Unusual neurological symptoms

RE: Unusual neurological symptoms

Balázs Abuzant — Wed, 17 May 2017 09:40:27 GMT

Thank you for your answers, I'm very grateful!

I found a storage disease of rottweilers, the mucopolysaccharidosis type I. Have you experiences with this disease?

The owner sent me a video, I try to upload.

Regards,

Katalin Hermándy-Berencz

RE: Unusual neurological symptoms

Thomas Johnson — Wed, 10 May 2017 15:34:46 GMT

[quote user="Anthony Todd"]Reading on these forums, the number of inconsequential samples seem to be higher.[/quote]

I would imagine that is due to case selection. FNAs that give an answer, which in my hands are the majority, don't get posted on here.

RE: Unusual neurological symptoms

Anthony Todd — Wed, 10 May 2017 15:27:56 GMT

Sorry turbo post deleted again, I'll just absorb the slings and arrows.

RE: Unusual neurological symptoms

Malcolm Ness — Wed, 10 May 2017 15:12:29 GMT

[quote user="Arlo Guthrie"] you're not entirely familiar with, such as FNA.[/quote]

Some may consider it ironic that on Googling "FNA" the very first hit is the Wikipedia article about fine needle aspiration.

RE: Unusual neurological symptoms

Arlo Guthrie — Wed, 10 May 2017 12:37:48 GMT

[quote user="Robin Grimmer"]FNA is such a routine procedure nowadays. I'm willing to bet you're the only vet on here that didn't know what the definition is. Just goes to show how hopelessly out of touch you are with modern veterinary practice.[/quote]

Steady on. I'm not deleting that post, because I don't think you're being gratuitously unkind, but making a point borne of frustration.

Still think you could have worded it differently. For example, something like:

Anthony Todd, in order to try and keep discussions focused on the matter in hand, please, please, please could you refrain from turbo-posting in a way that sidetracks the discussion, especially when it is a subject that you're not entirely familiar with, such as FNA.

RE: Unusual neurological symptoms

Robin Grimmer — Wed, 10 May 2017 12:20:52 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]suffice to say you were giving your opinion and criticism of them without knowing what they were.[/quote]

Just to close and clarify I thought Trucut biopsies were grouped as "fine needle aspiration" [as opposed to mass removal and section] but I have been corrected, thanks, won't confuse them again.

The distinction was beside my point in fact but will be used as a rod to beat me with for evermore.

[given one star to save you all the effort.]

[/quote]

FNA is such a routine procedure nowadays. I'm willing to bet you're the only vet on here that didn't know what the definition is. Just goes to show how hopelessly out of touch you are with modern veterinary practice.

RE: Unusual neurological symptoms

Anthony Todd — Wed, 10 May 2017 02:07:55 GMT

[quote user="Robin Grimmer"]suffice to say you were giving your opinion and criticism of them without knowing what they were.[/quote]

Just to close and clarify I thought Trucut biopsies were grouped as "fine needle aspiration" [as opposed to mass removal and section] but I have been corrected, thanks, won't confuse them again.

The distinction was beside my point in fact but will be used as a rod to beat me with for evermore.

[given one star to save you all the effort.]

RE: Unusual neurological symptoms

Robin Grimmer — Tue, 09 May 2017 17:29:29 GMT

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]it turned out he didn't know what it was![/quote]

Quite true, I didn't know the difference, nor realise that they would be given such weight, with their unreliability, particularly when my point was that removing the entire mass was, in many cases, by far the best option, independent of which preliminary sample you take.

I am surprised it is given such weight and I know it is widely used in human diagnostics.

Where do you go after a "negative" FNA?

Back to square one. Take another one, or two?

Just use the down button if it upsets you so much and in the meantime find me some contradictory evidence that trial diagnostic dosing sometimes is the best way to proceed in some conditions, as in the current thread.

Makes be smile when modvets go on and on about EBM then accept an opinion, although from someone with an advanced degree, but no evidence, and rubbish what has yet to be challenged as pretty clear evidence that dogs can tolerate trial dosages, even if it came via Google.

