The essential publication for BSAVA membersThe essential publication for BSAVA members

companionSEPTEMBER 2012Vet inspections at dog shows

Clinical ConundrumAcute-onset hindlimb paresisP8

How To...Approach chylothoraxP12

At CongressCatch infection controlP20

01 OFC September.indd 1 16/08/2012 08:27

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EJCAP ONLINE

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

Advances in total joint replacementTotal joint replacement is now considered a routi ne surgical opti on for small animals with advanced joint disease. This review highlights the current state of the art and potenti al future developments.

Evaluati on of preputi al cytology in diagnosing oestrogen producing testi cular tumours in dogsThis study found that the preputi al cytology has a high sensiti vity and speci city for the diagnosis of oestrogen producing testi cular tumours in dogs.

Free skin graft s for immediate wound coverage following tumour resecti onThis paper concludes that free graft ing can be used reliably to reconstruct extensive surgical wounds in the distal limb in dogs aft er large tumour resecti on, without the need for a delay to allow granulati on ti ssue to form.

Canine idiopathic epilepsy: prevalence, risk factors and outcome associated with cluster seizures and status epilepti cusThe authors found a high prevalence of cluster seizures in dogs with idiopathic epilepsy. Neutering status appears to in uence cluster seizure occurrence with intact females more likely to experience more frequent episodes.

companion is published monthly by the British Small Animal Veterinary Association, Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley, Gloucester GL2 2AB. This magazine is a member-only benefi t. Veterinary schools interested in receiving companion should email companion@bsava.com. 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 MRCVSCPD Editor Simon Tappin MA VetMB CertSAM DipECVIM-CA MRCVSPast President Andrew Ash BVetMed CertSAM MBA MRCVS

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 reproduced in any form without written permission of the publisher. Views expressed within this publication do not necessarily represent those of the Editor or the British Small Animal Veterinary Association.

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

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

3 BSAVA NewsLatest from your Association

47 Vets in showThe impact of vets at shows

811 Clinical ConundrumAcute-onset hindlimb paresis

1216 How Toapproach chylothorax

1819 BSAVA Publications50 years in the making

2021 Congress 2013Infection control for nurses

2223 PetsaversFunding report and fundraising ideas

2425 WSAVA NewsReports from the World Small Animal Veterinary Association

2627 The companion InterviewJill Moss

29 Focus OnSouthern Region

3031 CPD DiaryWhats on in your area

Additional stock photography Dreamstime.com Atesevich; Erik Lam; Isselee; Pseudolongino; Tom Wang; Vitaly Titov; Willeecole

Whats in JSAP this month?

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

Errors in abdominal ultrasonographyThis study demonstrates that whilst errors of diagnosis do occur, understanding the causes of these errors will contribute to the development of this imaging modality.

Measurement of prothrombin ti me and acti vated parti al thromboplasti n ti me in citrated whole blood samples from clinically ill dogs following storageStorage of citrated whole blood at room temperature did not signi cantly alter the measurement of prothrombin ti me but resulted in signi cantly shorter acti vated parti al thromboplasti n ti me results.

Geriatric screening in rst opinion practi ceThis paper found that screening elderly dogs identi ed unrecognised health risk factors, as well as signs of age-related diseases resulti ng in early diagnoses and surgical and medical interventi ons to improve quality of life.

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

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As seen on TV

BSAVA is delighted to welcome Amanda Stranack as the new Head of Business Unit to lead its Congress team. Amanda brings 20 years experience in event management and will head-up a refreshed and enlarged Congress team to ensure

that the event continues to meet the needs of the profession, offering a fresh, engaging experience for delegates and exhibitors alike.

Amanda has enjoyed a career within the corporate event agency sector, particularly working with pharmaceutical clients on their global medical congress activity.

Helping to take the worlds largest event for companion animal vets forward is an exciting opportunity for Amanda, who says: The profession really benefits from having an event that is primarily run by veterinary professionals for their peers. The team at HQ is here to make sure that we help our volunteers fulfil their ambitious vision.

Easy-fill Congress form

First VN Merit Awards filling fastT

he inaugural Rehabilitation and Physiotherapy VN Merit Award is already fully subscribed, with places on other programmes proving

hugely popular.The first two Merit Awards start this month.

Although the places on Rehabilitation and Physiotherapy have been booked, interested individuals can join a waiting list for the Spring 2013 course. The Anaesthesia and Analgesia award has also proved popular, with just a few places left at the time of writing. Further Merit Awards in wildlife nursing and in surgical nursing are planned for next year. If you have any questions please email courses@bsava.com or visit www.bsava.com/cpd.

BSAVA is pleased to announce the appointment of Gregory Moxon as Head of Publishing for its prestigious Publications Department. Gregory brings more than 30 years experience in publishing. He will lead the Editorial and

Design team at Woodrow House who are responsible for producing our valued and respected veterinary titles, as well as providing a strategic focus for the Associations ongoing digital plans.

Gregory is an experienced marketing and managing director, having worked with the medical publisher Radcliffe Publishing, as well as running his own business, The Content Development Partnership. He combines expertise gained across various media sectors with organisations including Granada Television, MicroProse Entertainment Software and Octopus Books.

The future of publishing is an exciting one for Gregory, who says The BSAVA, with its great breadth and depth of content, is uniquely placed to take advantage of current changes in publishing technology and forms of delivery, in order to publish high quality and relevant material in forms and formats that meet the evolving needs of its members and of the profession as a whole. See the Publications story on page 18.

New publishing expertise

New Congress lead

Inside this edition of companion you can find your Priority Member Registration Form for Congress 2013. Simply complete the form and send it

in, or register online before 31 January to beat the Early Bird deadline.

Have you spotted the fifth edition of the BSAVA Manual of Exotic Pets on TV yet? If not, keep an eye out for the latest BT Hola advert (other telecommunication providers are available!). Towards the middle of the advert, we see a young woman entering her flat

brandishing this very popular BSAVA Manual.This is not the first title to make a break into television the BSAVA

Manual of Canine and Feline Surgical Principles was featured in an early advert from the same series. BSAVA was approached to provide materials that would help illustrate that Anna, one of three students living in the fictional BT flat, was studying to be a vet. We are waiting to see if she ever gets to sip from her Congress mug or make use of her PetSavers poop bag!

BSAVA Manual of Exotic Pets

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Vets in show

gambled that, even if some dogs did fail the inspections, it was necessary to demonstrate that the dog show community was addressing the problems highlighted in the 2008 documentary Pedigree dogs exposed.

Dean asked the then BVA president Harvey Locke to help recruit volunteer veterinary surgeons to examine the dogs in the 15 breeds (see box) at Crufts and at other top level shows during the year. Two experienced general practitioners were chosen to cover the 4-day event: Staffordshire practitioner Will Jeffels, who has served for many years as honorary vet at shows in the North of England; and Alison Skipper, a Surrey practitioner who has a long association with the Australian Cattle Dog breed and has been a regular contributor to the dog press.

They were given detailed instructions by the Kennel Club on the proposed inspection protocol and the range of conditions that they were supposed to be checking for. There were four main issues: eye conditions like ectropion and entropion; dermatological problems due to excessive skin folding; breathing difficulties

Many dog breeders were unhappy when veterinary checks on the winners of best in breed at Crufts in March 2012 led to the disqualification of 6 out of the 15 breeds tested. Yet at subsequent championship shows across Britain there have been few disqualifications and very little fuss. So are vet inspections helping to improve the health of pedigree dogs entering the show ring? John Bonner reports

Dont judge a dog by its breeds reputation alone. If every small animal practitioner had been asked to bet on a modern English

Bulldog passing a veterinary health check at Crufts this year, few would have staked their house on it. The breed is well known for the respiratory problems caused by its conformation. But when the winner of the Best in Breed title failed the inspection which would have allowed it to progress on to the competition for Best in Show, the issue wasnt respiratory.

Eye disease rather than breathing problems caused the disqualification of the bulldog bitch Ch Mellowmood One in A Million. Plus, five other winners of Best in Breed titles joined her in being disqualified from the competition because they showed signs of various serious ocular conditions.

Kennel Club invites vet health checksIt was Kennel Club chairman Steve Dean who proposed the idea of health checks for high profile breeds known to have serious problems with diseases caused by their exaggerated conformation. He

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in brachycephalic breeds; and conformation-related lameness.

