The essential publication for BSAVA members

PDP
The Professional
Development Phase
initiative P6
How To
Decide whether CT
or MRI is best for
your patient P14
companion
OCTOBER 2010
Respiratory
problems
Brachycephalic dogs
P22
Clinical
Conundrum
...a confusing
case of
polydipsia
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companion
3 Association News
Latest news from BSAVA
45 Monty Halls Congress Adventure
Congress 2011s keynote speaker
68 PDP Hit or Miss?
Three years into the Professional Development Phase
initiative, John Bonner reports on the scheme
913 Clinical Conundrum
Consider a confusing case of polydipsia
1420 How To
Decide whether CT or MRI is best for your patient
21 Neurology to turn heads
A look at BSAVAs forthcoming Neurology Roadshow
2224 Publications
Airway problems in brachycephalic dogs
25 Petsavers
Latest fundraising news
2628 WSAVA News
The World Small Animal Veterinary Association
2930 The companion Interview
Sandy Trees
31 CPD Diary
Whats on in your area
Additional stock photography Dreamstime.com
Joop Snijder; Nikolai Sorokin; Swinnerrr; Yuri Arcurs; Zoran Stojkovi c
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 726700
Email: companion@bsava.com
Web: www.bsava.com
ISSN: 2041-2487
Editorial Board
Editor Mark Goodfellow MA VetMB CertVR DSAM DipECVIM-CA MRCVS
Senior Vice-President Richard Dixon BVMS PhD CertVR MRCVS FRSE
CPD Editorial Team
Ian Battersby BVSc DSAM DipECVIM-CA MRCVS
Esther Barrett MA VetMB DVDI DipECVDI MRCVS
Simon Tappin MA VetMB CertSAM DipECVIM-CA MRCVS
Features Editorial Team
Caroline Bower BVM&S MRCVS
Andrew Fullerton BVSc (Hons) MRCVS
Design and Production
BSAVA 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
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aying your annual membership by Direct Debit allows us to
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In the coming months you will be renewing your membership
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ASSOCIATION NEWS
N
o other British veterinary conference offers as much choice for
delegates, with over 40 streams over four days. The quality of the
BSAVA Congress programme is acheived by a committee of volunteers
vets and nurses working in all aspects of the profession who know whats
needed to push the science forward and make your lives better and easier.
Weve introduced more interactive lectures, where you can vote and
answer questions using keypads, management and communication streams,
and an appropriate spread of cutting edge and controversial topics. So, new
topics are head lined as well as the return of the ever popular subjects.
By using your exclusive free access to the lecture podcasts after the event,
BSAVA Congress can enable you to complete your entire annual CPD, with
some of the most impressive experts in the world. n
SUBMIT AN ABSTRACT
Submissions for Clinical Research Abstracts take
place online until 28 October. Clinical research
abstracts are a valued and integral part of
Congress and run concurrently with the main
scientific programme. BSAVA particularly
welcomes submissions from practitioners, as well
as from those in research and academia, but only
online submissions can be considered. Visit
www.bsava.com or call 01452 726705 for
more details. n
31
March 3 April: the dates for BSAVA
Congress 2011, and this month members
will be sent priority registration packs,
ahead of anyone else. Of course, members get the
best discounts whenever and however they book.
However, to really get ahead of the crowd and
save money you can register online, as web
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The price for veterinary nurses now includes the
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congress@bsava.com or call 01452 726700
during office hours. n
Book online
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Register for Congress online and
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E
ach year on the Thursday of Congress, BSAVA holds its awards
ceremony. The awards are made in recognition of the contributions
made by individuals working in the field of small animal medicine
and surgery and are just one of the ways BSAVA supports success in the
profession. The Awards Committee, comprising the Presidents of the
BSAVA, RCVS and BVA together with the chairs of the BSAVAs Scientific
and Publications Committees, meet every December to consider
nominations for Awards. Of course the Committee cannot make
nominations and relies on the BSAVA membership putting forward names
for consideration. Visit www.bsava.com to nominate a colleague or email
secretary@bsava.com to get a nomination form. Nominations must be
received before 12 November 2010. n
Nominate now for
BSAVA awards
Not-to-miss science
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Congress
Monty Halls stunning stories of underwater
experiences will be illustrated with amazing images
and fantastic film footage from his adventures when he
delivers the BSAVA Congress Lecture on the Thursday
afternoon of Congress. He follows in the footsteps of
the likes of Joe Simpson, Phil Hammond, Simon King
and Susan Greenfield, who have all proved popular
guest speakers with Congress delegates.
