From the very beginning:
Hospital above Betty
New approaches in veterinary epileptology
(An interview article which appeared in the Metropolitan Veterinary Medicine)
Introduction:
The surgery of dr. Gabriella Kiss has opened in May 1990 under her direction, as soon as this was possible after the fall of the communist regime. The „FAVORIT” Veterinary Service as one of the first private veterinary practices in Újpest. Gabi has been working with her husband, Péter Kolarics in a perfect marital division of labour for the past 18 years. The wife carries out the veterinary work, while her husband acts as the practice manager and carries out additional duties: marketing, drug supply, transport of patients to and from the surgery, etc. A lot of people know that Gabriella is nearly obsessively dedicated to a specific medical discipline, the assessment and management of epilepsy. However, her methods and results are less known.
I understand that you qualified in 1986 at the Veterinary University in Budapest. How did your life progress from there?
After my grammar school Matriculation I obtained a research laboratory technician post in the Institute of Pharmacology in 1976. I worked on the study of newly developed anti-hypertensive drugs under the direction of doctors and pharmacologists in the Cardiovascular Research group.
In September 1977 I entered a 2-year course in the High School of Health and Safety at Work. My practical training in laboratory workers’ health protection was carried out in various hospitals in Budapest. I found both the theoretical and practical training in the school of remarkably high standard. All subjects (anatomy, medicine, microbiology, immunology, neurology, laboratory diagnostics etc) were taught by medical experts of the particular field.
It was not the most leisurely 2 years of my life, I worked during the day and attended the school during the evenings. Having passed my final examinations with distinction in 1969 and obtained my Summa cum Laude Diploma, I decided to become a veterinarian.
The 5 years spent at the Institute remains filled with fond memories for me, not only because it was spent in a wonderful company, but also because my teachers gave me a taste of learning. My unquenchable thirst for knowledge dates from this period, as well as my growing fondness of dogs. One of our projects was the study of antihypertensive drugs in renal hypertensive dogs.
In the 1970s there were no specific legal animal welfare controls, and consequently in the Animal House of the Institute unlimited numbers of stray dogs were at our disposal. The so-called Grollman operation was necessary to perform on dogs selected for the study. This comparatively painless procedure resulted in renal hypertension within 4 weeks through the disruption of the renin-angiotensin system. I was chosen for the selection of these dogs. The required selection criteria were female sex, weight under 15 Kg, high intelligence, obedient disposition, keen learning ability, total lack of aggression, and potenial for mutual trust and love. These required the application of tests for which I had to dedicate myself to the study of dog psychology for years to come.
At this period I came across Bözsi (Hungarian for Betty) and we became inseparable. Of course one day she also had to undergo the Grollman procedure. I performed all such operations speedily and efficiently. In this case, however, her anaesthesia became lighter, and she moved. I fainted! (This never happened to me again.) At this point I have realised just how much bond had developed between the dog and myself.
As expected, Bözsi became hypertonic in 4 weeks time and fell under my direct supervision. According to literature dogs subjected to the Grollman procedure, with unilateral nephrectomy die after one year due to uraemia. Bözsi did not seem to have read these publications and thrived after one year, continuing her participation within the trial. (Her less fortunate mates died by then without exception).
However, there came a dreadful day, when the fate of Bözsi became sealed. She got out of her cage at night and killed about 500 experimental mice and rats. Some rats had very expensive electrodes implanted in their skull for anti-epileptic drug studies (appx. 150 DM each!). The directive came to put Betty asleep!
With the help of my colleague Kati Jacsics we smuggled Bözsi out the same night. I took her home and spend 4 happy years with her until the signs of uraemia appeared. Kati became a laboratory technichian of the Faculty of Internal Medicine. We often recall that fateful night. I am eternally grateful to her, as she was risking her job helping me, but she knew what the dog meant to me.
It was when I was admitted to the Veterinary University, that the signs of the terminal uraemia appeared. Dr Laci Papp kept Bözsi alive as long as he could until the time of final decision had to come. Bözsi fell asleep in my arms forever. 16 years after her death, my surgery was built above her grave and by chance my computer is exactly above her. Every morning I come to the office, saying “Hello Betty, I’m back!”.