Health and welfareWill and Alison were told that they should be looking for obvious signs of disease to establish whether the dogs health and welfare is compromised, rendering it ineligible to compete in the group competition on the day. They were only required to examine the dogs visually and so were not expected to make a full clinical diagnosis, nor were they expected to comment on the overall conformation of the dogs. That was the job of the show judges, whose ability to identify serious breed issues was under review leading to the introducing of the checks.

Although veterinary surgeons are usually present at dog shows to monitor the welfare of those competing, they do not carry out routine checks of animals on arrival, unlike the situation in competitions involving livestock species or even cats. Unless there was considerably more professional manpower available, it would not be practical to examine every one of the 20,000 plus dogs that compete at

Crufts. Historically, however, dogs were examined for infectious diseases like distemper, which have been largely controlled through vaccination, and so these checks are still possible under the Clubs rules.

Finding faultBetween them Will and Alison found eye disease problems in the winners of the Basset Hound, Clumber Spaniel, Mastiff, Neapolitan Mastiff and Pekingese breeds, as well as the English Bulldog.

Both vets express considerable sympathy for the owners of those dogs whose ambitions were thwarted so publicly. However, it wasnt just the individual owners who were upset. A protest group Canine Concern was set up as a result of the controversy, with the key goal of persuading the Kennel Club to abandon the checks.

At subsequent shows the breed clubs for some of the affected breeds refused to put forward a representative for the later stages of the competition rather than risk another embarrassing rejection. Supporters of Canine Concern forced a

vote at the Kennel Club annual general meeting on 16 May their motion to suspend the veterinary checks was defeated by 92 votes to 56.

Lessons learnedThe campaign against the checks was and continues to be fought in the pages of the dog press and in cyberspace. Alison Skipper admits to having been troubled by some of the comments she has seen in print and on bulletin boards. We were obviously aware that we had ruffled a few feathers. We didnt receive hate mail or any

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Vets in show

personal abuse but there many people who felt free to speculate on our decisions and there were many rumours circulating of varying degrees of helpfulness. We were bound by rules of confidentiality and so we could not respond as we would have wished, she says.

With hindsight, Steve Dean admits that in introducing the checks there were some aspects of the process that could have been handled better. He feels that the Kennel Club worked hard to communicate with the judges, breeders and owners of those dog breeds subject to the checks. But he accepts that more could have been done to explain to the wider dog show world why the tests were being carried out and what exactly they involved.

Inevitably most of the attention has been on the eye checks and particularly on assessing the condition often referred to by

breeders as haw. Most vets would take this term to mean protrusion of the nictitating membrane, or third eyelid. But it is clear that some dog owners have a different understanding of the phrase, to mean sagging of the lower eyelid which exposes the palpebral conjunctiva or ectropion.

Making it workTo ensure that judges and exhibitors appreciate what conditions the health checks are intended to identify, and what degrees of deviation from normal eye morphology are acceptable, the Kennel Club organised two well attended owner meetings in London and Stoneleigh in July, where they were addressed by the respected veterinary ophthalmologist Sheila Crispin. The Club is also considering holding further meetings and producing a video to explain the issues to the rest of its membership.

The Club has also set up a working group, under the chairmanship of its veterinary consultant and BVA past president Nick Blayney, looking at whether the health checks should continue after the initial one-year trial and what form they should take. Harvey Locke has also been invited to join the working group, which should submit its report by the end of this year.

Its task has been made easier by the fact that there has been some cooling off in the opposition to veterinary checks in some parts of the dog show world. That is likely to be due to a number of factors but certainly there is a better understanding of the purpose of the inspections, and also they appear to be achieving their aim.

Positive signsIn 16 championship level shows held since the Kennel Clubs main annual event, 142 dogs from the high profile breeds have been examined and only

2 were rejected. I feel deep sympathy for those people whose dogs have failed the examinations but the statistics show that the system is working, Steve Dean suggests.

He argues that since no Bulldogs have been rejected this year because of breathing problems it is possible to produce healthy animals even from breeds with the most notorious problems and that this is a vindication of the efforts of the Kennel Club members to tackle the health issues caused by generations of overzealous selective breeding. The overriding message is that the dogs that people are showing, and judges are selecting, are in good order. They are getting through these health checks pretty consistently.

Vets confirm that their job has also been made more comfortable by a greater understanding and appreciation of what they are doing. Writing in the veterinary press, Mike Findlay, a Hampshire practitioner and duty vet at the Southern Counties Canine Association Show, said inspections at the show ran very smoothly. The dogs and owners/handlers were fully cooperative and the whole experience proved painless to dogs, owner/handler and veterinarian.

However, the problems have not completely died down. Will Jeffels has attended subsequent championship shows. There was still significant animosity towards these checks at the show. Owners of the affected breeds feel that they have been victimised and dont understand why their breeds have been chosen when there are health problems in other breeds. So to some extent I can understand why they feel that way.

Breed specificsThe question of what breed societies need to achieve before a breed can be removed Kennel Club / Matt Timbers

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AffeCTed breeds

Basset Bloodhound Chinese Crested

Dog* Chow Clumber spaniel Dogue de

Bourdeaux English Bulldog French Bulldog

German Shepherd Dog

Mastiff Neapolitan Mastiff

Pekingese Pugs Shar Pei St Bernard

*Chinese Crested Dogs differ from the main group. They are examined for signs that hair has been shaved or removed with a depilatory agent, rather than for any conformational problem.

from the list of those subjected to the checks will be addressed by the working party. It will also be looking at the other obvious issue of whether more breeds should be subject to the same tests.

Steve Dean explains that the main list of 14 breeds (and Chinese Crested Dogs*) was whittled down from the 30 breeds mentioned in a Council of Europe convention on pedigree dogs dating from 1995, long before the BBC television programme revived this particular controversy. He feels that it is reasonable to focus on particular breeds when they have long been the focus of public concern.

However, the working party is tasked with ensuring that the veterinary checks operate as fairly as possible. So it will be examining other concerns raised at the two public seminars, such as whether it is possible for owners or judges to appeal against disqualification, as the vets decision is final under the existing rules.

The bigger pictureOne further question that the working party cannot hope to answer in the time available is what effect will an inspection system that focusses only on a small population of show dogs have in addressing health problems in the wider population?

Our biggest problem is not the show people. They are vociferous and dont like the changes but they toe the line because they are responsible pedigree owners. The bigger problem is the unregulated breeders who dont care, or they are ignorant of what tests need to be done. Numerically, they more important and it is they that will hold these breeds back, Will Jeffels observes.

Steve Dean accepts that the vet inspections are no panacea to the health problems of pedigree dogs. But we hope

that by setting a standard in the showring that will influence other top breeders and the exhibitors that buy stock from them. Then there is the chance that the message will trickle through to the rest of the people who buy pedigree dogs.

Bottom up changeMoreover, the vet examinations are not the only initiative that the Kennel Club is involved in. Its accredited breeder scheme is intended to raise awareness of efforts to improve health standards and ensure that prospective owners know where they can go when looking for puppies that have been bred responsibly and the parent dogs tested against any relevant inherited defects, he points out.

Sally Everitt, Scientific Policy Officer with the BSAVA, agrees with Will Jeffels that it is unwise to rely on the trickledown effect from the top show dogs in raising the general standard of pedigree dogs in the UK. I dont think it will reach those people whose purpose for breeding dogs is a financial motivation.

One solution would be stricter legal controls on those people who want to earn money from the pedigree dog trade. But, as the Associate Parliamentary Group for Animal Welfare (APGAW) pointed out in its report A healthier future for pedigree dogs in July, the Coalition Government has made it very clear that it has no intention of legislating in this area.

The pressure for change will not be top down, so it has to be bottom up, Dr Everitt says. If you are going to change the market for pedigree dogs you have to change the behaviour of the consumers so that those producing the goods are forced to respond. Those consumers are our clients and so we as veterinary surgeons have to find a way to make them ask far more questions before they decide to go and buy a new puppy.

Kennel Club / Matt Timbers

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Clinical conundrum

Construct a problem list for this patient Acute-onset right hindlimb paresis Increased respiratory rate and effort

Consider the differential diagnoses for these problems Acute-onset right hindlimb paresis:

Arterial thromboembolism (e.g. cardiac disease, neoplasia, other trigger for thromboembolism)

Spinal disease (e.g. intervertebral disc disease, neoplasia, vascular injury)

Trauma Neuromuscular disorder

Increased respiratory rate and effort: Pleural space disease Pulmonary oedema Parenchymal disease Upper respiratory tract pain or distress Metabolic acidosis compensation

Given the acute-onset hindlimb paresis with increased respiratory effort, a tentative diagnosis of arterial thromboembolism (ATE), likely secondary to heart disease, was made. In cats with underlying heart disease clots form within the heart (usually the left

atrium) and have the tendency to dislodge and travel to other locations, particularly the termination of the abdominal aorta.

