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5/26/2018 Companion November2012
1/36
The essential publication for BSAVA members
companionNOVEMBER 2012
Diagnosing felinenasopharyngealdiseases
A dogs lifein prisonA pet project withoffenders P4
Clinical ConundrumUnilateral oculardiscomfortP8
How ToApproach the patientwith PU/PDP12
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EJCAP ONLINE
Dont forget that as aBSAVA member you areentled to free onlineaccess to EJCAP register
at www.fecava.org/EJCAPto access the latest issue.
PETSAVERS FUNDED STUDY
Hair nicone concentraons indogs exposed to environmentaltobacco smoke (ETS)
This PetSavers-funded study found that
nicone concentraons in dog hair appear to
be strongly associated with reported exposure
to ETS, and the range and median were
similar to those reported in children. This
suggests that dog hair could provide a useful
method of determining the amount of ETS
exposure in environments common to pets
and children.
Analysis of 14,008 uroliths from dogsin the United Kingdom
This study found that associaons between
breed, gender, age and urolith formaon
were similar to those reported elsewhere.
However, temporal trends and novel breed
predisposions were idenfied.
Quesonnaire-based assessmentof owner concerns and doctorresponsiveness for caninechemotherapy paents
The authors conclude that quesonnaire-
based surveys appear to be an effecve tool
companionis published monthly by the BritishSmall Animal Veterinary Association, WoodrowHouse, 1 Telford Way, Waterwells Business Park,Quedgeley, Gloucester GL2 2AB. This magazineis a member-only benefit. Veterinary schoolsinterested in receivingcompanionshouldemail [email protected]. We welcomeall comments and ideasfor future articles.
Tel: 01452 726700Email: [email protected]
Web: www.bsava.com
ISSN: 2041-2487
Editorial BoardEditor Mark Goodfellow MA VetMB CertVR DSAMDipECVIM-CA MRCVSCPD Editor Simon Tappin MA VetMB CertSAMDipECVIM-CA MRCVSPast President Andrew Ash BVetMed CertSAM MBAMRCVS
CPD Editorial TeamPatricia Ibarrola DVM DSAM DipECVIM-CA MRCVSTony Ryan MVB CertSAS DipECVS MRCVSLucy McMahon BVetMed (Hons) DipACVIM MRCVSDan Batchelor BVSc PhD DSAM DipECVIM-CA MRCVSEleanor Raffan BVM&S CertSAM 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 reproducedin any form without written permission of thepublisher. Views expressed within thispublication do not necessarily represent thoseof the Editor or the British Small AnimalVeterinary Association.
For future issues, unsolicited features,particularly Clinical Conundrums, arewelcomed and guidelines for authors areavailable on request; while the publishers willtake every care of material received noresponsibility can be accepted for any loss ordamage incurred.
BSAVA is committed to reducing theenvironmental impact of its publications
wherever possible and companionis printedon paper made from sustainable resourcesand can be recycled. When you have finishedwith this edition please recycle it in yourkerbside collection or local recycling point.Members can access the online archive ofcompanionat www.bsava.com.
3 BSAVA NewsLatest from your Association
46 Its a dogs life in prisonPioneering projects inside jails
811 Clinical ConundrumUnilateral ocular discomfort
1217 How ToApproach the patient with polyuriaand polydipsia
1822 Diagnosing felinenasopharyngeal diseasesExtracts from the new FoundationManual on feline practice
23 Congress FreebiesMaking the most of your eventbootie
2425 Congress Psychology inPractice streamAn example of the fresh newapproach being taken by BSAVA
2627 PetSaversNews, reports, and a chance to runin the London Marathon
2829 WSAVA NewsThe World Small Animal VeterinaryAssociation
3031 The companionInterviewAimee Llewellyn
33 Focus OnSurrey and Sussex Region
3435 CPD DiaryWhats on in your area
Additional stock photography Dreamstime.com
Indigofish; Katrinaelena; Soland; Steve Mann;
Virgil Naslenas; Vitaly Titov & Maria Sidelnikova; Vivian Seefeld; Vladyslav Starozhylov
Whats inJSAP
this month?Here are just a few of thetopics that will feature inyour November issue:
for communicang dog owners concerns
regarding chemotherapy and potenally for
monitoring a clinicians aenveness. Owners
expressed concerns at approximately half of
chemotherapy appointments.
A new method of compung thevertebral heart scale
This study compared a simplified VHS method
with the Buchanan VHS method. Providing
clinicians with precise guidance would
decrease variability and improve the reliability
of results.
Determining the cause of canineurolith formaon by advancedanalycal methods
The results of this study appear to confirm
the causave role of absorbable suture
material in the pathogenesis of hollowchannel structure in some canine
compound uroliths.
Log on to www.bsava.comto access
the JSAP archive online.
5/26/2018 Companion November2012
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Regions take
grass roots leadat strategy weekend
Representatives from all 12 of BSAVAs
regional committees got together in
Oxford in September to produce plans
for offering the very best CPD and
support to members in 2013.
The dedicated and energetic volunteers
that make up the regional committees
demonstrated how committed they are to
finding the most effective ways of
delivering high-quality low-cost
CPD. Ideas flowed freely during the
two-day meeting which takes place
twice a year so experiences can be
shared and new initiatives developed.
One of the big successes of 2012
has been the introduction of TurningPoint
voting technology to allow interactive
regional meetings. Attendees at Congress
will be aware of the great utility of this
technology, and how it can make for a much
more enjoyable lecture experience. This will
become an increasingly prominent feature in
the 2013 diary with more regions offeringinteractive events.
The central topic at all these biannual
meetings is a discussion about how BSAVA
can deliver even more to its members,
especially through regional committees.
Offering accessible CPD is a priority, of
course; however, if you have any other ideas
about how we can ensure we give you the
best possible support, then do please give
us your thoughts or even find out more
about becoming a regional volunteer.
Email Ben Dales at [email protected].
With a treasure chest of dedicated
resources the BSAVA invites vet nurses to
benefit from an expanded membership
package in 2013.
VN membership had a quiet launch in 2012
and since then BSAVA has listened to those who came
on board early and worked hard to create a package
that meets the needs of all VNs.
Improved benefitsVN Membership costs just one third of the general
membership fee. With the huge range of FOC CPD
this means that a BSAVA VN Member can get their
entire annual CPD, all from BSAVA, all for just 72.
Along with the nurse pocketbook, a collection of
vital info, stats and doses, that is being launched at
Congress, VN Members in 2013 will also get
complimentary subscription to companion, freelunchtime webinars, and hundreds of hours of
Congress lecture podcasts.
An especially welcome addition to the benefit
package is that VNs will also now be able to download
all the BSAVA Apps, including the Formulary (availableon iPhone and Android formats), and have access to a
brand new legal helpline.
VNs will of course be entitled to member discounts
too allowing a significant saving on all the Manuals,
CPD and four days at Congress from as little as 103
(in 2013). Of course VN Members also get exclusive
rights too. They can upgrade their Congress
registration to allow attendance at the veterinary
lectures as well as the nursing streams.
VNs to
benefit morefrom BSAVA
STOP THE PRESS NEW LEGAL HELPLINE
Watch out in your December issue for news of the new legal helpline for BSAVAmembers. Making your membership subscripon worth even more than ever before.
Response onanaesthesiaconsultation
In the October issue of companionwe invited members to comment onthe role of the vet nurse in monitoring and maintaining anaesthesia.
Thank you for the excellent responses we have already received. You
can still have your say until 30 November at www.bsava.com/
consultations.
Personal or practice investmentBSAVA is offering VN Membership to help nurses who
are keen to expand their clinical knowledge andachieve all their ambitions. So whether
its an investment in your own career
or is part of the training package
from the practice BSAVA
membership is the most
cost effective way to get all their
CPD requirements and a whole
raft of resources and benefits.
All VNs or practice principals
interested in VN Membership
can contact the BSAVA
membership team either
via www.bsava.comor
call 01452 726700.
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Its adogs lifein prison
Strouds Digest on the Diseases of Birdsis the
first textbook that should be consulted by
anyone who wants to know about the
redemptive power of working with animals. It
was written by a violent career criminal who had been
sentenced to hang for the murder of a prison guard.
But while being held in solitary confinement he found
an injured bird which he nursed back to health. This
led to him being allowed to keep canaries in his celland he went on to become a leading authority on the
diseases of caged birds.
Robert Stroud, the famed Birdman of Alcatraz
died aged 73 in a medical centre for federal prisoners
at Springfield, Missouri. In contrast for the 18- to
21-year-old inmates of the Polmont Young Offenders
Institution near Falkirk the future may not be so bleak.
Rebecca Leonardi, a postgraduate student at the
University of Stirling is responsible for a new initiative
aimed at preventing reoffending.