I graduated „summa cum laude”. Having received my diploma I spent a brief period at the Department of Virology of
the National Institute of Animal Health where I became acquainted with the beauty of rabies diagnosis – I mean this literary, as the virus-infected neurons in the sections of brain samples showed a beautiful colour-composition with immunofluoresce in the darkened microscopic field. After this I returned to work in the Cardiovascular Research Group where I was employed before entering the University, this time as a fully qualified veterinarian. In 1988, my son was born, Andrew. In May 1990 my husband opened the surgery. I will not tell the difficulties of the past 18 years, but by now a hospital complex consisting of a waiting room, office, consulting room, operating room, and an EEG lab is ready. In the meantime, my daughter Andrea was born in 1993. It was difficult to look after the two children as the surgery, conferences, participation in postgraduate training, and continuous studies in human and veterinary epileptology left me little time for the family.
I understand that you have been dealing deal with canine epileptology for many years. How did you decide to study and specialise in this difficult discipline?
Since the beginning, surprisingly many epileptic dogs were brought to my surgery, and I was treating them according
to the guidelines prevailing during the 1980s in Hungary and internationally. In cases of acute crisis I used injections of diazepam and I prescribed phenobarbital. For long term therapy I prescribed pirimidone, bromates or phenytoin. I have realised that neither parenteral treatment, nor the long term therapy brought satisfactory results.
I noticed also that in many cases these preparations may paradoxically provoke rather than control the attacks. At that time did not know the answer to these questions, but now I do, so for reasons clear to me, I do not use these products today.
The “Nil Nocere” principle still manages to guide and pervade my work, not only in ambulatory consultations, but also in the long term psychiatric care of patients with epilepsy. In the 1970s and 1980s the neurological Directive included the use of i/v Pentobarbital in grand-mal type seizures. To be frank, I have never used this drug for epilepsy. In the cardiovascular research work, anaesthesia was carried out on dogs with pentobarbital-chloralhydrat mixture for the Grollman unilateral nephrectomy, according to its primitive 1980-period anaesthesia protocoll. The spectacles of the pre- and post narcotic excitement period lasting for several minutes were distressing. Considering that the grand mal and the subsequent hyperexcitement are causing enough problems for the dog, I did not wish to aggravate their serious physiological consequences by using a narcotic of such narrow therapeutic index. Naturally its anticonvulsive action is not disputed, its has been useful both in human and in animal neuro-intensive care, but not without the direct availability of ECG, EEG and artificial respirator at hand.
I became determined to solve the riddles of the aethiology, symptomatology and intensive, lasting therapy of canine epilepsy. I was monitoring with meticulous records dogs put on continuous therapy by colleagues, as to symptoms, medication, and response to therapy. I particularly plotted the types of anti-epileptic medication given to cases of increasingly frequent attacks, or grand mal, and the short and long term responses to these. In the course of time it became clear to me, that neither the clinical diagnosis nor the differential diagnosis or the therapy of epilepsy showed consistency in general practice in spite of performing everything „lege artis”.
There followed the years of systematic gathering of experience, learning and consulting. This process continues for me to the present day both in human and in animal epileptology and neuropsyschiatry. I constantly question myself, whether I know in fact the full spectrum of symptomatology of canine epilepsy. It has been well known from literature and experience for 60 years in human epileptology, that genuine epileptic seizures may be preceded as well as followed by neuropsychiatric symptoms. In what format manifest themselves in animals these well documented and diagnosable human syndromes? How can one distinguish these from behaviour changes arising from fear or pain? Another question was the choice of anti-epileptics, why are they restricted in veterinary medicine to phenobartital, bromides, pirimidon and phenytoin. Having worked in pharmacology, I knew that these drugs had to go through rigorous efficacy and toxicological testing procedures in canine epileptic models before submitted to preclinical testing for human use. It is therefore logical to use any human anti-epileptic drug for long term use in dogs also.
It has become evident from my human studies that for the diagnosis and exclusion of epilepsy an EEG examination is indispensable. Having encountered in my daily work numerous cases of grand mal, need I remain within veterinary guidelines or could I employ the protocols of human long-term intensive therapy? Why do I come across in my daily work stories of „miraculous cures „ from animal owners? I quote the usual statement: -„My dog had a single fit, and the vet cured him with a single injection” Or: „when the attack comes, all I have to do is to push down a tablet on the throat of my dog, and it is over”. It took a few years for being able to answer these questions for myself, when I was able to distinguish true epilepsy from pseudo-fits, from symptoms of „functional” epilepsy, the occasional attacks and psychogenic attacks. These manifest in an incredible array of symptoms both in man and in animals alike. It was an American neurologist, Penfield, known as the „Father of Neuropsychiatry”, who described the rich array of symptoms of human epilepsy most succintly: : „Epilepsy is the grand teacher of neurology”.