Given the patients respiratory distress, what immediate measures should be instituted?

Cage rest with oxygen supplementation is recommended. An oxygen cage is

ideal, since it allows good observation of the patient but

requires minimal handling. Providing opioid analgesia

(e.g. buprenorphine or methadone) is

recommended in cats with ATE, even if they do not seem

overtly to be in pain.

Alex Lynch, Resident in Emergency and Critical Care at the Tufts Cummings School of Veterinary Medicine, Massachusetts, USA, invites companion readers to consider a mature cat with acute-onset hindlimb paresis

Case presentationAn 11-year-old spayed female Domestic Shorthair presented for assessment of acute-onset right hindlimb paresis. The cat had no previous pertinent medical history, weighed 7 kg and had a body condition score of 8/9.

At presentation the cat was distressed, open mouth breathing with a respiratory rate of 50 breaths per minute. No abnormalities were detected on thoracic auscultation. Heart rate was 200 beats per minute. Right hind femoral pulses were not appreciated and the leg was painful with pale cold footpads. Rectal temperature was 38.4C. The rest of the physical examination was unremarkable.

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Breathing abnormalities often improve following analgesia, implying that pain contributes to their tachypnoea. If crackles are present on thoracic auscultation, a single low dose of frusemide (12 mg/kg i.m. or i.v.) can be administered; however in this case this was not felt necessary. Although frusemide is potentially lifesaving when pulmonary oedema is present, it has the potential to worsen systemic hypoperfusion.

Can you more objectively determine the likelihood of arterial thromboembolism in this case?A readily available test in an emergency setting is the blood glucose differential. Obtaining a blood glucose level from the affected limb and comparing it to a sample from an unaffected limb gives information regarding regional hypoperfusion. The affected limb tends to have a considerably lower glucose level compared to the unaffected limb, implying reduced aerobic metabolism due to ischaemia. In addition, higher lactate levels are expected in the affected limb for the same reason.

In this instance the glucose in the affected limb was 2.1 mmol/l and lactate was 6.7 mmol/l, compared to 11.3 mmol/l and 3.1 mmol/l in a normal limb. Assessment of perfusion using a Doppler monitor to document arterial blood flow can also be done but can be less easy to perform in distressed patients.

How would you investigate this case further?

Thoracic radiography can provide helpful information once the patient is more stable. It is particularly helpful in establishing whether the patient may be in congestive heart failure (CHF) and would benefit from diuretics.

Echocardiography is an invaluable tool in assessing cardiac function, cardiac chamber enlargement, the presence of pleural and pericardial effusion and intracardiac thrombi. The amount of information that can be gleaned from echocardiography is operator-dependent but emergency assessment of left atrial to aortic diameter is a clinically useful skill to learn.

Normal LA:Ao ratio is 11.2:1 and cats with CHF often have obviously enlarged left atria.

Baseline laboratory work (e.g. urea, creatinine, glucose, electrolytes, PCV and total solids) are helpful in the emergency setting. A full biochemistry profile would be ideal.

An electrocardiogram, if tolerated, is also useful, particularly if there are concerns regarding acidbase and electrolyte disturbances.

A right lateral thoracic radiograph was obtained at admission. How would you interpret this image?A rounded partially mineralized soft tissue opacity is evident on the lateral projection (Figure 1). There is a slight interstitial lung pattern and suspicion of a nodule in the distal third of the thorax at the level of the 8th rib. This mass is consistent with a pulmonary neoplasm. No evidence of cardiomegaly or pulmonary oedema is appreciated. Echocardiography was performed and revealed no evidence of underlying heart disease.

How do you interpret the blood results (Table 1)? Azotaemia is commonly documented with

hypoperfusion, contributing to pre-renal azotaemia. Thromboemboli affecting the renal vasculature may occasionally occur leading to azotaemia.

Hyperphosphataemia is commonly documented in

Figure 1: Right lateral thoracic radiograph

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Clinical conundrum

ATE, likely due to a combination of reduced glomerular filtration rate and extracellular leakage of phosphorus from damaged ischaemic muscle cells.

No significant electrolyte abnormalities were detected at admission.

Elevated PCV with hyperproteinaemia is likely due to haemoconcentration.

Markedly elevated CK and AST are supportive of ischaemic myopathy.

What is your overall clinical impression?The patient has an ATE affecting the right hindlimb but no heart disease. From the literature we know about 46% of ATE cases are due to underlying neoplasia, with primary lung tumours being most commonly implicated; this is the likely cause of the ATE in this case.

How would you manage this case?Supportive care is the mainstay of ATE treatment. In cases due to underlying heart disease treatment specific to the underlying pathology is recommended. Hypertrophic cardiomyopathy is most commonly implicated, with a predilection in middle-aged male DSH cats.

Fluid therapy was initiated in this case as the patient was azotaemic and no underlying cardiac dysfunction was noted. Fluids are not contraindicated in cats with underlying heart disease, although they should be used more cautiously. Analgesia was continued (buprenorphine 0.01 mg/kg i.m. q6h) and physiotherapy was commenced.

Abdominal ultrasonography was performed and revealed no evidence of neoplasia. A thoracic CT scan (Figure 2) was obtained, and confirmed a large lung mass that was thought most likely to be a primary lung tumour with evidence of metastases. The potential for surgery was discussed with the owners, given the suspicion of a primary lung mass. However, since metastases were visible, the owners elected not to pursue this option.

The cats azotaemia worsened over the first few days of hospitalization despite fluid resuscitation (Table 2). One potential explanation for this deterioration could be the occurrence of reperfusion injury associated with the restoration of perfusion to the limb following ischaemia. However, these signs may also reflect an acute deterioration in kidney function.

This cat developed hyperkalaemia, which is a major concern given the potential effects on cardiac function. Appropriate treatment options to manage hyperkalaemia include fluid therapy, calcium gluconate, insulin/dextrose therapy and bicarbonate. Refractory cases of hyperkalaemia may benefit from terbutaline. This should be used cautiously in cats with Figure 2 CT scan of thorax

Parameter Value Reference range

Glucose 11.3 3.86.6 mmol/l

Urea 16 5.311.7 mmol/l

Creati nine 180 79175 mmol/l

Phosphorus 2.26 12 mmol/l

Packed cell volume 50 3146 %

Total protein 80 6077 g/l

Sodium 148 146158 mmol/l

Potassium 3.6 3.45.2 mmol/l

ALP 34 1079 IU/l

ALT 125 25145 IU/l

AST 871 542 IU/l

CK 144,018 14528 IU/lTable 1: Selected clinicopathological results at admission (abnormal results in bold)

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CONTRIBUTE A CLINICAL CONUNDRUM

If you have an unusual or interesti ng case that you would like to share with your colleagues, please submit photographs and brief history, with relevant questi ons and a short but comprehensive explanati on, in no more than 1500 words to companion@bsava.comAll submissions will be peer-reviewed.

Parameter Day 1 Day 3 Day 5 Day 7 Reference range

Urea 16 35 22 18 5.311.7 mmol/l

Creati nine 180 528 387 193 79175 mmol/l

Sodium 148 142 148 147 146158 mmol/l

Potassium 3.6 6.2 4.5 4.0 3.45.2 mmol/lTable 2: Selected biochemistry values over course of hospitalization (abnormal results in bold)

underlying heart disease. In this case with continued treatment the azotaemia progressively improved over the course of the following 7 days.

Recovery from ATE events relies on in vivo fibrinolysis. Clinical trials using thrombolytic agents (clot busting drugs) have been performed in cats. However, these medications have been associated with safety concerns due to high mortality rates, and their efficacy is disappointing. Therefore, the use of thrombolytic agents, such as tissue plasminogen activator, is not recommended in cats.

Perfusion is generally restored to the affected limb(s) within 24 days as a result of fibrinolysis and improved collateral blood supply. Thromboprophylaxis is warranted but there is a paucity of information to clearly recommend a specific regime. Platelet inhibition, using treatment with aspirin or clopidogrel, is often instituted. Unfractionated heparin and low molecular weight heparin (e.g. dalteparin) may also be used. However clear survival benefit has not been demonstrated with any antithrombotic medications and no consensus exists as to the best drug combinations to use. Warfarin has also fallen out of favour given safety concerns in cats.

