Diabetes: Pets and People

Stone - Diabetes

November is American Diabetes Month. To highlight how veterinarians care for pets with diabetes, I thought I would tell the story of one of my patients, a fluffy, grey and white cat named Stone.

Stone is a youngster, just under two years of age. He came to see me because his owner had noticed weight loss and excessive drinking. Weight loss and excessive drinking are common clinical signs of diabetes, but Stone was much younger than the typical cat with diabetes. Hyperthyroidism can also cause weight loss and increased drinking, but typically occurs in older cats.

Another cause of weight loss and excessive drinking is chronic kidney disease, but again, typically in older cats. I wasn’t really sure what was wrong with Stone until the blood tests showed sugar in his urine and an elevated blood sugar.

Dogs and cats have different forms of diabetes. Dogs commonly have Type I diabetes, which is a total lack of insulin production by the pancreas. Cats have Type II diabetes which occurs most commonly in middle to older overweight cats. Unlike humans with Type II diabetes, cats require insulin injections where humans can often manage Type II diabetes with oral medications and diet. Strangely, with weight loss, insulin therapy, and a special diet, some diabetic cats will become normoglycemic again and no longer require insulin. This happened to my own cat and he stopped needing insulin for a year. Then became permanently diabetic and required insulin for the rest of his life. I think chronic inflammation of the pancreas (known as pancreatitis) was the likely cause of the diabetes.

Stone was in to see me just a few days ago. On twice daily insulin therapy, he has gained back some of the weight he lost and is eating his special diabetes diet with gusto. Blood tests indicate his blood sugar is well controlled and his owner notes it is getting harder for her to test his urine to measure the urine sugar level. I am suspicious he may be heading for a period of diabetic remission.

To help my readers understand the similarities between their own diabetes and that of their pets, I included a table below with a comparison of the common features of the disease.

Comparison of diabetes between people and their pets:

  Cat Dog Human
Occurrence 0.58% of cats 0.35% of dogs 9.4% of Americans
Type I diabetes No Yes Yes
Type II diabetes Yes No More than 90% of diabetes
Diabetic retinopathy No Rare Yes
Diabetic nephropathy No No Yes
Association with pancreatitis Yes Yes No
Oral treatments No No Yes
Insulin injections Yes Yes Yes
Spontaneous remission resolution Yes No No
Diabetic cataracts Rare Yes Yes
Linked to obesity Yes Yes Yes

Going Viral: AMC’s One Health Day Event

One Health Day

November 3, 2018, marks the third annual One Health Day, a global campaign celebrating the need for a One Health approach to address shared health threats at the human-animal-environment interface. The One Health concept uses a transdisciplinary approach to recognizing and caring for the interconnected health of humans, animals, plants, and our shared environment. To celebrate One Health Day 2018, AMC will host a panel discussion with three New York City-based One Health experts; each panelist is a veterinarian AND an expert in a different One Health arena.

A Public Health Veterinarian
Sally Slavinski DVM, MPH, Diplomate ACVPM has an impressive list of letters after her name. Dr. Slavinski is a veterinarian with specialty training in public health. As the Assistant Director Zoonotic, Influenza and Vector-borne Disease Unit in New York City’s Department of Health and Mental Hygiene’s Bureau of Communicable Disease, Sally stands at the juncture between animal and human disease in New York City. When you hear a warning about rabies in Central Park raccoons and the risk to your dog and yourself, Sally is behind that alert. She will provide attendees an overview of her role at the health department, explain the role of epidemiology and disease surveillance, and highlight the relationship between the Department of Health and Mental Hygiene and the animal health community.

A Veterinarian and Environmental Health 
Ellen P. Carlin, DVM works for EcoHealth Alliance as a Senior Health and Policy Specialist. She is also a Research Associate at the Smithsonian Conservation Biology Institute and holds positions at Columbia University National Center for Disaster Preparedness and Cornell University’s College of Veterinary Medicine. Her role on the panel is to discuss the often forgotten third point of the One Health triad, environmental ecological health. Dr. Carlin will discuss her role and contributions to understanding environmental elements of disease transmission, particularly in the context of disease transmitted between animals and humans.

A Wild Animal Veterinarian, Human and Environmental Health
Paul P. Calle, VMD, Diplomate ACZM & ECZM (Zoo Health Management) is the Chief Veterinarian and Vice President for Health Programs and the Director, Zoological Health Program at the Wildlife Conservation Society (WCS), lovingly known to New Yorkers as the Bronx Zoo. The WCS does more than care for the animals in the NYC zoos; the WCS is instrumental in working on international health issues such as West Nile Virus, Ebola, and Avian Influenza. Diseases like these become global issues due to loss of animal habitats as a result of expansion of the human population and transport of disease vectors and causative agents by traveling humans.

