companion march2012

Dog EndsPassive smoking and petsP4

Clinical ConundrumA vomiting Yorkshire TerrierP8

How ToApproach the hypertensive patientP12

The essential publication for BSAVA membersThe essential publication for BSAVA members

companionMARCH 2012Cutting through reconstructive surgery at Congress

01 OFC March.indd 1 20/02/2012 10:46

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Your views sought

on the VSA

Your views

on the VSA

companion is published monthly by the British Small Animal Veterinary Association, Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley, Gloucester GL2 2AB. This magazine is a member-only benefi t. Veterinary schools interested in receiving companion should email [email protected]. We welcome all comments and ideas for future articles.

Tel: 01452 726700Email: [email protected]

Web: www.bsava.com

ISSN: 2041-2487

Editorial BoardEditor Mark Goodfellow MA VetMB CertVR DSAM DipECVIM-CA MRCVSSenior Vice-President Grant Petrie MA VetMB CertSAC CertSAM MRCVS

CPD Editorial TeamIan Battersby BVSc DSAM DipECVIM-CA MRCVSSimon Tappin MA VetMB CertSAM DipECVIM-CA MRCVSPatricia Ibarrola DVM DSAM DipECVIM-CA MRCVS

Features Editorial TeamCaroline Bower BVM&S MRCVSAndrew Fullerton BVSc (Hons) MRCVSMathew Hennessey BVSc MRCVS

Design and ProductionBSAVA Headquarters, Woodrow House

No part of this publication may be reproduced in any form without written permission of the publisher. Views expressed within this publication do not necessarily represent those of the Editor or the British Small Animal Veterinary Association.

For future issues, unsolicited features, particularly Clinical Conundrums, are welcomed and guidelines for authors are available on request; while the publishers will take every care of material received no responsibility can be accepted for any loss or damage incurred.

BSAVA is committed to reducing the environmental impact of its publications wherever possible and companion is printed on paper made from sustainable resources and can be recycled. When you have finished with this edition please recycle it in your kerbside collection or local recycling point. Members can access the online archive of companion at www.bsava.com .

3 BSAVA NewsLatest from your Association

46 Dog-end DangersPassive smoking and pets

7 PetSavers at CongressWays to help and ways to win

811 Clinical ConundrumVomiting in an unvaccinated terrier

1219 How ToApproach the hypertensive patient

2021 Progress in PathologySue Murphy at Congress

2223 Browsing on the BalconyPublications at Congress

2426 Reconstructive SurgeryMike Pavletic at Congress

27 Bulgaria to Benefit at BSAVA CongressOur special guests for 2012

2829 VN CPSNew Nurse Merit Awards from BSAVA

3031 Join the Scottish Congress ClanAll about Edinburgh this summer

3233 WSAVA NewsThe World Small Animal Veterinary Association

3435 The companion InterviewCecilia Gorrel

37 Focus OnKent region

3839 CPD DiaryWhats on in your area

The Defra consultation on changes to the Veterinary Surgeons Act 1966 is currently underway and BSAVA is encouraging members to have a voice

As you are probably aware, Defra is currently undertaking a consultation into the membership and size of the RCVS Disciplinary Committee and Preliminary Investigation Committee. At this stage the intention is to enact these changes through a Legislative Reform Order (LRO) to the current Veterinary Surgeons

Act (VSA) rather than through a new Act.Under the current system, RCVS Council both sets the standards for the profession

and, through its Disciplinary and Preliminary Investigation Committees, deals with any possible breache s of those standards. The proposed amendment to VSA will separate this overlap of functions, bringing the veterinary profession in line with other professions (such as doctors, through the General Medical Council and dentists through the General Dental Council).

It is suggested that these changes will:

Increase impartiality and independence in dealing with complaints Increase public confidence in the complaints system Bring the veterinary profession in line with best practice in professional regulation Enable the statutory committees to hear cases more quickly Reduce the likelihood of challenge on human rights grounds to a decision made by

RCVS disciplinary committees Enable the RCVS to balance its public and professional interests better.

BSAVA is currently seeking members views on these proposals; please visit the Consultation Section of the website (under the Advice tab at www.bsava.com) to access more details.

Additional stock photography Dreamstime.com Dimitri Zimmer; Jeffrey Van Daele; Jose Manuel Gelpi Diaz; Kodo34; Lars Christensen; Silkyk; Vedran Vidovic

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Researchers from the University of Bristol have recently published evidence that the prevalence of Borrelia in the UK tick population is considerably higher than previously thought.

Ticks were collected from dogs selected at random from veterinary practices throughout the UK. The study found that of 3534 dogs examined, 810 (22.9%) were carrying at least one tick, and Borrelia was detected in 2.3% of ticks sampled. Although the paper draws on the results to discuss the risk of Lyme disease in humans, and does not provide any new information on clinical Lyme disease in dogs, the research findings do have implications for veterinary practice.

Ticks are common on dogs even when the owners dont realise it, so protection against ticks throughout the year is sensible.

Lyme disease is also widespread, and in this respect the study simply shows that ticks in areas that dogs (and their owners) walk may carry Borrelia.

The study also demonstrates the ability of data collected from first opinion practice to contribute to research and surveillance. BSAVA hopes to build on this through its involvement with SAVSNET.

Further details of the research and information about Lyme disease is available online in the Advice section at www.bsava.com.

A record-breaking year at NAVCN

AVC (1518 January, Orlando) is one of the largest conferences that BSAVA attends, and this years event was hugely successful. Weve

always had a big welcome from our American colleagues, but this year was record breaking, with the team signing up over 100 new overseas members and the highest ever Manual sales. The most popular titles were Ultrasonography, Behavioural Medicine,

Ophthalmology and Oncology, with stock selling out before the end of the event.

Our lecture-share programme with the NAVC saw Christine Heinrich and Sally Turner presenting ophthalmology lectures. These talks were so popular that there was standing room only and delegates were overheard singing their praises. An all-round success, and proof that BSAVA science has great value across the pond.

BSAVA President Andrew Ash presenting Dory Stricker, the 100th overseas member joining at NAVC, with the latest edition of the BSAVA Small Animal Formulary

Sue Paterson, Chair of Education Committee, reveals highlights of latest plans

When the Education Committee assembled for their first meeting of 2012 it

was decided that centrally organised courses should be given a separate and unique identity to differentiate them from regional events.

With the loss of the modular medicine courses to the phenomenally successful PG Certificates, and the popularity of the mini-modules over the last few years, it was decided to make the latter a strong focal point in the new programme. These courses will run over a three-day period (some consecutive and others as separate days) with a single theme, and will cover both medicine and surgical topics.

Two other new initiatives are also to be explored in the 2013 programme. The first will be more extensive use of the very popular

Turning Point interactive equipment in which BSAVA has invested. These handsets allow BSAVA speakers to ask the audience during the lecture. Courses will be themed, with a variety of different subjects covering a wide range of interests.

The other new concept will be split-day courses, where the audience will be divided into two tiers and lecturers will alternate between two rooms. Delegates can choose between different species, medicine or surgery, basic or advanced, etc. This new concept will also allow BSAVA to run courses for their new nurse members to provide them with high-quality CPD given by veterinary experts in their fields.

For more information about how you can make the most of your CPD budget and membership discounts email [email protected].

Making BSAVA CPD stand out

Ticks & Lyme disease

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Dog-end dangersProfessor Clare Knottenbelt of the University of Glasgow describes how PetSavers funding helped her to carry out research into the impact of passive smoking on pets

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Tobacco smoke has long been associated with ill health in humans, increasing the risk of cancer and cardiorespiratory disease in both smokers and those exposed to

environmental tobacco smoke (ETS) through passive smoking. Health professionals have campaigned to reduce the exposure of working adults to second-hand smoke (SHS) culminating in the ban on smoking in public places. There are ongoing campaigns to make smokers more aware of the effects that SHS can have on both adults and children in the home and during car travel and to encourage outdoor smoking.

Smoking and petsTo veterinary professionals it seems obvious that pets in the household are also exposed to SHS. However, in pets the development of ETS-related diseases has been difficult to prove. Studies have used owner questionnaires to establish ETS exposure, but inaccurate owner estimates and differing pet behaviours make these estimations extremely difficult.

Despite these difficulties, studies have shown that in cats, exposure to ETS is associated with increased expression of oncogenic p53 in oral squamous cell carcinoma and an increased relative risk of lymphoma. In dogs there is an increase risk of nasal and paranasal sinus neoplasia and lung cancer, and significant changes on bronchioalvealoar lavage in dogs exposed to ETS. In addition, air nicotine concentrations have been found to be higher in households in colder climates, suggesting that SHS exposure may be higher in Britain than in other parts of the world.

Where to find the evidenceIn humans, hair nicotine concentrations (HNC) are a useful biomarker of ETS exposure over the previous 23 months. Dogs and cats have a similar rate of hair growth to humans (extrapolated from Muller et al., 1989) suggesting that HNC would reflect a similar time frame of ETS exposure in pets. Closeness of interactions between children and smokers are thought to explain the 35% higher HNC seen in children and this effect is likely to be mirrored by many petowner relationships.

