The essential publication for BSAVA members

Clinical ConundrumConsider the case of an anorexic bearded dragonP8

How ToProvide effective oxygen supplementationP12

The essential publication for BSAVA members

companionSEPTEMBER 2009

Kitten TrainingThe benefits of kitten classes to the practiceP20

Where does the profession

stand on waste regulations?

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3 Association NewsIntroducing the Petsavers Management Committee

47 What A WasteThe rules on the disposal of healthcare waste. John Bonner reports

811 Clinical ConundrumConsider the case of an anorexic bearded dragon

1215 How ToProvide effective oxygen supplementation

1618 GrapeVINeFrom the Veterinary Information Network

19 PetsaversLatest fundraising news

2021 Kitten ClassesKersti Seksel outlines the benefits of kitten clubs

2224 WSAVA NewsThe World Small Animal Veterinary Association

2526 The companion InterviewElizabeth Simpson

27 CPD DiaryWhats on in your area

companion is produced by BSAVA exclusively for its members.BSAVA, Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley, Gloucester GL2 2AB.Telephone 01452 726700 or email companion@bsava.com to contribute and comment.

BESTBEHAVIOUR

Additional stock photography Dreamstime.com Barbara Helgason | Dreamstime.com Eyewave | Dreamstime.com Fabian Schmidt | Dreamstime.com Linncurrie | Dreamstime.com Marianna Raszkowska | Dreamstime.com Marzanna Syncerz | Dreamstime.com Srdjan Srdjanov | Dreamstime.com Tony Campbell | Dreamstime.com Vclements | Dreamstime.com

The NEW edition of the BSAVA Manual of Canine and Feline Behavioural Medicine will be published soon and will be an essential update for members practice library shelves. Building on the success of the first edition, published in 2002, the Editors have again brought together a host of international experts on behavioural medicine of dogs and cats. This new edition is designed to be even more practical and user-friendly, with the following considerations discussed for a range of behavioural presentations:

Evaluation of the patient, including any possible underlying diseaseEvaluation of client attitudes, beliefs and behaviourRisk evaluation Behavioural biology of the condition Acute management protocols Long-term treatment strategies Prognosis Follow-up Preventive measures.

ISSN 2041-2487

The Manual will include history-taking forms and questionnaires, together with a CD containing a series of useful client handouts that can be printed out, and to which you will be able to add your practice details.

Members will soon be able to order the new edition online at www.bsava.com or from our Membership and Customer Service Team (telephone 01452 726700, fax 01452 726701, email administration@bsava.com).

Member price 49. Members get great savings (typically 30% or more) on BSAVA Manuals, as well as further discounts on selected titles at participating BSAVA events.

A new edition of the BSAVA Manual of Canine and Feline Behavioural Medicine is due out next month, edited by Debra Horwitz and Daniel Mills

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ASSOCIATION NEWS

INTRODUCING THEPETSAVERS MANAGEMENT COMMITTEEPetsavers was established in the early Seventies (originally called the CSTF) by a group of veterinary surgeons who recognised a need to fund high quality research into conditions which affect small animals. This is how the Management Committee works to improve the knowledge and treatment of SA diseases whilst maintaining the highest ethical and scientific standards

Jo ArthurJo is Chair of Petsavers Grant Awarding Committee (GAC). Her role is to provide information about how the GAC has awarded the funds raised by Management Committee. Jo has raised a lot of money for Petsavers by participating in six London 10K runs since 2004.

Sarah CollinsSarah is a qualified veterinary nurse working at Langford Veterinary Services. She was invited to join the management committee to provide a nurses input as this group have always been great supporters of the charity, helping to explain the work of the charity to pet owners. Sarah has served on the committee for the last year, and has recently taken over the job of putting together the Bulletin.

Mark PertweeMark is Chair of the Management Committee, having previously acted as a regional Petsavers representative. He has raised money for the charity with his various climbing expeditions and often represents Petsavers at events. Mark works in practice in Worthing.

Ed HallAs Senior Vice President, Ed sits on Petsavers Management Committee as the BSAVA Officer. The Officer is there to provide their wider experience of the Association and to help identify where there are opportunities to work with other committees or organisations.

Want to get more involved with BSAVA? For details about volunteering email Carole Haile (c.haile@bsava.com) or call 01452 726717.

Whos who on PMC

Over the last 35 years Petsavers has funded many groundbreaking and important research projects into diseases such as diabetes, arthritis and neoplasia. In order to qualify for an award a research project must show that it will be of benefit to small animal clinicians and must not involve the use of experimental animals. In addition, Petsavers has funded various three year clinical training scholarships at vet schools throughout the UK. Subjects have included, oncology, orthopaedics, medicine, anaesthesia and critical care, dermatology and neurology. Frequently the recipients have gone on to become leading specialists in their field.

The Petsavers Management Committee is made up of

volunteer veterinary surgeons and nurses, plus a full time fundraiser. The role of the committee is to find ways to raise awareness of Petsavers amongst the profession and the public. This is achieved through events like the London 10K run, competitions and the sale of Petsavers branded products such as heated pads, pet carriers, collars and cards. Petsavers also provides support to individuals who wish to raise money for the charity through their own personal fundraising projects. The committee is constantly looking for new ways in which to raise the profile of the charity. For more information visit www.petsavers.org.uk or email info@petsavers.org.uk to find out how you can get involved and download copies of the Petsavers Bulletin. n

Simone Der WeduwenSimone discovered Petsavers through her role as Secretary in the North West region, where she organised raffles and other fundraising activities. She has also run the 10k and the London Marathon on behalf of Petsavers and says she enjoys being involved in raising awareness of this veterinary charity, which doesnt just help individual pets during their lifetime but improves the welfare of our pet population for many generations to come.

Michelle SteadMichelle is Chair of Southern Region as well as volunteering with Petsavers. She is involved with the selection of our annual charity Christmas cards, works on our stands at events such as Discover Dogs, and generally pitches in wherever she can with her invaluable support.

Darren PeartDarren worked in small animal practice after graduation before working in industry as an advisor then product manager and Field Sales Manager. He now works for Intervet/ScheringPlough Animal Health and brings his commercial and veterinary experience to his involvement with Petsavers fundraising.

Ruth CorkhillRuth has worked in practice in Birmingham and has an interest in breeding. She is also Petsavers regional representative for the Midlands. She joined Petsavers Management Committee to help reinforce the influence of practitioners on the fundraising strategy for the charity.

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REGULATIONS

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WHAT A WASTEFour years on from the introduction of new rules on the disposal of healthcare waste and everyone involved in the process knows exactly what is expected of them yes? Well, not exactly, says Mike Jessop, Past President and BSAVAs in-house expert on what we used to call clinical waste. He tells John Bonner that despite all the work BSAVA and the Goat Vet Society did in helping BVA produce guidelines, the veterinary profession still needs clarification on key details of the regulations or it may soon find itself in a mess

This is the kind of case that keeps Mike Jessop awake at nightClients bring in their 60kg Rottweiler to his practice in South Wales for surgery on its knee. Somehow, the wound becomes infected with the MRSA bacterium. Despite the best efforts of the clinical team, they are unable to control the infection and the animal has to be euthanased.

Due to the national authoritys strict interpretation of the waste disposal legislation, the cadaver is classified as hazardous waste. It is taken to a transfer station where it is mixed with other

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REGULATIONS

dangerous materials before being taken away to a specialised hazardous waste incineration plant. The practice then has to present the already distraught clients with a bill of 720 to simply cover the cost of disposing of the dogs remains. Can we have his ashes back?, ask the clients. No? Well in that case can we at least go and see his last resting place? The vet looks down and shuffles his feet in embarrassment...

Fighting your cornerMike had the misfortune of being the BSAVA officer who was assigned responsibility for drafting the Associations response in the consultation process on the Hazardous Waste Regulations (England & Wales) 2005. As such he became embroiled in dealing with legislation that is extremely complicated, onerously detailed and not just a little bit soporific although it also has enormous implications for the way that small animal practitioners run their businesses.

Before these rules were introduced, life was much simpler for practitioners. All animal parts, swabs, soiled dressings, etc were dropped into yellow clinical waste bags and taken off with any cadavers for incineration at the nearest pet crematorium. Now, the crematoria need to obtain a special licence to incinerate material other than animal carcases. Meanwhile, the practice waste has to be sorted into a bewildering array of different receptacles, depending on whether they are classified as hazardous or non-hazardous, and the intended means of disposal.

Regulation regulation regulationThose categories are based on the European Waste Framework Directive which controls the disposal of all forms of hazardous waste,

either by burial or incineration. The 2005 regulations implement the directive in England and Wales, with similar regulations already introduced in Scotland and soon to be in Northern Ireland. Two other documents are also important in determining how practices should deal with what now must be called healthcare waste. These are the Department of Health guidelines produced in 2006 (see www.dh.gov.uk) and the Special Waste Regulations 1996, which attempt to define which chemical and biological materials should be classed as hazardous. This includes a key definition of infectious waste as any substances containing viable microorganisms or their toxins which are known or reliably believed to cause disease in man or other living organisms.

