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Baby Velasquez

As I entered the hospital room a dark cloud rolled in from Puget Sound obliterating the sunshine streaming through the window. The young couple had been anticipating the arrival of their baby with both the excitement and trepidation common to first-time parents. There was no forewarning of disaster. After twenty years the delivery of bad news was not any easier for me.

“Perfect,” I thought, “now the sun goes away.”

Mrs. Velasquez’ smooth milk chocolate countenance was framed by the mass of her black hair spread on the snowy pillowcase. Mr. Velasquez, short and stocky, his dark skin further darkened from working outdoors, was standing with his abdomen pressed against the bed. He gently massaged the back of his wife’s right hand with his thumb.

“Hello, I’m Dr. Jenkins.” I extended my hand to Velasquez who took it and returned my squeeze. His hand was rough, calloused but clean, even the fingernails. “I’m a neonatologist, …” They both stared at me without comprehension. I tried again. “I’m a baby doctor, I take care of newborn babies.”

“When can we see our baby?’ asked Velasquez. “They took her away as soon as she was born. Why can’t we see her, hold her?”

“Yes, where is my daughter,” Mrs. Velasquez’ voice cracked.

“I’m afraid the news is not good. Your daughter was born with a very serious condition and she is in the intensive care ward for new babies. We have to stabilize her then you can see her.”

“What’s wrong with her?”

Bad news is best delivered early and fast. “I’m not positive yet, we still have to run more tests but I believe she has a condition known as glycine encephalopathy.”

Both of them stared at me.

“It’s a congenital disease, something your daughter was born with. In a few days, when some test results are back, I’ll be able to tell you more about her condition, her treatment and what we can expect.”

More blank stares.

“But when can I hold her?” asked the wife.

“She’s much too ill for you to hold her.”

“I want to see her, we both want to see her,” said the husband.

“Of course, but she is in intensive care. You cannot go into that room but I will tell the nurses to put her close to the observation window so you can see her. You must be prepared though. She has a tube going through her nose into her stomach and she has tiny tubes in the veins in both legs so we can give her intravenous fluids. She also has a tube in her windpipe and is hooked up to a ventilator so we can breathe for her and she has electrodes and other devices attached so we can monitor her heart and breathing.”

The young woman grabbed her husband’s wrist, his skin blanched. She searched his face for reassurance.”

He reached over her with his left hand and gently smoothed the dark damp hair away from her forehead and eyes. “It will be OK Chiquita; this medico knows his business.” He turned back to me. “You do don’t you?”

“Yes, I do.”

“When can we see her?”

“I will arrange a wheelchair for Mrs. Velasquez so you can both go to see her. One of the nurses’ aides will take you there. I have to get back to take care of your daughter. It will be a little while, maybe half an hour. OK?”

“Yes, yes, … half an hour.”

I stopped at the maternity ward nurses’ station to make arrangements for a wheelchair and an aide then proceeded to the neonatal intensive care ward where my senior resident, Frank Williamson, was adjusting one of Baby Velasquez’ intravenous pumps while he added medication to the IV line. The newest resident on my service, fresh from a pediatrics residency program, was engrossed with her tablet computer.

“Well, Dr. Hernandez, I’m happy to see you this morning. You speak Spanish I hope?”

“Yes, sir.”

“Good, this baby’s parents will come to see her soon. I want you to join them at the observation window and explain what is happening. She is their first-born. I need you to tell them what they can expect since I’m not certain they speak English well enough to understand me. You might as well learn how to deliver bad news. That’s part of the job. I presume you have read enough from her records to understand this baby is not likely to live for more than a year and a half, two at the most? It’s going to be a rough time for this family.”

She held up her tablet. “I was just going through her records.”

“OK, what’s the presumptive diagnosis, how did we arrived at it, what further tests are needed? What’s the prognosis and what treatment we will be providing?”

