Companion August2008

The essential publication for BSAVA members

Coping with the cascadeP7

NEW Veterinary Information Network discussionP18

Happiness and work-life balanceP4

Happiness and Coping with the

The essential publication for BSAVA members

companionAUGUST 2008

Haemorrhagic vomiting

Test your diagnostic skills

NEW Veterinary NEW Veterinary Information Network discussionP18

NEW Veterinary

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CONTENTS3 Latest News

Hydatid Disease, Practice Standards, Montenegro guests

46 Dont Worry, Be HappyPete Wedderburn reviews NI Congress success

79 Coping with the CascadeJohn Bonner on prescribing new medicines

1013 Clinical ConundrumA collapsed dog with profound haemorrhagic vomiting

1417 How ToNavigate the Pet Travel Scheme

1819 Letters from AmericaNew feature selected discussions from the Veterinary Information Network

20 PetsaversFundraising news

21 Getting Tough on SeizuresSimon Platt looks at the treatment options

2225 WSAVA NewsWorld Small Animal Veterinary Association

26 The companion InterviewVictoria Roberts

27 CPD DiaryWhats on in your area

companion is produced by BSAVA exclusively for its members.BSAVA, Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley, Gloucester GL2 2AB.Telephone 01452 726700 or email [email protected] to contribute and comment.

KNOWLEDGE BANK

Additional stock photography Dreamstime.com Alexandr Sysoev | Dreamstime.com Amy Harris | Dreamstime.com Bruce Parrott | Dreamstime.com Ina Van Hateren | Dreamstime.com Lyn Baxter | Dreamstime.com Martin Murnsky | Dreamstime.com Orlando Florin Rosu | Dreamstime.com Raja Rc | Dreamstime.com Sgame | Dreamstime.com Stuart Monk | Dreamstime.com Vicente Barcelo Varona | Dreamstime.com

How does BSAVA contribute to your personal professional development? As well as companion as a BSAVA member you also get a complimentary subscription to the Journal of Small Animal Practice (JSAP) and one free copy of each new edition of the BSAVA Small Animal Formulary plus the opportunity to build your library of BSAVA Manuals at significant discounts.

August sees the release of the new Manual of Raptors, Pigeons and Passerine Birds, which promises to be a valuable addition to the series. Edited by John Chitty and Michael Lierz, with contributions from some of the most prominent experts on the subject, the manual will be available from the end of this month.

Other new titles planned for the coming year include:

Manual of Canine and Feline Advanced Veterinary Nursing, 2nd editionManual of Canine and Feline Wound Management and Reconstruction, 2nd editionManual of Rodents and Ferrets Manual of Canine and Feline Abdominal Imaging

As these are released they can be purchased online at www.bsava.com or you can of course find all the latest releases when you visit the Publications stand at Congress. In April the Publications stand will have a brand new home offering an even more comprehensive service on the balcony in the NIA.

For more information visit the website, email [email protected] or call 01452 726700.

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LATEST NEWS

COMMENT ON STANDARDSBSAVA would like to invite members to comment on updating the RCVS Practice Standards scheme.

Pam Mosedale sits on the BSAVA Membership Development Committee. She is actively involved in the scheme as

an RCVS Practice Standards Inspector. In addition Pam is leading the BSAVA initiative to produce more online tools for members in practice the latest resource is a sample Clinical Governance Policy, which can be adapted specifically for your

practice. Find this online in the Resource section at www.bsava.com. Pam would like to hear your comments both on the Practice Standards scheme and the clinical governance policy document. Email [email protected] n

MONTENEGRO BENEFITS AT BSAVA s part of BSAVAs commitment to support small animal veterinary associations in developing countries, BSAVAs International Affairs

Members of the Montenegrin delegation with BSAVA president Frances Barr at BSAVA Congress 2008. From left: Nebojsa Scekic, Frances Barr (BSAVA President 20072008), Wolfgang Dohne (International Affairs Committee Member and organiser of the Visit Programme), Dusanka Kazic and Savo Nikovic

Committee arranged for a small group of surgeons from Montenegro to be guests of honour at this years BSAVA Congress.

The majority of veterinary surgeons

practicing in Montenegro are graduates from Belgrade and, although now an independent state, Montenegro is still very closely connected with neighbouring Serbia, which meant that delegates had to travel to Belgrade for their UK visas.

As there is currently not enough demand for small animal medicine in Montenegro to support 100% small animal practices, all the invited vets were working in mixed practice. However with increasing economic wealth they were beginning to see an increasing demand for small animal work.

Only very few clinics are currently using gaseous anaesthesia and with the average cost for a bitch spay at 50, expenses still have to be kept to a minimum. There is no established pet insurance scheme in Montenegro and dogs are by far the main small animal species treated. Montenegrin delegates were amused to learn that a year old tortoise can cost well over 100 in the UK, considering that the same animals are a fairly common sight in their own gardens.

The guests from Montenegro took full advantage of the BSAVA Congress Scientific and Social programme, and were delighted to have a meeting with then President Frances Barr. n

HYDATID DISEASE CAMPAIGNbeen known as a hot-spot for the disease, regular supervised worming of farm dogs is taking place and those dogs are then being monitored. During the campaign all farms in the area will be given the opportunity to participate in the scheme and those involved will be visited four times during the year.

Rural Affairs Minister Elin Jones said, Hydatid disease can be dangerous to humans and it can be avoided by the simple procedure of regular worming of dogs. More information and a poster can be found online at www.wales.gov.uk/animaldiseases. n

The regular worming of dogs is the best protection against Hydatid Disease, which can affect both dogs and people, so the Welsh Assembly Government is funding a campaign for control of Echinococcus granulosus.

In South Powys, which has previously

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Pete Wedderburn reports on the happiness programme at the BSAVA/SPVS/BVNA weekend in Northern Ireland in May

mountain biking, a climbing wall, and the usual conference-related social events. By the end of the weekend there was no excuse to return to work feeling stressed, and delegates were well briefed on techniques such as deep breathing, direct talking and anger management.

AwarenessMost vets are now acutely aware of the professions increased risk of succumbing to drug/alcohol abuse and mental health issues. Yet, despite this wider awareness, the general public still sees vets as cosy, companionable, relaxed James Herriot types. Ironically, Alf Wight, the author of

the James Herriot books, suffered from severe depression himself in the early 1960s, before writing his books.

Self-awareness of the problem within the profession is just the first stage in dealing with this major issue. Over the next decade, much work still needs to be done in addressing and publicising an issue that remains, at some level, a subject of social taboo.

Suicide is clearly the worst of all stress-related events. The rate of suicide among vets is three to four times higher than the national average, higher than for any other profession or sector of population.

The problem of the high suicide rate amongst veterinary surgeons was first publicly highlighted when an article was published in the British Medical Journal in 1983. A number of publications confirming the statistics followed. Work published in the Australian Veterinary Journal showed a similar high incidence of suicide, suggesting that the trend may be a global problem in the profession. In 2005 Richard Mellanby, a specialist in small animal internal medicine now at Edinburgh University, published an update in the Veterinary Record on these earlier statistics on veterinary suicide.

Studying the causesThere is still much debate about the reasons for the high suicide rate. Intuitively, onlookers suspect that the biggest contributory factor is vets access to lethal drugs, and knowledge about the practical procedure of euthanasia. Most suicides among vets, both males and females, are by drug overdose and markedly more vets use this method than other sectors of the population.

The veterinary profession has reacted proactively to reports of stress-related

Over the past twenty years, the problem of stress-related crises in the veterinary profession has repeatedly been highlighted in the veterinary media and the profession has been finding ways of addressing the mental health issue. The Society of Practising Veterinary Surgeons recently organised an innovative programme at the joint conference with the Northern Ireland branches of BSAVA and BVNA. The theme of the weekend was Happiness and WorkLife Balance, with lecturers drawn from research psychologists, life coaches and television comedians. As well as lectures, delegates took advantage of

DONT WORRY, BE HAPPY

John Hill, President of SPVS with partner Susie Turner

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problems, including suicide. The RCVS has chaired various working parties that have looked into the problem. More recently, it has been recognised that if appropriate preventive action is to be taken, more specific research is needed into the precise nature of the issue.

