The essential publication for BSAVA membersThe essential publication for BSAVA members

companionJUNE 2011

RSPCAMemorandum of UnderstandingP4

Clinical ConundrumMultiple cutaneous massesP8

How Toget the best from liver samplesP14

Focus on feline ophthalmology

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companion

companion is three years old! What do you think of it so far? How does it rate amid the many different publications you receive?

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 .

Have your say to win 100 M&S vouchers

3 Super Scottish CongressUpdate on the 26th Annual BSAVA Scottish Congress

47 Understanding the MemorandumHow can the profession work with the RSPCA more effectively?

811 Clinical ConundrumConsider an unusual case of multiple cutaneous masses

1213 PublicationsUpdating the nursing classic

1418 How ToGet the best from liver samples

1920 CPDTaking a better look focus on ophthalmology

21 PetsaversLatest fundraising news

2223 BVA CongressBSAVA small animal programme

24 PublicationsMedicines information: client leaflets

2527 WSAVA NewsThe World Small Animal Veterinary Association

2829 The companion InterviewDr Clare Rusbridge

30 Meet Your RegionSpotlight on Scottish Region

31 CPD DiaryWhats on in your area

Additional stock photography Dreamstime.com Cleo; Dink101; Evangelos Thomaidis; Indigofish; Lian Deng; Sean Gladwell

BSAVAs scientific journal, the Journal of Small Animal Practice, celebrated its 50th Anniversary not so long ago. So we felt it was time we got to know your thoughts on both JSAP and companion. How does JSAP fit in with your information requirements? Wed like to know how you use the journal. What sort of JSAP papers do you tend to read, and why? And for companion we want to know which bits you like best, and what you would like to see more (or less) of. Do you read it for the CPD, or to find out whats going on at BSAVA, or both? Who else in your practice reads it?

To get your views on these questions we have set up a short readership survey which is available on the website. Wed love to get your feedback to help us decide our editorial strategies for the years ahead, in order that we can provide the most relevant content to the veterinary profession.

Please take a few moments to complete the online survey, which can be found at www.bsava.com/journalsurvey. It should take no more than five minutes. Please note that the survey is intended for BSAVA members and, although you can submit your answers anonymously, if you do provide your name and a contact email, we will enter you into a draw to win 100 of M&S vouchers.

Please complete the survey by 15 July. If you have any other feedback you are very welcome to send this to us at companion@bsava.com.

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Congress

Having changed the timing into the summer and moved the location to the beautiful city of Edinburgh, BSAVA Scottish Congress has a renewed position in the veterinary CPD calendar, and now has the kind of unrivalled social, exhibition and, importantly, science programme that makes it an extremely attractive way to spend your CPD budget.

The overall aim of Scottish Congress is to provide top-quality CPD, accessible to vets and nurses from Scotland and even further afield. We are proud to welcome delegates from all regions, as well as from every veterinary career path, to join us in celebrating our profession and to keep abreast of advances in an ever-changing clinical world. Scottish Congress is the highlight in the calendar for the Scottish Region of BSAVA, and we want to see as many people join us as possible to have a weekend full of learning, socialising and

meeting friends and faces we may not have seen since the same time last year, says the regions Chairman Ross Allan.

Where, when and whatDelegates gave superb feedback on the Edinburgh Conference Centre (ECC) last year so we are going back again. As ever the gala dinner will be on the Saturday night, and this years amazing venue is the Corn Exchange. Our theme this year is based on the popular kids cartoon character Bob the Builder Can we fix it? Together we can! We will be looking at the many aspects of what is new in veterinary thinking, with a bias this year toward treatment and care of older pets. That particular category represents the majority of patients that we all see on a daily basis.

Saturday and Sunday are split into lectures in the mornings and seminars in the afternoons, with plenty of time built in for visiting the exhibition. Our keynote speakers for the Nursing Stream include Emma

Super Scottish Congress

SCOTTISH CONGRESS

The 26th Annual BSAVA Scottish Congress takes place in Edinburgh from 2628 August and has a programme worth travelling North for

Keeble who will be speaking to delegates about exotic animals and wildlife, and Samantha Lindley who will give an overview of rehabilitation, pain management and hydrotherapy. For the vets we have called upon Norman Johnson to take us through dentistry in practice, and Angie Hibbert will be speaking on feline geriatric medicine, including renal disease, hypertension and osteoarthritis management.

The event will also feature a case presentation competition for vets and nurses to present the interesting and unusual cases they have seen in the past 12 months to an audience of their peers. The deadline for submitting a potential case is 15 June (see the website for details).

For more information about the science, the social and the exhibition, or for details about location and accommodation visit www.bsava.com/scottishcongress or email b.dales@bsava.com.

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MEMORANDUM

Discussions are planned between the RsPCA and BVA on updating the Memorandum of Understanding between the charity and private practitioners, designed to ensure that professional treatment is available for all sick and injured animals. first signed in 1939, the agreement has not been looked at since 2006 and now needs urgent attention as some believe the relationship between the two sides is in poor health and could even be starting to break down. John Bonner reports

it is better to give than to receive especially when it comes to a clinical examination. however, North wales practitioner Evelyn Barbour-hill found himself on the receiving end when he rang the RsPCA national call centre to obtain the log number he would need to be reimbursed for the treatment of a stray cat brought in with a bad eye injury.

After being given what he says seemed like a clinical examination on his plans for dealing with the case, he was told that the charity would refund him the cost of the drugs to be used in treating or euthanasing the unfortunate animal but not for his time spent in dealing with the case.

The following conversation, he recalls, went something like this:

E.B-H: i think you are misinterpreting the rulesRSPCA: No, i have been doing this telephone job

for a year and that is how i have been trained. Any of my colleagues would tell you the same

E.B-H: You mean, if i were presented with a cat with a broken leg, and i splinted the leg thus stabilising its condition and relieving pain, and also gave a pounds worth of analgesic drug, RsPCA would only pay a pound?

RSPCA: Yes, that would be the payment.As the discussion went on, the exchanges became

increasingly ill-tempered, concluding with a stern

Understandingthe MemorandumUnderstandingUnderstandingUnderstandingthe MemorandumUnderstandingthe MemorandumUnderstandingUnderstanding

MEMORANDUM

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MEMORANDUM

ThE MoU sTATEs ThE fOllOwiNg:The RsPCA is willing to financially assist veterinary surgeons in their initial emergency treatment or euthanasia of emergency cases, as well as the reasonable cost of a visit to the scene of an accident where the owner of the animal is unknown and the case has been referred to the veterinary practice by the public or if it is a wild animal.

small wild animals and birds should be treated free of charge if brought to the surgery during normal practice hours but a reasonable fee can be charged for a visit to an accident or as an out-of-hours surcharge.

The practice must inform the National Call Centre of the iET or euthanasia as soon as practicable and before any further treatment is undertaken. The NCC will issue a log number which must be quoted in all correspondence, including the detailed invoice which should be sent by the practice to the relevant regional headquarters.

The RsPCA will contribute a maximum of 60* towards the provision of emergency care, as deemed necessary by the veterinary surgeon. But only in exceptional cases should the iET include procedures such as X-rays, etc. such procedures should be discussed and agreed with staff of the regional headquarters.

it is the RsPCAs intention that the veterinary surgeon be paid their expenses and a reasonable fee for their time in the circumstances, but equally the RsPCA trusts that the fees rendered will be reasonable and subject to any discount agreed between the RsPCA or branch and veterinary surgeon from time to time.

The RsPCA accepts that it will often be the case that any fees paid constitute a contribution to costs rather than full reimbursement and acknowledges the partnership in welfare shared with members of the veterinary profession.

*The memorandum notes that this sum should be reviewed every three years to take account of retail price index inflation and a revised sum agreed.

admonition from the call centre operator to the effect that he would be marking the case record drugs only.

A wider problem?As a senior practitioner with nearly 40 years experience, Mr Barbour-hill says, i was very surprised to be spoken to in that way. he started a thread on the Veterinarysurgeon.org online discussion group, asking if any colleagues had experienced similar difficulties in their dealings with the call centre staff. The response revealed that there is a groundswell of resentment among practitioners over the way that the RsPCA has been handling emergency treatment for wildlife casualties and injured strays.

Andrew Mellor from Blackpool believes the situation began to change around a year ago. he says it is not unusual now to be told that the practice will only receive payment for drugs at cost price with no injection fees, call out or consultation fees. There is a lot of bad feeling out there. we share on-call with another practice and have even discussed stopping doing any more RsPCA work. Of course that is not really possible; we have a professional duty to relieve pain in all emergency cases and so we have to uphold our side of the bargain. But who exactly is the charity here?