Since nicotine adheres to the surface of hair it is likely that pets internalise more nicotine through self-grooming. Exposure to ETS may therefore be even greater in pets than in children. The main aim of my study was to establish if we could use the HNC to measure the amounts of ETS that pets are inhaling and compare these to the levels found in children due to passive smoking.

Finding a sample groupIn order to perform the study we needed to recruit at least 20 pets from both smoking and non-smoking households. PDSA facilitated collection of samples by University of Glasgow vet Jenny Hammond. Samples were taken with owner consent from dogs and cats presented to the PDSA PetAid hospital, Glasgow Shamrock Street. In addition, staff and students from the University and pet owners referred to the University Small Animal Hospital provided hair samples from their pets.

The samples were analysed by the University of Strathclyde. Unfortunately the cat hair was not able to withstand the washing techniques previously described. However the Strathclyde team have developed a new technique which will allow us to perform a larger study into the hair nicotine in cats once further funding is secured.

The study has allowed us to confirm that dogs are exposed to similar amounts of ETS as adults and children in a smokers home. It also suggests that smoking outdoors can significantly reduce ETS exposure. Interestingly, some dogs in non-smoking households had nicotine in their hair, which could reflect environmental pollution or exposure to ETS of which the pet owner is unaware.

Thanks to PetSaversThis project was funded by a Clinical Research grant from PetSavers, who saw the potential in the project and its importance to developing a policy for reducing the amount of ETS exposure in pets. It has already sparked interest from the media, anti-smoking charities, health professionals committed to reducing passive smoking in children and disabled adults, and of course the pro-smoking lobbyists.


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Dog-end dangers

The way aheadMy next goals are to perform a complete study in cats to establish if their differing behaviour affects the amount of ETS they are exposed to. I have established links with the University of Aberdeen and hope to be able to measure the small particulate matter (the carcinogenic part of tobacco smoke) that dogs are exposed to. Finally I would like to conduct a larger scale study into the variable levels of hair nicotine found in dogs from non-smoking households, as the increase in outdoor smoking may be influencing air quality for pets outdoors too. Of course this will all depend on getting funding in increasingly difficult times.

Practice and owner engagementMedical health professionals are adopting a policy of questioning all patients about their lifestyle (diet, exercise, alcohol, tobacco and drug usage) at every consultation. This policy is one which veterinary surgeons broadly adopt, but too few of us address the issue of ETS exposure despite in many cases being able to tell as soon as the patient enters the room that it comes from a smokers household!

The PDSA has been been trying to reduce the amount of ETS that pets are exposed to by encouraging pet owners to give up smoking through various means such as posters and media articles.

They have also worked with a number of local health authorities to support this important issue.

The Roy Castle Lung Cancer Foundation (www.roycastle.org) are developing material trying to encourage pet owners to consider quitting for the sake of their pets or to smoke outdoors to reduce ETS exposure for both children and pets. The problem for many of us is that once the pet has developed a disease that could be associated with ETS exposure it becomes very difficult to raise the issue without distressing owners.

Impact on healthMany of us have experienced the terrible effects of smoking amongst family and friends and I am confident that owners might be more willing to give up smoking for their pet partly because they are more likely to see the negative effects during their own lifetimes. As veterinary surgeons we champion the prevention of illness and disease, and I believe that we should do more to encourage our clients to avoid exposing their pets to SHS.

In my role as a Clinical Professor at the University of Glasgows Small Animal Hospital, I meet many owners who are desperate to do the best for their pets and yet have not even considered the possibility that exposure to ETS could harm their pet. I hope that by raising this issue the profession can start to ask the difficult questions of owners and thereby ensure that pets under their care get the smoke-free air that they deserve.

This article with references is available online at www.bsava.com/companion

SUPPORTING PETSAVERS

Donati ng to PetSavers ensures conti nued funding into clinical research projects such as this. If you are interested in making a one-o donati on, or want to nd out more about committ ed giving and leaving a legacy, please telephone 01452 726723, email [email protected] or visit the PetSavers secti on at www.bsava.com.


companion | 7

If you are coming to Congress please pay us a visit and meet some of our dedicated volunteers who will be ready and waiting to answer any questions you might have about PetSavers.

Win a KindlePetSavers will be running a competition at Congress again this year, which you can enter at the PetSavers stand. All you have to do is fill in an entry form available from our stand or in the exhibition vouchers booklet, and answer a few simple questions. One lucky person will be in for the chance of winning a brand new Kindle!

Banquet raffleFor those who are lucky enough to be attending the

Banquet, PetSavers will be holding a raffle and one lucky person will win an original, signed, limited edition print by Alex Echo. The print entitled Carnival Skies (pictured) is worth an astounding 1,450 and has been kindly donated by Castle Fine Art (www.castlefineart.com).

There will be raffle envelopes on each table into which you can put your donation. Alternatively, if you are not able to attend this years Banquet but would like to make a donation, please visit us on our stand where we will be happy to let you know how you can best support the charity.

PetSavers in your practiceOn the stand you will be able to find out about the range of products that PetSavers has available, including heated pads and protective collars. Of course, even if you cant come to Congress this year, you can shop online anytime at www.petsavers.org.uk.

Volunteering for PetSaversIts going to be great fun on the stand this year and we would love you to come along and meet the team of volunteers who make the charity work. In addition, if you are interested in volunteering for PetSavers, this is a great chance to find out whats involved. And if you dont get chance to talk to us at Congress contact us anytime via email [email protected] or call us on 01452 726723. n

PetSavers pleased to see you

You cant miss PetSavers at BSAVA Congress. The stand greets you as you enter the BSAVA Balcony in the NIA

Visit our website www.petsavers.org.uk to find out more about PetSavers and what we do.

Carnival Skies by Alex Echo

07 Petsavers.indd 7 20/02/2012 10:42

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Clinical conundrum

What is your problem list? Rationalise the likely differential diagnoses

Problems identified were jaundice, cranial abdominal pain, vomiting and delayed gastric emptying (vomiting food 8 hours after eating). Dehydration and lethargy were thought be secondary problems, but needed addressing nonetheless.

Causes of jaundice (icterus) can be considered in three groups:

n Pre-hepatic causes (haemolysis from drugs/toxins/immune-mediated disease/massive haematoma) were considered unlikely because no haematomas or bruising were identified, mucous membranes were pink and pulses were not bounding making anaemia unlikely.

n Hepatic causes of jaundice include: infection (canine adenovirus (CAV), leptospirosis); acute or chronic hepatitis related to drugs/toxins, breed or idiopathic; neoplasia; cirrhosis; hepatopathy secondary to sepsis, pancreatitis or metabolic disease; or amyloidosis. Leptospirosis was a particular concern given access to the urban pond; CAV was also considered given the dogs unvaccinated status. Chronic disease and neoplasia were thought less likely given acute history and obesity.

n Post-hepatic jaundice follows biliary rupture or extra-hepatic bile duct obstruction (EHBDO). EHBDO can be intraluminal (inspissated bile/cholelithiasis), intramural (cholangitis/

Eleanor Raffan of the University of Cambridge invites companion readers to consider a case of vomiting in an unvaccinated Yorkshire Terrier

cholecystitis, neoplasia, stricture) or extramural (pancreatitis, neoplasia, duodenal mass/foreign body).

Acute vomiting can follow gastrointestinal obstruction (foreign body ingestion, intussusception, neoplasia or functional/motility disorders); gastrointestinal inflammation (infection, toxins, diet, inflammatory bowel disease); gastrointestinal ulceration; peritonitis; systemic disease (hepatopathy, pancreatitis, azotaemia, sepsis, metabolic/endocrine disease); vestibular disease/motion sickness; or toxicity.

Delayed gastric emptying can follow:

n Reduced motility (secondary to gastrointestinal inflammation, pancreatitis, peritonitis, uraemia, sedation, metabolic/electrolyte abnormalities or primary motility disorders/neurological disease).

n Pyloric obstruction (foreign body, mural or regional mass, pyloric hypertrophy/fibrosis/scarring); or pylorospasm (stress).

Few differential diagnoses can be ruled in/out from this clinical sign.

Abdominal pain is caused by many abdominal problems (organ/peritoneal inflammation, visceral stretch/displacement, trauma) or referred musculoskeletal pain. Focal cranial abdominal pain was considered most consistent with pancreatic, gastric, small intestinal or hepatobiliary disease.

Overall the combination of vomiting, jaundice and cranial abdominal pain implicated hepatobiliary disease, pancreatitis, duodenal foreign body/mass or sepsis as the most likely differential diagnoses. Other important rule-outs were haemolysis, other gastrointestinal diseases and metabolic abnormalities.

Case presentationA 7-year-old, FN unvaccinated Yorkshire Terrier presented with an 8-day history of inappetence, lethargy and vomiting (several times a day), preceded by restlessness and retching. Vomitus was froth or partly digested food and vomiting occurred up to 8 hours after feeding. Urination was normal. The dog was restricted to the house and urban garden containing a pond. There was no history of dietary indiscretion or toxin exposure.