She is running Paws for Progress, a scheme which
offers offenders the opportunity to become involved in
training the dogs at a local rescue kennels so that they
are suitable for adoption by those wanting a well
behaved adult dog. The project, which began in August
2011, is a collaboration between the university, the
Scottish Prison Service and the Dogs Trust, and has thesupport of a number of organisations, including the
Society for Companion Animal Studies which promotes
the use of animals in improving human welfare.
Origins of an ideaThe idea behind the initiative is that through taking
responsibility for a dog, the behaviour of the young
men will also change; they will become involved with
the educational opportunities available and improve
their chances of getting a job on release.
Ms Leonardi is currently analysing data from the
first year of the scheme as part of her PhD thesis, and
the early indications are that it is achieving its goals.That is not surprising since the scheme is based on
Project POOCH (Positive Opportunities Obvious
Change with Hounds), a similar programme that has
been successfully changing the lives of young men
What do abandoned dogs and young offendershave in common? These two groups know onlytoo well what it feels like to be unwanted andcondemned to spend their days behind bars.In a pioneering Scottish project the inmates ofa young offenders institution and abandoneddogs living in welfare charity kennels are helping
each other to develop the behaviour and skillsthey will need to be accepted back intomainstream society. John Bonner reports
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and their canine charges at the MacLaren Youth
Correctional Facility in Woodburn, Oregon, since 1993.Project POOCH in turn was based on an initiative that
began 12 years earlier at Purdy Womens prison in
neighbouring Washington State. Similar projects have
since been launched at prisons in Australia, Canada,
South Africa and Spain.
This has been a mutually beneficial
project for all involved. The young men at
Polmont have enhanced their
employability and literacy skills and, as a
result of their involvement in Paws for
Progress, have even been awarded aScottish Qualifications Certificate. I look
forward to reading Ms Leonardis
findings in the future and seeing how this
research can be utilised to improve the
efficiencies of the prison estate.Kate Donegan, Governor at Polmont,
Scottish Prisons Service
Working with the probation serviceMany other prisons have attempted to calm prisoners
behaviour by allowing them contact with animals,
particularly cagebirds and fish that can be easilycared for in a cell. Liz Ormerod is a veterinary
practitioner from Fleetwood in Lancashire and
chairwoman of SCAS. She has studied the effects of
what has become known as Pet Facilitated Therapy
through her work with a former senior probation officer
for the county, Mary Whyham.
Together they surveyed the policies in place at 156
penal institutions around the UK and maintain that in
those places where prisoners had contact with animals
there were a number of very significant benefits. These
included better relationships between the prisoners
and their guards, a reduction in violence, fewer
incidents of self-harm and suicides, a reduction in drug
taking, and improved self-esteem among the inmates.If these effects are seen consistently in all
institutions that allow pet-keeping, then why is it the
case that less than one-in-three prisons surveyed have
such a policy? Liz Ormerod believes that there is
opposition from the public and within the prison
service to anything that smacks of pampering theprisoners. That does seem strange when they are
allowed to have a television but are not allowed to keep
a bird or fish in their cell, she asserts.
The hard cellThere have been a number of other objections
based on claims that bringing in animals would
provoke allergic responses in prisoners or staff, or
that larger animals brought in from outside the prison
could be serving as a drugs mule.
Security is certainly an issue because of the
continuing increase in the prison population.
Prisoners are being kept two or even three to a cellin facilities that were only designed for one. In some
cases, prisoners are kept locked up for most of the
day because there are not enough staff available to
oversee educational and training programmes like that
at Polmont.
Even in those places which have introduced
policies on pet ownership or to allow animals to visit
the institution, there is no guarantee that such
privileges will be maintained. Mary Whyham points out
that the attitudes of the prison governor and senior
colleagues are crucial, and many schemes have
foundered after key staff moved on to be replaced by
those with different views.
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Its a dogs life in prison
Yet Liz Ormerod insists that maintaining such
policies would make the working lives of prison staff
much easier. It builds a different, more cooperative
atmosphere. Both the prisoners and the prison officers
start to see each other as better people. A pet gives
both sides something to talk about and the guards willoften bring in little treats for the animals. So the anger
that many prisoners feel starts to go away.
One obvious aspect to looking after an animal is
the time that it takes, an asset that inmates possess in
greater quantities than they would wish. Liz maintains
that it also fulfils a deeply held need to nurture another
living being, especially among the genuine hard
cases. At one prison I talked to a man who has stayed
up solidly for 72 hours looking after a sick budgie.
I wish I had that sort of commitment more often from
the clients that I had at my practice. But for some of
these men having a pet is the first time that they have
felt unconditional love.
Positivity in prisonSo pet keeping can help to improve the prisoners
behaviour in the short term but the goal of the dog
training projects is to produce permanent changes.
Joan Dalton established Project Pooch when she was
vice principal of the school connected to the MacLaren
Correction Facility for Young People. Her job was to try
to help her students gain the credit points that would
allow them to gain the high school graduation
certificates needed by most US employers. She
estimates that around 500 students and 600 dogs
have passed through the scheme since its inception.
Students could gain credits in subjects such asbiology and civics through their involvement with the
dog training project but, according to the students
own reports, the most important thing that they learned
was patience, she explains.
They discovered that they could only train the dogs
once they had built up a good relationship with the
animal, and that the necessary changes in canine
behaviour would only come about through positive
reinforcement. Generally the animals chosen for the
training programme are those that the dog pound finds
most difficult to re-home and few offenders fail to
appreciate the parallels between their dogs plight and
their own.
Joan believes that the educational qualificationsand improved self-esteem that participants gain from
the scheme help them to make a new life once they
are released. Usually many offenders will go on to
become regular clients of the prison service as they go
through their lives, but study by psychologist Sandra
Merriam found a zero recidivism rate among graduates
of the scheme. Indeed, many former students with jobs
outside do return but only to help the Project POOCH
organisers at fund raising events to help them continue
their work.
Properly run not a panaceaMary Whyham warns that dog training schemes are
unlikely to provide a panacea to the problem of youthoffenders. Moreover, a badly organised scheme with
the wrong choice of supervisors, trainers and dogs is
unlikely to produce the goods and may even do harm
by discrediting this work in the eyes of the prison
authorities.
Joan Dalton agrees that it is vital that the
schemes are properly organised and wonders
whether the eight-week training programmes
envisaged for the Polmont scheme will be enough for
every student and every dog. She points out that
under Project POOCH, some trainers and some
dogs have needed much longer periods of training
before they are ready to be released or re-homed.But once both sides are considered ready, they will
have been equipped with the skills that they will need
to survive in their new roles either as a family pet or as
a free member of society.
In Oregon state we do have something like 8 per
cent unemployment but our students can compete
successfully in the job market because they have
acquired skills that can be useful in a lot of fields, such
as doggy day care centres and pet shops. One recent
student has just started a dog grooming business and
another has plans to train as a veterinary technician,
says Joan.
The important thing is that by creating a
relationship with their dogs that is based on respect,they learn to respect themselves. They start to see
that they do have some value and will no longer think
of themselves as just some stupid criminal that
nobody wants. n
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For more information or to book your course
www.bsava.com
Learn@LunchwebinarsThese regular monthly lunchtime (12 pm) webinars areFREE to BSAVA members just book your place throughthe website in order to attend. The topics will be clinical lyrelevant, and particularly aimed at vets and nurses infirs t opinion practice. There will be separate webinarprogrammes for vets and for nurses.
This is a great MEMBER BENEFIT.
Coming soon What to say to a grieving owner webinar for nurses,
14 November Cascade update webinar for vets, 5 December Dealing with nasty dogs webinar for nurses,
12 December
All prices are inclusive of VAT. Stock photography: Dreamstime.com. Alptraum; Alterf alter; Isselee
Surgery of the pelvis4 DecemberDesigned for general practitioners, offeringa clinically relevant approach to thediagnosis and decision making
SPEAKER
Kevin Parsons
VENUE
Woodrow House, Gloucester
FEES
BSAVA Member: 227.00Non BSAVA Member: 340.00
New, importantinformation onfeline viral disease15 JanuaryFirst talk in the Feline Mini-Modularprogramme covering the major andemerging viral infectious diseases of cats
SPEAKER
Andy Sparkes
VENUE
Hilton Stansted Airport
FEES
BSAVA Member: 233.00Non BSAVA Member: 350.00
Infectious diseasesof the rabbit20 NovemberA cutting-edge day course for veterinary
surgeons treating rabbits in practice
SPEAKER
Emma Keeble
VENUE
Woodrow House,Gloucester
FEES
BSAVA Member:227.00Non Member:340.00
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Clinicalconundrum
Describe the abnormalities in Figure 1In the right eye no abnormalities were detected. In the
left eye there was a central stromal ulcer with
associated corneal oedema and peripheral corneal
neovascularisation. A periocular tenaciousmucopurulent discharge was also present.
Describe an appropriate ophthalmicexam
Menace response. This was positive in both eyes,
indicating that vision was present bilaterally.