Initial Emergency TreatmentMessrs Mellor, Barbour-hill and other contributors to the online debate all stress that they enjoy cordial relations with their local RsPCA branches, their only gripe is with the national organisation. The local groups and national RsPCA are run as separate charities and one of the reasons for having the Memorandum of Understanding (MoU) in place is to ensure clarity for those dealing with this complicated and potentially confusing arrangement. The MoU covers various aspects of the working relationship between practitioners and the society at both local and national level. But it is the section on initial Emergency Treatment (iET) which has generated the controversy.

from the wording of the MoU, it is clear that the call centre operative that Mr Barbour-hill encountered was mistaken in his belief that iET payments do not cover professional fees. Yet was that the result of a genuine misunderstanding or does the RsPCA want to scrap the agreement?

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MEMORANDUM

Understanding the Memorandum

RSPCA and the ProfessionBVA President Mr harvey locke says the Associations officers have met their counterparts at the RsPCA to discuss these problems and have been assured that there is no intention of the latter withdrawing from the arrangement. But it is clear that the charity is equally concerned about the way that the iET procedures are followed.

RsPCA spokesman Andy Robbins says that the national charity is currently spending about 2 million a year to support the scheme and that over recent years these costs appear to have been rising at above the rate of inflation. he points out that, in addition, the charitys local branches will often take responsibility for supporting the costs of further ongoing treatment.

Mr Robbins also states that some practitioners seem not to realise that the sum of 60 stated in the current agreement is a maximum and not a flat rate fee. so the RsPCAs national control centre is now asking vets about the treatment provided and what the costs were when they call, and agreeing the payment on the telephone at that point.

This figure is then added to our incident log so that our regional finance departments can see the agreed price and pay only what has been agreed, he explained. we understand the financial pressures faced by practices but, in the face of difficult economic conditions, the RsPCA needs to be careful how our finite resources are spent.

however, the problems encountered by Mr Barbour-hill are not unique. so is the charity encouraging its call centre staff to test the limits of the current agreement in an effort to constrain the costs of iET? some practitioners may feel that the present problems may be the result of a deliberate instruction by the charity; although another explanation is that its an old-fashioned cock-up.

The people manning the national call centre are not RsPCA staff but are employed by a private company, Ventura, which provides the charity with the 24/7 service that it needs. while they do receive some training, they are not animal welfare specialists, as the company provides a similar service for a range of other clients in different sectors.

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MEMORANDUM

but with the great majority in the middle on both sides, they do

realise the importance of keeping a good working relationship

MEMORANDUM

Consultation feesMuch of the current tension appears to have been produced by a simple misunderstanding about what vets mean by a consultation fee. Those call centre staff had been told by the RsPCA that a consultation can only be carried out with the animals owner, since it should involve history taking and a discussion of the prognosis. The charity prefers the term clinical assessment where the main goal is to work out the immediate treatment needed to relieve suffering. however, staff at the national call centre have now been told that the two phrases can be used to describe the same thing and hopefully any confusion has been cleared up, said Mr Robbins.

Difficult timeswhile the RsPCA is recognised as one of the wealthiest charities in the UK, it is not immune from the effects of the current recession and many local branches have struggled to cope with the effects of both a reduction in income and, in some areas, a shortage of willing volunteers. The consequence has been a number of closures and mergers between local groups, which can have knock-on effects for practices like Andrew Mellors which find much of their kennel space filled with welfare charity cases with nowhere to go.

All changeAlthough the profession and the RsPCA are supposed to meet regularly to update the document, there is little incentive to re-open discussions when it is operating relatively smoothly and this was certainly the case when the economy was more buoyant. however, the current difficulties have convinced both parties that it needs urgent revision and their representatives will be going through the text line by line this summer, Mr locke explained.

indeed, the BVA and RsPCA were already planning to look at the agreement in the light of changes introduced last september to the latters policy on the use of pentobarbital for euthanasing animals injured in road traffic accidents. The RsPCA realised that the permission granted long ago by the home Office for its non-veterinary field staff to use the drug could be challenged under current legislation.

This was another reason for taking the MoU off the shelf and dusting it down. There was concern that the

changes could put more pressure on practices by having to call out veterinary staff to the scene of the accident. so far we havent had any complaints from our members and we are hoping that it may not be so much of an issue, Mr locke notes.

Typically, RsPCA field officers were having to use the drug on around 500 such animals a year and if those incidents were spread evenly around the country that would mean that a practice would experience a call out less than once a year. But it is possible that a disproportionate number of those cases may occur within the catchment area of a relatively small number of practices, and so far the BVAs optimistic attitude has not been tested over a full year, in which there can be considerable month-to-month variation in risk.

More cooperationBsAVA President Andrew Ash believes that whilst there is a general consensus that the current system has its limitations, it is essential that the profession finds a way of working alongside the RsPCA. he says, The existing scheme continues to generate some difficulty for many practices and a review would certainly be an advantage. however every vet will want to contribute to the welfare of any animal and will see the benefit of a productive and mutual relationship, not only with the RsPCA but with the other rescue centres in their area. we should all be working towards a more effective and transparent relationship.

Mr locke says the BVA is keen to see the agreement updated to re-establish more satisfactory contacts between two groups whose common interests greatly outweigh their differences. The charity has been a valuable ally for the profession in lobbying for a number of important initiatives covering wild, laboratory and farm animals, as well as pets.

Once the agreement has been clarified, the two sides can resume having effective cooperation on welfare issues at both a local and national level. There will always be some members of the profession who think that the RsPCA are failing in their responsibilities just, as some RsPCA people, i am sure, may think we are too interested in our fees, says harvey locke. But with the great majority in the middle on both sides, they do realise the importance of keeping a good working relationship.

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CLINICAL CONUNDRUM

Clinical conundrum

Mat Hennessey of the Nantwich Veterinary Group and Elizabeth Villiers of Dick White Referrals invite companion readers to consider an unusual case of multiple cutaneous masses

conundrum

Case presentationA one-year-old male entire Border Collie presented with a 24-hour history of lethargy and numerous cutaneous lumps covering his body.

The dog had been seen on two previous occasions, 5 and 6 months previously. On the first occasion the owners had noticed peripheral lymphadenopathy, the dog was clinically well and the lymphadenopathy resolved spontaneously over a 7-day period. On the second occasion the dog was presented again with lymphadenopathy as well as marked conjunctivitis. Fine-needle aspirates of the popliteal lymph nodes were taken and were consistent with reactive lymphadenopathy and mild lymphadenitis.

After the conjunctivitis failed to respond to topical ocular medication, a biopsy of the conjunctiva was taken and histopathology was consistent with nodular granulomatous episcleritis. The lymphadenopathy resolved spontaneously as it had done previously. Similarly the episcleritis resolved following a short course of topical steroid.

Outline your broad differentials for the problems identified

Cutaneous nodules Inflammatory Infectious (generalised bacterial furunculosis

syndromes, subcutaneous and deep bacterial and fungal infections, mycobacterial skin disease, demodicosis)

Sterile (urticaria, sterile granuloma/pyogranuloma syndrome, sterile panniculitis, reactive histocytosis, eosinophilic granulomas, dermal calcium deposition)

Neoplastic (intracutaneous cornifying epithelioma, histiocytoma, cutaneous lymphoma, mast cell tumour, metastatic disease)

Pyrexia Infectious: bacterial (e.g. pyelonephritis,

discospondylitis); viral (e.g. distemper); protozoal (e.g. Neospora, Toxoplasma); fungal (e.g. aspergillosis); parasitic (e.g. Angiostrongylus vasorum)

Immune-mediated (e.g. meningitis/meningioencephalitis, polyarthritis, vasculitis)

Neoplasia (e.g. haemangiosarcoma, lymphoma, leukaemia, malignant histiocytosis)

Non-septic inflammation (e.g. pancreatitis) Idiopathic pyrexia

Physical examinationThe dog was very bright and in good body condition (BCS 2.5/5). Rectal temperature was elevated at 39.5C. Numerous small, firm, hairless, pink cutaneous nodules were present over the thorax and abdomen (Figure 1). Peripheral lymphadenopathy was present, with the popliteal lymph nodes being most prominent.