Your pet, your world and you: expand your knowledge about all three by spending an evening with these three fascinating experts at AMC’s annual One Health Day on November 1st, 2018 from 6:30-8:30 pm. Register for free today!

Should I Adopt an Older Dog?

Adopt a dog

October is Adopt a Dog Month or Adopt a Shelter Dog Month. Either way, I hope your family is thinking about whether or not adopting a dog is the right move. Keep in mind, adopting a dog at the wrong time or without considering its impact on your family is always a bad idea. Adopting a puppy, with her big eyes and fluffy coat, is easy until the little devil comes home. Adopting an adult dog, may circumvent some of the puppy-raising challenges puppy families face.

Advantages of a Grown-Up Dog
In my mind, adopting an adult dog bypasses one of the biggest challenges of having a puppy: housebreaking. Adult dog adopters shouldn’t expect perfection from the new arrival, but after a few days, most housebroken dogs will realize how they go “out.”

Teething is another puppy milestone avoided by adopting an adult dog. Last week, one of my teething puppy patients ate some shoe trees, a bottle of Zantac, and a box of tissues after letting himself into the bedroom. Other puppy patients have eaten woodwork, chair legs, and shoes. Once a dog hits about one year of age, their indiscriminate chewing tends to subside.

Last spring, one of my mature clients got a new puppy. Both of his aged dogs had died over the winter. The new puppy was delightful, except for the stubborn Giardia infection. In a moment of diarrhea-related frustration and puppy induced exhaustion, he asked me to find her a new family. Now that the diarrhea is cleared up and she is approaching her first birthday as a much calmer grown-up dog, there is no chance of him giving her up, but this vignette shows how trying puppies can be.

Points to Consider When You Adopt Any Dog
Puppies require a series of visits to the veterinarian for vaccinations and other preventive health care procedures. While these medical expenditures will not be necessary in an adult dog that is already well vaccinated and spayed or neutered, all pets need medical care. Your family needs to consider not only the cost of preventive care but how you will manage a catastrophic illness or injury. Other ongoing costs to include in budget planning are food, treats, grooming, boarding, and the inevitable wardrobe of seasonal collars, leashes, and bandanas you just can’t resist at your local pet emporium.

Adopting is Not for Everyone
Some families need the predictability of a purebred dog. Certain breeds are easier for people with allergies, making the decision to have a purebred dog a medical decision. Those of us living in apartment buildings face restrictions on dog size and breed. A cute puppy with an unknown family tree may result in a lovely pet that exceeds the size limit set by the building’s board of directors. Who needs that kind of heartbreak?

Did this blog post make your choice between a puppy and a dog easier or more difficult? Whatever your decision, consider adopting, not shopping.

Immune Mediated Neutropenia

Schnauzer

I recently wrote about the concept of immune disease; those disorders where the immune system goes haywire and attacks normal cells in the body. In more recent blog posts, I wrote about two important immune diseases: immune mediated hemolytic anemia (IMHA) and immune mediated thrombocytopenia (ITP or IMTP).  Today’s blog post focuses on a third immune disorder of blood cells: immune mediated neutropenia.

Neutrophils Fight Infection
Neutrophils are the first responders of the immune system. When you get a splinter in your finger, neutrophils rush to the site to start cleaning up bacteria and other nasties. The accumulation of neutrophils in a focal site is known as an abscess. Without neutrophils, the immune system cannot inactivate infectious agents, and patients run the risk of developing a life-threatening systemic infection.

Immune Mediated Neutropenia
Neutropenia is just a fancy way to say a low neutrophil count. Similar to dogs and cats with IMHA and IMT, the immune system of pets with immune mediated neutropenia destroys blood cells, specifically, neutrophils.

Recognizing Immune Mediated Neutropenia
Immune mediated neutropenia is much less common than either IMHA or IMT and is less common in cats than in dogs. A recent study found dogs with immune mediated neutropenia saw their veterinarian because of poor appetite, lethargy or fever, which are all very non-specific clinical findings. A complete blood count is required to identify a low neutrophil count, but if neutropenia is identified, your veterinarian will recommend a battery of tests to evaluate your dog or cat’s low neutrophil count. In addition to immune mediated destruction, low neutrophil counts can result from an infectious disease like ehrlichiosis, a fungal disease such as histoplasmosis or a bone marrow disorder.