Physical examinationThe dog was dull but responsive and mildly obese. Skin and sclerae were yellow. Mucous membranes were tacky, pink and yellow tinged. CRT was 1.5 seconds. Dehydration was estimated as 5%. The heart rate was 140 beats per minute and the respiratory rate was 60 breaths per minute. Otherwise, thoracic auscultation was unremarkable. Pulse quality and temperature were normal. Cranial abdominal palpation elicited signs of pain. The rest of the examination was unremarkable.

08-11 CLINICAL CONUNDRUM.indd 8 20/02/2012 10:41

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What management and initial diagnostic procedures would you perform in this case to narrow your differential diagnosis list?The dog was admitted to isolation and barrier nursed in case of infectious and zoonotic disease (leptospirosis/CAV). Sampling was performed prior to administration of fluid therapy to prevent this confusing interpretation of PCV and renal parameters.

Haematology was performed to evaluate for evidence of pre-hepatic causes of jaundice and inflammation/infection. Serum biochemistry was performed to investigate metabolic or organ dysfunction as a cause or consequence of disease. Amylase, lipase and canine pancreatic lipase immunoreactivity (cPLI) were specifically requested to evaluate for evidence of pancreatitis.

Urine was obtained by cystocentesis and dark-field microscopy performed to look for spirochaetes. Following acquisition of diagnostic samples, intravenous fluid therapy was commenced to correct dehydration (Hartmanns solution at 6 ml/kg/h for 12 h). There was no advantage to delaying analgesia and methadone (0.2 mg/kg i.m.) was administered pending results.

Do the results of diagnostic testing (Figures 1,2 and 3) alter the differential diagnoses?Haematology ruled out anaemia from haemolysis, confirming the clinical assessment that jaundice was hepatic/post-hepatic in origin.

Hyperbilirubinaemia confirmed severe jaundice. Marked increases in liver enzymes were consistent with a primary hepatopathy or cholestasis. Secondary hepatopathy (hypoxia, metabolic disease, sepsis) would usually cause lesser elevations. The greatest elevation

Haematology Day 1 Day 3 Reference interval

WBC 9.29 22.70 6.0017.00 x109/l

Neutrophils 7.8 19.3 3.011.5 x109/l

Lymphocytes 0.7 1.6 1.04.8 x109/l

Monocytes 0.7 1.4 0.21.5 x109/l

Eosinophils 0.1 0.5 0.11.3 x109/l

Basophils 0.0 0.0 0.00.5 x109/l

RBC 6.52 5.86 5.508.50 x1012/l

Hb 16.2 14.7 12.018.0 g/dl

HCT 0.448 0.404 0.3700.550 l/l

MCV 69 69 6077 fl

MCH 24.5 24.3 19.524.5 pg

MCHC 36 35 3237 g/dl

RDW 13.6 14.5 13.217.8 %

Platelets 375 410 175500 x109/lFigure 1: Haematology results

Biochemistry Day 1 Day 2 Day 3 Day 8 Post discharge: 2weeks 6 weeks

Reference interval

Sodium 139.7 145.4 146.2 148.7 148.6 147.5 135.0155.0 mmol/l

Potassium 3.24 3.81 3.68 3.51 4.27 4.65 3.505.80 mmol/l

Chloride 99.2 112.9 105.3 109.4 112.1 110.8 105.0120.0 mmol/l

Urea 6.0 5.0 7.9 7.0 7.8 3.38.0 mmol/l

Creatinine 38 46 78 98 103 45150 mol/l

Glucose 6.5 5.7 5.3 5.2 5.6 3.45.3 mmol/l

Total protein 71.7 65.1 69.9 71.6 62.6 60.080.0 g/l

Albumin 30.4 28.4 34.6 36.2 31.9 25.040.0 g/l

Globulin 41.3 36.7 35.3 35.4 30.7 25.045.0 g/l

Calcium 2.70 2.59 2.62 2.69 2.55 2.302.80 mmol/l

Phosphate 1.39 1.37 1.35 1.58 1.25 0.781.41 mmol/l

ALT 2402 1682 781 74 57 2159 IU/l

AST 514 378 85 22 31 2032 IU/l

CK 284 997 339 193 224 76228 IU/l

ALP 12103 11809 7871 1220 221 3142 IU/l

GGT 152 113 67 112 9 010 IU/l

Total bilirubin 176.7 152.4 16.9 19.5 3.6 2.017.0 mol/l

Cholesterol 24.42 23.11 9.48 4.31 5.69 2.505.90 mmol/l

Amylase 1883 1238 785 1114 1154 1671126 IU/l

Lipase >400 400 130 160 114 0250 IU/l

Specimen comment

Icteric Icteric Icteric Icteric Icteric *

Figure 2: Serum biochemistry results* Sample lipaemic and haemolysed: will increase phosphate and bilirubin

Cystocentesis sample

Reference value

WBC

10 | companion

Clinical conundrum

was in ALP, suggestive of primary cholestatic disease with secondary hepatocellular damage.

Steroid induction of ALP was unlikely because exogenous steroids had not been given and the dog was not clinically cushingoid. Bone remodelling, gastrointestinal or placental release result in only mild increases in ALP. Cholestasis is further supported by the presence of hypercholesterolaemia. Endocrine disease (hypothyroidism, diabetes mellitus (DM), hyperadrenocorticism), nephrotic syndrome, primary hyperlipidaemia or postprandial causes were considered unlikely causes of hypercholesterolaemia in view of the clinical and clinicopathological findings.

Hypokalaemia and hypochloraemia were considered to be a result of vomiting as other causes were not supported by the remaining biochemistry profile. Elevated amylase and lipase were consistent with pancreatitis but are non-specific findings.

Results confirmed hepatic or post-hepatic causes of jaundice and ruled out some metabolic causes of vomiting (DM, typical Addisons). Leptospirosis is commonly associated with azotaemia but could not be ruled out as dark-field microscopy is insensitive. The dog continued to be barrier nursed pending further assessment.

On the basis of these findings what changes in management should be undertaken? What is your next diagnostic step to distinguish between hepatic and post-hepatic causes of jaundice?Fluid therapy was adjusted to correct hypokalaemia (potassium chloride (KCl) was added to the Hartmanns solution to produce a potassium concentration of 28 mmol/l). Administration continued at 6 ml/kg/h over 12 hours.

Abdominal radiography and ultrasonography (Figures 4 and 5) were

performed to investigate abdominal disease. A skilled ultrasonographer can distinguish between hepatic and post-hepatic causes of jaundice and evaluate pancreatic pathology. For this procedure the patient received sedation (acepromazine (0.01 mg/kg i.m.) in addition to the previously administered analgesia.

Imaging revealed bile duct distension with normal hepatic parenchyma. There was no visible intraluminal or mural abnormality of the bile duct and distension was reduced distal to the pancreas, which had the typical appearance of pancreatitis on ultrasonography (see legend to Figure 5).

On the basis of these findings which remaining differential diagnoses can be excluded?Ultrasonographic findings of a normal hepatic parenchyma with bile duct dilatation are consistent with EHBDO. Furthermore, pancreatic appearance consistent with pancreatitis implicates this as the cause of the EHBDO. Other differential diagnoses including leptospirosis/CAV were ruled out on the basis that other clinical findings were not supportive and that acute pancreatitis causing EHBDO explained all the presenting signs. Abscessation and pancreatic neoplasia as causes or complications of pancreatitis were excluded on the basis of imaging findings.

Figure 4: abdominal radiograph taken in right lateral recumbency. Prominent splenic shadow. C shaped moderately gas-filled loop of small intestine. Faeces in colon

B

Figure 5: abdominal ultrasound report. Pancreas: Pancreatic body enlarged (1.14 cm) and mottled hypoechoic appearance with hyperechoic fat surrounding this. the left limb is particularly hypoechoic. the right limb has a more normal appearance. liver: Within normal limits. Gall bladder large. the main change is severe dilatation of the common bile duct which is tortuous and up to 1.25 cm wide in the portion proximal to the pancreas. more distally (at entry point into duodenal papilla) it measures significantly less (0.46 cm) but is still distended. (a) note hypoechoic pancreas and surrounding hyperechoic fat. (B) note enlarged common bile duct (CBD) next to part of the gallbladder (GB). (C) note narrower width of CBD distal to pancreas.

a

C


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CoRReCtion to FeBRUaRy CliniCal ConUnDRUm

In the February issue, the Clinical Conundrum by Carl Bradbrook and Ambra Panti contained a table with incorrect data. the table on page 11 should have appeared as below. apologies for any confusion caused. The online PDF has also been corrected to reflect this change. Thank you to all the readers who spotted the mistake and let us know.

Are antibiotics required?Infection is uncommon in pancreatitis and antibiotics are usually not warranted. If infection is suspected then cholecystocentesis/bile culture should be performed but can result in bile leakage peritonitis. There was no indication of infection in this case and the risk from cholecystocentesis was not justified.

