Them Bones, Them Bones

So, I was out for a long run on Monday. Actually, I didn't have access to a car, my daughter having absconded with it and I had no other way to go home. Now a more sane person might have called someone for a ride, or at least picked the most direct route home. But nooo, I mapped out a 12 mile route, including a little turn around the high school track for good measure and trotted off. The thing about long runs is that there is a period of time where there is nothing to do other than to let one's mind drift, and drift mine did. As various things started to ache, I focused on a bunch of things that I wanted to write about, most of which I have forgotton, but I'll try to stick with the free association that I went through over the two hours it took me to get home to dinner.

First, I was thinking how I should think of things to write about. Seems to make sense. Then I realized that no one, not even one person, ventured a guess about the film references. I'm not going to assume that there are no readers out there (my ego couldn't take it) so I'll assume there are no Italian film fans. The references were to Amarcord, a 1973 coming of age film with everything a guy could want in a movie with subtitles except there was no karate.

Then I realized that no one knew that in our practice, Bichons, are the master stone formers. They just pop back and forth between struvite and oxylate, frustrating the heck out of their owners and their doctors alike.

By the second mile, I was all warmed up and feeling pretty good. I looked down at my feet and realized that I will need new running shoes after this race in September. (I never race in new shoes) Then I was thinking about the shoe drive that we are running at our hospital, collecting used but wearable shoes to be distributed by souls4soles, a non profit outfit that is actually in Hati right now as we speak, delivering shoes to those who are bare foot.

That kept me distracted for a while, until I started thinking about my pace and heart rate and all of those mundane things that I need to keep track of if I am to finish this run in any kind of shape and still be able to get the rest of my work outs in over the week. I was trying to juggle my schedule so that I didn't have runs on back to back days because that is really hard on my legs. Which led me to think how lucky I am that my knees are good. My mind quickly did some trick to ward of the evil eye and then I thought I should talk about arthritis in pets. There was one brief digression as I ran on a bit of roadside path that made me worry about ticks and lyme disease, but that topic doesn't really fit the trend of nutritional posts I wanted to write and maybe I could put that off for a week or so, even though we are getting into the second peak season for deer ticks that spread the disease, even tho we don't have a lot of deer in my area and then I notiticed that I hadn't taken a breath and the run on thought had become a run on sentence and I was going to pass out if I didn't slow down.

So miles 4 - 8 were mostly on joint disease. Now, both dogs and cats are subject to degenerative joint disease. I am talking about the type of arthritis that is caused by wear and tear on the joints. There may be underlying instability in the joint as in hip dysplasia. Sometimes it is a genetic predisposition such as the abnormal looking joints in Basset Hounds. And sometimes, it is just part of the aging process. We think of dogs as being arthritic, but there was actually a retrospective study that looked at the x ray films of cats admitted to hospitals for other reasons. 22% of the cats over a year old in this study showed radiographic evidence of osteo arthritis.

So what are we to do? There are plenty of medications out there to treat arthritis in dogs, not so many in cats. Some are non-steroidal anti-inflamatory medications (not in cats please). There are nutriceuticals such as glucosamine, chondroitin, green lipped muscles (who knew they had lips). There are surgical treatments (not so good). New research shows promise using stem cells. And we have had some very good success using our laser to treat painful joints in both dogs and cats. But what if you could do one thing to prevent, or at least mitigate, the degenerative changes in the joints.

Well, if you are a regular reader, you know that weight control is very important in preventing arthritis in pets. Purina did a great study in labs showing a correlation between arthritis and increased (excessive) body weight. (Leaner dogs also lived longer) So, work with your veterinarian to get the weight off of your heavy furry friends. Or, better yet, don't let them get fat to begin with.

What if they are thin and have arthritis anyway? It does happen you know. There was a series of three articles published in the past year in the Journal of the American Veterinary Medical Association (JAVMA) showing that there was an excellent response to a diet made by the folks at Hills. Dogs fed J/D (Hills cleverly uses initials to make it easier for veterinarians to remember what the food is for. Joint Diet - get it?) had a good resolution of clinical signs related to arthritis. In fact, there were all sorts of things that were measured and showed improvement over the initial 30 day period that the food was fed. I know, these diets are expensive. Not really when you consider that one of the articles demonstrated that dogs could reduce the amount of NSAID that they took when they ate this food. Add that savings in (not to mention that there are no side effects to feeding J/D and there can be with medications) and then the food is not that expensive after all. Oh, what about cats you ask? Well, they just came out with a diet for cats (Feline J/D, so clever those folks at Hills) and it works great too.

Now stop your whining before you start. "My cat won't eat that food" I can hear it already. They have a money back guarantee, my rep told me so today. If your cat won't eat the stuff, you can return it to your vet and get your money back.

So, here it is, you can actually decrease your pet's chances of getting a debilitating disease by feeding it optimally to prevent obesity. And if your pet is unlucky enough to develop osteo arthritis, you can "treat" the condition with food. Hey we all have to eat anyway, why not feed something that will make your pet's legs get better.

