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STRESS STATUS (MILD, MODERATE AND SEVERE) VIZ`-A-VIZ` LEADING RISK FACTORS AMONG CLIENT-OWNED DOMESTICATED CATS (Felissilvestriscatus) AFFECTED WITH THE 'PANDORA' SYNDROME: A RETROSPECTIVE STUDY.

Byline: A. Naureen, M. S. Khan, M. A. Khan, A. Maqbool, J. A. Khan and M. Avais

ABSTRACT

The present study was conducted to analyze association b/w depression status (mild, moderate and severe) and different risk factors (n=14) leading to the 'Pandora' syndrome among cats. To this end, risk factors were divided into 2 groups on the basis of demography(n=5) and general history (n=9). No particular breed predilection was found, however, majority (n=300) of cats attended were Siamese. Male to female ratio was found to be 2.5: 1. Depression status was found to be highly associated (P-value = 0.000) with winter season, and all but one (stranguria; P-value = 0.774) clinical signs.Remaining risk factors were not inclose association with that of depression. This study debunked previous notions like strong association of commercial diets and canned foods with this syndrome, in Pakistan majority fed with home-cooked food. Moreover, cases in Siamese breed were larger than Persian breed. The proportional morbidity rate (PMR) observed was estimated to be 8.7%.

The PMR values show more about interests of clinicians rather than the incidence of disease in that population.

Keywords: Depression status, risk factors, 'Pandora' syndrome, client-owned domesticated cats

INTRODUCTION

The 'Pandora' syndrome (Buffington 2011a) has been known as an important leading veterinary problem till antiquity (Kirk 1925), previously designated with different names viz., Feline Interstitial Cystitis (FIC), Feline Urologic Syndrome (FUS), Feline Lower Urinary Tract (FLUT) etc. (Buffington et al. 1997 a, b).It has been classified into obstructive and non-obstructive (Walker 2009). Specific clinical signs seen in approx. 1.5% of the cases (Lund et al. 1999) attended. Previously, incidence and proportional morbidity rate (PMR)has been reported many times from developed states (Osborne et al. 2000), however not reported from developing country like Pakistan till yet.

Many risk factors viz., age, breed, sex, neutering, diets, feeding frequency, excessive weight, decreased water consumption, season, indoor life style, etc. have been identified (Willeberg 1981), however, depression is one of the important factors concurrently triggering other factors (Osborne et al. 1984) in the form of predictable biochemical and clinical abnormalities viz., hypercalcemia, hyperphosphatemia, metabolic acidosis etc. Public system in Pakistan is rigid compared to those of developed countries especially w. r. t. human-animal bond and majority of domesticated cats taking diet based on table-scraps or home cooked food. This is the first ever report from Pakistan regarding the issue of risk factors and PMR values due to poor cognizance of practicing veterinarians.

MATERIALS AND METHODS

Present study was undertaken to evaluate association between depression status (viz., mild, moderate and severe) and important risk factors (n=14) directing to the 'Pandora' syndrome along with the proportional morbidity rate (PMR) among502 client-owned domesticated felines presenting within a period of two years (2008-2010) in different clinics (Veterinary Medical Teaching Hospitals as well as private clinics) at3 cities (Lahore, Faisalabad and Islamabad)of Pakistan.

Study animals and settings: Inclusion criterion was based on important signs linked to this syndrome among felines irrespective of sex, age, breed, etc., as per Buffington (1994). Complete historical along with depression status was recorded on a modified predesigned proforma by taking complete structured interview of owner as per Osborne et al. (1984).

Categorization of depression status: Depression status studied was categorized on the basis of depression severity status as: mild (anxiety and anorexia), moderate (aggression towards owner as well as other cats), and severe (moribund), in order to make measurement in improved form (authors' own categorization for analysis) based on depression severity status.