Hernandez didn’t need to consult her computer. “Shortly after delivery the baby presented hypotonic, was comatose and had a seizure. You were consulted and suspected glycine encephalopathy. Plasma and cerebrospinal fluid samples were drawn and both were positive for elevated glycine levels and the ratio was greatly increased. Urine was analyzed and the possibility of ketotic hyperglycinemia was excluded.”

“OK, what next?”

She hesitated. “I don’t know, test for some sort of enzyme deficiency? I haven’t had time to read about this condition yet.”

“Fair enough. Dr. Williamson, can you enlighten our neophyte?”

“We need molecular testing for the constituent GLDC, AMT and GCSH genes and for GCS enzyme activity.”

I shook my head. “OK Frank, you just gave me a headache with all those acronyms. So we’ll do the liver biopsy this morning after the parents have seen their baby. Juaquina how long until we can get the results from a liver biopsy?”

“No idea, I would guess several days, maybe a week?”

“Find out for certain when you submit the biopsy sample. Let’s assume, best case, Baby Velasquez has some residual glucosylceramide synthase enzyme activity. What do we do Frank?”

“Aggressive treatment with sodium benzoate to reduce plasma glycine concentrations. NMDA receptor antagonists have improved outcomes in some trials. We treat symptomatically with antiepileptics, a ketogenic diet fed through the nasogastric tube, watch for gastro-esophageal reflux and we have to monitor plasma carnitine because it can decrease with sodium benzoate treatment.”

“Good God Frank you memorized all that since I left to visit with the parents?”

He smiled ignoring my sarcasm.

“What else?” I asked him.

“We’ll need a MRI to rule out a more severe encephalopathy and hydrocephalus. We also need to recommend a medical genetics consult for the parents in case they want more children.”

“OK Juaquina find out all you can about this condition in the next twenty minutes. I’m depending on you to explain what is happening to the parents but in terms they can understand. Don’t talk down to them. Don’t allow them to feel guilty, it’s not their fault and for God’s sake don’t let Frank talk to them, he’ll scare the feces out of them.”

She nodded her head. “OK, I understand. I checked and Mr. Velasquez does have health insurance through the landscaping company he works for, but it’s minimal coverage with a low limit. This will probably bankrupt them.”

“That’s not our concern. You’ll have to come to grips with it. We can do a lot to keep this baby alive, if you want to call her condition living. The hospital administrators, after collecting all they can from the insurance company, will make the parents miserable before they finally write off the majority of the charges. The emotional toll especially on the parents but also on us and on the nurses will be enormous. Keep both the parents and the nurses in mind. Take extra care how you interact with them, OK? Not long ago this baby would have died within days. It’s difficult for me not to believe everyone, including the baby, would be better off if it could still happen.”

“I don’t know about everyone being better off if the baby dies,” said Juaquina.

“You’re suggesting a baby not likely to ever be able to reason or have orderly thoughts or participate in society in a meaningful way, who will be a burden to her family as long as she lives, financially and emotionally, still warrants our best efforts?”

“Absolutely, … not likely still means maybe.”

“So you think a baby like this can benefit society?’

“Not for me or you to decide.”

“OK, it doesn’t really matter what you or I or Frank or our nurses believe. She’s here, and in our care. We are legally required to do everything we know how to do to keep her alive. If we purposely allow her to die we could all end up in orange jump suits. Perhaps you can convince the parents to sign a DNR. It could be helpful but it would only come into play in case of cardiac or respiratory arrest.”

“I agree with Dr. Jenkins,” Frank chimed in. “What is the point in keeping this baby alive, well in reality just keeping her breathing and her heart beating for a few weeks or months? How does that benefit anyone, including the baby? Certainly not the parents.”

“Not for us to decide,” repeated Juaquina.

***

Dr. Hernandez formed an instantaneous and special relationship with the parents, especially the young mother. She took extra time communicating with her and making certain both the mother and father were able to provide all the care needed once we released the baby from the hospital. Before Mrs. Velasquez could be released from the hospital the family was told the baby had to have a name. Baby Velasquez was named Juaquina after their new best friend. Dr. Hernandez couldn’t stop smiling.