I'd be very disappointed if Andrew disputed the evidence I found but, if he did, I'm sure he would produce a very good rebuttal.

Sometimes accepted dogma or opinions have to be challenged, even by a dinovet.

[/quote]

I don't want to get in to an argument about FNAs again - suffice to say you were giving your opinion and criticism of them without knowing what they were.

RE: Unusual neurological symptoms

Anthony Todd — Tue, 09 May 2017 16:59:12 GMT

[quote user="Robin Grimmer"]it turned out he didn't know what it was![/quote]

I am surprised it is given such weight and I know it is widely used in human diagnostics.

Where do you go after a "negative" FNA?

Back to square one. Take another one, or two?

I'd be very disappointed if Andrew disputed the evidence I found but, if he did, I'm sure he would produce a very good rebuttal.

Sometimes accepted dogma or opinions have to be challenged, even by a dinovet.

RE: Unusual neurological symptoms

Ruta — Tue, 09 May 2017 13:21:09 GMT

Dear, colleagues,

I think it is a very nice discussion. In ideal world we want to have diagnosis first before treatment, but sometimes it is not possible. I receive lab results which was negative, but I tried Mestinon and it worked. So there was a prove for false negative results.

Anyway, in this case if we considere that MG most likely there is no explanation of circling and falling to the left side?

How about cranial reflexes, any nistagmus, any ear diseases? Is there any proprioception deficit? Spinal reflexes?

I would think about vestibular disease (either central or peripheral), abnormalities in brain ( hydrocephalus or tumor)?

What do you think?

With the best regards,

Ruta

RE: Unusual neurological symptoms

Robin Grimmer — Tue, 09 May 2017 11:07:18 GMT

I disagree Arlo. I think Anthony's turbo posting just drowns out the thread. It's the giving opinions on things he knows nothing about that really irks me, and his tireless mantra of diagnostic tests blah blah. In a recent thread he was critical of FNAs (fine needle aspirate) and then it turned out he didn't know what it was! A basic everyday test commonplace to anyone in practice. QED.

RE: Unusual neurological symptoms

Anthony Todd — Tue, 09 May 2017 10:12:49 GMT

[quote user="Malcolm Ness"]EBM is NOT merely looking for a paper to two that supports preconceptions. Indeed, the Cochrane collaboration and the concept of EBM has gained considerable traction BECAUSE of the manifest shortcomings of that approach. Anyone who purports to using EBM has a duty to learn what the practice actually involves.[/quote]

I do realise that, and anyone reading some papers [on vaccine immunity, for example] will realise that too.

Conversely a paper, not an opinion, that questions said, apparently unsupported, opinion must be open to scrutiny.

[classic opinions, widely repeated, always with extremes or exaggeration, are the steroid horror stories]

The "toxicity " paper seemed, to me, pretty comprehensive, decent numbers, [unlikely to get through now because it was too extreme] seemed to question the idea that the drug was definitely dangerous in normal animals. I wonder if anyone on here even read the summary?

There has been no rebuttal or comment

While I do respect the posts of Andrew Kent surely I can challenge one when they seem exaggerated or perhaps wrong.

It is disappointing, to me anyway, that there is an all pervading approach that treatment is never begun until a diagnosis is positively made even when relief could have been safely started before the "diagnosis" is arrived at, however unhelpful as it is sometimes. [foot lesions recently]

Of course there are cases and this thread, IMHO, and with some justification, is not one of them when a diagnosis is essential and some where a response can be taken as confirming the diagnosis.

Anyway I have never intended to cause offence but when faced with the dichotomy of treating with or without a diagnosis I'm for treatment, and ASAP, particularly if it helps the animal and does no harm.

I think this is the main difference between back-in-the-day vet. med. and today. How often nowadays is anything treated with out a preliminary "test"?

PS the one case posted where treatment was given without a diagnosis went well......