While that wording seeks to minimise the risks to the public from cadavers of animals that have died from diseases caused by zoonotic pathogens, it could also be interpreted to mean many other materials. That might include a disposable towel handled by someone who carries MRSA on their hands, Mike points out.

As with much EU legislation, the interpretation of the legislation is crucial. The Commission attempts to draft reasonable rules covering a wide range of industrial sectors and the differing national requirements of 27 member states. There can also be further variation in the way that the rules are applied, as in Scotland where different terminology is used to define waste and the responsible authority is the Scottish Environmental Protection Agency, rather than the Environment Agency for England and Wales. Further down the process, it is possible for different interpretations of the rules to emerge at a local level, according to the whims of individual inspectors.

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REGULATIONS

Counting the costSo far, there have been no known examples of the nightmare scenario that Mike suggests and there is an understandable view among some senior members of the profession that sleeping dogs should remain undisturbed. However, he believes that the profession needs clearer guidance on what exactly constitutes hazardous waste, or its members may find themselves at the mercy of the specialist waste contractors.

Currently, an animal that dies or is euthanased at the practice is sent for incineration and any bedding is classed as offensive waste and put in the yellow and black tiger bags for deep landfill. That would cost me 2.60 for a 7kg bag. But if everything is treated as hazardous waste the costs for disposal at one of the few sites licensed to dispose of those materials rises to about 1.85 a kilo. On top of that, the practice would have to pay a consignment fee for every item handed over to the contractor, together with a fee to the Environment Agency. The costs of disposing of the carcase could easily run into hundreds of pounds.

When Mike has raised this issue with the Environment Agency, its staff have made reassuring noises about the small number of animal carcases likely to fall into this category, though he reckons that in a typical small animal practice there could, with pedantic interpretation of the definitions, be at least one or two cases a month of animals dying or being euthanased with an infection that is potentially transmissible to humans. If there are about 4500 practices in the country each seeing two cases then around 100,000 pet owners a year could have a further reason to lament the loss of their animal.

These rules could have a particularly dramatic effect on the work of animal welfare groups, Mike warns. The charity clinics see a disproportionate number of infectious diseases because their clientele have a traditionally poor uptake of vaccination. So an RSPCA clinic may produce four to five cases per vet per month.

What is waste?Cadavers, of course, are not the only items produced by a veterinary practice which might be classified as hazardous waste. Clear guidance on the disposal of medicines has been produced by the BSAVA and is available online under the ADVICE section of www.bsava.com. There is less certainty, though, about the rules on other waste materials such as sharps and the waste chemicals produced in the practice laboratory.

Sharps are a particularly contentious issue, with the Scottish authority advising those practices north of the border to separate off special (i.e. hazardous) and non special waste items. But the Environment Agency appears to regard all sharps as potentially hazardous and would like them to be subject to the more stringent disposal process. The Department of Health is taking a similar line, and applying the precautionary principle to the much greater volumes of these materials produced by the National Health Service.

This indifference to the costs of disposing of the highest category materials could be a consequence of the sort of economies of scale that an organisation of the NHSs size should be able to negotiate with waste disposal contractors. However, Mike speculates that there may be another explanation, in the lack of accountability often displayed by such a financial

behemoth. I suspect that they may not realise why they are paying this bill until the Audit Office comes along in five years time and asks what is all this for?

ImplicationsAs small businesses, veterinary practitioners tend to be much more concerned about wasting money than the public sector seems to be. Yet the need to control costs is not the only reason why Mike is worried about how the term hazardous waste will be defined. If the process is taken to its illogical conclusion, practices could be required to apply for a licence to transport its hazardous materials from a branch premises for storage at the main site. Mike has queried this with his local Environment Agency and been told that strictly speaking the carriage of small quantities of waste material that is not the carriers own waste should require a waste carriers licence. However, given that the waste is transported to the main collection centre by an employee or the owner of the establishment, the agency would not pursue any licensing requirements at this time. Though it is reassuring, the Welsh Environmental Agencys response does not provide guarantees that inspectors at other offices may not come up with a different opinion, or that the local view may not change with time.

If the agency finds that a practice has infringed the regulations, the penalties can be severe. If your waste bag splits open at the land fill site and spills some theatre waste, the practice owner is legally responsible and may pay a fine of currently up to 5,000 plus costs. Serious breaches of the rules which may endanger life, such as a needle stick injury, carry the possibility of an unlimited fine or imprisonment, he warns.

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REGULATIONS

To ensure that the practice does not fall foul of the law, staff must carefully follow the rules as they are currently understood. This means that we should be segregating waste according to the instructions given in the BVA good practice guide produced in conjunction with BSAVA and the Goat Vet Society, and ensure that the practice has a contract with a properly licensed and approved waste disposal company. It is also important for the responsible person at the practice to fill in all the paper work every time that a consignment of waste is handed over for disposal. That person may be the practice manager or the senior nurse but it is the practice owner who is ultimately responsible and they must ensure that they know what is happening and have established the necessary practice protocols and policies, he says.

Going forwardMeanwhile, Mike insists that the BVA (as the professions lead organisation on this issue) should be pressing the Environment Agency to reconsider the status of animal cadavers under the rules and to clarify its position on the other areas where there is still confusion.

These problems over the disposal of pet animals have arisen only in the UK because the other EU member states have taken a different route in implementing the legislation. Everywhere else in Europe, dead pets are treated the same as fallen livestock and disposed of under the relevant animal waste legislation. Under those rules, it is permitted in Britain to send a sheep or cow with a transmissible spongiform encephalopathy to be incinerated at the nearest facility, usually one of the networks of pet crematoria.

So despite the complexity of the broader legislation there is a relatively straightforward solution to the issues which Mike has raised. That is for the Environment Agency to recognise that a dead dog or cat is not a uniquely dangerous item that needs to be treated as significantly more dangerous than human or farm animal remains.

At the moment there is this bizarre situation in which a human dying of MRSA or some other infection such as salmonella

can be buried in a public cemetery or cremated at the local crematorium, with the family receiving the ashes back. However, if a dog dies of those same diseases, it has to be treated as hazardous waste. What we are calling for is a simple change, for the cadavers of domestic pets to be removed from the hazardous waste regulations or to allow existing pet crematoria to handle these supposedly hazardous carcases as they were previously allowed to do. n

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CLINICAL CONUNDRUM

CLINICALCONUNDRUMLivia Benato, RCVS Trust Senior Clinical Training Scholar in Rabbit and Exotic Medicine at the Royal (Dick) School of Veterinary Studies, invites companion readers to consider the case of an axorexic bearded dragon

Case PresentationA 11/2-year-old male bearded dragon (Pogona vitticeps) weighing 430 grams was presented because it was anorexic, thin and reluctant to move. The animal had been purchased from a local pet shop one year before and was housed alone in a glass vivarium. The vivarium was furnished with a branch for climbing; a heat lamp was installed on the top of the tank, and fine sand used as substrate. The vivarium also contained a UV lamp that had not been changed for a year. The bearded dragon was misted once daily and fed with variably sized crickets and vegetables dusted with a calcium and multivitamin supplement. Water was provided by means of a small bowl on the bottom of the tank. No monitoring of temperature and humidity was possible inside the vivarium. The owner reported that in the previous 4 weeks the dragon had become anorexic and had stopped passing faeces, spending most of the time in the same position. On clinical examination the bearded dragon appeared dehydrated, with sunken eyes, and was lethargic. The oral cavity and teeth were in good condition. The skin appeared dry and relatively inelastic, with evidence of incomplete shedding. An elongated soft mass was palpable in the middle of the coelomic cavity. No other abnormalities were detected.

Identify problems from the clinical history and physical examination

Sub-optimal husbandry Lack of monitoring temperature

and humidity The UV light had not been changed

during the previous 612 months and may not be working correctly

The water bowl was too small Fine sand is a poor choice of

substrate as it has been associated with intestinal impaction

Vitamincalcium supplement provided by dusting only

AnorexiaLethargyDehydration (dry skin, sunken eyes)Elongated mid-abdominal massNo faecal output during the preceding 4 weeks

Consider the differentials for the problems: can they be prioritised based on the information so far?

Anorexia is a non-specific clinical sign that can be associated with a variety of disorders, such as systemic infection, gastrointestinal disease, metabolic bone disease, renal disease, liver disease, stomatitis, pneumonia and electrolyte disorders.Lethargy is also a non-specific sign and can occur in hypoglycaemia, hypocalcaemia, hypothermia and metabolic bone disease.Differentials for the abdominal mass would include gastrointestinal obstruction, abscess, uroliths and neoplasia.Dehydration may have developed due to the poor husbandry, or water intake may have decreased secondary to another disease process.

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CLINICAL CONUNDRUM

Faecal output may have been reduced due to parasitic disease, gastrointestinal impaction/obstruction, uroliths or neoplasia.

What would be your first steps in investigation?