Based on the information so far assimilate your problem list Cutaneous nodules Pyrexia Lymphadenopathy Lethargy (considered to be secondary to the other

problems)

Figure 1: Firm hairless pink cutaneous nodules on thorax and abdomen

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CLINICAL CONUNDRUM

Lymphadenopathy Reactive Lymphadenitis Neoplasia (lymphoma, metastatic)

Based on the information presented so far which of your differentials are more likely and why?Given the acute onset of pyrexia, lymphadenopathy and numerous cutaneous nodules, it is reasonable to assume all are related and to problem-solve for a common cause. All these signs could be the result of a number of inflammatory, infectious or neoplastic diseases.

Cutaneous nodules caused by infectious diseases, may bear draining sinuses (which are not present in this case). Furthermore, such conditions usually have a chronic course.

Neoplastic disease is less likely given the young age of the patient but notably histocytomas are seen in young dogs (< 4 years). These tumours are usually solitary but occasionally individuals bear multiple lesions.

The pyrexia, acute onset and smooth appearance of the cutaneous nodules make an immune-mediated or inflammatory cause of disease most likely. Urticarial reactions could cause similar looking lesions but these are not usually associated with lymphadenopathy and there may be a noted inciting event. Finally, the history of a waxing and waning lymphadenopathy is more consistent with an inflammatory aetiology.

How would you investigate this case? Justify your approachInvestigation was focused on the cutaneous nodules and lympadenopathy, as this was felt most likely to yield information leading to a specific diagnosis. Fine-needle aspirates of the cutaneous lesions and popliteal lymph nodes were taken for cytological examination to determine whether the nodules were inflammatory, infectious or neoplastic in origin. A complete blood count, serum biochemistry, and urinalysis (cystocentesis sample) were performed as a minimum database. These were performed to assess for haematological changes consistent with an

inflammatory, infectious or neoplastic process. Furthermore, occult causes of pyrexia (e.g. pyelonephritis) and paraneoplastic syndromes (e.g. hypercalcaemia, hypergammaglobulinaemia) could be identified. Urine culture was performed to check for an occult UTI.

Initial findingsThe CBC, serum biochemistry and urinalysis were unremarkable.

Cytology of the aspirates of the lymph node is shown in Figures 2 and 3. Cytology of the skin masses produced a similar picture.

Figure 2: Cytology of lymph node aspirate (X50)

Figure 3: Cytology of lymph node aspirate (X100)

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CLINICAL CONUNDRUM

Clinical conundrum

Is the cytology consistent with inflammatory, infectious or neoplastic disease?The lymph node aspirates showed a very mixed population of lymphoid cells, with approximately 60% small lymphocytes and 40% lymphoblasts as well as small numbers of plasma cells. There were also significant numbers of histiocytic cells. These are large round cells with a large round nucleus and abundant light-staining cytoplasm (arrowed). The nuclei contain finely, or sometimes coarsely, stippled chromatin and occasionally have a single nucleolus. The cytoplasm sometimes contains phagocytosed cellular debris, but intracellular organisms were not observed. There were small to moderate numbers of non-degenerate neutrophils. Fungal elements were not observed.

The mixed population of lymphocytes is consistent with a reactive lymph node. Infectious organisms and degenerate neutrophils were not present, which makes an infectious cause less likely, although this does not completely exclude it. The infiltration of well differentiated histiocytic cells is consistent with histiocytic disease. Other differential diagnoses include steroid-responsive granulomatous lymphadenitis or lymphadenopathy associated with underlying infection, such as fungal disease or bartonellosis.

Histocytic disease of dogs can be broadly subdivided into two categories.

Inflammatory (Reactive)1. Cutaneous histiocytosis single or multiple

waxing and waning cutaneous lesions without spread of histiocytes beyond the draining lymph node.

2. Systemic histiocytosis skin lesions as in cutaneous histiocytosis but lymph nodes and mucous membranes including nasal and ocular mucosa are often involved and histiocytic infiltration of body organs occurs.

Neoplastic1. Canine cutaneous histiocytoma benign

spontaneously regressing tumour of young dogs.

2. Langerhans cell histiocytosis Multiple cutaneous lesions histologically identical to canine cutaneous histocytoma. However, unlike histiocytoma, rapid systemic metastasis occurs. Very rare.

3. Histiocytic sarcoma and disseminated histiocytic sarcoma (malignant histiocytosis) solitary or disseminated disease caused by malignant histiocytes which may present as a subcutaneous mass, splenic mass or multiple infiltrates in internal lymph nodes, spleen, liver, lung and bone marrow. Cutaneous involvement is uncommon but can occasionally accompany infiltrates in these other sites.

In this case the histiocytic cells do not exhibit criteria of malignancy, although cells in histiocytic sarcoma complex can sometimes appear cytologically bland and malignant disease cannot be excluded on the basis of a single cytological examination. However the breed, normal haemogram, serum biochemistry and extensive cutaneous lesions make malignant histiocytosis unlikely. Similarly histocytoma is rarely multiple and has very rarely been documented spreading to the lymph node. Since no infectious agents have been identified, an infectious cause is considered unlikely although not entirely excluded. Systemic histiocytosis is considered the most likely differential diagnoses.

How would you further investigate the extent of disease?Survey imaging of the thorax and abdomen was performed to check for systemic organ involvement. Thoracic and abdominal radiographs were taken under general anaesthesia (to allow inflated views of the thorax to be taken). The thoracic radiographs were unremarkable and abdominal radiographs revealed a prominent splenic silhouette with an irregular border. Abdominal ultrasonography was performed (Figure 4).

How do you interpret these findings?The ultrasound examination revealed the splenic parenchyma to be diffusely patchy with a mixed echogenicity, and there was enlargement of the medial iliac lymph nodes.

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CLINICAL CONUNDRUM

Fine-needle aspirates of the spleen were obtained using ultrasound guidance.

Cytology of the splenic aspirates showed results similar to the samples taken from the skin lesions and lymph nodes, with a mixed population of lymphoid cells and well differentiated histiocytes.

Can a diagnosis be reached at this stage?A tentative diagnosis of systemic histiocytosis was made based on the presence of well differentiated histiocytes in the cutaneous, lymph node and splenic aspirates.

Do any further tests need to be completed at this stage?Definitive diagnosis requires histopathology, and a popliteal lymph node was excised and submitted. Given that systemic histiocytosis has occasionally been found associated with fungal or Bartonella infection, blood samples were submitted for Bartonella PCR, and fungal stains (PAS and ZiehlNeelsen) were requested along with the histology of the lymph node. The Bartonella PCR was negative and the histology also negative for the presence of fungal organisms and acid-fast bacteria.

To distinguish systemic histiocytosis definitively from Langerhans cell histiocytosis and histiocytic sarcoma, extensive immunohistochemical analysis is required (performed at the University of California, Davis). Since Langerhans histiocytosis is so rare, because mucosal involvement was present which is typical of systemic histiocytosis, and because of financial constraints, immunohistochemistry was not performed.

In light of this diagnosis, comment on the dogs previous historyIt is likely that the initial episodes of lymphadenopathy and nodular granulomatous episcleritis were early manifestations of the histiocytic disease process.

How would you treat this case?Some cases of reactive histiocytosis will wax and wane, even spontaneously regress, and may not

Figure 4: Ultrasound image of the spleen

require treatment. However, typically, systemic histiocytosis is progressive and in patients with persistent clinical signs, immunosuppressive therapy is needed. Immunosuppressive doses of corticosteroids are occasionally effective but most dogs require other immunosuppressive drugs. Ciclosporin A or leflunomide have been shown to be particularly effective and both drugs are potent suppressors of T cell activation. Given the expense and potential adverse effects of these drugs, trial treatment with corticosteroids is always justified.

OutcomeThe dog was monitored for signs of spontaneous regression over the following 7 days, during which time his body temperature remained elevated and his appetite had started to wane. Immunosuppressive therapy was initiated with prednisolone at 2 mg/kg q12h with concurrent gastroprotective treatment (cimitidine and sucralfate).

After 24 hours of treatment pyrexia had resolved, and during the following 14 days the lymph nodes returned to normal size and the skin lesions resolved.

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PUBLICATIONS

Early in the writing of this new edition the RCVS released the latest syllabus for veterinary nurse training, which saw the biggest changes in VN teaching for many years. The syllabus now has core units that require trainee veterinary nurses to learn about a wider range of animals at a more basic level before specializing in their chosen pathway, e.g. small animal. Most notably, this involved the inclusion of horses and other equine species at core unit level.