How would you manage this patient based on your diagnosis?Most cases of EHBDO will respond to appropriate medical management. The dog no longer required isolation or barrier nursing. Analgesia and intravenous fluid administration, supplemented with potassium, were continued. Maropitant (1 mg/kg s.c. q24h) was given as an anti-emetic. Ranitidine (2 mg/kg s.c. q12h) was chosen as a prokinetic and combined with sucralfate (0.5 g orally q8h) for gastroprotection as vomiting and inappetence could be associated with gastric ulceration. S-Adenosylmethionine 110 mg q24h was given to reduce the hepatotoxicity of bile stasis.

On day 2 the dog was brighter, she had stopped vomiting and her electrolyte concentrations had returned to normal (Figure 2). Clinically dehydration was not apparent. The rate of fluid administration was decreased to 2 ml/kg/hr and was supplemented to give a potassium concentration of 20 mmol/l. The dog ate baby rice/chicken. Faeces seen on the thermometer were acholic, suggesting complete EHBDO.

Comment on the sensitivity and specificity of the performed tests for diagnosis of pancreatitisA number of the non-specific clinicopathological findings (leucocytosis, dehydration, raised liver enzymes and hyperglycaemia) are commonly seen in pancreatitis. Elevated amylase and lipase

are found as commonly in patients with pancreatitis as in those without. As such they are supportive rather than diagnostic for the disease.

Abdominal ultrasonography by an experienced operator is highly specific for pancreatitis in dogs, but identification of enlargement of the pancreas alone is not sufficient for a diagnosis. Of the presently available tests, canine specific pancreatic lipase immunoreactivity (cPLI) is the most sensitive and specific and identifies pancreatitis in over 80% of affected dogs.

On day 3, we received the cPLI result 684 ng/ml. cPLI 400 is consistent with pancreatitis.

OutcomeOver the following days, analgesia was continued. Haematology and biochemistry showed marginal improvement in liver enzyme activities (Figures 1 and 2). Increased CK was explained by the catabolic state and intramuscular injections. Mature neutrophilia was an appropriate response to pancreatitis.

On day 5 faeces were pigmented for the first time, suggesting the bile duct was no longer completely obstructed. On biochemistry bilirubin was reduced by two thirds. Low-dose ursodeoxycholic acid (UDA, 5 mg/kg orally q24h) was given, having been withheld during complete

EHBDO, and the dog was monitored closely for adverse affects.

Had there been no improvement in the dogs clinical status then surgical intervention and bile duct stent placement would have been appropriate at this stage. Both are associated with a high complication rate.

By day 8, jaundice was reduced and appetite/demeanour were much improved. Ultrasonography showed reduced biliary distension. The dog was discharged on day 9 on UDA, S-adenosylmethionine and a low-fat diet.

Follow-upThe dog was rechecked 2 and 6 weeks later. She was generally well apart from transient dullness/inappetance after she had scavenged fatty foods. Haematology, biochemistry and cPLI normalised gradually. Ultrasound examination initially showed gallbladder sludge, so UDA/S-adenosylmethionine was continued until the second visit when there was no sludge and the pancreas was considered normal.

TLI was measured at the second visit because exocrine pancreatic insufficiency (EPI) can develop with chronic pancreatitis. Slight elevation ruled out EPI but was not diagnostic for pancreatitis (TLI = 20 ng/ml (35 pancreatitis)). Sixteen months afterwards the dog remains well with no signs of EPI. n

table 3: How to prepare a solution of dextrose at 2.5% and 5% using a 50% dextrose solution

Final solution concentration Bag size 50% Dextrose (ml)

2.5% (1:20 dilution) 500 ml 25

2.5% (1:20 dilution) 1000 ml 50

5% (1:10 dilution) 500 ml 50

5% (1:10 dilution) 1000 ml 100


12 | companion

How to approach the hypertensive patient

Systemic hypertension can be defined as persistently raised blood pressure (BP) and is increasingly recognised in both the

canine and feline populations, particularly in older patients. The presence of systemic hypertension can be damaging not only to the cardiovascular system but also to other target organs, such as the eye, kidney and central nervous system. It is therefore extremely important to monitor BP and, when a diagnosis of systemic hypertension is confirmed, to implement appropriate long-term treatment and monitoring strategies in order to prevent ongoing target organ damage (TOD).

Categories of hypertensionSystemic hypertension is usually categorized into one of three classes, depending on underlying aetiology.

Secondary hypertension: This is where systemic hypertension results from an underlying disease process (Table 1). Secondary hypertension can also be attributable to the administration of certain drugs that can result in increased BP, e.g. phenylpropanolamine, glucocorticoids, mineralocorticoids or erythropoietin.

Idiopathic hypertension: This refers to the presence of systemic hypertension where no underlying disease state can be identified. Idiopathic hypertension has been reported to affect approximately 20% of cats diagnosed with systemic hypertension but is considered rare in dogs.

White-coat hypertension: This is the phenomenon whereby systemic BP is transiently increased due to activation of the sympathetic nervous system with excitement or anxiety during a clinic visit. Distinguishing white-coat

Rosanne E. Jepson from the Royal Veterinary College helps us get to grips with this high pressure problem

hypertension from idiopathic hypertension can be challenging.

How to recognise the hypertensive patientIn human medicine, systemic hypertension is often referred to as the silent killer because there can be very few warning signs and the same is true for many of our veterinary patients. In some patients suspicion for the presence of systemic hypertension can be raised by evidence of TOD (Box 1). These changes can be dramatic, such as the cat that presents with sudden-onset blindness as a consequence of retinal detachment or gross hyphaema, or the very rare patient presenting with neurological signs associated with hypertensive encephalopathy (e.g. obtundation or seizures). In most instances, however, clinical signs associated with systemic hypertension are minimal and vague. More often the clinical signs reported will be those related to an underlying disease process. Systemic hypertension is therefore most often diagnosed on the basis of careful and repeated assessment of blood pressure (Box 2).

In which patients should we be monitoring blood pressure? Regular monitoring should be

performed in any patient diagnosed with an underlying condition that has previously been associated with systemic hypertension (Table 1), even if initially normotensive. For example:approximately 20% of cats that are normotensive at diagnosis of hyperthyroidism, will develop systemic hypertension after instituting anti-thyroid medication

Any patient with TOD (Box 1) but especially those presenting with ocular or neurological signs that could be

Table 1: Clinical conditions associated with the development of secondary hypertension

disease conditi on Reported prevalence of hypertension with underlying disease conditi on

Dogs Cats

Chronic kidney disease 1080% 2065%

Hyperthyroidism NA Pre-treatment 1025%Post-treatment 20%

Hyperadrenocorti cism Pre-treatment 6085%Post-treatment 40%

NA

Diabetes mellitus 25-50% No associati on made

Primary hyperaldosteronism

Unknown 50100% (Uncommon conditi on)

Phaeochromocytoma 4085% (Rare conditi on) Unknown (Extremely rare conditi on)

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BOX 1: TargeT Organ damage (TOd)

Figure 1: Ocular lesions secondary to systemic hypertension. (A) Feline fundus with evidence of multifocal intraretinal haemorrhages, large bullous retinal detachment and oedema. Marked variation in vessel calibre, with marked apparent loss/attenuation of retinal arterioles, is present (likely due to detachment/oedema). (B) Feline fundus with central focal bullous retinal detachment; peripherally similar smaller circular lesions can also be identified. There is also generalized oedema. Note how the blood vessel is raised by the bullous detachment (arrowed). (C) Feline fundus with multifocal areas of pigmentary disturbance. These represent old/inactive lesions likely to be secondary to small bullous detachment in the past (for example, that indicated by arrow). This cat did not have any detectable visual problem. (D) Feline eye demonstrating an area of total bullous retinal detachment, with large folds of retina displaced anteriorly within the vitreous and therefore now visible directly via the pupil with a focal light source (optic disc more posterior and obscured by retinal folds in this image). Multifocal intraretinal haemorrhages are present. Note also the marked mydriasis. This cat was clinically blind on presentation with similar changes observed bilaterally. (E) Feline eye with evidence of gross hyphaema (blood in anterior chamber). The blood has formed a solid clot. Also note the mydriasis, which is suggestive of concurrent fundic damage. (F) Canine eye with evidence of gross hyphaema. ((A)(E) courtesy of R. Elks.)Reproduced from BSAVA Manual of Canine and Feline Cardiorespiratory Medicine, 2nd edition.

A C

E F

B

D

Systemic hypertension can cause damage to a number of target organs, for example the eye, kidney, cardiovascular system and central nervous system.

Eyes: Studies suggest that approximately 60100% of cats with systemic hypertension will have evidence of ocular damage, namely hypertensive retinopathy/choroidopathy. Lesions can be relatively subtle but may include multifocal bullous retinal detachments, retinal detachment, fresh or resolving retinal haemorrhages, retinal vessel tortuosity or perivascular oedema creating the impression of vessel narrowing and hyphaema (Figure 1). Ocular manifestations of systemic hypertension are much less common in the dog, with the prevalence reported to be only 520%.

Kidney: In order to maintain glomerular filtration rate and protect the kidney, glomerular capillary pressure is tightly controlled in the afferent arteriole by autoregulation. Systemic hypertension can override this autoregulatory process so that the glomeruli are exposed to elevated pressures resulting in glomerular hypertension, glomerulosclerosis and proteinuria.

