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Language Barriers

I run an all-feline veterinary hospital, and we have a fairly large Japanese client base. This is not by accident. One of my technicians, Hiromi, is Japanese, and she made it clear to me when I hired her 8 years ago that she would like to actively help me cultivate a Japanese clientele. In speaking with her cat-owning Japanese friends and acquaintances, Hiromi has heard countless tales of frustration, as they described the difficulty in explaining exactly what it is about their cat that had them worried, as well as their inability to fully understand what the doctor had told them.

Cats are complex creatures, and the physical and behavioral changes that they display when they aren’t feeling well can be rather nuanced. Without significant mastery of English, these subtle but important observations go unreported. Hiromi wanted to help remedy this situation and I was all for it. We advertised in Japanese publications. She translated and transcribed some of the medical articles I had written, and we posted them on our website. Word soon got out, and the Japanese clientele began to grow.

The language barrier, however, operates both ways. Some things are easy for me to explain, and very little additional interpretation is necessary by Hiromi. There’s nothing really esoteric about an upper respiratory infection. “Your cat has a cold, and this medicine should help.” Some illnesses are much more complex, and require more intense translation. Explaining a diagnosis of diabetes isn’t too difficult, because most people have a basic understanding of the disorder. The treatment of diabetes is detailed and complicated, however, and explaining how much insulin to give, how to draw it into the syringe, how to inject it, signs of an overdose, etc. can be daunting.

Of course, the difficulty lies in the fluency of our Japanese clients, both in speaking and in comprehending. In our practice, this varies greatly. Most of our clients have a very good grasp of the language, and Hiromi only really chimes in to clarify the difficult concepts. A few clients, however, speak very little English, and without Hiromi, both the client and I would be totally helpless in the exam room.

Occasionally, I’ll have a Japanese client that speaks English pretty well, but doesn’t understand what I’m saying, especially the medical terminology. Or I’ll have the reverse situation, where the client doesn’t say much, but seemingly understands everything I’m saying, and when I’m done speaking, they’ll ask me a follow-up question (in Japanese, via Hiromi) that impresses me as to how well they understood what I had told them.

I really hadn’t thought too much about the language barrier, since having Hiromi present has always alleviated the problem. Last week, however, I got a poignant lesson on the importance – and power – of language, when dealing with such emotional topics as the health of our beloved pets.

It had been a bad week to begin with. During the week I had evaluated four cats with significant illness, and was in the process of scheduling them for additional diagnostic procedures. In one cat we had narrowed our diagnosis to either inflammatory bowel disease (IBD) or lymphosarcoma. A second cat with chronic vomiting and diarrhea was in the same situation. A third cat had already been diagnosed with IBD over a year ago, but had developed jaundice and elevated liver enzymes and had stopped eating.

The fourth cat was Po, an elderly cat who had lost a lot of weight recently. On physical examination, I felt a mass in the cranial abdomen. I suspected a tumor of the stomach, but couldn’t be certain.

Po’s owner is Japanese, and her verbal skills in English are passable. I think her ability to understand what I say is probably better than I suspect, but I really just cannot be sure. When it comes to diagnosing more obvious things, language is less of a problem. But when I feel a cat’s abdomen and I think I feel a tumor, my English-speaking brain immediately starts formulating the gentle words and sentences I hope to use to deliver the worrisome news. And here lies the problem. I may be thinking in my head, “your cat has a mass in the abdomen, it’s probably cancer”, but of course, I would never deliver this type of news so bluntly. What I’d like to say is, “well, on physical examination, something in the very front part of the abdomen feels a little strange. I think I feel a lump. Initially, I was thinking this was a piece of stool, but this mass is a bit larger than a typical piece of stool. And pieces of stool are compressible with my fingers, but I’m trying to compress this, and it’s not yielding like a piece of poop would. I’d like to take an x-ray to see if I can characterize this mass a little better.”

Will Po’s owner understand “lump”, “abdomen” “compressible”, “yielding”, and “poop”? Probably not. When Hiromi translates what I’ve said to the client, will all of the subtleties be intact, or will they be lost in translation? One reason I really like my Japanese clients is that they are unfailingly polite, and will always smile or nod respectfully when I address them. In many cases, I cannot tell if they’re smiling and nodding because they understand what I’m explaining, or if they’re simply being polite.

I took an x-ray of Po’s abdomen, and I saw what I believed to be the mass that I was feeling with my hands. It looked like it was the stomach. Again, on an x-ray, you can’t be totally certain, but it definitely looked suspicious.