From marine to marine biology
Halls left the Royal Marines at the age of 29 after a
successful career that included a stint in South Africa.
He chose to study marine biology at the University of
Plymouth, where he was involved with a project filming
a rare species of crocodile in Belize in partnership with
the Natural History Museum. He graduated with a First
Class Honours degree in 1999.
Media career
Halls first caught the eye of television producers in
2004 when he won Channel 4s Superhuman show,
and after that came two series of Great Ocean
Adventures for Channel 5 and Journey To The Centre
Of The Earth on Channel 4. His Great Hebridean
Escape television series was shown in April/May 2010
on BBC2. This followed Montys experiences living in
the Outer Hebrides for six months working as a
volunteer wildlife ranger. Living in a restored crofters
cottage on the island of North Uist, Monty and his dog
Reuben (the real star of the show) explored the natural
Monty Halls
Congress Adventure
Ocean adventurer, writer,
television presenter Monty
Halls next adventure will be to
inspire BSAVA delegates with
his tales of derring-do
H
es been variously described as the shark
whisperer and the new Cousteau. Monty Halls
is an adventurer in the true old-fashioned sense
of the term. The former Royal Marines Officer is a
professional diver and a trained marine biologist who
has led teams through some of the most demanding
environments in the world. His adventures include
discovering prehistoric settlements amid great white
sharks, avoiding the bullets of poachers, and
photographing a dangerous rare crocodile underwater
for the first time. A popular TV presenter, his two series
of Monty Halls Great Escape for the BBC have won
him fans worldwide.
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Congress
beauty of the area. A third series of Monty Halls Great
Escape has been commissioned.
International adventures
Monty Halls first made the news in 2002 when he led
a multinational team of adventurers and scientists to
South-east India to discover the ruins of a lost
civilization beneath the sea. This established Monty
as a new star of British exploration. In South Africa, he
led an international project seeking out sites of
prehistoric settlements.
Before TV notoriety he had led a pioneering
expedition in sea kayaks up the inland shore of one of
Africas great rift lakes, photographing new
underwater species and contacting remote villages
and indigenous peoples en route. He has also led
successful projects in Indonesia, Honduras and the
Philippines. In total Halls has completed three
circumnavigations of the earth, seeking out the
greatest encounters in the oceans. He has also led an
expedition to the ten greatest shipwrecks in diving,
and memorable experiences include swimming with
wild killer whales off New Zealand and exploring an
ancient Maori cave system.
Awards and charities
Monty has found time to record his adventures. He has
published several books including Dive: The Ultimate
Guide and Great Ocean Adventures, as well as a book
about Beachcomber Cottage and his life-changing
Congress
adventure living on the West Coast of Scotland for the
first Great Escape series.
In 2003 Monty Halls was awarded the Bish Medal
by the Scientific Exploration Society for his services to
exploration. He is passionate about conservation,
particularly of the worlds reefs and shark populations.
He is a patron of several international charities
including Help for Heroes, The Shark Trust, and The
Whale and Dolphin Conservation Society, and is
Honorary Ambassador to the Galapagos Conservation
Trust.
His enthusiasm, energy, passion and sense of fun
are said to be infectious. Halls style is dynamic,
light-hearted, frequently hilarious, and hes open to
investigation and questioning from the floor. His
lecture will take place on the Thursday afternoon of
Congress and all delegates can apply for a free ticket
when they register.
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PDP
T
hey said it was unnecessary and irrelevant and
even if they wanted to do it, they couldnt
because they would be unable to spare the time.
Back in 2007 there were a significant minority of the
graduating year who felt this way about PDP. They
were being asked by their professional body to make a
note of the numbers of different procedures they
carried out in their first job in practice and to record
the details on a password-protected website, along
with their comments on how they felt their clinical skills
were developing.
Being asked to carry out a potentially time-
consuming task that was never demanded of previous
generations of new graduates caused grumbling
among many in that 2007 cohort. Yet the vast majority
did eventually register on the Royal College website
93 per cent of that years output, according to RCVS
figures. It is believed that the remainder were mainly
foreign students returning to their home countries or
are working in non-clinical areas, such as meat
hygiene work, where the PDP is irrelevant.
In theory, new graduates will be developing, what
the College calls, Year 1 skills during the PDP process,
but importantly it was never intended that the goal
should be to complete this within a single year. Many
young vets may not begin work immediately and they
may decide to get their feet under the table in practice
before signing up. Moreover, their progress in
completing the PDP portfolio may depend on many
factors including some beyond their control, such as
the practice caseload, in addition to their own energy
and commitment.