David Bartram, a 1988 graduate of the RVC, is currently working on this subject. David has been working with research psychiatrists at Southampton University, and has been designing and analysing a questionnaire that has enabled a thorough, objective assessment of the problem.

In late 2007, he sent out the questionnaire to a stratified random sample that represented 20% of the practising profession, including all who were using their MRCVS in any form. In total, 3200 out of 16,000 vets were contacted. Around 1800 questionnaires were returned, representing a response rate of 56%. It is unusual to achieve higher than a 40% response rate to postal questionnaires, and David feels that this high return rate may reflect the fact that vets feel that the stress problem is highly relevant to their daily lives. The research provides very comprehensive coverage of the profession, from new and recent graduates through to vets approaching retirement, and from vets in all types of work from different types of practice through to industry, government and academia. The parameters measured are compared with those for the general population and for other related professions.

David says, The questionnaire was designed to adopt a holistic approach, looking at positive aspects of veterinary careers (so-called satisfiers) as well as the stressors. Previous research has

demonstrated that doctors believe that the feel good bits of their job mean that they are able to deal with more stress than they would otherwise be able to do. This same principle may apply to vets. Davids results are currently being collated and he hopes that they will be ready for publication in 2009.

Additional work is being carried out by Richard Mellanby, who is undertaking a study with Professor Keith Hawton, head of the Centre for Suicide Research at the University of Oxford. Their research aims to explore further the circumstances immediately preceding veterinary suicides, through examination of coroners reports and interviews with friends and family of the deceased. A further questionnaire-based survey of the mental health status of the profession is also planned, funded by the Veterinary Benevolent Fund, RCVS and Hills Pet Nutrition.

It is hoped that the culmination of the various ongoing research projects will allow objective, evidence-based recommendations to be made as to how vets should try to address the alarming incidence of suicide. The profession will then be in a much stronger position to identify subgroups of the population at risk, as well as specific stressors that predict poor health.

Todays supportEven without the benefit of detailed research into the background to the problem, a number of initiatives have been set up in an attempt to deal with the stress affecting veterinary surgeons.

Several years ago, the Veterinary Benevolent Fund, with a core aim of supporting vets in financial difficulties,

merged with the two other organisations that were providing support to the profession:

1) The Veterinary Surgeons Health Support Programme (VSHSP) was established by the veterinary profession in March 1999 to help combat problems of alcohol, drugs, eating disorders and other addictive and mental health issues. The programme was based on similar schemes that had been available to members of the dental and pharmaceutical professions. The last independent clinical audit described the VSHSP as highly efficient and effective. The scheme is completely confidential and is run by a National Coordinator who is a health professional. VSHSP treatment

DONT WORRY, BE HAPPYBE HAPPY

merged with the two other organisations

An older delegate helping a younger participant on the climbing wall

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programmes vary but are designed to suit an individuals addictive state.

Often people with a problem of addiction dont recognise that they have an issue, or delude themselves that they can handle it. Family, friends and colleagues are often the first to realise that someone needs help, and they are encouraged to contact the VSHSP. The VSHSP is autonomous and totally confidential both for those needing help and for those seeking help for others. It is recognised that the path to recovery offered by the professions own Health Support Programme is not the only one available to a veterinary surgeon but it is hoped that those seeking help or advice will make use of this freely available, confidential service by contacting the VSHSP Programme Coordinator on 07946 634220.

2) The Vet Helpline There are currently twenty-five anonymous and unpaid volunteer helpers that run this 24-hour service. They are largely veterinary surgeons or their spouses and offer empathetic discussion of emotional, addictive or financial problems, referring callers on for specialist advice where appropriate. Tel: 07659 811118 (local call rates apply; 24-hour rapid response answer phone).

The Veterinary Support Working Party, whose chairman is Dr Wendy Harrison, is a group which was formed with representatives from all the main veterinary organisations in response to concern over the high rate of suicide and depression within the veterinary profession. A new website, www.vetlife.org.uk, was launched in October 2007. The website aims to provide information about the support available to veterinary students, veterinary nurses and veterinary surgeons on a wide range of issues from both the established veterinary care organisations and from outside the profession.

The veterinary profession has learned much about the fact that it has a stress problem in the past twenty years. It seems that now, at last, we may be on the way to learning how to deal effectively with our problem.

DONT WORRY, BE HAPPY

Delegates about to head out mountain biking

DONT WORRY,

Beautiful weather and a spectacular location dominated by the mountains of Mourne provided the backdrop for a conference combining excellent clinical lectures with a programme on Happiness and WorkLife Balance. Learning how to manage stress was the main SPVS theme at this years combined SPVS, BSAVANI and BVNANI Congress 2008, which took place over three days in late May at the beautiful Slieve Donard Resort and Spa in Newcastle, Co. Down.

The happiness lectures, delivered by Joe Griffen, Des Rice and Nuala McKeever, included a series of thought-provoking seminars on how to cope with life as a modern practitioner. As well as coaching delegates on how to manage workloads and how to ensure that we all have adequate amounts of rest and exercise, therapies such as Emotional Freedom Therapy (EFT) and Neurolinguistic Programming (NLP) were explored.

BSAVANI supplemented this with excellent lectures on dermatology by Steve Shaw, ophthalmology by Pip Boydell, and alternative therapies from the BVNA. These were lively and informative and included plenty of practical information for vets and nurses to implement when they returned refreshed to their own practices. The closing Keynote Lecture included warmth, wit and wisdom on lessons learnt in practice in the Dales from Jim Wight, who shares the same gift of story telling as his father Alf (James Herriot).

The Northern Ireland BSAVA weekend is traditionally a family affair,

HAPPY DELEGATES AT NI CONGRESS

with a vibrant social programme for all ages, and a superb crche to ensure that vets, nurses and spouses can enjoy lectures and some quality chill-out time, safe in the knowledge that the kids are having fun too. John Hill, the immediate Past-President of SPVS and an Ulsterman, merged the successful SPVS Annual Conference format with the regular Northern Ireland weekend, and it was hard to find a less-than-smiley face anywhere, as delegates from far and wide mingled enthusiastically over salsa dancing, photography, laser clay target shooting, climbing walls, mountain biking, and a spectacular Gala Dinner.

Both John Hill and Shane Murray (BSAVA NI Chairman) were grateful for the tremendous support from industry, which ensured a top-class weekend. Over 160 delegates were able to linger over stands representing 40 companies and charities in the beautiful Chandelier Suite overlooking Murlough Bay and the mountains beyond.

Overall, the conference demonstrated that when you get the balance right, work and play can be successfully combined, resulting in very contented vets.

Jim Wight, son of Alf Wight, with John Hill, President of SPVS

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COPING WITH THE CASCADEThe rapid progress being made by the animal health industry in developing new medicinal products can cause problems for veterinary practitioners. John Bonner reports

Many of the drugs in the veterinary armamentarium were originally developed for human use and many have never been specifically tested in domestic animal species. However, increasing numbers of medicines have been launched in recent years for use in companion animals after a rigorous examination of their safety, efficacy and quality. Whilst that makes life easier for us, it also creates difficulties, notably when a licensed veterinary drug arrives to replace a product previously borrowed from the human pharmacy. As the new product will have been through a costly registration process, it will inevitably be considerably more expensive.

Seeking adviceThis issue was highlighted by a letter to the Veterinary Record from Oxfordshire practitioner Martin Whitehead (VR May 3, p599). He complained about being forced to

use the veterinary licensed drug Prilactone (CEVA Animal Health) to treat canine heart failure. This replaced use of a human generic drug spironolactone, which he had been using successfully for many years, and which he insists is equivalent in safety and efficacy to the licensed product. In short, I use Prilactone because the law demands it, not because I have been provided with any evidence or reason to think that the change will make a significant difference to my patients, he explained.

Dr Whitehead asked for advice from the regulator on whether he would be obliged to switch to the licensed product when treating patients whose condition was stabilised under the generic drug. Steve Dean, chief executive of the Veterinary Medicines Directorate, said his organisation does take account of a veterinary surgeons clinical judgement and would not oblige him or her to interrupt successful treatment but any new patients would be expected to be treated with the licensed drug.