Cardiovascular system: Cardiovascular changes that have been associated with systemic hypertension include left ventricular hypertrophy and associated murmurs, arrhythmias and gallop rhythms. Epistaxis can also be a primary clinical sign of vascular damage secondary to systemic hypertension.

Central nervous system: Neurological signs of systemic hypertension have most often been documented in experimental studies and include obtundation and seizures but are rare in clinical patients. However, neurological complications of systemic hypertension may be under-recognised and many owners will report an improvement in demeanour of their pet with successful management of systemic hypertension.

associated with systemic hypertension and which may require immediate anti-hypertensive therapy

Any patient started on medication that can cause increase in BP particularly if there is any evidence of underlying TOD

Part of a geriatric screening programme for cats and dogs over ~9 years

Any patient receiving anti-hypertensive medication

How do I diagnose systemic hypertension?One of the main difficulties when approaching a patient that you suspect to be hypertensive is deciding exactly when

to make the diagnosis and when to start treatment. Recently the tendency has been to move away from a single BP value which defines systemic hypertension. Instead guidelines have been formulated as part of the American College of Veterinary Internal Medicine (ACVIM) Hypertension Consensus Statement, which consider diastolic and systolic BP as continuous variables and categorize them according to the risk of developing TOD.

The risk categories for systolic hypertension are listed in Table 2. In general, unless there is evidence of hypertensive retinopathy/choroidopathy or hypertensive encephalopathy it is not currently advocated to start anti-

hypertensive medication for those patients that fall within the minimal or mild risk categories (systolic BP

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BOX 2: HOW TO MEASURE BLOOD PRESSURE

Figure 2: Oscillometric blood pressure measurement in the cat

Figure 3: Doppler blood pressure measurement in the cat

Techniques availableThe gold standard for measuring BP is via direct arterial catheterisati on. This technique provides conti nuous assessment of mean, systolic and diastolic BP. However, it is an invasive procedure which is not applicable to routi ne monitoring requirements. Direct arterial BP monitoring is therefore most oft en performed in those emergency pati ents requiring parenteral anti -hypertensive medicati on within an intensive care environment or during general anaesthesia.Most oft en BP is assessed using an indirect technique, e.g. using an oscillometric device (Figure 2) or Doppler sphygmomanometry (Figure 3). Oscillometric devices rely on the detecti on of pressure oscillati ons of air within the cuff when the artery is parti ally occluded. When using an oscillometric device the mean BP is measured and systolic and diastolic pressures are calculated using inbuilt algorithms.The primary advantage of an oscillometric device is that, aft er cuff placement, the process is automated. This means that the technique requires litt le training and may make the machine easier to use in a fracti ous pati ent. However, oscillometric machines can be slow to take readings and may fail to obtain a measurement in pati ents with higher heart rates, arrhythmias or if the pati ent does not remain sti ll throughout measurement.

The Doppler technique uti lises a piezoelectric crystal to detect blood ow, converti ng this signal into an audible sound. The Doppler technique requires some degree of operator experience, but with a small amount of practi ce is easily mastered. However, it provides only reliable assessment of systolic BP. It is important to realise that in human medicine standards have been set for the validati on of indirect BP measuring devices but that no veterinary device currently meets these criteria in conscious dogs and cats.

For the Doppler technique, it is usual to perform an alcohol wipe and apply acousti c jelly in order to obtain adequate contact. In most instances clipping of fur adds additi onal stress for the pati ent and is not required. In long-haired pati ents clipping may be advantageous but the pati ent should be allowed to reacclimati se aft erwards.

It is widely advised that the fi rst measurement obtained is discarded and that subsequently a series of fi ve consecuti ve and consistent measurements should be recorded and the mean calculated. For readings to be consistent, ideally there should be

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Risk category Systolic blood pressure (mmHg)

recommendation for starting treatment

Minimal 180 The risk of development and progression of TOD is high White-coat hypertension is uncommon Immediate anti-hypertensive therapy indicated if ocular or CNS TOD present otherwise confirmation

of category status should be made on at least two occasions

Table 2: ACVIM risk categories for systolic hypertension

SBP measurement performed

No evidence of hypertensive retinopathy/choroidopathy or encephalopathyHypertensive retinopathy/choroidopathy or encephalopathy present

Instigate immediate antihypertensive medication

Go to Chart 2 (cats) or Chart 3 (dogs)

SBP 170mmHg in geriatric cat, consider antihypertensive

medication for idiopathic hypertension. All other patients continue to monitor

Predisposing disease present Repeat measurement of SBP on at least 12 visits 714 days apart If SBP persistently at higher end of category consider starting

antihypertensive medication If consistently at lower end of category continue to monitor every 23

months unless evidence of progressive TOD when antihypertensive medication should be started

SBP >180 mmHg

No predisposing disease present Repeat measurement of SBP on 23

visits 714 days apart Less likely to be white coat

hypertension if persistently >180 mmHg Start antihypertensive medication

Predisposing disease present Repeat measurement of SBP on one

occasion Instigate antihypertensive medication if

remains >180 mmHg

Chart 1. Reproduced from BSAVA Manual of Canine and Feline Cardiorespiratory Medicine, 2nd edition.

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For all patients in which you suspect systemic hypertension it is advisable to obtain a minimum database:

Complete history Full physical examination Serum biochemical profile Packed cell volume and total solids Urinalysis (specific gravity, dipstick,

urine protein:creatinine ratio and sediment examination)

Ophthalmological examination.

If there is clinical suspicion and supportive evidence from your minimum database you may wish to consider:

Total T4 (cats) ACTH stimulation test / low dose

dexamethasone suppression test Total T4/ TSH (dogs) Ultrasound assessment of kidneys and

adrenal glands Evaluation of urinary/plasma

metanephrines Plasma aldosterone concentrations.

It is also important to consider other clinical factors that could influence BP measurements in your patient:

Age: Systemic hypertension is more common in older patients (>9 years)

Breed: Sight hounds are reported to have systemic BP 1020 mmHg higher than other breeds. The exception to this rule is Irish Wolfhounds, that reportedly have BP lower than other sight hounds. So far no breed associations have been made in the cat.

Medications being administered, e.g. phenylpropanolamine, corticosteroids, mineralocorticoids, erythropoietin

Hydration status Recent intravenous fluid therapy.

How to diagnose idiopathic hypertensionA diagnosis of idiopathic hypertension should only be made if persistent hypertension is documented, perhaps with evidence of hypertensive ocular changes in combination with a full and unremarkable diagnostic work-up. BP should be assessed on at least two or three occasions 714 days apart. Theoretically the diagnostic evaluation should include direct assessment of glomerular filtration rate (GFR) to exclude the possibility of non-azotaemic kidney disease, although in practice this is rarely performed.

Some patients with systemic hypertension but no evidence of increased creatinine concentration demonstrate an inappropriate urine-concentrating ability (urine specific gravity

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Suggested guidelines for instituting and modifying anti-hypertensive treatment are outlined in Chart 2 (cats) and Chart 3 (dogs). Currently there is no indication in veterinary medicine to treat those patients with white-coat hypertension.

When starting anti-hypertensive therapy: Always explain and discuss the

rationale for anti-hypertensive therapy with owners so that they understand the importance of long-term management

and BP monitoring for their pet Introduce anti-hypertensive agents at

the lowest therapeutic dose Monitor BP more frequently, e.g. after

approximately 2448 hours if there is concern regarding TOD (e.g. ocular

Cat with systemic hypertension

Elevated SBP with hypertensive retinopathyElevated SBP with hypertensive encephalopathy Elevated SBP conrmed on 23 occasionsPerform diagnostic testing

SBP 160 mmHg or evidence of development or progression of TOD Conrm owner/cat compliance as treatment with amlodipine is

usually eective Add ACE inhibitor to protocol Re-examine 714 days

If SBP drops to 160 mmHg Conrm owner/cat compliance as treatment is usually eective Check for underlying disease process Consider diagnosis of white coat hypertension

Hyperthyroidism If no evidence of TOD consider white coat hypertension. Treat hyperthyroidism but monitor SBP

carefully as may increase If evidence of TOD treat as above

Hyperaldosteronism Remove the source of elevated aldosterone (likely an adrenal tumour) If no evidence of TOD consider spironolactone alone. If control inadequate add amlodipine as above If evidence of TOD follow as above in addition to spironolactone prior to adrenalectomy

SBP >160 mmHg or evidence of development or progression of hypertensive retinopathy Increase dose of amlodipine to 1.25 mg

orally q24h Re-examine at 714 days

Immediate antihypertensive medication

Re-examine at 714 days

Perform diagnostic testing Re-examine at 13 days

Start amlodipine (0.625 mg orally q24h)

Start amlodipine(0.625 mg orally q24h)


OR

then

OR

Hospitalization and continuous BP measurement for use of peripheral

vasodilators (e.g. hydralazine, nitroprusside)


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changes). Monitoring after 714 days is appropriate in most other situations

