Companion August2012(1)

The essential publication for BSAVA membersThe essential publication for BSAVA members

companionAUGUST 2012

How to health screen older cats

Pets are good for usSCAS and the humananimal bondP4

Clinical ConundrumOral and oesophageal ulceration P8

Congress 2013How to pick your lecturesP21

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NEW ISSUE ONLINE

Dont forget that as a BSAVA member you are enti tled to free online access to EJCAP register at www.fecava.org/EJCAP to access the latest issue.

Sinonasal aspergillosis in dogsSinonasal aspergillosis is an uncommon, yet debilitati ng and oft en frustrati ng conditi on to treat in dogs despite years of research. This review examines the current evidence for the pathogenesis of sinonasal aspergillosis in dogs, as well as the various diagnosti c opti ons. The available evidence for common therapeuti c opti ons and their likely outcomes is also explored.

Biochemical assessment of canine body cavity e usions using three bench-top analysersThis study found acceptable results for total protein (VetScan) and creati nine (Vetscan, Vett est). The Spotchem was found to be of limited value in canine e usion analysis.

Total hip replacement for the treatment of atraumati c slipped femoral capital epiphysisThe authors conclude that THR can be a successful technique to treat SFCE in dogs.

Cutaneous trunci re ex for localising and grading thoracolumbar spinal cord injuriesThis paper demonstrates that the cutaneous trunci re ex facilitates clinical

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 Board

Editor Mark Goodfellow MA VetMB CertVR DSAM DipECVIM-CA MRCVS

Past President Andrew Ash BVetMed CertSAM MBA MRCVS

CPD Editorial TeamSimon Tappin MA VetMB CertSAM DipECVIM-CA MRCVSPatricia Ibarrola DVM DSAM DipECVIM-CA MRCVS

Features Editorial TeamAndrew 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

47 Pets are good for youThe work of the Society for Companion Animal Studies

811 Clinical ConundrumConsider a case of oral and oesophageal ulceration

1214 The PG Cert ExperiencePioneer Students tell their story

1620 How ToHealth screen older cats

21 PetSaversFluid therapy funding

2225 Fresh Congress ScienceHow to pick your lectures

2627 Starting from ScratchDesigning a new practice

2829 WSAVA NewsThe World Small Animal Veterinary Association

3031 The companion InterviewDerek Attride

32 You Can Shape Your RegionVolunteering in your Region

33 Focus OnNorth East Region

3435 CPD DiaryWhats on in your area

Additional stock photography Dreamstime.com Alvaro Pantoja; Lculig; Santos-diez; Scott Griessel; Steveheap

Whats in JSAP this month?

Here are just a few of the topics that will feature in your August issue:

segregati on of dogs with ambulatory paresis into mild and severe categories.

Low level laser therapy reduces ti me to ambulati on in dogs aft er hemilaminectomyThis preliminary study found that low level laser therapy in combinati on with surgery decreases the ti me to ambulati on in dogs with T3-L3 myelopathy secondary to intervertebral disk herniati on.

Erythema multi forme and epitheliotropic T-cell lymphoma in the oral cavity of dogsHistological features alone are not always diagnosti c in such cases, and immunohistochemistry and clonality testi ng may assist in the di erenti ati on between the two. In ambiguous cases, repeated biopsy and clinical follow-up are essenti al.

Logon to www.bsava.com to access the JSAP archive online.

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With the pioneers about to complete their first year, BSAVA offers a huge congratulations to the first ever students on the Postgraduate

Certificate programmes. These delegates were the lucky ones on enrolment day the places famously sold out in under half an hour. If you are interested in either the Surgery or Medicine Programmes you can read about the student experience on page 12 and email [email protected] to register your interest and get more information. Enrolment into the programmes for 2013 will open via www.bsava.com at 9am on Monday 1 October and places are, once again, likely to be heavily subscribed.

Frank Beattie Travel ScholarshipA

pplications are invited for the Frank Beattie Travel Scholarship. This travel scholarship of 2000 is specifically to help a BSAVA member to undertake a trip abroad to study a particular aspect of veterinary practice.

The scholarship was established in 1988 in memory of Frank Beattie, a well respected veterinary surgeon and a long-standing member of the BSAVA. It is awarded annually from a generous gift given by Franks widow, Annie. Previous recipient Liz Mullineaux says; The scholarship might most obviously appeal to someone in academia wanting to see practice with an overseas specialist. However, applications are especially encouraged from practitioners.

Its a great opportunity, Liz enthuses, but just needs some imagination and the confidence to apply.

For more information email [email protected]. The deadline is 14 September along with nominations for all other BSAVA Awards (see the nomination form inside this issue).

How often have you left getting your Christmas cards until the last minute? With first class postage costs on the increase, it is definitely worth planning your deliveries this year. Every

winter hundreds of practices around the UK use Christmas cards in order to keep up their communication with clients and spread a little seasons greetings. When choosing PetSavers cards, vital funds for veterinary research are raised at the same time.

With packs of 10 available from as little as 3.00, and a range of great designs, you or your practice can make a huge difference to the ability of our profession to progress veterinary research and have a greater understanding of the diseases that effect companion animals.

The Christmas cards are part of a series that includes sympathy cards and notelets suitable for personal or practice use. For more information or to buy online visit www.petsavers.org.uk or call 01452 726700.

Put PetSavers in the post

PG Certificates: enrolment approaches

Pre-registrations for Scottish Congress (31 August 2 September) are at their highest ever. The programme for this year is particularly impressive as is the price. To enjoy a weekend in Edinburgh with superb CPD call 01452 726731 or visit

www.bsava.com/scottishcongress.

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Here is a recipe for disaster take one neurotic Border Collie and place it in a care home for young men with severe mental health problems.

It is no surprise that the results of this particular experiment in what has become known as animal-assisted therapy were not what staff at the institution had been hoping for. The dog, which was picked from among the animals at a local rescue centre, proved wholly unsuitable for its role. After biting several of the young men it had been brought in to help, it was euthanased and is now interred in the garden at the home.

That result was disappointing for all concerned tragic for the animal, but also for the people bitten and the managers who had heard that having an animal on the premises would make their clients happier and calmer. If the project had been handled differently then that is certainly what could have been achieved, but when little thought goes into the planning stage and particularly into selecting the right animal for the job then there is always a danger that things will go wrong.

The idea wasnt a bad one, but the care home could have done with the help of a more knowledgeable organisation to help it achieve its ambitions.

Ambitions for getting it rightPeople with mental illnesses ranging from schizophrenia to depression do show clinical improvements after petting an animal. We know about this largely through the efforts of bodies like the Society for Companion Animal Studies and its sister organisations around the world. They have supported much of the original research or ensured that the findings are widely known among those in the healthcare and social work professions.

Similarly the trust and affection of a companion animal has been shown to help old people stay healthy and independent, encourage the normal physical and social development of children, and even help those confined in prisons or young offenders institutions to rebuild their lives.

Yet when a group of vets, psychologists, psychiatrists and social workers met to form SCAS in

Keeping a companion animal helps people to lead happier and healthier lives. This is the conclusion from the activities of the Society for Companion Animal Studies. Since it was founded in 1979, SCAS has been investigating the effects of the humananimal bond and applying that knowledge to the benefit of all not just the pet owners themselves. Yet the society is facing an uncertain future and it will need the support of the veterinary profession if it is to carry on its valuable work. John Bonner reports

Pets are good for you

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Dundee 33 years ago, few others would have agreed with their belief that the interactions between people and pets was a subject for serious academic study. When we started, people just laughed at us, recalls Liz Ormerod, the Societys current chairwoman and a partner in a small animal practice in Fleetwood, Lancashire.

A 1975 graduate from Glasgow vet school, Liz had already gained an insight into the strong bonds between clients and their animals in her first job, running the schools charity clinic in one of the less salubrious parts of the city. There were clients there who were living terrible lives, in bad health and dreadful poverty. If they had the companionship of a pet they were able to cope. But often when their animal died, they would fall apart.

Humananimal bondLizs observations supported those of the early pioneers of research into the humananimal bond. Foremost amongst these was the New York-based child psychologist Boris Levinson, who noticed that troubled children became more responsive when he took his own dog into his consulting room. Leo Bustad was another founding father of the discipline. As Dean of Washington State Universitys veterinary school he established a programme using dogs in the rehabilitation of offenders and went on to establish the Delta Society, now called Pet Partners, SCASs equivalent body in the US.