Integrated learningRather than just add in extra chapters on horses, the Editors have sought to incorporate the new content within the existing chapter framework, allowing comparative learning and reflecting modern teaching. Many chapters therefore now cover dogs and cats, horses (and donkeys) and the common exotic pets (small mammals, birds and reptiles), within an integrated whole.

The addition of a specialist equine Consulting Editor (Professor Tim Greet from Newmarket) and authors that work primarily in equine nursing, has ensured that this new content is as accurate and up to date as possible. Fortunately, all three of our main Editors have also either worked in mixed practice or own horses themselves as does our freelance illustrator so we have expertise throughout the team, although it has been a challenge for some to remember all they might once have known about horses. For our copy-editors at Woodrow House, usually fluent in the language of BSAVA Manuals, it has also been a steep learning curve, but they are now conversant with terms such as quidding, frogs (a whole new meaning!) and clinches.

Updating the nursing classicRising to the equine challenge

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nursing classicRising to the equine challenge

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The BSAVA Textbook of Veterinary Nursing (formerly Joness Animal Nursing) remains the core textbook for

veterinary nursing students and throughout its many editions has always adapted to reflect the changes in

requirements for VN training and qualifications. The fifth edition, to be published in Autumn 2011, is no exception but has provided the editors and authors with some new

challenges

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PUBLICATIONS

Complete coverageThe intention was to provide complete coverage of the syllabus for those training to be small animal veterinary nurses. However, it soon became obvious that the inclusion of horses and their cohorts was at a level that required equine content through a whole range of subjects, including anatomy and physiology, animal management and handling, laboratory medicine, anaesthesia, diagnostic imaging, and reproduction. The finished product therefore will be essential reading for all those training to be veterinary nurses, whether equine or small animal. The addition of the new material has not been at the expense of ensuring that the small animal content is up to date and of a level that reflects the ongoing development of small animal practice. The only question is how big a bag the student nurses will need to take this book to college!

Health and safetyWith the inclusion of all things equine, important new topics include how to safely achieve the following:

Putting on a bridle with a bit Twitching (nothing to do with birds apparently) Grooming/bathing a horse Removing a horses shoe Safe management of horses for anaesthesia

and surgery.

H&S is, of course, not just important around horses. Safety considerations for other animals, including awareness of aggressive behaviour and infectious zoonoses, are considered throughout. There is a new special emphasis on MRSA and associated

relevant hygiene measures, and incorporation of the new BVA/BSAVA/GVS waste management regulations. As the legislation in the area of Health and Safety evolves continuously, the reader is also referred to useful websites where the latest information can be found, not forgetting the BSAVAs own website.

Nursing models and care plansAlongside the increasing development of the professional role of veterinary nurses, there has been an emphasis on the importance of developing up-to-date evidence-based nursing practice through the implementation of care plans. These allow nursing care to be systematically planned and delivered by nurses, with effectiveness of care being evaluated by the whole veterinary team. In this new edition, the information has been expanded and widened into a stand-alone chapter. The nursing process and a range of nursing models are described, with case examples given for dogs, cats, horses and rabbits.

The role of the veterinary nurseSince the last edition of Joness the nursing profession has advanced its own professional status, with the designation of Registered Veterinary Nurse and a new Guide to Professional Conduct. These changes are reflected in revised coverage of legal and professional responsibilities, and an updated discussion of the application of ethics within veterinary nursing.

Ultimately, getting these things right is about having a good education in the first place, and there is no doubt that the new edition of Joness will contribute to this.

Main picture: Svetlana Mihailova; Dreamstime.com

All other pictures reproduced from BSAVA Textbook of Veterinary Nursing, 5th edition

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HOW TO

How to

Get the best from liver samplesSusana Silva of Great Western Referrals guides us through the selection of appropriate techniques to achieve diagnostic liver biopsies

The diagnosis of most hepatic diseases relies on histopathological examination of a liver biopsy sample. However, biopsy comes at the end of a diagnostic pathway which includes a complete history, clinical examination, clinicopathological data and imaging such as ultrasonography.

Examination of liver samples is needed to achieve a gold standard diagnosis, to direct therapy and to offer prognostic information. However it is important to remember that liver biopsy will produce only a small sample of the liver tissue as a whole and as such might not be a representative sample of ongoing pathology. Although in most cases biopsy is required to achieve a diagnosis, in some cases it is possible to obtain sufficient information by less invasive methods such as cytology.

To avoid frustration for clinicians and inappropriate expectations from the owners, it is very important to understand the indications, limitations and possible complications associated with each specific technique of sampling hepatic tissue.

When to consider sampling the liverPotential situations in which obtaining hepatic tissue should be considered are:

Evidence of hepatic dysfunction, such as elevated bile acids or jaundice of hepatic origin

Diffuse changes in echogenicity on ultrasonography

Discrete hepatic lesions Hepatomegaly of undetermined cause Persistently elevated liver enzymes without a

detectable inciting cause Evaluation for the presence of a breed-specific

hepatopathy.

Techniques for obtaining liver samplesThere are several different techniques by which hepatic samples may be obtained. These are:

Fine-needle liver aspiration (FNA) under ultrasound guidance

Needle biopsy Surgical biopsy (laparoscopic or via coeliotomy).

These techniques all have indications, advantages and contraindications (Table 1).

Cytology samplesFNA is the least invasive technique and is usually performed under ultrasound guidance using a 22G needle of an appropriate length; for most cases a 22G 1.5 inch needle is appropriate (Figure 1).

Hepatic FNA can often be performed with the patient conscious, although sedation or general anaesthesia will be necessary in a nervous or less cooperative patient. As the size of the needle is small, the risk of post-FNA bleeding is minimal and therefore multiple sites can be sampled without major risk. Provided there is no evidence of haemostatic problems with previous venipunctures, it is not mandatory to assess clotting times.

Table 1: Practical considerations regarding the different methods of obtaining hepatic tissue

Fine-needle aspiration

Surgical biopsyTru-Cut needle biopsy Laparoscopic Coeliotomy

Anaesthesia +/ + + +

Ultrasound-guided + +

Invasiveness + ++ +++

Cost + ++ +++ +++

Experience needed ++ ++ +

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HOW TO

Get the best from liver samples

The areas to be sampled should be carefully chosen so as to be as representative as possible while avoiding structures like the gallbladder and blood vessels. The needle is introduced into the liver tissue under ultrasound guidance, targeting the specific areas to be sampled. To avoid haemodilution, it is preferable to use the needle alone rather than having a syringe attached and applying negative suction. The needle should be rapidly moved in and out of the parenchyma (a so-called woodpecker-like motion) and a slight twisting motion applied to maximise the cell yield. Afterwards, the cells should be carefully transferred on to a microscope slide and smeared. The spreader slide should not be pushed down too vigorously as this will increase the likelihood of cell lysis and risk non-diagnostic sampling.

Overall, liver cytology is usually the initial diagnostic test in most cases of hepatic disease. FNA yields cells without the presence of structural architecture and therefore is mainly useful in cases where a diagnosis can be obtained from individual cells (e.g. lymphoma). Criteria such as architectural changes, the presence and location of inflammation within a lobule, and location and degree of fibrosis are important when assessing a hepatic biopsy sample and are impossible to evaluate on liver cytology, thereby contributing to the rate of poor agreement between the two techniques.

Studies documenting the agreement between cytology and surgical wedge liver biopsy have shown a poor correlation between the final diagnosis. However, clinicians should not feel discouraged from obtaining hepatic FNAs as they can prove worthwhile. The suspicion of vacuolar hepatopathy and neoplasia (especially lymphoma) are the main indications for hepatic cytology, and for these specific groups of disease the agreement with liver histology is better than in cases of chronic hepatopathies or in vascular anomalies where cytology is unlikely to provide useful information.

FNA can also be used to collect bile for cytology and culture, especially in cases of feline inflammatory liver disease when bacteria are thought to be involved. Care should be taken to empty the gallbladder as much as possible to reduce the possibility of leakage; this technique is contraindicated in cases of extrahepatic bile duct obstruction. Although a transhepatic approach was previously recommended, this is no longer the case and any approach is considered reasonably safe.

If cytology does not provide or is thought unlikely to provide sufficient information, hepatic biopsy should be considered.

Histopathology samplesGeneral anaesthesia is usually recommended to collect samples for histopathology and therefore fasting is essential; a full stomach might also interfere with sample collection. The presence of liver disease reduces the bodys ability to metabolise drugs and therefore the protocol chosen for sedation and/or anaesthesia should take this into account.