If a single anti-hypertensive agent fails to adequately control BP consider increasing the dose or adding a

second anti-hypertensive agent Always confirm owner and patient

compliance prior to any dose adjustment

Always reassess BP approximately

714 days after any dose adjustment or sooner if there is TOD (e.g. ocular)

Aim to achieve BP in the minimal or mild ACVIM risk category (systolic BP 160 mmHg, or evidence of development or progression of TODStart amlodipine at 0.1 mg/kg q24h

SBP160 mmHg or evidence of development or progression of TODConsider addition of beta-blocker or substitution of amlodipine with hydralazine

Elevated SBP with hypertensive encephalopathy Elevated SBP with evidence of hypertensiveretinopathy

Hospitalization and continuous BP measurement for useof peripheral vasodilators (e.g. hydralazine, nitroprusside)

Elevated SBP on 23 occasions


If evidence of TOD re-examine after ~48 hours otherwise 714 days

If evidence of TOD re-examine after ~48 hours otherwise 714 days


If veryacute

Hyperadrenocorticism If no evidence of TOD then treat hyperadrenocorticism and re-assess BP If TOD present or hypertension persists with control of hyperadrenocorticism then follow CKD

antihypertensive protocol

Phaeochromocytoma Treat with phenoxybenzamine and titrate dose to eect Surgical resection of adrenal mass


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The first line anti-hypertensive agent in cats is amlodipine besylate, a calcium channel blocker. Cats appear to have a unique sensitivity to this anti-hypertensive agent and invariably a reduction in blood pressure of 2030 mmHg can be expected. Angiotensin-converting enzyme inhibitors (ACEis) are the most common second line antihypertensive agents but have a relatively limited antihypertensive action, reducing BP by approximately 510 mmHg.

Care should always be taken when introducing an ACEi, particularly in cats with moderate to severe chronic kidney disease (CKD) or evidence of dehydration, when use of an ACEi may result in a rapid reduction in renal function and worsening azotaemia. Monitoring of renal function is advocated after introduction of this medication.

Systemic hypertension in dogs is much more challenging to manage than in cats. In dogs with CKD and systemic hypertension the first line anti-hypertensive agent is an ACEi, although response to this agent can be variable and disappointing. However, there is evidence that ACEis may have additional benefits in dogs with CKD by reducing proteinuria. Once again care must be taken if introducing this class of medication to dogs with moderate to severe kidney disease or dehydration due to the concerns regarding decline in GFR.

If BP is inadequately controlled with an ACEi alone, then amlodipine besylate is often added to the regime. Hydralazine, beta-blockers and aldosterone antagonists can be considered if the combination of an ACEi and amlodipine are ineffective, but great care must be taken and frequent monitoring performed to ensure against episodes of hypotension (systolic BP

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Congress 1115 APRIL 2012

Progress in pathology

What does a veterinary practice expect from the service that it gets from a commercial pathology lab? It certainly hopes for a speedy and accurate response when it

sends off a biopsy sample from an animal with a possible tumour. The vet who took the sample would like to know what sort of cell type is involved, so that he or she is able to tell the client whether the mass is benign or malignant.

But what if the report that comes back from the lab can identify the specific gene mutation causing the problem and give a reliable assessment of the likely disease progression, based on the previous findings in other animals with that particular abnormality?

Unfortunately, at present not even the most advanced laboratory can offer that sort of deluxe service but it wont be very long before they can, Animal Health Trust oncologist Sue Murphy will tell colleagues at the BSAVAs annual Congress in Birmingham.

Seeing into the futureIn her presentation on genetic testing in oncology on Saturday 14 April Sue Murphy will outline the current limitations and future potential of this powerful new technology. Whether the initial cause is a spontaneous mutation, caused by exposure to an environmental mutagen, or by the actions of a viral oncogene, all cancers are a result of damage to the patients DNA. So it is possible for those changes to be passed on to succeeding generations, and certain forms of cancers are known to occur more commonly in particular dog breeds brain tumours in Boxers, osteosarcomas in Wolfhounds, etc.

The AHT is one of several veterinary research centres around the world that is taking samples from related dogs affected by the same form of cancer and performing a genome wide analysis to find out how their DNA differs from that of healthy individuals with the same pedigree. There is a very good chance that in such closely related animals any consistent differences between the two groups will have had some role in the development of the disease in the affected dogs.

Such information can identify those genes that are key to the development of particular forms of cancer, not just in that particular breed but in other types of dog and even in humans. And by identifying the particular problem gene it should be possible to test dogs and bitches to be used for breeding and ensure that their offspring will be healthy.

Delegates at BSAVA Congress will hear about the potential of genetic testing in oncology from Sue Murphy

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Results of a search to locate inherited gene mutations that predispose Labrador Retrievers to developing mast cell tumours

20-21 Congress Murphy.indd 20 20/02/2012 10:32

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Individual gainHowever, the research that Sue Murphy and her colleagues are doing will also have implications for the health of individual cancer patients as well the breed. They have been trying to identify the genetic factors that determine whether, and to what extent, a tumour is malignant. We have been comparing the genetic profiles from two groups of dogs with mast cell tumours that have spread and those whose tumours didnt spread. The idea is that if we can identify a genetic signature of badness we can council owners accordingly and plan an appropriate treatment, she explains.

Yet with the solitary exception of the very rare condition RCND (renal cystadenocarcinoma and nodular dermatofibrosis) in German Shepherd Dogs, all the cancers that have been identified so far have been multifactorial conditions, controlled by a number of different genes. So it is unlikely that an accurate diagnosis can be achieved on the basis of a single, simple gene test. More likely, both the diagnosis and prognosis will be based on a gene profile that identifies a quantifiable risk in a particular individual dog.

Benefitting from genome projectStill, rapid progress is being made in the science that will enable the creation of this sort of technology. Sue Murphy says these developments are being helped by the completion in 2004 of the international project to map the canine genome. The potential value of dogs in comparative oncology studies is widely accepted and so it is no longer such a struggle to attract the funds needed to support this branch of veterinary research.

That project has allowed the development of tools that enable genetic investigations to be carried out much more effectively funding bodies are aware that investigators have access to these tools and therefore are more likely to look favorably on investigations of this type, she points out.

However, the research that Sue Murphy and her colleagues are doing will also have implications for the health of individual cancer patients as well the breed. They have been trying to identify the genetic factors that determine whether, and to what extent, a tumour is malignant. We have been comparing the genetic profiles from two groups of dogs with mast cell tumours that have spread and those whose tumours didnt spread. The idea is that if we can identify a genetic signature of badness we can council owners accordingly and plan an appropriate

Yet with the solitary exception of the very rare condition RCND (renal cystadenocarcinoma and

SUE MURPHY AT CONGRESS

Geneti c testi ng in oncology: where are we? Saturday PM

See the full Science Programme online at www.bsava.com/congress

Impact on practiceSo what impact will this work have on first opinion practices and what does the future hold? Ideally vets will be taking a few cells of certain tumour types via fine needle aspiration on to a special microscope slide which the practice will send off to be processed. That will confirm the tumour type and give an objective idea of the prognosis for that individual tumour and also whether it is likely to be sensitive to the treatment options open to practitioners. I cant see that happening in the next decade, it will be more like 20 years, Sue Murphy suggests.

However, i f practitioners want to get hold of these valuable diagnostic tools any earlier than that, they will have to play their part in supporting the necessary research.

We can only do this research if we have samples collected by vets and owners. We can provide cheek swab kits for breed-based research and a special fixative RNAlater for tumour samples. Contact us for kits!

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Browsing on the Balcony

Four important new editions and the inaugural BSAVA Foundation Manual will be launched at the bookshop on the BSAVA Balcony. Come and browse and benefit from some great special offers

BSAVA Manual of Canine and Feline Endocrinology, 4th edition

Edited by Carmel Mooney and Mark Peterson

Since publication of the third edition in 2004 there have been important advances in the field of endocrinology. Several endocrine disorders, such as feline acromegaly and hyperaldosteronism, have risen in importance. The use of diet and novel insulins in diabetic cats, and new drugs such as trilostane and methimazole, which were mentioned briefly in previous editions, are now considered routine. In addition, the genetic risks associated with many disorders have been elucidated.

There has been a change in the format of the Manual to provide easier access to relevant information. The first chapter deals with the type of assays used for hormone measurement and the collection and storage of samples and how this may influence the results obtained.

The second chapter represents a new and exciting venture, outlining the principles for interpreting endocrine test results and introduces the reader to

assessment of test performance and how to improve diagnostic confidence.

The following chapters describe disorders associated with each major endocrine gland. The final section of the Manual provides information on solving both clinical and clinicopathological abnormalities for w hich endocrine disorders are a major consideration.

Congress price: 49.00BSAVA members: 44.00*

BSAVA Manual of Canine and Feline Haematology and Transfusion Medicine, 2nd edition

Edited by Michael Day and Barbara Kohn

The first edition of the BSAVA Manual of Canine and Feline Haematology and Transfusion Medicine was a leader in its field, and this new edition has been eagerly awaited.

The basic principles of haematology, which form the core of the Manual, have been updated to include new diagnostic procedures and new treatment strategies. There are new chapters on anaemia of inflammation and neoplasia, non-regenerative anaemia, and vascular thrombosis.