VMD positionHowever, in an article published in Veterinary Times earlier this year (VT February 25, p16), Mr Dean reminded veterinary surgeons of their responsibilities under the cascade. He insisted that the changes introduced with the Veterinary Medicines Regulations 2005 were partly a

response to the lax way that practitioners had interpreted the requirements of the cascade... to the extent that human-authorised products were used routinely, despite the availability of suitable authorised veterinary products. Where the only consideration applied is the cost of the medication, and particularly where no clinical judgement is applied, the cascade derogation does not, and has never, permitted this.

Mr Dean went on to warn practitioners against assuming that the biological activity of a human generic product will necessarily be equivalent to that of the licensed veterinary drug. That assumption cannot be reached unless the appropriate studies are carried out and there are many additional reasons why it would be preferable to use the licensed formulation, such as a lack of technical support from the manufacturer of the human product, he said.

Industry viewJuliet Penaliggon, small animal marketing manager for CEVA, points out that the safety and efficacy studies carried out in dogs to obtain a licence for Prilactone have generated new information that had not emerged during human tests. They showed, for example, that in the canine gut the drug is absorbed more effectively when given with food.

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Support from veterinary practice in using the licensed product is essential if the company is to generate the income needed for further studies on the drug. Currently, Prilactone is only licensed for the treatment of heart failure due to mitral valve disease but the company is now carrying out work to obtain a data sheet indication for the treatment of the other main canine heart condition, dilated cardiomyopathy, she added.

Meanwhile, Phil McGuire, regulatory affairs manager with the company, suggests that with a veterinary licensed product now available, more dogs are likely to be given an effective treatment for their congestive heart failure. He believes that practitioners like Dr Whitehead are in a minority in the UK profession. CEVA have carried out independent research into the dosages and contraindications of the human drug, but most vets would prefer to wait until there is a data sheet available, rather than taking the risks of using a product off-label.

Client concernsDr Whiteheads concern is for the welfare of his own clients animals. He points out that the licensed drug is only used in combination with a number of other drugs, all of which have to be paid for by the client. Clearly, the cost of using the licensed product depends on the size of the dog and the dosage needed but in a 30 kg animal he calculates that a client would pay another 20 a month on an already considerable drugs bill.

John Foster, chairman of the BVA medicines group, warns that owners of dogs with mitral valve disease are not the only

ones that may have to face some difficult decisions about the future of their pets. Although there is an increasing array of products available to treat chronic disease in companion animals, some patients will be unable to benefit. New licensed products for conditions such as epilepsy will cost owners many times more than the old generic product. It is very difficult for practitioners to square the circle, simply because a lot of pet owners dont have much money, he notes.

There are, of course, other ways of financing the cost of veterinary treatment. Some owners may be eligible for help from one of the animal welfare charities and others may have been prudent enough to take out a pet insurance policy. But as Mr Foster who also acts as a veterinary advisor to the pet insurance industry points out, the expense of long-term treatment for chronic disease is one of the factors driving up the cost of pet insurance premiums. So owners may find it increasingly difficult to obtain policies with appropriate cover.

Cascades purposeThe cascade system was designed to protect the public, and particularly consumers of animal-derived products, by ensuring that all veterinary medicines are used responsibly. It was seen as providing a rational balance between the legislative requirement for veterinary surgeons to prescribe and use authorised veterinary medicines where they are available, and the need for professional freedom to prescribe other products where they are not. It was also intended to guarantee that a range of

medicines is available for use by veterinary surgeons by ensuring that the companies who invest in research are rewarded appropriately for their efforts.

On that basis, the system has been largely successful, and representatives of the profession meet regularly with officials from the VMD to sort out any problems as they arise. However, no system is perfect and practitioners are likely to face increasing tensions between their responsibilities under the legislation and their duties towards their clients and their animals.

As Mr Dean explained in his article, the VMD feels that on too many occasions in the past practitioners have erred in favour of their clients. So it has now withdrawn its former guidance that the use of human generics might be acceptable in the exceptional circumstances where an animals health and welfare could be compromised because the owner lacked funds. He said this was necessary because of the way practitioners had interpreted the advice in a way that was not within the spirit of the legislation or guidance.

Professions concernsFor colleagues working in farm practice, euthanasia on economic grounds has always been a fact of life and so it may become with increasing frequency in companion animal practice, Mr Foster warns. It is a very difficult situation for practitioners to find themselves in they know what the diagnosis is and they know what the best treatment is but they cant use it for financial reasons. They will have to say, I am sorry but I have to put your animal to sleep. That is an awful position to be in.

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Guidance from the Veterinary Medicines Directorate on the Cascade1 states that: If there is no medicine authorised in the UK for a condition affecting a non food-producing species, the veterinary surgeon responsible for treating the animal(s) may, in particular to avoid unacceptable suffering, treat the animal(s) in accordance with the following sequence:

(a) a veterinary medicine authorised in the UK for use in another animal species or for a different condition in the same species;

or, if there is no such product:

(b) either (i) a medicine authorised in the UK for

human use; or(ii) in accordance with an import

certificate (see VMG Note 7), a medicine authorised for veterinary use in accordance with Directive 2001/82 (as amended) in another Member State;

or, if there is no such product:

(c) a medicine prepared extemporaneously, by a veterinary surgeon, a pharmacist or a person holding an appropriate manufacturers authorisation, as prescribed by the veterinary surgeon responsible for treating the animal.

As stated in the article, the Veterinary Medicines Directorate . does take account of a veterinary surgeons clinical judgement. The following cases are practical examples of prescribing under the cascade.

Case OneYou have diagnosed a chronically vomiting dog with lymphoplasmacytic gastritis and gastric ulceration by endoscopy, and the owner is enquiring about treatment. What drugs, under the Cascade, can you prescribe?

Zitac (cimetidine (Intervet)) is the only acid blocker with a veterinary market authorisation for the oral treatment of gastritis in dogs, and if cimetidine is your drug of choice you must prescribe this product. You cannot choose a different product containing the same active

molecule just because it is cheaper. Thus, you cannot prescribe potentially cheaper human products (e.g. Tagamet (GSK)) or generic cimetidine. Clients may prefer to buy these products over the counter at their local pharmacy, but you must prescribe Zitac. However, as the authorised therapy is a POM-V, the veterinary surgeon should strongly recommend the use of the veterinary product given that the human products are not authorised for veterinary use and the dosage and directions for use could well be different to those described for humans on the label. Should there be an adverse reaction related to the treatment using a human product, the responsibility would rest with the owner and a veterinary surgeon would be expected to strees the risks involved in this course of action.

You may make a clinical judgement that you should prescribe a different acid blocker because the potential side-effects of cimetidine are of concern in a particular case and an alternative product may have additional properties that would be useful in a specific case. Ranitidine, for example, is at least as efficacious as cimetidine, may not have some of the side-effects associated with cimetidines cytochrome P450 inhibition and, perhaps importantly in chronic gastritis, has a prokinetic effect. Chronic gastritis is often associated with delayed gastric emptying and where this is suspected as a complication a prokinetic may be beneficial. As there is currently no veterinary licensed ranitidine preparation, the cascade would permit you to recommend a product authorised for human use such as Zantac (GSK). The owner should be made aware of the reasons for the recommendation and the potential risks associated with the unauthorised medicine.

If the gastric ulceration is severe you may make a clinical judgement to use sulcrafate and a proton pump inhibitor. There is no veterinary licensed version of sucralfate, and so you could prescribe the preparation Antepsin (Chugai Pharma) authorised for human treatment. Omeprazole does have a veterinary market authorisation for horses (GastroGard (Merial)), but the concentration of active ingredient in the paste makes safe administration to dogs impossible. Therefore, where safety is an issue, a

human licensed preparation (e.g. Losec, AstraZeneca) could be prescribed. If a suitable veterinary authorised proton pump inhibitor became available it must be prescribed.