Thromboprophylaxis in neoplastic causes of ATE is less certain, since histopathology of clots has confirmed the presence of neoplastic cells indicating the primary mass is the likely site of origin. However, the possibility of paraneoplastic hypercoagulability cannot be ruled out. Therefore, clopidogrel and dalteparin were both started in this case. In cats with underlying heart disease clots form within the heart (usually the left atrium) and have the tendency to dislodge and travel to other locations, particularly the termination of the abdominal aorta.

What is the likely prognosis for cats with ATE?From the literature, between 33 and 39% of cats will survive an initial ATE event. When cats euthanized at presentation are removed from study analyses, survival approaches 50%. Negative prognostic indicators (e.g. hypothermia and bradycardia) at presentation tend to reflect systemic hypoperfusion. Cases of bilateral hindlimb paresis generally do less well.

A significant number of cats who survive an initial event will develop another clot, which may be fatal. Longer-term prognosis depends on the underlying disease and the ability to regain use of the affected limb(s).

This cat was able to ambulate by 5 days and showed progressive improvement in her mobility and azotaemia. She remained asymptomatic for 4 months, at which point she developed another thrombembolic event and was euthanized.

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08-11 CLINICAL CONUNDRUM.indd 11 17/08/2012 16:04

12 | companion

How to approach chylothorax

Chylothorax is caused by the accumulation of chylous effusion within the pleural space and is an uncommon condition in both dogs and cats. In cats, many cases have an underlying

identifiable cause, such as heart disease or the presence of a mediastinal mass, but in most dogs chylothorax is idiopathic and associated with thoracic lymphangiectasia.

Although diagnosis is usually straightforward, successful management can be challenging and depends on the underlying aetiology. Management of idiopathic chylothorax often requires specialist surgery, but in experienced hands the outcomes are fair. The recent development of minimally invasive procedures may improve visualisation of thoracic structures, such as the thoracic duct, and hasten patient recovery.

PresentationClinical signs of chylothorax are typical of any pleural space disease and include: exercise intolerance, lethargy, increased respiratory rate and effort, a shallow respiratory pattern, and possible cyanosis. The signs may be insidious because of the gradual accumulation of effusion over time, but some animals present with acute signs due to decompensation (more common in cats). Some animals may also have appreciable weight loss, due to the chronic effects of respiratory dysfunction or concurrent intestinal lymphangiectasia which is occasionally present.

Idiopathic chylothorax is reported in animals of a variety of breeds (including mixed breed dogs), but sight hounds (notably the Afghan Hound) and Oriental breeds of cat (such as the Siamese) are recognised as

predisposed to this condition. Anecdotal evidence also suggests that Bullmastiffs within the United Kingdom have been diagnosed with increasing frequency over the last decade. Animals may present at any age, although it may be commoner in middle-aged dogs.

DiagnosisClinical examination of animals with chylothorax generally reveals findings consistent with pleural space disease. Auscultation may reveal muffled heart and lung sounds, and reduced resonance on percussion of the chest can reveal a fluid line in the ventral thorax of larger patients. Depending on the underlying aetiology other clinical signs can also be present; for example, in right-sided heart failure jugular pulses may be evident, and in cats the presence of a cranial mediastinal mass may reduce the compliance of the cranial thorax on palpation.

Thoracic radiography and ultrasonography can be used to document the presence of pleural effusion and should always prompt thoracocentesis to obtain a sample for laboratory examination. In dyspnoeic animals, with the suspicion of pleural effusion on physical examination, immediate diagnostic, followed by therapeutic, thoracocentesis, may well be a safer option than laying the animal in lateral recumbency for imaging. Thoracocentesis is usually performed in the

sixth to the eight intercostal space, about a third of the way up the thoracic wall. The needle is positioned off the cranial aspect of the rib, to avoid damaging the nerve and vascular bundle that run caudal to the rib.

Typically chyle has a characteristic milky white appearance and low viscosity (Figure 1). Occasionally the fluid is pink, particularly if previous thoracocentesis has been performed. Samples of the fluid obtained should be submitted for cytology (in EDTA and fresh air-dried smears), biochemical analysis and culture (both in separate plain tubes).

Chyle is typically a modified transudate with a total protein in the range of 2565 g/l and a nucleated cell count of 1 to 17 x 109/l. Chyle contains mainly lymphocytes, but also non-degenerate neutrophils and macrophages. Chylomicrons can be seen and stain with Sudan Black. Conformation of the presence of chyle is based on comparison of

Alasdair Hotston Moore of Bath Veterinary Referrals helps us with this challenging presentation

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the triglyceride and cholesterol levels in the pleural fluid to those found in serum. Chyle has a higher triglyceride content and a lower cholesterol content compared to serum.

Further investigationsInvestigations are used to identify underlying causes and assess for secondary effects. Routine haematology and blood biochemistry are often normal, although lymphopenia may be present due to a stress response and loss into the effusion. Thoracic ultrasonography is important to eliminate the possibility of a cranial mediastinal mass, pericardial effusion or cardiac disease. Detailed thoracic radiology is also important and should be carried out after thorough drainage of the pleural space. Thoracic CT is a very suitable alternative and can be combined with contrast studies.

Imaging is used not only to look for underlying causes, but also to assess for the possible complication of pulmonary cortication (Figure 2) due to fibrosing pleuritis. This is deposition of fibrin on the pulmonary pleural surface restricting lung expansion,

Figure 1: Chylous effusion. This effusion was collected from the thoracic cavity of a 13-year-old cat, which presented with tachypnoea and dyspnoea. This effusion is typical of a chylous effusion (milky white colour and opaque). Chylous effusions may also appear more pinkred coloured, strawberry milkshakeReproduced from the BSAVA Manual Canine and Feline Clinical Pathology

Figure 2: Lateral thoracic radiograph of a cat with lung lobe cortication. Following drainage of the pleural space of a chronic effusion, the lobes have failed to re-expand. There is a moderate pneumothorax and the caudal lung lobe in particular is seen to be rounded and has a thickened visceral pleura (cortication)Image courtesy of Dr Frances Barr

even after pleural evacuation, and is suggested radiographically by scalloping of lung borders and failure of the lobes to expand. Severe cortication is a poor prognostic indicator and can be confirmed at thoracoscopy or surgical exploration. Decortication (surgical stripping of the thickened pleura) is a possible option in these cases, but can be associated with significant parenchymal damage, leading to increased morbidity and mortality as a result of haemorrhage and air leakage.

Underlying causes

Chylothorax can occur due to trauma to the thoracic duct (e.g. blunt trauma, penetrating injuries or thoracic surgery); in these cases the thoracic duct is expected to heal spontaneously. Improvement is usually rapid, but resolution can take 710 days.

In cats, cardiac disease (particularly cardiomyopathy) and cranial mediastinal masses (such as lymphoma (Figure 3) or thymoma) are often identified as underlying causes.

Most dogs an underlying cause is not identified and idiopathic chylothorax, secondary to thoracic lymphangiectasia is diagnosed. In a minority of

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14 | companion

How to approach chylothorax

cases underlying heart disease, thoracic neoplasia (particularly cranial mediastinal masses), lung lobe torsion, thrombosis of the cranial vena cava or heartworm are present. Restrictive pericarditis is a postulated cause and is discussed further later. When an underlying cause is found, this should be managed appropriately. The prognosis will depend on the underlying aetiology.

TreatmentA sequential approach to treatment is suggested. The first step is placement of a chest drain to allow drainage of the pleural space (Figure 4). In most

animals, unilateral drain placement allows drainage of fluid from both sides of the thorax, but occasionally bilateral drains are required. Thoracic radiology is repeated to check drain placement. Placement of a chest drain rather than repeat needle thoracocentesis (particularly in dogs) is suggested for initial medical management, as in a small number of cases, most often those caused by trauma, chylothorax resolves after a few days of frequent drainage.

Although texts often suggest that a low-fat diet may be therapeutic, in the authors experience this is not the case and that these diets worsen cachexia, which is a complication of chylothorax and drainage, so these are no longer recommended.

There is anecdotal evidence for the use of rutin (a flavonoid glycoside neutraceutical used as a food supplement) to reduce the effusion. Its mechanism of action is unknown, but it is thought to activate macrophages and increase their numbers, thereby increasing proteolysis and protein removal. Suggested dose rates are 50100 mg/kg three times daily orally. The author offers this treatment to owners who will not consider surgical management or when surgery has failed; a minority of animals seem to respond.