Improving trends
Encouragingly, the time taken to fill in and submit the
required portfolio has shown a clear downward trend
in the 2008 and 2009 cohorts, as successive waves of
new graduates get a better understanding of both how
the system operates and its possible benefits in
providing them with more focussed and structured
training in those first anxious months in practice.
Although it is too early for detailed comparisons
between the different academic years, some trends
are clear. On average, it took 16 months for the 2007
group to complete their PDP and 13.5 months for the
next years cohort. The 2009 cohort are finding the
process even easier, with 58 candidates having
already completed and returned their portfolio before
the end of August 2010.
Winning graduates over
Will Oldham is a 2008 graduate from Edinburgh who
completed his PDP while working in small animal
practice with Cinque Port Veterinary Associates in
Kent. He says that unhappiness with the schemes
demands continued well beyond the first year. I was
very sceptical about PDP at the beginning and there
was quite a lot of animosity among my year group at
being made to jump through yet another hoop. But I
soon found it useful to be able to look back at my
clinical records and see which areas I needed to
Three years into the Professional
Development Phase initiative, the RCVS
appears to be winning the battle to persuade
new graduates of the need to record details
of their postgraduate training. John Bonner
asks some of those young veterinary
surgeons how they feel about the scheme
and wonders what changes may be planned
for their future colleagues
PDP
Hit or miss?
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PDP
strengthen. I was getting a lot of cat neutering but not
enough bitch spays. So I was able to go to my boss
and ask for those cases to be passed on to me.
Working independently for the first time, it can be
difficult for a newly qualified clinician to assess their
own progress, said Aaron Harper, a 2008 Cambridge
graduate at a practice in Burnley. The website is a
very good tool for seeing how you are doing. You can
compare the numbers of procedures that you have
done with the average for your cohort. I perhaps
lacked a bit of confidence in surgery at first and so it
made me chase up cases that I might have avoided if I
had been given the choice.
Less onerous
One reason for the increased acceptance of PDP is
that recording the necessary data is not as tedious
and time consuming as some may have feared.
However, the new graduate must still be reasonably
well organised, as 2009 RVC graduate Loreen Chan
explains. I found it difficult to remember all the
cases I saw, so I wrote down everything I did in a
notebook which I then added on to my PDP record
later. It takes an average of an hour per week to
record online but I think the time spent reflecting on
cases to identify things that could be improved next
time is well justified.
Ayrshire practitioner Fiona Brockbank, who
graduated from Glasgow in 2008, found the website
easy to navigate around and so the process was
pain-free. The one thing I would warn others about is
to remember to press save immediately after you
have updated the numbers, otherwise you forget and
move on to something else. I made that mistake a
couple of times and it is very irritating.
However, not all the new graduates are entirely
clear about their responsibilities for recording PDP
data. Stephen Ware is one four senior clinicians
appointed by the Royal College as postgraduate
deans to monitor progress and give advice to the
younger colleagues. One area of concern to the
former Royal College president is that many of his
charges record the numbers of procedures they
undertake but add inadequate notes. We are not
looking for a truncated version of the clinical notes,
what we need is a few words to give us some
assurance that the new graduate is thinking about
what they have learned. In most cases these
problems can be overcome by simply reading the
explanatory notes and frequently asked questions
on the website.
Another issue highlighted by fellow postgraduate
dean Julian Wells is that of clinicians filling in the forms
from the top downwards so that categories towards the
bottom are completed in a rush, with unsatisfactory
results. He notes that a high proportion of respondents
fail to include anything in the section on biosecurity,
with small animal practitioners maybe thinking that this
only applies to farm animal work.
Of course, as Fiona Brockbank points out, it is
impossible for the website text to fit every practitioners
personal circumstances. So often the young vet has to
interpret these instructions in a manner appropriate to
their own situation. Biosecurity is not just a concept
used in preventing epidemics in high-density pig herds
it also necessary in preventing the transmission of
infections between small animal patients.
it made me
chase up cases
that I might have
avoided
PDP
Aaron Harper
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PDP
PDP Hit or miss?
Finishing up
At the last count, 440 of the 662 registrants from the
2007 cohort and 295 out of 663 in the 2008 group
have completed their PDPP requirements, so what has
happened to the rest? To the frustration of the RCVS
and postgraduate deans, their answer is We dont
know. They have found that while it may be possible
to persuade new graduates to sign up for PDP, it is a
different matter getting them all to finish the job.