It is important to assess coagulation status by evaluating activated partial thromboplastin time (APTT), prothrombin time (PT) and platelet count ideally less than 24 hours before the procedure; a buccal mucosal bleeding time (BMBT) test should also be considered, especially in breeds predisposed to von Willebrands disease. The liver produces all the clotting factors except for factor VIII and bleeding is indeed the most frequent complication of liver biopsy.

Liver biopsy should be avoided in patients with clotting abnormalities or severe thrombocytopenia (< 80 x109 platelets per litre).

Even though normal clotting times make significant bleeding less likely, it is possible to have abnormalities that are not detectable by changes in PT and APTT. While it is possible to apply compression during surgical (laparoscopic and coeliotomy) biopsy this is not feasible with needle biopsy (e.g. Tru-Cut), making significant bleeding a very realistic possibility.

The method chosen to acquire hepatic tissue is influenced by the size of the liver, the presence or absence of ascites, the main differential diagnoses, and the clinical condition of the patient. For example, if the liver is small it is unlikely that meaningful information will be obtained from cytology as the main differentials would be either vascular disease or a chronic hepatopathy with cirrhosis; in this instance Tru-Cut liver biopsy would also be contraindicated due to microhepatica. Additionally, if there is biochemical and ultrasonographic evidence of a vascular problem such as a congenital portosystemic shunt, an exploratory surgery with portovenography shunt ligation and biopsy would be preferred over laparoscopic assessment and biopsy.

Figure 1: Example of a liver mass that could be sampled via FNA with a 1.5 inch needle; the scale in centimetres on the right side of the screen allows estimation of the depth of the nodule

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HOW TO

Get the best from liver samples

What constitutes a good specimen?An ideal sample should be of appropriate size and representative of the primary hepatic pathology.

In diffuse diseases any area is likely to be representative, whilst in focal or regional disease it might be more difficult to get a representative sample and therefore ultrasound and/or direct inspection are valuable tools. If the pathology seems focal then samples should be collected from both the abnormal-looking areas and from the normal-looking areas, as it is not uncommon for what seems normal to actually be abnormal.

Ideally two or three samples should be obtained from separate areas. As needle biopsy samples are smaller, the potential for non-representative samples is greater. Most authors suggest avoiding the use of 18G needles, as the samples get easily fragmented and tend not to have enough portal areas to be diagnostic; the sizes most commonly used are 16G needles for cats and small dogs, and 14G needles for larger dogs.

Needle biopsyThere are two main types of needle used for liver biopsy; with these a small cylinder of tissue is obtained. The Menghini technique involves tissue aspiration, usually blind, using a syringe attached to a large-bore hollow needle. This technique has been largely superseded by the use of Tru-Cut type needles and it will not be discussed here.

Tru-Cut needle biopsy is usually performed under ultrasound guidance, even though it is possible to use this type of needle blindly in cases of very severe hepatomegaly. The Tru-cut needle is composed of an outer cannula and an inner notched stylet in which the specimen becomes lodged (Figure 2). The notched stylet is advanced first and the hepatic tissue fills the 2 cm notch. Then the outer cannula (with sharp cutting edges) is advanced over the stylet and the liver parenchyma is cut, leaving a sample in the notch (Figure 3). Afterwards, the whole needle is withdrawn and the inner stylet is exteriorized again to expose the sample obtained.

There are three types of Tru-Cut needle: manual, semi-automatic, and those used with a gun-type device.

The manual needles are difficult to control and their use is not advisable unless under direct visualization.

The semi-automatic type needles are the most expensive ones and can be used in both dogs and cats.

Biopsy guns fire the needle, at high speed, once the trigger is pushed. The speed at which the needle is fired makes the process of obtaining samples from a hard fibrotic liver easier. Biopsy guns are a costly piece of equipment and, while

Figure 2: Tru-Cut biopsy needle with the stylet extruded and showing the notch in the stylet where the tissue sample becomes lodged

Figure 3: Step-by-step view of the Tru-Cut needle as the sample is collected. Please note that this would be the happening inside the organ. (A) The loaded Tru-Cut needle is inserted into the organ. (B) The Tru-Cut needle loaded and with the stylet advanced. Note that the stylet is extending about 2 cm deep to the initial placement site. During this step the hepatic parenchyma fills the notch of the stylet. (C) Tru-Cut needle fired. The piece of parenchyma that had previously filled the notch has been cut out and is contained within the outer sheath; the needle is ready to be removed. Again note that the tip of the needle is about 2 cm deeper within the target organ than the original placement site

A

B

C

the biopsy needles used are then not very expensive, the initial cost is high; therefore this technique is most commonly used in hospitals where a large number of needle biopsies are performed. The use of an automated gun-type device is contraindicated in cats due to the potential for vagal-induced shock (often fatal) due to the sudden impact wave in the liver.

While the automatic gun device fires both the inner stylet followed by the outer sheath, the semi-automatics only fire the outer sheath after the inner needle core is manually advanced by the operator.

If it is economically feasible to have only one type of needle, then semi-automatic Tru-Cut needles

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HOW TO

Performing a Tru-Cut liver biopsy overleaf

Figure 4: Inspecting the liverReproduced from the BSAVA Manual of Canine and Feline Endoscopy and Endosurgery

Figure 5: Biopsy of the liverReproduced from the BSAVA Manual of Canine and Feline Endoscopy and Endosurgery

Figure 6: Liver post biopsy with a small amount of haemorrhageReproduced from the BSAVA Manual of Canine and Feline Endoscopy and Endosurgery

have the advantage that they can be used in both dogs and cats.

The decision to perform a Tru-Cut liver biopsy should be not made lightly. The potential for complications is real and bleeding from the biopsy site can be significant, especially if a main vessel is damaged. Additionally, the experience of the operator is critical to minimise the risk of complications. Tru-Cut needles will advance approximately 2 cm deeper than the tip of the needle. Therefore when selecting a site for biopsy a 2 cm depth in front of the needle should be devoid of major vessels or biliary ducts.

Tru-Cut liver biopsy should be avoided in patients with prolonged clotting times or thrombocytopenia. Microhepatica, significant abdominal effusion and operator inexperience are also contraindications.

Surgical biopsy

Laparoscopic biopsyObtaining liver samples is one of the most common indications for laparoscopy as it can be accomplished reasonably quickly and with minimal trauma to the patient. The samples obtained with the cupped forceps are smaller than those obtained via coeliotomy but bigger than those obtained via Tru-Cut biopsy. Care should be taken to ensure that the sample contains not only subcapsular superficial tissue but also deeper tissue, as the former may not be a representative sample.

With this technique it is possible to inspect the liver (Figure 4) and the rest of the abdomen, to sample macroscopically abnormal areas (Figure 5) and to visualise and apply direct pressure for haemostasis caused by the biopsy (Figure 6). Laparoscopy requires special equipment, training and is more expensive than Tru-Cut biopsy.

CoeliotomyA celiotomy will also allow good visualisation of the abdominal contents but also allow more detailed investigation of the biliary tree and vasculature. As with laparoscopy, it is important that the samples collected have sufficient tissue and that not only superficial areas are obtained; a 1 to 2 cm depth is recommended. In cases of diffuse disease, at least two areas should be sampled. If the pathology is localized then normal and abnormal areas should be sampled.

ConclusionLiver biopsy is essential in the investigation of almost all hepatic diseases. There are several options available to the clinician, with various pros and cons attached to each procedure. Consideration of these points will help make the right decision for each patient and their owner.

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HOW TO

Get the best from liver samples

PERFoRmINg A TRu-CuT LIvER BIoPSy

It is a sensible policy to keep the animals hospitalized for a minimum of 12 hours so that the vital parameters can be monitored and, in case of suspicion of bleeding, the abdomen can be examined with ultrasound.

If there is evidence of bleeding post-biopsy the patient should be closely monitored and the use of fresh frozen plasma should be considered to supply additional clotting factors.

It is uncommon for emergency surgery to be needed due to uncontrolled bleeding after Tru-Cut biopsies of the liver unless big vessels were damaged during the procedure.

1. Answer the following questions:a. Are liver samples deemed

necessary?b. Considering your differential

diagnoses, what information are you expecting to obtain by liver biopsy?

c. Would it be possible to obtain the same information with cytology? (If so consider performing FNA prior to biopsy).

d. Does the patient have significant ascites or microhepatica? (If so consider other techniques)

e. Is a vascular anomaly one of the main differentials? (If so consider other potential techniques)

f. How many biopsy samples do you think are needed and what are they going to be tested for? (Check with the laboratories the requirements for special tests and make sure the containers needed are available).

g. How many biopsy samples do you estimate can be safely obtained in this specific case?