I thought in this situation, perhaps a picture would be helpful. So I showed the client the x-ray, and while I pointed and narrated, Hiromi translated. Then we sat down and discussed the options. I recommended abdominal ultrasound to get a better picture of what this mass was, and to get an ultrasound-guided biopsy to get a definite diagnosis. Po’s owner nodded. I had Hiromi tell her that given the cat’s age, and the fact that I think I see and feel a discrete mass, the likelihood is that this is some kind of cancer. Hiromi translated this. The client nodded, but I could see her eyes welling up. I said that lymphosarcoma is the most common cancer we see in cats, and that there are two types – a milder, less aggressive low-grade type, and a more serious, aggressive, high-grade type. I told her that when there’s a discrete tumor, it’s more likely to be the high-grade type. Hiromi translated. Po’s owner remained composed, and didn’t say much. I told her that if it was indeed high grade lymphoma, surgery wasn’t really an option here. Treatment would be with chemotherapy. She asked about the chemo. I briefly described the medications and the protocol. She asked about the prognosis. I said that some cats go into remission, while others do not. She asked what happens if they don’t go into remission. I said that we would have to put her cat to sleep. Hiromi translated. Po’s owner nodded. A few seconds later she quietly began to cry.

I felt terrible. I felt like the evil messenger. I would say something. Hiromi would translate. Po’s owner would become upset. Then there’d be silence. I’d say something again. Hiromi would translate. Po’s owner would cry. It’s weird to have a profession where you can really devastate someone’s life with one or two sentences.

After all the explanations and descriptions, we decided to go for the chemotherapy. Po will need to come in for medical treatment almost every weeks for ten weeks, initially, and if he goes into remission, we can cut back to an every-three-weeks schedule.

In my profession, it’s important to attend continuing education meetings and to read the journals. We’re always learning; it’s the nature of being a veterinarian. But sometimes, my greatest lessons don’t come from the journals and textbooks. I’m grateful to my Japanese clients for helping to teach me the importance of language and for making me aware of how crucial proper communication can be, when it comes to such important matters as the health of our beloved cats.

Addendum: After 3 weeks of chemo, Po is doing well. In a few days, we’ll give the fourth treatment, and then will do abdominal ultrasound to see if the stomach tumor is shrinking, or (hopefully) undetectable.

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This is Trouble : Adopt Trouble

This is Trouble
Trouble has a black belt in cute

Trouble can chase catnip toys with her mind

If Trouble was in the military there would be no war


Adopt Trouble
212-721-2287
mcs@manhattancats.com

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Our Hospital Cat Topeka Paws One Kibble at a Time

Our wonderful and moderately dainty Manhattan Cat Specialists hospital cat, Topeka, has an unusual way of eating her food.

At the end, you get to see her most excellent cyborg laser eye.

Have a watch.

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I Tossed Crispy’s Insulin in the Trash

Most diabetic cats require lifelong oral or injectable medication. For a few lucky cats (and owners), however, diabetes resolves. How does this happen?

My cat Crispy has terrible skin allergies. A few years ago, it got really really bad. She was chewing at her feet and the insides of her legs non-stop. I tried a hypoallergenic diet, but that made no difference. I would have liked to have tried antihistamines but Crispy is impossible to medicate. It’s embarrassing that I’m a veterinarian and I prescribe medications to cats all day, and yet I cannot medicate my own cat. I’ve tried flavored liquids, I’ve tried hiding pills in treats, I’ve had treats made up with the medication blended throughout the treat (she ate exactly one of them, and never ate another one, ever again). Omega-3 fatty acids are anti-inflammatory in some cats, and may help reduce skin inflammation when given daily. So I tried putting them on her food. She caught one whiff of them on her food and that was that. She absolutely refused to touch the food thereafter.

I could tell from the appearance of the skin problem that this type of allergic dermatitis would probably respond nicely to steroids. I’m not crazy about giving steroids to cats, but with skin allergies, you give steroids initially at a high-ish dose, and then you rapidly taper the dose down to the lowest dose that controls the signs. I was figuring 1 tablet of prednisolone twice daily for 5 days, then once daily for 5 days, then every other day thereafter. I was hoping that once I got down to the every other day dosing, it wouldn’t be too horrible. Well, several bite and scratch wounds later, I abandoned the process. Crispy will simply not allow herself to be orally medicated. Period.

I had to do something. Look at what she was doing to her leg!


As a last resort, I gave Crispy an injection of a long-acting steroid.

