The essential publication for BSAVA membersThe essential publication for BSAVA members

companionSEPTEMBER 2011

One MedicineDisease surveillance initiativeP4

Congress LordRobert Winston coming to 2012P7

How toApproach hypercalcaemiaP14

A case of severe dyspnoea in

a young Dobermann

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companion

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 benefit and is not available on subscription. We welcome all comments and ideas for future articles.

Tel: 01452 726700Email: companion@bsava.com

Web: www.bsava.com

ISSN: 2041-2487

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

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

Features Editorial TeamCaroline Bower BVM&S MRCVSAndrew Fullerton BVSc (Hons) 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 Association News Latest news from BSAVA

46 One Medicine a global effort Discussing the value of disease surveillance in companion animals

7 Lord of Congress Congress 2012s invited guest speaker

811 Clinical Conundrum Consider a case of severe dyspnoea in a young Dobermann

1213 Certificates to Suit You BSAVA postgraduate certificates

1418 How To Approach the hypercalcaemic patient

19 Petsavers Latest fundraising news

2022 Publications Investigating migrating foreign bodies

23 Congress Science Hidden disease of the older cat

24 Welcome to the World Congress Reasons to attend

25 The Veterinary Profession The first 250 years

2627 WSAVA News The World Small Animal Veterinary Association

2829 The companion Interview Michelle Stead

30 Meet Your Region Spotlight on Southern Region

31 CPD Diary Whats on in your area

Additional stock photography Dreamstime.com Daniela Jakob; Isselee; Noiral; Oleksiy Mark; Sally Wallis; Sandra Cunningham; Vadmary

With over 7000 members from students to retired surgeons, BSAVA aims to fulfil its remit to promote excellence in small animal practice through education and science in ways that are relevant at all points during your career. And we thank you for being part of this diverse group bonded by a passion for this profession.

Good time to be a memberBenefits have expanded this year to include iPhone and Android Apps making the Formulary and Congress information even more accessible and useful. You will also be glad to hear that there is a comprehensive Health and Safety section now too a resource to take the headache out of most peoples least favourite subject. At www.bsava.com/healthandsafety youll find downloadable risk assessment forms, guidelines, and useful links.

Other useful new benefits online include the Veterinary Poisons Triage Tool and the Client Information Leaflets on medicines, which proved immediately popular when launched this Summer.

RenewalsIn September and October BSAVA will begin contacting members about membership renewal for 2012 asking you to update your details, consider Direct Debit, and trying to make it easy for you to renew promptly to ensure you dont miss out on your current benefits or any continued loyalty bonus due to you.

For more information about benefits and renewal visit the website or email administration@bsava.com. We appreciate the ongoing support of all our members and hope you continue to access all the benefits you are entitled to.

IMPORTANT: CONGRESS REGISTRATION INFOPlease note: Because you can register for 2012 Congress over two membership years it is possible to register in an incorrect category. For instance, you might be a 3rd Year Qualified Member in 2011, but be a Full Member in 2012. So please make sure you renew promptly and that you select the appropriate registration for your status in 2012. If you have any questions, please email congress@bsava.com.

Are you making the most of all the benefits available to you, from discounts on Congress, Manuals and courses, to the digital resources, including the new Formulary App for the iPhone and Android?

Remember youre a Member

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ASSOCIATION NEWS

CPD IN THE CITYBVA Congress in London, 2224 September, promises not only a fascinating contentious issues series, but a brilliant small clinical programme thanks to BSAVA. We will deliver a superb small animal scientific programme covering feline medicine, gastroenterology medicine and surgery, and cardiorespiratory medicine. Speakers include Ian Ramsay, Hattie Syme, Sue Murphy, Penny Watson, Alex German, John Williams, Mike Martin, Adrian Boswood, Pete Mantis, Sophie Adamantos and Jackie Brearley.

Members of either BVA or BSAVA will receive discounted registration. So if you cant wait until our 2012 Congress to catch such excellent teaching, this is a great opportunity to spend some quality CPD time in the Capital. See www.bva.co.uk/BVA_Congress for more information.

BSAVA support for vital VBF programmeBSAVA donates a proportion of membership income to the Veterinary Benevolent Funds Veterinary Surgeons Health Support Programme (VSHSP). This has been in excess of 20k over the last four years and Vanessa Kearns, VBFs Administration Manager, has asked us to thank the membership for their continued support and encouragement.

The VBF depends on these and regular donations from individuals so that they can continue to provide vital financial and other assistance to deserving vets, and their relatives and dependents, who are, or have been on, the Register of the Royal College of Veterinary Surgeons.

The VSHSP gives completely confidential professional treatment and advice on alcohol, drugs, eating disorders, and other addictive and mental health issues.

The health issues associated with veterinary professionals are well reported and if we havent been touched directly, many of us know someone who has. Their annual report indicates that there continue to be more and more approaches to the Programme from members of the profession suffering with mental health problems including stress and depression.

There are a number of ways to donate, by phone on 020 7908 6385, online at justgiving.com/vbf/donate and even through payroll giving, visit payrollgiving.org.uk.

BSAVA is delighted to announce that the impact factor for Journal of Small Animal Practice has risen above the magic number of 1. The latest figures from the Journal Citation Reports have seen JSAPs impact factor rise by over 20% to 1.173. The impact factor, a measure of recent citations to papers published in the preceding two years, has doubled over the past six years thanks to the hard work of the Editorial Team, previously under Katie Dunn and now led by Carmel Mooney. Their aim has been to increase the quality and accessibility of the Journal. In total, JSAP articles were cited more than 2600 times during 2010 again, an increase of over 20% compared with the previous year.

The journals that most cited JSAP during 2010 include Veterinary Clinics of North America: Small Animal Practice, Journal of Feline Medicine and Surgery, Veterinary Surgery, Journal of Veterinary Internal Medicine, the Veterinary Journal and Journal of the American Veterinary Medical Association.

JSAP is just one of your many BSAVA member benefits. Visit the Membership page at www.bsava.com to access the Journal or find out more about submitting a paper. Your feedback and queries about both companion and JSAP are always welcome contact us at companion@bsava.com.

JSAPs impact factor increases again

The exhibition at BSAVA Congress is, as anyone who has walked it will know, huge. The vast arena floor and concourse area of the NIA is filled with hundreds of exhibitors, many of whom have incredible displays and elaborate stands. But how does it all get there, and how long does it take to set up and dismantle again at the end of Congress?

It is hard to believe that the build-up starts the Monday before Congress, so the exhibition takes three days to create, yet it is dismantled in less than a day. This demands precision organisation and the skills of dedicated workers, to whom BSAVA owes a big thank you.

So now you can see what goes into creating one of the largest veterinary events in the world with our timelapse film of the Congress 2011 build-up. A great taste of things to come for 2012. See www.bsava.com/congress.

See Congress in seconds

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Timelapse technology reduces the four day event to mere moments

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ONE HEALTH

One Medicine a global effortIt is estimated that three quarters of the new diseases that emerged in humans over the last century originated in animals. So why have we taken so little interest in a potential source of new health challenges that may be sitting quite literally right under our noses? Professor Michael Day of Bristol Veterinary School and currently Junior VicePresident of BSAVA tells John Bonner about the efforts to persuade politicians and medics of the value of disease surveillance in companion animals

One Medicine is like an old tune given a new airing and then, all of a sudden, just about everybody is whistling it.The idea that all aspects of managing disease in

man and animals surveillance, diagnosis, prevention and treatment are fundamentally the same makes scientific, practical and economic sense. Yet there is something in the equation: Human + Veterinary Medicine = One Medicine, that doesnt quite add up.

Every time anyone spoke about One Health/One Medicine it was about human health and production animals what diseases can we get from pigs, cattle and chickens? Then the discussion broadened out to include the environment, climate change, deforestation, etc. and how as a result of those factors, diseases in wildlife will become more important. But what had been missing all along was companion animals we share our lives with cats and dogs and we can also share their diseases. So why are they not part of the discussion? says Professor Michael Day, who chairs the Scientific Advisory Committee and the newly formed One Health Committee of the World Small Animal Veterinary Association.

One Health historyIt wasnt always so; the great proponents of the One Medicine concept in the Victorian era made no distinction between different animal species when assessing the value of comparative medicine. As the great Prussian physician and polymath Rudolph Virchow observed, Between animal and human

medicine there is no dividing line nor should there be. The object is different but the experience obtained constitutes the basis of all medicine.

In those days, dogs were used extensively in laboratorybased studies, as they are today. But the idea that there is something to be learned by human medics from the experiences of their veterinary colleagues fell out of favour over the past 50 years or so. That period coincided with the emergence of dogs and cats as genuine companions rather than useful working animals. One might speculate about why some human doctors seem uncomfortable over the ambiguous status of our pets are they a frivolous toy that doesnt need batteries, or a member of the family that just happens to have more hair than is strictly necessary? Or would recognising the importance of our relationship with companion animals shed an uncomfortable light on our treatment of less favoured species?