Arthropod-transmitted infectious diseases in companion animals are increasingly significant, reflected in updated chapters on leishmaniosis, babesiosis, monocytic ehrlichiosis and anaplasmosis, where haematological analysis is part of the first line of diagnosis.

Another area in which there have been significant advances since the first edition is feline haemoplasmosis, and a completely revised chapter provides the latest information on these infectious agents.

The section on transfusion medicine has been reorganised and expanded, with stand-alone chapters on canine and feline blood groups and transfusion. A new chapter considers the use of blood substitutes. The information in the Manual is presented in a way that is easily applied to the clinical case the practitioner is reading about. Substantial background information is provided for those who want to learn more about that particular topic.


BSAVA Manual of Canine and Feline Surgical PrinciplesA Foundation Manual

Edited by Stephen Baines, Vicky Lipscomb and Tim Hutchinson

Meticulous attention to the basic principles of surgery is critical if a good surgical outcome is to be achieved. Good surgeons are not simply those who are skilled at surgery, but those who ensure that every aspect of patient care is performed to the highest standard. Complications that arise following surgery are often attributable to a lack of understanding or appreciation of the importance of these basic principles.

The Manual is divided into three main sections: surgical facilities and equipment; perioperative considerations for the surgical patient; and surgical biology and techniques.

The Manual covers those key topics required for surgical success that are often overshadowed in larger textbooks of veterinary surgery and which are relevant to all members of the veterinary team.

The BSAVA Manual of Canine and Feline Surgical Principles provides a solid grounding in best practice for the basic

Lipscomb and Tim Hutchinson

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BSAVA Textbook of Veterinary Nursing, 5th edition

Edited by Barbara Cooper, Elizabeth Mullineaux and Lynn Turner

Equine consulting editor: Tim Greet

The new edition of the classic core textbook, updated to reflect changes in the RCVS Veterinary Nursing syllabus, covers the whole range of veterinary nursing in small animal practice, and core unit equine content, with all chapters revised or rewritten.

New content:

Anatomy and physiology presented in a single integrated chapter to allow easy comparison

Stand-alone chapter on Nursing Models, with clinical application examples

New chapter on Professional responsibilities, Regulation and Ethics

Up-to-date content on MRSA and PETS regulations

Addresses equine species as required by VN core units including details on anatomy, handling, stabling, feeding, bandaging, radiography, reproduction and anaesthesia.


*BSAVA MEMBERS EXCLUSIVE OFFER

BSAVA members get an additi onal 5 OFF all ti tles at Congress on producti on of a valid membership card. Remember to show the sales team your card to receive the discount.

ATTENDING A SATELLITE MEETING?

BSAVA is pleased to announce that this year there will be two BSAVA Stands open on Wednesday 11 April.

Registrati on Area in the NIA ICC (top of the escalators by the internet

caf)

Both stands are open from 10am to 6pm

For those att ending A liated Group meeti ngs who are not att ending the main BSAVA Congress, or those who want to beat the rush during the main exhibiti on, this will provide an opportunity to nd out about BSAVA membership, become a member, and purchase copies of BSAVA Manuals.

RELATED LECTURES AT CONGRESS

A problem-oriented approach to focal and multi focal alopecia in dogs and cats Rosario CerundoloThursday 12 AprilHall 5 08.3009.15

Blood smears (practi cal) Roger PowellThursday 12 AprilHall 7 14.0017.30

Feline hyperaldosteronism Hans KooistraFriday 13 AprilHall 3 15.1015.55

Managing a diabeti c cat: what do you need to know? (nursing lecture) Jacqui RandSaturday 14 AprilHall 8 11.1512.00

Disorders of hypercalcaemia: how much should I react? Dennis ChewSaturday 14 AprilHall 4 14.1515.55

Principles of intesti nal surgery Bryden StanleySunday 15 AprilHall 5 09.5510.40

principles of veterinary surgery, which will be particularly helpful for veterinary students, new graduates and veterinary nurses as well as any veterinary surgeon wishing to update their knowledge.


BSAVA Manual of Canine and Feline Dermatology, 3rd edition

Edited by Hilary Jackson and Rosanna Marsella

Dermatology constitutes a large percentage of the daily caseload in small animal practice and can represent a challenge for the busy practitioner, as many different diseases have similar presenting signs. Thus, a solid understanding of how to approach a dermatological case logically and sequentially is essential for a successful outcome.

The BSAVA Manual of Canine and Feline Dermatology begins by providing the reader with a grounding in examination and investigative techniques. The second section provides a problem-oriented approach to the common dermatological conditions encountered in practice, including erosions and ulcerations, focal and multifocal alopecia, and pruritus.

The final part of the Manual covers the major skin diseases of dogs and cats caused by bacteria, yeasts, fungi and parasites.


22-23 Congress Publications.indd 23 20/02/2012 10:31

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Congress 1115 APRIL 2012Congress 1115 APRIL 2012Congress 1115 APRIL 2012Congress

John Bonner meets Mike Pavletic, a man driven to explore the boundaries of reconstructive surgery and who will be sharing his enthusiasm and expertise with delegates at Congress next month

The possibilities of reconstructive surgery

ago, before effective reconstructive surgery techniques were developed for veterinary use. But since then there has been remarkable progress in methods to restore both function and cosmetic appearance in a badly traumatised animal, and no-one has made a greater contribution to that work than one of the speakers at BSAVA Congress in April.

American pioneerDr Mike Pavletic, director of surgical services at Angell Animal Medical Center in Boston, Massachusetts, is the author of the Atlas of Small Animal Wound Management and Reconstructive Surgery, the standard text on the subject, now in its third edition. He has also developed more than 50 original surgical techniques and was awarded the BSAVAs Bourgelat

Treatment options used to be pretty limited for a dog that arrived at a veterinary clinic with extensive burns or any similar large scale injuries. To spare the animal a lifetime of pain

and discomfort there would usually be little choice except euthanasia. That was the situation 30 years

24-26 Congress_Pavletic.indd 24 20/02/2012 10:29

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international award in 1996 for contributions to small animal practice. He will be delivering a series of three presentations in the reconstructive surgery stream.

A 1974 graduate of the University of Illinois veterinary school, Mike first became interested in this particular branch of surgery during his first year in veterinary practice. He was presented with a feline case whilst working as an intern at the clinic where he is currently based. (He returned to the Angell clinic in 1998 after spells as a professor of surgery at Louisiana State University and head of surgery at nearby Tufts University.)

A cat arrived with a tumour involving the left cheek region, he recalls. Removal of the growth would have resulted in a wound that could not be closed in any conventional manner. Since this area of surgery was never discussed in any depth at veterinary school, I found an old human textbook in the library. In it, a plastic surgical technique was described for use in a human with a similar lesion. The technique, a transposition skin flap, was what I replicated to close the large facial defect in the cat. At that moment, I became excited by the idea of moving and using other regional tissues to reconstruct defects after trauma or the removal of diseased tissues.

A growing passionHowever, Mike found that there was little veterinary literature to fuel his new found enthusiasm for

reconstructive surgery, and so to further his knowledge he spent many hours in the university library studying books and journal articles produced by human surgeons. I also performed numerous cadaver studies to understand the anatomy and circulation to the skin and muscle. Over the years, I have focused my research on skin flaps, skin grafts, muscle flaps, footpad reconstruction, facial and oral surgery. I have also studied traumatic wounds and their management, including gunshot wounds, burns and bite wounds. Each of these forms of trauma can result in massive tissue loss, he explains.

One of the problems he faced was that most of his veterinary colleagues regarded this area as an interesting niche of surgery but with little practical application in their routine work, he says. What they failed to understand was the fact that reconstructive surgery used to close traumatic wounds opened the door to more advanced cancer surgery in veterinary medicine. Surgical oncology and reconstructive surgery are closely linked: wide tumour resection creates large, problematic defects where other tissues are needed to close the hole. Plastic and reconstructive surgery can oftentimes restore function to a body region damaged by neoplasia.

The cosmetic appearance of the wound site after it has healed may be important but it is not the main surgical priority. Most owners simply want their pet to

(Main picture): Mike Pavletic examining a 25-year-old feline patient recovering from surgery. A tumour was resected from the right side of the face and the area was reconstructed with a transposition flap elevated from the lateral cervical area. (Above from LR): Views of the: tumour; surgical defect; closure with a transposition flap.


26 | companion


AVAILABLE FROM BSAVA

BSAVA Manual of Canine and Feline Wound Management and Reconstructi on, 2nd editi on

Edited by: John Williams and Alison Moores

This latest (2009) editi on has been completely updated under its new editorial team. As before, emphasis is placed on practi cal decision-making, underpinned by an understanding of the biological wound healing process. Chapters have been expanded to take account of recent developments in wound care and in surgery.

Practi cal decision-making Advanced aps, graft s and microsurgery Step-by-step Operati ve Techniques Case examples

ContentsThe biology of wound healing; Wound aeti ology and classi cati on; Decision-making in wound closure; Management of open wounds; Surgical drains in wound management and reconstructi ve surgery; Tension-relieving techniques and local skin aps; Axial patt ern aps; Free skin graft ing; Pedicled muscle aps; Microsurgery; Special considerati ons in wound mangement; Complicati ons of wound healing; Index.

