Urolithiasis is a common complaint in dogs and cats presented to veterinary emergency, primary care, and specialty services. Although uroliths can appear anywhere along the urinary tract, the bladder is the most common location.

Uroliths can be identified incidentally because of a workup of urinary signs, or a life-threatening urinary obstruction. Prompt diagnosis and intervention are important to maximize the likelihood of a successful outcome. 

Many patients with urolithiasis present for lower urinary tract signs such as hematuria, stranguria, and pollakiuria. In cases of a urinary obstruction, they may present with a history of straining to urinate without production, vomiting, and anorexia. Although diagnostic imaging is the ideal method of diagnosis for urolithiasis, other diagnostics should not be overlooked.

Uroliths are broadly categorized as radiolucent or radiopaque, although in clinical practice there is more of a spectrum than a binary classification. Historically, urate crystals and cystine calculi are classified as radiolucent, and other stone types (eg, calcium oxalate, struvite, silica, and brushite) are classified as radiopaque.

Following confirmation of the presence of cystic calculi, it is essential to perform additional diagnostics to identify any concurrent conditions that may contribute to stone formation and recurrence. Such additional diagnostics include a biochemistry panel to evaluate for hypercalcemia, a known risk factor for calcium oxalate formation, or changes in synthetic liver enzymes that may signal liver pathology or presence of a portosystemic shunt that can drive urate stone formation. A urinalysis should also be performed to screen for bacteriuria or pyuria as well as to measure pH in the event that alkalinization or acidification of the urine is necessary following a determination of stone type to minimize the chances of recurrence.

Depending on the size and number of calculi, as well as the size and species of the patient, various treatment options may be available such as voiding urohydropulsion, cystoscopic retrieval, or surgical options such as a cystotomy or percutaneous cystolithotomy. It is important to note that the only stone type amenable to dissolution is struvite.

A caudal celiotomy is performed, and the bladder is isolated and exteriorized. A stay suture is placed in the bladder apex using 3-0 or 4-0 monofilament, as appropriate. A stab incision is made into the ventral aspect of the bladder, and the incision extended with Metzenbaum scissors. A bladder spoon may be used to remove the calculi in the bladder. A red rubber catheter of appropriate size should be passed retrograde and used to flush any remnant urethral calculi into the bladder for removal. Surgery should not be considered complete until all residual calculi have been removed via the cystotomy. A small sample of bladder mucosa should be obtained and submitted for culture. Closure of the bladder may proceed in a simple interrupted or continuous pattern, using a 3-0 or 4-0 monofilament suture. The bladder heals very quickly, reaching normal tissue strength in 14 to 21 days, so a quickly absorbable monofilament such as Monocryl or Biosyn is recommended for closure. A leak test is at the discretion of the surgeon but is strongly recommended for novice surgeons. This may be done either via the urinary catheter or by injecting sterile saline directly into the bladder with a syringe and needle.

 Uroliths at the trigone of the bladder as observed using endoscopy.

This is a newer technique used to remove cystic calculi as well as obtain bladder biopsies in a minimally invasive fashion. This technique requires some additional instrumentation such as an Alexis wound retractor, a pediatric cystoscope or flexible ureteroscope, laparoscopic ports, and ideally a stone extraction basket. The advantages of this technique include fewer long-term stone recurrences, a lower likelihood of incomplete removal of uroliths, and shorter hospitalization times in addition to the traditional advantages of minimally invasive surgery, such as decreased pain and a quicker recovery.

For this technique, an approximately 2-cm ventral midline incision is made following placement of a large urinary catheter, and an Alexis wound retractor is placed to provide radial retraction. A stay suture is placed in the apex of the bladder, and then 2 additional stay sutures are placed, forming a triangle. A stab incision is made in the center of the triangle using an No. 11 blade, and a 5-mm laparoscopic point is inserted into the cystotomy. At this point, the endoscope can be introduced and fluids connected to the urinary catheter. Calculi will generally accumulate toward the trigone and can be visualized with the endoscope (

). Small stones can be flushed through the laparoscopic port and collected, but larger ones will need to be manipulated with the stone extractor basket to be removed.