2. Check the clotting times and platelet count no more than 24 hours prior to the procedure.

If the clotting times are prolonged delay the procedure, consider administering parenteral vitamin K1 and rechecking the clotting times 48 hours later.

3. Immediately prior to the biopsy choose the areas to sample using ultrasonography and estimate the number of potential samples that can be safely obtained; remember that representative samples are needed.

4. Make sure that you have all the material required (Figure 7).

5. Surgically prepare the skin, allowing for generous areas of clipped and scrubbed skin around the entry points.

6. Using a scalpel blade, make a small incision of the skin on the site where the needle will enter the abdomen; the use of sterile gloves is recommended. Special sterile sleeves are available for the ultrasound probes. If these are not available, the probe should be thoroughly cleaned with the scrubbing solution and the operator should be careful to avoid touching the probe with the biopsy needle.

7. Examine the Tru-Cut needle for any problems and fire it once outside the patient to make sure it is working appropriately (this is also the time to make sure that you understand fully how the needle works).

8. Re-load the Tru-Cut needle and it is then ready to be used (Figure 8).

9. Apply a generous amount of sterile ultrasound gel to the abdomen and, under ultrasound guidance, carefully insert the needle into the liver. Take into account that while with cytology the area sampled is the area where the tip of the needle lies, with Tru-Cut needles the area to be sampled lies in front of the tip of the needle (see Figure 3).

10. Double check that there are no important structures in the 2 cm area in front of the needle.

Figure 8: Semi-automatic Tru-Cut needle in a neutral position (A) and in a loaded position with the fire-trigger pulled backwards(B)

A

B

Figure 7: material needed to perform Tru-Cut biopsy of the liver (Tru-Cut needle, scalpel blade, sterile gloves, sterile ultrasound gel)

11. Perform the biopsy and withdraw the needle.

12. Open the needle and, with the help of a sterile needle, gently ease the sample into the appropriate container.

13. Using ultrasonography, check for the presence of a significant amount of free fluid, which is likely to indicate significant bleeding, and check the liver parenchyma at the biospy sites for evidence of active haemorrhage.

14. Repeat the procedure to obtain more samples.

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CPD

Ophthalmic examination may be pivotal to making an early diagnosis in neoplastic, dermatological and neurological diseases, infectious systemic diseases and endocrinopathies. In addition, ophthalmologists must also be surgeons, performing procedures ranging from orbitotomies, rhytidectomies and complicated blepharoplastic techniques to microsurgery including corneal grafts, cataract surgery and endolaser.

Every eye tells a story and it is a bit like being a Crime Scene Investigator interpreting the findings. For example, pigment on an anterior lens capsule can be congenital and associated with persistent pupillary membrane remnants, or may be the result of contact with the posterior surface of an inflamed iris after an episode of uveitis; two totally different events with differing implications.

If you want to learn how to interpret the evidence, then enrol for this years BSAVA mini-modular ophthalmology course, which will be held at the Crowne Plaza Hotel near Gatwick Airport, 14 September, 12 October, 16 November and 7 December.

The speakers this year are Sue Manning and Jim Carter, both of whom are RCVS Diploma holders in veterinary ophthalmology working in private referral practice. They are both enthusiastic and experienced lecturers and have structured their modules with the objective of inspiring the delegates in the subject of ophthalmology using a mixture of richly illustrated and interactive lectures, videos and small group seminars.

The modules aim to be practically orientated, covering most of the presentations and procedures seen and performed in general practice on a daily basis. They will also inform delegates of the more advanced procedures available in cases when they may provide a better outcome for patient and owner.

Taking a better lookOphthalmology has to be one of the most fascinating subjects. In what other discipline can you look at an extension of the brain, differentiate venous and arterial vascular disease without complicated imaging, or visualise nematode infections without faecal sampling or BAL?

ABOuT THE OphthalmOlOgy MINI-MODuLARSpeakers: Sue manning and Jim CarterVenue: Crowne Plaza, London Gatwick AirportFees: Full series: BSAVA Member: 813.00 Non-member: 1219.83 Individual courses: BSAVA Member: 213.83

Non-member: 320.74

OphthalmOlOgy 1Cats are not small dogs: a day of feline ophthalmology thursday 15 September

The aim of this module is to provide delegates with a complete overview of the approach to feline ophthalmology. The key to diagnosis of any ophthalmic disease is the ability to perform a systematic ocular examination and understand the significance of any findings. This will be covered at the outset and, combined with the subsequent presentations, should provide the knowledge to diagnose and effectively manage most feline ocular conditions presented in general practice. The presentations will be well illustrated with photographs and videos, and will include case based examples and interactive discussion. This module will specifically address:

How to perform a comprehensive ocular examination

Feline infectious and inflammatory ocular surface disease

Feline uveitis and glaucoma Feline retinal and orbital disease.

CPD

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CPD

Taking a better look

OphthalmOlOgy 2First aid in ophthalmology: a first line approach to ocular emergencies thursday 13 October

This will be a purely surgery-based day, which will cover all surgical cases from eyelid mass removal and enucleation through to cataract surgery and endolaser, as well as covering the principles of ocular surgery from induction to recovery. This module will concentrate on providing delegates with the tools necessary to obtain the optimal results for those procedures routinely performed in general practice. It will also improve awareness of the more advanced surgical techniques available for patients that present with sight threatening conditions such as cataract, glaucoma and retinal detachment. The presentations will be well illustrated and include videos of commonly performed techniques as well as interactive discussion. This module will specifically address:

Principles of ocular surgery Adnexal and corneal surgery Intraocular surgery; what is available

and emerging? Anaesthetic considerations in

ophthalmic surgery.

OphthalmOlOgy 4the eyes have it! Ocular manifestations of systemic disease thursday 8 December

Internists, neurologists, oncologists and dermatologists all need ophthalmologists! So many systemic diseases will have ocular manifestations that the ability to recognise them may be critical to early

ABOuT THE SPEAkERSSue manningSue graduated from the university of Bristol in 1987. She worked in Swansea for 16 years, both in mixed practice and small animal charity practice, and gained her RCVS Certificate in Veterinary Ophthalmology in 2001. Sue gained her RCVS Diploma in Veterinary Ophthalmology in 2006 after undertaking a residency at Willows Referral Service in Solihull. She set up the ophthalmology referral service at Rutland House Referrals in St Helens, Merseyside, in May 2008. Sue is currently a member of the BVA/kC/ISDS Eye Panel. Her clinical interests include corneal surgery, lens luxation and cataract surgery.

Jim CarterJim Carter graduated from the RVC in 1996, then spent over three years in farm animal practice before gaining the RCVS Certificate in Veterinary Ophthalmology in March 2000. In August 2000 Jim started a clinical training scholarship in Veterinary Ophthalmology at the university of Bristol under the tutorage of Professor Sheila Crispin and Dr David Gould, and was awarded the RCVS Diploma in Veterinary Ophthalmology in 2003.

diagnosis and potentially improve the outcome. This module aims to illustrate some of the more common systemic diseases with ocular involvement that are presented in general practice, as well as demonstrate a practical approach to diagnosis using readily available investigative tools. The presentations will be well illustrated with photographs, and will include case based examples and interactive discussion. This module will include:

Ocular manifestations of systemic disease presentations

Smaller group seminars discussing diagnostic techniques

Clinical pathology appropriate laboratory testing in different diseases, in-house ocular cytology

Diagnostic imaging ocular ultrasonography, MRI, CT

Interactive case based illustrations.

The aim of this module is to provide delegates with the techniques and knowledge to deal with ocular emergencies that will present in general practice and result in significant sight and globe threatening conditions. We will cover the diagnostic steps for identifying, along with surgical and medical techniques for treating, the conditions listed below, as well as several more. The presentations will be illustrated with photographs of cases pre and post treatment, along with videos of surgery to aid in the explanation and description of treatment and prognosis. This module will explore:

Proptosis Melting ulcers Acute glaucoma Lens luxation.

OphthalmOlOgy 3a stitch in time: all you need to know about small animal ophthalmic surgery thursday 17 November

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PETSAVERS

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Improving the health of the nations pets

Qualified veterinary surgeons are invited to apply for funds to support a clinical study in companion animals, and in the next round of awards Petsavers is especially keen to see more applications from people in practice, who are likely to have a more representative caseload than referral practices or academia. General practitioners might appreciate the additional support now available to them in terms of study design and statistical analysis.