For the postgraduate deans, the problem is in
maintaining contact with their charges. In their first few
years in practice, new graduates are highly mobile and
many dont bother to keep the Royal College informed
of their new postal address. Even their email
addresses may change, for example, in the case of
RVC graduates who may use their college email for a
limited period after graduation. Those PDP candidates
that dont receive or even ignore the reminders sent
out by the postgraduate deans, will find that this was a
mistake when they do have to get in touch with their
statutory body.
Aaron Harper was in contact with Horseferry Road
when he decided to enrol for the new certificate in
advanced general practice. He notes that his
application would have been turned down if he hadnt
already proved his competence in the more basic
clinical skills through his completion of the PDP.
Yet not all young veterinary surgeons have the
ambition to advance their professional expertise
through the certificate system. How are the
postgraduate deans to persuade the many stragglers
to finish the course?
If the certification carrot doesnt work, the Royal
College feels that it may be necessary to wave the
stick of disciplinary proceedings. Although
completing PDP is not a statutory requirement under
the current legislation, there are potential
consequences for those that ignore the RCVSs
advice. So the RCVS is planning to identify those that
have not completed their PDP within two years of
registration and have failed to respond to messages
from their postgraduate dean. Defaulters will then be
sent two further letters pointing out that CPD is a
requirement for complying with the Royal College CPD
policy and later that their non-compliance may be
taken into account if a complaint about them is made
to the colleges professional conduct department.
Making improvements
To date, the RCVS has made no significant changes to
the PDP system, believing that the initiative would
need some time to become properly established. Any
immediate changes would be confusing to both the
new graduates and their employers, whose
responsibilities are explained in a booklet sent out to
each registrant.
However, now would be a good point to look for
possible improvements, says Freda Andrews, head of
the RCVS education department. Three years is a very
long time in world of IT and her colleagues are talking
with a software designer on plans to update the
website. This process will take into account the
comments received from those sending in their PDP
portfolio. Loreen Chan recalls her confusion when she
started the PDP process with the requirements for
entries in the notes section of the log. My
postgraduate dean, Professor Agnes Winter, provided
me with a few examples of reflective notes from
another graduates PDP. This was exceptionally helpful
and I think some examples of notes should be
included in the guidelines for the future.
Any modifications to the PDP system will not be
considered in isolation. Ms Andrews explained that the
Royal College is currently discussing with the seven UK
schools a plan for a similar system for online recording
of the training received by veterinary undergraduates in
their extramural studies. Rather than allowing each
school to go it alone, the RCVS will take the lead in
trying to encourage institutions with different training
cultures to use the same software system.
She hopes that by introducing a self assessment
system for recording a young clinicians developing
skills and competencies at student level, this will have
benefits as they progress to the PDP and beyond.
Many other equivalent professions already have an
online system for keeping these records. If members
can become familiar with what is expected of them
when they are undergraduates we hope it will become
a seamless process as they continue into PDP and
then into a career of lifelong learning. n
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CLINICAL CONUNDRUM
Clinical
conundrum
Mary Trehy, intern at Davies Veterinary Specialists
invites companion readers to consider a confusing
case of polydipsia
Case presentation
A 12-year-old, 30 kg male entire
Golden Retriever presented
with a 2 day history of
weakness and anorexia. The
owner describes a weak and
wobbly hindlimb gait and
reports that the dog is drinking
excessively. She has estimated
his water intake is
approximately 4 litres daily. On
presentation, the dog is
subdued, rectal temperature is
38.1C and heart rate is 68 bpm.
Peripheral pulse quality is good
and mucous membranes are
moist and pink. Thoracic
auscultation and abdominal
palpation are unremarkable.
Create a problem list based on
the information so far
The problem list consists of:
Anorexia
Polydipsia (as estimated water intake
(4000 ml/30 kg) exceeds 100 ml/kg/day)
Hind limb weakness
Ataxia.
As a clinical sign, anorexia has low
diagnostic value and is commonly a sequel
to a primary disease process; therefore, it
is appropriate to direct investigations
towards the main problems of polydipsia,
ataxia and weakness.
potassium and calcium), hypoglycaemia,
anaemia or endocrinopathies. Given the
ataxia, a neurological condition was
considered more likely. Differentials to
consider for primary neuromuscular
weakness include peripheral neuropathies,
junctionopathies and myopathies.
Construct an initial diagnostic
plan. What is your rationale for
performing these tests?