Liz recalls that the majority of those founding members of SCAS were veterinary surgeons, including Andrew Edney, then President of the BSAVA. Although people from a broad range of other professions have since become members, the veterinary influence on the societys work still plays a crucial role.

Vet input essentialAs more and more schools, care homes, hospitals, prisons and other institutions recognise the advantages of allowing contacts with companion animals, the contribution of vets is essential to avoid the sort of mistakes made by the well-meaning woman who ran the mental care unit. A veterinary assessment is needed to ensure that the animals chosen are healthy and have the right temperament for dealing with their

intended audience. A vet will also be needed to draw up the preventive medicine protocols that will ensure there is no risk of transmitting zoonotic diseases.

Getting these projects off the ground is very much an interdisciplinary effort, needing people from all sorts of professions, but vets are absolutely key. If vets arent there to do this work, then there is a risk that things will go pear-shaped, Liz points out.

Engaging vets, medics and clientsLiz wants veterinary surgeons and VNs to become more actively involved in educating people about the health and social benefits of the humananimal bond. SCAS representatives regularly visit the UK veterinary schools to discuss their work and its relevance to those employed in companion animal practice. Students understand that the principles of the bond underpin pretty well everything that they will do in practice. So we get a very positive response. This is something that many of them say they want to get involved in.

Gaining a better understanding of the interactions between humans and companion animals may once have been considered a frivolous activity by colleagues in the medical profession but not any more. In 2009 the National Institutes of Health, the largest funding organisation for biomedical research in the US, set up a project looking at the influence of pets

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Pets are good for you

on early development in children. Here in the UK the National Institute for Health and Clinical Excellence, the body responsible for assessing the cost effectiveness of healthcare interventions, has come out in favour of using animal-assisted therapy.

Much of this enthusiasm among the human medical authorities has been a result of studies which not only show that contact with animals can be clinically effective, but also which begin to explain why. Liz says that the mechanism involved in the observed physical and mental health benefits appears to be through stimulating oxytocin production. Years ago this hormone was thought to be concerned solely with pregnancy and lactation, but it has now been found to be both an important influence on cardiovascular function and a major factor in the development of trust and better social relationships.

Having an animal is recognised as being useful in autistic children, who appear to cope much better with the world and are easier for their carers to deal with. Their oxytocin levels increase through contact with an

animal. The same effect is seen when you spray the same hormone up their nose but it wasnt considered ethically acceptable to do that routinely. So why not just get them a pet? Liz points out.

Ambitions and concerns for SCASSCAS hope to encourage further work on the physiological response in people and ensure that the results are widely disseminated. It is also heavily involved in training people from many different disciplines in different aspects of the bond, such as organising animal-assisted interventions in nursing homes, hospices and other settings, and in providing emotional comfort for those experiencing grief as a result of the loss of a pet. Since resources are limited both for SCAS and those undergoing this tuition, much of the training is delivered over the internet, in form of distance learning modules and webinars.

Unfortunately, there may be even greater need for the Society to control expenditure as it will be losing its main sponsor at the end of the year. For 10 years, the Blue Cross has provided both economic and administrative support for SCAS but has now decided that it needs to devote its attention to its core activities in pet animal welfare. We are currently undergoing a review of our core services as we look to consolidate our efforts to give more pets who come into our care a healthy life in happy homes, said the charitys director of external affairs, Steve Goody.

So in order to continue its work, the societys trustees are looking to establish a similar relationship with some other organisation working in the veterinary and animal welfare fields. They maintain that despite the advances made over the past few decades there is still much to be done, particularly in the area one of the organisations key activities aimed at the elderly.

Helping the agedThe Pets for Life campaign is intended to address the scandalous numbers of old people who are obliged to give up their pet when they go into sheltered housing or care homes. A study carried out several years ago by researchers at the University of Warwick found that 140,000 people a year had to find new homes for their pets and around 38,000 of the animals were euthanased. A follow-up study found no evidence that

Indusfoto Limited

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it really is a no-brainer, when people have a pet to look after, they are going

to be happier, healthier and make fewer demands on the health service

or on society as a whole

the situation had improved indeed there were some indications that this figure underestimated the size of the problem.

With some honourable exceptions like the London Borough of Wandsworth and the Isle of Wight, few local authorities in the UK have policies which allow people in council care homes to have pets. Either there is a blanket ban or the matter is left to the managers of the individual institutions. Even where people have been allowed to keep their pet, they are then at the mercy of any management changes that result in a no pets policy.

Despite its claims to being a nation of animal lovers, the UKs record in this area compares poorly with those of other developed countries. Legislation was passed in France in 1975 which considers pet ownership a basic human right for those in social housing. Similar laws have been introduced in countries including the US, Norway, Spain and Greece. Meanwhile, in Japan attitudes changed completely after the Kobe earthquake of 1995, which left thousands homeless. The authorities found that many old people preferred to live in garages rather than surrendering their animals in order to move into the shelters provided. Realising the importance of pets in their owners lives, the Japanese state now encourages architects to take account of the needs of pet owners when designing social housing, Liz points out.

In December 2009, a Private Members Bill was introduced by Conservative MP Nigel Waterson to make provision for residents of care homes and sheltered accommodation to keep domestic pets in certain circumstances. Although the proposal gained cross-party support, it failed to reach the statute book. SCAS hopes that another attempt will be made during the current Parliament and the Tory MP Therese Coffey has expressed interest in taking up the challenge.

However, Liz is not relying solely on politicians to bring about change. She says much can be done at a local level. Although elderly people are often unwilling to be seen to be making a fuss, there have been many instances where an institutions no pet rule has been challenged by the residents or those considering going into the home. On many occasions I have been asked to speak on their behalf we havent lost a case yet, Liz says.

Yet there are still considerable numbers of cases of forced separation which Liz doesnt get to hear of and so can do nothing about. She urges other veterinary surgeons and VNs to do all they can to find out what is going on in their area and to educate local authorities and their staff about the benefits of allowing their residents to keep an animal. Often the institutions managers will cite health and safety issues as the reason for refusing to allow contact with animals but Liz is adamant that they can eventually be convinced that the benefits far outweigh the risks.

It really is a no-brainer, when people have a pet to look after, they are going to be happier, healthier and make fewer demands on the health service or on society as a whole. So why are we still having this argument? she asks.

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Andrew Holdsworth, intern at Southern Counties Veterinary Specialists, invites companion readers to consider a case of oral and oesophageal ulceration

Case presentationA 4-year-old male neutered Domestic Shorthair cat presented with a 48-hour history of dyspnoea and anorexia. The cat had a previous history of chronic vomiting secondary to an intestinal impaction caused by ingestion of grass and plant material. An enterectomy had been performed 2 years previously to remove a 20 cm section of small intestine associated with the impaction. The remainder of the history was unremarkable.

On presentation the cat was bright, but was open-mouth breathing; although respiratory rate was slightly increased (24 breaths per minute), respiratory effort was normal. On physical examination, the tongue and lower lips were markedly swollen, which prevented the cat from closing its mouth fully. The tip of the tongue was protruded. The cat was agitated, and conscious examination of the oral cavity was not tolerated, although the tip of the tongue appeared ulcerated and ptyalism was noted (Figure 1). Rectal temperature was elevated at 40.4C.

Clinical conundrum

Create a problem list based on the cats history and physical examination Lingual swelling and ulceration Dyspnoea and open-mouth

breathing Pyrexia Anorexia Ptyalism

What differential diagnoses should be considered based on the problem list?The VITAMIN D mnemonic can be followed, which classifies diseases according to their mechanism. The acute onset of the clinical signs meant that lingual swelling / ulceration and dyspnoea were the most important problems to be considered.

Lingual swelling and ulceration: Infectious: calicivirus, infection

secondary to foreign body Inflammatory: glossitis Toxic: caustic agents, drug reactions,

irritants Traumatic: foreign body, electric

cord shock, thermal injury, insect bite/sting

Anomalous: allergic reaction Immune-mediated: pemphigus

vulgaris, bullous pemphigoid, systemic lupus erythematosus, toxic epidermal necrolysis

Neoplastic: oral neoplasia (squamous cell carcinoma, melanoma, fibrosarcoma)

The open-mouth breathing (without an increase in respiratory effort) was considered to be secondary to the lingual swelling, although further consideration was given due to the importance of this clinical sign in cats.