In addition symptomatic treatment with a low-fat, highly digestible diet or an exclusion diet may resolve the problem. Of course, if you believe in Helicobacter as a cause of gastritis, antibiotic therapy alone may be beneficial.2

Case TwoYou wish to give an antiemetic to a cat with acute persistent vomiting.

Cerenia (maropitant (Pfizer)) has a market authorisation for the treatment of vomiting in dogs, but is not licensed for use in cats. There is no other formulation of maropitant, but the use of a similar human licensed product, aprepitant [Emend (Merck)], as well as being foolhardy because there is no safety data for its use in animals, would not be not allowed under the Cascade.

There is reliable evidence that Cerenia is safe and effective in cats even though not specifically licensed in cats3. However, you can make a clinical judgement to use an established anti-emetic such as metoclopramide. This judgement must be based on its potential efficacy and safety in cats, and not on cost.

1 http://www.vmd.gov.uk/General/VMR/vmg_notes07/VMGNote15.pdf

2 Leib MS, Duncan RB & Ward DL. Triple antimicrobial therapy and acid suppression in dogs with chronic vomiting and gastric Helicobacter spp. Journal of Veterinary Internal Medicine 2

3 Hickman MA, Cox SR, Mahabir S, et al. Safety, pharmacokinetics and use of the novel NK-1 receptor antagonist maropitant (CereniaTM) for the prevention of emesis and motion sickness in cats. Journal of Veterinary Pharmacology and Therapeutics. 2008: 31: 220229

PRACTICAL EXAMPLES OF PRESCRIBING UNDER THE CASCADE

The popular BSAVA Small Animal Dispensing Course takes place in Basingstoke on 23 October. Places are limited. Please email [email protected] or call 01452 726700 for more information.

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Case PresentationA 4-year-old female neutered Hamilton Stovare presented collapsed, as an emergency. Twenty four hours prior to presentation the dog had stolen a large amount of homemade flapjack from a work surface in the owners kitchen. During the course of the following day the dog vomited numerous times. Initially the dog brought up undigested flapjack; however, 6 hours prior to presentation the vomit became haemorrhagic (Figure 1). Clinical examination revealed pale mucous membranes, a moderate tachycardia and poor peripheral pulses. A large haematoma, with bruising, was present at the site of previous venepuncture (Figure 2). Dark tarry melaenic faeces were present on the thermometer after the patients temperature was taken.

Simon Tappin of Dick White Referrals invites you to consider your approach to a collapsed dog presenting with profound haemorrhagic vomiting

Figure 1: Marked haematemesis shortly after presentation

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Case PresentationA 4-year-old female neutered Hamilton Stovare presented collapsed, as an emergency. Twenty four hours prior to presentation the dog had stolen a large amount of homemade flapjack from a work surface in the owners kitchen. During the course of the following day the dog vomited numerous times. Initially the dog brought up undigested flapjack; however, 6 hours prior to presentation the vomit became haemorrhagic (Figure 1). Clinical examination revealed pale mucous membranes, a moderate tachycardia and poor peripheral pulses. A large haematoma, with bruising, was present at the site of previous venepuncture (Figure 2). Dark tarry melaenic faeces were present on the thermometer after the patients temperature was taken.

Simon Tappin of Dick White Referrals invites you to consider your approach to a collapsed dog presenting with profound haemorrhagic vomiting

Figure 1: Marked haematemesis shortly after presentation

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CLINICAL CONUNDRUM

What differential diagnoses should be considered at this stage?Pale mucous membranes, a moderate tachycardia and poor peripheral pulses suggest hypovolaemia. Marked haematemesis and melaena suggest that the hypovolaemia is likely to have resulted from blood loss originating from the upper gastrointestinal tract, with gastric or duodenal ulceration most likely. An oral or pharyngeal injury should also be considered, as this could lead to blood being ingested. Given the haematemesis, melaena and haematoma, a coagulopathy should be strongly suspected.

Given that a coagulopathy is considered, what are the next steps?Trauma and handling should be kept to a minimum to avoid further bleeding. Blood samples for planned diagnostic tests should be taken from peripheral veins (cephalic or saphenous) as bleeding after sampling will be less severe and can be controlled more easily with pressure than at a jugular site. Gastroprotectants such as sucralfate, H2 receptor antagonists and proton pump inhibitors may help protect the gastric mucosa, limiting further bleeding. As hypovolaemia is present, replacing circulating fluid volume is essential; crystalloids should be considered in the first instance, with blood products being considered later to replace red cells, platelets and coagulation factors as appropriate.

Is a primary or secondary coagulopathy present?Primary coagulation describes the formation of a platelet plug over the area of blood vessel wall that is damaged. This is then stabilised by a fibrin meshwork, which is the product of the secondary coagulation pathways. Defects in primary haemostasis are caused by inadequate platelet numbers, abnormal platelet function or reduced levels of von Willebrand factor, and usually lead to petechial haemorrhages. Petechial haemorrhages, which may coalesce into ecchymoses, are the hallmark of primary coagulation defects and were not seen in this case. Defects in secondary coagulation are caused by reduced levels of one or more of the coagulation factors and are usually associated with large volumes of blood loss; examples include epistaxis, melaena and haemothorax.

In this case the clinical signs are most consistent with a secondary coagulopathy; however, a primary coagulation defect cannot be excluded by clinical signs alone, and tests of haemostatic function are needed to investigate the underling cause (see Table 1).

Blood samples were taken which revealed a low PCV (18%) and low total solids (54 g/l; reference interval 6080 g/l), consistent with acute haemorrhage. A blood smear revealed normal platelet numbers and buccal mucosal bleeding time was normal, both of which excluded a primary coagulopathy. Blood taken into an ACT (activated clotting time) tube did not clot after 5 minutes; this, in the presence of normal platelet numbers, suggested a secondary coagulopathy. This was confirmed by the laboratory finding of markedly elevated APTT and PT (both 10-fold greater than the control samples). D-dimers were normal, revealing no evidence of fibrinolysis. This suggested disseminated intravascular coagulation (DIC) was unlikely, which was supported by normal platelet numbers.

What differentials should be considered for a secondary coagulopathy?Secondary coagulopathies can be inherited or acquired. Inherited coagulopathies are rare but the most common are haemophilia A (factor VIII deficiency) and haemophilia B (factor IX deficiency). Haemophilia A and B are sex-linked diseases, usually seen in young male dogs, and are diagnosed either by genetic tests or by factor assays. Other factor deficiencies have been occasionally reported, such as factor X deficiency (most commonly reported in American Cocker

Figure 2: Brusing and haematoma formation at the site of previous venepuncture

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CLINICAL CONUNDRUM

CLINICAL CONUNDRUM

Spaniels) and factor VII deficiency (most commonly reported in Beagles). In this case both the APTT and PT were elevated, implying that either coagulation factors in both the intrinsic and extrinsic pathways or a single factor in the common pathway was affected (Figure 3). This could be further evaluated by individual factor analysis.

Acquired secondary coagulopathies are more common and can result from: liver disease leading to decreased factor

production; Angiostrongylus infection; or the antagonism of vitamin K. Vitamin K is required for the activation of factors II, VII, IX and X and in its absence the intrinsic (factor IX), extrinsic (factor VII) and common pathways (factors II and X) are all affected. As factor VII has the shortest half-life (6 hours compared with 14 hours for factor IX) the PT will be elevated before changes are seen in the APTT, but both are usually elevated at the point clinical signs

develop. The most common cause of Vitamin K antagonism is rodenticide toxicity; however, decreased vitamin K absorption is also possible and can be associated with exocrine pancreatic insufficiency, biliary duct obstruction and lymphangiectasia.

DiagnosisFurther investigation revealed the dogs liver function was normal on the basis of a bile acid stimulation test. No signs of intestinal disease or biliary tract obstruction were present on ultrasound examination, revealing no evidence of a disease process affecting vitamin K absorption. Angiostrongylus infection was excluded on the basis of negative thoracic imaging and faecal parasitology.