Whatever the explanation, there was a feeling among many medical scientists that spontaneously occurring diseases in cats or dogs are of little importance to mainstream medicine. Moreover, veterinary practitioners have often expressed frustration at the perceived lack of knowledge of, and interest in, zoonotic infections among medical practitioners.

A turning tide?In more recent years there have been signs that the medical establishment has begun to appreciate that the twoway transmission of pathogens between

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ONE HEALTH

humans and animals is worthy of serious consideration. In 2005, the British Medical Association and the British Veterinary Association teamed up to produce a special joint issue of the BMJ and the Veterinary Record dedicated to zoonotic infections and the links between the two professions. The following year the American Medical Association (AMA) and the American Veterinary Medical Association (AVMA) formed a joint committee, and there have been a number of other initiatives at national and international level. This culminated in the first international One Health Conference held in Melbourne, Australia, in February 2011, which attracted 650 medical and veterinary scientists from 24 countries. Yet, in a packed threeday programme containing more than 100 separate presentations, only six tackled the diseases occurring in companion animal species.

One Health focusWith his WSAVA colleagues, Michael Day had already begun work to address this imbalance and last year set up the Associations One Health committee, which held its inaugural meeting in Orlando, Florida in January 2011. The committees work will focus on three main areas. It hopes to contribute to the growing body of evidence on the physiological and psychological benefits of pet ownership, from reducing blood pressure to helping in the rehabilitation of disturbed children and prison inmates. The committee also wants to use the experience and expertise within the WSAVA to support basic and clinical research on conditions common to humans and animals, complementing the work of organisations such as the UK Comparative Clinical Science Foundation, which is already active in this area.

However, its first priority will be investigations into the many human diseases Michael estimates that the figure is at least 50 in which companion animals play an integral role in the transmission or act as reservoirs of infection. Top of the list is rabies, which he points out is often considered a neglected disease, despite being responsible for an estimated 50,000 human deaths a year. These cases occur mainly in Africa and Asia, and include disproportionately high numbers of children. The other major target is leishmaniosis, which infects an estimated 12 million people in 88 countries, 72 of them developing nations.

If there is sufficient time and resources, then there are numerous other zoonotic conditions which, although less frequently fatal, at least in the developed world, are the cause of significant morbidity for example, infections caused by Toxocara, Toxoplasma, Bartonella and Ehrlichia. Indeed, the sheer numbers of people affected by these conditions has proved a convincing argument for many of those medical researchers whose prior interest in zoonotic conditions stretched no further than, say, the transmissible encephalopathies or avian influenza. When you point out how many companion animals there are, how closely their lives are interwoven with ours and the number of diseases that affect both sides, then people see immediately that this a worthwhile project, Michael says.

One Health many contributorsTo achieve its goals, the committee will need friends in high places senior staff in the large international bodies responsible for shaping global health policy as well as controlling the funding for the research which underpins any new strategy. Together with the WSAVA President Professor Jolle Kirpensteijn, Michael has been lobbying those organisations and has persuaded representatives of three of them to join the One Health committee Chand Khanna, the Canadiantrained veterinarian who heads the comparative oncology programme at the US National Institute of Health; Carol Rubin, Associate Director for Zoonoses at the Centers for Disease Control in Atlanta; and Alex

(Left to right) Professor Michael Day (Chairman of the WSAVA One Health Committee), Professor Jolle Kirpensteijn, President of the WSAVA, Dr Bernard Vallat, Director General of OIE and Dr Alex Thiermann (President of the Terrestrial Animal Health Code of the OIE)

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ONE HEALTH

One Medicine a global effort

Theirmann, President of the Terrestrial Animal Health Code at the Office International des Epizooties (OIE) in Paris. Dr Liz Mumford of the Disease Monitoring Assessment and Control Group of the World Health Organisation in Geneva has also engaged with the work of the committee.

As the most important international forum for discussing animal health issues, the OIE General Assembly is where the WSAVA needs to be if it wants its voice to be heard. Having signed a formal memorandum of agreement and been granted observer status at this years annual assembly, the Association will have the right to speak directly to the chief veterinary officers and their entourages from the OIEs 178 member countries at the next meeting in May 2012.

Surveillance systemIn the meantime, the committee will be preparing a position paper, explaining in detail what it sees as the problems and potential solutions to controlling the transmission of disease pathogens between companion animals and humans. It will make the case for putting the same sort of efforts into surveillance for these conditions as is devoted to the major livestock plagues.

At the OIE, they already have the infrastructure to do this. There is an OIE computerised reporting scheme into which all the national veterinary offices input their data on livestock infectious diseases. A system has also been set up for recording conditions in wildlife and so it would not be beyond the realms of possibility to organise one for the major companion animal diseases.

The quality of the data produced needs to be much better than that provided by the only OIE initiative for recording diseases in dogs. The rabies reporting scheme is recognised by OIE as being inadequate, says Michael, as many countries fail to submit adequate and timely reports.

That could be improved upon if the WSAVA and other organisations were able to draw up clear standards for diagnosis of the main diseases to be monitored ensuring, for example, that any report of rabies in a dog is based on proper laboratory analysis of its brain tissue rather than relying on unverifiable reports of animals demonstrating behavioural signs of the disease.

The system would also depend on the skills and enthusiasm of the network of 80,000 small animal practitioners in 80 countries who belong to WSAVAaffiliated national organisations. These

WSAVA AT CONGRESSProfessor Michael Day will be presenting a report from the WSAVA One Health Committee on Sunday morning of Congress 2012. There is also a WSAVA lecture by Daniel Mills on Friday afternoon entitled One Health One Welfare: psychological and physical well being. In addition WSAVA are presenting a CRA prize for the best abstract on the One Health theme.

For more information about the Congress programme visit www.bsava.com/congress.

individuals could provide a valuable resource for accurately estimating the threat posed by existing diseases and for giving early warning of the emergence of any new ones. The example I use is that of a practitioner in rural China who starts to see cats that have severe respiratory signs. Could that be the first indication that a new strain of avian influenza adapted to mammalian hosts has emerged and could spread to humans? If the condition is reported, it can be investigated and the necessary measures taken to contain it.

The big challengeIn most cases the sort of conditions that the One Health committee wants to be included in the reporting scheme are not strategically important in international trade and therefore are not notifiable conditions. If practitioners have no statutory duty to report such cases, will they choose to do so?

That is a challenge because practitioners everywhere are busy people and if a task doesnt seem important, they may not always find time for it. The important things are to provide the education, so that everyone understands why they are being asked to do something, and a simple procedure that doesnt take up too much time. I think the SAVSNET project run from the University of Liverpool does show that a voluntary scheme for reporting small animal diseases can produce good results. So it is a question of finding a way to extend that idea on an international scale. n

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He has been described as truly a Renaissance Man, and is widely regarded as the UKs pre-eminent expert in reproductive medicine. Lord Robert Winston is Professor of Science and Society and Emeritus Professor of Fertility Studies at Imperial College and this years invited guest speaker for the BSAVA Congress 2012 Lecture.

ScienceLord Winston runs a gene transplant research programme at the Institute of Reproductive and Developmental Biology, where the team has achieved significant advances, particularly in endocrinology, IVF and genetics. For some years, Lord Winston has been Chancellor of Sheffield Hallam University and he has recently been appointed Chairman of the Council of the Royal College of Music.

PoliticsIn the field of politics, Lord Winston sits on the Labour benches and speaks regularly in the House of Lords, particularly on science, education, medical ethics and the arts. He sits on the House of Lords Select Committee on Science and Technology.

MediaA seasoned and popular television presenter, Lord Winston wrote and presented Superhuman, The Secret Life of

Twins, Child of Our Time and the BAFTA Award-winning The Human Body. He presented five series of Your Life in Their Hands for the BBC. In addition to his science-based programmes, Lord Winston displayed his musical abilities in Play It Again, where he learned to play a saxophone, from scratch, in five months. He has even appeared in an episode of The Archers, as a fertility expert.

A regular contributor to Any Questions, Question Time and the Today programme, Lord Winston has also appeared on Have I Got News For You, Start The Week and Desert Island Discs. He has contributed articles to all the national newspapers and to journals ranging from The Spectator to Good Housekeeping.

SpeakingLord Winston is much in demand as a conference speaker, and is known for explaining enthusiastically how the human mind is expanding exponentially and for advocating greater trust in scientists, in everything from food scares to climate prediction. Lord Winston promises to be a thought-provoking and thoroughly engaging speaker for the BSAVA Congress Lecture, which takes place on the Thursday of Congress and is free for delegates to attend (tickets available on request). Those attending can look forward to hearing him convey his enthusiasm for science with a terrific sense of humour. n

Early Booking Bonanza

Book early to win brilliant prizes the earlier you book the more chances of winning

Congress registration is now open. You can book online and download forms from www.bsava.com/congress. This year registrants are immediately entered into a prize draw. Every month, everyone registered for the event will go into the draw, so not only will you save money by booking before the Early Bird deadline and have the best chance to secure any Masterclasses and social tickets you might want you will also get the chance to walk away with a great prize. Register in August and you will go into a draw every month until December, so thats five chances to win one of the prizes which include:

n Free registration for you and your friends/colleagues for Congress 2013 (up to a value of 1000!)

n The entire BSAVA manual library for you or your practice including the latest releases from Congress 2012! Worth over 3000!

n A laptop computer to help you stay connected on the move and do more in less time.