Figure 1: The cat at presentation. The tip of the tongue is ulcerated and marked ptyalism is present

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Dyspnoea: Upper airway obstruction Pulmonary disease Pleural space disease

Pyrexia, anorexia and ptyalism were considered likely to be secondary to underlying pathology, although required addressing as part of the ongoing diagnostic and treatment plans.

A prioritised list of differential diagnoses for this case would be:

1. Foreign body2. Insect bite/sting3. Chemical injury4. Acute viral infection5. Oral neoplasia

What diagnostic procedures would you perform in this case?The cat was admitted to the hospital for initial stabilisation with oxygen therapy. Analgesia was provided using buprenorphine. Routine haematology and serum biochemistry were performed to evaluate for metabolic causes of ptyalism, and consequences of the anorexia, prior to further investigations requiring general anaesthesia.

Haematology revealed a mild anaemia (Table 1) but no leucocytosis was identified. Serum biochemistry (Table 2) revealed a mild elevation in alanine aminotransferase (ALT) and glucose, and a moderate elevation in creatine kinase (CK), which could be secondary to changes affecting the lingual muscles. The normal biochemistry results ruled out metabolic causes and consequences of ulceration, ptyalism and anorexia.

As the cat was clinically stable, it was anaesthetised to perform a thorough examination of the oral cavity. Extensive

ulceration was noted, with sloughing of the epithelium affecting the entire dorsal surface and edges of the tongue, and the hard palate. The lips were swollen and inflamed. Thoracic radiographs were normal, which ruled out pulmonary/pleural space disease and a radiopaque intratracheal foreign body. A flexible endoscope was used to inspect the lining of the oesophagus; this revealed ulceration and sloughing of the mucosa in the proximal portion of the oesophagus (Figure 2). No evidence of oesophageal perforation was seen.

No evidence of a foreign body, trauma or bite/sting were identified on examination of the oral cavity, which made these differentials less likely. The extensive distribution of the ulceration and the involvement of the proximal oesophageal mucosa made neoplasia and viral lesions much less likely. The findings were highly suggestive of ingestion of a caustic or corrosive

Parameter Result Reference interval

RBC 5.02 5.510.0 x 1012/l

Hb 7.2 9.017.0 g/dl

HCT 24.8 2750

MCV 49 40.055.0 fl

MCH 14.3 13.021.0 pg

MCHC 29.1 31.536.5 g/dl

Platelets Platelets clumped count probably normal

WBC 8.7 4.015.0 x 109/l

Neutrophils 5.48 2.512.5 x 109/l

Lymphocytes 2.18 1.57.0 x 109/l

Monocytes 0.44 0.00.8 x 109/l

Eosinophils 0.61 0.01.5 x 109/lTable 1: Haematology results (abnormal results in bold)

Parameter Result Reference interval

Total protein 54 54.080.0 g/l

Albumin 28 26.042.0 g/l

Globulin 26 15.060.0 g/l

Sodium 152 125160 mmol/l

Potassium 4.1 3.66.0 mmol/l

Chloride 116 110140 mmol/l

Total calcium 2.04 2.03.0 mmol/l

Phosphate 1.2 1.22.6 mmol/l

Urea 4.1 4.012.0 mmol/l

Creatinine 87 80.0180.0 mol/l

ALP 2 0.050.0 IU/l

ALT 76 0.040.0 IU/l

Gamma GT 0 0.010.0 IU/l

Total bilirubin

5 0.010.0 mol/l

Bile acids 3 0.110.0 umol/l

Glucose 7.3 3.56.6 mmol/l

Creatine kinase

3295 0.0152.0 IU/l

Table 2: Serum biochemistry results (abnormal results in bold)

Figure 2: Endoscopic view of the proximal oesophagus, showing ulceration and sloughing of the mucosal surface


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Clinical conundrum

substance and a presumptive diagnosis of chemical injury was made.

The distal two thirds of the oesophagus appeared normal on endoscopic examination (Figure 3). The endoscope was subsequently passed into the stomach, which contained a large volume of coarse grass material (Figure 4), preventing full inspection of the gastric

mucosa. Following endoscopic retrieval of the grass material, inspection of the gastric wall was unremarkable. Given the cats previous history of grass ingestion and the normal endoscopic appearance of the distal oesophagus and stomach, the grass material found in the stomach was considered coincidental and unlikely to be related to the lingual ulceration and swelling.

How would you manage this case?Given the extent of the oral and oesophageal lesions, and the fact the cat was anorexic, it was judged necessary to place a feeding tube to allow pain-free feeding until the lesions had healed.

Consideration was given as to the appropriate choice of feeding tube to place. Naso-oesophageal and oesophagostomy tubes were contraindicated due to the presence of oesophageal ulceration; placing a tube which passed through the oesophagus may have caused further oesophageal damage and increased the risk of infection. Also, naso-oesophageal tubes are used for short-term nutritional support and would have been inappropriate in this case as longer term feeding was anticipated. A PEG (percutaneous endoscopic gastrostomy) tube was considered the most appropriate choice of feeding tube for the following reasons:

The tube does not pass through the oesophagus

It can be used for long-term nutritional support

Placement is a relatively non-invasive procedure (as opposed to a surgically placed gastrostomy tube)

The endoscopy was already in use.Figure 4: Endoscopic view of the stomach, showing grass material within the pylorus

Figure 3: Endoscopic view of the normal distal oesophagus

RER (kcal/day) = 70 x (bodyweight in kg)0.75 for both cats and dogs

or

RER (kcal/day) = (30 x bodyweight in kg) + 70 for animals weighing 230 kg

How would you manage a PEG tube?PEG tubes should not be used for feeding in the first 24 hours after placement, to allow a primary seal to form between the stomach and the body wall. The tube should be flushed with 510 ml of lukewarm tap water before and after each feed. After periods of anorexia, feeding is gradually re-instated using the following regime. On day 1 of feeding, one-third of the Resting Energy Requirement (RER) should be given; increasing to two-thirds of the RER on day 2; and full RER on day 3.

The RER should be given over 46 feeds each day. Food should be warmed to body temperature prior to feeding and injected slowly over several minutes. If there is any concern regarding tube migration, a radiograph should be obtained immediately following instillation of 57 ml/kg of sterile iodinated contrast medium.

The stoma site should be inspected, cleaned and redressed at least twice daily. More frequent cleaning may be required if there is more than a little discharge from the stoma site, and antibacterial barrier creams (e.g. Bactroban) may be applied. Gastrostomy tubes should remain in place for a minimum of 10 days prior to removal to allow a permanent adhesion to form between the stomach and body wall; otherwise leakage of gastric contents into the peritoneal cavity may occur.

How would you calculate the resting energy requirement?RER may be calculated as follows:


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formation as healing progresses in the proximal oesophagus. Stricture formation can follow deep oesophageal injury which extends into submucosal and muscular layer of the oesophagus and can lead to a circular band of scar tissue. The owners were instructed to monitor for typical signs associated with this condition, including: regurgitation, dysphagia and ptyalism. It is reported that steroids may be used to decrease the risk of stricture formation; however, a non-steroidal anti-inflammatory drug was chosen in this case due to the degree of oral discomfort on presentation.

Follow-upThe cat was reassessed after 2 weeks. Extensive areas of lingual ulceration remained, especially affecting the midline, tip and sides of the tongue. The pharynx also appeared inflamed. The cat was refusing all food offered per mouth and the owners were advised to stop this, as there was concern over the cat developing a food aversion.

ConTRIBUTE A CLInICAL ConUndRUM

If you have an unusual or interesting case that you would like to share with your colleagues, please submit photographs and brief history, with relevant questions and a short but comprehensive explanation, in no more than 1500 words to [email protected] submissions will be peer-reviewed.Figure 5: Appearance of the tongue at the 6week recheck

What medications are indicated?Omeprazole, a proton pump inhibitor, was used in order to reduce gastric acid secretion and prevent further irritation to the oesophagus in the event of reflux or vomiting. Meloxicam and buprenorphine were administered to provide analgesia. Injectable medications were administered initially, as oral administration would not have been tolerated and administration of medication via the tube was contraindicated for the first 24 hours. Subsequent to this, medications were administered via the tube. Intravenous broad-spectrum antibiotic cover was provided for the first 24 hours using amoxicillin/clavulanate and lincomycin until the pyrexia had resolved; antibiotic therapy was then continued using amoxicillin/clavulanate and clindamycin administered per tube.

