When is a bladder not a bladder?

My  patient, 10 y/o German Shepard Dog, came in with the complaint  of incontinence. She was wetting her bed at night, something she had never done. With some extra questioning I found that she had been "off" for weeks with decreased appetite and weight loss. On exam I felt something large in her belly so I called for radiographs and saw this:

On the left side is a large round area that looks like a very large urinary bladder. I asked my technicians to walk her outside and let  her pee and she did a lot. But after she came back from the yard a second view looked the same. What was going on? In this case Ultrasound gave me the answer. Sadly, this is a very large abdominal tumor leaning on her urinary bladder. That is what was making her urinate at night. Sometimes it takes multiple tests to get the right answer.

Diet cures feline hyperthyroidism

When I was still in veterinary school at Tenessee I remember the Internal Medicine folks announcing that C/D diet for cats was going to cure feline cystitis and, "You'll never see another P/U surgery again."  It didn't quite work out that way though C/D, S/D and W/D have worked as more arrows in our sling against that troublesome disease. Lately though Hill's has taken it's aim against another killer of cats,  Hyperthyroidism. 


Standard Hyperthyroid treatments


Traditionally we have had three possible treatments for Hyperthyroid cats: surgery, Radioactive iodine treatment and oral methimazole (Tapzole). Of course the trouble with the three is the first is invasive and expensive, the second requires days away from home and is expensive, the last choice is, at least, inexpensive though it can cause vomiting in any number of cats and at least some fall to severe drug reactions or simply can't stomach it. 


What hath Hill's wrought? 


So now Hill's thinks that they have the fix for all of these troubles with Y/D (hYperthyroid diet), a severely iodine restricted diet and, by the way, a vegetarian diet. This is really an unusual move as the most recent research seemed to show low iodine levels actually causing hyperthyroidism¹


What Hill's did was to put a group of cats with hyperthyroidism and put them on a severely restricted iodine diet. All cats had lower  thyroid levels within three months, most were normal. They continued with the kitty's for two years and they all were apparently healthy and continued with normal thyroid levels throughout. So what's the catch? Well, first they can't eat anything else as other foods will have higher iodine levels and thus ruin the effect. Second, no one knows if this will work and be safe for all cats. Nine cats is not a large test group. In early commentary on this diet one board certified veterinary endocrinologist expressed some real concern about Y/D. The iodine restriction is so severe that the cats will be iodine deficient. Clearly this is not a safe food for a normal thyroid cat, is it safe for a hyperthyroid cat to eat for years? "Too many unknowns", he commented.² 


So what cats should be on Y/D diet?


Certainly any cat that is too sick for surgery or radioactive iodine treatment and is allergic to methimazole is a candidate for Y/D diet. Perhaps some may be early adopters and want to try Y/D for their cat before even  using any of the standard treatment but a long discussion the risks inherent in an untried diet will need to be part of the treatment plan. 


1. http://www.ncbi.nlm.nih.gov/pubmed/20800208
2. VIN link

Key Benefits

Easy. Effective. Safe.
Clinically proven nutrition to restore thyroid health
Improves thyroid health in 3 weeks* (when fed as the sole source of nutrition)
Complete daily nutrition with a taste your cat will love

Additional Info

Additional benefits for overall health
Supports kidney health with controlled phosphorus and low sodium
Helps maintain bladder health with controlled mineral levels
Promotes heart health with essential nutrients like taurine and carnitine
Promotes healthy skin and a luxurious hair coat with high levels of omega-3 and -6 fatty acids


IMPORTANT
Because iodine intake from other food sources -- treats, another pet's food, etc. -- can compromise the effectiveness of low-iodine nutrition, it's critical that you follow your veterinarian's feeding instructions carefully and feed only y/d.

Laser Therapy

Below is a summary of my notes and comments from the VVMA meeting this last weekend. My final opinion is, if Laser therapy truly is effective then it should be clearly marked as a medical unit ( anyone can buy these on the  internet) and further marked as "experimental" as it is clear to me that we have no clue what we are doing. If it really has effect then we shouldn't be randomly irradiating tissues, if it has no effect then it needs to be a door stop. Luckily, you have an  in-house expert. :-)

Laser therapy is currently used to treat anything. Really, anything. As with any modality there's not a chance that it works for everything and Dr. Godeine  does not claim it does though he is very insistent that it does work. He gave a case study of a dog with TCC that he had surgically removed, it returned with a vengeance and, additionally, the dog was in heart failure and renal failure. He discontinued all pharmaceuticals and started  laser therapy with a LED belt type unit similar to this one Cold laser pad. The dog went back to eating and drinking and followup US showed regression of the tumor. The dog lived another year before being PTS.