Dazzle and direct pupillary light reflexes. These
were also positive in both eyes, indicating function
of the neurological pathway from the retina to the
facial nerve (cranial nerve (CN)VII) and the
oculomotor nerve (CN III).
Schirmer tear test 1 (STT 1). In the right eye the
result was over 15 mm/min, indicating adequate
levels of aqueous tear production. In the left eye
the STT reading was 0 mm/min. This test should
be performed before any topical medications
are applied.
Fluorescein dye test. There was no dye uptake on
the right cornea but there was fluorescein uptake
at the site of the ulcer present on the left cornea
(Figure 2). This pattern of uptake on the left eye
suggests that the ulcer is mid-stromal.
Slit lamp examination. This instrument is useful to
assess the depth of the ulcer in the left eye, which
was confirmed to be mid-stromal.
Fundic examination. Examination of the right eye
fundus using indirect ophthalmoscopy revealed no
abnormalities but was not possible for the left eye
due to the corneal pathology. Intraocular pressure measurements. IOP was
normal in the right eye (16 mmHg) but was not
measured in the left eye (due to the risk of further
damaging the cornea).
Andrew Lewin, an Intern at WillowsVeterinary Centre and Referral Service,invites companion readers to consider acase of unilateral ocular discomfort andredness in a young cross-breed dog
Case presentationAn 18-month-old male cross-breed dog
presented with a 2-week history of left ocular
pain and redness. A general physical examrevealed no other abnormalities. The dog had
been previously treated with systemic and
topical non-steroidal anti-inflammatory drugs
and topical ocular lubricant.
A
B
Figure 1: The right eye (A) and left eye (B) of an 18-month-old
male cross-breed dog at the time as observed of initialpresentation
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What is the significance of theabnormalities seen in Figure 3?The diagnosis in this case based on the findings so far
was keratoconjunctivitis sicca (KCS) and ulcerative
keratitis in the left eye. A physical examination revealed
unilateral crusting of the nares on the left hand side.
This indicates that the KCS may be of neurogenic
origin as both the lacrimal gland and the lateral nasal
gland share a common innervation. Other clinicalsigns which are occasionally observed with
neurogenic KCS include Horners syndrome, facial
paralysis and trigeminal nerve deficits, none of which
was present in this case.
What is the normal range for the STTtest and what is your interpretation of thevalues obtained in this patient?A STT test can be performed either with (known as
STT 1) or without (STT 2) a topical anaesthetic applied
to the cornea prior to placing the test strip in the lateral
half of the lower conjuctival sac. Performing the STT
without the aid of topical anaesthesia is preferred, as
this measures both basal and reflex tear production,
whereas only basal tear production can be measuredin the anaesthetised eye.
The normal value for STT 1 in the dog is over
15 mm/min, as was found to be the case in the right
eye of this patient. It is necessary to measure the
production of tears for a full minute as it has been
shown that the value will not rise in a linear fashion
during this time. A value of 614 mm/min indicates
mild to moderate KCS and a value of < 5 mm/min
indicates severe KCS, as was detected in the left eye
of this patient.
It is important to remember that occasionally
qualitative tear deficiencies can be present which
may present with a normal STT value. Qualitative
tear deficiencies can be detected using a tearbreak-up test, which is performed by applying a
drop of fluorescein into the eye and allowing the
patient to blink. The eyelids are then held open and
the corneal surface observed with the aid of a blue
A
B
Figure 2: The right eye (A) and left eye (B) after fluoresceinhad been applied bilaterally at the time of presentation.
There is no uptake of dye in the right eye and is an obviouscorneal defect in the central left cornea. Observation of thedefect using fluorescein is one method which the cliniciancan use to determine the depth of an ulcer
Figure 3: Nasal crusting observed on the left hand side
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Clinical conundrum
light source such as that found on a handheld slit
lamp. The time taken for the first dry spot to appearis noted and compared against normal values.
A normal tear break-up test time is 1525 seconds
and a value of 10 seconds or less is indicative of
tear film instability.
Which primary conditions cancause KCS?
Immune-mediated: this is the most common cause
of KCS in dogs.
Drug therapy: topical atropine and systemic
trimethoprim sulphonamides can both cause
reduced tear production. Infectious conditions such as distemper virus.
Acinar hypoplasia is a congenital condition
occasionally seen in toy breeds such as Yorkshire
Terriers, which can often present unilaterally
leading to KCS.
Iatrogenic KCS can be created by removal of the
tear gland of the nictitans membrane.
Systemic conditions including hypothyroidism,
diabetes mellitus and hyperadrenocorticism can
lead to reduced tear production.
Neurogenic KCS: this can be caused by a loss of
parasympathetic innervations to the lacrimal gland
(CN VII) or a loss of sensory innervation to cornea
(CN V). Loss of parasympathetic innervation can
be either idiopathic or due to middle/inner ear
disease. Neoplasia involving the nerves innervating
the lacrimal gland can also be responsible for
causing the condition.
Which further investigations may beuseful in the management of this case?Radiography (relatively insensitive), computed
tomography (CT) or magnetic resonance imaging
(MRI) can be used once a diagnosis of neurogenic
KCS has been reached, to try and determine an
underlying aetiology.
In this case CT was used to image the tympanicbullae and surrounding soft tissue, the region of the
left facial nerve and retrobulbar spaces. No pathology
was detected, so a final diagnosis of idiopathic
neurogenic KCS was reached. MRI is arguably a more
sensitive method of detecting neuritis than CT, but
was not used in this case as CT was deemedsufficient for ruling out neoplasia and middle ear
disease. There were also financial limitations with this
case which were partly responsible for the choice of
imaging modality.
Construct an initial treatment plan for theophthalmic problemsThe treatment plan for this dog had to address both
the ulcerative keratitis and the underlying idiopathic
neurogenic KCS. Despite the ulcer being mid-stromal,
a medical approach was adopted given the marked
associated corneal neovascular response.
The ulcer was treated with systemic analgesics(carprofen 4 mg/kg q24h), broad-spectrum systemic
antibiotics (cefalexin 15 mg/kg q12h) and topical
antibiotics (polymyxin B ointment applied four times
daily to both eyes)*. The neurogenic KCS was treated
with ocular lubricants (applied every 2 hours to both
eyes) and oral pilocarpine. Pilocarpine is a muscarinic
parasympathomimetic drug available in various
concentrations which was historically used for the
treatment of glaucoma.
Pilocarpine has a non-specific
parasympathomimetic effect, and so will not only
stimulate secretion from the lacrimal glands but will
also have systemic side effects. It is irritant when
applied topically so can be used diluted at 0.1% in this
way (based on anecdotal evidence) or used orally at
1% as was done in this case (1 drop/10 kg q12h orally).
The oral dose can be increased until signs of toxicity
are observed (hypersalivation, vomiting, diarrhoea and
cardiac arrhythmias). In some cases the pilocarpine
treatment can be stopped altogether after around six
months but in others it will need to continue as a
lifelong therapy.
Other treatments which were considered in this
case were bandage contact lenses to temporarily
protect the ulcer from further erosion and parotid duct
transposition. In this case medical management was
deemed sufficient without the need for surgery.
OutcomeAt a re-check appointment 9 days later, the right eye
was unchanged after therapy, with a good tear film
* Editors Note:
Readers are remindedthat the PROTECTposter (available atwww.bsava.com) hasguidelines on empericselection of antibioticsfor use in cases ofcorneal ulceration.
5/26/2018 Companion November2012
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AVAILABLE FROM BSAVA
BSAVA Manual of Small Animal
Ophthalmology2nd editon
Edited by: Simon Peterson-Jones and Sheila Crispin
This Manual provides a praccal, consulng room guide tosmall animal ophthalmology, but with suffi cient detail tosasfy those who wish to study this fascinang specialty ingreater depth. Features:
Surgical principles Chapters dedicated to exoc pets High quality full-colour photographs throughout
...an excellent book, clear and easy to read, and illustrated throughout withphotographs that aid clinical diagnosis. All praconers should own a copy...JOURNAL OF FELINE MEDICINE AND SURGERY
Member price: 55.00Non-member price: 85.00
CONTRIBUTE A CLINICAL CONUNDRUM
If you have an unusual or interesng case that you would like to share with yourcolleagues, please submit photographs and brief history, with relevant quesonsand a short but comprehensive explanaon, in no more than 1500 words to
All submissions will be peer-reviewed.
ACKNOWLEDGEMENTS
Thanks to Mike Rhodes for his help in the preparaonof this arcle and to Chrisne Heinrich for her kindpermission to use her photographs.