D-dimers and platelet numbers were normal, suggesting DIC was unlikely, with investigations revealing no evidence of an underlying trigger such as pancreatitis or haemangiosarcoma. Although there was no known history of exposure to rodenticides, rodenticide toxicity was considered the most likely cause on the basis of the results obtained and appropriate management was commenced. Serum was submitted for analysis for first- and second-generation rodenticides, and was negative for both; however, a markedly increased ratio of vitamin K to vitamin K epoxide was present. This is extremely suggestive of rodenticide toxicity: vitamin K epoxide accumulates in the presence of rodenticides as they inhibit vitamin K epoxide reductase (Figure 4).

Studies have shown this is a sensitive way to differentiate dogs that have been exposed to rodenticides from dogs that have not, with the accumulation of the epoxide becoming most marked after vitamin K treatment, allowing samples to be collected after treatment has commenced (see box opposite). Second-generation rodenticides, such as bromodiolone, are commonly used in the UK. These are highly protein-bound, which means they can be absent from serum screens by the time clinical signs develop.

In this case a definitive diagnosis can not be made, as a toxin has not been identified.

Table 1: Tests to investigate haemostasisTests of Primary HaemostasisPrimary haemostasis relies on normal platelet numbers, normal platelet function and adequate levels of von Willebrand factor.

Platelet numbers can be checked by routine automated haematology analysers, but numbers must be confirmed manually by examining a fresh blood smear. The blood smear is checked for platelet clumps and the platelets counted in the mono layer just behind the feathered edge. In this region one platelet per X100 field is equivalent to a circulating platelet count of approximately 15 x 109/l. If platelet clumps are present an accurate count is not possible, but the presence of clumps usually suggests that adequate platelet numbers are indeed present.Platelet function and levels of von Willebrand factor can be assessed crudely by the buccal mucosal bleeding time (BMBT). Platelet numbers should be checked prior to performing a BMBT as thrombocytopenia will lead to markedly increased bleeding time. The BMBT is performed by making an incision on the oral mucosa with a standard device such as the Simplate II. The upper lip is usually folded and tied back to allow the incision to be made; once made, excessive bleeding is absorbed using a swab, taking care not to touch the actual incision site. Normal BMBT times are approximately 121/2 minutes for the cat and 11/241/2 minutes in the dog. Both von Willebrand factor and platelet function can be assessed in more detail using laboratory-based tests.

Tests of Secondary HaemostasisSecondary haemostasis relies on adequate levels of coagulation factors to allow stabilisation of the platelet plug by a fibrin mesh.

The whole blood coagulation time (WBCT) crudely assesses both the intrinsic and common pathways. Blood is taken into a warm glass tube and tilted every 30 seconds until it clots. At 37C this should normally occur within 67 minutes.The activated clotting time (ACT) test is a more sensitive way to examine the intrinsic and common pathways and uses a commercial tube with a clay activator. Blood is taken into the tube and, whilst being warmed at 37C, the tube is tilted every 10 seconds until a clot is seen. Blood should clot within 5075 seconds in cats and 60120 seconds in dogs. The I-Stat analyser can also run ACT as a bedside test.More detailed coagulation times can be run at external laboratories or on bedside analysers such as the Idexx Coag Dx analyser. The prothrombin time (PT) allows investigation of the extrinsic and common pathways of coagulation, with the activated partial thromboplastin time (APTT) allowing investigation of the intrinsic and common pathways. These tests are run on citrated blood samples; test results >25% longer than the control samples are abnormal.

companion | 13

CLINICAL CONUNDRUM

Test centreMeasurement of vitamin K1 and vitamin K1 epoxide and screens for first- and second-generation rodenticides can be performed at the Human Nutristasis Unit of Guys and St Thomas Hospital, London. Two millilitres of serum is required for each of the two tests and samples should be protected from strong light as this will inactivate vitamin K. Further information is available at www.nutristasis.com or by contacting the laboratory directly (tel: 0207 188 6816).Diagnostic importance of vitamin K1 and its epoxide measured in serum of dogs exposed to an anticoagulant rodenticide. Mount M.E. & Kass P.H. (1989) Am. J. Vet. Res. 50 17041709

However, there is very strong evidence to support a diagnosis of rodenticide toxicity an elevated vitamin K epoxide ratio, the presence of a coagulopathy, and an appropriate clinical response response to vitamin K.

Treatment and outcomeWhilst investigations were undertaken an intravenous catheter was placed and the dog was given two 10 ml/kg boluses of lactated Ringers solution each over 15 minutes. During this period the dogs

peripheral pulse quality, tachycardia and demeanor all improved. Once vitamin K antagonism was suspected and all diagnostic samples were collected, vitamin K1 was given at 5 mg/kg subcutaneously into several sites. Splitting the injection volume over multiple sites helps to minimize injection-related haematoma formation. To replace vitamin K-dependent coagulation factors, 15 ml/kg of fresh frozen plasma was administered intravenously over the course of 60 minutes, whilst monitoring closely for transfusion reactions. An ACT performed after transfusion was normal.

The dog received antiemetics and was started on intravenous gastroprotection, which was continued orally for 7 days once the vomiting had stopped. Oral vitamin K1 was commenced and continued for 28 days (2.5 mg/kg q12h). The dog made a good clinical recovery over the course of the next 24 hours and was discharged.

At re-examination 4 weeks after discharge the dog was clinically very well and a repeat PT performed 48 hours after the withdrawal of vitamin K1 was normal; this confirmed that the toxicity had resolved. As factor VII has the shortest half-life, checking that the PT is normal 48 hours after the withdrawal of vitamin K1 ensures adequate treatment has been given. If the PT were still elevated, treatment would be continued for a further 4 weeks and the PT checked again at the end of therapy. At this stage the PCV had also returned to normal and the owner reported she had discovered a neighbour had been using rat poison on land the dog was walked on, 3 days prior to initial presentation.

In circumstances of suspected toxicity, identification of the rodenticide ingested allows vitamin K treatment to be tailored to the specific toxin: first-generation coumarin rodenticides, such as warfarin, are treated with vitamin K for 7 days; second-generation coumarin rodenticides, such as brodifacoum and bromodiolone, are treated for 46 weeks; and indaniones, such as diphacinone, are treated for 34 weeks. Most cases reported are due to second-generation coumarin products; thus, when rodenticide toxicity is suspected but the toxin is unknown, treatment is usually instigated for 46 weeks.

Figure 3: The coagulation pathways

Intrinsic

Common

APTT PT

Contact/Platelets

Factor XII Tissue Factor

Factor VIIFactor XI

Factor X

Fibrin

Thrombin (II)Factor V

Factor IX

Factor VIII

Extrinsic

Figure 4: The role of vitamin K in clotting factor production

Vitamin KEpoxide

Reductase

ActiveVitamin K

InactiveVitamin KEpoxide

InactiveClotting Factors(II, VII, IX & X)

ActiveClotting Factors(II, VII, IX & X)

14 | companion

HOW TO

NAVIGATE THE PET TRAVEL SCHEME

HOW TO

The Animal Health Rabies Operation branch, Chelmsford Animal Health Divisional Office, offers essential advice for vets in practice as a follow-up to our June article The Quarantine Question

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HOW TO


The introduction of the UK Pet Travel Scheme (PETS) on 28th February 2000 heralded a much campaigned for end to a quarantine period being the only option for cats and dogs travelling into the UK with their owners. However there was also a predictable fear factor in potentially opening our shorelines to a disease as notorious as rabies.

The scheme had a lot to prove in its infancy. Was it robust enough to do a job that had been effectively carried out for generations by the convenience of being an island coupled with a rigorous quarantine system? Modern animal identification techniques and effective vaccines meant that the argument for maintaining quarantine, for most cats and dogs, from many countries, was becoming obsolete and less durable. However the alternative had to provide the same level of protection that quarantine had given for so long.

Todays schemeThe current legislation is now governed by an EC Regulation, which covers the non-commercial movement of pet animals between listed qualifying countries. The

UK, Republic of Ireland, Malta and Sweden have been allowed to retain, for a transitional period, additional requirements for blood sampling and parasite treatment that were already included in their domestic legislation at the time the Regulation came into force.

Eight years on the success of the scheme, and popularity with the pet owning public, is due in part to its simplicity.