One challenging aspect of performing a cystotomy to remove calculi is maintaining visualization. In conjunction with this, urothelium is a sensitive tissue and quickly becomes edematous with manipulation. The creative use of stay sutures can facilitate visualization and decrease frustration with the procedure. When performing a cystotomy, the placement of not only the stay suture at the apex but also one on either side of the cystotomy can aid in visualization of the trigone and proximal urethra (

 Stay suture placement at the bladder apex to optimize visualization and manipulation

An additional challenging element during a cystotomy may be the retrograde placement of a urinary catheter in a female dog or cat. One method to tackle this is to first pass a urinary catheter normograde until it exits the urethra and then suture a second urinary catheter of the same or a smaller size to the first. The original urinary catheter may now be pulled backward, which will facilitate placement of the retrograde urinary catheter. Another method to tackle this problem is the 2-catheter technique for urethral catheterization described by Dornbusch et al.

This is a technique in which a large urinary catheter is placed somewhat dorsal to block off the vagina. A second, more appropriately placed urinary catheter is then inserted and is unable to be deflected into the vagina and will thus enter the urethra.

Following a routine cystotomy, an unobstructed patient is ideally maintained on isotonic crystalloids at a maintenance rate as well as analgesia such as a pure μ-opioid. Methadone (0.1-0.2 mg/kg intravenously every 6 to 8 hours) is a common choice following cystotomy. An indwelling urinary catheter is not necessary in the postoperative period. Most patients can be discharged the following day and are managed on routine oral medications such as gabapentin (10 mg/ kg orally every 8 hours) or codeine (1-2 mg/ kg orally every 8 to 12 hours). Nonsteroidal anti-inflammatory drugs should be avoided if the patient presented with an obstruction, and postoperative blood gases should be monitored in this case to ensure appropriate correction of potential electrolyte derangements and azotemia.

Readers are directed to more specific texts for management of urinary obstructions. The decision to prescribe postoperative antimicrobials should be made based on preoperative diagnostics and the likelihood of a concurrent urinary tract infection or concern for a break in sterility.

Stones collected should be sent to a reference lab for identification to tailor follow-up care and minimize chances of recurrence. Identification of any comorbidities should also prompt the clinician to recommend treatment and may alter postoperative management of the patient with urolithiasis. Depending on the type of stone that is identified, follow-up recommendations may include acidifying or alkalinizing the urine, castration, dietary changes, or regular diagnostics such as radiographs and urinalyses.

Veterinary Surgery: Small Animal Expert Consult. 

Cruciani B, Vachon C, Dunn M. Removal of lower urinary tract stones by percutaneous cystolithotomy: 68 cases (2012-2017). 

2020;49(suppl 1):138-147. doi: 10.1111/ vsu.13398

Runge JJ, Berent AC, Mayhew PD, Weisse C. Transvesicular percutaneous cystolithotomy for the retrieval of cystic and urethral calculi in dogs and cats: 27 cases (2006-2008). 

2011;239(3):344-349. doi:10.2460/ javma.239.3.344

Grant DC, Harper TAM, Werre SR. Frequency of incomplete urolith removal, complications, and diagnostic imaging following cystotomy for removal of uroliths from the lower urinary tract in dogs: 128 cases (1994-2006). 

2010;236(7):763-766. doi:10.2460/javma.236.7.763

Dornbusch JA, Yaxley PE, Hechler AC, Bryon JK, Selmic LE. A novel two-catheter method for urethral catheterization improves success rates of urethral catheterization in female dogs and cats weighing less than ten kilograms. 

. 2023;261(11):1623-1627. doi:10.2460/ javma.23.04.0209

Articles

Management of the condition includes postoperative therapy
and follow-up care

Identifying and treating canine and feline urolithiasis

Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ, explains how SGLT2i can be used to manage feline diabetes mellitus

Fetch On Demand Chrisopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ, managing feline diabetes mellitus with SGLT2i Interview

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Sodium-Glucose Cotransporter 2 inhibitors (SGLT2is) have been used in human medicine for several years. Recently, 2 specific SGLT2is saw their introduction to feline medicine: Bexagliflozin (Bexacat;Elanco), and velagliflozin oral solution (Senvelgo; Boehringer Ingelheim). 

During an interview with dvm360, Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ, explained how they work in the management of feline diabetes mellitus. Byers outlined the effectiveness of these medications on cats, and why it can prevent the development of clinical hypoglycemia. 

Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ: 

Both of these drugs, this class of medication, inhibits a specific cotransporter located in the proximal tubule of the kidneys, specifically the S1 segment of the proximal tubule. Under normal circumstances, that cotransporter is responsible for absorbing 90% of all of the glucose that gets filtered at the level of the glomeruli, through Bowman's capsule. 

When we inhibit that cotransporter with an SGLT2i, like Bexacat or Senvelgo, we don't resorb that 90% of filtered glucose, but if we travel a little bit further down the proximal tubule, into the segment that's called S2/S3, we'll find another cotransporter, called Sodium-Glucose Cotransporter 1, or SGLT1. Under normal circumstances, that cotransporter is responsible for resorbing the remaining 10% that SGLT2 doesn't absorb. But, when we block SGLT2... SGLT1 becomes more efficient.

Christopher G. Byers, DVM, DACVECC, DACVIM (SAIM), CVJ, explains how Sodium-Glucose Cotransporter 2 Inhibitors are used to manage diabetes mellitus in cats 

Managing feline diabetes mellitus with SGLT2i

On this week's episode of The Vet Blast Podcast presented by dvm360, Ashley Randall, DVM, founder and CEO of Muse Veterinary Group, explains to our host Adam Christman, DVM, MBA, her journey into practice ownership and founding Muse Veterinary Group. Throughout the episode, Randall shares what is important when considering opening your own practice, because it is not for everyone; what lead her to open her own practice; and the advice she has for future veterinary practice owners.  

The big question is, why? Why practice ownership? And I know this is the question I'm sure you get asked [by] a lot of mentees about, should I do or should I not? And walk me through some of the questions that go through your mind when you decided to take that leap.

 I think the question that you just asked is actually the most important question, you know, why? Why do you really want to do this? Because it's not just like the the easiest thing to do. Practice ownership takes a lot of mental fortitude. It takes, it takes some financial leveraging, and it takes a lot of grit, and you have to be flexible and creative, to really be a good practice owner, to be a well rounded practice owner. For me, that answer lies in purpose. I felt like my purpose was to marry these amazing skills that I had a passion for with animals, with my communication skills and really challenge myself to bring veterinary equity to a part of Atlanta that was basically a veterinary desert. 

So for me, that question, the answer to that question for individuals, truly lies within what their overall purpose is in life. And I think that you know, the more you ask yourself, kind of what you want in life overall, kind of from a broad spectrum, you will kind of figure out whether or not practice ownership is for you or not.

Ashley Randall, DVM, shares her story into practice ownership and provides tips to help others interested in owning their own practice as well

Is practice ownership for me?

The opening of new veterinary clinics is crucial for expanding access to veterinary care for pets and their owners. With more facilities available, communities can benefit from increased availability of services, shorter wait times, and improved overall pet health. These new clinics play an important role in ensuring that pets receive the medical attention they need, which contributes to a healthier and happier environment for animals and their families.

Below are 3 clinics opening across the United States:

ASPCA Community Veterinary Clinic (New York City)

ASPCA Community Veterinary Clinic in NYC. (Photo courtesy of the American Society for the Prevention of Cruelty to Animals)

The American Society for the Prevention of Cruelty to Animals (ASPCA) recently announced the opening of a 3rd ASPCA Community Veterinary Clinic at 36-01 14th Street, Long Island City, Queens, New York. The new clinic will offer affordable veterinary care to tens of thousands of pet owners in underserved areas each year, bettering the health and wellbeing of dogs and cats in the local community, according to a news release.

"The need for affordable veterinary care is at an all-time high, and for many pet owners, keeping their beloved pets healthy can be a challenge, which puts stress not just on the animals, but on owners, families, and entire neighborhoods, because everyone is impacted when a vital family need is unmet," Matt Bershadker, ASPCA president and CEO, said in the release.

A lack of affordable veterinary care in the area influenced the clinic’s location, according to the organization.

 The new facility will serve residents of nearby NYC Housing Authority (NYCHA) developments within walking distance, including in Queensbridge, Ravenswood, and Astoria. The clinic will provide partially and fully subsidized basic and preventive care for dogs and cats, including vaccinations, treatment for minor health issues, and spay/neuter surgeries. It will also offer spay/neuter surgeries and vaccinations to homeless pets supported by local rescue organizations.