Initial investigations should include a
haematology profile, to assess for
alterations in leukogram and to rule out
anaemia (although the clinical examination
was not suggestive of marked anaemia).
A full biochemistry screen, in conjunction
with urinalysis, is indicated to evaluate
serum electrolytes (particularly sodium,
calcium and potassium) and to investigate
other potential causes of polydipsia (for
example renal or hepatic disease). A full
neurological examination is required to
further investigate the weakness.
The results of these initial investigations
are presented in Table 1 parts ad.
Haematology Reference
Interval
RBC 5.12 x 10
12
/L (5.08.5)
Hb 12.5 g/dL (1218)
Hct 39 % (3755)
Platelets 160 x 10
9
/L (160500)
WBCs 12.5 x 10
9
/L (615)
Neutrophils 11.25 x
10
9
/L
(3.011.5)
Lymphocytes 1.13 x 10
9
/L (1.04.8)
Monocytes 1.13 x 10
9
/L (0.01.3)
Eosinophils 0.0 x 10
9
/L (0.01.2)
Basophils 0.0 x 10
9
/L (0.00.2)
Platelet comment: Occasional small cluster
Table 1a: Haematology
What are your differentials for
these problems?
Differentials for polydipsia in this case
include structural renal disease, diabetes
mellitus, hyperadrenocorticism,
pyelonephritis and electrolyte
derangements (hypercalcaemia or
hypokalaemia). Other differentials
including diabetes insipidus and renal
glucosuria are less common and were
considered less likely.
The dogs hindlimb weakness could be
a consequence of primary neuromuscular
disease or could be seen in association
with metabolic disorders including
electrolyte imbalance (particularly
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CLINICAL CONUNDRUM
Clinical conundrum
Biochemistry Reference
Interval
Total protein 75 g/L (5277)
Albumin 39 g/L (2640)
Globulin 36 g/L (2047)
Sodium 140 mmol/L (139154)
Potassium 3.3 mmol/L (3.56.0)
Chloride 105 mmol/L (99125)
Magnesium 1.0 mmol/L (0.61.2)
Total calcium >4.0
mmol/L
(23)
Ionised
calcium
1.98
mmol/L
(0.752.0)
Phosphate 0.64 mmol/L (01)
Urea 11.1
mmol/L
(29)
Creatinine 138 mol/L (40106)
ALT 25 U/L (025)
Alkaline
phosphatase
148 U/L (20150)
Total
bilirubin
5 mol/L (09)
Glucose 5.4 mmol/L (3.55.5)
Cholesterol 5.1 mmol/L (3.87.0)
Amylase 478 U/L 01800)
Lipase 200 U/L (0250)
Table 1b: Biochemistry
Urinalysis
Sample appearance Pale yellow, clear
Specific gravity 1.009
pH 5
Protein Negative
Glucose Negative
Ketones Negative
Urobilinogen Negative
Bilirubin Negative
Haemoglobin Negative
RBCs 1 /hpf
WBCs 3 /hpf
Crystals None seen
Casts None seen
Table 1c: Urinalysis
Neurological exam Left Right
Mental status Normal
Fundus Normal
Cranial nerves
I Olfaction 2 2
II Menace 2 2
Following 2 2
Obstacle course 2 2
III PLR 2 2
Consensual PLR 2 2
Strabismus Absent Absent
IV Lateral rotation Absent Absent
V Motor 2 2
Sensory 2 2
VI Medial strabismus Absent Absent
VII Facial muscles 2 2
VIII Hearing 2 2
Head tilt Absent Absent
Nystagmus spontaneous Absent Absent
Nystagmus positional Absent Absent
Nystagmus physiological Present Present
IX/X Swallowing, gag Normal
XI Trapezius Not performed
XII Tongue muscles 2 2
Postural reactions
Wheelbarrowing 1 1
Extensor thrust 1 1
Hemistand 1 1
Hemi-walk 1 1
Proprioception 1 1
Hopping 1 1
Tactile placing Not performed
Visual placing Not performed
Spinal reflexes
Biceps Not performed
Patellar 1 1
Anal 2 2
Panniculus 2 2
Withdrawal reflexes
Thoracic limb 1 1
Pelvic limb 1 1
Nociception
Thoracic limb 2 2
Pelvic limb 2 2
Head 2 2
Perineum 2 2
Table 1d: Neurological exam. 0 absent, 1 reduced, 2 normal, 3 exaggerated
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CLINICAL CONUNDRUM
How does your interpretation of
the test results help you refine
your problem list and differential
diagnoses?