You dont have to do anything other than register either for yourself or for your practice. Every person who pays for a registration between now and 29 December 2011 will go into the draw.

So check out the programme, book your hotel, and register for Congress 2012 as soon as you can. Visit www.bsava.com/congress for full details and terms and conditions. n

Following in the footsteps of prestigious and popular Congress guests that have included Susan Greenfield, Simon King and Monty Halls is doctor, scientist, politician and television presenter Lord Robert Winston

Lord of

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CLINICAL CONUNDRUM

Clinical conundrum

Sheena Warman, Senior Clinical Fellow at Langford Veterinary Services, University of Bristol invites companion readers to consider a case of severe dyspnoea in a young Dobermann

conundrum

Case presentationAn 18-month-old neutered female Dobermann was presented with a 4-week history of dyspnoea, coughing and lethargy. The cough was productive, with frothy mucus apparent on several occasions. There had been no improvement following treatment with enrofloxacin (5 mg/kg orally q24h for 2 weeks). The dog was current on routine vaccinations but had not been wormed recently. There was no history of travel outside the UK. Abnormalities detected on physical examination included tachypnoea (40 breaths/minute) with increased respiratory effort, and adventitious lung sounds (crackles and wheezes) bilaterally throughout both lung fields during both inspiration and expiration. Pinching the trachea induced a soft cough. Sinus arrhythmia was noted, with a heart rate of 80 beats/minute.

Construct a problem list for this case Dyspnoea/tachypnoea Productive cough Adventitious lung sounds Lethargy

Consider the portions of the airways most likely to be involved and list likely differential diagnosesThe presence of the productive cough and adventitious lung sounds suggested that infectious/inflammatory lower airway or parenchymal disease was the cause of the dyspnoea. In the presence of sinus

arrhythmia and absence of a

heart murmur, cardiac failure was unlikely; one of the earliest signs of cardiac failure is loss of sinus arrhythmia due to increased sympathetic tone. The lethargy was considered to be secondary to the respiratory problems.

Differential diagnoses for chronic lower airway disease Inflammatory/immune-mediated e.g.

chronic bronchitis, eosinophilic bronchopneumopathy

Infectious e.g. Oslerus osleri, Angiostrongylus vasorum, bacterial infections

Foreign body Neoplasia (rare)

Differential diagnoses for pulmonary parenchymal disease Inflammatory/immune-mediated e.g.

aspiration pneumonia, eosinophilic bronchopneumopathy

Infectious e.g. bacterial pneumonia, Angiostrongylus vasorum, rarely viral or fungal pneumonia

Neoplasia primary, secondary or metastatic; rarely lymphomatoid granulomatosis

Vascular e.g. pulmonary contusions, pulmonary thromboembolism, pulmonary oedema

Outline and rationalise your diagnostic stepsRoutine haematology and serum biochemistry were performed to assess for evidence of inflammation and to assess organ function. Faecal parasitology was submitted to detect in particular Oslerus osleri or Angiostrongylus vasorum infection. Arterial blood gas analysis was available (see Box on page 11 for further details); pulse oximetry could also have been used to assess oxygenation non-invasively. Thoracic radiography was performed

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Abnormalities detected on physical examination included tachypnoea (40 breaths/minute) with increased respiratory effort, and adventitious lung sounds (crackles and wheezes) bilaterally throughout both lung fields during both inspiration and expiration. Pinching the trachea induced a soft cough. Sinus arrhythmia was noted, with a heart rate of 80 beats/minute.

parenchymal disease was the cause of the dyspnoea. In the presence of sinus

arrhythmia and absence of a

Infectious e.g. bacterial pneumonia, Angiostrongylus vasorum,fungal pneumonia

Neoplasia primary, secondary or metastatic; rarely lymphomatoid granulomatosis

Vascular e.g. pulmonary contusions, pulmonary thromboembolism, pulmonary oedema

Outline and rationalise your diagnostic stepsRoutine haematology and serum biochemistry were performed to assess for evidence of inflammation and to assess organ function. Faecal parasitology was submitted to detect in particular osleri or Arterial blood gas analysis was available (see Box on page 11 for further details); pulse oximetry could also have been used to assess oxygenation non-invasively. Thoracic radiography was performed

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CLINICAL CONUNDRUM

(under sedation with oxygen provided by face-mask) to investigate airway and parenchymal diseases further.

Laboratory testingRoutine haematology showed eosinophilia (5.24 x 109/l, reference range 0.21.4). Serum biochemistry showed mild hypoalbuminaemia (29 g/l, reference range 3238) and mild hyperglobulinaemia (38 g/l, reference range 2035). Faecal parasitology was unremarkable. Further details of arterial blood gas analysis are shown in the Box on page 11.

What are the most likely causes of the laboratory abnormalities and how does this help refine your differential list?Eosinophilia in association with respiratory signs was most likely due to parasitic disease or allergic/eosinophilic diseases. Mild hypoalbuminaemia with hyperglobulinaemia was consistent with an inflammatory process and was not specifically investigated.

What is your interpretation of the thoracic radiographs (taken under sedation with oxygen supplied via face-mask) in Figure 1?There is a marked bronchointerstitial pattern throughout the lung fields. Caudodorsally there is a significant alveolar pattern with air bronchograms evident. There are multiple discrete, well defined nodules ranging in size from 0.5 to 3 cm scattered throughout the lung fields. The cardiac silhouette and pulmonary vessels are unremarkable. Significant hilar lymphadenopathy is not apparent. On the VD film, pleural fissure lines are evident caudally, consistent with pleural thickening.

What is the significance of the radiographic abnormalities?The severe bronchoalveolar pattern is consistent with bronchopneumonia due to infection (viral, bacterial or parasitic) or allergic/eosinophilic disease (eosinophilic bronchopneumopathy). The presence of

nodules is consistent with pulmonary eosinophilic granulomatosis (PEG), primary or metastatic neoplasia, mycotic infections, or the very rare condition lymphomatoid granulomatosis. However, neoplastic conditions would not normally cause such severe bronchial changes and are unlikely in a dog of this age. Systemic fungal infections are extremely rare in the UK. In conjunction with the peripheral eosinophilia, a parasitic infection or eosinophilic bronchopneumopathy were considered most likely.

What would be the next diagnostic step?In view of the predominance of bronchoalveolar changes on radiographs, bronchoscopy and bronchoalveolar lavage (BAL) were considered the most appropriate diagnostic procedures. Bronchoscopy allows visualisation of the airways and targeted collection of BAL samples for cytology and culture. Cytology of BAL samples is useful to assess cellularity (in particular inflammatory or neoplastic cells) and also to help detect any parasitic larvae or bacteria. Even with negative faecal parasitology, and no evidence of concurrent haemorrhagic diatheses, A. vasorum could not be excluded at this stage. Bacterial culture of BAL samples enables identification and antibiotic sensitivity testing of primary or secondary bacterial infections; mycoplasma culture could also be performed if available.

Bronchoscopy and bronchoalveolar lavageThe trachea and mainstem bronchi appeared inflamed with mucosal thickening, erythema and excessive yellow-green mucus. Mucus was collected for cytology (Figure 2), and BAL samples were collected for cytology and bacterial

Figure 1: (A) Right lateral thoracic radiograph. (B) Ventrodorsal thoracic radiograph

A

B

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CLINICAL CONUNDRUM

culture; results are shown in Table 1. No airway collapse was observed.

Fine needle aspiration of a nodule was not performed as it would have been technically difficult due to the small size of the nodules and could have resulted in haemocontamination of BAL samples or complications such as pneumothorax. Lung biopsy was not considered appropriate at this stage due to the risks associated with anaesthesia and surgery.

What is your interpretation of the mucus cytology (Figure 2)?There are high numbers of eosinophils

present, with occasional neutrophils and macrophages.

What is your diagnosis?A diagnosis of severe eosinophilic bronchopneumopathy was made based on radiographic and cytological findings. The nodular pattern was suggestive of pulmonary eosinophilic granuloma (PEG), which is considered a severe form of eosinophilic bronchopneumopathy;

surgical biopsy would have been required to confirm this and to exclude lymphomatoid granulomatosis definitively but this was not considered appropriate.