I'm not going to go into what I ws thinking about for the last couple of miles of the run. It wasn't pretty, and the thoughts were not all that pleasant. Just leave it to I finished, I was happy with the time it took, my legs felt OK and I had a cold beer waiting for me. My idea of optimal, post workout re hydration and recovery.

Something's Amiss if a Dog ....

OK, so no one read the last blog post. It can't be that no one knows where the film quotes are coming from. But just in case there are hundreds of you out there and you are just to shy to let me know what movie I'm rambling on about, today's post title is another hint.

I also purposely skipped dogs in last week's post about lower urinary tract disease. No, not because I think dogs are second class pets. It's just that their disease is actually easier to write about and the photos that I have are better, or at least more dramatic.

Now, dogs with lower urinary tract disease often have infections. These respond well to antibiotics. The diagnosis is made by clinical signs, (frequent urination other than marking by unaltered males), +/- blood in the urine, a urinalysis indicating infection or inflammation, and sometimes a culture. Simple UTIs (urinary tract infections) are more common in females than males, an anatomical issue not a sexist one, and should respond to a short course of antibiotics. Cure should be confirmed with a follow up urinalysis. UTIs that do not respond to treatment usually fall into one of several categories. 1. The antibiotic chosen was not appropriate for this specific infection due to bacterial resistance, solution, culture to get correct antibiotic sensitivity. 2. Antibiotic was appropriate, but not given for a long enough time or at the correct dose. 3. There is some sort of underlying problem causing the infection or the clinical signs that are interpreted to be an infection. These can be any of the following; bladder failing to empty completely due to anatomical defect or neurological problem, obesity causing anatomy problems leading to ascending bacterial infections, bladder tumors, or (if you peaked ahead) bladder stones.

This radiograph is a much better illustration than the cat photo from last week. Need I point out the mass of minerals in this poor dog's bladder. I hope not because I still haven't gotten around to the use of arrows in my photographs. (any hints on this would be greatly appreciated.)

Bladder stones in dogs are similar to urinary stones in most mammals. They are mineral concretions that form in the urinary tract. We do see calcification of the kidneys as well, but clinical kidney stones are less common than bladder stones in dogs. The most common stones historically were struvite stones. These phosphate based stones need a nidus to form, usually a bacteria and are therefor associated with UTIs. An important factor when talking about prevention. Struvite stones are usually smooth, yellow to tan colored little rocks. They tend to form in alkaline (not acid) urine but I have seen them look like anything and form in all sorts of urine. The only way to tell what type of stone the dog has is to get one and send it off to the lab. Now, in male dogs, there is usually only one way to get one, surgery. I have been lucky in females and have been able to get them to pee out a small stone that we can have analysed. The other cool thing about struvite stones is that they can be dissolved by diet. While the SO diet by Royal Canin will do this, I find that S/D (could that be for stone diet?) made by Hills does a great job. Struvite stones can be dissolved in about 1 month in most dogs. There is a catch for the guys tho. I don't like to try to dissolve stones in a male dog. The thing is, that before a stone dissapears, it becomes small. Small stones can pass out of the bladder and get stuck in the urethra, just above the os penis (penis bone) This can cause an obstruction, a true surgical emergency.

So for all you guy dogs out there, and you know who you are, your choice is surgery. Here's what came out of the bladder above.

Pretty impressive collection, huh? Now once the stones are out, if they turn out to be struvite, we do put the dogs on S/D just to make sure that we are good to go and that nothing else is forming. Then we put the pet on a maintenance diet and monitor the urine every month. What are we looking for? Infection. Remember, these stones need a nidus of bacteria to form, so if we can catch the UTI early, we can prevent the struvite stones from forming. The thing we have to be careful about tho is the other end of the spectrum, stone wise. We used to try to promote an acid urine, either by diet manipulation or by adding acidifiers to the diet to prevent these stones from forming. That's when we started to see an increase in the number of oxylate stones in our canine patients. These stones cannot be dissolved by diet, do not need infection to form, and must be removed surgically in males and females. They are rough surfaced and can stick to the lining of the bladder. They can be difficult to remove and I can only assume that they are quite painful. Once out, we usually use the Royal Canin diet to prevent them from coming back. This diet maintains a neutral ph so as not to encourage struvite stone formation and works by decreasing the precursors for stone formation in the bladder. Another new improved option is Hills C/D multicare, it does the same thing. I won't put another set of links to the website, just follow the ones above.

So the take home message is, re occurring bladder symptoms in the dog are not usually just repeated infections. Additional testing needs to be done to find out why the dog is having the problem, what the problem is, and what can be done to cure this episode and prevent future ones. It is an on going problem that can be managed very well with diet and follow up.

Oh, and if anyone thinks they know their stones, here's a little trivia question. What breed do you think has the greatest incidence of bladder stones in our practice. I'll give you a hint, nah, no hint, but I will give you a prize. First person that doesn't work at my hospital to leave the right answer as a comment will get a $10 gift certificate for some really outstanding pet food. Check it out at www.TheVetsChoice.com.