Six weeks later Juaquina Velasquez was back in neonatal intensive care. We were able to wean her from the ventilator after ten days and got her seizures under control by gradually titrating the dosage of the antiepileptic agent that we mixed with the ketogenic diet given via the tube going through her nose into her stomach. It took our best efforts over four weeks to get her stabilized enough to send home with her parents again.

Two months later I answered the page from Dr. Hernandez and saw her fussing over the baby as I entered the neonatal ICU.

“What’s going on Juaquina, when did the parents bring her in?”

“It was four this morning. I gave them my cell-phone number the last time they were here and they called to say she was having seizures. I told them to bring her directly to the ER and I would be waiting for them. We admitted her and I’ve increased the dose of sodium valproate, it seems to be working.”

“Good, what dose are we at now?”

“We got her stabilized at thirty milligrams per kilogram, in divided doses twice daily before we released her the last time. The parents gave her another half dose, as I instructed, when she started seizures last night then they called me. I gave her another ten milligrams per kilo when they got here and just gave her another dose because she was still seizing at her regular six AM feeding time.”

“So what total daily dose are we up to now?”

“Forty milligrams per kilo per day in divided doses.”

“Any more seizures since her last dose?”

“Nope.”

“OK then. While we have her here let’s check her plasma carnitine levels.”

“Already sent blood to the lab for that and a CBC.”

“Good girl, we’ll make a neonatologist out of you for certain, given enough time.”

I smiled then after a pause she smiled in return.

“Have the parents reported any signs of cognition in this baby? Can they get a smile out of her?  Does she follow them with her eyes?”

“I asked them about that and they are convinced she recognizes them and responds to them. I haven’t seen any evidence of that however.”

“Wishful thinking then?”

“I believe so, yes.”

“OK, when did you last talk to them, are they still here, in the waiting room?”

“About fifteen minutes ago, I told them she was resting comfortably again. Yes, they are still here they won’t leave her here alone. Rita, Mrs. Velazquez, already asked me if she could stay as long as little Juaquina is here.”

“Did you tell her it might be days, maybe weeks before we could send the baby home with her again?”

“Yes, but she is determined.”

So it went. We got the baby girl stabilized again with her seizures under control. We adjusted her diet and feeding schedule and other treatments and she actually gained a few ounces before we sent her home each time. But every six to eight weeks Juaquina Velazquez was back, sometimes with seizures, sometimes with breathing difficulties, sometimes with gastrointestinal disorders, most of the time with more than one set of problems to deal with.

Five days after her first birthday party photos of the occasion arrived for the neonatal intensive care staff to share. Little Juaquina was dressed all in pink, even a pink bonnet on her head, but we all saw the vacant expression on her face. Mrs. Velazquez and the baby were back late that same afternoon. This time the baby was having almost continuous seizures. She had vomited and apparently inhaled some of the vomitus. She was in very bad shape. Dr. Hernandez was nearly as distraught as the baby’s mother.

“She’s up to the maximum dose of valproate Dr. Jenkins, sixty milligrams per kilo and still having seizures. She’s got both moist and crepitant rales, pneumonia for sure, and her heart rate is very high.”

“OK, let’s get an EKG and determine if it’s sinus or ventricular tachycardia. You know why we need to have that information?”

“Yes Sir, V-tach is much more dangerous, her heart could fibrillate.”

“Exactly.”

It was ventricular tachycardia and despite doing everything possible we were only able to keep little Juaquina Velazquez alive for five more days. Mrs. Velazquez stayed in the hospital the whole time, often standing at the observation window watching one or all of us, including one or more nurses, working on her baby. The total hospital bill for the last weeks of Juaquina Velazquez’ life amounted to over one hundred thousand dollars.

