argument at all - in most commercial labs its at least £20-30 without interpretation; money wasted in the vast majority of cases[/quote]

I reckon probably less than £20 and I'd hope we can manage the interpretation of a biochem panel, so pretty dirt cheap in the grand scheme of everything else that might be possibly be considered (CSF, MRI, years of treatment etc.) IMHO. Often low yield - yes - but given those few with other specific abnormalities often need completely different management, good value, IMHO again.

Re: ? peculiar cat fit

Hannah Wynne Richards — Tue, 04 Sep 2012 13:41:35 GMT

Wynne

Re: ? peculiar cat fit

Martin Atkinson — Tue, 04 Sep 2012 12:27:48 GMT

[quote user="Simon Neuhoff"]

and what is the need for a red star on this post?

[quote user="David Mills"]

What, exactly, in this situation would 'baseline bloods' tell you - and what is their diagnostic yield in a case like this?

[/quote]

[/quote] Just because it's David Mills?

Seriously, we've recently had a very similar case, 13 year old cat, long-term hyperthyroid on treatment with Felimazole so is blood tested regularly. Latest test as the seizures started were unremarkable: mildly raised Amylase, globulin and stress hyperglycaemia, very mild neutrophilia, T4 48.5 (>40 recommended for cats on medication but owner now been able to comply well recently) so nothing that shouts out. Owner is impecunious so further investigations not possible. Cat went home for observation and possibly start phenobarb if fits worsened but it went into status and was PTS out of hours at another vet 10 days later so not a lot of help for the OP unfortunately. IMO it is always worth doing a blood profile on these cases but IME in older animals with no prior history of fits there is usually some brain pathology.