RE: Unusual neurological symptoms

Arlo Guthrie — Tue, 09 May 2017 07:54:58 GMT

Sorry, but at risk of perpetuating the diversion to the OP, but ...

I can help feeling that whilst some find Anthony Todd's persistent, um, challenges to opinions and advice given in the forums to be frustrating (that may not be the right word!), they DO often draw out further information or elicit a more precise justification for a given course of action, which, whilst it may seem obvious to some, could be helpful for anyone looking for information on a subject and coming to the thread cold.

I think that anyone one-starring Anthony should bear that in mind before hitting the one star!

Anyway, Andrew Kent for your (as always) very graceful reply.

Incidentally, the latest round of developments on VetSurgeon took much, much longer than I had anticipated, but I am now hoping we can progress the 'accountable reaction' feature coming soon (ie not just anon stars, but a range of quick responses which display whodunnit, so to speak).

Let's get back to the OP ...

RE: Unusual neurological symptoms

Beats — Tue, 09 May 2017 07:51:25 GMT

FWIW I killed a boxer administering it's first mestinon tablet on one occasion.

It was pretty weak and aggressive and the stress of me shoving my hand down its throat was presumably the final straw rather than the drug per se as it literally keeled in front of my eyes.

I was waiting for the blood test result to come back, it had megaesophagus and signs suggestive of MG. Holiday period and I couldn't get edrophonium.

Assuming you don't have in-date Mestinon on the shelf, then to order a whole pot rather than send a confirmatory test in a non-critical patient sounds ill-advised to me. I post my MG tests to Nationwide Hormone Lab (formerly Dechra Specialist Labs, formerly Cambridge Specialist Lab) and I assume they send them on to USA but I haven't the details to hand.

It can be hard to determine response to mestinon which requires dose adjustment - I'd rather be tinkering around with the dose until I get the response I want knowing that dog has MG than tinkering around with the dose because its not working when the dog might not have MG.

Edrophonium makes a more clear cut trial assuming the signs are weakness rather than purely focal megaesophagus. But it's going to cost you a lot more than a blood test, so I'd only do this if time was of the essence... and chances are I'm not going to be able to get it in those circumstances anyway...

In a very suggestive case, where I had open, in-date, bottle of mestinon on the shelf and the cost of blood test or edrophonium were too expensive then sure, I'd do a mestinon trial. Equally, in that very suggestive case, in the absence of edrophonium, I'd do a mestinon trial in a patient that can't wait for the blood result (tinkering up to the point that the blood result came back anyway).

RE: Unusual neurological symptoms

Malcolm Ness — Tue, 09 May 2017 07:32:49 GMT

[quote user="Anthony Todd"]

https://www.ncbi.nlm.nih.gov/

National Library of Medicine / National Institutes of Health. Offers many important databases (PubMed, GenBank, OMIM) and some tools.

See what you think.......you can always Google it if you can't find it.....it's what I did.

[/quote]

I have pointed this out before but the message hasn't got through.

EBM is NOT merely looking for a paper to two that supports preconceptions. Indeed, the Cochrane collaboration and the concept of EBM has gained considerable traction BECAUSE of the manifest shortcomings of that approach. Anyone who purports to using EBM has a duty to learn what the practice actually involves.

RE: Unusual neurological symptoms

Andrew Kent — Tue, 09 May 2017 07:25:39 GMT

[quote user="Anthony Todd"]I don't suppose you read the initial post which indicated that the poster was pretty suspicious. and gave the reasons.[/quote]

I didn't read it as that at all - for me it was a list of theories based on unusual symptoms and not something that was considered likely.

Indeed the OP highlights some of the reasons it might be unlikely.

Myasthenic dogs typically tire at exercise - so they get progressively shorter strides before lying down. The signs should be fairly symmetrical, they don't usually circle, so based on the description I am not at all convinced - thats a big reason why I personally would not do a trial treatment.