To evaluate for the presence of intestinal parasites, the cloaca was swabbed and the sample spread on a glass slide. A small amount of warm saline solution was added and a smear made and examined microscopically. No parasites were found (if more material had been available, faecal flotation and/or concentration would have been more sensitive).A blood sample (0.5 ml) was taken from the ventral coccygeal vein and a blood smear made. The remaining blood was placed in a lithium heparin microcontainer and submitted for haematological and biochemical

evaluation to assess: renal and hepatic parameters; serum calcium (ionised); the degree of dehydration; inflammation (infectious/non infectious). All results were within the laboratorys normal reference ranges for this species apart from haematocrit which was at the very top end of the normal range. No toxic changes were detected in any cell line.A radiographic examination was performed to evaluate the mass and to assess the possibility of gastrointestinal obstruction. Cotton wool was placed around the patients head to apply slight pressure over the eyes and stimulate the immobilising vago-vagal reflex. The patient was taped onto the radiographic cassette with micropore non-adherent tape. A dark and quiet environment contributed further to its immobilisation. Lateral and dorsoventral full body exposures were taken.

Interpret the radiographic findings and make a diagnosisThe radiographs showed a mass in the caudal coelomic cavity that is consistent with an intestinal impaction (arrowed in Figure 1). No other radiographic abnormalities were detected and skeletal density was considered adequate.

A diagnosis of intestinal impaction associated with dehydration and sub-optimal husbandry was made. The nature of the impaction could not be determined from the tests conducted thus far.

How would you treat this case?The treatment plan had a number of aims: to address the underlying causes, such as sub-optimal husbandry; to correct the dehydration; and to resolve the intestinal impaction by a surgical or medical approach.

Figure 1: A horizontal beam lateral view radiograph of the bearded dragon

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CLINICAL CONUNDRUM

CLINICAL CONUNDRUM

Figure 3: Cat with simple closed urinary collection system

Husbandry: The bearded dragon was hospitalised and placed in a vivarium with newspaper as substrate. Newspaper was chosen as it is both digestible and non-toxic should it be ingested. A heat lamp and a UV-B lamp were placed on the top of the cage at a maximum distance of 20 cm from the patient. The average temperature was maintained between 30C and 32C with a top temperature of 40C under the basking light. The relative humidity was maintained at 3050%. Temperature and humidity were monitored using a thermometer and hygrometer placed inside the cage. A shallow water bowl was also provided.

Rehydration: Options for rehydration therapy comprised:

Bathing in shallow warm water (reptiles can absorb water from the cloaca, the warm environment stimulates their metabolism and the patient can drink the bathing water)Subcutaneous fluid administrationOral gavage of an electrolyte solution.

In this case a bath in shallow warm water helped to rehydrate the bearded dragon while minimising stress associated with excessive handling. The bath was repeated three times daily.

In addition, a bolus of 10 ml of Hartmanns solution (2% of body weight) was given subcutaneously into the dorsal area and 13 ml of electrolyte solution (3% of body weight) was given orally via crop tube. This fluid supplementation totalled 5% of body weight and was repeated twice within the next 24 hours.

Electrolyte solution was preferred over assisted feeding during the first 24 hours of hospitalisation to avoid metabolic imbalance, common in anorexic reptiles. The use of oral electrolyte solution also rehydrates the gastrointestinal contents and aids avoidance of refeeding syndrome in which rapid administration of calories may provoke a life-threatening metabolic imbalance. From the second day of hospitalisation, the electrolyte solution was replaced with Critical Care Formula for

Reptiles (VetArk) at the same quantity three times daily.

Resolution of intestinal impaction: In this case, because the intestinal impaction was thought to be due to dehydration rather than an intestinal foreign body it was decided to start with medical treatment and rehydration, rather than performing surgery. An enema using 5 ml of warm sterile saline solution was given gently three times daily in order to rehydrate the intestinal mass causing the impaction and to stimulate intestinal motility.

OutcomeOn the fourth day of hospitalisation, the bearded dragon passed a significant amount of faeces and a dry mass of urates (Figure 3).

During the following 2 days some mealworms were left in the cage and the bearded dragon resumed eating and started to become more active. On clinical examination the bearded dragon appeared relaxed and the coelomic cavity was not tense when palpated. No masses were found. The treatment was discontinued and the patient was discharged.

What advice would you give to the owner regarding prevention?At home, the owner was advised to improve their husbandry and management of the bearded dragon. The fine sand substrate was replaced with newspaper that was changed on a regular basis. A UV-B lamp was added to the cage, and the bearded dragon was bathed daily. It was recommended that a variety of vegetables and invertebrates be fed, and to offer vitamin and mineral supplemented gut-loaded crickets rather than supplying the supplement by dusting alone.Figure 2: Warm water bathing to encourage rehydration

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CLINICAL CONUNDRUM

Figure 3: Dry urates passed by the bearded dragon on day 4 of hospitalisation

At follow-up 1 and 4 weeks post hospitalisation, the client reported that the bearded dragon was very active, was eating well and was taking different types of invertebrates and vegetables daily. The owner had changed the substrate to artificial grass that was cleaned and washed regularly and a shallow water bowl, big enough for the bearded dragon to bathe in, had been provided. The owner had not weighed the reptile, even though it had been advised.

DiscussionThe bearded dragon is a desert lizard native to Australia. It is a very popular pet, particularly amongst beginner herpetologists. However, in captivity this species frequently suffers from disease problems that are directly due to poor husbandry and management.

Gastrointestinal impaction can occur for several reasons, such as stress, inappropriate feeding, inadequate temperature and humidity in the vivarium and, frequently, the accidental ingestion of substrate.

Obtaining a thorough and accurate history is an important part of the reptilian

clinical examination, as many medical problems are related to the experience of the owner and the quality of the management and feeding. In this case the owner was not an experienced herpetologist and was not fully informed about the management and feeding of

Reptile husbandry and health a practical approachThe BSAVA Manual of Reptiles, 2nd edition is edited by Simon Girling and Paul Raiti and features a host of international expert contributors. Correct husbandry is the starting point of the Manual and is emphasised throughout as of prime importance. Details of clinical examination and procedures including anaesthesia and surgery follow. Disorders are then discussed on a system basis, with separate chapters devoted to parasitology and infectious diseases. Useful appendices include a drug formulary, a table of differentials for presenting signs, and a protocol for handling venomous snakes and lizards. Full-colour photos and useful tables complement the text throughout.Member price: 59 (89 to non-members)Available from www.bsava.com or ring 01452 726700

bearded dragons. Sunken eyes are a common clinical sign of dehydration in bearded dragons and might have been detected by a more experienced owner. Lethargy, anorexia and weakness are common clinical signs in animals with intestinal impaction. In this case the intestinal impaction was secondary to dehydration and accumulation of dry urates in the caudal part of the intestinal tract, but ingestion of inappropriate substrate might also have been implicated.

This case illustrates that incorrect husbandry in reptiles can rapidly lead to life-threatening conditions that are entirely preventable. Simple supportive care, by providing appropriate temperature, lighting and humidity, are frequently all that is required, in combination with long-term changes in the home environment and diet to prevent further disease.

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HOW TO

PROVIDE EFFECTIVE OXYGEN SUPPLEMENTATION

HOW TO

Karen Humm of the RVC discusses the pros and cons of methods of oxygen supplementation

Direct from a cylinder using oxygen tubingBreathing system attached to an anaesthetic machinePiped source: Using oxygen tubing Using a breathing system.

HumidificationIrrespective of the method of administration, oxygen is supplied in cylinders or tanks of dry gas or produced as a dry gas from an oxygen generator. Administration of dry oxygen at high rates can lead to increased viscosity of respiratory secretions, impaired muco-ciliary clearance, mucosal desiccation and an increased risk of respiratory tract infection. Therefore if oxygen is to be administered for longer than an hour or so, it should be humidified. This is particularly important in patients with nasal or tracheal catheters or those undergoing mechanical ventilation as the administered oxygen bypasses the upper airway, the natural site of humidification in an animal. Humidification is achieved simply by allowing oxygen to bubble through sterile water. Bubble humidifiers are cheap (Flexicare Medical Ltd.) and will fit onto flow meters designed for piped oxygen (Figure 1). If a humidifier is not available, regular nebulisation can be performed but this requires intensive nursing care and expensive equipment. Alternatively, some commercially available oxygen cages have an integral humidification system.

Short term methods of oxygen supplementationWhen a patient in respiratory distress presents to the practice, a quick but thorough physical examination should be

performed (focused on the patients respiratory, cardiovascular and neurological systems) and initial stabilisation performed. During this period oxygen is generally supplemented non-invasively. However, the requirement for a member of staff to stay with the patient constantly means that this is usually a short term option and facilities for administering oxygen on a longer term basis may need to be organised.

Respiratory distress is triggered by hypoxia, hypercapnia or a marked increased in the work of breathing. Hypoxia is by far the most common of these causes and generally patients with hypercapnia or a marked increase in the work of breathing have concurrent hypoxia. Therefore oxygen supplementation is of key importance in managing any patient with respiratory distress. If there is uncertainty as to whether a patient is in respiratory distress, supplemental oxygen should be administered while they are evaluated.