Clinical conundrum

Figure 2: Tracheal mucus stained with modified Wrights stain; original magnification x 1000Courtesy of Kathleen Tennant, Langford Diagnostic Laboratories, Langford Veterinary Services, UoB

Left caudal lobe Right caudal lobeMacroscopic appearance

Colourless, turbid fluid Pink, turbid fluid

Cellularity High ModerateCytology Some red blood cells

Nucleated cells: Epithelial cells 40% (many

dysplastic) Neutrophils 25% (no bacteria/

organisms) Eosinophils 30% Macrophages 2% (some reactive) Mast cells 3%

Numerous red blood cellsNucleated cells: Epithelial cells 45% (many

dysplastic) Neutrophils 20% (no bacteria/

organisms) Eosinophils 30% Macrophages 3% Mast cells 2%

Culture Negative for bacteria Negative for bacteriaTable 1: BAL results

How would you treat this case?Eosinophilic bronchopneumopathy is an immune-mediated condition and requires immunosuppressive treatment. Due to the severity of radiographic changes, in particular the presence of granulomas, both prednisolone (1 mg/kg q12h po) and azathioprine (2 mg/kg q24h po) were used. Fenbendazole (50 mg/kg q24h po for 7 days) was given in case of occult parasitic infection. A broad-spectrum antibiotic (amoxicillin/clavulanate, 10 mg/kg q12h po) was administered until bacterial culture results were available. Strict rest was advised.

OutcomeFour weeks later the dog was asymptomatic. Radiography was performed to reassess the lung changes, in particular the previously detected nodular lesions. Radiographs (Figure 3) showed a marked improvement with resolution of the nodular lesions and a mild residual bronchointerstitial pattern. The doses of prednisolone and azathioprine were reduced and gradually withdrawn over the following 3 months, with regular monitoring of haematology in case of azathioprine-induced myelosuppression.

Figure 3: (A) Day 27 right lateral thoracic radiograph. (B) Day 27 ventrodorsal thoracic radiograph

A

B

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CLINICAL CONUNDRUM

In view of the dyspnoea, arterial blood gas analysis was performed to assess oxygenation. Arterial blood gas analysis is an extremely useful technique which, with a little practice, is relatively straightforward to perform. The dorsal metatarsal artery is generally the most accessible in all but the smallest of dogs/cats. Hair is clipped and the area briefly wiped with spirit. It is important NOT to prepare the area thoroughly as this can cause the muscular wall of the artery to spasm. A 23G needle attached to a 1 ml heparinised syringe is normally used. Commercial dry-heparin syringes are available. Alternatively, undiluted heparin solution can be used to coat the syringe change the needle before taking the sample. The artery is palpated (using more than one finger so the course of the artery is appreciated) and the needle directed towards the artery at a slightly steeper angle than usually used for venous sampling, as the arterial wall is thicker.

Normal PaO2 is 80100 mmHg when the animal is breathing room air. For animals receiving supplementary oxygen, a normal PaO2 should be 45 times the inspired oxygen concentration (e.g. on 100% oxygen PaO2 should be 400500 mmHg).

The oxygenation status, and particularly any ventilation/perfusion mismatch, can be further assessed using

the alveolar gas equation, also known as the alveolararterial oxygen gradient. In the absence of a diffusion abnormality or a ventilation/perfusion mismatch, the arterial oxygen concentration (PaO2) should be almost equal to the partial pressure of oxygen within the alveoli (PAO2); a difference of up to 20 mmHg is considered normal in room air. This equation takes into account the effects of ventilation status (i.e. PaCO2) and the inspired oxygen concentration on the patient, using the following equation:

PAO2 = FiO2(PatmsPH2O)1.2 (PaCO2)

At sea level in an animal breathing room air (FiO2 = 0.21) this simplifies to:

PAO2 = 150 1.2 (PaCO2)

The alveolararterial gradient (PAO2 PaO2) can then be calculated. Normal is

12 | companion

CPD

registration for the BSAVA postgraduate certificates in medicine and surgery will begin on 3 October. With hundreds having already registered their interest, both programmes look set to be fully subscribed, but it isnt too late to pursue your potential, as Academic Director Dr frances Barr explains

The rCVS CertAVP today has many individuals enrolled on a wide range of modules so why introduce the BSAVA Postgraduate Certificates? The answer is that the BSAVA Postgraduate Certificates are academically equivalent to the rCVS CertAVP, but provide a different option in terms of subject emphasis and learning style. They will appeal to different individuals, and thus will broaden provision of postgraduate education, encouraging more to participate.

A new beginningThere will be two BSAVA Postgraduate Certificates beginning in January 2012 one in Small Animal Medicine and one in Small Animal Surgery. The programmes will take place in the South West and in Manchester. The overall standard of the programmes will be overseen by Nottingham Trent university, who will be validating the awards.

These BSAVA Postgraduate Certificates are designed to be particularly relevant to individuals working in general practice, with a balance between structure and flexibility. One-day courses and workshops will provide structured teaching and the opportunity to ask questions and enter into discussion. The aim is for students to get to know each other, and begin to develop a supportive, close-knit community. An impressive array of teachers, chosen for their clinical expertise

The veterinary profession attracts the most able and highly motivated individuals. Admission on to a veterinary degree is extremely competitive, and completion of the veterinary training requires organisation, hard work and commitment. Its hardly surprising then that, after a year or two working as a qualified vet, many individuals begin to look for the next challenge. for some that challenge comes from activities outside work or the demands of a growing family. But for others there is a desire not only to keep up to date, but to enhance knowledge and skills, and to become more confident and competent at work.

A different approachThere is now a well recognised tier of diploma qualifications in Europe, equivalent to similar qualifications

elsewhere in the world. The most usual route towards gaining these specialist qualifications is a full time residency training programme. Such programmes are highly sought after but are not appropriate for every individual. Its clear that there is room in the veterinary profession for a middle tier of expertise, recognised by the award of postgraduate certificate level qualifications.

Of course, certificates are not new in postgraduate veterinary education within the uK. The rCVS awarded certificates in a wide range of subjects for many years, which were well regarded within the uK and abroad. In 2007, a new rCVS Certificate in Advanced Veterinary Practice (CertAVP) was introduced, with a modular structure designed to support flexible learning, and the old style certificate began to be phased out.

CPDCPD

Certificates to suit you

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CPD

companion | 13

and their enthusiasm and flair for teaching, will deliver these courses.

The online resources and activities which are linked to each course will allow students to study at times and in places which suit them, yet maintain support and interaction through the online discussion boards. The casebook will give the opportunity to show the application of knowledge and skills to the diagnosis and management of real cases taking into account legislative requirements, animal welfare, financial constraints and so on. Personal support and encouragement will be an important feature throughout the BSAVA programmes, with each student provided with a mentor.

Enrolments will open on 3 October this year through the BSAVA website www.bsava.com. Initially a maximum of 30 students will be accepted on to each programme, to assure the quality of teaching and learning support. If there are more applicants than places available, then those who cannot be allocated a place for 2012 will be allowed to pre-enrol for 2013, and will be provided with some introductory online materials and activities so that they can prepare for their studies.

The annual enrolment fee (in 2012 2900 + VAT) includes:

Attendance at each of the taught courses run for the relevant programme during the year

Access to all online activities All assessment fees Academic and pastoral support BSAVA membership, and Discounts on attendance at BSAVA

Congress and purchase of BSAVA manuals.

There are no hidden extras.You may choose to study intensively,

with completion of the programme over three years, or you may prefer to spread out your studies over a maximum of five years, but you must enrol for each year of your studies. Students must pay the full

STruCTurE Of ThE BSAVA PG CErTIfICATES Module I: Attend twenty courses,

each one day long, over a period of two to four years. Each course has linked online resources and activities, with interactive discussion and feedback. At the end of the module, students must pass a formal written exam before progressing to the next part of the programme.

Module II: Preparation and submission of a casebook, with guidance available. Students will take part in an oral examination to discuss the casebook.

Small Animal Medicine Gastrointestinal tract I and II

Endocrinology I and II

Neurology

urinary tract I and II

Critical care

Clinical pathology and cytology

haematology

Clinical nutrition

Oncology I and II

respiratory

Cardiology

Infectious disease

Ophthalmology / dermatology

Immunology

Toxicology

reproduction and neonatology

Small Animal Surgery Principles of surgery

head and neck I, II and III (P)

Abdomen I, II and III (P)

Thorax I

Endoscopic techniques and Thorax II (P)

Surgical oncology and reconstructive surgery (P)

Abnormalities of bone

Abnormalities of joints

fracture management I and II (P)

forelimb I and II (P)

hindlimb I, II and III (P)

Neurology

(P) denotes practical workshop

annual enrolment fee for each of the first three years of study. If studies are extended, then students do not pay a full enrolment fee in years four and five; in these years students only need to pay their BSAVA membership fee and a modest fee to cover university registration, but still have access to any relevant courses, online activities, assessments and the support structure.

If you are interested in finding out more about the BSAVA Postgraduate Certificates, please go to www.bsava.com/postgradcert or email certificate@bsava.com. Enquiries are welcome from potential students, individuals interested in becoming mentors, and from those who would be interested in contributing to online activities.