I know that this is done quite often by other veterinarians, but I rarely do it. Long-acting steroids have the potential for side effects. First of all, they are immunosuppressive. This is why we give them. If the immune system is causing problems, we want to dampen the immune response. With skin allergies, we want the steroids to get those inflammatory cells out of the skin, where they’re making the cat miserable. But, by suppressing the immune system, you put the cat at increased risk for developing opportunistic infections. Steroids are also antagonistic to insulin. Give for a prolonged period, they can induce a diabetic state in the cat. Steroids also cause retention of water. In most cats, it’s not a problem. For cats with heart disease (especially mild, undiagnosed heart disease), the increase in blood volume caused by the steroids may be enough to result in congestive heart failure. This is why I prefer pills to an injection. With pills, if adverse signs develop, you stop the pills, and the drug is out of the body is just a few days. With an injection, once you give it, you cannot take it back. Steroid injections can last anywhere from 3 weeks to perhaps 3 months! In Crispy’s case, I was left with few options, so I gave her a steroid shot, but at a reduced dose, and I monitored her carefully. Crispy’s skin cleared up immediately, and she had no worrisome side effects at all. Her skin looked great.

About two months later, the signs returned. Once again, I had the same dilemma: a skin problem in a cat who won’t allow me to medicate her. I tried a topical spray, but that didn’t help. She hated the sound that the spray bottle made, and the way it felt on her skin. As soon as she saw me coming, she’d run for the hills. That got me a bit depressed. Her legs started looking as bad as they did several months prior. Reluctantly, I gave her a second steroid shot. Within two weeks, her skin had healed up and the fur had started to grow back where she had licked and pulled it out. And then…

I noticed that the clumps of urine in the litter box were getting big. Really big. They were like cinderblocks! I knew Crispy was the culprit, because Crispy urinates in the back of the litter box, while Mittens urinates in the front. I also noticed that Crispy would often have clumping litter stuck to her feet. We call this “frosty paws”, and it is a sign that a cat is making a lot of urine. Fearing the worst, I brought her into my hospital for some routine blood tests, and my fears were confirmed: Crispy was diabetic.

Before I get to the good part, i.e. how the diabetes resolved, let me give everyone a little refresher course on diabetes in cats.

Diabetes 101

Diabetes is one of the most common endocrine (glandular) disorders in cats. While the exact cause of diabetes in not known, obesity, genetic predisposition, pancreatic disease, hormonal imbalances, and certain medications have all been incriminated. Diabetes occurs when the pancreas fails to produce adequate amounts of insulin, a hormone necessary for controlling blood glucose (sugar) levels. When food is digested, sugar enters the bloodstream. The body uses this sugar for energy, growth, and repair. Insulin is necessary for the sugar in the bloodstream to enter into tissue cells where it is needed – in muscles, for example. Without enough insulin, sugar accumulates in the bloodstream where it eventually gets filtered out into the urine. Large quantities of water accompany the sugar that is lost through the kidneys. Consequently, diabetics produce a large volume of urine. To avoid getting dehydrated, cats compensate for this fluid loss by drinking excessively. Because the sugar cannot get into their cells without insulin, they switch to using fat and protein as an energy source, and diabetic cats usually lose weight as a result. Overweight cats are more likely to be afflicted with diabetes.

Diabetes is usually easy to diagnose. Most cats are presented to the veterinarian with the classic signs of diabetes: excessive urination, excessive thirst, very good appetite, and weight loss. High levels of sugar in the blood and the presence of sugar in the urine allow for a straightforward diagnosis. Occasionally, the clinical signs can be misleading, and the blood and urine tests can be equivocal, making the diagnosis somewhat tricky. In these instances, some additional tests may be necessary before arriving at a definitive diagnosis.

Treatment of diabetes involves medication and special diets. The majority of feline diabetics receive insulin injections. Although some cat owners are distraught at the thought of administering injections and would prefer to give pills, in most cases, insulin injections are the best choice and are actually much easier to administer than pills. Crispy could not be pilled, but giving her insulin injections was the easiest thing in the world.

Type 1 and 2 (and 3) vs. IDDM and NIDDM

In humans, we classify the diabetes as Type 1 or Type 2. Type 1 diabetes is characterized by genetic susceptibility to diabetes as well as destruction of the beta cells, the pancreatic cells responsible for producing insulin. Type 1 diabetics cannot produce enough insulin to keep their blood sugar regulated, and are dependent on insulin treatment for control of the disease. People with Type 1 diabetes are therefore classified as having insulin-dependent diabetes mellitus (“IDDM”). Humans with Type 2 diabetes, on the other hand, usually have a combination of insulin resistance and beta cell dysfunction. Their beta cells produce insulin, but usually in inadequate amounts, and their bodies don’t recognize or react to the insulin in the proper way. In humans with Type 2 diabetes, control of the diabetic state is usually possible through diet, exercise, and oral drugs. In other words, most humans with Type 2 diabetes can be controlled without the need for insulin and are said to have non-insulin-dependent diabetes mellitus (“NIDDM”). If beta cell dysfunction and insulin resistance become severe, however, insulin may eventually be necessary. As such, humans with Type 2 diabetes can have IDDM or NIDDM.