Oxygen supplementation methodsOxygen makes up approximately 21% of the gaseous component of room air. Various methods of increasing this percentage are available, each with its own advantages and disadvantages. For both short and long term options the percentage inspired oxygen achieved will be affected by the size of the patient, their respiratory rate and the flow rate of oxygen used. Rough guides for flow rates are given below but they only act as a starting point and adjustments may need to be made on a patient by patient basis.

Oxygen sourceThe source of oxygen for patients in respiratory distress will vary between practices depending on their facilities. However most practices will use one (or more) of 4 options:

Figure 1: Bubble humidifier

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HOW TO

1) Mask supplementationUsing a mask to provide oxygen to a patient is simple and effective. An oxygen flow rate of one (for cats and small dogs) to ten (for giant breeds) litres/minute should be used. Whilst a high percentage of inspired oxygen (8090%) can be achieved in anaesthetised dogs using a tight fitting mask, the majority of conscious dyspnoeic patients will not tolerate a tight fitting mask and therefore the actual percentage of inspired oxygen in clinical patients is closer to 3555%. Calmer patients will tolerate a mask gently held over the muzzle allowing free movement, but many patients, particularly cats, will not allow a mask near their head. Struggling with a patient to administer oxygen is counterproductive as their oxygen demand will be increased by the stress and increased muscular activity. Collapsed or weak patients are ideal candidates for mask oxygen supplementation as they do not move (although unconscious patients need intubation to protect their airway from the

risk of aspiration) (see Figure 2). Care should be taken as a tight fitting mask can easily lead to hyperthermia and inadvertent use of lower oxygen flow rates than the patients minute volume re-breathing will result in hypercapnia.

2) Flow-byFlow-by supplementation is not an efficient means of oxygen supplementation (Figure 3). The conscious patient is likely to receive an inspired oxygen percentage of considerably less than the maximum, 40%, achievable by this method. However, flow-by is usually ready within seconds, is non-invasive and is less stressful than mask supplementation. Flow rates of 210 litres/minute should be used and the oxygen outlet should be held as close to the patients nose (or mouth if they are panting) as possible without causing distress. Sometimes a patient will tolerate flow-by when tubing is directed to the side of their mouth rather than in front of it.

3) Tracheal oxygen supplementationIf a patient is showing signs of severe respiratory distress secondary to upper respiratory tract obstruction (increased inspiratory effort and marked inspiratory noise audible without a stethoscope) a catheter can be placed percutaneously into the trachea. A brief clip and clean of the overlying skin is required and a large bore, 14 or 16 Gauge, catheter is inserted into the space between the tracheal rings 4 and 5 or 5 and 6. Once the stylet is within the trachea the catheter is advanced into the tracheal lumen in the direction of the carina and the stylet removed. Oxygen is then administered in a flow-by fashion directed at the catheter. This technique is only useful in dogs over approximately 10 kg who have a sufficiently large tracheal lumen to allow catheter placement. Invasive tracheal oxygen can be difficult to maintain and so is really only suitable for short term oxygen supplementation.

Figure 2: Oxygen delivered by mask is most suitable for weaker patients

Figure 3: Oxygen flow-by

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HOW TO

PROVIDE EFFECTIVE OXYGEN SUPPLEMENTATION

Longer term oxygen supplementationFollowing an initial physical examination and emergency stabilisation (e.g. furosemide administration or thoracocentesis) it is often beneficial to allow a patient to calm in a kennel prior to further manipulation. Oxygen supplementation is continued with flow by or mask supplementation whilst preparations for delivery of oxygen supplementation in the longer term are made.

1) Nasal cathetersOxygen can be supplied direct into the respiratory tract via nasal catheters in both dogs and cats. Feeding tubes are commonly used as catheters with a 5 French catheter being suitable for a cat and an 8 or 10 French for most dogs. Before placement the catheter should be pre-measured against the animal from the nostril to the lateral canthus of the eye. A few drops of 0.5% proxymetacaine or 2% lidocaine should be administered into the nostril 10 minutes prior to placement of the catheter. The patient is gently restrained with their nose pointing dorsally and the catheter is advanced into the ventral meatus. Pushing the nasal planum

dorsally while aiming the catheter ventro-medially can aid correct placement. The catheter should be gently but rapidly advanced as patients often move and sneeze during this part of the procedure. If the catheter is not in the ventral meatus it will not advance the pre-measured distance as the dorsal and middle meatuses end at the ethmoid turbinates rather than in the nasopharynx. Once the catheter is in the correct position it should be fixed in place with sutures or tissue glue attached to butterfly wings of tape round the catheter. The catheter should loop round the alar cartilage with fixation close to the nasal orifice to prevent dislodgement (Figure 4). The catheter is then looped dorsally between the eyes (which may decrease the chance of the patient removing it) or onto the lateral aspect of the head to be secured just below the ear.

The procedure should be abandoned if an animal becomes distressed as this may lead to marked worsening of their hypoxia. The procedure is also contraindicated in coagulopathic animals. Once in-situ catheters can be displaced by determined patients, so a buster collar may be required which again can be stressful. However, if a

patient will tolerate placement and maintenance of a nasal oxygen catheter they can provide a consistent inspired oxygen percentage of 4050% with an oxygen flow rate of 50100 ml/kg/min. The placement of a second nasal catheter can increase this percentage further to 6070%. Unfortunately, if a patient consistently pants then the mixing of air in the pharynx leads to a decrease in the percentage inspired oxygen.

2) Nasal prongs/cannulasProngs designed for oxygen supplementation in humans can be used for dogs. They come in 2 sizes (paediatric and adult Flexicare Medical Ltd). The prongs advance approximately 1 cm into the nostril and will provide a percentage inspired oxygen of around 40%. They are minimally invasive but are therefore easily displaced by an intolerant patient. Administration of proxymetacaine or lidocaine into each nostril approximately 10 minutes before placing the prongs can be useful as can taping the prong tubing together (but not to the dog) over the dorsal aspect of the muzzle (Figure 5). As with a nasal catheter this method is less efficacious in the panting patient.

Figure 4: Nasal catheter looped around alar cartilage and fixed in place using bandage butterflys

Figure 5: Nasal prongs in situ

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HOW TO

Approaches to respiratory distressThe BSAVA Manual of Canine and Feline Emergency and Critical Care, 2nd edition is edited by Lesley King and Amanda Boag, with contributions by experts from the UK, North America and Europe. The Manual provides a practical resource for what remains one of the most important areas of veterinary medicine. Chapter 7 covers the general approach to dyspnoea including emergency stabilisation through oxygen supplementation. Member price: 56 (85 to non-members) Available from www.bsava.com or ring 01452 726700

3) Tracheal catheterSome texts describe administering oxygen via a tracheal catheter on a longer term basis, particularly for patients with facial or upper airway injury. A standard intravenous catheter can be used or a long stay catheter of increased length placed as described above. In the authors hands this is not an effective method for longer term supplementation as the catheter is difficult to secure and prevent from kinking.

4) Buster collar oxygen hoodOxygen can be administered into an enclosed buster collar (either practice-made or commercially produced (Kruuse UK Ltd)). Practice-made collars should have a small gap left at the top of the collar to allow venting of humid air and carbon dioxide. Despite this vent hole, many dogs and some cats become hyperthermic, particularly in hot conditions. Placement of the collar may be poorly tolerated, however most dogs and cats do settle if left in a kennel. A high flow rate should be used initially to fill the collar with oxygen and then a rate of approximately 1 litre/min is suitable for a medium size dog and should result in a percentage inspired oxygen of approximately 40%.

5) Oxygen cageCollapsible (Figure 6) or lightweight oxygen cages are commercially available in various sizes (e.g. J.A.K. Marketing Ltd or Kruuse UK Ltd). They have adaptors for breathing systems and are simple to use. Models vary in presence of means of thermoregulatory or humidity control. Some practices also have permanent fixed oxygen cages although again they are rarely temperature or humidity controlled. As the cages are completely sealed hyperthermia can rapidly develop, particularly in dogs. It is of note that once a cage is opened the level of oxygen within it rapidly drops to room level. This can mean that if a patient is frequently being handled their inspired oxygen fraction is barely increased.

An oxygen cage can be made in the practice when required by placing cling-film over the front of a cage although the gaps present and the large volume of the cage relative to the patient within it, mean that even with very high flow rates the percentage of oxygen is often barely increased.

6) Endotracheal intubation and ventilation

It is very rare that an animal in respiratory distress requires anaesthetising and

intubation allowing provision of 100% oxygen. This most commonly occurs in patients with upper respiratory tract obstruction when intubation allows by-passing of the obstruction such as in cases of laryngeal paralysis. Judging when intubation is required can be difficult. Less invasive oxygen supplementation techniques in conjunction with stabilisation should be attempted first and the patients response assessed. If a patient still has marked respiratory distress despite treatment then intubation and ventilation may be required. If the cause of respiratory distress is not upper respiratory tract in origin the prognosis for patients that require intubation and ventilation is unfortunately very poor.

