Is length the most important thing? (Day -160)

Quality vs Quantity of life in dogs

I’ve recently spent some time within some of the top oncology (cancer) referral vets within the UK and been in consults with people who have to be told that the biopsy says it is cancer. One of the most difficult questions that pet guardians will then ask is how long a loved pet has left – this is an awful question that has to be answered so carefully because we just do not know.

We try to use evidence based studies looking at different treatments when discussing the options – however these studies over use statistics to give averages. Unfortunately within veterinary research many studies only have a small amount of patients which is caused by the way the veterinary industry works. This means that when looking at a study with average life duration from start of treatment of 3 months that some dogs may have died at 1 week whilst others lived until 9 months or a year. I am personally starting to believe that statistics should be limited to use only in sample sizes over a defined minimum limit to improve reliability (I wrote about statistics here).

However what is missing from most of these studies is perhaps even more important and is the second question that most pet guardians ask. That is what the quality of life is like. It is something that may sound strange however it is much easier to quantify quantity of life (i.e. days) than it is quality (i.e. happiness) of a pet.

This is still something in it’s infancy within veterinary medicine – with humans we can explain that it will hurt now but it will mean that they are good later. The first time I saw this discussed was within surgery decision making in the AWSELVA journal in 2014 (J. Yeates & S. Corr) to evaluate treatment options based on the amount of painful time vs the amount of pain free time.

This is something that is difficult though as we need to define how we recognise the quality of life. For example if we consider movement as an indicator as recently there have been studies using accelerometers (step counters) to monitor the activity of an animal. A study just published used this to measure the physical activity in dogs receiving chemotherapy as an oncology treatment which may be acceptable.

However if we look at dogs with neurological problems that may have abnormal circling or pedalling movements then activity may not be the best quality of life. Here is where other techniques may come into play with things such as a seizure diary being kept to record frequency and duration of seizures to allow comparison of good time vs bad time.

Hopefully soon we will have better measures for the quality of life – and be able to apply these when making decisions that may impact animal welfare.

Harvey Cushing – A life in surgery – A Review (Day -266)

Dr Harvey Cushing - A Life in Surgery

As the first biography I have ever read cover to cover this book was absolutely gripping with me wanting to find out what happened next.

Many people may have heard of Cushings Syndrome or Disease which is where the pituitary gland often has a tumour which increases the amount of hormone released from it. This increased secretions has a big effect on the rest of the body and was defined by Dr Harvey Cushing. However in addition to this Dr Cushing was also the founder of modern brain surgery.

Back in 1887 when Cushing looked to train as a surgeon there was no such thing as neurosurgery – actually there were no requirements other than money for the fees to get into medical school. The medical schools were run by practicing doctors from the local area that did it to supplement their income. Surgery back then however was only an emergency last attempt – there was no elective surgery – and when it happened the odds of the patient surviving were tiny. Not just from the actual surgery itself which was often only amputations but from the infections that occurred afterwards.

Dr Cushing started his studies at Yale before moving to Harvard and in 1896 was planning to travel to Europe to study when instead he was offered a place to study with Dr Halsted at the new John Hopkins Hospital after being initially denied. Learning from Dr Halsted the techniques of haemostasis, good surgical dissection and aseptic surgery.

When the skull was opened here the patient in most cases suffered from something called fungus cerebri which is infection of the brain. In 2016 there are neurosurgeons that have had entire careers without seeing such a thing. This is largely thanks to the careful use of aseptic technique that Dr Cushing had learned from Dr Halsted.

Something that really interested me was the use of dogs within the surgery training courses at these medical schools. Initially they started as just using dogs for trying out new techniques, then for the training of new surgeons, however these training centres evolved into the first veterinary hospitals with human doctors treating dogs for surgical diseases not treated before. Some of the research that evolved from dogs has been instrumental in developing modern neurosurgery.

For example the Cushing reflex which says that when the pressure inside the skull raises, then the blood pressure will rise as well to compensate and keep the brain oxygenated. Dr Cushing investigated this by opening a dogs skull and replacing a section with glass so that he could see the vessels of the brain as he increased the pressure in the skull. He noticed that as he increased the pressure the vessels initially became compressed, however then the blood pressure of the body increased to force blood back into these brain vessels.

The thing that Dr Cushing is most known for however is that of Cushings syndrome or disease which is where a tumour on the pituitary gland at the base of the brain causes excess hormone release into the rest of the body causing clinical signs. Dr Cushing did a range of experiments here both on dogs and with human patients looking for a way to treat those suffering from acromegaly which is increased growth. At the time the function of the pituitary gland was unknown, so this work was ground breaking.

I would highly recommend that anyone interested in the history of surgery reads this book.

Is it a brain, skull, or something else??? (Day -283)

Vet student in surgery

I remember many years ago watching ER with Carter dealing with a burn victim and on failing being told it doesn’t get any worse than this. No matter how much time you spend in clinic there are always going be surprises. Especially when you think it cannot get any worse, something will come in and take that place. I’ve seen some horrific things, sometimes enough that I wonder if I sleep if I will get nightmares.

The scary thing is however that a lot of horrific things are also extremely cool. Today was one of those horrific things that was also amazingly cool.

Cool because the kitten was alive. Cool because the kitten was ok neurologically. And cool because it was not something that you will see every day. Actually not sure when you would see it at all.

Now these are where the skills that cannot be taught in the classroom really are tested. I like a challenge, and this is definitely that. When the discussion you are having is whether what you are looking at is skull or dura (the covering of the brain).

Yes. There is a kitten running around. Playing. Drinking. With a great massive hole in its head.

So now to do something? I’ve spent hours and hours in textbooks and cannot find a single mention of what to do. We’ve not got CT or MRI. I so wish we did so that we knew what it was, and what was underneath.

Is there a brain abscess? Dunno… Maybe.

So kitten is scheduled in for cleaning of the wound. And then maybe we will know more.