Unless conservative management shows an improvement within a few days surgery should be considered in cases without an identified underlying cause (i.e. idiopathic chylothorax). Animals managed conservatively for longer periods are at risk of: nutritional complications (due to the loss of lipids; proteins and fat-soluble vitamins from repeat drainage); immunocompromise (due to lymphocyte depletion); and fibrosing pleuritis (due to chronic exposure of the visceral pleura to chyle). In some patients these signs are well developed at presentation.

A number of surgical techniques have been described for treatment of idiopathic chylothorax, suggesting that no one technique is a definitive procedure. Thoracic duct ligation is generally the first option considered, aiming to reduce chylous flow through the leaking thoracic lymphatics and allow new anastomoses to open between the lymphatic and venous systems. If thoracic duct ligation is carried out, lymphangiography is suggested to define the thoracic duct anatomy preoperatively and confirm complete ligation postoperatively.

Figure 4: Chest drain placed to drain chylothorax in this Labrador Retriever with idiopathic chylothorax. The dog is under general anaesthesia in theatre and prepared for thoracoscopic thoracic duct occlusion

Figure 3: Thoracic radiograph taken after drainage of a chylous effusion revealing a large cranial mediastinal mass. Fine needle aspirates, taken under ultrasound guidance, revealed this to be lymphoma

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Catheterisation of abdominal lymphatics to achieve this is challenging in all but the largest patients; however, injecting contrast into a mesenteric or peripheral lymph node (e.g. popliteal) may offer a possible alternative (Figure 5). Recently, thoracic duct ligation combined with cisterna chyli ablation, has been reported as another possible option in the re-routing of chylous flow. Following

excision of the cisterna, chyle re-routes to the major abdominal vessels.

In recent years, there has been a particular interest in pericardectomy, as a high response rate to this as a sole procedure has been reported. The suggested rationale for pericardectomy is that subtle restrictive pericardial disease increases central venous pressure, lading to chylothorax. However, the experience of others has so far not replicated the initial promising findings. Although reductions in central venous pressure following this procedure have so far not been documented in a clinic setting, pericardectomy is helpful in preventing the progression of restrictive pericarditis as a result of the presence of the chyle. Therefore most commonly, pericardectomy is performed concurrently with additional techniques such as thoracic duct ligation.

Thoracic duct occlusion and pericardectomy may be approached through a lateral thoracotomy (right side in dogs, left in cats) (Figure 6), sternotomy or thoracoscopically (the authors preference) (Figure 7). To make the thoracic duct branches more visible during surgery, the animal may be fed a high-fat meal preoperatively (small amounts of double cream are often used for this purpose) and/or methylene blue may be injected into the abdominal (via the mesenteric

Figure 5: (A) A right lateral abdominal view after popliteal lymphangiography has been performed. The popliteal lymph node has been manually stabilised and iohexol (60 mg iodine/kg) injected slowly using a butterfly catheter. Contrast medium appears in the thoracic duct 210 minutes after injection. (B) A right thoracic radiograph post popliteal lymphangiography. This dog had had previous thoracoscopic surgery to ligate the thoracic duct using clips (visible in the dorsal thorax) but the signs of chylothorax had not completely resolved. The lymphangiogram reveals a collateral vessel more dorsal to the thoracic duct which is patent. Repeat surgery to ligate this vessel was curativeImages courtesy of Jon Wray

B

A

Figure 6: Ligation of the thoracic duct in the caudal mediastinum of a dog with a combination of ligatures and clips. A right lateral intercostal approach at intercostal space 8 has been used. Note the extensive thickening of the mediastinal pleura, which makes identification of the duct itself difficult

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lymph nodes) or hindlimb (via the popliteal lymph nodes) lymphatic system.

Other surgical techniques that have been reported in small case series and isolated case reports include pleural omentalisation as a sole procedure; pleurodesis (via chemical irritation such as instillation of tetracycline, carboplatin or talc slurry, or via mechanical abrasion); thoracic duct or cisterna chyli embolisation with cyanoacrylate; implantation of an indwelling vascular access port to allow intermittent drainage; and implantation of a pleuroperitoneal shunt. Many of these techniques are unproven as they have variable success, but may have a role in managing chylothorax if traditional methods fail.

Prognosis and outcomeIn general the outcomes for surgery are reasonably good, with an overview of the recent publications suggesting that success rates of around 80% should be offered to owners, using techniques that include thoracic duct occlusion or cisterna chyli ablation, together with pericardectomy. At the present time, the evidence does not clearly suggest one technique as being superior to another.

In animals in which surgery fails and chylous effusion persists, repeat surgery should be considered after evaluation of the lymphatic anatomy.

How to approach chylothorax

Figure 7: Thoracoscopic thoracic duct ligation in a dog. A right-sided approach is being used with the dog in sternal recumbency. Some surgeons prefer a bilateral thoracoscopic approach but few centres can offer this practically

In a small number of cases the effusion may become non-chylous (e.g. an inflammatory exudate or modified transudate); in some of these animals, therapy with anti-inflammatory corticosteroids may be useful.

Given the complex nature of the causes of chylothorax and the significant cost associated with management of these cases, owners of affected animals must be counselled carefully about the disease at an early stage. However, with appropriate management, committed owners and specialist surgery as needed, outcomes are fairly encouraging and may improve further as our expertise in minimally invasive procedures such as our knowledge and expertise improves.

AVAILABLE FROM BSAVA

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Edited by: Virginia Luis Fuentes, Lynelle R. Johnson and Simon Dennis

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For more information or to book your course

www.bsava.comAll prices are inclusive of VAT. Stock photography: Dreamstime.com. Alle; Anke Van Wyk; Anna Dudko; Lena Andersson

BSAVA dispensing course27 SeptemberCourse for VNs, vets and managers, meets the RCVS Practice Standards veterinary hospital pharmacy course requirements

SPEAKERS

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

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Coughing in the Dog and Cat4 OctoberThoracic radiography, bronchoscopy, how to take a good BAL all you need to know

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Crusty Canines and Festering Felines6 NovemberEnjoy greater confidence with diagnosis and treatment of dermatology cases. Includes a practical cytology workshop

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17 CE Advert.indd 17 16/08/2012 09:14

18 | companion

BSAVA Publications50 years in the making

The BSAVA Manual series currently has over 40 titles, covering subjects from anaesthesia to wildlife. New titles are regularly

produced and manuals updated with new editions. In addition to the regular updating of existing manuals, over the past 10 years, on average, one brand new title has been added to the series each year. The popularity of subject areas changes over time, and these trends are reflected in the sales of the manuals.

For example, the top five best selling titles from September 2001 to August 2002 were dominated by exotics:

1. Exoti c Pets, 4th editi on2. Rabbit Medicine and Surgery3. Veterinary Nursing Manual4. Canine and Feline Behaviour5. Ornamental Fish, 2nd editi on

Whereas in in September 2011 to June 2012 the top five best selling titles were concerned with core clinical and diagnostic subjects:

1. Veterinary Nursing Textbook, 5th editi on2. Canine and Feline Ultrasonography3. Canine and Feline Dermatology, 3rd editi on4. Canine and Feline Surgical Principles5. Canine and Feline Endocrinology, 4th editi on

also be useful to any practice looking to renovate their business or update their services.

The second part of the Manual is devoted to the people that make a practice the staff and includes chapters on leadership, communication, management and employment law. The final section of the Manual tackles the business aspects relevant to veterinary practice and covers health and safety, finance, marketing and clinical governance amongst other topics, providing accessible information on these often complex subjects. A Manual of Practice Improvement acted as a guide and source of reference for many years and we are confident that the new Manual of Small Animal Practice Management and Development will achieve the same success.

One of the first publications for BSAVA members can be attributed to C.E. Woodrow a 1962 book entitled The Export and Import of Dogs and Cats. Fifty years on, the BSAVA Manual series is still going from strength to strength

Practice managementBSAVA has been providing support and advice on practice management since 1973 when we published A Manual of Practice Improvement, edited by Ian Hughes. This loose-leaf, ring-bound publication was updated and transformed into a proper book with the second edition, edited by Peter Fry, published in 1982. BSAVAs latest venture in this field is the brand new BSAVA Manual of Small Animal Practice Management and Development, edited by Carole Clarke and Marion Chapman, which was published in July 2012.

ESSENTIAL READING

According to the RVC library, 22 BSAVA Manuals featured in the top 100 ti tles checked out in the past year. The BSAVA Manual of Canine and Feline Anaesthesia and Analgesia was highest placed, at number 2.

ORDER TODAY

To purchase your copy of the BSAVA Manual of Small Animal Practi ce Management and Development, order online at www.bsava.com or contact our Membership and Customer Services Team on 01452 726700.