Risk factors and control measures: A total of 14 important risk factors viz., gender, breed, age, weight, season, cohort, litter box usage, litter box type, type of food, drinking water, vaccination status, neutering status, housing type, and recurrence rate, were included in present study and compared with depression status among feline patients. Allabove mentioned risk factors (n=14) were further distributed into 2 groups as: Demographic distribution (n=5; gender, breed, age, weight, season) shown in Table (1), and General medical history (n=9; cohort, litter box usage, litter box type, type of food, drinking water, vaccination status, neutering status, housing type, recurrence rate) shown in Table (2).

Diagnosis: Primary diagnostics made on basis of complete history, gross clinical signs, complete physical examination and urinalysis profiling, and ancillary diagnostics were compiled based on sero-biochemical profiling, radiography, hyperkalemia and ultrasonography. Diagnostic tests were performed and included in data depending on its availability.

Proportional morbidity rate (PMR): It is proportional number of cases of any disease calculated out of total number of cases attended (particular animal species) in practice or private clinic as per Willeberg (1984).

Statistical analysis: All data were analyzed through SPSS version 16. Chi-square test and Fisher Exact test, applied to see the association in qualitative attribute. P-value less than 0.05 were taken as significant. The Proportional morbidity rate(PMR) is calculated by applying formula as the ratio of cases divided by total number of cases attended in practice, private clinic, or clinic (Willeberg 1984).

RESULTS

Total of 502 client-owned domesticated felines (n=502) spontaneously affected with the 'Pandora' syndrome (PS) were included in study(data collected from 2008 to 2010;from different cities viz., Lahore, Faisalabad and Islamabad of Pakistan). Final data analysis was compiled and presented at the Department of Clinical Medicine and Surgery, University of Veterinary and Animal Sciences, Lahore, Pakistan. Out of total feline patients studied (n = 502), 30, 357, and 97 had mild, moderate and severe depression, respectively. According to first table shown, as such no significant association (P-value = 0.715; P-value = 0.224) was found regarding average weight and age of feline patients. However, body weight found to be significantly associated factor (P-value=0.000) in Persian breed as compared to other breeds. No particular breed predilection was found, however majority (n=300) of cats attended were Siamese.

Male to female ratio was found to be 2.5: 1 in this study and depression status was statistically same (P-value = 0.469) in all breeds, however it was highly significant (P-value = 0.000) in winters followed by summer, autumn, and spring. According to table (2), out of total (n = 502) cats attended majority (n = 427) were exclusively indoor and depression status was found insignificant (P-value = 0.760) related to that of housing-type, recurrence rate (P-value = 0.847), neutering status (P-value = 0.450), drinking water (P-value = 0.574), type of food (P-value = 0.623), vaccination status (P-value = 0.921), cohorts (P-value = 0.269), and the type of litter box (P-value = 0.246). Contrarily, it showed strong association with the litter box usage (P-value = 0.000).On the whole depression was found strongly associated (P-value = 0.000) with all forms of clinical observations except that of stranguria (P-value = 0.774; not mentioned in data).

Table 1. Depression status (mild, moderate and severe) viz'-a-viz' demographic distribution of risk factors related to spontaneous Pandora syndrome among client-owned domesticated cats

###Demographic distribution of risk###Depression (n = 502)

###Total

###factors###Mild###Moderate###Severe###p-value

###(n = 502)

###(n = 5)###(n=30)###(n=375)###(n=97)

1. Gen###Male###22###272###76###370

###0.294

###der###Female###28###111###20###132

###Long hair domestic###3###35###5###43

###Non-Descript###6###55###14###75

2. Breed###Persian###6###48###18###72###0.496

###Small hair domestic###0###8###4###12

###Siamese###15###229###56###300

###Autumn###0###39###11###50

###Spring###1###37###6###44

3. Season###0.000

###Summer###9###90###45###144

###Winter###20###209###35###264

4. Weight###Overall###30###375###97###502###0.715

5. Age###Overall###28###391###83###502###0.224

Table 2. Depression status (mild, moderate and severe) viz'-a-viz' risk factors on the basis of general medical history related to spontaneous Pandora syndrome among client-owned domesticated cats

Distribution of risk factors (n = 9)###Depression (n = 502)