As a practitioner himself and Chairman of Petsavers, Philip Lhermette says, However inspired a practitioner may be to undertake such a project in addition to their already packed workload, it is often the case that it is the study design and analysis that puts them off. That neednt be the case. BSAVA is an association mostly made up of people in general practice, and it is those professionals that we are determined to support in very practical and relevant ways. So those in general practice should apply with confidence that they wont be alone in their efforts. The BSAVA will put them in touch with statisticians at academic institutions in their region who can assist where necessary.

The terms of the grants indicate that

Petsavers invites applications for funding, and has additional support available for successful applications from general practitioners

PETSAVERS

Improving the health of the nations petsImproving the health of the nations petsImproving the health of the nations pets

your study must have the objective of advancing the understanding of the cause and/or management of a clinical disorder. The study must not involve experimental animals and should further the knowledge of the small animal practitioner.

Applications are welcome from both private practice and academia and funding is available for grants between 1000 and 8000.

If there are any questions about Petsavers please contact us on 01452 726723 or email info@petsavers.org.uk.

Funds for fun runnersWe are delighted to report that Petsavers has been over-subscribed with people wanting to take part in the London 10K this July which has become something of a summer tradition for the charity

Around 30 to 40 yellow T shirt-clad joggers will be enjoying the sites of Westminster and beyond as they puff and pant for Petsavers next month, raising thousands of pounds along the way. Please help support them and encourage their efforts by sponsoring them as individuals, or you can do so collectively anytime at www.justgiving.com/petsavers no amount is too small, and dont forget to Gift Aid it if you are eligible. Thank you so much we really do rely on the support of the profession and appreciate your ongoing commitment to helping us advance veterinary knowledge.

The closing date for Clinical Research Project applications is the 31 August 2011. The applications will be considered by the Petsavers Grants Awarding Committee in September, with the final vote decision made in March 2012.

Full guidelines and terms and conditions can be found on the Petsavers website: www.petsavers.org.uk Application forms can also be downloaded from the Petsavers website.

Petsavers grants 2011Practitioners wanted

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BVA CONGRESS

This year the BVA Congress carries the theme Vets in a changing world, and will be held in Central London on 2224 September at the Royal College of Physicians.

As a result of discussions between the BVA and BSAVA on better ways of working together for the benefit of the profession, it was decided to support an expansion of the already impressive BVA programme with the help of BSAVAs resources and experience in

creating exemplary CPD to companion animal professionals.

We are delighted to announce the collaboration between our two associations, said BVA President Harvey Locke. BVA Congress is an important date in the veterinary political calendar, while BSAVA Congress is internationally renowned for the quality of its CPD.

BSAVA President Andrew Ash described the upcoming event as a good opportunity to combine the experience and

World-class sc ience in the Capital

expertise of the two organisations. We are keen to inject the excellence of BSAVA Congress into an already prestigious event, he said.

Talks of the townThe three clinical CPD streams covering feline medicine, gastroenterology medicine and surgery, and cardiorespiratory medicine, will be delivered by leading experts, including Alex German, Penny Watson, Ian Ramsey, Sue Murphy, Hattie Syme and our own BSAVA Congress Chairman, John Williams.

The BVA has announced that Congress will be opened by Defra Minister Jim Paice MP in a keynote speech titled Vets in the Big Society, in which the Minister will outline the Coalition

BSAVA provide clinical programme for BVAThis years annual British Veterinary Association Congress will see BSAVA team up with BVA to provide two days of small animal CPD alongside the BVAs popular political and social programmes

Just because some types of patient appear regularly on the consulting room table doesnt mean that they are easy cases to manage. And no matter how frequently some conditions are seen, there is nearly always scope for carrying out a faster, smarter and more cost-effective clinical work-up, delegates will be told during BVA Congress in London

private referral centres. They will be focussing on feline medicine, on gastrointestinal medicine/surgery, and on cardiorespiratory medicine, explains Professor Ian Ramsey, of the University of Glasgow veterinary school, who drafted the menu.

The one thing that these three disparate areas of practice have in common is that they provide a constant challenge to the clinical skills of general practitioners in small animal and mixed practices. So Ians idea in choosing the speakers was to look at disciplines in which efforts to improve and refresh clinical knowledge will have immediate applications in providing a better service to clients, he explains.

Now that cats have overtaken dogs as the most commonly kept domestic animal, is there any need for a particular focus at the meeting on routine feline conditions? Prof. Ramsey points out that feline medicine is still a relatively new discipline and cats are not the most cooperative of patients. They hide their symptoms so well that they are usually at a much more advanced stage of the disease process by the time that they are brought in for treatment than an equivalent case in a dog, he says. Moreover, the rise in numbers of

BSAVA has drawn up a high-quality CPD programme to complement the political debates at BVAs annual meeting. This comprises lectures from leading specialists from university and

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BVA CONGRESS

The Early Bird deadline is 30 June

cats covered by pet insurance, and the growing expectations of cat owners, mean that first opinion clinicians cannot afford to rest on their laurels.

Meanwhile, the two other streams share a common feature, focussing on deep body tissues. It is very much harder to work out what is going on in the gut or in the heart compared with, say, dermatology cases. True there is now a wide range of advanced imaging techniques available at referral centres. But if a general practitioner has only limited experience of these technologies they may not be able to properly interpret the report when it comes back to them, he says.

One of the problems facing busy practitioners is time pressure, which will often encourage them to have one eye on the treatment options when they should be concentrating on the diagnostic work-up. So the speakers will be reminding their audience of the necessity for taking logical and orderly steps towards reaching a diagnosis.

Prof. Ramsey will himself be delivering three presentations in the feline medicine stream: on polyuria, hyperthyroidism and diabetes mellitus. The first paper will set out a useful model for carrying out an effective diagnostic work up in a wide

World-class sc ience in the Capital

BSAVA provide clinical programme for BVAGovernments view of the role of vets in the UK today.

With dangerous dogs, vaccination and pet travel all high on the Governments agenda, delegates will hear first-hand how far the Governments Big Society vision crosses over into private practice, and debate whether vets are already contributing enough.

A changing worldBVA Congress will also mark World Veterinary Year Vet 2011 in recognition of the 250th anniversary of the foundation of the worlds first veterinary school in Lyon, France, and in celebration of the profession across the globe.

This years contentious issues and overseas programmes will highlight the

role of vets in a changing world and discuss how we can adapt to new challenges as individuals and as a profession, Mr Locke explained.

The overseas sessions will explore the role of vets in disaster situations, comparing and contrasting man-made and natural disasters and asking when and where external agencies should intervene.

Under the contentious issues stream, the scope of a new Veterinary Surgeons Act will be explored, including the difficult issue of regulation for paraprofessionals and veterinary nurses, following reports that Defra has invited the RCVS to prepare detailed proposals for a draft Bill.

Questions raised by the current economic climate also feature prominently in the programme, with a session on the impact of rising tuition fees on tomorrows veterinary graduates and a debate on the link between a clients ability to pay for their pets healthcare and the treatment options available.

Fun and networkingFinally, the all-important social side of Congress. Both BVA and BSAVA have built up reputations for the quality of networking opportunities. Thursday evening will combine the awards ceremony and Presidents welcome speech with exhibition drinks and buffet, providing a fantastic opportunity for delegates to socialise, network and celebrate.

The social programme highlight will take place on Friday night in the exquisite Ballroom of the 5-star Langham Hotel on Regent Street. Plus, with all of Londons major shopping and sightseeing attractions just minutes away from the Congress venue, there is plenty for delegates to see and do to make the most of the weekend.

In recognition of BSAVAs contribution to BVA Congress, BSAVA members will receive a member discount of 100 across the two days, making it a low-cost and fun way to earn high-quality CPD. More information and booking is available at www.bva.co.uk/congress. n

range of clinical situations. There are only six common causes of polyuria and a few more which are only seen very rarely. I will try to show the best approach for identifying which particular one is involved, it is just like following a recipe. If you carry out this test and then take that step you will arrive at the right answer. It is when you try to jump a step or take them in the wrong order that you will have problems because the results of one test will help you interpret the results of the next one in the sequence, he says.