Member price: 55Non-member price: 85

In the years that have passed, the veterinary profession has changed a great deal and this newest addition to the BSAVA Manual range is a very different book to its predecessors. It begins with several chapters outlining how to set up a practice from scratch, with information on construction, design, equipment and maintenance, covering all areas of the practice. Whilst indispensible to those starting up a practice, these chapters will

Pocketbook for vetsBSAVA Publications also produces a number of books which form part of the benefits of BSAVA membership. These include the BSAVA Small Animal Formulary the essential reference guide for drug use in small animal practice the BSAVA Guide to Procedures in Small Animal Practice, and the BSAVA/VPIS Guide to Common Canine and Feline Poisons, which was launched at BSAVA Congress this year.

The latest addition to this stable is the BSAVA Pocketbook for Vets. Originally conceived in response to member feedback, this book is a collection of useful bits and pieces from the extensive range of BSAVA Manuals, articles from companion

18-19 Publications.indd 18 16/08/2012 09:27

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and other source material. As Sheldon Middleton, editor of the pocketbook and member of the BSAVA Membership Development Committee, explains: The BSAVA Pocketbook for Vets is really a formal version of the notebook we all had as new graduates, which is a collection of useful dose rates, differential diagnoses, parameters, etc., that we noted down to save time. I still have mine and it was the starting point for this much better laid out pocketbook.

The BSAVA Pocketbook for Vets forms part of the new graduate package. This means that anyone converting from student e-membership to first year qualified membership will receive a complimentary copy. However, as Sheldon points out, having said that the book is mainly aimed at new graduates, many experienced vets I have spoken to about the book have requested a copy! BSAVA has therefore decided to offer it for sale as well. The BSAVA Pocketbook for Vets will be available in October visit the BSAVA website (www.bsava.com) for further information.

are available in translated editions, including German, Italian, Japanese, Korean, Polish, Portuguese, Russian and Spanish. These help to spread veterinary knowledge to areas where English is not widely spoken.

Helping vets around the worldMany veterinary surgeons around the world are doing a great job under difficult conditions and with limited resources. The donation of BSAVA Manuals helps provide study books to veterinary surgeons who have difficulty accessing good sources of information for their continuing professional development. BSAVA Publications has made a number of donations to worthy causes in the past couple of years, including the Veterinary Teaching Hospital at the University of Peradeniya in Sri Lanka, the Esther Honey Foundation in the Cook Islands and the Watamu Turtle Centre in Kenya. In addition, we have also donated a number of different titles to the Worldwide Veterinary Service who help support veterinary charities across the globe.

enthusiastic response and it is great to know that our Manuals are highly regarded all around the world. As part of our promotion for the 2012 WSAVA/FECAVA/BSAVA World Congress, we took the Manuals to Amsterdam, Barcelona, Istanbul, Jeju, Las Vegas, Orlando, Porto and Seville. Many delegates joined BSAVA as overseas e-members in order to benefit from the discount on the books and to gain access to the wide range of online member benefits. Look out for BSAVA at a conference near you!

The futureSo, what does the future have in store for BSAVA Publications? There are several new titles currently in production, including a new edition of the BSAVA Manual of Canine and Feline Neurology (which will be accompanied by a DVD containing video clips of neurological examinations and specific diseases) and the brand new BSAVA Manual of Exotic Pet and Wildlife Nursing. The digital age is now upon us. Delegates at BSAVA Congress 2012 and visitors to the BSAVA website took part in a survey about digital publishing, and their responses will help inform our electronic offering in the future.

Professor John Cooper presenting Nicky Parazzi and Dr Faraj Faisal from the

Watamu Turtle Centre with a copy of the BSAVA Manual of Reptiles, 2nd edition

Andrew Ash (BSAVA President 20112012) presenting Dory Stricker, the 100th overseas member joining at NAVC 2012, with the latest edition of the BSAVA Small Animal Formulary

(www.bsava.com) for further information.

Professor John Cooper presenting Nicky

BSAVA Manual of Reptiles, 2nd edition

Manuali BSAVA: la risposta praticaBSAVA Manuals are not just available in English. Through a series of agreements with local publishers, several of our titles

Out and aboutThe BSAVA Publications team always enjoys getting out and about and meeting the people who actually use the books we publish. We are usually met with an

18-19 Publications.indd 19 16/08/2012 09:28

Congress 47 APRIL 2013

20 | companion

Catch infection control at Congress

which maybe self-limiting. It is very easy to fall into the habit of giving an animal antibiotics just in case. I hope that the advice I give will provide the confidence to know when that isnt necessary.

Veterinary staff will also have to change the expectations of those pet owners who like to receive medicines for their pets at the end of a consultation. Ian says that VNs have an important role in explaining to clients why antimicrobial treatment may not be necessary and why it should be avoided when it is unnecessary.

Few people understand that treatment doesnt directly cause resistance but simply creates the conditions under which resistant bugs can be selected for. All clinical staff occasionally need reminding of the importance of strictly controlling antibiotic use, although those that have had to deal with an animal with a hard-to-treat infection caused by a resistant bacterial strain will inevitably be more circumspect. The more that clinicians know about the development of resistance, the less likely they are to slip back into bad habits, he says.

Both as individuals and as a profession, veterinary staff have a duty constantly to question whether antibiotic treatment is necessary and to help build a better evidence base to guide future decisions. Ian points out that the recommended duration of treatment for very similar conditions in veterinary and human patients are often very different. In National Health Service hospitals patients with a simple urinary tract infection, for example, are likely to receive a 3-day course of treatment, while cats and dogs would probably be treated for 710 days.

Ian says there may be variation between species in their response to antibiotic treatment but there is no clear justification for these differences in the published literature. He says there is no suggestion that the manufacturers have recommended longer treatment than is necessary but the requirements of licensing trials may differ from those of routine clinical treatment. He believes that this issue should be the focus of further studies to which first opinion practices can make a significant contribution.

Banishing bad habits and acquiring positive new ones will be the secret to preventing the spread of infectious diseases in companion animal practices, and veterinary nurses attending next years BSAVA Congress will get practical expert advice about how to do just that

infection at Congress

Speakers at a session in the VN stream on Friday 5 April will look at various aspects of the nurses role in preventing infections arising, stopping their transmission between patients

and avoiding the dangers of zoonotic diseases infecting clients or staff.

Rational use of antibioticsIan Battersby, an internal medicine diplomate at Davies Veterinary Specialists in Hertfordshire, will explain the importance of rational use of antibiotics in limiting the risks from infections caused by drug-resistant bacteria such as MRSA and MRSP (meticillin resistant Staphylococcus aureus and S. pseudointermedius).

Vets and VNs need to exercise stewardship in ensuring that these valuable therapies are used properly to ensure that they maintain their efficacy, he says. So it is important that there is consensus on where and when these products should be used. Ian was one of the main authors of the poster issued last year by SAMSoc and BSAVA on antimicrobial prescribing (The PROTECT poster distributed with companion October 2011 and available for download at www.bsava.com).

Ian will discuss the controversy of prescribing antibiotics for conditions where they may not always be necessary, such as incidents of acute diarrhoea,

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Congress 47 APRIL 2013

MRSA and MRSPAnother way of reducing the exposure of bacteria to antibiotics and so preserving the efficacy of these drugs is to use alternative control strategies. That is the option being investigated by Louise ODwyer, head nurse at the Pet Medics emergency clinic in Manchester and another of the speakers at the session.

Louise is currently studying for a PhD in the epidemiology of MRSA and MRSP infections at Manchester Metropolitan University, in which she will be looking at the use of unconventional topical treatments such as manuka honey in preventing wound infections. She will outline the progress she has made during her update for VN colleagues on the prevention, recognition and treatment of MRSA and MRSP.

Louise points out that limiting the selection pressure for antibiotic resistance is particularly important for human and veterinary nurses, as they are often using bactericidal products and would be likely to come into contact with those bugs. So should veterinary staff be tested regularly to show that they are not carriers of MRSA or MRSP? Louise says no, because that could create a blame culture and give rise to complacency and lax hygiene in the majority of staff that test negative.

So instead the emphasis must be on educating all members of staff about the risks of antibacterial resistance and rigorously following those guidelines introduced to stop it happening. The things that you need to do are pretty straightforward. Getting staff to wash their hands thoroughly has made a huge difference to the incidence of MRSA in NHS hospitals, she points out.