Also opening the doors of a new clinic is CityVet. Located at 1520 N Main St, Suite 600, Keller, Texas, the new facility will offer preventive treatments, diagnostics, surgical procedures, dental treatments, and advanced surgical options. The clinic is led by Kelsey Daugette, DVM, a graduate of Texas A&M University with 9 years of experience. According to CityVet, Daugette’s interests include soft tissue surgery, preventative care, ultrasound, and the human-animal bond.

“As a passionate animal lover and dedicated professional, I’m thrilled to welcome the Keller locals and their furry family members into our new clinic,” Daugette said in a news release.

 “At CityVet-Keller, we understand the deep bond between pets and their owners, and are committed to building long-lasting relationships. We’re eager to become your trusted partner in your pet’s healthcare journey.”

“We’re looking forward to partnering with Dr Daugette as we celebrate the opening of our 25th location in Dallas-Fort Worth,” said David Boguslawski, CityVet president and CEO, in the release.

 "Dr Daugette’s expertise, passion for veterinary medicine, and dedication to personalized care make this occasion even more special as we serve the Keller neighborhood and their pets,” he continued.

Chewy Vet Care Halcyon (Atlanta, Georgia)

Chewy Vet Care in Forsyth County, Alpharetta. (Photo courtesy of Chewy)

A new Chewy Vet Care location will be opening later this year. The clinic will be located at Halcyon, a mixed-use destination in Forsyth County. The opening will be part of Halcyon’s Phase III, according to a news release.

 Like its other veterinary practices, this new clinic will offer services like routine wellness care, urgent care, and surgeries.

“We are excited to open our third Chewy Vet Care location in Atlanta, which consistently ranks as one of the most pet-friendly cities in the country," said Mita Malhotra, president of Chewy Health, in a news release.

 "Our newest location at Halcyon represents our ongoing commitment to providing exceptional, personalized veterinary care throughout the region. We look forward to serving even more pets and their parents in this vibrant community."

The new Chewy location will be the 3rd in the metro Atlanta area. The clinic will provide in-person visits 6 days a week and 24/7 virtual health support. It will also offer mobile access to medical records, care plans, prescriptions, and appointment scheduling through a virtual pet portal.

ASPCA® opens third Community Veterinary Clinic in New York City, providing affordable veterinary care to underserved pet owners in Queens. News release. American Society for the Prevention of Cruelty to Animals. September 17, 2024. Accessed September 25, 2024. 

https://prnmedia.prnewswire.com/news-releases/aspca-opens-third-community-veterinary-clinic-in-new-york-city-providing-affordable-veterinary-care-to-underserved-pet-owners-in-queens-302250541.html

CityVet, a leading network of veterinary-owned practices, continues expansion in Dallas-Fort Worth with a new clinic opening in Keller, TX on Thursday, September 19th. News release. CityVet. September 12, 2024. Accessed September 25, 2024. [email]

Halcyon welcomes Chewy Vet Care’s third metro Atlanta location. News release. August 26, 2024. Chewy. Accessed September 25, 2024. [email]

Take a look at these 3 veterinary centers newly opened or coming soon

Clinic center: New veterinary clinics opening in the country 

 Lance canine tooth in a Shetland sheepdog.

Oral health is a cornerstone of overall well-being. Although factors such as diet and hygiene influence dental health, genetics also play a significant role. For some oral diseases, the genetic basis has been confirmed, whereas a breed predisposition has been identified for others. For example, certain breeds with crowded teeth and skeletal malocclusion may have anatomical predispositions that facilitate bacterial accumulation.

Malpositioned second premolar and persistent primary canine tooth in a 7-month-old pug.

Jerzy Gawor, DVM, PhD, DAVDC, DEVDC, worked with the Polish Small Animal Veterinary Association (PSAVA) to establish an evidence-based system to document the occurrence of hereditary oral and maxillofacial defects in purebred dog populations. The PSAVA Dental Working Group developed a list of 49 breeds that are prone to single or multiple oral/maxillofacial defects, referencing literature on each breed-specific condition and recommending diagnostic criteria, including clinical assessment, imaging, and laboratory tests (histopathology and genetics). Moreover, each defect was scored from 1 to 3 based on its negative impact on the animal’s health and vital functions, with 3 being the most deleterious.