Figure 4: The right eye (A) and left eye (B) as observed 9 daysafter the time of initial presentation to the referral service.The right eye appears to be unchanged from the time ofinitial presentation. The left eye has markedly improved inappearance: the central corneal ulceration has resolved andsuperficial neovascularisation is visible in this region
A
B
and no signs of ulceration. The central ulcer in the
left eye had healed and there was superficialneovascularisation and associated corneal opacity
in this region (Figure 4). The left eye was confirmed
to be visual with a positive menace test. Both eyes
were comfortable and STT confirmed a reading of
> 15 mm/min bilaterally.
The dose of pilocarpine was increased gradually
until a side effect (hypersalivation) was observed. Atthis point the dose was reduced and treatment was
continued while monitoring STT levels, which remained
within the normal range in both eyes. One month after
initial presentation the dog was re-examined and
was found to have made excellent progress, and the
dose of pilocarpine was gradually reduced while
monitoring STT levels.
Eventually the drug was discontinued and one year
later the dog is continuing to do well without treatment.
It has been recently suggested that approximately half
of dogs with neurogenic KCS will not require
permanent treatment as they may have a self-limiting
underlying disease process.
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How to approach thepatient withpolyuriaand polydipsia
An animal that is drinking and
urinating more than normal can
be a diagnostic challenge. There
is a long list of possible
differential diagnoses (Figure 1) requiring
logical progression through the diagnostic
pathway. Investigation may very quickly
and simply give an answer (e.g. diabetes
mellitus) or may need extensive, and
possibly expensive, testing to achieve adiagnosis (e.g. partial central diabetes
insipidus). Owner education is key, as until
a diagnosis is made and correct therapy is
instigated the problem is likely to be
frustrating for both the owner and their pet.
Healthy animals drink 2070 ml/kg/day
and produce 2045 ml/kg/day of urine.
Animals, especially cats, fed a wet diet
may need to drink very little to maintain
hydration, as wet diets can contain up to
80% water. Animals fed a dry diet will often
drink a large proportion of their daily water
requirement within an hour or two of eating,
which can create unusual drinking patterns
if diet or feeding times are changed.
In normal animals urine concentration
is controlled by antidiuretic hormone (ADH,
also known as arginine vasopressin). ADHis produced in the hypothalamus and
stored in the posterior lobe of the pituitary.
It is released in response to changes in
serum osmolality and acts on the kidneys
to retain water by increasing tubular
permeability. Thirst is also important in
water balance but is stimulated at a higher
osmolality threshold than that needed for
ADH release.
PU/PDPolyuria (PU) and polydipsia (PD) usually
exist concurrently, with determination as towhich is the primary problem being one of
the major diagnostic challenges. Polydipsia
is usually defined as water intake of
>100 ml/kg/day and polyuria as urine
production >50 ml/kg/day. A large number
of disease processes can cause PU/PD,
and most affect the way ADH is produced
or exerts its action within the kidney.
However, as always, there are some
exceptions, for example osmotic diuresis
secondary to diabetes mellitus or a poor
medullary concentrating gradient
secondary to hepatic insufficiency.
Investigation starts with a detailedhistory to allow confirmation of the
presence of PU/PD and to rule out
misinterpretation of related clinical signs
such as dysuria or incontinence. Asking
the owner to measure water intake
definitively over a 24-hour period will helpconfirm the presence of PU/PD.
At the outset of investigations,
collecting multiple urine samples to
measure specific gravity (SG) can be very
helpful (Figure 2) as wide variations in
normal SG are reported (results in healthy
dogs range between 1.006 and 1.040).
Serial urine samples with an SG 1.030 support normal
urine-concentrating ability.
Careful clinical examination may also
help provide clues as to the origin of thePU/PD. Neutering status is important,
alerting the clinician to the possibility of
pyometra in the intact bitch for example.
In this condition E. coli toxins interfere with
the action of ADH within the kidney. Careful
examination of peripheral lymph nodes
helps to exclude lymphoma, and evaluation
of the anal sacs helps exclude anal sac
adenocarcinoma; both of which can cause
PU/PD through hypercalcaemia. Skin
changes such as bilaterally symmetrical
alopecia, thin skin and calcinosis cutis
suggest possible hyperadrenocortisim
(Figure 3).
Simon Tappin from Dick White Referrals helps usget to grips with this tricky presentation
Primary polydipsia (psychological/behavioural)
Central diabetes insipidus Nephrogenic diabetes insipidus Diabetes mellitus/primary glucosuria Hyperadrenocorcisim Chronic renal failure Hypercalcaemia Infecous focus (e.g. pyometra / sepsis)
esp. with Escherichia coli Hepac insuffi ciency Primary hyperaldosteronism Pyelonephris Hyponatraemia Hypokalaemia Hyperadrenocorcism Acromegaly Very low protein diets Hyperthyroidism Erythrocytosis
Iatrogenic drugs phenobarbital, potassium
bromide, glucocorcoids, diurecs(e.g. furosemide), lithium
Figure 1: Differential diagnoses for polyuria andpolydipsia in dogs and cats
Figure 2: Urinalysis and serial urine specificgravity measurements are essential early in theinvestigation of PU/PD
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Initial further investigations (Figure 4)
are aimed at excluding diseases that
interfere with the action of ADH within the
kidney (secondary nephrogenic diabetes
insipidus) and diseases which lead to
osmotic diuresis (e.g. renal failure and
chronic renal failure). Urinalysis (including
culture), haematology and full
biochemistry, including a bile acid
stimulation test are a good starting point,
before more focused investigations such
as adrenal function tests and imaging are
performed. If these investigations areunremarkable, and renal concentrating
ability has not been proven by random
urine samples, investigations then focus
on investigating the presence of diabetes
insipidus (central or nephrogenic) or
primary (psychogenic polydipsia).
Diseases leading to osmoticdiuresis
Diabetes mellitusDiabetes mellitus leads to elevated serum
glucose levels through the absolute or
relative deficiency of insulin. This elevationin glucose quickly exceeds the renal
tubules ability to resorb glucose and leads
to glucosuria. The presence of glucose in
the urine leads to an osmotic effect,
causing excessive water loss, primary
polyuria and hypovolaemia. This leads to
the stimulation of thirst, increased water
intake and a secondary polydipsia.Urinalysis and fasting glucose levels are
usually sufficient to diagnose diabetes;
however in cats, where stress-induced
hyperglycaemia is relatively common, the
measurement of fructosamine or
glycosylated haemoglobin can be helpful.
GlucosuriaPrimary renal glucosuria is an uncommon
disease which is most commonly seen in
Norwegian Elkhounds and the Basenji. It
results from the congenital inability to
resorb glucose from the renal tubules,
leading to osmotic diuresis in the same
way as diabetes mellitus. These dogs have
glucosuria but normal serum glucose
levels. Some dogs and cats may also have
glucosuria as a component of Fanconi
syndrome. This is a tubular disorder, which
results in increased urine concentrations of
glucose, potassium, phosphate,
bicarbonate and amino acids due toreduced tubular resorption.
Renal failureChronic renal failure (CRF) is caused by a
gradual reduction in the number of
functioning nephrons present within the
kidney. At compensation the remaining
nephrons increase their glomerular filtration
rate (GFR). This leads to an increased
amount of filtrate being presented to the
distal tubules and, as a result, less sodium
and urea are reabsorbed. This leads to
osmotic diuresis, which is worsened by a
reduced medullary concentrating gradient.
Animals with CRF usually have increased
serum urea, creatinine and phosphate
levels, as well as isosthenuric urine
(SG 1.0081.012).
Figure 3: A Yorkshire terrier withhyperadrenocorticisim with marked bilaterallysymmetrical alopecia
History and physicalexaminaon
Laboratoryinvesgaons
Urine and blood
PU/PD Abnormal?Suspect:Hyperadrenocorcism Pyometra Hyperthyroidism Hypercalcaemia
Specialist tests:Plasma osmolarity
Water deprivaon testDDAVP trial
Increased BAS or Ammonia?Suspect: Liver disease Portosystemic shunt
Hypercalcaemia?Suspect:Hyperparathyroidism Hypercalcaemia of
malignancy
ACTH stmulaton
Exclude:
AddisonsHyperadrenocorcism
Central diabetes insipidusPrimary polydipsia Nephrogenic diabetes insipidus
Glucosuria?Suspect:Diabetes mellitusRenal glucosuria
Normal if S.G.>1.025 Dogs>1.030 Cats
Azotaemia?Suspect renal disease
Figure 4: Diagnostic pathways for the investigation of PU/PDBAS = bile acid stimulation
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How to approach thepatient with polyuria and polydipsia
Acquired or secondarynephrogenic diabetes insipidusMany disorders interfere with the normal
interaction between ADH and its receptor
in the kidney or lead to reduced medullary
concentrating ability. These can appear
with marked PU/PD but the ADH sensory
and release mechanisms are present but
disease interferes with ADH action.
PyelonephritisPyelonephritis leads to inflammation of
the renal pelvis, which affects the
concentrating ability of the renal medulla.