Haematology was unremarkable. The main
significant findings on biochemistry were a
high total and ionised calcium, mild
azotaemia and mild hypokalaemia. Other
electrolytes were within normal limits. The
urine sampled was isosthenuric but
otherwise normal.
Diabetes mellitus can be excluded on
the basis of biochemistry and urinalysis.
Hyperadrenocorticism is considered
unlikely given the absence of a stress
leukogram. The urine specific gravity is
inappropriately low and given the
azotaemia could suggest renal
dysfunction. This interpretation is
complicated by the presence of
hypercalcaemia, as this impairs the
function of ADH and results in the
production of dilute urine. The presence of
hypercalcemia would explain both
polydipsia and the anorexia. The history of
anorexia could account for the
hypokalaemia.
The neurological exam revealed
reduced hind limb spinal reflexes with
reduced postural reactions and
withdrawals in all four limbs. These findings
are consistent with a peripheral
neuropathy, junctionopathy or myopathy.
There is no direct evidence for a metabolic
cause of the dogs weakness although
hypercalcaemia can exacerbate pre-
existing neuromuscular weakness.
The revised problem list therefore
includes:
Anorexia
Weakness
Ataxia
Polydipsia
Hypercalcaemia
Neuromuscular disease
What are your differential
diagnoses for hypercalcaemia
and can these be narrowed
based on the information so far?
addressed as a priority.
In this case, intravenous fluid therapy
with 0.9% NaCl at 6ml/kg/hr was initiated.
After 24 hours of fluid therapy, ionised
calcium remained significantly elevated, so
following adequate rehydration, furosemide
was prescribed (at 2 mg/kg BID) to
promote calciuresis and IVFT was
continued at 2 ml/kg/hr.
In order to investigate the cause of the
hypercalcaemia a rectal exam, thoracic
radiographs and abdominal and cervical
ultrasound were indicated (to assess for
evidence of neoplasia and evaluate the
parathyroid glands). Further investigation
for neuromuscular disease was also
indicated, to distinguish between a
junctionopathy (e.g. Myaesthenia gravis), a
peripheral neuropathy or a myopathy.
Following furosemide, serum calcium
normalised. Thoracic radiographs were
performed under general anaesthesia and
were unremarkable. Electromyography
(EMG) was also unremarkable. Repetitive
nerve stimulation was not suggestive of
myasthenia gravis (which would typically
produce a decremental amplitude during
the stimulation train), however nerve
conduction studies indicated reduced
conduction velocity (31 m/s) of the sciatic
nerve (: reference range 6080 m/s) with
polyphasia and temporal dispersion
(Figure 2).
These findings were suggestive of a
polyneuropathy. However, EMG changes
would also be expected with a
polyneuropathy as the loss of some axons
causes the muscles they innervate to
become hyperexcitable. This is usually
evident as fibrillation potentials or positive
sharp waves. The normal EMG in this case
may be due to the acute onset of
neuromuscular signs as these changes
take 57 days to develop.
A nerve biopsy was considered to
further characterise the disease but as this
The differentials for hypercalcaemia
are most easily remembered with the
mneumonic HARD IONS G
Hyperparathyroidism
Addisons (and hypervitaminosis A)
Renal secondary
hyperparathyroidism
Vitamin D toxicity
Idiopathic (Cats) or Iatrogenic (oral
phosphate binders)
Osteolysis
Neoplasia
Spurious result (lipaemia,
postprandial)
Granulomatous Dx
The most commonly diagnosed cause of
hypercalcaemia is humoral hypercalcaemia
of malignancy, seen particularly with
lymphoma and anal sac adenocarcinoma.
Other differentials to consider in this case
are primary hyperparathyroidism and
granulomatous disease.
Hypervitaminosis D and lytic bone
lesions were unlikely differentials owing to
a lack of known toxin exposure or
hyperphosphataemia on biochemistry.
Renal secondary hyperparathyroidism was
also considered unlikely as ionised calcium
tends to be decreased or low-normal in
these cases.
What are the immediate
treatment priorities and what
further investigations would
you perform?
With the potential adverse effects of
sustained hypercalcaemia (mineralisation
of soft tissues and potential renal failure
due to nephrocalcinosis), this should be
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was unlikely to alter the management of the
patients condition, it was not performed.