Dr. Hernandez attended the funeral, still providing emotional support for the family. Three days later she was in my office.

“I don’t think I’m cut out for this Dr. Jenkins. It’s too difficult. I care too much. I think I will be much happier just taking care of mostly healthy babies in a routine pediatric practice. I’m beginning to think that you were right. What’s the point in keeping babies like little Juaquina alive when all it does is bankrupt the family both emotionally and financially? I don’t know if they or I will ever recover from this.”

“Give it some time Juaquina, please. You are doing very well on this service. We manage to save more babies than we lose and that is satisfying, even gratifying. You know that’s true because you’ve experienced it. We need people with your abilities, your skills your empathy. You will learn to keep your emotional distance but I hope you will still let families know you care. The families of the babies we are able to save need us, … need you. I think you should take a week or so off. Maybe go backpacking in the Cascades. It will be good for you.”

“Backpacking? You’re kidding me. Backpacking! I’ve never even gone for a walk in the forest, let alone camping out. Backpacking, is that your thing? Is that how you cope?”

I smiled, “Works for me. Communicating with nature, gives a person perspective.”

She shook her head. “No thanks, I’ll pass.”

“Will you take a week off and consider not leaving? Maybe visit your family and talk to them before you make a decision?”

“Yeah, … OK, you sure?”

“Yes, I’m sure, but I do need you to return and finish your residency. If you decide you are unable to continue I will ask you to stay until we can identify a replacement. Will you agree to that?”

“Yes, I can do that.”

 

 

First Born

It was at least six months since I could encircle her waist with my hands but the rest of Rosalie’s body was still reed thin. Saturday afternoon and we were sitting on the couch. I was holding her very close. A dust storm raged outside rocking the eight by forty-foot house trailer. We each wore wet handkerchiefs tied over our nose and mouth their purpose to filter as much dust as possible. The handkerchiefs smelled like the first drops of rain falling on a dusty dirt road. The trailer shuddered, slipping on the concrete blocks supporting the far end, where we were huddled. The swirling dust inside was so thick I could barely make out the passageway from the kitchen area to the walk-through bedroom only ten steps away from where we huddled.

“It feels like it will tip over,” she moaned.

“No, we’re solid,” I lied. “It will be OK. It would be more dangerous to go outside than to stay put.”

Mister lay panting at our feet, occasionally sneezing to clear his nose. It was August in Paradise Valley, north of Phoenix, and hot, very hot in the closed tight mobile home. The dust turned to mud in skin creases on our necks and on the inside of our elbows where sweat had collected. I wasn’t certain if the threat was greatest from dust inhalation, heat prostration or the house trailer being blown over. Finally, the wind started to abate. I wiped the dust from the face of my wrist watch and peered at it.

“Only forty-five minutes but it sounds like it may be over. It seemed to last a lot longer than usual.”

A last burst of wind slammed the trailer adding to the thick cloud of brown dust. Then it was quiet. Mister sat up and licked Rosalie’s hand to reassure her.

“I am hot, unbelievably hot. I can’t stand this anymore.” Rosalie stood and alternately coughed and sneezed.

“OK,” I said. “I think it’s over. I’ll get up on the roof and take apart the cooler and clean it up so we can turn it on. When I get it apart I’ll yell down and you can turn on the fan.  It won’t do much to cool the trailer down but if you open the windows maybe it will blow out some of the dust.”

After stepping carefully on the slippery hot metal of the trailer’s roof I worked my way over to the evaporative cooler. Imagine a car that has been sitting in the Phoenix sun with all the windows rolled up, that was our home. I took off the first of the four side panels and the heat from inside the trailer pushed past my face. Each of the excelsior filled panels was full of mud. I unplugged the circulating pump.

“Honey, turn on the fan and then come around and hand me up the hose, OK?”

I climbed halfway down the ladder to reach the hose Rosalie handed up.

“OK, when I holler turn on the water. I’ll clean out the cooler pan and the excelsior pads.”