IS ThE BSAVA PG CErTIfICATE rIGhT fOr YOu? I enjoy working in practice

but Id like to become a more confident clinician

I prefer to concentrate my studies on clinical subjects

I like the idea of a structured teaching programme

I will need some flexibility to fit my studies around my work and family/friends

I want academic support and guidance to be available

General support and encouragement is important to me

If you agree with all or most of the above, then consider the BSAVA PGCert.

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14 | companion

HOW TO

How to

Kirsty Roe of Willows Veterinary Centre and Referral Service works us through this challenging presentation

Approach the hypercalcaemic patient

Hypercalcaemia can be an unexpected abnormality on a biochemistry profile and although it can be a fortuitous finding in a patient displaying non-specific clinical signs, it is often difficult to decide how to proceed. When developing a diagnostic and treatment plan consideration must be given to the magnitude of the hypercalcaemia, the rate of its development, progression and the clinical state of the patient. Animals with rapid and progressive increases in calcium require aggressive therapy, which is discussed at the end of the article.

Calcium is required for many intracellular and extracellular functions including enzyme reactions, transport of substances across membranes and membrane stability, nerve conduction, neuromuscular transmission, muscle contraction, smooth muscle tone, blood coagulation, hormone secretion, control of hepatic glycogen metabolism, bone formation, and cell growth and division. A basic knowledge of calcium metabolism within the body is essential to help develop a logical approach to the hypercalcaemic dog or cat.

Calcium metabolism99% of body calcium is contained in the skeleton as hydroxyapatite. Serum calcium is found in three fractions: ionised calcium (55%), protein-bound calcium (35%) and complexed calcium bound to citrate,

lactate, bicarbonate and phosphate (10%). Ionised calcium (iCa) is the biologically active form and protein-bound calcium acts as a storage pool or buffering system for iCa.

Regulation of calcium concentration requires the integrated action of parathyroid hormone (PTH), vitamin D metabolites and calcitonin. PTH and calcitriol (1,25-dihydroxyvitamin D3) are the main regulators, with PTH regulating minute-to-minute iCa concentration and calcitriol regulating the day-to-day iCa.

Parathyroid hormone is synthesised and secreted by the chief cells of the parathyroid gland when iCa decreases. PTH increases serum calcium concentration via:

Increased renal tubular reabsorption of calcium, resulting in decreased calciuria

Increased bone resorption and number of osteoclasts on bone surfaces

Accelerated formation of active vitamin D (calcitriol) by the kidney through the synthesis and activation of 1-alpha-hydroxylase.

PTH secretion is inhibited by increasing serum iCa and calcitriol (Figure 1).

Vitamin D is absorbed in the intestine and converted to 25-hydroxyvitamin D3 (calcidiol) in the liver. This is further hydroxylated to 1,25-dihydroxyvitamin D3 (calcitriol) in the kidney via 1-alpha hydroxylase. Decreased phosphorus and iCa (via PTH) increase calcitriol formation, which acts to:

Increase calcium and phosphorus absorption from the intestines

Stimulates renal reabsorption of calcium and phosphorus from the glomerular filtrate.

Calcitriol secretion is inhibited by calcitriol, hypercalcaemia and phosphate loading.

Calcitonin is synthesised by the C cells of the thyroid gland when iCa increases. Calcitonin inhibits osteoclastic bone resorption and at high doses may enhance renal calcium excretion.

Clinical signs associated with hypercalcaemiaHypercalcaemia most commonly affects the kidneys, central nervous system, neuromuscular system, gastrointestinal tract and heart. The most common clinical signs are polydipsia, polyuria, lethargy,

Serum calcium

Serum phosphate

PTH

25(OH)D3 1,25(OH)2D3

Intestine

Bone

Parathyroidglands

+

Figure 1: Feedback control of the formation of 1,25-dihydroxyvitamin D3 (1,25 (OH)2D3) from 25-hydroxyvitamin D3 (25(OH)D3)

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HOW TO

weakness and anorexia. Signs vary depending upon the underlying cause, magnitude of hypercalcaemia, rate of development and duration: rapid development and increased magnitude of hypercalcaemia results in more severe clinical signs. Soft tissue mineralisation, in particular the heart and kidneys, is a serious complication of hypercalcaemia and the extent is dependent upon serum phosphorus in addition to the magnitude of hypercalcaemia. Table 1 lists the clinical signs and conditions associated with hypercalcaemia.

Upper and lower urinary tract effects: Polyuria occurs due to impaired renal tubular response to antidiuretic hormone and impaired tubular reabsorption of sodium and chloride, which results in a dilute urine and compensatory polydipsia. It is worth remembering that poor renal concentrating function can not be diagnosed from hyposthenuric urine in a hypercalcaemic patient. Renal failure can occur as a consequence of hypercalcaemia and there is a higher risk of this if the calcium (mmol/l) x phosphorus (mmol/l) product is >6 due to progressive renal mineralisation, vasoconstriction and depletion in extracellular fluid volume.

Chronic renal failure is a more common consequence of hypercalcaemia than is acute renal failure. Dysuria, haematuria and pollakiuria may be observed in patients with calcium oxalate urolithiasis. Urinary tract infection may occur secondary to urolithiasis or polyuria.

Central nervous system and neuromuscular effects: Lethargy and weakness may result from decreased excitability of the central and peripheral nervous systems and muscular tissue. Seizures and muscle twitching may occur as a result of cerebral microthombi or secondary to neuromuscular depression.

Gastrointestinal tract effects: Decreased excitability of gastrointestinal smooth muscle may result in anorexia, vomiting and constipation. Decreased renal clearance of gastrin may contribute to gastric hyperacidity and vomiting.

Cardiac effects: Clinically significant effects on the heart are uncommon. On an ECG P-R interval prolongation and Q-T interval shortening can occur. Severe hypercalaemia may induce serious arrhythmias.

Conditions associated with hypercalcaemiaCommon (the most common causes in dogs versus cats are listed in Table 2) Lymphoma Anal sac adenocarcinoma Primary hyperparathyroidism Chronic renal failure Hypoadrenocorticism Physiological in young growing animals

Uncommon Multiple myeloma Hypervitaminosis D

Iatrogenic, cholecalciferol rodenticides, calcipotriol/calcipotriene psoriasis creams, plants containing cardiac glycosides (Cestrum diurnum (Day-blooming Jessamine), Solanum malacoxylon (South American eggplant), Trisetum flavescens (Oat grass))

Idiopathic (cats) Haemoconcentration/dehydration

Uncommon to rare Carcinoma

Lung, pancreas, mammary, nasal, thyroid, skin, testicle, thymus, vaginal

Spurious Lab error, lipaemia, haemolysis

Granulomatous disease Angiostrongylus vasorum, (+ other

conditions such as blastomycosis or histoplasmosis which are not present in UK)

Acute renal failure Nutritional secondary

hyperparathyroidism Hyperthyroidism Melanoma Skeletal lesions (malignant)

metastatic or primary bone neoplasia, myeloproliferative disease

CommonPolydipsiaPolyuriaAnorexiaDehydrationLethargyWeaknessVomitingPre-renal azotaemiaChronic renal failure

UncommonConstipationCardiac arrhythmiaSeizuresTwitchingDeathAcute renal failureCalcium oxalate urolithiasis

Table 1: Clinical signs and conditions associated with hypercalcaemia

DogsNeoplasia: lymphoma and anal sac

adenocarcinomaPrimary hyperparathyroidismChronic renal failure

CatsChronic renal failureIdiopathicNeoplasia: lymphoma and squamous

cell carcinoma

Table 2: Most common causes of hypercalcaemia in dogs versus cats

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HOW TO

Approach the hypercalcaemic patient

Skeletal lesions (non-malignant) osteomyelitis, hypertrophic

osteodystrophy, disuse osteoporosis

Diagnostic approach to the hypercalcaemic patient1. Confirm the result with an external laboratory: Ensure the hypercalcaemia is not

spurious before pursuing a costly investigation by rechecking the total serum calcium and measuring ionised calcium.

If total hypercalcaemia is present but ionised calcium is within or below the reference range, laboratory error or chronic renal failure should be considered.

Correction formulae to correct the total calcium relative to albumin concentration have been described but this is less accurate than measuring ionised calcium and use of these formulae are not recommended.

2. Review the signalment and history: In young dogs renal failure, lymphoma

and hypoadrenocorticism are the most common causes of hypercalcaemia.

Dogs with primary hyperparathyroidism are often quite bright, whereas dogs with neoplasia, renal failure, vitamin D toxicity and hypoadrenocorticism are more likely to be systemically ill.

Primary hyperparathyroidism is more common in Keeshonds and dogs older than 8 years; malignancy (other than lymphoma) is more common in older patients.

A waxing and waning history of illness may occur with hypoadrenocorticism.

Ensure no access to rodenticides or psoriasis creams and check that calcium-containing supplements are not being administered.

Check for any possible ingestion of toxic plants that contain glycosides of calcitriol such as Day-blooming Jessamine (Cestrum diurnum).

Check for the possibility of mollusc ingestion, the dogs endoparasiticide regime and its geographical location to determine whether angiostrongylosis is a possibility.