Any surface in the hospital environment can become contaminated, but special attention has to be given to things like door handles and computer keyboards which are regularly touched by human hands. Therefore, veterinary nurses must pay attention to maintaining good standards of hygiene in the clinic. This doesnt have to be a hugely onerous or time-consuming task, as the disinfectant

products used in veterinary practice are highly effective in destroying these particular bacteria.

Isolating animalsOf course, not all infectious diseases encountered in veterinary practices are of bacterial origin. Those attending the session will be reminded of the steps needed to control serious viral infections by Rory Bell, Head of Internal Medicine at Glasgow Universitys Small Animal Hospital.

In his talk on isolating animals with highly infectious conditions, he says he will be addressing two main issues: When is it necessary to put an animal in isolation, and how you should go about it? I will be looking at the particular conditions that will necessitate this sort of approach and the practical steps, through effective barrier nursing, to ensure there is no risk of disease transmission to other patients or to staff.

In some respects, isolating infectious patients presents a bigger challenge in first opinion practices than in a big teaching hospital like Glasgow because of the more limited facilities available. Rory points out that one of the standard approaches for a canine infectious disease is to keep the patient in a cat ward and the cats in a canine ward. But the veterinary staff will have to find alternative arrangements when they are faced with any conditions that can readily cross the species barrier, such as parvovirus, Rory explains.

products used in veterinary practice are highly effective in destroying

INFECTION CONTROL STREAM AT CONGRESS 2013

The following talks are included in the Infecti on Control stream in the VN programme on the Friday of Congress next April.

Hygiene: a primary tool in infecti on control, with Allison Young

Isolati ng animals, with Rory Bell MRSA/MRSP, with Louise ODwyer Rati onal use of anti bioti cs, with Ian Batt ersby

For more informati on about the programme or to register for Congress visit www.bsasva.com/congress

20-21 Congress.indd 21 16/08/2012 09:43

22 | companion

Christmas cards: never too early

Order forms are available from the BSAVA on request, or cards can be purchased online atwww.petsavers.org.uk

Individual packs of cards

Pre-selected bundle of cards

PetSavers Christmas cards come in packs of 10 and include envelopes. The inside of the card contains the message Happy Christmas.

Robin on Frosty Twig

Dimensions: 90mm x 176mmPrice: 3.99 per pack of 10Code: PS077

Christmas Morning Run

Dimensions: 127mm x 127mmPrice: 3.99 per pack of 10Code: PS074

Snowman and Lantern

Dimensions: 127mm x 127mmPrice: 3.99 per pack of 10Code: PS075

Westward Journey

Dimensions: 127mm x 127mmPrice: 3.99 per pack of 10Code: PS050

Winter Shelter

Dimensions: 127mm x 127mmPrice: 3.99 per pack of 10Code: PS076

PetSavers has a number of preselected bundles of 4 packs of 10 cards. The bundles are perfect for practices but stocks are limited so get your order in early!

Price: 8.00 for 4 packs of 10Code: PS078

SAVE50%

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

22-23 PetSavers September.indd 22 16/08/2012 09:45

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On 8 July 2012, over 25,000 runners gathered in London to take part in British 10K London Run. This years run was a unique one with all eyes on

London as preparation for the Olympic Games was underway. Event host Reggie Yeates warmed up the PetSavers running team with motivational music and inspirational footage to set them on their way.

Gemma White, PetSavers Coordinator, took part as well as helping to organise the charitys delegation. Gemma said, Despite the rain, the PetSavers team had a great day out. Everyone managed to complete the race, raising lots of money for PetSavers in the process. We would like to thank everyone who ran for PetSavers, and all those who showed their support and sponsored the team. PetSavers London 10K runners have raised over 2000 which will go towards research which aims to improve the health of pets.

Participants in the London 10K team included: Paul Freeman, KellyAnn Fry, Lucy Fryer, Steph Gowers, Lydia Holmes, Craig Hughes, Tom Kerr, Chris King, Philip Lhermette, Geri Long, Chris Money, Ryan Seymour, Julia Thomson, Charlotte Townshend and Gemma White.

Its not too late to sponsor just go to www.justgiving.com/petsavers. Or, if you have been inspired by this years runners, why not get in touch and reserve a place for 2013. Places are limited so get your place secured early. Find out more by visiting www.petsavers.org.uk, or you can email info@petsavers.org.uk.

Carly L. Ball of Rutland House Referral Hospital outlines her PetSaversfunded clinical trial to investigate the in vivo antimicrobial action of two different antiseptic ear cleaning solutions in cases of canine otitis externa

Canine otitis externa is a very common complaint seen in veterinary practice. Although there are a number of studies reporting the in vitro efficacy of ear cleaners in laboratory situations against Malassezia pachydermatis, Gram positive and Gram negative bacteria, the in

vivo action and efficacy of cleaners over time against these microorganisms in clinical cases of canine otitis is unknown.

Although antibiotics are essential for the treatment of many microbial infections there is strong evidence to suggest that overuse and inappropriate use of antibiotic products is contributing to the recent increase in resistant bacterial infections in small animals. Licensed veterinary eardrops are polypharmaceuticals containing antibiotics, antifungal and antiinflammatory agents. This means therapy with such products may inevitably lead to prescription of components of the drops that are unnecessary. Antiseptic ear cleaning solutions have been recognised as having antibacterial and antiyeast effects in vitro and as such offer an alternative to antibioticbased drops.

PetSavers is funding a study to measure the antimicrobial actions of two ear cleaners: Otodine (ICF) and Malacetic Otic (Dechra) over time in cases undergoing an ear flush procedure for bacterial and yeast otitis. Ear swabs are taken from the ear before and every 5 minutes for 20 minutes after ear cleaner applications. The microbial levels present at each time point will be assessed by culture.

Derek Attride, Chair of the PetSavers Grants Awarding Committee, comments, Ear problems are commonly seen in general practice and some prove difficult to treat due to bacterial resistance. If these ear cleaners can be shown to have antibacterial or anti-yeast effect in clinical cases it is possible they could be recommended as adjunctive or replacement therapy in cases of otitis externa to help reduce antibiotic usage and development of antibiotic resistance. This is also important for the impact on human medicine with regard to bacterial resistance development. PetSavers funded this study as it may provide a useful insight into the treatment of a very common presentation in general practice.

Fundraising fast movers

PetSavers Coordinator Gemma White tells us about the determined spirit of the 10K runners which wasnt dampened by a bit of London rain

All ears

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This is a once in a lifetime opportunity to come to New Zealand and experience a world class small animal veterinary conference at the same time. March is summer in New Zealand

a perfect time to visit. Getting to New Zealand is easier than you may think Aucklands International Airport is the gateway to New Zealand. Auckland is an exciting, vibrant city nestled between bush-covered hills and sparkling harbours. It is deserving of the name City of Sails. You will be able to experience Polynesian culture and sample our fabulous food and wine. Plan to spend extra time in New Zealand and take the opportunity to see the thermal wonderland of Rotorua, magnificent rain forests and the remote fjords where the Lord of the Rings was filmed.

Our scientific programme features over 60 experts in all aspects of small animal medicine. There will be something for everyone with either concurrent streams and over 180 hours of continuing professional development hours on offer. We have internationally recognised speakers from all over the world.

No matter what your area of interest, we have something to please everyone, including dermatology, oncology, orthopaedic surgery, ophthalmology, anaesthesia, nutrition, dentistry and endocrinology, to name only a little of what will be available. In addition, to the general programme we have added six State-of-the-Art lectures where true experts in their fields will be presenting the very latest research.

To see our full programme please go to our website www.wsasa2013.org.

Registration is now open get in early to obtain the early bird specials and to ensure your place at the pre-congress events that have limited numbers. See you there! n

WSAVA/FASAVA World Congress 2013

A letter of invitation

Pieter Verhoek, Chairman of the local organising committee, is delighted to invite you to join your kiwi colleagues from 69 March 2013 at the Sky City Convention Centre, Auckland

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Registrations for the WSAVA 2013 Congress are well under way and this is an opportunity to let you know the quality of some

of the speakers that we are excited to have attending.

Dear to my heart is the impressive list of high quality speakers in the surgery stream. This stream runs every day for each of the four days of the Congress, with varying themes on each day. The stream is divided into two days of orthopaedic surgery and two days of soft tissue surgery. Good friends and legends in the USA, Don Hulse and Brian Beale from Texas, will cover the elbow, shoulder, hip and stifle joints, while Ursula Krotscheck from Cornell University in New York will handle the challenges of fracture repair. Our very own Brent Higgins from Christchurch will complete the orthopaedic lectures with two sessions on facial fracture management.