OutcomeOver the following days, the cats demeanour markedly improved. By day 2, the cat had a normal rectal temperature and appeared much brighter. Both the lingual swelling and salivation had decreased substantially. On day 4, opioid analgesia was discontinued as the cat appeared much more comfortable and was displaying grooming behaviour. Food was offered per os, although the cat showed no interest.

The cat was discharged to the owners care following a 1-week period of hospitalisation. The tongue had reduced to a normal size and the cat was able to close his mouth fully. The areas of lingual ulceration were showing signs of healing. Medication with amoxicillin/clavulanate, clindamycin, omeprazole, sucralfate and meloxicam was continued.

What possible complications should you make the owner aware of?There is a risk of oesophageal stricture

Re-examination after 1 month revealed progression of healing of the tip of the tongue and granulation over the remainder of the ulcerated surface. The cat appeared very comfortable and had been showing a clear interest in food at home over the previous few days. The owners were advised to continue tube feeding and to offer small amounts of liquid or soft food per os.

Re-examination at 6 weeks revealed the tongue to be almost completely healed with only a small rim of granulation tissue near the edge (Figure 5). The owner reported that the cat was eating almost his entire daily requirement orally and the PEG tube was removed.

Medication with sucralfate and omeprazole were advised to be continued until the lingual ulceration had completely resolved. A 2-week course of amoxicillin/clavulanate and a 6-week course of clindamycin were administered in total. No signs compatible with oesophageal stricture formation were reported.

The cause of the oral ulceration was never determined, but with diligent supportive care the cat made a full recovery.

Editor's Note: Readers are reminded that selection of suitable antibiotics emperically and determination of a length of course of treatment is not always straightforward. The PROTECT poster supplied with the October edition 2011 of companion and available online in the Advice/Practice Pack section of www.bsava.com, can aid decision making.


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The BSAVA Postgraduate Certificate experience

Frances Barr, Director of Education, talks to several pioneers on the popular new programme from BSAVA

Throughout 2011 there was tremendous interest within the profession regarding the development of the BSAVA Postgraduate Certificate Programmes. The aim of these

programmes was to provide a structured and supported option for professional development for individuals working in first opinion practice who wish to improve their knowledge and skills.

When enrolments opened in October of last year, demand vastly outstripped the places available (30 students per programme). Both the medicine and surgery programmes quickly filled in under half an hour.

These pioneering groups of students are now well into their studies. From the perspective of the teachers, it has become clear that the students are committed and enthusiastic. The teachers are really enjoying interacting with a close-knit group who are comfortable asking questions and willing to enter into debate.

Good to talkSo, what do the students themselves think? With such an ambitious new offering, BSAVA knew it was essential to seek out the opinions of the pioneer group. At the beginning of the year, each of the enrolled students was asked to complete an introductory questionnaire, and they have since engaged in continual dialogue to find out where we might refine the programmes.

Although the majority were relatively recent graduates (15 years post graduation), there were plenty of more mature graduates (some are more than 20 years post graduation). There was a good mix of male and female students (although medicine is predominantly female and surgery predominantly male). Individual students were based in England, Scotland, Wales and Northern Ireland, as well as two based elsewhere in Europe.

Students with something to sayOur student body represents this broad mix which, while undoubtedly healthy, makes it impossible to choose a typical student to tell us about their experience. Nonetheless we invited one student from each programme to share their impressions of the programmes so far.

Andy Nelson graduated from Bristol in 1997. He worked in mixed practice for three years before taking time to locum and travel for several years. Since that time, Andy has worked in 100% small animal practice. He is enrolled on the surgery programme.

Zoe Cleaver is also a Bristol graduate (2010). Since graduation she has been working in a small animal practice with nine other vets. Zoe is enrolled on the medicine programme.

There are also comments here from some of the other students enrolled on the programmes and thanks to all those who have been quoted.

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Many students also addressed this question in the introductory questionnaire, and some of the comments are given below.

The main reason is that over the years I have developed an interest in medicine. This is an area where I feel I can make a significant difference to my clients and patients in general practice, and I want to do the best job that I can.

To keep updating and fulfil mandatory CPD requirements in the most rewarding and interesting way. Also to improve my mentorship of more junior vets.

A genuine love of surgery and desire to improve.

To continue to develop my abilities; optimising the care of my clients and their pets.

Christine Howells (medicine) graduated from Cambridge in 1987. She started off in mixed practice, but moved into small animal practice after having a family. She says: I didnt want to turn into a dinosaur, and I like the modular structure with additional tasks which tends to keep me focussed on studying. I had already done another modular course and found it a good way of studying for me.

What made you want to continue studying?

Andy: I want to do my job as well as possible. I also wanted the challenge of working towards a definite aim with structured CPD. I tried the old-style RCVS Certificate in Small Animal Surgery about six years ago, and have always been a bit frustrated that I didnt stick with it. But I learnt a lot from the experience. Im hoping to learn a lot again but hope to get to the qualification at the end this time!

Zoe: I wanted to improve my skills as a small animal vet in a structured way as it can be difficult to stay up to date in a broad range of areas.

Why did you choose this particular programme?

Zoe: I chose this programme as, being run by the BSAVA, I know it would be recognised as a good quality programme and be well organised with respected speakers. The structured approach to the course appealed to me personally, as I felt the set times to complete tasks would focus my attention. As I struggle with writing essays, the format of the learning tasks really appealed to me.

Andy: I chose this programme as I liked the idea of something really new. I found the old style RCVS certificates were difficult as there was very little support structure. I considered the other options but thought that the BSAVA programme was the best mix of support and structure as well as a lot of graft. I believe its a certificate that will really mean something to those who have it and to the rest of the profession who will respect the work involved.

Andy Nelson Zoe Cleaver

What have been the highs and lows of the programme so far for you?

Andy: On the whole, expectations have been met. The first few courses have been dryer subjects and background knowledge. I cant wait for the two days coming up on fractures, and I expect a lot of us will be more excited by this and the practical aspect promised. The support from the experts has been the best thing, getting the online feedback about cases and the online learning tools. The web-based activities have been excellent and a great way to do a bit of study on those days when you cant face the textbooks! If Im honest, I think the group size is probably pitched slightly too high and it may be better to have two smaller streams of students going through, or just restrict numbers more.

Zoe: Highs of the programme include attending the lecture days everyone is so friendly and all the


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The BSAVA Postgraduate Certificate experience

speakers really engaging. I also enjoy getting a day to do something a bit different and its rewarding when something you have learnt helps your approach to a case. The only negative is the travel involved; however, the train journeys are a good opportunity to get some studying done. So far the programme has exceeded my expectations: the learning material is set at just the right level and I have enjoyed all the online exercises.

Have you found returning to study a challenge?

Zoe: As I am a recent graduate returning to study hasnt been difficult but the main challenge is finding time to study while working full time.

Andy: So far the studying has been going OK, although I realise Ill need to do more hours as I go along. Time and space to study is not really a massive problem; I quite enjoy it. The last month or so has been very busy for me with the opening of a new practice, so studying has had to take a bit of a back seat but Ill get stuck back in soon. The frequency of CPD days keeps things ticking along nicely and I find myself looking forward to the next scheduled event.

How do the students connect are the forums useful?

Andy: Ive made a few friends. I think the camaraderie will be better after our first two-day course as well have a chance for a drink and meal together after the first days lectures. It would be good if the first two courses in the programme were grouped together for this reason, to encourage everyone to go out and socialise more, rather than just heading off after the lectures. The discussion forums are very good and I definitely value them. Id like it if participation in these could be encouraged more, as the same faces keep appearing and it would be good to hear more peoples views.

Zoe: I have enjoyed meeting all the other students on the programme. The discussion forums are great. Its really good to hear about other peoples interesting cases, and working through the cases presented on the forums is useful. The best thing about the forums is having somewhere to ask questions and get advice on cases, where everyone is so helpful.

What impact has this undertaking had on your life at work so far?

Zoe: I am starting to have a more logical approach to cases at work now; I can definitely apply the majority of what I am learning within the constraints of first-opinion practice, and also have productive, informed conversations with colleagues and referral centres.

Andy: Ive changed a few little things at my practice. I can apply what weve learnt but Ive not had much chance to share with colleagues due to the building of the new practice. I hope well be back to our usual practice clinical discussion groups soon, as there are a few things I really want to discuss and pass on to the rest of them at work.