Treatment of Immune Mediated Neutropenia
Like the other immune blood cell disorders, initial treatment of dogs and cats with immune mediated neutropenia involves suppressing the immune system with steroids. According to recent research, most dogs with immune mediated neutropenia responded quickly to steroid administration, while a few required additional immunosuppressive agents to correct the neutropenia. While I hope your dog or cat never gets immune mediated neutropenia, the majority of pets diagnosed with this disorder survive for an extended period of time.

Medical Machines: Infusion Pumps

Fluid Pumps

“Medical Machines” is a new series of blog posts highlighting the equipment AMC veterinarians use to provide state-of-the-art care to thousands of pets annually. These machines save lives, but pet families rarely ever have the opportunity to see them up close and personal. This series will give readers a glimpse into the equipment AMC veterinarians rely on every day.

The machine for today is an infusion pump, sometimes called a fluid pump.

Not Just for Fluid
Infusion pumps, fluid pumps, and IV pumps are commonly used terms to describe a device which delivers a precise volume of liquid over an exact period of time. The pump can be used to administer a wide variety of liquids including intravenous fluids, antibiotics, or pain medications. Pumps are also used to deliver liquid feeding solutions into the stomach or intestine and for blood transfusions. Pumps free the nursing staff from monitoring fluid delivery rates for more important duties. If the infusion rate varies from the setting, the pump beeps to alert the nursing staff of a problem.

How They Work
AMC has two types of pumps: peristaltic and syringe pumps. In the peristaltic pump, the tubing for the fluid fits between rollers which compress the tubing as they roll. This rolling action forces the liquid through the tubing. Peristaltic pumps are commonly used for IV fluids. AMC also uses syringe pumps. A syringe loaded with medication is placed in a slot on the pump and a motorized screw turns to push the syringe plunger at a controlled rate to deliver the fluid. Syringe pumps are commonly used for very small patients or for very small volume infusions. Above, you can see a puppy receiving a blood transfusion via syringe pump.

A Machine of Major Importance
Infusion pumps don’t really impress like a CT scanner or linear accelerator.
But what pumps lack in size, they compensate for in sheer numbers. Our best estimate is that AMC has over 200 peristaltic pumps and at least 50 syringe pumps. Our ICU has enough peristaltic pumps for each patient to have two at all times, plus some extras. Our animal ER has about 10 peristaltic pumps which they use to deliver fluids at a very high rate in patients with shock.

In researching infusion pumps for this blog post, one of our senior nurses who remembers a time before infusion pumps remarked, “Infusion pumps revolutionized patient care at AMC. We no longer had to stand by each patient’s IV line counting the number of drips per minute; we simply set the pump to the correct rate and were then free to take care of the patients, not the fluid infusion.”

Infusion pumps are one of AMC’s most valuable medical machines.

Cleaning Up Eye Goop

dog eyes

Last week I took calls from pet families on SiriusXM “Doctor Radio,” which is broadcast from NYU Langone Medical Center. Although I answered numerous calls during the one hour show, one question stood out in my mind for its pure practicality: “What products are safe for me to use around my pet’s eyes?”

Dirty Eyes
Pet families have many reasons to want to clean their pet’s eyes. The first might be a bit of debris, twig, or other foreign object that has found its way into your pet’s eye causing discomfort and possibly an injury. During allergy season, itchy eyes cause pets to rub their face with their paws or on furniture. The resulting ocular discharge adheres to the fur around the eyes and can even lead to dermatitis in that area. Some dogs develop tear staining around their eyes when bacteria reproduce in the moist fur. The brown staining is unsightly but not a health concern.

Flushing the Eye
To remove debris, a twig, or other foreign object that has found its way into your pet’s eye, sterile saline used by contact lens wearers is easily obtained and safe for pet eyes. In fact, you should keep an unopened bottle in your pet first aid kit for use in an emergency.

Cleaning the Fur
When ocular discharge adheres to the periocular fur, warm water and a washcloth or gauze pads can be used to moisten and wipe away the discharge. If more than warm water is required to clean the area, one drop of no-more-tears baby shampoo in a cup of warm water makes an eye-safe cleaning solution. This solution can also be used to remove the bacteria causing brown tear staining, which is especially noticeable on white dogs. Daily washing around the eyes also decreases pollen on the face, a major cause of allergic conjunctivitis. For those on the go with their pet, little packets containing individual eyelid wipes can be found in the eye section of the drug store, and work well in pets.

Have more questions about eyes? Read about common eye conditions, your dog and cat’s third eyelid, and dry eye.

Everyday Medicine: Is it Vomiting or Regurgitation?

megaesophagus

“Everyday Medicine” is an intermittent series of blog posts highlighting tests, treatments, and procedures common in daily Animal Medical Center practice. Some past examples of this type of blog post include “Cytology” and “Packed Cell Volume.” Today’s post focuses on the question: Is it vomiting or regurgitation?