In the soft tissue field you can be assured we have the experts, with Theresa Fossum from Texas A&M University presenting on intestinal and thoracic surgery, Dan Brockman of the Royal Veterinary College (London) on gastrointestinal and urogenital surgery, and Masseys Jon Bray covering oncological surgery. Local specialists Alex Walker and Alastair Coomer round off the programme with lectures on reconstructive surgery and

World Congress 2013: science to look forward to

Richard Jerram, Chair, Scientific Programme, gives a preview of what will be on offer in Auckland

surgery of the rear end, respectively.A highlight of our speaker group would

have to be the impressive list of high quality speakers in the internal medicine stream. The first speaker to present on internal medicine: endocrinology will be Richard Nelson from the University of California Davis, who will be presenting topics related to diabetes, hypercalcaemia and Cushings disease. Richard will be joined by Carmel Mooney from Dublin with expertise in diseases of the thyroid gland.

The second day of internal medicine focuses on urology, with Larry Adams from Purdue University in Indiana and Harriet Syme from London covering everything from acute renal failure to urinary tract infection management. Larry will also be presenting a State-of-the-Art lecture on renal and ureteral stones as an added bonus.

On the Friday, internal medicine switches to the gastrointestinal tract, with Reto Neiger from Germany covering a range of topics, followed by Lynelle Johnson of Davis, California filling the afternoon with topics in respiratory disease.

The final day in internal medicine is devoted to infectious diseases with two world-renowned speakers, Sverine Tasker from Bristol University and Johan Schoeman from Pretoria, covering topics from feline infectious peritonitis to

babesiosis. Both speakers will be presenting State-of-the-Art lectures in their fields of expertise, Sverine on feline haemoplasma and Johan on canine parvovirus.

For the companion animal veterinarian and for those in mixed practice, this Congress will be like nothing that has been in New Zealand before. Whatever you do, do NOT miss this opportunity to attend the greatest veterinary event to enter these shores. n

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Jill Moss grew up in North London, where her father ran a property business and her mother was a housewife. She trained as a child actress, appearing in film and on television, and took a BA in broadcast journalism. Jill has worked as a journalist and presenter, and also trained as a group facilitator and role-play performer for corporate companies. In 2004 her Samoyed dog Bella became the first recorded dog to die of MRSA following cruciate surgery on her knee. Bellas death inspired Jill to develop the Bella Moss Foundation in 2005. The mission of the Foundation is to work with the veterinary profession and pet owners alike in improving knowledge of MRSA and other serious infections affecting companion animals.

Jill Mossthe companion interview

important to the Foundation. The second problem was the understandable suspicion with which I was viewed by some. Here I was, a pet owner with no clinical knowledge, telling the veterinary profession how it had failed my dog and other animals with serious infections. What made the difference, I think, was that the people I spoke to came to understand that I was more interested in solutions than blame, and it was good timing, I suppose, that MRSA in animals was becoming an important issue in academic and research areas. I believe my involvement with Defras Darc Committee on MRSA in animals has greatly advanced the work of the Foundation.

How do you continue to pursue that relationship with the profession?Our basic philosophy from the start was to be collaborative, and that continues to this day. The people in the profession we work with know that we wont misrepresent issues or tailor things just to suit our needs, and we can trust them to give us good, clear advice and guidance. We respect deeply the knowledge and experience of our board of clinical advisors and they respect our position as representing the needs and anxieties of pet owners. Since 2005 our clinical advisors have also become dear friends. Not a day goes by where I do not consult at some level with them on issues of science or strategy.

What have been the key milestones for BMF?The most important advance had been the move away from an almost purely empirical approach to infection control and management at the practice level. When we took CPD seminars on tour in 2006/7 we saw attitudes change in the room. This was quite amazing, and only possible because of the calibre of speakers we had. Weve also been fortunate to see the

QWhen you started the Foundation you said your aim was to work with veterinary professionals in raising awareness of MRSA how easy was that?

AIn the beginning it was difficult to develop a link with the veterinary profession, mainly for two reasons.

The first, I was deeply immersed in the emotional loss of Bellas death and simply wanted to get the message out there regardless of who I upset. I was fortunate to have my partner who helped me understand how the profession needed to be approached, and that led to a number of relationships that have become

Jill at Crufts

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infections do occur, but early detection

and targeted treatment is the key to reducing

the risk of fatality

veterinary associations, both national and European, take up the challenge of improving infection control practice. BMF is the only lay member of Defras committee on antimicrobial resistance in animals and we are now involved in FECAVAs working group on hygiene and responsible use of antimicrobials in veterinary practice. BMF is also collaborating with the Department of Health for the 2012 National Antimicrobial Awareness day on 18 November. Collaboration between human and animal health organisations is the greatest milestone that we have achieved, considering our humble beginnings.

How have things changed since you started the Foundation?In 2004 I searched the internet for facts on MRSA in animals and there was very little available. Due to the international scientific conferences we have held, latest research from academics has helped practioners to take on board some of the important issues that we promote in animal health.

I think the big change recently is in how much attention individual practitioners have given the issue of hygiene in veterinary practice, and how theyve adapted their own work as a result of our CPD alongside BSAVA, BVA, the RVC and University of Liverpool. We have all been working for some time to bring to vets up-to-date evidence-based information that can have practical implications for protecting practices against resistant bacteria.

Have you developed any veterinary heroes in this time?In the UK, Professor David Lloyd and Anette Loeffler at the RVC have been key supporters and advisors, as have Tim Nuttall and Susan Dawson at the University

of Liverpool. BSAVA Past President Mike Jessop has helped us enormously, as has Chris Laurence of Dogs Trust and Paul Manning. The tragic deaths of Nick Mills and Tracy Mayne have robbed the Foundation of two inspirational veterinary mentors. In North America Dr Scott Weese at the University of Guelph has done an enormous amount to support vets and pet owners in contact with us. All of these are our heroes because of their willingness to help and give up their free time to commit to the issues.

If you could go back in time, might you choose a veterinary career yourself?I had, when much younger, dreamed of becoming a vet, and I wonder how my life would have been different had I done that. I did toy with the idea of training last year at the Royal Veterinary College. I discussed this with our advisors who thought I would be best concentrating on the Foundation moving forward as a charity that can make a real difference, so I am now doing just that alongside taking a business degree.

What about communicating issues around infection with pet owners?Pet owners need to know the facts, but they also need to know how to use these facts. Although the relationship between vet and pet owner is between two equals, they do not approach a consultation in an equal state. Pet owners are subject to a range of negative emotions when concerned about the health of a pet and this affects their ability to absorb and act on information. This makes the job of being a vet difficult because it complicates the way they approach giving information. This is where BMF can help. On a daily basis I am dealing with the public who contact BMF for support. I always tell every owner,

no matter how distressed they are, that it is futile to try to pinpoint where the bacteria came from, they need to communicate with their vet on clinical management of serious infections. The majority of pet owners appreciate transparency from vets; through our work they understand there are no guarantees, infections do occur, but early detection and targeted treatment is the key to reducing the risk of fatality.

You often focus your educational resources on VNs why is this?Vet nurses have massive influence on the way work is carried out in a practice, and a trusted nurse is of immense value to a vet. Vet nurses know that their standing is supported by their knowledge and understanding and are hungry for more. We also want veterinary nursing to be a properly recognised and regulated profession, and knowledge is the key to achieving that. BMF have built a great relationship with veterinary nurses and we hold lectures every year at BVNA.

What are the best resources available?We direct vets from all over the world to the BSAVA website, and to BVA. I am proud to say that we are re-launching our website 1 October. At www.thebellamossfoundation.com we will have video recordings of our clinical advisors speaking about resistant bacteria, aimed at both veterinary surgeons and the general public. The new BMF will have separate portals, pet owners, vets, livestock, and we are collaborating with Defra and the VMD, as well as other human health organisations to ensure the information is up to date and evidence-based. The new BMF website will be a formidable resource for vets, and we continue to rely on BVA and BSAVA for support in making sure all of our information is accurate and helpful.

Jill with Clarissa Baldwin and Chris Laurence of Dogs Trust

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For more information or to orderwww.bsava.comBSAVA reserves the right to alter prices where necessary without prior notice.

companion offer of the monthExclusive offer for companion readers call BSAVA on 01452 726700 and quote companion offer Fractures.

Missed this recent edition?BSAVA Manual of Canine and Feline

Haematology and Transfusion Medicine2nd editionWith the advent of automated haematology and serum biochemistry analysers, most clinics