Do you feel you have been supported throughout your studies so far?

Andy: The support has been very good. I still dont know who my mentor is though?

Zoe: The BSAVA staff are approachable and helpful and are always easy to contact online. I havent needed to ask my mentor for any support yet but she regularly sends emails to see how I am getting on and I definitely feel that she is someone I could turn to if I need help or support.

If you were advising someone who is considering enrolling themselves, what advice would you give them?

Zoe: Definitely do it! Im really enjoying it so far.

Andy: I would recommend it, Id say go for it. Youll learn lots, get to know like-minded people to share experiences with, and be able to make a real difference to what you do on a day-to-day basis. I also think it is a good way to (hopefully) achieve a worthwhile qualification in practice. My other advice would be to try to get your boss to pay!

Onwards and upwardsSo far, the BSAVA Postgraduate Certificate Programmes are running smoothly. Listening to the views of students like Zoe and Andy when we ask for, and listen to, feedback from the students after each taught unit means we can continue to refine the programmes. The teachers have, without exception, been keen to receive the feedback so that changes can be made where necessary to the units for next year. All involved with the programme are grateful to this first cohort of students for their ongoing and constructive comments. n

FURTHER INFORMATION

Enrolments into the programmes for 2013 will open via www.bsava.com at 9am on Monday 1 October. If you have any questions about the programmes, or would like to register your interest, please email [email protected]


For more information or to book your course

www.bsava.comAll prices are inclusive of VAT. Stock photography: Dreamstime.com. Anna Dudko; Ernst Daniel Scheff ler; Tine Grebenc

BSAVA dispensing course27 SeptemberThis course meets the RCVS Practice Standards veterinary hospital pharmacy course requirements

SpeakerS

P. Sketchley, S. Dean, F. Nind, J. Hird, P. Mosedale, M. Jessop

Venue

De Vere, Daresbury Park Village

FeeS

BSAVA Member: 232.00Non BSAVA Member: 348.00

Surgery Mini Module3-part programme covering surgery of the stifle, elbow and pelvis

Surgery of the stifle with Rob Rayward on 4 September

Canine Developmental elbow Disease with Noel Fitzpatrick on 9 October

Decision making for the hips and pelvis with Kevin Parsons on 4 December

FeeS


The courses take place at Woodrow House in Gloucester and each part can be bought individually

Advanced Reptile MedicineApproach to the sick herp

18 September This course is aimed at practising veterinary surgeons, who are seeing reptiles on a regular basis, or would like to advance their knowledge of reptile medicine

Speaker

Joanna Hedley

Venue

Blackpool Zoo

FeeS

BSAVA Member: 227.00 Non BSAVA Member: 340.00

Infectious Disease Mini Module3-part programme covering infectious diseases of the dog, cat and rabbit

Canine infectious diseases with Patricia Ibarrola on 12 September

Old bugs and new bugs: feline infectious disease with Samantha Taylor on 25 October

Common and emerging infectious diseases in the pet rabbit with Emma Keeble on 20 November

FeeS


The courses take place at Woodrow House in Gloucester and each part can be bought individually

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Thanks to better diets and care in general, more and more of our cats are living to an advanced age. Seeing and examining apparently healthy mature cats is important,

since it can help to identify clinical problems before they reach a crisis point. Unfortunately, for many illnesses clinical signs are subtle, gradual in onset and progression, and therefore easy for an owner to miss.

Clinical signs can also be confusing, for example, rather than showing lameness, cats with osteoarthritis may show a reluctance to use the catflap. For some of these cats, this may be manifested as an elimination problem, for example defecating in the house.

The author recommends that clinicians follow the Feline Advisory Bureau (FAB) WellCat guidelines for assessment of older cats in order to diagnose illness promptly. FABs WellCat guidelines advocate that:

Cats of all ages should be assessed at a veterinary practice at least once a year and their weight and body condition score recorded in addition to a general physical examination and discussion of appropriate preventive health care

In addition to this: Mature cats those aged 7 years should

have their blood pressure (BP) checked once a year and a urinalysis performed.

Senior cats those aged 11 years should have blood tests done (haematology, serum biochemistry, total T4) once a year. Consideration should be given to increasing the frequency of BP and urinalysis check-ups to every 6 months in these cats.

Geriatric cats those aged 15 years

should be assessed at a veterinary practice every 6 months, at which time a clinical examination, weight check, body condition score, BP and urinalysis should be performed. Blood tests should continue to be done annually unless there is any clinical indication to increase the frequency of these.

The author prefers to see Senior patients every 6 months and Geriatric patients every 3 months.

Urine collection and analysisA free-catch urine sample is adequate for initial urinalysis and can be obtained by the owner with the cat at home. To collect a free-catch sample from a cat, the patient is confined with an empty litter tray or one containing non-absorbent cat litter (commercial brands include Katkor, Mikki; non commercial options include clean aquarium gravel, chopped up plastic bags, etc).

Once the cat has urinated, a urine sample is collected using a pipette or syringe (Figure 1) and placed into a sterile tube for subsequent analysis. Free-catch sampling can affect interpretation of bacterial culture, sediment examination and proteinuria results.

Dr Sarah Caney, CEO of Cat Professional Ltd, points out what we need to look out for in our older feline patients

Figure 1: Annual urinalysis (dipstick and specific gravity) is recommended in cats over the age of 7 years. Free-catch urine samples brought in by the owner are acceptable for this purpose

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Cystocentesis urine samples are preferred if urine bacteriology or protein assessment is required. Urine samples can be obtained from conscious cats with minimal restraint (Figure 2). The only requirements for successful sampling are a calm cat whose bladder can be palpated.

In-house urinalysis

Gross examination and specific gravityUrine should be observed and its colour, clarity and presence of gross contamination determined. Urine specific gravity (USG) should be assessed using a refractometer (Figure 3B) and NOT dipsticks! Urine may be defined as isosthenuric (USG = 1.0071.015, same as glomerular filtrate), hyposthenuric (USG 1.015). Most normal cats will produce very hypersthenuric urine, usually 1.0401.060. USG can be artificially raised by glucosuria, heavy proteinuria or radiographic contrast media.

A USG 1.040 is normal; a USG between 1.035 and 1.040 is in a grey area and repeat measurement and/or further monitoring is recommended. In cats with USG

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Protein: Dipsticks are relatively insensitive in documenting proteinuria and do not take into account the concentration of the urine for example, most cats will produce urine with a trace/+ reading on the dipstick. For a cat with very dilute urine, this could be misleading, as a small amount of protein in a very dilute urine sample generally equates to significant amounts of protein loss overall. For this reason, determination of the urine protein to creatinine ratio (UPC) is recommended in all cats with known renal disease or where protein assessment is required. Normal cats have a UPC ratio of

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Ideally, diagnostic evaluation should include systolic (SBP) and diastolic (DBP) blood pressure measurement. The author recommends Doppler measurement of blood pressure since oscillometric techniques have been shown to be unreliable in conscious cats.

A detailed ophthalmic examination is essential both in the diagnosis and assessment of the extent of ocular disease. A thorough ocular examination is most easily done by using distant indirect ophthalmoscopy. This requires the following:

A dark room. If a dark room is not available it may be necessary to dilate the pupils using tropicamide.

Hand-held lens e.g. 2.2 Dioptre, panretinal lens held at arms distance, just in front of the cats eye.

A light source held by the side of your head: best is a focussed light source (e.g. Finhoff transilluminator attached to the otoscope/ophthalmoscope body) but good working alternatives would be a standard ophthalmoscope set to a small circle or, failing that, a pen torch. Shine the light into the cats eye; once a tapetal reflection can be seen, insert the lens just in front of the cats eye and an upside-down image of the fundus will be seen.

Direct ophthalmoscopy can be used to have a closer look at any lesions identified.

Blood pressure measurement should be performed in a quiet room, away from barking dogs and telephones, ideally allowing the cat 10 minutes to acclimatise to these surroundings before the measurements are taken. This acclimatisation period helps to reduce the incidence of white coat hypertension.