This leads to PU/PD and eventual renalfailure. Bacterial toxins especially those
from E. coli, compete with ADH binding
sites within the kidney, which leads to
further polyuria. Pyelonephritis may be
very difficult to diagnose, needing a
combination of techniques such as
abdominal ultrasonography, looking for
evidence of subtle changes within the
renal pelvis (Figure 5) and pyelocentesis to
collect culture samples. In some cases this
may not be possible and is a sufficient
suspicion regarding pyelonephritis (e.g.
previous recurrent urinary tract infection)
then a trial treatment with a suitable
antibiotic (potentiated amoxicillin or a
fluoroquinolone) may be an appropriate
alternative. If this improves clinical signs,
antibiotics should be continued for
46 weeks.
Liver diseaseHepatic insufficiency and portosystemic
shunts both lead to PU/PD. The exact
mechanism is unclear; however, it is most
likely that reduced urea production leads to
a reduced medullary concentrating
gradient or that toxins alter the perception
of thirst. A bile acid stimulation test is the
best screening test of liver function.
HyperadrenocorticismHyperadrenocorticism, or Cushings
syndrome, is a relatively common cause ofPU/PD in middle-aged to older dogs. Signs
may be classic and associated with
polyphagia, skin signs and a pot-bellied
appearance (see Figure 3); however in
their absence hyperadrenocorticism
cannot be excluded and should be
considered as a possible differential.
Haematology will often reveal evidence
of a stress leucogram, mild thrombocytosis
and erythrocytosis are less commonly
documented. Biochemistry may reveal
increased alkaline phosphatase (seen in
approx. 9095% of cases) and cholesterol(seen in approx. 75% of cases). A urine
sample should be collected by
cystocentesis for culture, even if an active
sediment is not present, as 4050% of
dogs will have active urinary tract
infections at presentation.
An ACTH stimulation test is the most
commonly used screening test for
hyperadrenocorticism as it is least
affected by stress. The ACTH stimulation
test has a sensitivity of 85% in pituitary-
dependent and 65% in adrenal-dependent
disease (specificity of 8590%). A low
dose dexamethasone suppression test is amore sensitive and reliable test (sensitivity
100% in adrenal-dependent and
9095% in adrenal-dependent
hyperadrenocorticism) however it can be
affected by stress and cannot detect
iatrogenic hyperadrenocorticism nor beused for monitoring treatment. Once a
diagnosis is reached, further tests can
help discriminate between pituitary- and
adrenal-based disease.
HypoadrenocorticismHypoadrenocorticism leads to the inability
to concentrate urine through the absence or
insufficient levels of aldosterone.
Mineralocorticoid deficiency leads to
chronic sodium wasting and loss of
medullary tonicity. There is also some
evidence to suggest that decreased
aldosterone reduce the sensitivity of the
ADH receptors, furthermore the
hypercalcaemia associated with
hypoadrenocorticisim may also contribute
to the PU/PD. Treatment with synthetic
mineralocorticoids typically corrects this,
although some dogs may need additional
dietary sodium chloride to correct their
PU/PD. Differentiating hypoadrenocorticisim
from renal failure can be difficult on
biochemistry and sodium:potassium ratios
alone, so an ACTH stimulation test is
needed for definitive diagnosis.
HypercalcaemiaIncreased serum calcium concentrations
inhibit the action of ADH in the kidney,
leading to primary polyuria and secondary
polydipsia, and can lead to renal failure.
Other clinical signs include weakness,
vomiting and dull mentation. The
differentials for hypercalcaemia can be
remembered with the help of the
mnemonic HARD IONS (Figure 6). The
most common cause of hypercalcaemia in
an older dog is malignancy (lymphoma
followed by anal sac adenocarcinoma and
multiple myeloma).
HyperthyroidismHyperthyroidism is often associated with
PU/PD in both cats (common) and dogs
Figure 5: Ultrasound evaluation revealing mildpyelectasia. In this dog this was caused by thepolyuria and there was no evidence ofpyelonephritis
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(very rare
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How to approach thepatient with polyuria and polydipsia
Phase 1: Preparaon
1. Determine water intake in a 24-hourperiod with free access to water
2. Three to five days before the testgradually decrease water intake to100 ml/kg/day
3. Starve the animal for 12 hours before thebeginning of the test
Phase 2: Water deprivaon
1. Prior to starng test
a. Withdraw all food (12 hourspreviously) and water
b. Empty bladder completely consider aurinary catheter
c. Obtain exact body weight
d. Check urine SG
e. Check serum BUN and electrolytesf. Check hydraon and CNS status
2. During testa. Completely empty bladder every
60120 minb. Check urine SG
c. Check exact body weight every 60 mind. Check hydraon and CNS status at
each interval
3. End test if:a. Urine SG >1.030
b. Dog appears clinically dehydrated orunwell
c. Dog has lost 35% of body weight
4. At end of phase 2:a. Collect serum for endogenous ADH
determinaon
b. Empty bladder and recheck urine SG
Phase 3: Response to exogenous ADH
1. Administer 25 IU i.m.
2. Connue to withhold food and water3. Empty bladder every 30 minutes for
12 hours
4. Recheck urine SG5. Check hydraon and CNS status
Phase 4: End of Test
1. Introduce small amounts of water(1020 ml/kg) every 30 minutes for2 hours
2. Monitor paent for voming, hydraonand CNS status
3. If paent is well 2 hours aer the end ofthe test, return to ad lib water intake
Figure 8: Protocol for the modified waterdeprivation test
Classically a water deprivation test is
needed to differentiate CDI from NDI andPP. The water deprivation test (WDT) is a
long, time-consuming test which does
carry some risks to the patient if not
completed carefully. A full description of
how to perform a water deprivation test is
found in Figure 8. In a normal dog (or a
dog with PP) as water is withheld urine SG
will rise gradually as the kidneys work hard
to retain water. If ADH is not present (CDI)
or is unable to have an effect within the
kidney (NDI), there will be no increase in
urine concentration. Once the animal has
become 5% dehydrated synthetic ADH
(DDAVP) is administered by intramuscularinjection and the response measured. If
ADH is absent (CDI) then the urine SG
should increase quickly; however, if the
kidney is unable to respond to ADH (NDI)
then urine SG will stay constant (Figure 9).
An addition to the standard WDT is to
measure plasma osmolality and
endogenous ADH concentrations before
the administration of DDAVP. This can be
very helpful in eliciting whether ADH is
being produced and is especially useful for
the differentiation of partial CDI from CDI
(Figure 10).An alternative to a WDT is to consider a
DDAVP trial. This relies on the fact that NDI
is very rare and CDI should respond well to
DDAVP, whereas additional ADH in an
animal with PP will make little impact on its
PU/PD. Suggested treatment at home is
using oral DDAVP (absorption of tablets
can be variable however) with an empirical
dose: for a 20 kg dog, 0.1 mg three times a
day for about 7 days; for a 40 kg dog,
0.2 mg three times a day for about 7 days.
Animals with CDI will respond quickly to
this treatment and the response can be
substantiated using urine samplescollected at home by the owners. The dose
of DDAVP is then slowly tapered to reach
the lowest possible dose that controls the
animals clinical signs.
Nephrogenic diabetes insipidus
Nephrogenic diabetes insipidus describesconditions where the kidneys do not
respond to ADH to produce concentrated
urine as expected. Normally the
hypothalamus produces ADH in response
to increased serum osmolality. When
released ADH acts in the collecting ducts
to increase permeability, thereby retaining
water and the the production of
concentrated urine.
As described above, acquired or
secondary conditions which interfere with
the way ADH works in the kidney are
common (e.g. endotoxins from E. coli,
drugs such as glucocorticoids and
metabolic conditions such as
hypercalcaemia and hypokalaemia)
however primary or congenital NDI is very
rare. Congenital NDI is caused by a
deficiency of ADH receptors and clinical
signs usually develop at a very young age.
Signs are severe with very marked PU/PD
(urine SG 1.0011.005). Diagnosis is made
after excluding causes of secondary NDI
and a WDT showing failure to concentrate
after administration of exogenous ADH.
The animal should always have free
access to water and will always bemarkedly polyuric and polydipsic. Dietary
sodium and protein restriction will reduce
the amount of solute presented to the
kidney therefore reducing the amount to
excrete in the urine each day by about
2050%. The addition of thiazide diuretics
(hydrochlorothiazide 15 mg/kg orally
q12h) to dietary restrictions may further
reduce urine production by increasing fluid
uptake in the proximal tubules.