Oxygen toxicityExposure of the lungs to an inspired oxygen fraction greater than 60% for greater than approximately 2472 hours can lead to oxygen toxicity. This causes damage to the alveoli potentially worsening any lung disease present. Ideally therefore oxygen supplementation should be kept below 60% for longer term supplementation. As most methods of oxygen supplementation in the practice situation do not achieve an inspired percentage greater than 60% this is generally a theoretical concern.

Figure 6: Commercially available collapsible oxygen kennel

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VIN

L. Dean Baird, DVM, Mountain Empire Large Animal Hospital, Johnson City, TN

This posting concerns a 3y F(I) Chihuahua that has had a heart murmur for the duration of the time that the owner has had the dog (approx. 1 yr). Recently, she has had a cough. Otherwise, the dog has apparently been healthy (I have done echocardiography only; I am not her regular DVM). She weighs 3.5lb. She has a loud holosystolic V/VI murmur that is loudest over the heart base. I do not believe that the murmur is present during diastole. Chest rads (which I have not seen, have reportedly shown some evidence of LV enlargement).ECG: HR 150-169, sinus arrhythmia, very tall R waves. Echo results (numerically): LVId 2.3, LVDs .9, VSd .5, VSs .9, LVWd .35, LVWs .9, LA:Ao 2.5:1, FS 56-62

On B-mode the LV and LA appeared enlarged, R side did not appear enlarged. There was no colour-flow evidence of a septal defect. Mitral valve structure did not appear distorted, EPSS was 0.2 cm. I could not see evidence of pulmonic or aortic stenosis. However, this seemed unusual, to me, about the aortic valve area: On the right parasternal short axis view, I could not see the hyperechoic line that is formed between the left coronary cusp and the noncoronary cusps of the aortic valve. Also, on the right parasternal long-axis left ventricular outflow view, the aortic valve cusp that is visible opposite the left coronary cusp appears to barely move away from the wall of the aorta/LVOT. I do not know if these concerns are important. I am not a cardiologist AND HAVE MADE THAT CLEAR to the owner AND, further, have recommended referral to one.

I do not think that they are going to go for referral. So,

1) Based on the information that I have provided, what do you think are the most likely rule-outs (I would have thought, perhaps, MV degeneration, even at this young age, except that the valves do not look diseased).2) Other than a PDA and, perhaps, pulmonic stenosis, is there any other congenital disease that has any chance of surgical repair, currently?

Mark D. Kittleson, DVM, PhD, Diplomate ACVIM (Cardiology), VIN Consultant, University of California, Davis

So this less than 2 kg dog has the LV the size of a 5 kg dog and what appears to be a very large left atrium. That could explain the very tall R waves on the ECG but the only congenital cardiac disease where we see an R wave in lead 2 that is out of all proportion to LV size is in PDA. So how tall was the R wave in lead 2? So far the breed, the tall R wave and the hyperdynamic, volume overloaded left heart make me think PDA is first on the list and then PDA and then PDA. I cant remember if you have color flow Doppler or not. If you do and theres no continuous turbulence on the main PA then its probably not a PDA. If you dont have color flow Doppler, go back and listen to the murmur with your stethoscope head in the left armpit to see if its continuous there or not. How about the femoral pulse? Bounding or normal? Can you get the chest rads to look at and post here? Things get a lot easier if theres a ductal aneurysm present on the DV. Obviously all of this is critical since a PDA can be fixed.

L. Dean Baird

I am at home so I have limited information. Without looking at the tracing, I cannot tell about the R wave size in lead 2. I need to either get the rads that were done (I have not seen them) or repeat them if I can get the dog back in. Also, I can do color flow on the MPA and re-auscult. But, it was the auscultation that has led me away from PDA; it was loud but not continuous (3 other DVMs agreed). Nonetheless, if I can get her back, I will re-auscult. Because, as you stated, this is the one thing that we can do something about and, the owners probably would.

GrapeVINeThe Veterinary Information Network brings together veterinary professionals from across the globe to share their experience and expertise. At vin.com users get instant access to vast amounts of up-to-date veterinary information from colleagues, many of whom have specialised knowledge and skills. In this regular feature, VIN shares with companion readers a small animal discussion that has recently taken place in their forums

Discussion: Chihuahua with congenital or acquired disease?

LVId: Left Ventricular Internal dimension diastole

LVDs: Left Ventricular Dimension systole

VSd: Intraventicular Septum diastole

VSs: Intraventricular septum systole

LVWd: Left Venticular free wall diastole

LVWs: Left Ventricular free wall systole

LA:Ao: Ratio of Left Atrial to Aortic diameter

FS: Fractional shortening

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VIN

What is the left side view for PDA you referred to? Information in my text pretty much limited to left cranial long axis view, and left base long axis view. We were basically taught left apical, on the other end, and left parasternal long and short.

Mark Kittleson

Peter, It is essentially a left cranial view but with the transducer almost on the sternum pointed almost directly up at the spine. Its the left cranial view of the main pulmonary artery and pulmonic valve but a little more extreme. It helps a lot if you have color flow Doppler to get you into the right region, at least.

Mark Rishniw

Its a relatively specialized view that most people without appropriate guidance (by a teacher) and echo experience wont be able to get, unfortunately.

Dave Hoch DVM, Gainesville, FL

I was curious, wouldnt a 3yr old with a PDA present for right sided failure as blood reverses through the ductus? Present with lethargy, inappetance, ascities, differential cyanosis, etc? I just havent seen any 3yr olds with the condition either fixed prior to that age or euthanized on presentation from CHF. Are the owners pursuing correction? If not the little one is just going to go into CHF.

Mark Rishniw, BVSc, MS, DACVIM (Cardiology), VIN Consultant, Ithaca, NY

>>> But, it was the auscultation that has led me away from PDA; it was loud but not continuous (3 other DVMs agreed).

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VIN

All content published courtesy of VIN with permission granted by each quoted VIN Member.For more details about the Veterinary Information Network visit vin.com. As VIN is a global veterinary discussion forum not all diets, drugs or equipment referred to in this feature will be available in the UK, nor do all drug choices necessarily conform to the prescribing rules of the Cascade. Discussions may appear in an edited form.

This thread appears in an edited form.To read the full thread and access the links mentioned visit http://www.vin.com/Link.plx?ID=68604

GrapeVINe

Mark Kittleson

Hi Dave, this dogs PDA has already been closed. Right heart failure definitely not. Reversal of flow? That is about the age a dog with a wide open (grade 6) ductus often shows up. Thats the type that has pulmonary hypertension from birth and no murmur. In all of the others reversal of flow at that age is really rare (dont remember seeing one). Those dogs, if they do show up, show up in heart failure. And weve seen dogs where the PDA has been missed show up much later than that. I dont know the record but my bet is that its 12 or 13 years of age. I know weve seen an 8-year-old this year.

>>> Present with lethargy, inappetance, ascities, differential cyanosis, etc? I believe I was taught that with L to R PDA they show up with the continuous murmur, with varying clinical signs > But as the dog ages, the right side of the heart hypertrophies eventually leading to right to left shunting. > I believe I was taught that with L to R PDA they show up with the continuous murmur, with varying clinical signs > But as the dog ages, the right side of the heart hypertrophies eventually leading to right to left shunting. Is that wrong? > But as the dog ages, the right side of the heart hypertrophies eventually leading to right to left shunting. Is that wrong?

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PETSAVERS

Improving the health of the nations pets

RUNNING THE LONDON 10K FOR PETSAVERS

PETS WE LOVE PHOTO COMPETITION

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

PETSAVERS

Jo Arthur describes how fundraising can mean a fun day out

The London 10K this July was the sixth that Ive taken part in to raise money for Petsavers and in my opinion the atmosphere was better than ever. Around 25,000 runners gave it their best for their chosen charity. Every time I take part in a run for charity Im always struck how such events reflect the best in people not just those who run, but all those who donate sponsorship.

Reasons to runThe number of supporters lining the streets seemed significantly larger than in previous years, all shouting encouragement and clapping us on. Was this because times are hard for many people at the moment, and charity events are an opportunity to feel good about ourselves and those who cant afford to donate sponsorship can at least get out on the street and cheer runners on?

Getting goingThe race officially starts at 9.35am the elite runners start first to the cheers and clapping of all the other runners and stirring music played over loudspeakers. The rest of us have to wait our turn, the last in line not reaching the start line until nearly 10.30am.

The weather was kind to us a mixture of sunny warm spells and overcast not like

the baking heat of one year, when Mark Johnston remarked that if we had been greyhounds or racehorses we wouldnt have been allowed to run. I was grateful for the clement weather, as my training had not gone well due to factors that no doubt affected many of the Petsavers runners during the weeks leading up to the run too much work and even mornings and evenings being too hot to run. I was also grateful for the support provided by Michelle Stead, on Management Committee, who cheered us on in two directions from Cleopatras needle.