Interpretation of SBP resultsA number of different reference ranges have been published for normal cats, citing SBP readings from 107 to 181 mmHg in healthy cats. When it is possible to measure it, the DBP of normal cats should be

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SBP >180 mmHg: severe risk of TODIn general, cats with SBP in excess of 180 mmHg are genuinely hypertensive and therapy is justified. However, some healthy cats may transiently have SBP above 180 mmHg. Hypertension should therefore never be treated solely on the basis of a single abnormal blood pressure reading. If evidence of TOD is present, the diagnosis of hypertension is confirmed and treatment can be instituted. In the absence of TOD it is prudent to re-check the SBP on another occasion before pursuing treatment. The author recommends the following steps are taken in cats with SBP readings >180 mmHg:

Ensure that measurements are taken correctly allowing at least 510 minutes for acclimatisation before readings are taken

Perform a clinical and ocular examination: if evidence of TOD, the diagnosis of systemic hypertension is confirmed

If no evidence of TOD: repeat measurements on one or two separate occasions within 12 weeks. If readings remain high, anti-hypertensive treatment is justified. Further investigations aimed at finding secondary causes of hypertension should be pursued.

SBP 160180 mmHg: moderate risk of TODSBP readings that are persistently between 160 and 180 mmHg are believed to pose a moderate risk of TOD. Persistence is defined as being present on several occasions over a 2-month period. If there is evidence of TOD or if the cat is known to have CKD or any other condition known to be associated with hypertension, then anti-hypertensive therapy is justified. In the absence of either of these, it might not be possible to rule out white coat hypertension and further monitoring might therefore be more appropriate.

SBP 150159 mmHg: mild risk of TODCats in this group may have mild hypertension but many normal cats will also give blood pressure readings in this range due to the white coat effect. Treatment is not normally recommended unless there is evidence of TOD. For those cats with conditions

known to predispose to hypertension, 13-monthly monitoring of blood pressure and evaluation for evidence of TOD is recommended once readings >150 mmHg are obtained.

SBP less than 150 mmHgMost normal cats have SBP readings of 120150 mmHg. This should be viewed as the ideal target range following treatment for hypertension.

Further investigationsBlood tests should be performed after an 8-hour fast (water intake should not be limited during this period). Mature and geriatric blood profiles ideally should include complete haematology and serum biochemistry with particular attention to proteins, liver enzymes, electrolytes, urea, creatinine and thyroxine.

ConclusionsThe potential benefits of maintaining contact with the mature healthy feline patient are easy to see. By identifying clinical problems such as osteoarthritis we can offer targeted therapy which can benefit the cats quality of life immediately. Diagnosis of some conditions such as systemic hypertension before it has resulted in clinical signs can prevent severe consequences such as blindness. Maintaining contact with healthy mature cats is definitely a challenge but hopefully one which is eminently rewarding to the cat, its owner and ourselves.

Further readingInformation on the FABs WellCat scheme can be accessed on the website of the International Society of Feline Medicine www.isfm.net. Free Download guides to urine collection, blood pressure measurement, ocular manifestations of systemic hypertension can be found on the authors website www.catprofessional.com

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Fluid therapy fundingHaving awarded over 45,000 in clinical research grants, there is some impressive work being undertaken thanks to your donations. Here is one such project; Sarah Thomson of Davies Veterinary Specialists tells us about her study into goal directed fluid therapy in high risk dogs undergoing abdominal surgery

Intravenous fluids are commonly administered during anaesthesia often at a fixed rate, which may result in hypovolaemia or volume overload. There

are limitations in the ability of currently used monitoring techniques to accurately detect hypovolaemia.

The confidential enquiry into small animal fatalities (CESAF) found that the risk of mortality associated with anaesthesia was 0.05% in healthy dogs and 1.33% in sick dogs. This is much higher than in humans (0.020.005%) and may be due to differences in standards of anaesthesia, such as monitoring.

About GDTGoal directed fluid therapy (GDT) is a technique used to maintain tissue perfusion by optimising cardiac output in order to prevent the development of an oxygen debt. Boluses of fluids are administered and the response in cardiac output is monitored. Fluids boluses are only repeated if the patient responds. If no response is observed, other drugs such as positive inotropes are used.

Oesophageal Doppler (OD) is a minimally invasive technique, used in human anaesthesia to continuously monitor

APPLYING FOR GRANTS

If you are interested in applying for a Clinical Research Project grant, please visit the PetSavers section on the BSAVA website www.bsava.com or email [email protected]. The deadline for applications is 31 August 2012 and will be considered in March 2013.

cardiac output and guide fluid therapy. GDT guided by OD has been shown to reduce post-operative complications, length of hospital stay, re-admission and re-operation rates in humans undergoing major surgery.

Benefit to high-risk dogsThe National Health Services National Institute for Health and Clinical Excellence recommends the use of OD (CardioQ-ODM, Deltex Medical, Chichester, UK) in patients undergoing major or high-risk surgery or other surgical patients whom a clinician would consider using invasive cardiovascular monitoring.

PetSavers is funding our study to investigate the use of OD to guide GDT in high risk dogs undergoing abdominal surgery. We hypothesise that this technique will reduce post-operative complication rates and may benefit the management of particularly the sickest animals in veterinary anaesthesia.

Reasons for fundingDerek Attride, Chair of the Grants Awarding Committee, explains why the funds were awarded to this project; PetSavers thought that this could prove to be a useful technique for monitoring high-risk patients. This project looks at the situation in human medicine and seeks to assess if it could apply in veterinary medicine and reduce mortality rates in anaesthesia of sick dogs. The technique is minimally-invasive and could eventually be more widely used in practice to alter the way IV fluids are used in critical patients. n

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Congress 47 APRIL 2013

Nick Bexfield, Congress Programme Committee Vice-chair talks you through the fresh approach to the lecture programme

How to pick your lectures for Congress 2013

BSAVA Congress has always catered for all its members with its wide-ranging scientific programme. For Congress 2013 you can expect the same superb quality in

the science programme, with a fresh approach offering something for the whole practice team: vets, nurses, practice managers, new assistants, experienced partners, specialists, general practitioners, and everyone in between.

With more than 300 lectures delivered by the worlds best speakers, career stage-, species- and topic-focused streams, veterinary small group sessions, veterinary and nursing practicals, clinical research abstracts and posters, three days of management lectures, and much more, how can you decide which scientific session to attend? Here is a handy guide to what will be available at Congress 2013.

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Following the success of last years stream, the 2013 Management Stream will be even bigger, with four streams running over 3 days. In the first of these streams, there will be a whole stream devoted to psychology in practice. Do you want to learn about psychology of confidence and how to achieve success in veterinary practice? Do you wish to improve your mentorship skills? If so, this management stream is a must!

Congress 2013 will then take you on a journey through the key elements of running your business; the focus for 2013 will be the culture of both your practice and of UK pet owners. There will be marketing inspirations from a leading corporate brand outside of the veterinary sector, sharing how their

customer-centred business works, as well as leveraging what the customer wants you will know the adverts! Key employment challenges will be looked at from a how do I do it? perspective, giving you answers to those very tricky questions of what to do with employees who need to find a different job. There is an intriguing financial perspective on productivity who actually produces more value for your practice? and a useful insight into the mind of a veterinary surgeon why do we do that? With case studies from practices that have been through challenges, ranging from a cultural turnaround to running a practice using skills learned in the health club sector, there will be something to suit everyone.

Management

Veterinary programmeCareer stage-focused streams

How to survive...This stream will contain twelve concise 20-minute presentations on medical and surgical emergencies commonly encountered in practice. A great way to enable the recent graduate, veterinary surgeons involved in emergency work, or any other member of the veterinary team, to discover handy hints and top tips to manage these emergency cases. If you want to learn how to survive a GDV, Addisonian crisis, blocked cat or an open fracture, this stream is definitely for you!

The first priorities in...Aimed at recent graduates and veterinary surgeons returning to practice, this stream is also suitable for any member of the veterinary team. Presentations will involve a short overview of a subject area followed by a case-based discussion including the opportunity for electronic voting. Topics will be wide-ranging, from poisoning to anorexic rabbits through to chronic diarrhoea.

Top tips for experienced vetsThe presentations in this stream are Advanced level and aimed at the experienced small animal practitioner who wishes to expand their knowledge in some of the more challenging areas of veterinary medicine. Topics covered will include the non-healing wound, acidbase interpretation, oesophagostomy and PEG tubes, plus many more.

Am I up to date on...Are you up to date on imported diseases, immunosuppression and avoiding antimicrobial resistance? If not, you should attend this lecture stream covering these and other topics designed to provide a refresher in each subject area, primarily focusing on recent developments in each field. This series of presentations will be of particular interest to those veterinary surgeons returning to practice after a career break, although other members of the veterinary team may also wish to update their knowledge.