Check for any history of lameness suggestive of bone pain.

Idiopathic hypercalcaemia is more common in long-haired cats.

Cats with idiopathic hypercalcaemia commonly have no clinical signs.

3. Physical exam: Remember to palpate all peripheral

lymph nodes for enlargement suggestive of lymphoma, although it is important to note that hypercalcaemic dogs with lymphoma can have a mediastinal mass and unremarkable peripheral lymph nodes. No single anatomical location of lymphoma has been found to be more likely to cause hypercalcaemia in cats.

Perform a rectal exam to palpate for anal sac masses.

Palpate the long bones and spine for evidence of pain.

Parathyroid masses are not usually palpable and the physical exam in dogs with primary hyperparathyroidism is usually unremarkable. In contrast, the presence of a palpable cervical mass in cats is suggestive of (though not pathognomonic for) hyperparathyroidism in a hypercalcaemic patient.

Perform a fundic exam to look for retinal lesions. For example, increased blood vessel tortuosity or retinal haemorrhage could occur due to hyperviscosity syndrome (multiple myeloma) or due to hypertension secondary to chronic renal failure.

4. Routine database: Perform complete haematology

including blood smear exam, biochemistry and urinalysis.

Normocytic, normochromic non-regenerative anaemia may occur with chronic renal failure, hypoadrenocorticism and various neoplasms.

If serum phosphorus is normal or low, renal failure, vitamin D toxicity and hypoadrenocorticism are less likely. Low, low normal or normal phosphorus are more consistent with primary hyperparathyroidism or malignancy.

Azotaemia is rare in primary

hyperparathyroidism as phosphate is often low or low normal.

Hyperglobulinaemia should raise suspicion for multiple myeloma.

Remember that hypercalcaemia itself results in decreased ability to concentrate urine by causing nephrogenic diabetes insipidus and that dehydrated vomiting patients may have a prerenal azotaemia. Consequently azotaemia and isosthenuria does not necessarily imply intrinsic renal failure.

Determining whether renal failure is primary or secondary to hypercalcaemia caused by another disorder when hyperphosphataemia and hypercalcaemia coexist with azotaemia is difficult. Serum ionised calcium concentrations are typically normal or decreased in renal failure and increased in hypercalcaemia caused by other disorders.

Hyperkalaemia and hyponatraemia are suggestive of hypoadrenocorticism. An ACTH stimulation test should be performed if these abnormalities are detected.

Urine may be isosthenuric or hyposthenuric in hypercalcaemic patients.

Note: Both hypoadrenocorticism and hypercalcaemia can result in azotaemia and isosthenuria where the azotaemia is prerenal. Following intravenous fluid therapy the azotaemia will improve if it is prerenal.

5. Aspirate any enlarged lymph nodes (even if not significantly enlarged).

6. Radiography of thorax and abdomen:

Performed primarily to search for a neoplastic focus.

Mediastinal lymphoma more commonly causes hypercalcaemia than other forms of lymphoma in dogs. Mediastinal masses can be subtle and good quality thoracic radiographs are needed (Figure 2), with or without thoracic ultrasonography. If a mediastinal mass is present, fine needle aspiration or Tru-cut biopsy should be performed, as

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HOW TO

hypercalcaemia has also been reported secondary to thymoma.

Remember to assess the spine and ribs for lytic lesions caused by multiple myeloma or neoplasia with bone metastasis. A core biopsy of a lytic lesion may be necessary if the diagnosis cannot be achieved by other less invasive tests.

Thoroughly evaluate the lungs for metastases or patterns suggestive of Angiostrongylus infection: a peripheral alveolar to diffuse interstitial pattern (Figure 3) is most common. Submit a pooled faecal sample for Baermann testing if suspicious of angiostrongylosis (a single faecal

Baermann test is only 50% sensitive). Metastasis to sublumbar lymph nodes

by an anal sac adenocarcinoma may be visible on abdominal radiographs.

Soft tissue calcification is rare but is most common with renal failure or hypervitaminosis D.

Calcium oxalate uroliths are radiodense and their presence should not be overlooked as medical dissolution is not possible. Owners of male dogs and cats with cystic calculi should be warned of the risk of urethral obstruction.

7. Abdominal ultrasonography: May reveal enlarged mesenteric lymph

nodes, hepatomegaly or splenomegaly from which fine needle aspirates can be taken.

8. Measure parathyroid hormone (PTH) and parathyroid hormone-related protein (PTHrp) concentrations:

PTH concentration should be interpreted relative to the calcium concentration. Serum PTH may be increased with primary hyperparathyroidism but a PTH concentration in the upper part of the reference range in a hypercalcaemic patient is inappropriate and therefore is also consistent with primary hyperparathyroidism. Dogs with renal failure may have increased PTH concentrations; therefore, to distinguish this from primary hyperparathyroidism, the result should be interpreted in the context of urea, creatinine, phosphorus and ionised calcium concentrations (Table 3) and other pertinent information.

Total calcium Ionised calcium

Phosphorus PTH PTHrp Calcidiol

Primary hyperparathyroidism or Normal or Normal Normal Normal

Nutritional secondary hyperparathyroidism

Normal or Normal or Normal or Normal or Normal

Renal secondary hyperparathyroidism

Normal or or Normal or or Normal Normal Normal or

Humoral hypercalcaemia of malignancy

or Normal or Normal or Normal Normal

Osteolytic hypercalcaemia of malignancy

Normal or or Normal Normal or Normal

Hypervitaminosis D (cholecalciferol)

or Normal Normal

Hypoadrenocorticism Normal or or Normal Normal Normal

Idiopathic (cat) Normal or or Normal Normal Normal

Table 3: Serum total and ionised calcium, phosphorus, PTH, PTHrp and calcidiol levels in diseases causing hypercalcaemia

Note: PTH concentration within the reference range is not normal in a hypercalcaemic patient and does not rule out primary hyperparathyroidism.

Figure 2: Right lateral thoracic radiograph showing a cranial mediastinal mass and megaoesophagus. Differentials include lymphoma with paraneoplastic polyneuropathy causing megaoesophagus or thymoma and secondary myasthenia gravis

Figure 3: Left lateral thoracic radiograph showing a peripheral alveolar lung pattern in a dog with angiostrongylosis

PTHrp measurement is helpful if malignancy is suspected, although PTHrp concentrations are not always increased in malignancy. PTHrp should be negligible if hypercalcaemia is not due to a PTHrp-secreting malignancy. Lymphoma and anal sac adenocarcinoma are the most common PTHrp-secreting malignancies.

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HOW TO

Approach the hypercalcaemic patient

9. Cervical ultrasonography: If primary hyperparathyroidism is still

suspected, ultrasound examination of the parathyroid glands should be performed. Results are highly dependent upon operator skill, experience and equipment. Parathyroid masses are usually hypoechoic, round to oval masses >4 mm in diameter in dogs (Figures 4a and 4b). Occasionally more than one parathyroid gland can be affected and the absence of a visible mass does not rule out primary hyperparathyroidism.

Note: In dogs, if the diagnosis still hasnt been made by this point, aspiration or biopsy of lymph nodes, spleen, liver and/or bone marrow should be considered to try to rule out lymphoma. If the hypercalcaemia is mild and there are only mild clinical signs without azotaemia, another option is to recheck the patient in 46 weeks. Inconclusive test results may become more conclusive with time or an occult neoplasm may become more evident.

In cats, if all investigations have been unremarkable, idiopathic hypercalcaemia is most likely.

Table 4: Hypercalcaemic disorders that may be steroid-responsive

LymphomaLeukaemiaAnal sac adenocarcinomaMultiple myelomaThymomaVitamin D toxicityGranulomatous diseaseHypoadrenocorticismIdiopathic hypercalcaemia

as CT may help detect lytic bone lesions (Figure 5) not evident on radiographs. However CT is rarely necessary in the investigation of hypercalcaemia as the diagnosis will often have been made following initial investigations.

there is a risk of hypokalaemia. Potassium chloride supplementation of fluids is usually necessary (no more than 0.5 mmol K+/kg bodyweight/h).

Glucocorticoids: These should be given only following confirmation of a diagnosis and at a dose of prednisolone 12 mg/kg orally q12h. Glucocorticoids decrease intestinal calcium absorption, decrease bone resorption of calcium and promote renal excretion of calcium. Hypercalcaemic disorders that are often steroid-responsive are listed in Table 4.

Calcitonin: This decreases osteoclast activity and formation of new osteoclasts. It is reserved for cases with severe hypercalcaemia and marked clinical signs where rapid normalisation of calcium is desired. Calcitonin 46 IU/kg s.c. q812h often decreases calcium within a few hours but hypocalcaemia can occur. Long-term use is not recommended as a lack of response to subsequent treatments can occur within a few days.