###Total

###on the basis of general medical###Mild###Moderate###Severe###p-value

###(n = 502)

###history###(n=30)###(n=375)###(n=97)

###Exclusively Indoor###26###320###81###427

###Exclusively

###0###4###0###4

1. Housing type###Outdoor###0.760

###In-door + Out-

###4###51###16###71

###door

2. Recurrence###No###18###238###59###315

###0.847

###rate###Yes###12###137###38###187

###No###19###273###64###356

3. Cohort###0.269

###Yes###11###102###33###146

4. Litter box###No###17###172###47###236

###0.496

###usage###Yes###13###203###50###266

###Commercial###5###60###16###30

5. Litter box

###Home made###9###145###170###375###0.447

###type

###No###16###30###46###97

###Commercial diet###2###11###5###18

###Extensively Home

###22###299###78###399

6. Type of food###cooked###0.623

###Home cooked +

###6###65###14###85

###Commercial diet

7. Drinking###Fixed###8###71###20###99

###0.574

###water###Restricted###22###304###77###403

8. Vaccination###No###23###275###71###369

###0.921

###status###Yes###7###100###26###133

###Castrated###7###128###32###167

9. Neutering

###Nil###19###213###60###292###0.450

###status

###Spayed###4###34###5###43

DISCUSSION

Previously, at different times and ages many scientists reported presence of disease worldwide (Engle 1977; Chew et al. 1986; Buffington 1997 a, b). An increase in incidence reported to be attributed to high frequency of indoor keeping of cats (Patronek et al. 1996) as compared to outdoor cats (Willeberg 1984). The present study shows a total of 8.7% PMR among feline patients attended, actually indicates the interests of clinicians rather than actual incidence of disease regarding population under study because denominator is highly selected and undetermined fraction of the population (Willeberg 1984). This value (PMR)is mostly misinterpreted with that of incidence of disease in the population at risk. Contrarily, true incidence is not too easy to estimate however, retrospective study is reported with preceding 12 months period (Willeberg 1984).

The core segment of our study was based on association between depression status and important risk factors leading the 'Pandora' syndrome (from year 2008-2010). All (n=502) feline patients attended in the present study showed depression (30 mild, 357 moderate and 97 with severe depression) may be attributed to solitary nature of this species and prefer to live either alone or in pair instead of any social group (Gittleman 1989). To this end, cats are more prone to the sensitivity regarding their surroundings as compared to other domestic animals. The element of depression may increase in cats with the increase of threat either related to any conflict (Moesta and Crowell-Davis 2011) or fetal developmental stress response system (Westropp et al. 2006; Buffington 2009) as also previously studied (Cadet et al. 1986; Braastad et al. 1998) in different species regarding maternal stressors.

In cats this syndrome is found similar to that in humans (Buffington 2004).Affected cats (36.4%) also reported with high aggression towards owner and other cats (Bamberger and Houpt 2006). One of the tentative diagnostic criteria may include investigation of factors activating central Stress Response System (SRS) (Westropp et al. 2006; Stella et al. 2011). The activation of SRS may lead to the rushing of environmental factors affecting the sensory neurons (Birder et al. 2011) in the form of loop by central as well as peripheral neural activity (Fields 2004). Moreover, this activation (SRS) may result in different forms of sickness behaviors(SB) (Carlstead et al.1993; Carlstead and Shepherdson 2000).

Depression status is attributed to external (environmental) as well as internal (visceral) stressors (Unusual external environmental events triggering hypothalamic SRS) (McEwen 2008; McEwen and Gianaros2010) leading to changes in moods (Miller et al. 2009) and SB viz., vomiting, diarrhea, anorexia, decreased water intake, decreased social interactions, etc (Dantzer et al. 2008) and are directly proportional to increase in urination outside the litter box (Stella et al. 2011) rather than disease status.