Using my thumb over the end of the hose to create a jet I rinsed out the cooler pan then each of the side panels and the pads.

“Watch out, I’m throwing the hose down.”

Mister pounced on the hose snaking on the ground and proudly carried the water spouting end to Rosalie in the process soaking her from the belly down.

“Mister, drop it,” she snapped. “Actually that feels pretty good.” She patted the dog’s head as she turned off the water faucet.

I put the cooler back together and Rosalie turned it on as I came down.

“That should help. I’ll help you clean up the mess inside.”

The people building what was to be the Paradise Animal Hospital were off for the weekend. I was starting my own practice. We had acquired the trailer for a hundred dollars in cash plus taking over the previous owner’s payments. We then moved it to the back of the lot that was the construction site for our hospital. I was spending most of my time going around and leaving business cards with everyone I could find letting people know I would take calls to treat horses or other farm type animals and could do simple things like vaccinations for their pets as house calls. The hospital building was due to be finished soon, or so the contractor kept telling me.

My Dad was an accountant. Two of his clients were retired veterinarians, Drs. Bramley and Shapiro. They would identify likely areas for a veterinary practice, purchase the land and build a clinic. They then leased the buildings to young veterinarians giving an option to purchase the practice after three years. It was a good financial arrangement and investment for them and a good deal, my Dad assured me, for someone like me without the financial resources to build a hospital and practice on my own.

“Animals are such agreeable friends – they ask no questions, they pass no criticism” – George Elliot

Mister rose to his feet and tip toed three steps to the metal door of our mobile home, the hair on his back bristling. Three sharp knocks announced a visitor. Rosalie struggled to her feet then leaned back to balance the watermelon-size protrusion that was to be our firstborn. Mister positioned himself between her and the door as she waddled towards it.

A hard-used woman was standing on the top of the three wood steps. She moved down two steps as Rosalie pushed the door open. She was dressed in dirty Levi cutoffs riding high on overly muscled thighs. A much washed and faded orange T-shirt did nothing to hide she wasn’t wearing a bra. The sweet/sour odor of unwashed armpits caused Rosalie to wrinkle her nose. The apparition’s face was leathery from too much sun, her hair a curly mop dyed jet black. Too thin lips were drawn into a sarcastic half smile, half sneer. She held her right hand behind her back.

“Yes,” Rosalie inquired?

“The Vet here?”

“No, I’m sorry. He’s out on calls.”

“You recognize me?”

“No, I’m sorry.”

“Thought you might, my picture’s been in both the Republic and Gazette. I was just acquitted for the murder of my girlfriend.”

“Oh.”

Mister leaned against Rosalie who took another step back.

“I’m a professional wrestler, Killer Amy, maybe you’ve heard of me?”

“No, I’m sorry, I haven’t.”

She brought her hand from behind her back, holding a chunk of skin covered with thick gray hair. Mister rumbled.

“I need to have the Vet tell me if this is human or not. I found it on my property. I don’t need more trouble. Will that dog attack?”

“My husband should be back soon. Can you come back in an hour or two?”

“Can’t I just leave it and he can call me when he gets back?  I’ll leave you my phone number if you’ve got pen and paper.”

The woman took a step up and extended the scalp, it smelled like meat left on the counter overnight by mistake. Mister rumbled louder and leaned against Rosalie forcing her back another step.

“I think it would be much better if you kept it in your possession until he can look at it.”

“Well, if you say so. You think he’ll be back in an hour?” She stepped back down as Mister growled again. “That dog’s pretty protective ain’t he?”

 

The mobile home was parked in back of our under-construction veterinary hospital in the summer of 1961. We expected to overcome the delays and get the hospital open within the next few months but meantime I was taking horse and other animal calls and even spaying a few dogs on our kitchen table, much to Rosalie’s consternation.

I was back and eating lunch when she returned. I went outside to examine the scalp.