Veterinarians Ask a Lot of Questions
The first part of any patient visit to the veterinarian is a Q&A called history taking. We ask the pet family questions about their pet’s health. You know the drill – How is his appetite? Do you send him to the boarding kennel? Do you have other pets? We adapt the questions to the situation. In the animal ER, the Q&A will be truncated and may only be, “Where did he get hit by the car?” rather than a lengthy set of questions about diet and exercise. In dogs or cats with vomiting, we often probe further to differentiate vomiting from regurgitation.

Vomiting
You know the sound of vomiting. First you hear a horrible gagging sound right before you find the big spot on the carpet. Always on the carpet because no self-respecting pet would vomit on the linoleum where clean-up is easy. Vomiting is an active process and you see contraction of the abdominal muscles a split second before the stomach empties.

Regurgitation
Until I went to veterinary school, I thought regurgitation was a more sophisticated word for vomiting. Not true. Regurgitation does not have the forceful expulsion of food from the stomach typical of vomiting. The food seems to fall out of the mouth rather than exploding from the stomach. Regurgitated food never makes it to the stomach because of poor esophageal function, and if undigested food seems to fall out of your pet’s mouth, he may be regurgitating. Regurgitation is much less common than vomiting and is associated with a disorder called megaesophagus.

Does the Answer Matter?
The short answer is yes. If a veterinarian can determine a patient is regurgitating rather than vomiting, then she will follow a different path of diagnostic testing. If your veterinarian suspects vomiting, an abdominal x-ray is commonly obtained. Because regurgitation suggests esophageal dysfunction, a chest x-ray will be part of the initial testing to see if the esophagus appears abnormally filled with air. Special movie x-rays called fluoroscopy can be used to identify esophageal dysfunction typical of megaesophagus.

To learn more about megaesophagus, watch this video interview by Insider.

Making the Most of Your Pet’s Microchip

microchip

The annual Check the Chip Day is Wednesday, August 15th. This pet health event reminds pet families to have the microchip in their pet checked by the staff in their veterinarian’s office to be sure it is working, as well as to update any information in the microchip database which links your pet’s microchip number to your contact information.

Microchip Basics
A microchip provides a permanent method of identifying your pet; it is not a GPS device. A microchip is about the size of a grain of rice. A veterinarian implants the chip under the skin over the shoulders. The microchip has no battery or moving parts, but emits a unique radiofrequency code and is designed to last for up to 20 years. Animal shelters and veterinary offices have microchip scanners to “read” the chip. Watch Nugget get his microchip scanned below. A microchip is typically a prerequisite for international pet travel.

And Also a Collar and Tag
A microchip is essential because many pets are not wearing a collar when they are separated from their family. But a collar with an ID tag displaying your phone number will get your pet home faster since anyone can read an ID tag, but only some have access to a microchip scanner. You might also consider putting your pet’s microchip number on their collar, but some folks choose to keep that information private.

The Power of a Chip
One of my patients escaped out the window when a workman inadvertently left the window open after doing repairs. Despite canvassing their neighborhood and following other suggestions for finding a lost pet, Sneezy was nowhere to be found. The little guy was MIA for two months until someone in the neighborhood noticed a scrawny, but very friendly cat they had not seen before. The kind neighbors scooped him up and delivered him to the local shelter. It took all of about ten minutes for the shelter staff to scan Sneezy, find his microchip and contact his jubilant family.

To make your lost pet story have a happy ending like Sneezy’s, be sure your pet’s microchip registration is up to date. If you only know the chip number, look up the company online. Also check the information on your pet’s ID tags and replace them if the information is out of date. If you want to keep your pet’s microchip information handy, download and print out this postcard from AMC’s Usdan Institute and keep it with his/her records.

Immune Mediated Thrombocytopenia

immune mediated thrombocytopenia

I recently wrote about the concept of immune disease – those disorders where the immune system goes haywire and attacks normal cells in the body. In a more recent blog, I wrote about one of the important canine immune diseases, immune mediated hemolytic anemia (IMHA). Today’s blog post focuses on a disease similar to IMHA, immune mediated thrombocytopenia (ITP or IMTP).

Defining ITP
The cell targeted by the out of control immune system in ITP is the platelet or blood clotting cell. The platelet is a powerhouse of coagulation. Under the microscope, a platelet is the smallest of the blood cells, yet the sticky platelet provides the first level of defense against hemorrhage. Platelets are in a large part responsible for the formation of a scab when you cut your skin while chopping vegetables or scrape your knee in a bike accident. Dogs, and the rare cat, with ITP can’t form a blood clot if nicked by the groomer because the immune system has destroyed their platelets. The lack of platelets can also result in spontaneous hemorrhage.