The 4 key steps to the successful entry into the UK

Step 1: IdentificationFirstly an animal must be unquestionably identifiable as that described in the documentation accompanying it. The form of identification must be tamper proof and unique. These criteria are met by the subcutaneous implantation of a microchip.

Step 2: VaccinationThe animal is vaccinated against rabies. In order to show that the vaccine has provided an adequate level of immunity, a blood test is taken and sent to a recognised laboratory. The sample must indicate a neutralising antibody titration at least equal to 0.5 IU/ml.

Step 3: 6-month waiting periodTo be sure that the antibody level indicated by the blood test is due to the vaccine rather than exposure to disease, the animal must remain in a qualifying country for 6 months from the date that a blood sample which gives a satisfactory result was taken to ensure clinical signs of disease do not develop.

Step 4: Additional requirementsThe Department of Health have added in additional treatments for ticks and tapeworms 2448 hours before checking in to travel to the UK. This aims to prevent the entry to the UK of other exotic zoonotic diseases that can be carried by cats and dogs. The treatment must be administered by a vet practising in the country of treatment. Section VI of the passport must then be completed by this vet, specifying the manufacturer of the treatment, the product used and the date and time of treatment. This entry must be signed and stamped by the vet. Collars impregnated with acaricide should not be used. In the case of Echinococcus multilocularis treatment, the same details must also be recorded in Section VII of the

companion | 15

HOW TO


The introduction of the UK Pet Travel Scheme (PETS) on 28th February 2000 heralded a much campaigned for end to a quarantine period being the only option for cats and dogs travelling into the UK with their owners. However there was also a predictable fear factor in potentially opening our shorelines to a disease as notorious as rabies.

The scheme had a lot to prove in its infancy. Was it robust enough to do a job that had been effectively carried out for generations by the convenience of being an island coupled with a rigorous quarantine system? Modern animal identification techniques and effective vaccines meant that the argument for maintaining quarantine, for most cats and dogs, from many countries, was becoming obsolete and less durable. However the alternative had to provide the same level of protection that quarantine had given for so long.

Todays schemeThe current legislation is now governed by an EC Regulation, which covers the non-commercial movement of pet animals between listed qualifying countries. The

UK, Republic of Ireland, Malta and Sweden have been allowed to retain, for a transitional period, additional requirements for blood sampling and parasite treatment that were already included in their domestic legislation at the time the Regulation came into force.

Eight years on the success of the scheme, and popularity with the pet owning public, is due in part to its simplicity.

The 4 key steps to the successful entry into the UK

Step 1: IdentificationFirstly an animal must be unquestionably identifiable as that described in the documentation accompanying it. The form of identification must be tamper proof and unique. These criteria are met by the subcutaneous implantation of a microchip.

Step 2: VaccinationThe animal is vaccinated against rabies. In order to show that the vaccine has provided an adequate level of immunity, a blood test is taken and sent to a recognised laboratory. The sample must indicate a neutralising antibody titration at least equal to 0.5 IU/ml.

Step 3: 6-month waiting periodTo be sure that the antibody level indicated by the blood test is due to the vaccine rather than exposure to disease, the animal must remain in a qualifying country for 6 months from the date that a blood sample which gives a satisfactory result was taken to ensure clinical signs of disease do not develop.

Step 4: Additional requirementsThe Department of Health have added in additional treatments for ticks and tapeworms 2448 hours before checking in to travel to the UK. This aims to prevent the entry to the UK of other exotic zoonotic diseases that can be carried by cats and dogs. The treatment must be administered by a vet practising in the country of treatment. Section VI of the passport must then be completed by this vet, specifying the manufacturer of the treatment, the product used and the date and time of treatment. This entry must be signed and stamped by the vet. Collars impregnated with acaricide should not be used. In the case of Echinococcus multilocularis treatment, the same details must also be recorded in Section VII of the

16 | companion

HOW TO

passport. This treatment must contain praziquantel as the active ingredient.

This 4-step procedure, the order of which is paramount, ensures that the cat or dog in question poses no disease risk to the human and animal population of the UK.

Success or failure?Eight years on, what are the main problems that have arisen with the scheme?

Unfortunately simplicity often creates the most complexity. It is the responsibility of the authorised carrier, be it a ferry company, Eurotunnel or airline, to ensure that the pets they transport comply with the requirements of the scheme. Animal Health audit checks of these carriers have identified some problem areas with the scheme as well some unexpected surprises.

So, what can the practising veterinary surgeon, struggling with a flow of clients keen to travel hassle-free with their pets, learn from the problems encountered in the past?

Worm and tick worriesApproximately 65% of pets entering the UK come through the South Eastern seaports

or channel tunnel. Animal Health at Dover audits these particular routes, and its experience in dealing with queries is likely to provide a representative insight into what requirements of the scheme have created the most queries.

Over the last 12 months 50% of the queries have related to problems with tick and tapeworm treatments. This can involve one treatment missing, type of treatments not recorded, date or time of treatment missing, or wrong date and time recorded. The best advice a UK vet can give a client is to ensure they visit a veterinary surgeon in the country of departure to receive appropriate treatment and to check that Section VI and VII of the passport have been completed with the correct and complete information. Clients should also be made fully aware of the window of travel time and any treatments that are not acceptable under the legislation.

Blood concernsSeventeen percent (17%) of queries related to the blood test. Information may be missing from the passport or may be incorrectly entered. A proportion of blood

sample queries will be due to owners attempting to travel before the 6-month waiting time has elapsed. Advice in this case should be to ensure that Section V of the passport has been completed with the date of sampling and signed and stamped by the vet. Making clients aware of the 6-month waiting period is the responsibility of the veterinary surgeon and stressing this point to avoid misunderstanding can prevent an unpleasant souring of the vetclient relationship in the future.

Microchip mistakesMicrochip problems constitute 11% of queries. The date of insertion may not have been appropriately recorded or may have been incorrect. Unfortunately there are also times when a microchip will fail. It is prudent for a veterinary surgeon to check that the microchip is working properly during routine visits to the surgery and always before an entry is made in the passport, such as before a rabies vaccination booster is administered.

In the event of a chip failure it is vital that the correct procedure is followed to ensure continuity of identification. The failed microchip must be located and removed under anaesthetic. A new microchip must be implanted at the same time and the details of that new chip recorded in the passport. The veterinary surgeon should then send the failed chip to the manufacturer who will confirm the failure and provide documentary evidence that the number corresponds to that originally recorded in the passport.

Once the vet is in possession of this evidence, a declaration should be made in section XI (Others) of the passport to indicate that the original chip was removed and replaced with another microchip on the same date and that the manufacturers have confirmed the number of the original chip that could not be read. If this procedure is followed the scheme does not need to be re-started.

Process problemsConfusion over the order of progression through steps 1 to 3 accounts for 8% of queries. In some of these cases, actions will


or channel tunnel. Animal Health at Dover audits these particular routes, and its experience in dealing with queries is likely

sample queries will be due to owners sample queries will be due to owners attempting to travel before the 6-month attempting to travel before the 6-month waiting time has elapsed. Advice in this case

sample queries will be due to owners

companion | 17

HOW TO

genuinely have been performed in the wrong order but in a significant proportion the pet owner states the dates recorded in the passport are incorrect and may either have supporting documentation with them or be able to obtain correct information from the vet.

Where the veterinary surgeon has not followed the correct order of preparation there is no choice but to re-start the scheme. This will include a repeat rabies vaccination and adherence to the 6-month waiting time following a satisfactory blood test result before the pet is eligible for travel into the UK. This will include a repeat rabies vaccination and adherence to the 6-month waiting time following a satisfactory blood test result before the pet is eligible for travel into the UK.

Proper proceduresThere cannot be many more unpleasant ways to end a trip abroad than to be told that your pet will have to remain in quarantine for 6 months. The only way to avoid this eventuality is for the vet issuing the passport to ensure that the procedure has been followed correctly and if not take any appropriate action, advise the client that their pet is not eligible to travel and for what period of time.

If there is any doubt enquiries should be made to ensure that all dates entered in the passport are correct and reflect the correct order of preparation. The remainder of the queries regard the inaccurate recording/missing of the vaccination valid until dates or in circumstances where the vaccine appears to have expired. Careful recording of all necessary information should avoid this problem.