Species-focused streams

Small mammalsDo you struggle to interpret dental radiographs of rabbits and rodents? Want to learn how best to deal with abscesses in rabbits or new strategies for the treatment of adrenal disease in ferrets? If so, this stream, which contains a wealth of additional informative presentations, is the one for you.

Feline foundationTo complement the BSAVA Manual of Feline Practice: A Foundation Manual, due to be launched at Congress, the Feline Foundation stream consists of General level presentations in areas of feline practice. Applicable to the whole veterinary team, presentations are by internationally recognised speakers involved in the writing of this Manual, guaranteeing the highest quality CPD.

Getting to grips with reptilesInexperienced with reptile medicine and surgery, but wish to develop your skills in these areas and appreciate the diagnostic techniques available to investigate these patients? If so, you should definitely make sure you attend this stream! Presentations will be given by world-renowned reptile specialists and are aimed at both General and Advanced levels.

Topic-focused streamsAlways highly popular, these streams, which contain both General and Advanced lectures, cover a wide variety of small animal topics. Each topic will be covered in six to eight lectures delivered over a whole day. In 2013, internationally recognised speakers will provide the latest information on renal disease, ophthalmology, dentistry, orthopaedics, dermatology, neurology, soft tissue surgery, oncology, pain management, liver, aural and cardiorespiratory disease. You can even test yourself (fortunately anonymously!) against the experts with interactive film reading.

Controversies streamListen to top class speakers discuss some of the more controversial topics in cardiology, gastroenterology and anaesthesia. Each topic is covered by a series of lectures at Advanced level, with some panel discussions which occupy a double slot. Examples include the use of antibiotics in acute diarrhoea, pre-anaesthetic screening and how to diagnose CHF in the new millennium. For the very latest controversial topics, check out the programme for the Journal of Small Animal Practice Current Advances stream nearer to Congress 2013.

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Congress

Nursing programmeFor Congress 2013, the Nursing Programme will be bigger than ever, containing 13 exciting streams. To get you in the mood, here is an overview of just some of the streams you can expect to find at Congress 2013.

Emergency and critical careThe emergency and critical care stream features well respected emergency and critical care specialist nurses speaking on a range of subjects, including respiratory emergencies through to abdominal emergencies. This stream will give both student and qualified nurses the opportunity to gain new skills in this vital aspect of nursing care.

AnaesthesiaThe anaesthesia stream brings with it top class speakers from around the world, specialists in their own field. The subjects vary from anaesthesia and analgesia to fluid therapy and will give all nurses the change to improve their knowledge and skills in this area.

Surgical nursingThis years surgical nursing stream brings presentations on a range of commonly seen surgical conditions, but will also cover some that are less common. If you want to learn how to run an effective theatre suite for instance, this particular lecture will allow you to gain the skills to schedule the days procedures more effectively and consider individual patients requirements.

Small group sessionsVeterinary small group sessionsFor Congress 2013, Small Group Sessions will be added to the Masterclasses and provide an opportunity to explore a subject in a more relaxed atmosphere where discussion is encouraged but is not enforced you can just sit, listen and learn. To attend these sessions, delegates are not expected to have specialist knowledge. Each Small Group Session runs for 3 hours, and is restricted to a maximum of 2040 delegates. To take part in a Small Group Session you need to purchase a ticket in addition to registering for Congress. Tickets for Small Group Sessions may be purchased at Congress if spaces remain but they have often sold out. To avoid disappointment therefore, we recommend that you purchase your ticket(s) at the same time as you register for Congress.

Veterinary and Nursing practicalsAn exciting new development for Congress 2013 will be the introduction of Practical Sessions, covering skills such as ultrasound-guided fine-needle aspiration, radiological interpretation and cytology, haematology, bandaging, and many others. These Practical Sessions will run for 3 hours, with participants working in small groups and moving between practical stations. To take part in a Practical Session, you need to purchase a ticket for that class in addition to registering for Congress. These sessions will be very popular and ticket numbers will be limited, so buy early!

Clinical research abstractsClinical research abstracts are at the heart of the ethos of Congress and yet are one of BSAVA Congresss best kept secrets! They consist of short presentations of current clinical, nursing and management research and are ideal for veterinary professionals working in small animal practice who wish to learn about the latest research applicable to all parts of their practice. Sessions are informal, with a small audience and the chance to ask questions.

Clinical research

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KEY DATES

Online Booking from 1 September 2012 Early Bird deadline 31 January 2013 Practi ce Badge Deadline 6 March 2013

To download the Advance Programme visit www.bsava.com/congress or for more information email [email protected].

Nursing programmeInfection controlNurses play a vital role in ensuring effective infection control procedures are carried out within the practice. This lecture stream will therefore look at the importance of this area and what can be done to ensure effective techniques are carried out. It will also give nurses a better understanding of the importance of testing and careful antibiotic selection.

NeurologyThe neurology stream brings together world experts in neurology; the lectures will cover commonly seen neurological conditions from patients with spinal disease to seizur ing animals through to vestibular disease. If you want to enhance your knowledge on the treatment options for these patients, this stream is a must!

DermatologyThe dermatology lectures at Congress 2013 feature something for both student and qualified nurses. The lectures will look at testing protocols for dermatological conditions and the reasons for them, as well as treatment options.

OrthopaedicsThe orthopaedic lecture stream will give nurses more confidence in dealing with these patients, as well as understanding the underlying physiology. Aimed at student nurses and also serving as a refresher for qualified nurses, the lecturers will help nurses gain solid background knowledge of this subject area.

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Clinical research

Types of lecturesGeneral lectures (Veterinary and Nursing)

Focus on common presentations Logical approaches to diagnosis and management

Aimed at veterinary professionals who would like to refresh their knowledge on a topic or who may not see small animals every day. The lectures will focus on common presentations and readily available diagnostic aids.

Advanced lectures (Veterinary and Nursing) Focus on improved decision-making Current controversies

Aimed at experienced veterinary professionals with a higher level of knowledge who are working in small animal practice. These lectures will focus on improving decision-making, dealing with difficult cases and current controversies.

State-of-the-Art lectures (Veterinary) Current concepts, cutting-edge technologies and ongoing

research in the field Up-to-date approaches to diagnosis and treatment

Aimed at all veterinary professionals interested in the how, when and why of the conditions they recognise and deal with.

Electronic voting (Veterinary) Case-based sessions with electronic voting to allow

interactive decision-making Personal delegate keypads allow anonymous voting

The speaker leads the audience through the presentation and work-up of one or more cases. The delegates become involved in the decision-making process for each case through their electronic voting keypads. The keypads, which are issued to each delegate as they enter the lecture hall, are simple to use and completely anonymous. Questions are directed at the whole audience rather than at individuals, and only you know the decisions that you make. Indeed, there is no need to vote at all if you prefer just to think about your answers. The responses given by the audience are displayed graphically after each question, so you can see the spread of decisions. And the speaker can then explain why one or more of the options would be better than others. It really is the ideal (safe and anonymous) way to practice clinical decision-making.

Clinical research postersClinical research posters are another way to learn about latest clinical research, especially the results of preliminary studies or interesting clinical cases. Posters will be displayed for the duration of Congress, allowing delegates to browse in their free time. There will also be the opportunity to discuss the poster contents with authors over wine and cheese at a reception during Congress.

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148+17,4

The oft repeated saying of location, location, location emphasises the importance of selecting the proposed position of a new premises for your practice with the utmost

care. However, preparation should begin somewhat earlier than searching for a potential site.

PeopleIt almost goes without saying that a veterinary practice will only prosper if there are sufficient animal owners within the target area to be converted into clients. Fundamental to the success of any business is customers. There is little point in investing heavily in small animal premises in the most idyllic hamlet in the county with just ten houses, six cats and three dogs. That might work if there is a substantial catchment area close at hand, but even then neighbours who have chosen to live in such an isolated place may be annoyed at the increase in traffic flow that could be created. So the need is for people: people with pets.

Pet owners are likely to live fairly stable lives, having put down roots and settled within the area. Districts where a high proportion of couples both commute for work are likely to have lower dog populations, but perhaps a higher ratio of cats. Small furry pets are more likely to be found in households with a growing family. Whilst these are broad generalisations, they do help set the scene.