If I saw the episode myself that might change. There are times we do trial treat because we can't wait for a lab test - that is usually in acute fulminant myasthenics, where the signs are really typical, or where we can perform an additional test (edrophonium response, repetitive nerve stimulation) to support the diagnosis at the time - again personally I don't feel we have enough evidence to support this right now.

[quote user="Anthony Todd"]Neither did you read that the test isn't totally reliable so that you have to go from lab to lab while the patient waits and waits.[/quote]

again not really true - there is a very reliable lab that runs the test and a lab to avoid.

[quote user="Anthony Todd"]Nor did you read that it appears that giving the drug to normal dogs, provided you don't give too much, doesn't do any lasting harm [although I'm sure the beagles weren't too thrilled].[/quote]

But you highlighted yourself here that the safe dose in normal dogs was lower than the described therapeutic range in myasthenic dogs. So its difficult to give a therapeutic dose and be completely safe.

[quote user="Anthony Todd"]

Add the fact that you will get a quick accurate answer 'cos the aim, usually entirely subordinate and incidental to a diagnosis these days, is to make the animal feel better.

[/quote]

The problem is that the signs of myasthenia and the signs of drug toxicity are very similar so actually its very difficult sometimes to decide if a dog is improving or getting worse and if getting worse whether you need more or less drug. I don't find it clear cut or an accurate answer when I am trying to do it.

So thats why having a confirmatory blood test is helpful as you then can be more confident in increasing doses.

[quote user="Anthony Todd"]

Frankly I think the board-certified specialist, who's opinion I usually respect just copied his warning from the BSAVA information sheet which refers more to "overdose".

[/quote]

Yep - you'll find a similar warning in the BSAVA formulary, Plumb's etc - mainly because them the risks! And as we've already discussed what is 'overdose' in a myasthenic can be low dose in a normal dog.

Also - could you point me to the threads in which you respected my opinion? I must have missed them!

[quote user="Anthony Todd"]Not sure who really should be embarrassed.[/quote]

I vividly remember the first dog I saw die after administration of neostigmine (alright different drug, similar idea) - its not nice and thankfully I have only seen it or heard of it a few times but its pretty unpleasant - I'd be more embarrassed if I didn't flag that in my opinion of this case we do not know enough to even consider a therapeutic trial.

Maybe a tangent would be a better place for further discussion as I think this is detracting from useful advice to the OP?

Andy

RE: Unusual neurological symptoms

Anthony Todd — Mon, 08 May 2017 23:57:01 GMT

PS:

NCBI - NIH

https://www.ncbi.nlm.nih.gov/

National Library of Medicine / National Institutes of Health. Offers many important databases (PubMed, GenBank, OMIM) and some tools.

See what you think.......you can always Google it if you can't find it.....it's what I did.

RE: Unusual neurological symptoms

Anthony Todd — Mon, 08 May 2017 23:40:28 GMT

[quote user="Robin Grimmer"]input of a board-certified specialist and then you chip in with what you've looked up on Google. Just embarrassing.[/quote]

So where is Evidence Based Veterinary Medicine in your argument?

Actually Google referred me to the search engine which found the paper which I quoted; so not that bad a source, really.

Frankly I think the board-certified specialist, who's opinion I usually respect just copied his warning from the BSAVA information sheet which refers more to "overdose".

Not sure who really should be embarrassed.

RE: Unusual neurological symptoms

Anthony Todd — Mon, 08 May 2017 23:27:25 GMT

[quote user="Jenny Boyd"]

And sorry if that comes across a bit harsh Anthony but couldnt believe what I was reading ?!

[/quote]

I don't suppose you read the initial post which indicated that the poster was pretty suspicious. and gave the reasons.

Neither did you read that the test isn't totally reliable so that you have to go from lab to lab while the patient waits and waits.

Nor did you read that it appears that giving the drug to normal dogs, provided you don't give too much, doesn't do any lasting harm [although I'm sure the beagles weren't too thrilled].

Add the fact that you will get a quick accurate answer 'cos the aim, usually entirely subordinate and incidental to a diagnosis these days, is to make the animal feel better.

So you'd better believe it.