“Looks like jackrabbit, I doubt it’s human but I can’t say for sure. If I were you I would take it to the police. They have labs that can identify human remains.”

We never found out if she took it to the police. We did see her name in the newspaper, the sports page, two weeks later. A story about a wrestling match.

***

Travels With Charlize, In Search of Living Alone is an Award-Winning Finalist in the “Spirituality: Memoir/Personal Journey” category of the 2016 Bookvana Awards”.

LOS ANGELES  –  Bookvana.com announced the winners and finalists of THE 2016 BOOKVANA AWARDS (BVA) on August 29, 2016. Over 70 winners and finalists were announced in over 40 categories. Awards were presented for titles published in 2014, 2015 and 2016.

The Bookvana Awards are a new specialty book awards honoring books that elevate society, celebrate the human spirit, and cultivate our inner lives.

Jeffrey Keen, President and CEO of i310 Media Group, said this year’s contest yielded hundreds of entries from authors and publishers around the world, which were then narrowed down to the final results.

If you encounter a really difficult problem and have used every inductive and deductive technique at your disposal to discover the answer to the problem but to no avail, the only recourse is to use the scientific method. The purpose of the scientific method is to make certain that Nature hasn’t made you think you know something that you don’t know. The scientific method starts with keeping a notebook. In the notebook you must write down everything you do to solve the problem. If you don’t write everything down you are more than likely to get confused and forget what you know and what you don’t know, what you have done and what you have yet to do. If you do not write everything down in your notebook you are almost guaranteed to become baffled.

The scientific method involves six steps that must be taken in order:

  • State the problem
  • Formulate hypotheses about the cause of the problem
  • Formulate experiments that test the hypotheses
  • Predict the results of the experiments
  • Observe the results of the experiments
  • Formulate conclusions based on the results of the experiments

Perhaps the most critical skill necessary to use the scientific method is to state the problem using no more than you absolutely know about it. For example; Why does the heart stop beating? This may sound stupid but the question is logical and correct. It presumes you know only that the heart was beating and then it stopped. An incorrect stating of the problem might be; Why does too much fat in the diet make the heart stop beating? This statement of the problem implies that you know that too much fat in the diet will make the heart stop beating.

If the problem statement is limited to only what you know, that the heart was beating then it stopped, you can formulate a number of different hypotheses that could be tested and many more that you probably cannot design experiments to test. One of the testable hypotheses might be that feeding too much fat to pigs for two years will cause the heart to stop before the pigs reach the end of their normal life span. However, this would be a poor hypothesis because it is likely that the type of fat or the ratio of different fats is what is important. The ART of the scientific method is stating a hypothesis that can be tested with the proper experiment or series of experiments. Since in this example we presumably can’t use humans to test the hypotheses we have to start by identifying a suitable animal model and do the experiments necessary to provide evidence that the model is suitable or cite the work of others who have done those experiments. Another potential problem is the actual cause of the lack of a heartbeat. Can too much of a specific type of fat, for example cholesterol, cause a blockage in one of the coronary arteries? How much cholesterol in the diet does it take to cause the blockage? Is there a threshold level for cholesterol circulating in the blood that will result in an infarction, a piece of the blockage that breaks away, is carried downstream and completely obstructs the artery? Does a coronary artery infarction always result in death? Is the location of the infarct in a particular coronary artery important?

What is called for is a very specific hypothesis that can be tested experimentally. For example: Will feeding a diet containing 25% animal origin cholesterol in an otherwise balanced diet for 16 weeks result in higher than normal blood cholesterol levels and the accumulation of fat deposits in the left anterior coronary artery of year old pigs but not in year old pigs fed exactly the same diet without the added animal origin cholesterol?

A major advantage of formulating a testable hypothesis is that the actual experiment can never be a failure. If feeding some appropriate number of pigs, the 25% animal origin cholesterol diet for 16 weeks does not result in the accumulation of fat deposits in that specific artery you have added to the body of knowledge, even with a negative result. You can still draw a valid conclusion from the experiment. Of course you might be able to repeat the same identical experiment in a different breed of pig and get a different result.