Central diabetes insipidusCDI is caused either by the absolute
(complete) or relative (partial) deficiency ofADH. Complete CDI leads to the complete
inability to produce concentrated urine,
whereas in partial CDI ADH is released in
subnormal amounts often only at higher
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Urinespecificgravity
Primarypolydipsia
PartalCDI
CDI
NDI
Administraon
of DDAVP
Time
Figure 9: Expected results of the water deprivation test
Figure 10: Measurements of plasma osmolality and endogenous ADH at the end of the WDT can bevery helpful in diagnosing partial CDI as small, but inappropriate amounts of ADH are released inresponse to increasing plasma osmolarity
PlasmaADH
Plasma osmolarity
Normal
CDI
NDI
Primarypolydipsia
Partal CDI
osmolality than expected. Pituitary orintracranial neoplasia (e.g.
craniopharyngioma or meningioma) are
the most common causes of CDI. Thus,
once a diagnosis of CDI is made,
advanced imaging of the pituitary glandis recommended. Severe head trauma
may lead to clinical signs, with
spontaneous resolution possible due to
regeneration of disrupted axons. If no
aetiology is evident then idiopathic
disease is suspected. This is mostcommon in younger animals; however,
they may develop lesions during the
course of their life which were not initially
evident during the primary investigations.
Treatment revolves around the ADH
analogue desmopressin (DDAVP,
1-deamino, 9-D-arginine vasopressin); this
provides antidiuretic activity for about
8 hours. One drop (1.5 to 4 g) placed two
or three times daily in the conjunctival sac
sufficiently controls the polyuria in most
dogs with CDI. In the absence of neoplasia
the long-term prognosis is good, with many
animals remaining asymptomatic onappropriate therapy.
Primary polydipsiaPrimary polydipsia is largely thought to be
behavioural in origin and can be controlled
in most cases by gradual water restriction
to the high end of normal (6080 ml/kg per
day). If this not successful then behavioural
modification (e.g. increased exercise,
changed environment or seeking a
veterinary behaviourists opinion) may help.
ConclusionsAlthough common presenting complaints,
both polyuria and polydipsia represent
significant challenges to the small animal
practitioner. With careful history taking
and examination, followed by logical
investigations the cause should be
determined, allowing directed therapy
and realistic expectation of outcome for
the owner.
Note:Some of the medications
mentioned in this article are not
authorised for use in dogs and
cats. Readers are reminded to
follow the Cascade when
prescribing medication.
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Diagnosing felinenasopharyngealdiseases
Suspected nasopharyngeal neoplasia, polyp,
fungal granuloma (nasal discharge, epistaxis,
nasal asymmetry, stertor).
In cats amenable to oral examination while
conscious, it may be possible to get a view of the
nasopharynx by grasping the tongue with your fingers
and extending it rostrally, using the projecting lingual
papillae to help you get a firm grip on the tongue. The
soft palate develops a V shape and a momentary
glimpse of the nasopharynx can be obtained. This may
allow sight of a grass blade or polyp in the caudal
nasopharynx (polyps are usually situated more
caudally than nasopharyngeal lymphoma or fungal
granulomas). If there is a large mass lesion in the
nasopharynx, it is also sometimes possible to see a
bulging of the soft palate.Under general anaesthesia (see Box 1), the
nasopharyngeal region is palpated through the soft
palate. Normally, the soft palate gives on palpation,
but if a polyp, granuloma or neoplasm is present, it is
generally possible to appreciate the presence of a
mass lesion, which may then be sampled by fine
needle aspiration.
With the cat in dorsal recumbency, the soft palate
can then be retracted to allow visualization of any
foreign bodies or soft tissue masses. Further
evaluation is aided by simple adjunct tools such as a
laryngoscope (Figure 1), spay hook (Figure 2) or
forceps, and a dental mirror.
Effective feline practice is grounded in a
knowledge of the clinical approach to, and
management of, a wide variety of problems
likely to be seen in cats, while making the
veterinary clinic as cat-friendly as possible. Focussing
on gold-standard preventive healthcare and the
common areas encountered in the first opinion setting,the BSAVA Manual of Feline Practicewill be a best
practice guide. Where appropriate, guidelines will also
be given as to the best steps to take when there are
financial considerations.
While the Foundation Manuals are particularly
relevant to students and recently qualified vets, or
those returning to practice after a career break,
recommendations will be given that can be followed by
all vets seeing feline cases. As an added feature,
quick reference guides (QRGs) throughout the book
will highlight practical techniques and treatment in an
easy-to-follow step-by-step fashion, aided by clear
colour photographs.These QRGs will include: tips for taking and
interpreting a thoracic radiograph; performing a
neurological examination; tips for performing dental
extractions; enucleation; managing diabetic
ketoacidosis; performing early neutering; skin scrapes
and skin cytology; performing bronchoalveolar lavage;
thoracocentesis; taking a liver biopsy; placing a chest
drain to name just a few.
Examining the nasopharynx in a catNasopharyngeal examination may be required in cats
for a number of reasons:
Evaluation of stertor (most commonly caused bynasopharyngeal polyp, neoplasia or stenosis)
Suspected nasopharyngeal foreign body
(e.g. acute onset sneezing/gagging, facial
discomfort, nasal discharge)
The BSAVA Foundation Manual on feline
practice will be published next year. Here,one of the co-editors, Andrea Harvey, whowill also be speaking at BSAVA Congress inApril, gives us a taste of what is to come
BOX 1: ANAESTHETIC CONSIDERATIONS
General anaesthesia is almost always required for furtherinvesgaon or for removal of a foreign body or polyp.Cats with nasopharyngeal disease can be at high riskof upper airway obstrucon. This is usually due to thepresence of associated discharge. Smulaon of thenasopharynx will also oen result in excessive mucusand saliva secreon, in addion to ssue oedema/inammaon. It is therefore prudent to ensure thatall necessary equipment is prepared prior to inducinganaesthesia. This should include: sucon equipment;swabs and coon buds to help remove secreons; alaryngoscope; various sizes of endotracheal tubes; and
a dog urinary catheter in case of diculty intubang.The cat should be pre-oxygenated, and intubated withan endotracheal tube that is as large as possible. Pulseoximetry monitoring should be used throughout, andsucon equipment kept to hand throughout inducon,the procedure and recovery.
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Figure 1: This 6-year- old MN DSH cat was presented with anacute history of sneezing and pawing at the face, afterhaving been outside in the owners garden. He had no nasaldischarge or stertor. These signs, plus their acute onset,suggested a nasopharyngeal foreign body such as a blade of
grass. Allis tissue forceps were used to retract the softpalate, and a laryngoscope used to assist evaluation. A bladeof grass was seen in the nasopharynx and removed intactusing forceps
Figure 2: This 1-year-old FN DSH catpresented with a few weeks ofprogressively worsening stertor. There
was no nasal discharge or sneezing.Under anaesthesia, a firm bulging ofthe soft palate was palpable. The softpalate has been retracted rostrallyusing a spay hook and anasopharyngeal polyp can be seen (thered lesion just caudal to the tip of thespay hook). This was successfullyremoved by traction, using graspingforceps. This photo is taken with thecat in sternal recumbency, but theauthor prefers to conduct theprocedure with the cat in dorsalrecumbency
Diagnostic imagingPlain radiography, CT and MR imaging all provide a
measure of the extent of a lesion and its precise
anatomical location or the presence of a foreign body.
However, imaging does not negate the need for
direct visualization. Plain radiographs are the most
practical diagnostic imaging modality for general
practice, with the most useful views being an intraoral
dorsoventral view of the nasal cavity and a lateral view
of the skull and pharynx, with the patient extubated inorder to be able to assess the nasopharynx. In the
majority of cases, however, these are of limited value
in reaching a diagnosis, and extubating the patient
may not be desirable.
Advanced imaging is not usually required but may
be considered in some cases where a diagnosis hasnot been possible using other methods; this should be
discussed first with a specialist to determine whether
or not it is likely to be of value before proceeding.
Retrograde rhinoscopyIf a flexible endoscope is available (either a small
gastroscope or a bronchoscope) then a very good
view of the nasopharyngeal region can be obtained
(Figure 3). The endoscope is fully retroflexed into a
U shape and inserted into the mouth, hooking the free
end over the top of the soft palate. It is then rotated to
be in a midline position (look for the endoscopic light
pointing cranially through the soft palate to show thatyou are in the correct position) and pulled rostrally.
This technique is of particular value when a foreign
body or nasopharyngeal mass is suspected but
cannot be visualized as described above. Referral may
be required.
Figure 3: View of the nasopharynxobtained though retrograderhinoscopy. This was a 5-year-old MNDSH cat that had been presented witha chronic mucopurulent nasaldischarge and progressivelyworsening stertor. There is a fungal(cryptococcal) granuloma (arrowed)occluding the posterior nares. Thesoft palate is at the top of the photo;its location can be determined bypushing on the soft palate with afinger during the procedure
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Diagnosing feline nasopharyngeal diseases
IndicationsNasal ush only: Where a foreign body is suspected or
has been identied and ushing isrequired to attempt to dislodge it
Where a mass has been identied or issuspected, and nasal ushing issuccessful in dislodging enough tissuefor histopathology (this can occur with
fungal granulomas and nasal lymphoma) In chronic rhinitis, to ush out tenacious
secretions (this can be therapeutic).