Bisphosphonates: These inhibit osteoclast function and therefore decrease bone resorption. Intravenous administration is more effective than oral and, as nephrotoxicity can occur as a side effect, good hydration must be achieved prior to administration. Serum calcium should normalise after a few days. The most commonly used bisphosphonate is pamidronate at a dose of 1 mg/kg in dogs and cats given over 2 hours with a saline infusion every 46 weeks, as needed. Oral bisphosphonate therapy can be prescribed for maintenance treatment in patients with recurrent hypercalcaemia where intravenous bisphosphonates have previously normalised calcium. Oesophagitis can occur as a side effect of oral bisphosphonate treatment.

Figure 5: Transverse bone-windowed CT image of the fifth lumbar vertebra, showing well defined regions of lysis in a dog with multiple myeloma

Figure 4: (A) Cervical ultrasound image showing a 12 mm diameter parathyroid nodule in a dog. (B) Parathyroid gland adenoma following surgical excision

A

B

10. Vitamin D metabolites: Measurement of 25-hydroxyvitamin D3

(calcidiol) in cases of suspected vitamin D toxicity can be helpful.

11. Further imaging: In dogs, if the underlying cause of

hypercalcaemia has still not been found, more advanced imaging such

Emergency management of hypercalcaemiaHypercalcaemia is regarded as a medical emergency when there is concurrent hyperphosphataemia due to the risk of progressive renal failure. The most important points to remember are to treat the underlying cause and not to administer glucocorticoids without a diagnosis as they can mask the clinical signs by reducing the size of lymph nodes and complicating the interpretation of fine needle aspirates in patients with lymphoma. Pre-treatment with glucocorticoids reduces the likelihood of successful induction of remission with chemotherapy for lymphoma.

Treat the underlying cause. Intravenous fluids: Correct any fluid

deficits then administer diuresis with 0.9% NaCl at 46 ml/kg/h (unless contraindicated e.g. congestive heart failure or hypertension). Fluid supplementation with potassium chloride may be necessary to prevent hypokalaemia (see below). Monitor carefully for signs of volume overload.

Diuretics: Give furosemide 2 mg/kg i.v. q412h to promote calciuresis if calcium is not decreasing with fluid therapy alone. Adequate hydration must have been achieved before starting diuretics. Monitor potassium, as furosemide is a loop diuretic and

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PETSAVERS

companion | 19

Improving the health of the nations pets

The Petsavers photography competition has had some really creative entries in recent years, and it attracts veterinary professionals and pet owners alike.

The theme for this years competition is Best Buddies. The judges will be looking for qualities like humour and character in the photos, as well as photographic skill. The winners of the previous years competitions are on the website, so take a look to see what has caught the judges eyes in the past to give you some ideas.

Previous winners have had their images made into Petsavers cards, so who knows you might even find Rex or Felix sending out thousands of Christmas greetings in the future.

How to enterThe competition has two categories: Adult (16 and over) and Junior (under 16). First prize in each category is 200 in photography vouchers, second prize is 100 in photography vouchers and third prize is 50 in photography vouchers. The closing date is Thursday 26 January 2012.

Entry to the competition could not be easier; simply email your photographs to info@petsavers.org.uk. An application form must also be submitted; this can be emailed with your photograph or alternatively you can print and fax the form to us at 01452 726701.

Getting the practice involvedYou can help us promote our photography competition by displaying leaflets in your place of work and telling your clients about it. It is also a great way to introduce them to the vital work that Petsavers does to improve the quality of life and welfare of companion animals. If you would like more information about Petsavers or this competition, including terms and conditions, then email us or visit the website. Good luck!

Get snappyThe annual Petsavers photography competition is now open, so visit www.petsavers.org.uk for full details on how to enter

Family, friends, colleagues and clients send some cheer this Christmas and raise money for Petsavers at the same time

Christmas cards: never too earlyPetsavers Christmas cards are available for a superb price of 3 for a pack of ten, including postage and VAT. There is a variety of designs and the cards are a great way to spread the festive cheer to your friends and colleagues, or you may like to send cards to your valued clients. This is often very popular with pet owners and makes them feel valued by your practice.

Order forms are available from the BSAVA on request, or cards can be purchased online at www.petsavers.org.uk. If you work in practice and would like to make these available to your clients we can send order forms to you to display in your reception.

Petsavers also has a good selection of notelets and sympathy cards, which are ideal for personal or practice use. However, if you are moving away from snail-mail at work or at home, then you can send an e-card from the Petsavers website and let the recipient know that what you are saving in postage you are donating to your favourite animal charity Petsavers! Visit the website or email info@petsavers.org.uk for more information.

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PUBLICATIONS

Various types of foreign body metal, bone, wooden or other vegetative material can penetrate the skin, resulting in a subcutaneous infection and abscesses, which are often associated with fistulous tracts. In these cases a focal soft tissue swelling is always present, indicating that the affected area should undergo an ultrasound examination in order to identify the retained foreign material.

IdentificationThe ultrasonographic appearance of foreign bodies is variable, depending on their size, shape and acoustic properties. Plant awns are visible as linear spindleshaped hyperechoic structures surrounded by a hypoechoic halo, representing oedematous tissue or fluid. Often two or three parallel interfaces are seen, corresponding to seeds and seed covers. Wooden, glass and metallic foreign bodies are less frequently encountered and their appearance ranges from medium echogenicity (wood) to hyperechoic (glass and metal) with

acoustic shadowing. Metallic foreign bodies may also be associated with comet tail artefacts.

The presence of acoustic shadowing is an important feature that enables a foreign body to be distinguished from other hyperechoic bands or lines formed by fibrin or connective tissue septa. A very careful examination of the affected area is important in these cases. Frequently, fistulous tracts are visualized as hypoechoic tubular bands, extending out into the surrounding tissue and possibly communicating with the skin surface. Fistulous tracts should be followed until the lesion is completely explored.

Inhaled foreign bodiesThe most difficult clinical situation arises when one or more foreign bodies are inhaled and travel through the airways before initially lodging in the lumen of a bronchus. Hunting dogs, which are most active in the spring and summer, are often affected. Due to the straight pathway and alignment with the trachea, the accessory and right caudal bronchi are common localizations. In the first few days following inhalation, the patient may cough due to the presence of focal bronchopneumonia; however, as the clinical signs can be very subtle, this often goes undetected.

Caudal migration of inhaled foreign bodies occurs via the diaphragmatic crura: respiration and contraction of the respiratory muscles push foreign bodes in a caudodorsal direction, following the caudal attachment of the diaphragm. The foreign body reaches the ventral aspect of the third or fourth vertebral body, where the iliopsoas muscle is located. Infection progresses along the muscle belly in a caudal and lateral direction, resulting in multiple (often bilateral) fistulous tracts in the flank region. Exploratory surgery of the flank region is usually unsuccessful

because of the multiple fistulae and the deep location of the foreign body.

Diagnostic imagingThe best way of investigating these cases is by using a combination of two diagnostic imaging modalities: contrastenhanced computed tomography (CT) and ultrasonography. These techniques are performed with the patient under general anaesthesia. This is very important because scanning deep areas requires a considerable amount of pressure, and this is only possible with a relaxed animal.

Contrastenhanced CT is important to:

Localize the extent of the disease multiple and long lesions are often detected, involving the thoracic and abdominal cavities along with the retroperitoneal space

Identify bronchial wall thickening and abnormal lumen contents in these cases, the presence of a foreign body in the bronchial lumen is very likely, and thus endoscopy is indicated. CT is very useful to guide the endoscopic inspection of the affected bronchus

Identify areas of pneumonia or lung abscess the presence of large areas of pulmonary infiltrate associated with areas of focal fluid collection, indicates lung infection and possible location of the foreign body within the pulmonary parenchyma. This situation is an indication for thoracotomy and lobectomy

Evaluate the thoracic wall carefully any site of pleura and soft tissue thickening or of rib changes (periosteal reaction) detected should be further explored by ultrasonography. If the pleura is perforated, spontaneous pneumothorax often occurs

Examine the sublumbar region carefully asymmetry and abnormal density of

Investigating migrating foreign bodiesMigrating foreign bodies are a frequent cause of soft tissue infection in small animals. Federica Rossi, from the Clinica Veterinaria dellOrologio in Italy, explains how diagnostic imaging can be used to explore these lesions further

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PUBLICATIONS

the sublumbar muscles are signs of possible foreign body location. Any subtle bony changes on the ventral vertebral body or small amounts of gas must be recorded. Abscesses appear as hypoattenuating fluid-filled cavities with a thin wall enhancement.

Ultrasonography should be performed immediately after CT.

All abnormal sites accessible by ultrasonography should be explored.

If an abscess is detected on contrast-enhanced CT, this should be carefully examined because of the high probability of finding a foreign body.

The typical appearance of a plant awn a surrounding hypoechoic halo is expected.

RemovalIf a structure with a typical foreign body appearance is detected, retrieval can be attempted under ultrasound guidance. If a draining tract is present, this can be used as the access port for the grasping forceps. If a draining tract is not present, a small stab incision can be made with a scalpel blade. Hartmann forceps are inserted through the skin incision and directed towards the foreign body under ultrasound guidance.