The theme of this years Petsavers photography competition is Pets We Love. It is open to all amateur photographers in the UK and judged in two categories (Adults: over 16; Junior: under 16). Remember, this is a great opportunity for you to develop your own budding snapper skills, but also to encourage your clients and introduce them to the work of Petsavers and we will provide you with flyers and posters to

All worth itMany thanks to everyone who ran the London 10K for Petsavers this year, and all those who ran in previous years. Its still not too late to get involved if you would like to show your support for the Petsavers 10K team and contribute to funding Petsavers Clinical Research Projects and Training Programmes, retrospective sponsorship is very welcome; just go to www.justgiving.com/petsavers to donate.

promote the competition in your practice.Photography vouchers will be awarded

to the top three photos from each category 1st prize receives 250 worth, 2nd prize 150 and 3rd 100. The competition closes on 28 January 2010. Full details can be found at www.

petsavers.org.uk. If you would like more flyers like the one

enclosed in this months companion, or a poster, please email your request to info@petsavers.org.uk.

budding snapper skills, but also to encourage your clients and introduce them to the work of Petsavers and we will provide you with flyers and posters to

petsavers.org.uk. If you would like more flyers like the one

enclosed in this months companionplease email your request to info@petsavers.org.uk.

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PUBLICATIONS

20 | companion

KITTEN CLASSEShow they help clients, pets and practiceDr Kersti Seksel is the principal of a referral only specialist practice for animal behaviour in Sydney and Melbourne in Australia and an author of the new BSAVA Behaviour manual (see page 2). Here she outlines the benefits of kitten clubs, having been involved with the popular Kitten Kindy organisation in Australia

Once upon a time it was thought that training a dog before it was 6 months of age was neither possible nor was it of benefit to the puppy or the owner. Now this is known to be incorrect. Puppy training classes were developed almost 20 years ago and are now considered the norm. Veterinary practices around the world have recognised the benefits and conduct the classes on a regular basis. This has benefited many of the 6 million dogs in the UK.

Unfortunately, although cats are thought to be one of the most popular pets in Britain, most of the 7.7 million cats in the country have never benefited from training. In Australia, training schemes such as Kitten Kindy are available. The very idea of training cats is a foreign concept to most people, and so is the idea of holding kitten

socialisation and training classes. Yet Kitten Kindy is one of the training programmes that has proved just as a successful as its canine predecessors like Puppy Preschool, working as a practice builder and delivering many benefits to owners, kittens and the veterinary practice.

What does it involve?Kitten Kindy is a socialisation and education programme designed to help owners and kittens start off on the right track. Like similar training schemes it looks to help prevent behaviour problems, and educate owners on all aspects of raising a kitten and then living with a cat in the family. The aim is also to establish a close bond between the cat, the owner and the veterinary practice. It is another valuable service that veterinarians should offer their patients and clients.

Kitten Kindy in particular is designed for kittens under twelve weeks of age to help them develop into manageable and social adult cats. Ideally kittens involved in such training should be no more than 14 weeks old when they complete the course to avoid the potential for fighting.

Classes like these allow kittens to explore, interact, play with toys and develop confidence. The classes teach

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companion | 21

PUBLICATIONS

owners about normal feline behaviour and how to play and interact with their kittens appropriately, and helps them to prevent or at least deal with many problem behaviours. The success of the programme depends on the support of all personnel within the practice.

Why do the classes?Put simply, it is a great practice builder and lots of fun. The specific objectives of kitten training will differ with the individual practice but generally include education of owners about health care, feline behaviour, appropriate play, early identification of any problem behaviours, and advice on management and socially responsible pet ownership.

What do you need to run a class?You need a secure area of the hospital so that exploring kittens cannot escape. It needs to be relatively large as it is transformed into a kitten gymnasium and needs to provide space for the kittens to explore as well as for the owners to be seated comfortably.

You should have:

a variety of scratching posts vertical and horizontalempty cardboard boxesa variety of toys such as: tunnels air conditioning tubing,

ready-made cat tunnels cat tracks balls / fluffy toys on elastic or fishing

rodscat basketslitter traysan indoor garden.

StructureKittens are obviously not small puppies. Although the basic principles of training are similar, classes cant be conducted the same way as puppy classes. The structure of the classes should suit the individual practice and you should aim to recruit the kittens at the time of their first visit, if not before, through advertising. Provide owners with written material on kitten care that emphasises the importance of training to their kitten.

Classes are best run over a 23 week period and each class lasts about 1 hour each week. The first class is best run kitten-free so that the owners can listen without being distracted by kittens. Kittens should be aged between 812 weeks when they start class. Only three to six kittens should attend each class with their owners. Owners of cats older than 14 weeks are encouraged to attend without their cat so that they too can learn about feline behaviour.

Two people are usually necessary to conduct the class as that allows for better observation of the kittens and more effective control of the class. The whole family should be encouraged to attend and get involved. All kittens attending class must have started their vaccination and worming programme.

What do you teach?With patience and time, kittens can be trained to come when called and sit, walk on a harness and give high-fives. Some kittens respond well to food and praise while others are more motivated by a game. However, the main aim is really to help owners understand their cats and why cats do what they do.

Kittens need to learn in a safe non-threatening environment. The key is always to reward appropriate behaviour. This can be done using small tasty treats such as dehydrated liver, barbecue chicken, cheese, minced meat, or Vegemite. It helps to start training when the kitten is most responsive, for example just before a meal. Each training sessions should be short no more than two or three minutes at any one time but get owners to repeat often at home.

During classes behavioural and medical issues can be discussed. Behaviour topics such as litter tray management (how often to change litter trays, how to clean them, where to place them), appropriate games, scratching posts etc should be covered. Flea control, nutrition and dental care can also be addressed.

Owners should be taught how to teach kittens to accept being handled and restrained. Giving owners a practical demonstration on how to hold kittens, clip nails and how to medicate using rewards are important. Showing owners how to groom and brush their kitten, and bath them if necessary can also be useful. Questions from owners are always encouraged. Homework sheets can be handed out at the end of each class that reinforce advice given in the class.

What can this bring to the practice?The classes help develop a strong bond between the client and the veterinary staff. They allow the opportunity to educate the owner that the veterinary hospital is more than a place for sick animals and annual heath checks. The kittens develop confidence and the owners learn that cats are trainable! Plus its fun!

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TOWARDS STANDARDS IN VETERINARY PRACTICE

Gastrointestinal Standardization GroupThe WSAVA Gastrointestinal Standardization Group was formed to develop a world-wide standard for the histological evaluation and diagnosis of gastrointestinal tract diseases. Without a uniform standard, it has been difficult to compare and contrast results reported in retrospective and prospective clinical trials. With the support of the WSAVA, the Group has been developing a standardized histological evaluation system for companion animal gastroenterological disorders. Standardization will yield several benefits including uniformity in the diagnosis of disease, staging of disease, and the subsequent development of controlled clinical trials for the treatment of canine and feline gastrointestinal disorders.

A look at the achievements and future plans of the WSAVA Standardization Projects

The Groups efforts have been presented at various conferences, including the WSAVA Congress in Dublin, the ACVIM Forum and the ECVIM Congress. The Group presented its report at a Full Plenary Session at the ACVIM Forum on June 7, 2008 in San Antonio, leading to an ACVIM Consensus Statement. These Statements are designed to provide veterinarians with guidelines regarding the pathophysiology, diagnosis, or treatment of animal diseases. The foundation of the Consensus Statement is evidence-based medicine, but if such evidence is conflicting or lacking, the appointed panels provide interpretive recommendations on the basis

of their collective expertise. A more formal version of the Consensus Statement has been submitted for publication in JVIM.

Future projects for the GSG include:

Developing a standard for jejunal and ileal pathologyStandards for surgical biopsy of the GI tractDiagnosis and staging of gastrointestinal lymphoma, especially well-differentiated feline lymphomaBiopsy standards for the diagnosis of intestinal lymphangiectasiaInvestigating the relationship between histopathological and clinical findings.

Key publications from the GSG Day MJ, Bilzer T, Mansell J, Wilcock B, et al. Histopathological standards for the

diagnosis of gastrointestinal inflammation in endoscopic biopsy samples from the dog and cat: a report from the World Small Animal Veterinary Association Gastrointestinal Standardization Group. Journal of Comparative Pathology 2008; 138: S1S43

Willard M, Mansell J, Fosgate G, et al. Effect of sample quality upon the sensitivity of endoscopic biopsy for detecting gastric and duodenal lesions in dogs and cats. Journal of Veterinary Internal Medicine 2008; 22: 10841090

ACVIM Consensus Statement on Guidelines for Histopathological Assessment of Intestinal Inflammation in the Dog and Cat. Submitted to the Journal of Veterinary Internal Medicine

An atlas of the Groups work WSAVA Standards for Clinical and Histological Diagnosis of Canine and Feline Gastrointestinal Diseases is projected for publication in 2010

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WSAVA NEWS

communication system that allows voice and visual conferencing on the study material. The system is cost-effective and allows sharing of high quality images and excellent internet-based voice communication. The images can be manipulated by any member participating in the conference. The project was presented at the ACVIM 2009 Forum in Montreal, Canada.