Nasal ush and biopsy: Where a soft tissue mass has been
identied or is suspected, and has notbeen dislodged with vigorous nasalushing
Where a cause (e.g. foreign body orpolyp) of the clinical signs has not yetbeen identied; ushing can be used tocollect samples for cytology, and nasalbiopsy samples obtained forhistopathology.
Equipment Suitably sized mouth gag Gauze swabs Gauze bandage Throat packs: these can be made by
rolling up a small piece of gauze swaband tying a gauze bandage around it;the swab can be packed into the throat,whilst the bandage remains outside themouth to allow easy retrieval.Alternatively, a small sponge with a tieattached can be used
Laryngoscope
Suction equipment Lidocaine Allis tissue forceps and/or spay hook Dental mirror 35 mm diameter tip (or smaller)
endoscope
Quick Reference Guide: Nasal ushing and biopsyby Andrea Harvey and Richard Malik
Cotton buds Small bowl of tap water 2 formalin pots 1 plain collection tube 1 or 2 EDTA collection tubes 0.9% saline 2 x 10 ml syringes and needle for
drawing up saline Suitable nasal biopsy forceps e.g.
alligator forceps with sharp cupped tips,otoscope biopsy forceps or endoscopic
GI biopsy forceps. The bigger theforceps that can be inserted, the largerthe samples that can be retrieved.
parameters (PCV and platelets) shouldbe checked and found to be normal priorto taking biopsies. The authors do notroutinely assess coagulation timesunless the cat has any other systemicabnormalities (e.g. liver disease).
General anaesthesia is required andanaesthetic considerations areimportant (see Box 1). With nasal ush biopsy, there is the additional concern
of even more risk of upper airwayobstruction and aspiration, because ofthe nasal ush uid and haemorrhagefrom biopsy. In addition to havingsuction equipment and gauze swabsand cotton buds to hand, the pharynxshould be packed (see below) andconsideration given to using a cuffedendotracheal tube.
Performing a nasalush
1With the cat anaesthetized and with an
ET tube in place, the pharynx is packedwith gauze swabs or small pieces of spongeattached to a tie.
Throat pack
Alligator forceps
Patient preparation The nasopharynx should be evaluated
prior to performing nasal ush or biopsy. Since nasal biopsy can cause signicant
haemorrhage, haematological
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2
One of the authors (AH) prefers to
have the cat positioned in sternalrecumbency, with the head and neckfacing ventrally over the edge of the table,to encourage uid to drain out rostrallyafter ushing.
3 Two to four 10 ml syringes are lled withsterile 0.9% NaCl that has been warmedto 38C. The end of the syringe iswedged into one nostril.
One hand is used to hold the syringe inplace and to occlude the contralateralnostril, while injecting 10 ml saline as fastas possible using the other hand.
A collection dish is held underneath thecats head to collect any material thatdrains from the nose or pharynx.
Unless a foreign body has beendislodged and thus the cause alreadyidentied, uid is then transferred to anEDTA tube for cytological assessment.
The procedure is repeated for the otherside of the nose.
Routine bacterial culture of ush uid is
rarely helpful, but in cases of chronic rhinitisculture can sometimes be useful in directingantibiotic therapy if a resistant infection isidentied (culture of tissue collected bybiopsy is more helpful).
The other author (RM) prefers cats to bepositioned in dorsal recumbency. Firm tapecan be used to hold the cats head inposition against the table top using themaxillary canine teeth as points ofanchorage (not shown here). Gauze tapecan be hooked around the mandibularcanine teeth to open the jaws (not showhere) or, if a third person is available, it isideal if they can hold the tongue (as shownhere) and endotracheal tube up and awayfrom the palate.
4After ushing, the throat packs can beremoved and examined for any foreign
material, or dislodged tissue. Usually foreignbodies and many mass lesions will bedislodged within two or three attempts.
Portions of dislodged tissue can be:
Used to make impression smears for
cytological assessment Placed in formalin for histopathology Retained for fungal culture if fungal
infection is suspected on the basis ofgross appearance, or suggested bycytology or histopathology.
5Following the procedure the pharynxshould be examined, and any
remaining secretions or uid suctioned out.
Performing nasalbiopsy
1The anaesthetized cat, with ET tube inplace, is positioned in sternal
recumbency with new throat packs placed(so that any blood resulting from biopsy isnot aspirated). Care must be taken not torisk penetrating the cribriform plate:forceps can be pre-measured from the
nares to the medial canthus of the eyeand a piece of tape used to mark theforceps at this point. The forceps must notbe inserted beyond this. WARNING: Thetape must not be allowed to get wet andslip during the procedure.
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Diagnosing feline nasopharyngeal diseases
ANDREA HARVEY AT
CONGRESS 47 APRIL 2013
Thursday 14.0514.50
Feline jaundice 15.0015.45
Feline pancreas Sunday
14.3515.20Conspaon/Obspaon
OUT IN SPR ING 2013
Edited by AndreaHarvey and SverineTasker, the BSAVAManual of FelinePractce: A Foundaton
Manual will be availablein Spring 2013.
Cat-friendly pracce ps Problem-oriented clinical approach
Common presentaons Management opons Praccal step-by-step guides
For more details and to register your interestemail [email protected]
20.10.2 ml of 1% lidocaine is instilledinto the nares via a cannula and a few
minutes allowed for this to take effect.
3The forceps are inserted anterogradeinto the ventral meatus. The forceps are
opened and then lodged up against anyarea of resistance, before closing andretracting them. The head should bedirected slightly ventrally, to encourage anyblood to fow cranially to the nostrils ratherthan caudally into the pharynx. Gauzeswabs and cotton buds should be on handto help stop any haemorrhage, whichinevitably occurs.
reserved in a plain pot on a moistened
sterile gauze swab, for bacterial andfungal culture.
Both sides of the nose should besampled, with at least six samplescollected from each.
Note: It is important to remember towash the forceps in water after eachsample has been placed in formalin(using the forceps), prior to insertingthem into the nose again to avoidformalin entering the nose.
Pre-measuring the forceps. This cat has a mouth gag
in place because retrograde rhinoscopy had just
been performed; a gag is not necessary for nasal
biopsy
5Following the procedure, the throatpacks should be removed once
haemorrhage appears to have ceased.The pharynx should then be carefully
examined and any remaining blood orblood clots removed with swabs or cottonbuds, and any secretions suctioned, prior torecovering the cat from anaesthesia.
The pharynx should be evaluatedcontinually for any ongoing haemorrhageprior to extubation, and anaesthesiashould be maintained until anyhaemorrhage has ceased.
The cat should be monitored very closely
in the recovery period, ensuring that suctionequipment, laryngoscope, ET tubes andintravenous anaesthetic agent are keptclose to hand until the cat is fully recovered.
Analgesia should be provided for at least24 hours following biopsy.
Typical samples collected from nasal invesgaons.
From le to right: nasal flush fluid in EDTA tube for
cytology; secreons from nasal flush on a gauze
swab for bacterial and fungal culture; ssue
samples from the le and right sides of the nose in
formalin for histopathology
4 Tissue collected is placed in formalin
pots (labelled with the side collectedfrom). A small amount of tissue is also
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Congress 47 APRIL 2013
scientificproceedings
veterinaryprogramme
47 April
The ICC/ NIA Birmingham UK
www.bsava.com
47 April
scientificproceedings
nursing programme
The ICC/ NIA Birmingham UK
www.bsava.com
All the fun of the freeYou know youll come away from Congress with moreknowledge and confidence thanks to the science, butyoull also come away with plenty of treats thanks to anabundant treasure chest of freebies in the NIAExhibition heres your guide to Congress booty
Stay cool with your
free daily tub ofdelicious ice cream
available from booths
in the NIA.
Sponsored by Petplan.
Smoothies are
one of the mostpopular rewards
and a quick way
to get in one of
your five a day.
Sponsored by
Virbac.
Stay hydrated all day with freebottles of water available at
the catering points in the NIA.
Sponsored by National
Veterinary Services.
Invaluable resources
to support your attendance at lectures
not only do you get the abstracts in the free
Proceedings book, members also get
access to all the lectures online after the
event. This means you can listen again, or
catch up on the ones you missed.
Help yourself to a cuppa
(tea or coffee) any time of
the day in the NIA youmight need that caffeine
to help you keep going.
Sponsored by Willows.
Early birds can also get
a hot drink in the morning
in the ICC & NIA.
Sponsored by VetPlus.
The first item youll pick up will
probably be your Congress bag from
the big blue container outside the NIA.
This will give you somewhere to put
all the rest of your goodies.
Sponsored by Royal Canin.
Not only does every delegate get a free
lunch bag each day (sponsored by
Norbrook Laboratories), this year you need
to look out for the equivalent of Willie
Wonkers golden ticket, with a winning
ticket in one of the packs the prize being
a trip to WSAVA Congress in South Africa
in 2014.