Now you are poised to do what all good scientists do. Formulate other hypotheses and design experiments to test them and those results will lead to other hypotheses. Most remarkably the end result of this exercise is that there is no end. As each hypothesis is tested more hypotheses come to mind and more experiments must be devised to test them. As hypotheses are tested and confirmed or eliminated their number increases exponentially. Parkinson’s law was an adage applied to the untrammeled growth of bureaucracies; “work expands so as to fill the time available for its completion”. Robert M. Pirsig in his bestselling book, Zen and The Art of Motorcycle Maintenance, has suggested a Parkinsonian-like law that says; “The number of rational hypotheses that can explain any given phenomenon is infinite.” Pirsig suggests that, if true, this law is “… a catastrophic logical disproof of the general validity of all scientific method”.

My own experience was that successfully crafted hypotheses and experiments resulted in ideas for more grant proposals, to secure more funds, to conduct more experiments, to learn more and more about less and less. I concluded there was no absolutely final answer to the ultimate problem because new questions to be answered kept arising. But the journey was so much fun!

First let’s talk about the thyroid gland. Dogs and cats have a divided thyroid gland located on either side of the trachea just below the larynx. Humans usually have just one gland more or less the shape of a butterfly. Some individual humans, dogs and cats can have ancillary thyroid tissue, usually small amounts, located along the trachea and airways. These are termed ectopic thyroid tissue and in some cases can maintain thyroid function if it is necessary to remove the thyroid gland surgically.

 

The thyroid gland is responsible for, or plays an important role in, many normal body functions. These include the regulation of body temperature, metabolism of fats and carbohydrates, weight control (both loss and gain), heart rate and cardiac output, normal function of the nervous system, growth and brain development in young animals, reproduction, muscle tone, and the condition of the skin and hair. So if the thyroid gland is not functioning normally we can expect changes in these functions and those changes result in symptoms or signs of the disease.

 

Thyroid disease is manifest as either low or absent thyroid activity (hypothyroidism) or excess thyroid activity (hyperthyroidism).

 

Signs of hypothyroidism include; weight gain, lethargy, generalized weakness, mental dullness, alopecia (loss of hair that can be generalized or in spots), excessive shedding, poor new hair growth, dry and/or dull hair coat, excessive scaling of the skin, recurring skin infections, and the inability to tolerate cold. In rare cases the animal may have seizures, a head tilt and infertility.

 

Signs of hyperthyroidism are, as one might expect, the opposite. There is a generalized increase in metabolism resulting in loss of weight despite an increased appetite. There is a general unkempt appearance and poor body condition. The animal may vomit and have diarrhea and frequently will be seen drinking water. This results in increased urine production. Some animals will have difficulty breathing and compensate with rapid shallow breathing. There is usually a rapid heart rate sometimes accompanied by so-called “gallop rhythm” a type of abnormal beat. The animals are usually hyperactive, and often the thyroid gland is enlarged.

 

Hypothyroidism is most common in middle-aged medium to large breeds of dogs. The condition is rare in cats. It is more commonly found in middle-aged dogs four to ten years of age. Anecdotal evidence seems to indicate that neutered males and females are at higher risk than intact animals. This condition is most commonly the result of inflammation of the thyroid gland or a decrease in active thyroid tissue from unknown cause(s). The condition can also occur as a result of treatment with the sulfa drug trimethoprim-sulfamethoxazole. In very rare cases iodine deficiency in dogs can result in hypothyroidism but commercially prepared dog and cat foods all contain adequate levels of iodine. The treatment for this condition is replacement therapy with levothyroxine or another type of thyroid replacement.