Looking to the future, the Group is exploring opportunities to prospectively gather more comprehensive case-specific information to be able to correlate disease classification, therapeutic protocol and outcome, thereby allowing better disease prognostication.

Please visit the GI Standardization page of the WSAVA website (www.wsava.org) for more information, including standardized forms for collecting and reporting information obtained during gastrointestinal endoscopy.

The WSAVA and WSAVA Gastrointestinal Standardization Group would like to extend its sincere appreciation to Hills Pet Nutrition for their generous sponsorship of this initiative.

Please visit the Liver Standardization page of the WSAVA website for more information.

The Groups work has been made possible through the generous sponsorship of Hills Pet Nutrition.

Please visit the Renal Standardization page of the WSAVA website for more information about the Groups activities.

The WSAVA and WSAVA Renal Standardization Group would like to extend its sincere appreciation to Bayer Animal Health and Hills Pet Nutrition for their generous sponsorship of this initiative.

Renal Standardization GroupThe purpose of this initiative is to employ the three diagnostic modalities used in human nephro-pathology (light, electron, and immunofluorescent microscopy) to accurately characterize glomerular disease in proteinuric dogs, and to relate these findings to clinicopathological presentation and outcome. The projects long-term goal is to better understand and evaluate, and thus optimize, the medical management of dogs with proteinuric renal disorders.

To accomplish this, two diagnostic renal pathology centres (DRPCs) Texas A&M University and Utrecht University purchased Aperio, a slide digitizing system and software. The equipment has been installed and configured, and is functioning beyond initial expectation. This system allows samples to be submitted to the DRPC for processing and then digital capture of the entire stained section(s) on each microscopic slide. The scanned slides then can be examined by any of the committee members anywhere in the world through a computer. Electron microscopic and immunofluorescent microscopy images can be (and are being) digitally added to the database for viewing as well. The group of participating renal pathologists has expanded to include a number of additional group members from the USA and Europe.

In addition, the group has developed an extensive electronic relational medial database for collecting clinical information on the patients for which biopsy samples are submitted. The goal is to develop a comprehensive and unbiased dataset, in which individual lesions can be quantified and manipulated statistically to identify logical and clinically useful combinations of clinical and pathological findings, which are needed to develop a classification system for proteinuric dogs.

The Group has successfully begun using a

Liver Standardization GroupThis Groups activities have culminated in worldwide standardization for histological evaluation of liver tissues for liver diseases of dogs and cats, including unified nomenclature, well-defined histological diagnostic criteria, and precise definition of chronicity stages and grades of diseases. Additionally, recommendations surrounding the requirements for tissue staining techniques and size of tissue specimens have been put forward for the different diseases. Descriptions of all relevant liver diseases of dogs and cats, together with typical slides, have been made available as a reference for all veterinarians through the publication of the WSAVAs first textbook, WSAVA Standards for Clinical and Histopathological Diagnosis of Canine and Feline Liver Diseases, available from Elsevier. The Group has presented extensively at various veterinary conferences around the world, including the recent ACVIM 2009 Forum in Montreal, Canada.

Helping to make the work possibleIntegral to the adoption of WSAVAs standardization projects is the peer-review provided by the WSAVA Scientific Advisory Committee (SAC). Chaired by Prof Michael Day, the SAC also provides crucial assistance in the planning of the various Congress scientific programs, assessing nominations and recommending WSAVA Award winners, and suggesting responses to the requests for input on scientific matters that are often received by the WSAVA Executive Board.

Another critical factor in the success of the WSAVA Standardization Projects has been that a number of industry leaders in small animal veterinary medicine, including Bayer Animal Health, Hills Pet Nutrition, and Intervet/Schering-Plough Animal Health, have recognized the benefits to global companion animal health. It is through their generous support that these initiatives have become a reality.

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WSAVA NEWS

WSAVA NEWSWSAVA NEWS

A FRESH LOOK AT VACCINESThe VGG is entering a new phase of activity

VGG group: left-right: Drs Ron Schultz, Marion Horzinek and Michael Day

The first phase of the work of the WSAVA Vaccination Guidelines Group (VGG) is now complete, and led to the production of international guidelines for vets that were published in the Journal of Small Animal Practice (volume 48 issue 9, September 2007, pages 528541)

and are also available on the WSAVA website. The guidelines were formally presented at the 2007 Sydney Congress and, since that time, members of the VGG have spoken widely on them in the USA, UK, elsewhere in Europe and in Australia.

The VGG has now been reconvened for a second phase of activity following agreement of sponsorship from Intervet/Schering-Plough Animal Health. This sponsorship will permit a further one-year cycle of activity with three face-to-face meetings. The first of these meetings was held from 13 February 2009. Under the leadership of the new VGG chair, Professor Michael Day, the second phase of the VGG will:

Update the 2007 guidelines Survey WSAVA member associations to collect and analyse feedback on the VGG guidelinesPrepare a new set of guidelines for pet owners and breedersPresent a discussion paper on key issues in teaching of veterinary immunology and vaccinology.

To access the 2007 guidelines and find out more about the VGG, visit www.wsava.org/SAC.htm

The members of the VGG and the WSAVA would like to thank Intervet/Schering-Plough Animal Health for their kind generosity in sponsoring the activities of the VGG.

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THE companion INTERVIEW

ELIZABETH SIMPSONElizabeth Simpson was born and grew up near Croydon, Surrey. Although her school didnt encourage academic ambition, her father, who worked in the City, helped her to choose science subjects at A-level to allow her to pursue veterinary medicine. Elizabeth applied to the veterinary schools in London, Bristol and Cambridge, being rejected by the first on the grounds that they had already accepted their female for the next years intake (1957), but was offered a place at each of the other two schools. Elizabeth chose Cambridge, where she was the only female student in her year, though she says she was never made to feel an outsider by either fellow students or teachers

You spent only a brief time in practice after qualifying in 1963. What attracted you to an academic career?A strong curiosity to find out more about the underlying pathophysiology of disease, an

interest awakened in me during my undergraduate exposure to cutting edge physiology and pathology in Cambridge and subsequently, during my clinical training, to morbid anatomy and histopathology under the guidance of Dr Arthur Jennings at the Cambridge veterinary school. During the two years I spent in practice I was often frustrated at not being able to explore disease diagnosis beyond an examination of biopsies histologically and carrying out postmortems when appropriate.

After returning from Canada in 1966, you worked at Cambridge before taking a post at the National Institute for Medical Research in London in 69. What was your first project there?My research work in Cambridge was focused on tumour rejection responses in

mice and dogs, and I obtained an MRC project grant for this. But I was also teaching pathology to clinical veterinary students as a University Demonstrator (i.e. junior lecturer), and I helped to run the postmortem and diagnostic pathology service of the veterinary school, under Dr Jennings guidance. I moved to the NIMR following an invitation by Sir Peter Medawar, who was then the Director, to spend some of my time providing pathology advice to the experimental animal division, but with the rest free to follow my research interests which by then had converged on the role of various lymphocyte subpopulations in graft rejection responses, a topic under intense scrutiny at the NIMR by a number of scientists, including the Director, at that time.

How difficult was it to build a scientific career at a time when it was still very much a male-dominated world?I found little or no evidence of sexism in attitudes towards me as a student, vet or scientist, either in Cambridge or in London. In contrast, in Canada I had experienced substantial discrimination in the profession,

and in order to work as a vet I had had to start my own practice in Fredericton, New Brunswick, where my then husband had registered for a PhD in geology at the university. When we moved to Ottawa, I likewise had difficulty in being accepted for veterinary posts (how would you, as a woman, do a postmortem on a cow? they seemed not to have heard of the block and tackle), so I moved into a virology research lab.

At the NIMR and the various other MRC research institutes where I worked as a research scientist, I was respected and well mentored by senior scientists such as Peter Medawar and Avrion Mitchison, and I also spent a very productive time at NIH in the US in the 1970s (and as a summer visitor to the Jackson labs in Maine from 1976). I was working in a very exciting area of cellular immunology, where conceptual and practical advances were being made rapidly on the international scene. In a sense, there was no time to be sexist, you just got on with what you personally thought was important, and were judged on what you did, whether male or female.

QA

26 | companion

THE companion INTERVIEW

You have built a formidable reputation as a cellular immunologist what specifically have been your interests in this area? At a fairly early stage in my research career I became fascinated in trying to fully understand a simple graft rejection system, with respect to both the genetics controlling rejection by the recipient and the exact molecules that were being recognised as foreign in the graft.

The simple graft I chose was the skin of males transplanted to females of the same inbred strain. The rejection target molecules were therefore encoded by a histocompatibility gene or genes on the Y chromosome (HY). These grafts were rejected by females of some inbred strains (e.g. rats, mice), but not others, so there were immune response (IR) genes of the recipient strain that also needed to be identified.