Were there any professional specialists who helped you to find your way in the labyrinth of epileptology?
At first I contacted dr. Professor Dénes Karasszon, who for 20 years had studied epilepsy in several animal species and I have developed a professional relationship with him. He welcomed my collaboration in the Training School for Guide Dogs for the Blind, where the EEG screening of dogs for training was conducted. My next contact was Dr Gyula Kómár jr. who trained me in EEG recording techniques. Both remained very good professional relationships to the present day. Dr Kómár very thoroughly edited my professional publications, the first of which appeared in „Kisállat Orvoslás” ten years after our first contact. I am grateful to both of them and I will be always keen to exchange professional experiences with them. In the meantime I constantly study human epileptology in contact with many psychiatrist, psychologist, neurologist and epileptologists. while visiting neurological hospital wards. I am grateful to numerous human professionals, who have given me for nearly two decades the opportunity for consultation in complicated cases in relation to EEG findings, treatment, or other problems.
I began to apply their published human epileptological methodology while still following the veterinary literature at home and from abroad also on this subject. I became familiar with the work of the International League against Epilepsy (NEL). It was founded after the 2nd World War and managed to establish an international nomenclature system, which is accepted and followed by all medical psychiatrists, epileptologists and neurologists in the world. It systematizes epileptic symptoms and syndromes in relation to aetiology, EEG results, diagnostic methods, and suggested therapy. The veterinary profession is aware of this system, both in Hungary and abroad, but judging from publications it is not sufficiently applied, to be helpful to veterinary practice. I consistently apply and follow new developments in this human nomenclature system in my everyday epileptological practice. Nevertheless, I still have not managed to fit epileptic syndromes, symptoms and EEG patterns of dogs and cats into this system.
One needs to be aware of the mechanisms of action of the various anti-epileptic drugs and their different efficacy in various types of epilepsy. Some act on focal, others on generalised, yet others on both types of epilepsy. Great care must be taken in their selection for focal or generalised cases and in the latter case, whether it is primary or secondary generalisation. Other determining factors are the origin of epilepsy whether it is congenital or acquired, the brain lobe where the seizures originate, whether they start during sleep or awake, and the age of the animal when symptoms first appeared. After 20 years of clinical study I am able to make an initial assessment from taking history whether I am dealing with a genuine case of epilepsy, or individual, phychogenic seizures, panic attacks, or frequently observed non-convulsive syndromes arising from the temporal lobe. Obviously this needs to be confirmed by clinical examinations and EEG. During the past 18 years I dealt with nearly five thousand canine and feline epilepsy cases and I store at present 400 EEG tracing records taken by myself. Each year I have 250-400 epilepsy cases under my constant care, which takes the lion’s share of my clinical veterinary activities.
How do you carry out the investigation and therapy of an epileptic case?
When a new patient calls on the telephone, I am usually able to judge the type of epilepsy and its origin in the brain, by listening to the initial descriptions of the owner. Face to face history taking lasts for 1 to 3 hours, followed by a detailed medical and neurological examination, EEG recording and blood sample collection. From the analysis of EEG-tracings I can usually deduct the type of epilepsy, the probability of it being congenital or acquired, the site and intensity of the of the causative mechanism in the brain and the nature of the organic lesion or physiological dysfunction as its cause. This is followed by a discussion with the owner about the need for any advisable imaging procedure (CT, MRI, PET, SPECT). The whole investigation usually takes around 4-6 hours. Therefore, I can only deal with 1-2 new patients a week. I have to plan advice and work within a wide range of financial limitations of owners. I take EEG recordings under acetylpromazine sedation, not under narcosis. Ideally recordings should be made in an alert, but relaxed. state, both with open and with closed eyes. Acetylpromazine satisfies these criteria in all respects, as it confers passivity to the patient as well as optimal muscle relaxation for the recording session.
You have listed requirements for several additional tests which are carried out by colleagues in differing disciplines. How do I go about consultation with them on a case?