 

The diagnosis of hypothyroidism usually requires laboratory testing that includes a complete blood count, biochemistry profile, and urinalysis. Your veterinarian may be able to make an initial diagnosis based on the results of these tests, but it might be necessary to measure the levels of T3 and T4 and other endocrine lab tests. Your veterinarian may also recommend X-ray studies to check for other associated abnormalities.

 

Hyperthyroidism is the result of overproduction of thyroxin by the thyroid gland usually the result of a thyroid gland tumor. It can also be an aftermath of inappropriate overmedication for hypothyroidism. It is rare in dogs but can occur. It is most commonly diagnosed in older cats usually about thirteen years old or older. Less than five percent of cats with hyperthyroidism are under ten years of age. In addition to a thyroid tumor hyperthyroidism can also be the result of congenital disease, iodine deficiency or the result of inappropriate therapy. Sometimes it is impossible to identify the cause.

 

The diagnosis of hyperthyroidism is often initiated by palpation of an enlarge thyroid gland during a physical exam and documentation of clinical signs suggesting this disease. This will usually lead your veterinarian to measure a thyroid profile that includes T3, T4, Free T4 and TSH in the blood. If the T4 is higher than normal the diagnosis is confirmed however some early cases demonstrate T4 and the other hormone levels in the normal range. The performance of a T3 suppression test might be indicated and can produce a diagnosis. If the T3 suppression test results are still equivocal and if hyperthyroidism is still suspected further tests including nuclear isotope imaging may be necessary to arrive at a diagnosis.

 

There are three types of treatment for hyperthyroidism; life long oral anti-thyroid medications, surgical removal of affected thyroid glands and treatment with radioactive iodine. Tapazole (methimazole) is a specific anti-thyroid medication. This is a treatment that must be continued for the rest of the life of the animal unless surgical removal or radioactive iodine removal are indicated. Sometimes Tapazole treatment is used prior to surgery or radioactive iodine therapy to reduce thyroid hormone levels into the normal range to reduce the risk of surgery or radioactive isotope therapy. It is also indicated when the animal has congestive heart failure resulting from the hyperactive thyroid. Side effects from Tapazole include depression, vomiting, appetite loss and more seriously blood abnormalities. If surgical removal is the choice of therapy the surgeon must be very careful to avoid damage to the parathyroid glands. Removal or injury to these glands will result in significant problems.

 

As always if you suspect your animal has thyroid disease consult your veterinarian.

Here I am in Granada, Spain looking for all I can find about the life, times and places of a remarkable man Samuel ibn Nagrela who was given the honorific Ha Nagid, the Prince. Ibn Nagrela was a rabbi, the chief advisor to two Caliphs of Granada, General-in-Chief of the second Caliph’s armies, intellectual, scientist, scholar and was fluent in Aramaic, Arabic, Hebrew, Greek, Latin and Latino the early form of Spanish. He was also a poet who wrote classic poems in Arabic and Hebrew and some of them survived until today and have been translated into English. That’s how I first heard about this remarkable man, who I intend to be the hero of my next novel.

Ibn Nagrela helped design the first construction of what became, over centuries, the Alhambra. In his day the fortress and palace only occupied the tip of the hilltop promontory it now covers. I found this bit of information by purchasing two books from the bookstore on site since I couldn’t gain admission.

There was a long snaking line to purchase entrance tickets to get into the site. The line didn’t move because the site is limited to 350 people at any one time and the tickets are timed during the day. Because of Santa Semana, the week before Easter,  a national holiday, all tickets were sold out. I was counted among the clueless that didn’t know it was necessary to purchase tickets on-line in advance if you want to get in. It is currently sold out until April 5th  many days late and many dollars short, the story of my life.

I was able to discern some of the original fortress construction, those portions constructed with rocks and mortar only. The structure has been repaired, rebuilt, remodeled and newly constructed many times in the last 990 years since ibn Nagrela’s time.  The bricks on the right from the Moorish period, the bricks on the left are much later probably from the Christian period. The original stones were probably covered with some sort of plaster.Alhambra, original const. 2