LASER EQUIPMENT

The equipment available include:

Lasers:

• Monochromatic and coherent light  
• Narrow spectral width

SLD: (Super Luminous Diode) 

• Monochromatic and less coherent
• Broad spectral width

LED:

• Monochromatic and incoherent
• Broadest spectral width

Laser light what does it do?

Wow, talk about unclear. The definition:  The use of light energy in the 600 to 1000nm range to promote homeostasis in damaged or diseased tissue resulting in tissue healing and pain modulation.
The theory is that light waves penetrating the skin activate Chromophores in mitochndria. The chromophores activate enzyme systems causing some biological effect. Proposed mechanisms would be:

• COX inhibition
• Decreased cellular apoptosis.
• Stimulation of monocytes and macrophages

How does it get there? 

• INFRARED light penetrates the deepest into tissue and is best for musculoskeletal pathologies
• RED light is best for superficial lesions such as wounds.
• Blue and Green light have antibacterial properties. 

Depth of penetration is primarily wavelength dependent. Having a laser of 800-930 nm is likely more effective than a laser with >930 nm.

 Have your cake and eat it too. 

Arndt-Schultz Law is another important factor in dosimetry.

• A weak stimulus will elicit a strong reaction.
• A medium stimulus causes a modest reaction
• A moderately strong stimulus usually inhibits the system slightly.
• A very strong stimulus can strongly inhibit the system.

Think "fire-pinning", if you apply small, low dose stimulus you trigger inflammatory type respsonse which can advance healing. A large dose can actually inhibit healing but conversely create pain relief. 

Bottom line: What do I do? 

Set the machine to a likely setting and run with it. Keep in mind the basic principle that pain relief requires higher doses and stimulating wound healing requires lower doses. 

• Superficial wounds and general biostimulation@ target depth*: 2-4 J/cm² not to exceed 5 J/cm².SLD’s and LED’s work well.
• Subacute inflammation or chronic pain: 5-10 J/cm² at target depth*. Low Frequencies.
• Acute inflammation and pain: 12-36 J/cm² at target depth. 2500-5000 Hz for inflammation and 2-20 Hz for pain.
• Systemic immune stimulation of Blood: Red and Infrared 4J/cm2 and at 700-2500 Hz.**

* "@ target depth". So how do you know what J/cm² you are delivering to 1 cm or more below the skin. No clue. WAG.
**Have a sick animal, hepatitis, renal failure, what not. Set the laser to the doses above and aim at large muscle masses. This should give general stimulation and encourage good health and better appetite .

Just for fun:

Try manual settings on the laser set to 8 Joule and use that as a nerve block for dentals. It takes effect in about 60 seconds and lasts for 48 hours. Dr. Godine has not tried this for declaws.

Seeing the Knees: Radiographic Diagnosis of Cruciate Disease

 I pulled this from a VIN rounds session. I was reluctant to copy all the pictures as there almost certainly are copyright issues even with taking a post this far, the pictures are helpful but here is the down and dirty of radiographing for Cruciate disease. 




1. Sedate the dog whenever possible.

2. Take images of only one stifle at a time.

4. Get the other soft tissues out of the way. (that would be fat dog bellies and, ahem, - in boy dogs- other things) 

5. With sedated dogs, it is simpler to get a straight caudocranial than a craniocaudal view. The trick with this view is to rotate the pelvis slightly (lift the good leg up) so that the femur and tibia are straight, rather than taking the shot with the leg out to the side.  

6. Don't overexpose soft tissues. If you can't readily see the soft tissues of the joint (not just the bone), take an additional radiograph and lighten up the exposure. Sometimes you have to really underexpose the bone (get it bright white) to see the soft tissues.

BIG INDICATORS and some practical tips on rad interpretation.
The first Big Indicator to look for is SWELLING. The best way to improve your skill at detecting swelling is to know what the normal joint looks like. There are two opacities in the joint, fat and water. (Remember that when we refer to "water opacity" in radiology, it does not always mean that there is literally water present. Soft tissues are composed mostly of water and can't be distinguished from fluid in radiographs. This is why you can't distinguish bladder wall from urine, or bowel wall from fluid contents, for instance.)

The second Big Indicator you will see is the formation of ENTHESIOPHYTES. Don't feel bad if you've never heard of enthesiophytes – it's a term you usually only hear in radiology. An enthesis is the point of bone origin (or insertion) of a ligament, tendon, or joint capsule. An enthesiophyte is an area of mineralization/ossification at the enthesis.  

The third Big Indicator to look for is DISPLACEMENT of the (single) popliteal sesamoid. It normally lives just above - or level with - the edge of the tibial plateau

The fourth Big Indicator would be OSTEOPHYTE formation.

Go here for the pictures and the discussion