In cats, it is very difficult to figure out whether a cat has Type 1 diabetes vs. Type 2. It is perhaps more accurate to classify feline diabetes as IDDM or NIDDM, based on their need for insulin to control the diabetes, rather than Type 1 or Type 2. At the time diabetes is diagnosed, about 70% of cats have IDDM, while NIDDM accounts for the remaining 30%.

And then there’s something we call Type 3 diabetes. Type 3 diabetes occurs when something within the patient is interfering with insulin, leading to glucose intolerance. Cushings' Disease (Hyperadrenocorticism) is the most common cause of type III diabetes in dogs. This is a disorder that occurs when too much of the hormone cortisol is released by the adrenal glands. Cortisol is the body’s own natural steroid. Cushing’s disease is rare in cats. In cats, the most common cause of type 3 diabetes is steroid (prednisolone or prednisone) therapy. Sometimes, this type of diabetes will often resolve after the drug is withdrawn.

Transient diabetes

A small percentage of diabetic cats – cats who developed their diabetes naturally, and not secondary to steroids, like Crispy – are revealed to be “transiently” diabetic, usually within a few weeks after the disorder is diagnosed and treatment has begun. In these cats, the high blood sugar, presence of sugar in the urine, and clinical signs resolve, and insulin treatment can be discontinued. How does this happen?
In normal cats, when the pancreas detects elevated levels of sugar in the blood stream, it responds by secreting insulin. Blood sugar levels will then drop, gradually returning to normal. Some cats, however, may have a hidden problem with their pancreas – a decreased number of beta cells, and an impaired ability to secrete insulin. They may appear clinically normal, but they’re actually on the “brink” of being diabetic. If they’re then given drugs that impair insulin function, or if they become overweight or obese, the cats become intolerant of carbohydrates and develop high blood sugar. In some of these cats, though, the high levels of blood sugar causes something called “glucose-induced desensitization”, a temporary, reversible state in which beta cell function becomes even further suppressed, and these cats become insulin-dependent diabetics. In this population of cats, if you lower the blood sugar by giving insulin and correct or control concurrent disorders, beta cell function may be restored, and they begin to release insulin again, and the cat returns to their subclinical state, i.e. they’re go back to being “on the brink” again. I’ve had cats like this in my practice. They were diabetic, and were being given insulin injections, and suddenly they have a hypoglycemic crisis – their blood sugar drops and they they get sick, often necessitating a trip to the emergency clinic. We drop their insulin dose, and soon discover that they actually no longer need the insulin. If this happens, it usually occurs within the first six months of the diagnosis. But not always. A patient of mine named Danny was diabetic and was receiving insulin for about five years, when his pancreas suddenly decided to start secreting insulin again.

With Crispy, after about 3 years of giving her four units of twice-daily insulin, I noticed that she never experienced any of the signs of diabetes at all.



No excessive thirst, no more cinderblocks of clumped urine in the litterbox, normal appetite, and (unfortunately) no weight loss. (She’s a fatty; a little weight loss would have done her good.) I decided to check her blood sugar and it was low. Not dangerously low, but definitely lower than normal, and she had no sugar in her urine. Most diabetics, even those that are pretty well-controlled, will have at least a trace amount of glucose in their urine. Crispy had zero. So, I weaned her insulin dose down from 4 units twice a day, to 3 units, to 2, then 1, then off. Her blood sugar stayed normal. It still is. I tossed her insulin and syringes away. It’s a great feeling, akin to throwing out your contact lens case and solution after Lasik surgery.

End of story?

So, is that it for Crispy and her diabetes? Well, I’m not sure. In a study, published in 1999, of 10 cats with transient diabetes, seven cats did not experience a recurrence of their diabetes. Three of the cats, however, had a recurrence of their diabetes, one six months later, one 14 months later, and one 3.4 years later. In the study, it was not possible to predict which of the transient diabetics were at higher risk of a relapse. Certainly, cats whose diabetes seems to have resolved should be considered to be susceptible to a recurrence of their clinical diabetes, and it would be important to avoid the circumstances that could promote a return to the diabetic state. That would include avoiding any medications known to antagonize the effectiveness of insulin, such as glucocorticoids and progestins, maintaining ideal body weight, and minimizing concurrent illnesses. I don’t know about maintaining her ideal body weight (no matter what I do, she seems destined to be three pounds overweight), but I certainly won’t be giving her steroids again.

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