Avoiding the issuesTo avoid the problems listed above it is paramount that the vet ensures that all information is completed accurately and indicates correct order of preparation and full compliance with requirements for entry to the UK.

Out of the control of the UK veterinary practitioner, but of real concern, is the importation of a breed or type of dog listed


under the Dangerous Dogs Act (DDA). Unfortunately as the range of countries participating in the scheme has increased, dogs that may be considered pit bull types have been brought to the attention of Animal Health by the authorised carriers.

These dogs may be described in their passports as American Bulldog, American Staffordshire or Irish Staffordshire Bull Terriers but the difficulty encountered is that if the dog is PETS compliant, there is little Animal Health can do. At present there is no provision within the existing DDA to prevent the importation of such dogs. All that Animal Health can do in these cases is to refer the details of the dog, including photographs, to the police at the final destination who, along with the district local authority, are the competent authority named in the DDA to act on this information.

Owner tacticsPeople will always be passionate about their pets and unfortunately normally law-abiding citizens may feel the need to take illegal action to ensure their pet remains in their possession and avoids quarantine. Owners may be fully aware that their pet does not qualify for entry to the UK and will still attempt to travel with them, hiding them in

vehicles and not declaring their presence. Thankfully these incidences are rare.

What now?At the time of writing, the EC Regulation governing the movement of non-commercial pet animals is under review. The transitional period that allowed the UK to retain the additional requirements for entry has been extended but there is no guarantee that these will be kept indefinitely. If we are required to harmonise with other Member States there is a chance that the blood sampling and tick and tapeworm treatment procedures will be removed.

However that is for the future. For now, the Pet Passport Scheme has proved itself to be an effective method of disease control. It has allowed pets are now able to travel with their families around the world, and more importantly, to come home again. As long as issuing veterinary surgeons are conversant with the requirements and able to make these clear to their client, the successful outcome will see many more travelling pets in the future.

For more information, including factsheets for distribution to clients, visit http://www.defra.gov.uk/animalh/quarantine/index.htm

When pit bull type dogs are identified at Dover during entry into the UK, the local authority and police at its destination are informed

genuinely have been performed in the genuinely have been performed in the wrong order but in a significant proportion wrong order but in a significant proportion the pet owner states the dates recorded in

18 | companion

VIN FORUMS

The Veterinary Information Network brings together veterinary professionals from across the globe to share their experience and expertise. At vin.com users get instant access to vast amounts of up-to-date veterinary information from colleagues, many of whom who have specialized knowledge and skills. In this new feature, VIN shares with companion readers a small animal discussion that has recently taken place in their forums.

Discussion Creator

Jessie is a 4 year old Springer who got into the laundry hamper.

Four days later he came to see me for his vomiting.

I ended up removing 52 of his jejunum. I was able to keep his ileum and a few feet of his upper SI.

It is now day three post-op. He is eating well, his Jackson-Pratt drain has had minimal discharge and he has been weaned off of IV fuids and IV antibiotics.

Jessie is having explosive/liquid bowel movements. He does not have urgency and seems to have no anxiety/discomfort.

I seem to remember that the remaining bowel will compensate for the lost bowel over a period of time. When would I expect to see some form to his stool?

I estimate I removed 50% of his bowel.

I used the GIA/TA for the R&A as well the Jackson-Pratt drain. The staplers have sped up my surgery considerably and the JP drain gives piece of mind. I did not use an LDS for this procedure, but ordered one as soon as I was finished, it is AMAZING how quick you can ligate with the proper instruments. Intestinal surgery is now FUN!!

Discussion Creator

....and just when I thought all was well, Jessie decided to eat his vetwrap bandage! I didnt know if it would pass, so ended up inducing vomiting to regain possession.

(Did I mention he also had a gastrotomy as well? That TA makes it fast!)

Reply 1

I dont know what the rule is for how much gut they can use (Im sure theres a formula somewhere), but one of the first times I ever posted on VIN was a similar case. Rottweiler with whips and intussusception. Ended up removing about 4 feet on SI with a little ileum thrown in. He was blowing out for about 3 or 4 days. Im a surgery wimp and the boss was out of town, so I was on my own. The surgery gurus here said not to worry, and sure enough he straightened out.

Good luck!

LETTERS FROM AMERICAThe Veterinary Information Network brings

LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM AMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICA

Discussion Creator

LETTERS FROM LETTERS FROM LETTERS FROM

18 | companion

VIN FORUMS

The Veterinary Information Network brings together veterinary professionals from across the globe to share their experience and expertise. At vin.com users get instant access to vast amounts of up-to-date veterinary information from colleagues, many of whom who have specialized knowledge and skills. In this new feature, VIN shares with companion readers a small animal discussion that has recently taken place in their forums.

Discussion Creator

Jessie is a 4 year old Springer who got into the laundry hamper.

Four days later he came to see me for his vomiting.

I ended up removing 52 of his jejunum. I was able to keep his ileum and a few feet of his upper SI.

It is now day three post-op. He is eating well, his Jackson-Pratt drain has had minimal discharge and he has been weaned off of IV fuids and IV antibiotics.

Jessie is having explosive/liquid bowel movements. He does not have urgency and seems to have no anxiety/discomfort.

I seem to remember that the remaining bowel will compensate for the lost bowel over a period of time. When would I expect to see some form to his stool?

I estimate I removed 50% of his bowel.

I used the GIA/TA for the R&A as well the Jackson-Pratt drain. The staplers have sped up my surgery considerably and the JP drain gives piece of mind. I did not use an LDS for this procedure, but ordered one as soon as I was finished, it is AMAZING how quick you can ligate with the proper instruments. Intestinal surgery is now FUN!!

Discussion Creator

....and just when I thought all was well, Jessie decided to eat his vetwrap bandage! I didnt know if it would pass, so ended up inducing vomiting to regain possession.

(Did I mention he also had a gastrotomy as well? That TA makes it fast!)

Reply 1

I dont know what the rule is for how much gut they can use (Im sure theres a formula somewhere), but one of the first times I ever posted on VIN was a similar case. Rottweiler with whips and intussusception. Ended up removing about 4 feet on SI with a little ileum thrown in. He was blowing out for about 3 or 4 days. Im a surgery wimp and the boss was out of town, so I was on my own. The surgery gurus here said not to worry, and sure enough he straightened out.

Good luck!

LETTERS FROM AMERICAThe Veterinary Information Network brings

LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM LETTERS FROM AMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICAAMERICA

Discussion Creator

LETTERS FROM LETTERS FROM LETTERS FROM

companion | 19

VIN FORUMS

Reply 2

52 inches of small bowel in a Springer sized dog is a lot of bowel. There is a fair chance that he will end up with short bowel syndrome, but it is

too soon to say.

All content published courtesy of vin.com. The names of participants have been removed from this feature. For more details about the Veterinary Information Network visit vin.com. As VIN is a global veterinary discussion forum not all diets, drugs or equipment referred to in this feature will be available in the UK, nor do all drug choices necessarily conform to the prescribing rules of the Cascade.

His weight prior to sx was 41 lb, he now weighs 40.6 lb and is at an ideal weight.

I found a JAVMA article that suggests the ileum can hypertrophy as can the remaining small intestine. Would this dog need supplementation/testing now, or is the cobalamin he had prior to his sx sustain him until his bowel recovers?

Vin members can access the link to the JAVMA article:

http://www.vin.com/Members/Viewer/Viewer.ashx?FileId=2766802&FileTypeId=6&IsOld=0

I was assuming the liquid BM was a consequence of his shortened bowel and may resolve over time. How do I know if its a problem that needs medical attention?

He seems to be doing great otherwise, hes boarding at my clinic for another week, so I get to keep a close eye on him. Hes back to normal as far as attitude and energy.

Im just not sure how worried I need to be. Id rather nip a problem early if it needs to be addressed.

Thank you for the help!

Vin Consultant

I agree, short bowel might be a concern but usually you can get away with 70-80%. At least you steered

clear of the ileocecocolic valve its when you lose that, you really have problems.