If the foreign body is in a deep location and direct retrieval is not possible, all information gathered regarding the location, size and relationship of the foreign body with other surrounding structures should be passed to the surgeon. The author recommends that this surgery is also assisted by ultrasonography the probe and cable can be aseptically wrapped so that the radiologist is able to scan the surgical site and provide the surgeon with a step-by-step guide during tissue dissection until the foreign body is extracted.

CLINICAL CASE 1

Mixed large-breed dog presented with a fistulous tract in the left zygomatic region (Figure 1A). This region was previously explored surgically. No foreign body was removed.

A porcupine spine (Figure 1C) was extracted during a second ultrasound-assisted surgical procedure.

1A 1B

1C

On ultrasound examination of the zygomatic region, the foreign body appears as a hyperechoic pointed structure with sharp margins (Figure 1B). The tip of the foreign body (on the right-hand side) is in contact with the hyperechoic bone surface of the coronoid process of the mandible (arrowheads). The temporal muscle (TM) is heterogeneous due to the inflammatory process.

CLINICAL CASE 2

Endoscopy and partial lung lobectomy were performed and three plant awns were found: two in the accessory bronchus and one in the lung parenchyma.

A 2-year-old male Kurzhaar presented with a presumed inhaled foreign body. A CT scan of the thorax was made using a dorsal plane and lung window (Figure 2A). The accessory bronchus shows a thickened wall and abnormal hyperdense content.

2A

2B 2C

A hyperdense lung infiltrate in the left caudal lobe and corresponding thickening of the pleura and thoracic wall are evident on dorsal plane images, using either a soft tissue (Figure 2B) or lung (Figure 2C) window (arrowed).

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PUBLICATIONS

AVAILABLE FROM BSAVAFederica Rossi is just one of the international contributors to the BSAVA Manual of Canine and Feline Ultrasonography. Her chapter on Superficial soft tissues provides information not only on foreign bodies but also on:

Mammary glands cysts, lactation and mastitis Superficial swellings and masses cavitary lesions,

trauma and surgical wounds Brachial plexus neoplasia.

The Manual is extensively illustrated with images of both normal anatomy and the abnormalities associated with disease. A DVDROM featuring video clips, including 11 for Federicas chapter, accompanies the Manual.For further information and to purchase your copy visit www.bsava.com.

Member price: 45.00Nonmember price: 70.00

CLINICAL CASE 4

A 6yearold English Setter bitch presented with fever and back pain. A CT scan of the lumbar region (Figure 4A) shows subtle thickening of the right iliopsoas muscle with some bony changes and a small gas bubble on the ventral aspect of the L2 vertebra.

An ultrasound examination of the sublumbar region (Figure 4B) shows a small abscess containing a plant foreign body (arrowed).

4A 4B

CLINICAL CASE 3

A 5yearold male Pointer was investigated following identification of a spontaneous pneumothorax. A CT scan of the caudal thorax (Figure 3A) shows pleural free air and a focal pleural thickening underneath the tenth rib on the left side (arrowed).

An ultrasound examination of the same area reveals a plant awn with a typical ultrasonographic appearance (Figure 3B) linear spindleshaped hyperechoic structure with multiple parallel reflecting interfaces surrounded by a hypoechoic halo. The hyperechoic interface on the lefthand side of the image corresponds to the pleural surface of the left caudal lung lobe (arrowheads).

3A

3B

Investigating migrating foreign bodies

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CONGRESS SCIENCE

NEW ENDOCRINOLOGY MANUAL COMING SOONEdited by Carmel Mooney and Mark PetersonThis comprehensively updated new edition will emphasise the common problems encountered in investigating and treating endocrine diseases and will cover the emerging new therapies. The manual will be divided into sections considering each endocrine gland, covering the major and minor disorders of cats and dogs.

Visit www.bsava.com to register your interest in this title.Last chance to buy! The BSAVA Manual of Canine and Feline Endocrinology, 3rd edition is still available at half-price; but stocks are running out fast, so buy now. Member price: 25

CONGRESS SCIENCE

WORLD CONGRESSWSAVA / FECAVA / BSAVA

investigating and treating endocrine diseases and will cover the

Amongst the broad and fascinating programme for Congress 2012 is a lecture that will explore one of the most under-diagnosed conditions in general practice

Hans Kooistra

Hidden disease of the older cat

Veterinary surgeons attending next years BSAVA Congress in Birmingham will be told about primary hyperaldosteronism, a feline endocrine condition that most will have never seen as it is so rare.

Or is it?Certainly not, says Hans Kooistra. He believes it is

possibly one of the most under-diagnosed conditions in small animal practice.

Hyperaldosteronism was first described as recently as 1983 and causes clinical signs associated with hypokalaemia, muscle weakness and arterial hypertension which may eventually lead to blindness. Dr Kooistra diagnoses the condition in about one cat a month in his clinic at the Utrecht veterinary school. Yet, when asking a group of colleagues whether they have ever treated a patient with the condition, few if any arms are raised in response.

General practitioners would report the condition more frequently if they carried out a fuller range of tests, he suggests. But the clinical signs are not very specific and vets will usually begin treatment before reaching a definitive diagnosis. The disease can be reasonably well controlled on the basis of symptomatic treatment to increase potassium levels and reduce blood pressure. But if the additional investigations are carried out to identify hyperaldosteronism patients,

then we would know just how important the disease is in cats. Also, veterinary surgeons would be able to offer a more specific, effective and possibly curative treatment to their clients.

It is the same in human medicine, Dr Kooistra explains. Studies have shown that only around 0.1% of hospital patients with arterial hypertension are reported as having the very similar human condition. But in those centres where there is active screening for the disease, the numbers increase by a huge margin, to 8% of the total population of hypertensive patients. In both human and feline patients the condition can be readily distinguished from all those causing similar signs by a blood assay to detect elevated aldosterone concentrations.

In cats the disease is one that mainly affects middle-aged and older animals and there is no obvious breed or gender predisposition. There are two main causes: adrenal hyperplasia or a malignancy. The latter is usually unilateral and can be treated by surgical removal of the affected adrenal gland. In the case of hyperplasia, that is usually a bilateral condition which is better controlled through the use of an aldosterone antagonist such as spironolactone. It should be given at a dose of 2.5 mg/kg orally once daily, alongside treatment for the hypokalaemia and arterial hypertension, says Dr Kooistra.

Hidden disease then we would know just how important the disease is in

carried out to identify hyperaldosteronism patients,

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CONGRESS SCIENCE

Congress has always been an international event and 2011 saw an increase in overseas delegates. However, as we prepare to host our WSAVA and FECAVA colleagues, BSAVA refuses to rest on past success and is determined to create its most expansive science programme, put on the most exciting social, and offer the most impressive exhibition in its 54-year history.

Superb CPDTo that end, the science programme of more than 300 lectures has been created by vets, nurses and management experts to ensure that this is now truly a CPD event for the entire practice team.

The introduction of a more complete programme for managers is especially welcome. The Management Marquee in the grounds of the NIA is set to be THE place to find the best advice and support for anyone involved in running the practice.

Now that BSAVA has nurse members, they can benefit from exclusive Congress discounts making four days of top-quality nursing CPD available from just 93. Plus, our VN e-Members have the exclusive option to upgrade to add veterinary lectures to their registration.

Stirring socialOf course Congress is famous for its social and networking opportunities and now, as well as the sumptuous banquet, the thrill-packed Party Night, and a host of free events including the lecture from Lord Robert Winston, you can start your party-going early, with the World Congress Welcome Party on the Wednesday.

Enticing ExhibitionMore than 250 exhibitors will have new launches, special offers, and discounted deals to tempt you into the NIA exhibition hall. BSAVA works hard with industry to make sure that there is a wide range of services available and that the very best expertise is on hand to advise and help delegates. And yes it is also a great place to pick up gifts and win prizes.

Full information about the science, social and exhibition will appear online at www.bsava.com, as soon as details are confirmed. So register as soon as possible and join us for the biggest event in the UK veterinary calendar.

Welcome to the World CongressWelcome to the World Congress

The 2012 WSAVA/FECAVA/BSAVA Congress will be the largest international veterinary event ever to be held in the UK. But thats not the only reason you should be there

CONGRESS SCIENCE

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PROFESSION

Thanks is owed to the author, Bruce Vivash Jones. Not only is he one of the original BSAVA members and author of the Associations first veterinary nurse textbook, he suggested the names for both the Bourgelat and Blaine Awards and continues to make an invaluable contribution to the BSAVA.

By celebrating the 250th anniversary of the start of veterinary education and the beginning of the veterinary profession we are commemorating the memory of Claude Bourgelat. He was the originator and the prime mover, with the result that on 1 January 1762 the Lyon Veterinary School opened its doors: it was not an auspicious day, there were only six students on the first course. The building was a disused inn with poor facilities on the outskirts of the town, but its opening attracted the attention of the executive bodies that advised Euro