Charts created by the PSAVA Dental Working Group are available 

. These charts demonstrate specific dog and cat breeds that are genetically associated with dental disease (

Brachycephalic breeds are predisposed to periodontal disease; these include flat-faced pugs, shih tzus, and bulldogs, as well as Persian, Scottish fold, and Himalayan cats. Their mouths do not have enough room to comfortably support 42 teeth for dogs and 30 teeth for cats (

The teeth of toy breeds, such as Yorkshire terriers, Chihuahuas, and Pomeranians, erupt closer together than larger breeds. This predisposes the toy breeds to increased plaque and tartar accumulation. A study published in the 

 analyzed more than 3 million medical records (collected from 2010 to 2014) across 60 breeds of dogs visiting US Banfield locations. Statistical modeling of the data showed that extra small dog breeds were up to 5 times more likely to be diagnosed with periodontal disease than giant breeds (

< .0001). Additional risk factors for periodontal disease diagnosis included age, weight, and time since the professional dental scaling visit. Toy breeds are also genetically predisposed to persistent primary teeth (

Oriental shorthair and Siamese cats may have a higher risk of tooth resorption. A 

study identified a potential genetic link to tooth resorption in Siamese cats, suggesting a breed predisposition.

Genetic markers include gene variations in inflammatory pathways, tooth development, and immune response. 

Genes produce and regulate inflammatory molecules within the gingiva, including cytokines and chemokines. These play a role in the development and progression of periodontal disease. A study published in the 

gene in dogs and found an association between specific polymorphisms and an increased risk of periodontal disease.

 Persistent primary canine tooth in a Yorkshire terrier.

Although plaque and tartar accumulation from bacterial activity are the primary culprits triggering periodontal diseases, the genetic makeup of a dog or cat influences the immune response to these bacteria and the ensuing inflammatory cascade.

Variations in genes responsible for tooth formation and enamel development contribute to structural defects, increasing the risk of dental pathology. 

 Mandibular distoclusion mandibular mesioclusion (underbite).

Genes that recognize and respond to bacterial pathogens, such as toll-like receptors (TLRs), are being studied for their potential role in periodontal disease susceptibility. A study published in the 

gene in dogs and found an association with increased susceptibility to periodontal disease.

Although specific genetic markers provide valuable insights, most oral pathologies in dogs and cats likely follow a polygenic inheritance pattern. Genes interact with environmental factors to determine susceptibility, each with a small effect. Because of the complex interplay, pinpointing the specific genes and their dominant or recessive nature is challenging. Moreover, modifier genes can further influence the expression and severity of a disease, even in the presence of a predisposing gene. Genes responsible for skeletal malocclusions, including mandibular distoclusion (overbite, overjet; 

), and maxillomandibular asymmetry (wry bite; 

), are generally considered to be inherited dominantly. In contrast, individual tooth malposition is probably inherited recessively. 

 Mandibular mesioclusion and mandibular/maxillary asymmetry (wry bite).

The future of unraveling inheritance patterns

Advancements in veterinary genetics hold immense promise for understanding the inheritance patterns of oral pathologies in dogs and cats. Next-generation sequencing allows for detailed analysis of entire genomes, potentially revealing rare genetic mutations contributing to specific dental pathology.

Genome-wide association studies are powerful tools for pinpointing specific gene variations associated with increased risk of dental disease. By analyzing the genomes of large animal cohorts, researchers can identify potential candidate genes for further investigation.

Gene-editing technologies, including clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9 gene editing, have the potential to correct specific genetic mutations that increase susceptibility to dental disease. However, this technology has ethical considerations and needs extensive research before clinical applications.

Working with breeders to improve oral health

Breeders can reduce the prevalence of inherited dental issues by selecting breeding stock with good dental conformation and monitoring the incidence of oral pathology within their lines. By collaborating closely with breeders, veterinarians can help decrease the inherited nature of oral disease in purebred dogs and cats.

One of the first steps to accomplish this collaborative goal is identifying the genetic variations associated with oral health issues in different breeds. Genomic studies have already uncovered potential risk factors, such as variations in the 

genes for periodontal disease susceptibility. However, more research is needed to establish robust genetic markers for various oral health conditions across breeds.