Another feature of the system I chose to study was the relatively slow rejection time, implying that the targets were weak transplantation antigens; in this way they resembled the tumour antigens that I had originally wished to study but with which I became frustrated, due to the difficulty of getting to grips with their molecular nature. So, for me, these grafts expressing weak transplantation antigens were a proxy for tumours, and I hoped that by studying them I would throw light on how better to tackle treatment of tumours in all species humans are, after all, to vets, just another species!

My work in this area resulted in identification of both the IR genes controlling responsiveness and the HY gene products that were the target of the response. It also showed that these graft rejection responses were effected by T lymphocytes, which recognised peptide fragments of the weak transplantation antigen presented in a specialised peptide

binding groove of a self cell surface molecule, the socalled MHC restricted responses (as described for viruses in 1974 by Zinkernagel and Doherty Doherty is also a vet who were awarded the Nobel prize for their discovery). MHC restriction turns out to be a fundamental property of all adaptive immune responses to viruses and other pathogens, as well as transplants, tumours and the autoantigens responsible for autoimmune disease. This understanding is fundamental for devising rational treatments such as vaccination and immunosuppression.

What have been the applications of your research?We now understand a great deal about adaptive immune responses to tumours induced by viruses and they can be tackled by vaccination approaches, e.g. papillomas in many species, certain leukaemias and lymphomas, although we need to understand better the normal regulatory responses that can limit effector function. Autoimmune disease is common in humans and is increasingly recognised in other species. Immunosuppression can be effective in treatment but has undesirable side effects, so better targeted approaches are being studied.

The research I have done is of a fundamental nature and therefore has application across a broad field, both clinically and experimentally. It has not been directed primarily towards addressing a specific clinical question. But clinical questions cannot be effectively solved in the absence of an underlying knowledge, and that, by the very nature of scientific advance, is an everchanging scene. We move from hypothesis to hypothesis, disproving one before proposing another that better fits the observations. Vets are uniquely trained as observers of the whole

animal, and in a very strong position to follow their observations and their scientific curiosity to open up new avenues for research and further knowledge.

What do you consider to be your most important professional achievement so far?Having had a very satisfying research career, contributing to the training of other scientists, and seeing my interests in science and medicine taken forward by them and their colleagues. Also important to me is my role, in the past and present, in contributing to the selection process for fellowships, both human and veterinary, awarded to young clinicians for going into research.

Who has been the most inspiring influence on your professional career?Sir Peter Medawar, the British zoologist. Medawars work on graft rejection and the discovery of acquired immunological tolerance, for which he was awarded a Nobel prize, was fundamental to the practice of tissue and organ transplantation.

What is the most significant lesson you have learned so far in life?The importance of keeping an open mind about all matters.

If you were given unlimited political power, what would you do with it?Reject it immediately.

If you could change one thing about your appearance or personality, what would it be?To become a little more tolerant!

What is your most important possession?My family, if I can be said to own them!

THE companion INTERVIEW

Since retiring from the Medical Research Councils Clinical Research Centre in Harrow Elizabeth has acted as consultant to various research charities (including the Wellcome Trust) who fund fellowships for young scientists (human and veterinary clinicians) at the beginning of their research careers. She is also an advisor to laboratory research groups, at Imperial College and elsewhere.

CPD DIARY

companion | 27

CPDDIARY

9 SeptemberWednesdayOrthopaedics: the diagnosis and management of carpal and tarsal problemsSpeaker Hamish DennyThe University of Bristol, Langford House, Langford, North Somerset BS40 5DU. South West RegionDetails from Kate Rew, kate@linhayvet.co.uk

EVENINGMEEtING

23 SeptemberWednesdayManagement of dermatophytesSpeaker Anita PatelThe Russell Hotel, 136 Boxley Road, Maidstone, Kent ME14 2AE. Kent RegionDetails from Hannah Perrin,hannah@burnhamhousevets.com

EVENINGMEEtING

12 OctoberMondayThoracic radiologySpeaker Nic HaywardThe University of Exeter, Queens Margaret Rooms, Streatham Campus, Northcote House, Exeter EX4 4QJ. South West RegionDetails from Kate Rew,kate@linhayvet.co.uk

EVENINGMEEtING

10 SeptemberThursdayPreparing for bonfire night special. Drugs used to treat behaviour/phobiasSpeaker Danny MillsThe Acorn House Veterinary Surgery, Linnet Way, Brickhill, Bedford MK41 7HN. East Anglia RegionDetails from Graham Bilbrough, graham-bilbrough@idexx.com

EVENINGMEEtING

10 SeptemberThursdayPractical haematology: detective work for nursesSpeaker Kostas Papasouliotis BSAVA, Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley GL2 2AB. Organised by BSAVADetails from the Membership andCustomer Service Team, 01452 726700, administration@bsava.com

DAYMEEtING

13 SeptemberSundayConsidering behaviour in veterinary medicineSpeaker Sarah HeathThe Pavilions of Harrogate, Great Yorkshire Showground, Harrogate HG2 8QZ. North East RegionDetails from Karen Goff, 01924 275249, northeastregion@bsava.com

DAYMEEtING

15 SeptemberTuesdayEndoscopySpeaker P.J. NobleThe Swallow Hotel, Preston New Road, Preston PR5 0UL. North West RegionDetails from Simone der Weduwen, 01254 885248, beestenhof@ ntlworld.com

EVENINGMEEtING

22 SeptemberTuesdayOncology ISpeaker Rob FoaleBSAVA, Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley GL2 2AB. Organised by BSAVADetails from the Membership andCustomer Service Team, 01452 726700, administration@bsava.com

DAYMEEtING

24 SeptemberThursdayGIT ISpeaker Penny WatsonThe Thorpe Park Hotel and Spa, 1150 Century Way, Thorpe Park, Leeds LS15 8ZB. Organised by BSAVADetails from the Membership andCustomer Service Team, 01452 726700, administration@bsava.com

DAYMEEtING

14 OctoberWednesdayDispensing lawSpeaker John HirdThe Holiday Inn Haydock, Lodge Lane, Newton Le Willows WA12 0JG. North West RegionDetails from Simone der Weduwen,01254 885248, beestenhof@ ntlworld.com

EVENINGMEEtING

7 OctoberWednesdayRational use of practical diagnostic imaging in common small animal emergenciesSpeakers Chris Lamb and Monica MerloThe Packfords Hotel, 16 Snakes Lane West, Woodford Green, Essex IG8 0BS. Metropolitan RegionDetails from Alison van Gelderen, 0772 0755000, allivetuk@yahoo.co.uk

DAYMEEtING

10 SeptemberThursdayECGs for dummies like meSpeaker Geoff CulshawThe L.A Lecture Theatre R(D)SVS, Edinburgh. Scottish RegionDetails from Claire Robertson, 07792 251003, claireadriennelamb@hotmail.com

EVENINGMEEtING

9 SeptemberWednesdayHaematology Road ShowSpeakers Guillermo Couto and Michael DayDay meeting at the Daventry Hotel, Sedgemoor Way, Daventry, Northamptonshire NN11 0SG. Organised by BSAVADetails from the Membership andCustomer Service Team, 01452 726700, administration@bsava.com

11SeptemberFridayHaematology Road ShowSpeakers Guillermo Couto and Michael DayDay meeting at Mottram Hall, Wilmslow Road, Mottram St Andrew, Cheshire SK10 4QT. Organised by BSAVADetails from the Membership andCustomer Service Team, 01452 726700, administration@bsava.com

14 SeptemberMondayHaematology Road ShowSpeakers Guillermo Couto and Michael DayDay meeting at the Marriott Hotel, Kingfisher Way, Hinchingbrooke Business Park, Huntingdon PE29 6FL. Organised by BSAVADetails from the Membership andCustomer Service Team, 01452 726700, administration@bsava.com

16 SeptemberWednesdayHaematology Road ShowSpeakers Guillermo Couto and Michael DayDay meeting at the De Vere Hotel, Hook Heath Road, Gorse Hill, Woking GU22 0QH. Organised by BSAVADetails from the Membership andCustomer Service Team, 01452 726700, administration@bsava.com

British Small Animal Veterinary AssociationWoodrow House, 1 Telford Way, Waterwells Business Park,

Quedgeley, Gloucester GL2 2ABTel: 01452 726700 Fax: 01452 726701

Email: administration@bsava.comWeb: www.bsava.com

For more information or to order visit www.bsava.com, email administration@bsava.com or call 01452 726700

BSAVA CPD Road Shows Keeping you ahead...

The veterinary profession is full of great practitioners and the BSAVA can help you stay at the forefront of your career through our extensive CPD programme. Over the coming months BSAVA is holding three Road Shows, bringing more choice and international specialists to your doorstep.

A series of 1-day courses which will deliver the very best CPD, at a convenient location and at a cost that is great value for money.

BSAVA CPD Road Shows Well see you there!

Haematology in practice all you need to knowGuillermo Couto & Michael Day