Recognizing ITP
You, as the healthcare advocate for your pet, may be the first one to recognize clinical signs of ITP. The hallmark of a low platelet count is little pinpoint hemorrhages on the skin, in the mouth or on the whites of the eyes. Hemorrhage may occur internally making the stool dark like tar or the urine bloody. One of my patients with ITP recently relapsed and came to the ER with a bloody nose. But, not every pet with a low platelet count or bleeding has ITP.

Causes of ITP
There are many other causes of low platelets that must be investigated before a diagnosis of ITP is made. Infectious disease tops the list of potential diagnoses for low platelets. Diseases transmitted by ticks top the list. Ehrlichiosis, Rocky Mountain spotted fever and Anaplasmosis may resemble ITP, but some readily available laboratory testing can quickly identify these diseases. Cancer, especially lymphoma or hemangiosarcoma can cause low platelet counts. Occasionally a reaction to a drug like an antibiotic can cause ITP. When a veterinarian cannot find an underlying cause of a low platelet count and a diagnostic evaluation is unremarkable, by the process of elimination, the diagnosis is ITP.

Treatment of ITP
Even though the blood cell affected in ITP is different than in IMHA, the treatment is similar since the overactive immune system needs to be suppressed to prevent more platelets from being destroyed. The first line therapy involves the use of drugs like prednisone to suppress the immune system. A chemotherapy drug, vincristine, when administered to dogs with ITP increases platelet release from the bone marrow and helps normalize their platelet count faster and shortens hospital stay. Dogs are often hospitalized for several days in case hemorrhage is severe enough to warrant blood transfusion. Most dogs recover from ITP, but some require additional drugs to suppress the immune system long term.

Other diseases affecting the immune system include polyarthritis and a variety of immune mediated skin diseases which will be the topic of a future blog post.

Heatstroke

heatstroke

It’s that time of year when the Animal Medical Center’s ER prepares to see dogs and cats with heatstroke. Heatstroke occurs when the ambient temperature overwhelms the body’s cooling mechanisms. Both heat and humidity contribute to the development of heatstroke. When humidity is high, pets cannot cool themselves by panting, a form of evaporative cooling. When the air is full of water, evaporation from panting occurs slowly and cannot keep the body temperature in a safe range.

Too Hot
The normal body temperature of dogs and cats is 100-102°F. AMC’s ER does not become concerned when a fever is as high as 104 or 105°F. Heatstroke is a body temperature 106-108°F. When the body gets that hot, multiple organs begin to fail.

Hot Pets
While heatstroke can happen to any pet, certain dogs are at greater risk. Snub-nosed dogs are unable to use evaporative cooling via panting as well as dogs with longer noses, and thus are a greater risk of developing heatstroke. Dark-coated dogs, golden retrievers, Labrador retrievers, overweight dogs, and those not acclimated to the heat are also at increased risk.

Heatstroke Symptoms
Hot skin, vomiting, panting, distress collapse, incoordination, and loss of consciousness are all indicators of heatstroke. If your pet is developing heatstroke, you will notice nonstop panting, hot, red skin and weakness. This may progress to incoordination, collapse and loss of consciousness. At the first hint of heatstroke, head to your local animal ER.

Head to the Animal ER
If you suspect heatstroke, go immediately to the closest animal ER, do not delay. Experts say trying to cool your pet off on your own wastes valuable time. But, if on your way out the door you can grab ice packs or frozen food from your freezer, put the frozen food on your pet in the car on the way to the ER.

Heat Injury
The extent of illness may not be apparent upon arrival in the ER. Heatstroke is a multi-organ system disorder. Pets experience circulatory shock from fluid loss from panting. Heat damages normal tissues like the brain and other vital organs. Damaged brain neurons cannot be replaced and may result in cognitive decline following an episode of heatstroke. Abnormalities in blood clotting and kidney function may not become apparent until hours after arrival in the ER.

Tips to Prevent Heatstroke
Preventing heatstroke is critical since data indicates half of pets suffering from heatstroke don’t recover.

1. Don’t exercise in heat of the day, only early or late. Heatstroke occurs most often in the afternoon.
2. Don’t leave pet in a hot car, even with the windows cracked. In one study, a hot car was the number one cause of heatstroke.
3. Provide access to cold water. Consider choosing a water bowl designed to keep water cool or add ice cubes to the bowl.
4. Provide shade with an umbrella or a covered kennel.
5. Try out a cooling jacket or mat.

Click for more suggestions on keeping your dog cool during the hot summer months.