During the years an extremely well-run team has been established, admittedly only within about 200 km radius. Excellent working relations have been developed with veterinary colleagues at the Department of Oncoradiology of the Agricultural University of Kaposvár, in particular with Dr. Rita Garamvölgyi and Henrik Örs Petneházy. They prepared MR images for my patients for nearly 10 years now (results are under publication). Dr.Mihály Albert veterinary pathologist provides me with histopathological backup for more than 15 years now. A large collection of brain sections is at our disposal from epileptic cases for planned publications. Dr. Béla Lakatos is also to be mentioned, with whom we study for about the past 15 years on our patient material the pathognomy and serology of FHV (Feline Herpes Virus) caused encephalitis in cats, and the correlations between Lyme’s disease and epilepsy in dogs. The surgical backup work is carried out by the veterinary clinic led by Dr. Lászlo Zsoldos (PRIMA-VET Animal Hospital Ltd.). The laboratory tests are made by HAEMO-VET Laboratory led by Dr Attila Szilágyi. The ultrasonic backup work is provided by Dr. Tamás Vrabély and Dr. Péter Csendes.
I understand that apart from you, not many veterinarians specialise in such depth in canine epilepsy. What do you think is the explanation for this?
Epileptology is the most difficult area of medicine. Constant and continuously updated knowledge is needed in the neurological and internal medicinal differential diagnosis and in the rich, varied manifestations of pain. Extensive knowledge and experience in animal psychology and ethology is required to differentiate manifestations of personality problems, aggressivity, pseudo-seizures and deficiencies in training. One has to be conversant with the interpretation of EEG tracings and of the results of the indispensable initial haematological and biochemical laboratory tests, which are also essential for the exclusion of Lyme disease. Imaging procedures (CT or MR), may be also required for the elucidation of organic pathological processes as a possible cause. These will be dealt with in more detail later. Just recently it gave me great pleasure to make contact with a colleague in Debrecen who initiated PET examinations for the diagnosis of canine epilepsy, with whom I look forward to a similarly fruitful collaboration as with the aforementioned colleagues.
Unfortunately, experience has shown that veterinarians are not aware of the laws and true nature of epilepsy. The seizure is not a disease, but a clinical symptom. The disease is in the brain, manifesting in the symptoms. So if if we prescribe an anti-epileptic drug, we only treat the symptom, not the disease. They are called anticonvulsants, even if we treat with them non-convulsant attacks.
In order to eliminate the chaos prevailing in the basic concepts of symptomatology and therapeutics of epilepsy, I decided to start private resfresher courses in veterinary epileptology with small numbers of participating veterinarians from November 2008 with the backing of the Veterinary Chamber’s Attendance Point System. Judging from the flood of telephone calls during recent years arriving at any time of the day and night from colleagues asking my advice for the solution of an acute crisis or for the construction of a long term therapeutical strategy, I expect a good turnout! I expect to hire the conference room of PRIMA-VET Animal Hospital Plc (XI district Rákos-út 60) and I plan to enrich my lectures with numerous case histories.
What are your long-term plans?
A great deal. I wish to pursue the above described teaching project, and to publish continuously for the profession. I have been approached for writing a book on epileptology partly for the profession, partly for animal keeping lay readers. In July 2007 together with my friend Katalin Takács we organised a lecture course with the title „Free University for Animal Keepers” under the egis of the Animal Protection League of Biatorbágy. For this series of six lectures twelve veterinarians, all specialists in their own field gave presentations at ELTE (Eötvös Lóránd University of Sciences, Budapest).
I also gave my first presentation in my life there. I was determined to impart my 17 years of epileptological study and experiences to those interested. While the planned 45 minutes lecture turned out to become a 4,5 hour session, Katalin asked the audience every 45 minutes if they desire a break, but each time „no”was the unanimous answer. Since my University years I was involved in animal welfare work. Few years ago with my Husband we organised an organ recital evening, donating all its revenue to the Noah Animal Rescue Centre. At present I am on the Panel of Directors of the „Animal and Man Animal Protection League”. I also act as their contracted veterinarian but I look after the animals of the „Futrinka Leage and Mini-Animal Rescue” too. I would like to establish a „Club for Epileptic Dogs” for their owners to exchange their experiences with each other and to approach me with their problems on club-afternoons. During the past 10 years I began to study aggression in dogs and cats and its appropriate treatment, approaching it not only from training, but also from neuropathological angles. Apart from these, I also deal with behaviour problems, clinical manifestations of panic or anxiety, keeping in mind both human and veterinary approaches, principles and experiences, like in the case of epilepsy.
Thank you for the interview, I wish you further success in your work. János Perényi