To be Fit as a Fiddle, a Cat Has to ....

OK, there it is, right in the title, my homage to Fellini. Not that the oblique film reference has anything to do with today's topic, I'm just trying to show that I am a multi dimensional kind of guy. The first person to identify the reference and leave it in a comment will win ..... My undying respect for your film knowledge. I mean come on, I gave you the artist, you should be able to figure this one out.

But on to our first topic in nutritional therapy, feline lower urinary tract disease. (maybe we should have stayed with Italian films). Back in the dark ages, when I graduated from vet school, (go Penn class of '84), we used to see a lot of cats with signs of lower urinary tract disease. You know, increased frequency of urination, perhaps some blood or straining in the litter box with little urine produced. In male cats it would frequently get bad enough that they would block and be unable to urinate at all, necessitating surgical intervention of some sort. Ultra sound was not readily available, so we assumed that these cats had infections and gave them antibiotics and made some diet recommendations (at the time Hills Prescription Diet C/D was all that was really available) and lo and behold, most of these cats got better. Logic, incorrect as it might have been, dictated that there was an infection that the antibiotics cured. Current theory was that the ph of the urine (measure of acidity calculated by the inverse of the negative log in base 10 of the hydrogen ion concentration, but now I am just showing off) was too high so we added acidifiers to the diet as well.

Theories came and went over the next few years, but the antibiotics stayed. In that time we thought it was the ash content of the diet, the magnesium content of the diet, the ph of the urine, and people even thought that urinary disease in cats was related to the phase of the moon. What did change, is that we started to culture some of these cats' urine and we found, you guessed it, no infection. So what was going on? We had made the urine acid, we had given antibiotics, but then after really screwing up the urine of these felines, we started to do some imaging. First was x rays. It's hard to see in this photo, (and I don't know how to put arrows in these yet but hey, I'm an old dog learning new tricks.)

The bladder is to the left of the bones and to the right of the black gas. If you look carefully, you can see a line of small white stones. This is what we started to see on a certain percentage of our bladder x rays. Stones are made of minerals so they show up white. Most are struvite (phosphate) or calcium oxylate stones. It is hard to tell which are which on radio graphs, you need to take them out and send them off for analysis. The thing is, a lot of cats had urinary tract signs, negative cultures, and no stones on radio graphs. Enter the ultrasound machine. Now, some people can read ultrasounds with no problem. I on the other hand have difficulty. So, I have a doctor that does imaging come to our practice to do our studies. And what he finds in many cases, is simply a thickening of the bladder wall. No infection, no stones, no nothing.

These are cases of sterile interstitial cystitis. A potentially serious inflammation of the bladder that causes all of the signs that we see. Sometimes it is self limiting and usually episodic. That explains why so many cases get better after a week of antibiotics. They would have gotten better even without antibiotics. Some do not resolve so quickly and others are real bears to manage. They require constant dietary manipulation and medication just to keep the disease under control.

So what do we do to manage feline lower urinary tract disease? Well if we find an infection, antibiotics are still the answer. If we find stones, we take them out. Here are the stones from the cat in the above radiograph. Easier to see now that they aren't in the cat.
We will send these off to the lab and once we know what type of stones they are, then we will make long term management recommendations. The tough cats are the ones with the sterile cystitis (SC). These get a combination of pain medications, anti inflammatory medications and even some anti anxiety medications. But the only thing that seems to have any science behind it is dietary manipulation. Now, anicdotally, colleagues of mine in feline only practices have told me that they have significantly reduced the incidence of FLUTD (feline lower urinary tract disease) in their patients simply by having all of their clients feed canned food. It seems that the increased moisture may play a roll. Cats are notoriously poor drinkers so it does make sense that a more dilute urine brought on by increased water intake might help with irritants in the bladder. There are actually studies showing that feeding canned SO a diet made by Royal Canin actually has been demonstrated to decrease the signs of FLUTD in cats. It will also dissolve those pesky struvite stones and prevent new calcium oxylate stones from forming. It is our go to diet for most of our cats with FLUTD. There are some issues tho, it is high in salt which can be a problem if cats have marginal kidney function.

Another choice is a Diet made by Hills. Remember the C/D I mentioned earlier? Come on, pay attention. Well it has been reformulated. It is designed to dissolve struvite stones in the dry form, so it probably will in the canned form as well. The canned formulation is lower in salt than the Royal Canin diet and we are going to start using this a bit more for our cats with SC.

So we have come a long way from just popping our feline friends with antibiotics every time they strain to urinate. And, we have done far fewer urethrostomy surgeries on blocked male cats, which is a good thing. We can control and treat many cases of FLUTD in cats with diet and common sense. Talk to your veterinarian for dietary recommendations and don't forget to let me know if you figure out the reference at the beginning of this post.

I didn't forget about dogs, they are just entirely different beasts and I will post about them next time.

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