Commercial genetic testing services, such as those offered by companies like Embark Vet and Paw Print Genetics, can provide valuable insights into an individual dog’s genetic predispositions. Once genetic markers are established, we can endorse genetic testing for breeding stock and potential breeding candidates. Breeders can avoid pairing 2 carriers by testing for known risk variants, reducing the likelihood of producing affected offspring. Additionally, genetic testing can help identify clear noncarriers, which can be prioritized for breeding to gradually reduce the prevalence of risk alleles within a breed population.

Although genetics play a significant role in dental health, proactive measures can help mitigate the risk of dental problems in predisposed breeds. Semiannual dental examinations, professional cleanings, and at-home dental care— including daily tooth wipes, brushing, and dental products accepted by the Veterinary Oral Health Council—are essential for all pets, especially those with genetic predispositions.

As research unveils the relationship between genes and oral health, we will move toward more personalized dental care strategies and improved overall patient well-being. The future of veterinary dentistry promises exciting advancements that will benefit pets for generations.

For recent updates to the Dentistry A to Z series:

ABCs of dentistry: Airway, breathing, circulation

Z is for zebras and other dental surprises

Gawor J. Hereditary oral disorders in pedigree dogs. proposals for their evidence and assessment. 

European Journal of Companion Animal Practice

. Accessed July 3, 2024. https://jukuri.luke.fi/bitstream/handle/10024/554104/Liite%202%20hammasongelmat.pdf;jsessionid=5206B9792FCCD394992FB8C25E881874?sequence=5

Wallis C, Saito EK, Salt C, Holcombe LJ, Desforges NG. Association of periodontal disease with breed size, breed, weight, and age in pure-bred client-owned dogs in the United States. 

. 2021;275:105717. doi:10.1016/j.tvjl.2021.105717

Whyte A, Tejedor MT, Whyte J, Monteagudo LV, Bonastre C. Blood parameters and feline tooth resorption: a retrospective case control study from a Spanish university hospital. 

. 2021;11(7):2125. doi:10.3390/ani11072125

Gonçalves-Anjo N, Requicha J, Teixeira A, Dias I, Viegas C, Bastos E. Genomic medicine in periodontal disease: old issue, new insights. 

. 2022;39(4):314-322. doi:10.1177/08987564221109102

Gonçalves-Anjo N, Leite-Pinheiro F, Ribeiro R, et al. Toll-like receptor 9 gene in periodontal disease - a promising biomarker. 

. 2019;687:207-211. doi:10.1016/j.gene.2018.11.060

Silva C, Requicha J, Dias I, Bastos E, Viegas C. Genomic medicine in canine periodontal disease: a systematic review. 

. 2023;13(15):2463. doi:10.3390/ani13152463

Oral health diseases in dogs and cats can be hereditary

Dentistry A to Z: G is for genetics

Renee Schmid, DVM, DABT, DABVT, talks about common toxins for older pets, as well as how breed impacts exposure

Schmid Age, Breed

Missed out on Fetch Kansas City 2024? No worries—we’ve got you covered! For just $199, Fetch On-Demand gives you access to the best sessions, speakers, and over 30 CE credits. Learn when, where, and how it fits into your busy life. Whether you’re catching up between appointments, learning from the comfort of home, or squeezing in a quick session over coffee, Fetch On-Demand gives you the flexibility you need to earn CE credits on your terms.

Are dogs and cats of certain ages more likely to be exposed to toxins? How does breed and species affect exposure? During an interview with 

about her lecture at the 2024 Fetch Kansas City Conference in Kansas City, Missouri earlier this year, Renee Schmid, DVM, DABT, DABVT, offered insight into how a pet’s age plays a role in their likelihood of toxin exposure. She also shared common toxins older pets may be more exposed to, as well as how a dog and cat’s breed may or may not affect their odds of getting into things.

When we have an older dog in the household, we may also have an older cat, or vice versa, and so there's more of those medications around. So those were like methimazole for hyperthyroidism. We saw heart medications—pimobendan, Vetmedin, was higher ranked in the older animals. Carprofen is higher ranked in the older animals.

And these are animals that are getting into an overdose, or maybe it wasn't their medication, it was someone else's medication in the household. And so I think it's just that [these medications are] more readily available. Animals are living longer. In veterinary medicine we're able to treat more diseases and try to improve their quality of life, and so we're seeing these animals that are getting into maybe their housemates’, medication, or maybe they were overdosed unexpectedly from an owner.