Cervical ultrasound revealed a discrete,
0.3 cm by 0.6 cm, hypoechoic nodule at
the caudal pole of the left parathyroid gland
(parathyroid diameter of greater than
0.2 cm is considered abnormal). A diffuse
but non-specific mild increase in hepatic
echogenicity was identified on abdominal
ultrasound when comparing the hepatic
parenchyma with the relative echogenicity
of the neighbouring spleen and falciform
fat. No parenchymal nodular pattern or
ultrasonographic pattern of hepatic
vascular congestion was identified. All
other structures were considered
unremarkable.
How do these findings influence
your differential diagnoses and
which further tests are
indicated?
Following the ultrasonographic
demonstration of a parathyroid nodule,
primary hyperparathyroidism was
considered the most likely differential for
hypercalcaemia, The other abdominal
Clinical conundrum
Endocrinology Reference
Interval
Parathyroid
hormone
2.2 pg/ml (0.025.0)
Table 2: PTH assay result
changes were considered less likely to be
significant at this time. As the parathyroid
nodule represented a potential source of
autogenous PTH production, a PTH assay
was conducted. EDTA plasma samples
were collected for PTH assay and were
transported immediately. The laboratory
was contacted to ensure samples had
been frozen upon receipt pending analysis.
Results, shown in Table 2 were available
within 48 hours.
Golden Retrievers was possible and may
have been exaggerated by the presence of
hypercalcaemia.
What is your interpretation of
the PTH results?
The PTH value is at the low end of the
reference interval, which is appropriate for
a hypercalcaemic state. This result
suggests the parathyroid mass was not
autonomously producing PTH and is thus
not responsible for the patients
hypercalcaemia. The mass could originate
from the thyroid or a parathyroid gland but
given the PTH result it was felt unlikely to
be related to the clinical picture. So it was
elected to re-evaluate the patient and
problem list before further action.
Based on the information so far
what are your most likely
differentials and what are your
next steps?
Low PTH with elevated ionised calcium
and normal phosphorus is compatible
with humoral hypercalcaemia of
malignancy. In this condition production of
Figure 1: Motor nerve conduction study of the right sciatic nerve
revealing reduced conduction velocity
Figure 2: Cervical ultrasound revealing a parathyroid nodule
(small arrows) within the thyroid (large arrows)
Differentials for polyneuropathy at this
stage included a paraneoplastic syndrome.
Although infrequent, this has been reported
in dogs with bronchogenic or mammary
carcinoma, lymphoma and multiple
myeloma. Idiopathic and hypothyroid
polyneuropathy were also considered
possible. Congenital polyneuropathies
were excluded on the basis of age however
a degenerative neuropathy described in
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CLINICAL CONUNDRUM
WRITING A CLINICAL CONUNDRUM
IS AS HELPFUL AS READING ONE
I observed this case being worked up during a medicine rotation as part of my
internship. I found the case interesting but slightly confusing, so spent some time
discussing the diagnostic approach and the interpretation of test results with the
clinician in charge.
I felt it would be useful to write the case up and decided to submit it to
companion. I saw it as an opportunity to understand the case more fully and to gain
some experience of writing an article for peer-review. I was given advice on
submitting Clinical Conundrums and also some more general guidance on the
problem oriented approach to medicine cases, which I found really helpful.
Having had a first attempt at the article, I was given some pointers on areas to
expand upon and revise. In particular, emphasising how each test result allowed us to
refine the differential diagnosis list. After more reading of lecture notes and textbooks
and some further revisions, I submitted the article for review. The constructive
feedback from the editor was also really useful and comparing my first and final
drafts, I can see how much my understanding of the case has improved.
I would definitely recommend submitting a case to other interns; its a great
opportunity to feel more involved with a case and to learn to justify every step taken in
reaching a diagnosis.
Mary Trehy
other mediators (including Parathyroid
hormone related peptide (PTHrP) and
Osteoclast Activating Factor (OAF))
accounts for calcium release. Options for
further investigations include measurement
of PTHrP and repeating screening
imaging. Given the delay in processing a
PTHrP assay, it was elected to repeat
imaging before submitting a sample for
determination of PTHrP.
Abdominal ultrasound was repeated
first to re-evaluate the mild changes
previously identified in the liver as 4 days
had elapsed. This revealed increased
echogenicity of the liver and an irregular
increased echogenicity in the spleen. Fine
needle aspirates (FNAs) were taken from
the liver and spleen to further characterize
the nature of this non-specific pattern and
were submitted for cytological analysis.
An experienced pathologist
should evaluate the smears in
detail but what are your initial
impressions of the cytology
pictures?
What is the final diagnosis and
can you explain all of the
problems you have identified?
What treatment options are
available?