Your drinks voucher can beexchanged for an alcoholic
or soft drink at the bar.
Sponsored by
Hills Pet Nutrition.
As well as all the BSAVA
treats, our Exhibitors
provide plenty of great
give-aways on their
stands and yourExhibition Voucher
Booklet contains thousands of
pounds worth of benefits (almost 17k
worth of vouchers in 2012!).
Discounts
SpecialOffers
Competitions
TheICC/ NIA Birmingham UKwww.bsava.com
47 April
exhibition
vouchers
Welcome drinks come and enjoy
complimentary canaps, wine, beer
and juice as we celebrate with our
exhibitors in the NIA on Thursday at 5.Sponsored by VetPlus.
The sweet shop on the concourse
brought to you by Mrialwill provide
you with a sugary treat to keep your
energy up over the four days.
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24/36
Congress 47 APRIL 2013
Delegates at Congress 2013 will hear of research intomental health, wellbeing and mentoring which shouldhelp in avoiding the problems that can get the betterof us in practice
Best practice isall in the mind
Important studyRosie is studying for a PhD in the universitys College
of Medicine examining mental health and wellbeing
in veterinary students. This involves following a
complete annual cohort of graduates from each UK
school, looking at how they adapt to life in practice
and the factors affecting their psychological state and
its effect on their job satisfaction and performance.
So in Birmingham she will describe progress in this
project and other research supported by various
veterinary institutions including the BSAVAs own
charity, PetSavers.
The first months in practice are known to beamong the most stressful periods that new graduates
are likely to face in their career. This is reflected in the
numbers of inexperienced practitioners that hand in
their notice and even go looking for new jobs outside
the profession that they have worked so hard to join.
The turnover rate for new graduates can be quite
high and that is probably linked to a disparity between
their expectations and the reality of life in practice.
They are certainly not lacking in the technical skills
needed for their work, the problem appears to be
mainly due to failings in confidence and
communication.
The best possible startWhile there may been some practice principals who
feel that being thrown into the deep end is the best
way for new graduates to develop the additional skills
that they will need to succeed, many others recognise
that young colleagues benefit from receiving
guidance from a senior colleague. In one of her three
presentations, Rosie will be looking at the concept of
monitoring and how it can help smooth the transition
from vet school to practice.
There are lot of practice owners and senior
veterinarians out there who support the idea of
mentoring but they dont know where to start with it orthey have struggled with it in the past, she explains.
So she will offer practical insights gained from her
investigations of mentoring systems employed both
within veterinary practice and in sister professions.
Rosie Allister from the University of Edinburgh
will be looking at the professions work in
tackling the mental illness issues that affect an
unacceptably high proportion of its members
in her talks at BSAVA Congress. She will explain how
researchers, like herself, are gathering the information
on the relative effectiveness of different interventions in
preventing depression and other mental
health problems and so allow
vets to begin looking after
their own.
24 | companion
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Congress 47 APRIL 2013
Learning from othersThe corporate practices will often have more advanced
support systems for their junior staff than a smaller
practice. We can learn from the way that doctors are
trained and mentored at the beginning of their careers.
Of course, veterinary practice may be unable on
economic grounds to allow staff to spend any
extended period shadowing a senior colleague.
Vets should be looking at the strategies that work in
other areas and adapting them for their own
situations, she says.
This is important not only to help the new
graduate but also to improve the efficiency of the
whole business. To work effectively as a team,
you need everybody to be well and coping with theirjob. As soon as one person begins to struggle, then
that can have knock-on effects on all of their
colleagues, she notes.
We arent all the same
One factor that makes it difficult for senior staff to
provide better help for their colleagues is that every
new graduate is different and so the support that they
need in their work may vary. Rosie is hoping to obtain
funding to develop a training programme for senior
vets in mentoring skills. This is intended to identify
what a new graduate needs to help them adapt to
practice life, and show how the practice can providethem with the most appropriate support.
Although we often think of new graduates needing
special support, the problem of poor mental health
can affect vets at all stages of their career. In this, as in
most situations, prevention is much better than cure
and so those attending this stream on psychology in
practice will also hear from Brian Faulkner, managing
director of Frontfoot Consultancy and 2008 Petplan Vet
of the Year.
Brian will be presenting some ideas gained
from the developing field of positive psychology
to improve the way that colleagues deal with
problems. He will raise questions about the typicalmindsets of veterinary surgeons and whether their
attitudes help or hinder them in developing the
psychological resilience needed to achieve
success in a veterinary career.
Psychology in Practiceat Congress
In your Congress programme you will see various icons. This
one indicates that the talk includes electronic voting. By popular
demand, this will be available in more sessions in 2013 than
ever before including the Psychology in Practice stream with
Rosie and Brian.
Using personal keypads delegates can answer questions posed to the
whole audience. This helps establish common opinions and experiences and it is all totally anonymous, so you can be as frank as you like.
Questions might be case-based in some instances, such as:
What do you think is the best test? Or you might be asked an
opinion-based question, like Do you agree with this statement?
The answers (always anonymous!) are presented on screen in
a graphical format that can be used as a basis for discussion
by the speaker.
This technology has been employed at Congress
for several years, and also in BSAVA CPD courses
across the country. If you havent attended one
before it really does help add to your
engagement in the talk and makes the whole
experience more interactive. For more
details about the programme visitwww.bsava.com, or email
would like us to send you a
programme.
Electronic Voting
Thursday 4 April
8.309.15: Understanding and managing values,beliefs and opinions as the basis of leadership.Brian Faulkner
9.2510.10: What is emoonal intelligence and howcan we use it to delivery customer sasfacon?Brian Faulkner
10.5511.40 Psychology of confidence, achievementand success in veterinary pracce. Brian Faulkner
11.4512.30: Wellbeing in the vet profession: what dowe know and why does it maer? Rosie Allister
13.5014.40: New graduates: approaches to reducingarion and improving performance throughunderstanding wellbeing. Rosie Allister
14.4015.35: Mentoring in pracce. Rosie Allister
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Calling all runners have you always wanted
to do the London Marathon but never got
around to applying for a place? Or perhaps
youve been disappointed in the ballot and
missed out. We can help you and you can really
help PetSavers.
By choosing to be the 2013 PetSavers Marathon
runner you could not only achieve a personal
ambition, but also contribute to the wellbeing of pets
throughout the world. Your sponsorship will be used
to fund vital research in one of the designated
PetSavers grants areas.
What to doGet in touch today tell us why you want to do the run
and how much you think you can raise. Applications
need to be in by 30 November and the minimum
sponsorship you would be expected to achieve is in
the region of 2000. We will help with lots of publicity
and ideas to make sure you can reach your target.
What we will doThe successful runner will hear from us before
Christmas and we will provide lots of help with
fundraising. Youll even get a PetSavers running
vest or T-shirt to inspire your training. Email
[email protected] call Gemma on
01452 726723.
Getting a spot on the start line for theLondon Marathon can be almost as difficultas running it we have a place on offer are you up for the challenge?
Marathon place
could be yours
PetSavers heated pads are ideal for keeping your
small pets warm this winter. The pads run on a low
voltage and can be left on constantly, even
underneath an animals favourite blanket. They
are safe, robust and easy to clean. The pad surface can
be easily wiped clean and be rolled up for storage when
not in use.
If you work in a practice, the heated pads are ideal for
minimising perioperative hypothermia, or just to keep them
warm in hospital. PetSavers pads are much cheaper than an
incubator and less hassle than hot water bottles. The plug-in
lead can be passed easily through the bars of a cage.
Heated pads are available to buy from the website at
www.petsavers.org.ukfor just 40.00 (including VAT).
Feelingwarm
all over
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PETSAVERS FUNDING
To find out more about how PetSavers fundsessenal research that ulmately helps vetssave pets please visit www.petsavers.org.uk or email [email protected] you wouldlike to find out how you can support thisimportant work.
Funding forstudy of urinalysisRachel Burrow of the University of Liverpool tells usabout her recently funded Clinical Research Projectentitled Comparison of non-validated in-house methodof urinalysis with the reference laboratory method
A
nalysis of urine is a commonly
performed and relatively simple
test that can help to investigate
diseases of the urinary system
and also many other body systems of bothdogs and cats.
Traditionally, urine was submitted to a
commercial laboratory where it would be
centrifuged to separate the cells and other
particles from the liquid part of the sample
by a standardised technique. Both parts of
the sample would then undergo various
tests and the results obtained would be
compared with well established standard
(normal) values.
In-house testsMany veterinary practices now havegreater in-house laboratory facilities,
including small bench-top centrifuges, and
are able to prepare urine samples
themselves. This is usually more cost-
effective and allows results to be obtained
much more quickly, which is of great
benefit to owners and their pets.
The technique is not standardised,
however, and it is not known if the results
obtained in a commercial laboratory are
directly comparable to th