An unusual feature of this CPD event is that participants will be taking part in a quiz session at the end, based on what they have seen and heard during the day. The idea of the quiz is that it should provide a little bit of fun at the end of a tough day but it also has a serious purpose. Attendees at any CPD event will only take in a percentage of the information given in the presentations, and even then they may not have the confidence to apply that new knowledge in the routine work. What we are hoping to do is to set the information in the context of a clinical case so that people will be ready to use what they have learned as soon as they go back to their practice, Prof. Ramsey says. n

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MEDICINES

The client drug information leaflets were the idea of Professor Ian Ramsey, Editor-in-Chief of the BSAVA Small Animal Formulary. He says, As a referral vet I write a lot of letters to owners and vets that include instructions about the drugs that I am prescribing or dispensing for a patient. Often these drugs are unusual or cytotoxic, and are very commonly only authorized for human patients. As Editor of the Formulary I am acutely aware of the responsibility that I have for making sure owners understand what these drugs are for and what the side effects might be.

There is an enormous amount of detail that should be relayed to clients, and remembering every detail for every drug is an unrealistic challenge. Professor Ramsey also points out that Vets have an obligation to provide detailed information on the drugs that they are dispensing to their clients. The BSAVA client information leaflets provide a ready source of information and also help solve the problem of clients forgetting what they have been told verbally by the clinician during a consultation.

Drugs coveredThe first batch of client information leaflets is now available for members to download

Medicines information: client leaflets

from the BSAVA website (www.bsava.com) and more may be added over time. These leaflets are specifically written for owners and relate to medications prescribed for dogs and cats only. Each of the leaflets has a space for veterinary practices to add their details before distributing them to their clients. The leaflets cover some of the off-label drugs most commonly used for dogs and cats, including:

Amitriptyline Atenolol Chlorphenamine Digoxin Famotidine Ursodeoxycholic acid.

Standard informationIn addition to a basic introduction to the Prescribing Cascade, each of the client leaflets provides the following information:

What is the drug? Why has my pet been prescribed the

drug? How should I store the drug? How do I give the drug to my pet? How long will my pet need to take the

drug? What should I do if I run out of tablets? What should I do if I miss a dose?

Over recent years advances in veterinary medicine have outstripped the availability of drugs that are authorized to treat various diseases in companion animals. As a result it is often necessary to utilise the Prescribing Cascade and prescribe medications off-label. However, until now there has been no source of standard information for owners regarding the use of such drugs. Debbie Grant of the Publications Committee explains further

PUBLICATIONS

What should I do if my pet is accidentally given too many doses?

Can my pet take this drug if I am already giving them other drugs?

What are the possible side effects of the drug for my pet?

What should I do if my pet is unwell while taking the drug?

What should I do if a person accidentally takes this drug?

Whom do I contact if I want to know more?

The BSAVA client information leaflets provide an excellent reference for owners and explain exactly what the drug does, as well as detail the potential side effects that may arise. Owner education is essential to help ensure any treatment-related problems are spotted early on, and to manage owner expectations of success.

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dogs and cats only. Each of the leaflets has a space for veterinary practices to add their

What should I do if my pet is

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WSAVA V5 Global Nutrition Guidelines launched

WSAVA is delighted to announce a major step forward with one of its key campaigns to ensure that a nutritional assessment and recommendation is made on every patient during every visit to the vet

availability via member associations and the media. It is our goal that every teaching institution in the world should formalise this approach in their curriculum as soon as possible.

Now that the V5 Guidelines have been published, the committee is working on the next phase of activity. It has formulated a plan to build an alliance of global veterinary organisations to help healthcare teams and pet owners begin implementing the guidelines together on an international basis. These efforts will be coupled with the Veterinary Companion Animal Nutritional Consortium founded by AAHA, of which WSAVA is a charter member.

We believe this project to be important given the influence of nutrition on every patient, whether to treating illness, preserving health or preventing future health problems, comments Professor Jolle Kirpensteijn, President of the WSAVA. Its vital for companion animals as theyre often fed the same diet at every meal with little attention paid to the quality or suitability of the nutrition they are receiving. Just as we led a global effort to elevate pain to become the fourth vital assessment, we also see the need to elevate a nutritional assessment to become the fifth vital assessment in a standard physical exam. We believe a sound nutritional recommendation from a veterinarian is crucial because pet owners are exposed to a myriad of nutritional myths that if acted upon can actually be harmful to their pets. To help ensure the

WSAVA V5 Global Nutrition Guidelines are assimilated worldwide, well be working towards getting the guidelines published and encouraging other stakeholders to get involved. We hope that global veterinary organisations will join forces with us to encourage veterinary healthcare teams and institutions in their respective geographies to make nutrition a routine part of their recommendation procedures.

The guidelines can be viewed on the WSAVA website at www.wsava.org. For further information on this project, contact wsavasecretariat@gmail.com.

We want this to become known as the 5th Vital Assessment (5VA), following the four vital assessments of temperature, pulse, respiration and pain, which are already routinely undertaken.

After a year of development work led by Dr Clayton MacKay, a Canadian veterinary consultant, the WSAVA Guidelines Development Committee has now finalised and launched its V5 Global Nutrition Guidelines which are aimed at helping veterinary surgeons and pet owners design a nutrition plan which is tailored to the needs of their specific dog.

The V5 Guidelines are available at, and are consistent with those produced by, the American Animal Hospital Association (AAHA). Were actively promoting their

Dr Clayton MacKay

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26 | companion

WSAVA NEWS

Diagnosing pain and suffering in companion animals and prescribing appropriate measures to manage and relieve it is one of the most vital functions a vet can perform but, as in many areas of veterinary care, the range of approaches and techniques varies dramatically across the world

Moving forward with pain management introducing the Global Pain Council

planned but will be dependent on industry sponsorship. They include:

The creation of a marketing plan and promotional materials to support the Global Pain Management Treatise and the CE programme

Further work with regional academic institutions and associations to ensure progress towards self-sufficiency/reliance on continued regional Pain Management CE

Further implementation of CE programme with a particular focus on academic institutions

Regional lobbying for access to needed pain management medication

Expansion into pet owner education/awareness.

For further information on this project, please contact wsavasecretariat@gmail.com.

The WSAVA, under the chairmanship of Professor Karol Mathews, is now moving ahead with an initiative to promote higher stands of pain management at a global level. The first step was the creation of a Global Pain Council (GPC) which has identified two initial activities:

The collation of pain assessment and management information into a Global Pain Treatise

The compilation of an inventory of pain management needs in regions around the globe.

Once these pieces of work have been completed, they will be used as a basis to help the GPC design and deliver targeted and customised educational (CE) programmes. The CE will be delivered in the regions, at WSAVA Congress, as part of WSAVA member association CE events, and through online CPD.

Further phases of activity for the GPC are also

planned but will be dependent on industry sponsorship. They include:

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WSAVA NEWS

Professor Dr. med. vet. Peter F. Suter, aged 80, passed away peacefully on Saturday, February 12th, 2011, in his home town of Affoltern am Albis following a brief but intense battle with pancreatic cancer. He leaves behind his loving wife of 51 years, Evelyn, his sons Martin, Chris and Roy, two daughters in law, five grandchildren and many close friends.

Born and raised in Switzerland, Peter initially assumed he would step into the shoes of his father and take over the family farm. However at the age of twenty he decided to become a veterinary surgeon and graduated from the University of Zurich in 1955. He met his wife while working at his uncles flower shop to help fund his studies. They married in 1959 and moved to Hedingen to raise a family. In addition to working as a veterinary surgeon at the Tierspital of the University of Zurich, Peter opened his own small animal practice during evenings and weekends. He soon became a favorite point of call for local families and farmers.

Impressed with his academic achievements, teachers and colleagues

encouraged Peter to pursue a full-time academic career in veterinary medicine. He was fascinated by the field of radiology, and soon moved his family to the USA to pursue his dream. He initially worked as an Assistant Professor in the radiology department at the Animal Medical Center in New York between 1967 and 1969. He then moved to California to join the radiology department of the University of California, Davis, Veterinary School, where he worked as a Professor from 1969 until 1981.

His ground-breaking research, publications and passion for teaching cemented his reputation as one of the worlds leading radiologists. In 1981 Peter returned to Switzerland where he took over the position of Director of the Clinic for Veterinary Medicine at the University of Zurich. During the following fifteen years until his retirement in 1995, Peter was a key driving force helping to establish Zurich as a veterinary school and clinic of international stature.

Throughout his career, Peter was a prolific author, publishing numerous textbooks, many of which have become

Some words of appreciationProfessor Peter Suter

Weve been saddened to hear of the passing of our illustrious colleague, Peter Suter. His family have prepared a brief eulogy which we thought you would like to share. He was a wonderful man and an exceptional vet

classics with both veterinary students and practicing veterinary surgeons alike aroun