Planning dataFinding the data that will help profile an area has become so much easier in recent years, and much of it is free. All local planning authorities (such as district, borough, unified or metropolitan councils) have websites containing a variety of population statistics. Sometimes finding this information takes a little hunting, but it is normally there, somewhere.

Some of the information is broken down into electoral wards and you will need to find the ward map (also on the website usually) to help analyse the data. Normally, details include the household types, often with population profiles and demographics.

Whilst all too often pushed down the priority list, considering the people a practice hopes to attract should be the very first step. This is the basis of the concept of marketing: reviewing the size and type of the potential market and aiming to satisfy market needs and wants.

Professional competitionHaving considered the overall market and gained knowledge of the size and mix of households, it is a good idea to study how that market is currently being satisfied. The level of local competition can help determine whether or not there is scope for the size and type of practice you have in mind.

Once again, life has become easier in recent times with publications such as the RCVS Register of Practices, which provides some information on the size, mix and staffing of existing practices. The raw number of practices can be obtained from commercial directories (both online and offline).

Mapping the areaPlotting the existing practices on a good sized street map will give a useful pictorial view of your proposed market. Take a drive around the area and look at the potential competition. Review the appeal of their premises, the general condition and maintenance. Note, specifically, their off-street parking, location and access. Record what you observe and how you think you could make a difference with your offering.

As well as checking out the local competition, this process provides a familiarisation exercise, which will help with the planning overview. You may note areas which would seem to be preferable, and some which may be best to avoid.

In addition, areas can be reviewed using one of the aerial view websites. However, whilst very useful, it is no substitute for travelling the streets yourself.

WebsitesMany practice websites at least hint at the number of vets working there, or will even have a Meet the Team section where you can see exactly how many vets,

Jim Wishart, a contributor to the new BSAVA Manual of Small Animal Practice and Development, looks at three key steps to consider before starting to design veterinary premises

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consultation or procedure. If appointments are to be at 10 minute intervals, that equates to six per hour. How many of those appointment slots will be taken and how many consulting hours will there be? The same process is repeated for in-patients. This practical approach helps visualise the plan.

Within the planning process is that thorny issue of whether to rent or buy. Leasing a property offers lower start-up costs. At the same time, there would be regular upward-only rent reviews and the fact that if you move to a larger premises you would leave behind a building with veterinary planning consent. With ownership there is the chance that your asset will grow in value, the lender has more security, and you are in command of any eventual disposal.

With the insight gained from these three elements of preparation, knowledge has been gained of the overall market and the locality. There is a strategy in place that demonstrates that the proposal is viable.

nurses and other staff are employed. Practice websites also give a good idea as to the overall attitude and approach they take.

Today, some of the more progressive practices are very open about their pricing structure, even having it available to view online. For their clients, this is really useful as they can avoid the embarrassment of having to telephone to ask the price before booking an appointment or procedure. It will also save you a lot of time if you know what prices exist in the local market.

CompareWith population data and the research on local practices, it should be straightforward to compare the total number of households with the total number of vets. Even with the rough statistic that one-in-four households is likely to have a dog or cat, you may get a feel for the scope for a new practice within the area. If the business plan proposes additional services (such as grooming or hydrotherapy), these should also be included in the facilities that you review in the area.

FundingAt some early stage there should be discussions with potential funders. Whether this is at the concept stage, or once there is some degree of target area, be prepared. For an early visit to the bank, the business plan may be somewhat hypothetical, but it should demonstrate the thought process.

Business planA business plan should include an overview of the intention and paint a picture of what is proposed. Bankers will want to see cashflow forecasts, potential trading results, and how much capital is being invested by the potential borrower. That figure may well be around 20%, but can include the value of existing assets.

Today, loan costs should be based on borrowing at around 56%. The cashflow modelling should be based on the expected costs, but you would be wise to also show the effect if the costs, or footfall, were 20% adrift of expectations. Cashflow should take into consideration workloads and the likely income per client attendance.

Current experience may help determine the pricing structure and, possibly, the average income per

NEW MANAGEMENT MANUAL NOW AVAILABLE

Jim Wishart is just one of the contributors to the new BSAVA Manual of Small Animal Practi ce Management and Development. He works with the Veterinary Management Consultancy, James M Wishart & Associates. The new BSAVA management manual is writt en by a range of experienced authors who have designed and built surgeries, managed veterinary sta , bought and used the equipment, and cleaned the oors; this excellent ti tle brings ideas and guidelines that will be useful in improving and running a small animal veterinary business, whether established or new.

Managing the planning and constructi on process Recepti on and client waiti ng areas The practi ce dispensary Leadership and self-management Principles of health and safety Clinical governance

BSAVA members: 55.00Non-BSAVA members: 85.00

Order your copy online at www.bsava.com or call our Membership and Customer Services Team on 01452 726700 today.

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28 | companion

The WSAVAs Continuing Education Committee has published its schedule for the rest of 2012, with Africa, Asia, Eastern Europe and Latin America set to benefit from over 30 CE

sessions. Highlights of the programme include:

n Sessions in African countries, covering renal disease, epilepsy and otitis externa

n A series of 11 sessions throughout Latin and Central America, focusing on emergency medicine, dentistry and dermatology

n Three sessions in China, offering a diagnostic approach to the anaemic or bleeding patient

n Sessions in Malaysia, Vietnam and the Philippines, concentrating on orthopaedics and dentistry.

CE Committee Chair Jill Maddison comments: Were focusing on delivering high quality, relevant, practical and inspiring training to regions which dont yet have the resources to develop CE programmes featuring international speakers. The topics chosen have been requested by the different regional and local organisers as being relevant to companion animal practice in their countries. Many of the worlds leading veterinarians give their time to participate in WSAVA CE sessions and we often receive feedback that theyve been inspired by the enthusiasm with which delegates embrace the topics they cover.

For more information on the WSAVAs CE programme and how member associations can benefit, please contact Jill at [email protected] n

Continuing education: a key focus for 2012

What wonderful feedback we had at Congress 2012! The number of veterinarians we spoke to who raved about coming to New Zealand was humbling. In fact everywhere weve been over the past year, delegates have said we cant wait to come

to Auckland, New Zealand, and experience the best that your country has to offer. New Zealand is on everyones bucket list and there is only one way to fix it register now! We also want you to enjoy our wonderful scenery, the exciting adventure activities and our people a cosmopolitan culture with a mix of European, Maori and the Pacific Islands.

Weve been on an incredible journey and now WSAVA 2013 is almost upon us and we cant wait! I can clearly remember the day when we first floated this idea and the day that we won the opportunity to host World Congress. I have the same excitement today and the dream of bringing the worlds best speakers covering all disciplines of veterinary science to New Zealand.

Please visit www.wsava2013.org to view the Scientific Programme, find out more about what we have to offer and register for the experience of a lifetime.

Registration for the WSAVA World Congress 2013 in Auckland SkyCity Convention Centre, 69 March is now open. Register early to take advantage of the early bird specials! n

Looking ahead to World Congress 2013

A message from Dr Pieter Verhoek, Chair of the WSAVA 2013 Local Organising Committee

hat wonderful feedback we had at Congress 2012! The

A message from Dr Pieter Verhoek,

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Only the WSAVA can pool veterinary expertise from around the globe, world experts, to address concerns affecting our

practice and standards of care to our patients. Some groups form the backbone of WSAVA, to establish its integrity and ensure that the direction of the Association remains true to its core mission.

In this issue, were focusing on the work of the Global Nutrition Committee (GNC), which is co-chaired by Dr Gregg Takashima DVM, American Animal Hospital Association Past president, and Dr Lisa Freeman DVM PhD DipACVN, Professor

Global nutritionDid you know that WSAVA has 14 working committees and focus groups working to develop the veterinary profession globally? Here we focus on the work of the Global Nutrition Committee

and Veterinary Clinical Nutritionist, Tufts Cummings School of Veterinary Medicine. The key goals of this Committee are to promote the importance of nutritional assessments and recommendations to every pet at every visit.

A brief historyThe GNC began life in 2010 with the task of developing a set of Global Nutrition Guidelines which were published in 2011. The aim of these Guidelines is to help the veterinary healthcare team and pet owners ensure that individual dogs and cats are on an optimal nutrition plan tailored to their needs. The Guidelines are now available in six languages, have been endorsed by 16 member associations, and have been published in over 15 journals.

The GNC met for the fourth time at World Congress this year and was endorsed by four leading international pet nutrition c

Documents

Companion August2012(1)