Member price 49Non-member price 75

The possibilities of reconstructive surgery

return home as a functional member of the family. Of the various body regions undergoing reconstructive surgery, owners are most concerned about their pets head, probably because we relate to our pets face to face. They are always appreciative when we can simultaneously restore function with the added bonus of reasonably good cosmetic results.

Continuing to get a kickEven after 30 years as a board certified surgeon, Mike gets a real kick out of the challenges that he faces when planning a complex reconstruction. Personally, there is nothing more exciting than to develop a procedure to resolve a problematic wound or surgical problem, he says.

Most of the cases that come into his clinic are cats and dogs but occasionally I have operated on exotic pets, zoo animals, and even raptors at a local wildlife rehabilitation facility. There is no shortage of problematic wounds to close. Most of the techniques translate well between species, although there are greater limitations in birds due to the significant anatomical differences from mammals, he says.

Expertise at CongressAlthough many of the techniques that he will be describing in his presentations in Birmingham are technically complex, Mike insists that this is not always the case. Many of the methods used in plastic and reconstructive surgery are simple and practical for use in routine surgical procedures. So he hopes that his sessions will attract both experienced veterinary surgeons with an established interest in reconstructive surgery and their junior colleagues who are looking to develop their skills in this area.

Mike is also keen for veterinary nurses to come along to the sessions (BSAVA VN members can upgrade to Vet Streams). He points out that VNs play a pivotal role in helping clients to understand the treatment that their pet will undergo and in

explaining the likely outcomes. Good nursing skills are also vital in ensuring the success of any surgical intervention.

Some surgical techniques are demanding and require detailed postoperative care for an optimal outcome. Infection is always a risk associated with surgery and there are a variety of factors that can contribute to its formation. Many factors can be minimised or avoided to prevent infection. Like most things in medicine, prevention is far more useful than treating a problem, Mike explains.

So what are the most challenging cases that the surgical team is likely to face? The challenge varies according to the size of the wound or surgical defect and its location. A while back I reattached the side of a cats face that was sheared off by the fan on a car engine. I was able to carefully reattach the face and restore function to the left eye where the upper and lower eyelids had been torn away from the skull. I was impressed by the pets resilience and over time function was restored.

MIKE PAVLETIC AT CONGRESS

How to manage trauma cases (Interacti ve Vet Stream) Thursday AM

Management of bite wounds (Wound Management Nursing Stream) Friday PM

Skin stretching techniques in reconstructi ve surgery (Reconstructi ve Surgery Vet Stream) Saturday PM

See the full Science Programme online at www.bsava.com/congress


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Each year a small group of colleagues from an emerging companion animal veterinary association is invited to visit Congress as part of a scheme run by BSAVAs International Affairs Committee (IAC)

International Affairs, Al Gibson, and will pack in as many lectures as they can in between social events like the Friday Banquet and Saturdays Party Night.

Insuring pets is not common in Bulgaria, so veterinary surgeons often find themselves limited in their experience of more involved procedures and treatments and there is little incentive in practice investment in expensive equipment that wont be used. However, members of this delegation represent two of the largest veterinary clinics in the country.

Nobody in the party has been to a BSAVA Congress previously and Maria says that they are particularly excited about the science: We are most looking forward to hearing the world renowned speakers in all those different fields; obtaining new ideas, methods, and sharing our experience with new colleagues.

Whos whoMaria graduated with honours from the Faculty of Veterinary Medicine in Sofia in 2007 and has been working in a practice since then, mostly with dogs and cats. Her clinical interests include ophthalmology, eye surgery, soft tissue surgery, oncology and critical care.

Krasimira graduated from Sofia in 2008. She is working as a general practitioner and her professional interests include small animal reproduction, internal medicine and exotics.

Anelia also graduated from Sofia in 2008. She is working at the Blue Cross clinic and her special clinical interests include cardiology, surgery and infectious diseases of small animals.

Mihail is the most recent graduate in the delegation, having left Sofia in 2010. He also works as a general practitioner at the Blue Cross clinic and his professional interests are emergency medicine, infectious diseases and orthopaedics.

Bulgaria to benefit from BSAVA

Choosing the nationWolfgang explains how the nation is selected each year: At the moment the Visiting Programme is only considering members of companion animal veterinary associations in European countries. The scheme is advertised though the directors of FECAVA, the Federation of European Companion Animal Veterinary Associations. Groups of up to four practising companion animal veterinary surgeons are asked once a year to submit an application of not more than 500 words in which they detail the composition of their group, their professional backgrounds and in which they explain how their daily work could benefit from a visit to BSAVA Congress. IAC reviews all submissions at the end of October and, based on the majority vote of its members, then decides who the visitors to next years Congress will be.

Much to gainMost participants in the scheme are amazed by the sheer size of BSAVA Congress, which in most cases is much bigger than any veterinary conferences they have visited before. Wolfgang says: They are particularly impressed by the variety of subjects that are covered in the lectures and about the opportunities to meet face to face with international leaders in their field of expertise. Frequent compliments are also made about the excellent social programme, the evening entertainment and the friendly atmosphere at Congress. A number of these visitors have used the Exhibition to set up business contacts between UK-based companies and businesses in their country.

In this World Congress year, overseas delegates are expected in even greater numbers than usual, and supporting our colleagues from Bulgaria in this way reinforces BSAVAs reputation as a world-class event. n

In recent years the International Visiting Programme has brought over guests from the Ukraine and Latvia. In 2012 it is the turn of Bulgaria to benefit from the

special invitation.

Aims of the schemeWolfgang Dohne, who usually plays host on behalf of IAC, explains: The aim is to enable a small group of practising veterinary surgeons from a smaller sister association to participate in the CPD available at BSAVA Congress and to transfer their knowledge back to their national association and of course to use their new information for the benefit of their own patients. It also promotes BSAVA Congress as the most important companion animal CPD event in Europe and should encourage more colleagues outside the UK to consider the benefits of BSAVAs overseas e-membership.

Bulgarian colleaguesThe Bulgarian Association of Small Animal Veterinarians will be sending four veterinary surgeons to the WSAVA/FECAVA/BSAVA World Congress in April 2012. Maria Savova, Krasimira Kodzhanikolova, Anelia Stoilova and Mihail Dimkov will be hosted by the Chairman of

27 Congress_Bulgarians.indd 27 20/02/2012 10:28

28 | companion

As part of its commitment to expanding provision of VN CPD, BSAVA is introducing a new and innovative offering to challenge and inspire vet nurses. Dr Frances Barr, Director of Education, explains

As part of its commitment to expanding provision of VN CPD, BSAVA is introducing a new and innovative offering to challenge and inspire vet nurses. Dr Frances Barr, Director of Education, explains

VN CPD and new merit awards

BSAVA has for many years encouraged veterinary nurses, as valuable members of the practice team who deserve the very best science on offer, to attend Congress for their

CPD. Now veterinary nurses can be BSAVA members in their own right, and membership brings with it

a range of benefits. This includes plans to develop and extend the provision of CPD for nurses outside Congress.

One fine dayIndividual day courses designed specifically for

nurses in first opinion practice will of course continue. These clinically relevant courses are delivered by excellent teachers and, at a heavily

discounted rate for members, offer great value for money. They are a fantastic opportunity to meet

other nurses, to concentrate away from the distractions of the practice, and to pick up those useful tips which can be applied day to day.

WebinarsIn 2012 BSAVA will also be introducing monthly Learn@Lunch webinars for veterinary nurses, which will be free to BSAVA members. Webinars are a wonderful way of keeping up to date without the difficulties of taking time away from work and travelling. We hope veterinary nurses will watch a webinar with colleagues over a sandwich and coffee at lunchtime or if lunchtime isnt a good time, will view the recorded webinar later at a more convenient time.

Something newThe most exciting development in 2012 for veterinary nurses is the launch of the BSAVA Veterinary Nurse Merit Awards. These awards will be for the motivated nurse in primary care practice who would like to expand his or her knowledge in a specific field.

There is an appetite amongst many veterinary nurses for more focussed and structured CPD to become available. BSAVA talked to many of the nurses attending Congress in 2011 and this research confirmed a demand for accessible CPD programmes for individuals with a particular interest. Not all individuals are in a position to be able to commit to diploma level training but the passion which led them into nursing in the first place continues.

28-29 CE VN Merit Awards.indd 28 20/02/2012 10:28

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FURTHER INFORMATION

Further informati on regarding the BSAVA VN Merit Awards can be obtained by emailing [email protected]. Individuals may also nd more informati on and enrol on either of the programmes in the CPD secti on of the BSAVA website www.bsava.com.

The opportunity to study a subject and develop the corresponding skills, and then to apply those in the practice, was an exciting prospect. The vets we spoke to also saw the benefit to the practice of having nurses with special interests and skills. To meet this demand, BSAVA have developed the Veterinary Nurse Merit Awards

companion march2012

Documents

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