What diet is he on? Id go with something highly digestible like EN, low res in small frequent feedings (46/day).

You could add soluble fibre. I doubt youll need cobalamin, questran etc if the ileum is intact, although it might be worth checking a cobalamin/folate.

A course of tylan and a probiotic wouldnt hurt either :)

Discussion Creator

>>> 52 inches of small bowel in a Springer sized dog is a lot of bowel. > Would this dog need supplementation/testing now, or is the cobalamin he had prior to

his sx sustain him until his bowel recovers? > How do I know if its a problem that needs medical attention?

20 | companion

PETSAVERS

Improving the health of the nations pets

The Petsavers products available from your wholesaler represent really great value for money, plus they are designed specifically to meet the requirements of small animal practice. A royalty is paid to Petsavers for each and every product bought and this provides a valuable source of income, which in turn is used to fund studies that advance our knowledge of small animal medicine and surgery.

PETSAVERS PRODUCTS FOR PRACTICEWhen you buy Petsavers merchandise through your wholesaler you get the highest standard products whilst raising essential funds for the charity

These items are listed under Petsavers in your wholesalers product catalogue. If you have any difficulty ordering products or would like more information, please contact Petsavers on 01452 726700 or email [email protected].

The money raised through these purchases really helps to continue to fund research into conditions that affect the animals that we treat.

Protective collarsThese are available in either clear plastic or opaque finishes. Assembly is easy and they come in a range of sizes. Every practice uses these, so why not use the Petsavers protective collar and help fund the future of veterinary expertise.

Recovery blanketsCompared to some blankets, these are very tough indeed. They are made of polyester and retain 95% of radiated body heat. The blankets can be used with a hypothermic patient and are great for preventing hypothermia during the anaesthetic period. They are also radiolucent and so diagnostic radiographs can be taken whilst the animal remains wrapped in the recovery blanket.

Pet carriersThese cardboard or plastic pet carriers are inexpensive and very popular with clients. They also help to advertise Petsavers with our logo and website address on the side. The hardwearing wire carrier is easily cleaned and has a hinged lid that allows full access to the interior of the carrier, making it easy to get pets into and out of, especially in the surgery.

Heated padsThe Petsavers heated pad has been hugely popular since it was introduced in 2006. It is ideal for cats, small dogs and other small pets when you need to minimise the risk of postoperative hypothermia or just to keep them warm. The key features of the pad are:

Detachable plug allowing wire to be passed through cage barsLow operating voltage (12v) for increased safetyThick durable cover to cope with normal wear and tear, and which can be easily cleaned.

These items are listed under Petsavers in your

Protective collarsThese are available in either clear plastic oropaque finishes. Assembly is easy and they come in a range of sizes. Every practice uses these, so why not use the Petsavers protective collar and help fund the future of veterinary expertise.

the surgery.

Protective collarsThese are available in either clear plastic oropaque finishes. Assembly is easy and they come in a range of sizes. Every practice uses these, so why not use the Petsavers protective collar and help fund the future of veterinary expertise.

Detachable plug allowing wire to be passed through

cover to cope with

be passed through

cover to cope with

companion | 21

GETTING TOUGH ON SEIZURESSimon Platt, Associate Professor in the Neurology Service at the University of Georgia and co-editor of the BSAVA Manual of Canine and Feline Neurology, looks at treatment options in managing epilepsy

Control of canine epilepsy is only possible in 7080% of cases with phenobarbital (PB) alone. Success may be improved if combination therapy with potassium bromide (KBr) is used. More recently, several human drugs have been evaluated for seizure therapy in veterinary patients. Such polytherapy has several potential disadvantages, including the increased cost, the need to monitor and to interpret serum concentrations of multiple drugs, potential drug interactions, and more complicated dosing schedules. Before polytherapy is started, all reasonable options for monotherapy should be tried. If the initial drug is ineffective, a second drug should be added.

What are the available drug options for canine refractory epilepsy?If treatment with PB and/or KBr is not an option for reasons of toxicity for instance, or if treatment with a combination of both has not been successful, there are now some human anticonvulsants that can be considered for use in the dog. Their safety and pharmacokinetics have been investigated and their clinical use in a small number of refractory epileptics have been evaluated. However, there is nothing to prevent their use in the appropriate circumstances as sole therapy.

1. GabapentinGabapentin has primarily been used as an adjunctive drug for humans with uncontrolled partial seizures with and without secondary generalisation. Gabapentin is well absorbed from the duodenum in dogs, with maximum blood levels reached in 1 hour after oral administration. The elimination half-life of gabapentin in dogs is 34 hours, meaning

that it may be difficult to attain steady state levels with q8h dosing. The currently estimated required dose to achieve some effect in dogs is 1020 mg/kg q8h. In dogs, gabapentin is metabolised in the liver; therefore, liver function needs to be closely evaluated when dogs are on this treatment. The author has used this drug with no deleterious effects as a third drug for dogs refractory to PB and KBr. At this point, about 50% of dogs seem to respond well to this addition, though sedation may be a problem in some dogs.

2. LevetiracetamStudies show that levetiracetam displays potent protection in a broad range of animal models of chronic epilepsy. Levetiracetam is not metabolised by the liver, is excreted by the kidneys and is free of significant drugdrug interactions; therefore, this is potentially a very safe drug to use in dogs and even cats. The dose range suggested for dogs is 1020 mg/kg orally q8h. No therapeutic range has been established and in humans serum levels do not seem to correlate with efficacy. No long-term trials have been undertaken evaluating the safety and efficacy of this drug; however, a recent short-term clinical trial demonstrated that using it as a third anticonvulsant decreased seizure frequency by over 50% in epileptic dogs.

3. ZonisamideThis drug has been shown to be effective for both focal and generalised seizures in human patients. Zonisamide is metabolised mainly by hepatic microsomal enzymes, and the half-life in dogs is approximately 15 hours. The dose suggested for use as an add-on drug in dogs is approximately 5 mg/kg orally q12h. A high safety margin has been demonstrated in chronic dosing studies in

Transverse (cross-sectional) MRI (T2-weighted) image indicating the presence of bilateral symmetrical oedema (arrowed) subsequent to prolonged generalised tonic seizure activity. Such oedema may lead to long-term damage and may create a more difficult to treat seizure focus

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dogs, but the drug is sulphonamide-based. A recent clinical trial has shown that the use of zonisamide has decreased seizure frequency by over 50% in approximately 50% of dogs on polytherapy, additionally enabling a reduction in the concurrent dose of PB.

These options may be expensive but provide owners with something further to try. Over the next few years, even more therapeutic options are to become available for the treatment of canine epilepsy and so we may anticipate a future with less problematic canine seizure cases. For now, they remain a common clinical problem in our practices. n

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GETTING TOUGH ON SEIZURESSimon Platt, Associate Professor in the Neurology Service at the University of Georgia and co-editor of the BSAVA Manual of Canine and Feline Neurology, looks at treatment options in managing epilepsy

Control of canine epilepsy is only possible in 7080% of cases with phenobarbital (PB) alone. Success may be improved if combination therapy with potassium bromide (KBr) is used. More recently, several human drugs have been evaluated for seizure therapy in veterinary patients. Such polytherapy has several potential disadvantages, including the increased cost, the need to monitor and to interpret serum concentrations of multiple drugs, potential drug interactions, and more complicated dosing schedules. Before polytherapy is started, all reasonable options for monotherapy should be tried. If the initial drug is ineffective, a second drug should be added.

What are the available drug options for canine refractory epilepsy?If treatment with PB and/or KBr is not an option for reasons of toxicity for instance, or if treatment with a combination of both has not been successful, there are now some human anticonvulsants that can be considered for use in the dog. Their safety and pharmacokinetics have been investigated and their clinical use in a small number of refractory epileptics have been evaluated. However, there is nothing to prevent their use in the appropriate circumstances as sole therapy.

1. GabapentinGabapentin has primarily been used as an adjunctive drug for humans with uncontrolled partial seizures with and without secondary generalisation. Gabapentin is well absorbed from the duodenum in dogs, with maximum blood levels reached in 1 hour after oral administrati

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Companion August2008