According to data analyzed in first half (Table 1), average weight/age were insignificant factors which contradict the data on mice and cats as per previous studies (Godbout et al. 2008; Walker 2009) however, data was inline regarding age as per Stella et al.(2011).In the present study, weight w.r.t. species was significantly higher (P-value=0.000) in Persian breed as per Defauw et al. (2011) as compared to previous study (Willeberge and Priester 1976) that showed trend of breed predilection. Particular breed predilection is supposed to be linked to genetic and epigenetic factors (Buffington 2011b) and found more among Persian breed (Walker 2009). Male to female ratio was 2.5: 1 in this study, much higher in male than female possibly due to trend of keeping male cats as pet to avoid litter problem in Pakistan. However, previously, no particular sex predilection was found (Walker 2009).

A case control study showed that a high increase in incidence rate increased during winter may be attributed to less activity and excessive body weight (including indoor litter pans) as per Jones et al. (1997) which is similar to our results.

According to second half of data (Table 2), majority (n=427) of cats reported were exclusively indoor as per Buffington (2011b). To cope with depression linked to indoor confinement, a new concept was introduced as the implementation of 'Triple Es' (Effective environmental enrichment) as per Herron and Buffington (2010), and thus helps in providing behaviorally enriched environment free of any kind of stressors.

To this end, one must organize environment into 5 basic 'systems' viz., physical resource (proper space alone or among cohorts), nutritional (free access to food and water), elimination (located in quiet area), behavioral (provided with the pillows or cat-safe plants for expression of natural investigatory behaviors like scratching and chewing) and social (close friendly relationship should be developed among cohorts as well as with humans in contact with the feline pet), to identify stressors for enhancement of improved health and behavior of feline pets under domestic housing (Barry and Crowell-Davis 1999; Buffington 2002; Van De Weerd et al. 2003; Overall et al. 2005; Herron and Buffington 2012). Hiding places within homes may help in improvement of feline health (Kry and Cassey 2007).

Recurrence rate was found strongly associated with stress triggered either by genetics or by environment (Buffington 2009) irrespective of present study result and it can be overcome by indoor enrichment. Likewise, no association was found between food-type and depression in the present study. Under enriched environment, contents of food play no significant role regarding this syndrome (Westropp et al. 2006; Stella 2011). In contrast, Walker (2009) found this syndrome in increased form among cats mainly fed on dry diets. No significant relation between cohorts and neutering status w.r.t. depression was found similar with previous study as per Fennell (1974). Some workersrelate cohorts directly towards this syndrome due to high increase in conflicts for life resources that can be handled by neutering all cats (Buffington 2011b) kept under one roof.

In this study, depression was directly associated with the litter box usage that will help in reducing this disease if placed in noise-free area (Buffington 2011b) along with its specific type (open/covered; Herron 2010) and number (one for each cat; Walker 2009).According to literature cited, diet and drinking water are main factors leading to this syndrome (Jackson and Tovey 1977; Willeberg 1981;Defauw et al. 2011). Here in Pakistan most of the cats were on home-cooked diet (table scrap) than commercial food contrary to the trend seen in developed states (Walker 2009) due to presence of more improved human-animal bond. On the whole depression was found strongly associated (P-value=0.000) with all forms of clinical observations as previously studied (Osbrone et al. 1984; Kirk et al.1995), however, depression was found to be insignificantly related to stranguria (P-value = 0.774).

In conclusion, depression is the main factor leading to PS among domesticated cats in Pakistan not reported thus far specifically. This study negates previous notions 'strong association of commercial diets and canned foods' with PS, in Pakistan majority affected felines fed with home-cooked (table scrap) food.

Moreover, cases in Siamese breed are larger than Persian breed. It has been strongly associated with indoor housing management. Additional work is still needed to further validate results and explore untouched areas of epidemiology. According to Buffington (2011b) repeat check-ins at 3-6 week intervals are needed, however, in developing country like Pakistan most of the owners let their animals to come to see vet in case of severe disease issue. Moreover, owners should be made aware of concept of 'Triple Es' for better environmental enrichment to improve the health status of domesticated cats (Anonymous, 2010) and thus owners' education is imperative for a positive response.

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