RE: Unusual neurological symptoms

Jenny Harris — Mon, 08 May 2017 17:34:54 GMT

And sorry if that comes across a bit harsh Anthony but couldnt believe what I was reading ?!

RE: Unusual neurological symptoms

Jenny Harris — Mon, 08 May 2017 17:33:00 GMT

What a load of rubbish. Why would you guess at a diagnosis? That's not veterinary medicine. The only time that should be happening is if the owner genuinely can't or won't test.

RE: Unusual neurological symptoms

Robin Grimmer — Mon, 08 May 2017 17:28:03 GMT

[quote user="Anthony Todd"]

Love to have some reasons for the usual unqualified anonymous one star.

I'm sure the original poster would have mentioned any other significant signs or symptoms if there were any.

We have what appears to be a sensible effective solution and the side effects as far as I know, aren't life threatening and may even be minimised with dose adjustment.

But, as usual with modvets, a diagnosis is much more important than a potential or probable control of a distressing condition.

[/quote]

Probably because yet again Anthony you are giving an opinion on a condition/treatment that you know absolutely nothing about except what you've typed in to Google. This is a difficult neurological case and we are lucky enough to have the input of a board-certified specialist and then you chip in with what you've looked up on Google. Just embarrassing.

RE: Unusual neurological symptoms

Anthony Todd — Mon, 08 May 2017 14:39:46 GMT

[quote user="Andrew Kent"]But, as usual, its about an informed discussion with the owner - if they elect for a treatment trial in possession of the pros and cons then that is their choice.[/quote]

Having found this I think the balance is somewhat restored.

Systemic anticholinesterase effects (other than enzyme inhibition) were observed only at doses of 2 mg/kg and greater, while local (gastrointestinal) effects and inhibition of RBC AChE were observed at doses as low as 0.05 mg/kg.

and these were poor old lab beagles.....! [some of them died at much higher doses.....]

from:

Fundam Appl Toxicol. 1990 Jan;14(1):40-53.

Pharmacological and toxicological evaluation of orally administered pyridostigmine in dogs.

Kluwe WM1, Page JG, Toft JD, Ridder WE, Chung H.

The dose rate, from another source, is 0.5-3mg/Kg b or tid which begins to sound a bit high....

Certainly one should be careful with the dose rate.

from:

http://www.petplace.com/article/drug-library/library/prescription/pyridostigmine-mestinon

Essentially, if someone is happy to dose dogs at the correct dose rate, and get the right response it seems an easier and quicker path than waiting to get the right lab result.

RE: Unusual neurological symptoms

Anthony Todd — Sun, 07 May 2017 23:45:08 GMT

[quote user="Ruta"]So, anyway, my recommendation would be put this dog on Mestinon and see what happens. You won't lose anything.[/quote]

There's a BSAVA sheet which is available from here:

www.plymouthvets.co.uk/download/i/mark_dl/u/4013067358/.../Pyridostigmine.pdf

but I'm sure the poster gave that to the client anyway.

RE: Unusual neurological symptoms

Andrew Kent — Sun, 07 May 2017 20:56:52 GMT

[quote user="Anthony Todd"]My search for side effects in dogs seem to suggest they are unpleasant but not life-threatening but perhaps there is more information. It may be that lowering the dose and/or dose rate will help.[/quote]

The most common side effects are indeed mild unpleasant things but the most severe are a cholinergic crisis - signs of which include bronchoconstriction, pulmonary oedema, respiratory paralysis, brady/tachycardia and cardiac arrest.

In truly myasthenic dogs those kind of signs would typically only be seen with overdose but in a non-myasthenic dog those could occur at a lower dose and I would suggest that we don't know enough about this case to be confident in that diagnosis - we might be if we see the episodes.

It's a disease for which we have a highly sensitive and specific blood test - so why would we not do that before using a potentially dangerous drug (however small the risk).

But, as usual, its about an informed discussion with the owner - if they elect for a treatment trial in possession of the pros and cons then that is their choice.

Andy