A diagnosis of hepatosplenic lymphoma
with paraneoplastic polyneuropathy and
humoral hypercalcaemia of malignancy is
sufficient to explain all of the clinical signs
and test results encountered.
This dogs lymphoma would be
classified as at least WHO stage IV
(indicating involvement of the liver and/or
spleen) and sub-stage b (due to the
presence of clinical signs). Based on the
certainty of the diagnosis achieved with
clinical and cytological findings,
histological confirmation of the diagnosis
was not deemed necessary. Similarly,
immuno phenotyping the lymphoma would
not have affected treatment decisions in
this case.
Treatment options include palliative
Figure 3:FNA of the hepatic parenchyma
The splenic and hepatic samples consist
of a population of large mononuclear cells
with variable to very high nuclear:
cytoplasmic ratio, moderate mitotic rate
and moderate nucleoli. Such cells are
neoplastic round cells. These changes
were considered by the clinical
pathologist to be consistent with
hepatosplenic lymphoma.
prednisolone or chemotherapy. The
majority of chemotherapy protocols are
based on either COP (cyclophosphamide,
vincristine and prednisolone) or CHOP
(also including doxorubicin) protocols.
Additional agents (for example
L-asparaginase and lomustine) can be
employed as rescue therapies.
The mean survival times for canine
lymphoma treated with a COP or CHOP
protocol are reported as a 68 months
and 13 months, respectively. However the
presence of clinical signs, paraneoplastic
polyneuropathy and hypercalcaemia are
all poor prognostic indicators. In this
case; the owners elected to treat with a
CHOP protocol.
Over the following 4 weeks the dog
remained normocalcaemic and its strength
improved. Unfortunately the dog then
relapsed, exhibiting weakness and
anorexia and at this point the owners
elected for euthanasia.
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Figure 1: (A) External appearance of a CT
scanner. (B) External appearance of a
high field MRI scanner (image courtesy of
the Animal Health Trust). (C) External
appearance of a low field MRI scanner
A
B
C
How to
Decide whether
CT or MRI is
best for your patient
Victoria Johnson of
Vet CT Specialists Ltd
helps us make this
decision
T
here has been a rapid increase in
the availability of cross-sectional
imaging techniques in recent
years. CT and MRI are now readily
accessible in many referral institutions.
In addition, mobile MRI and CT units
make frequent visits to veterinary
practices all over the UK and some first
opinion practices are investing in low field
MRI systems and CT scanners. This
means that vets are now faced with a
situation where they have the choice
between these two advanced imaging
modalities and a need to understand their
respective strengths and weaknesses.
This article aims to simplify that
choice and guide you in selection of an
appropriate imaging modality. In some
situations this is easy and there is a
clear clinical benefit to using one
modality over the other. There are,
however, some circumstances where
other factors such as cost, time,
accessibility or personal preference
become more important in selection.
What is CT?
Computed tomography (CT) (Figure 1A) is
a cross-sectional imaging modality based
on X-ray technology. X-rays are produced
from a high-powered X-ray tube and pass
through the patient to be received by a
panel of detectors. The X-ray beam is
attenuated as it passes through the patient
and this allows an image to be created
based on the relative density of the different
body parts. In most modern X-ray
machines the tube rotates around the
patient as the CT bed moves forwards or
backwards. The bed can either move in
small steps, creating a single slice of the
patient, or can move constantly as the tube
rotates. The latter creates a helix of imaging
data from the patient (so-called helical CT)
that can then be reconstructed by a
computer into different formats.
Usually the data are reconstructed
into transverse slices of varying thickness,
but sagittal, dorsal and three-dimensional
reconstructions can also be created and
are extremely useful. The most up-to-date
CT scanners have multiple panels of
detectors to receive the X-ray beam after it
has passed through the patient. This
multidetector CT (MDCT) technology
allows extremely rapid imaging (as little
as 10 seconds to image an entire dog
from nose to tail) and generates a
volume of attenuation information, thus
enabling exquisite multiplanar and 3D
reconstructions. MDCT also facilitates
highly detailed CT angiography to be
performed using iodinated contrast media.
CT Key features
Ionising radiation
Equipment, setup and maintenance
usually cost less than MRI
Images acquired in transverse
plane, but with MDCT additional
planes can be reconstructed with
equivalent resolution
Extremely quick, especially MDCT
Intravenous iodinated contrast
media used for most examinations*
Can easily perform angiography
with helical CT scanners
* In general contrast medium is advised for
most CT examinations with the exception of
cases where its administration could
compromise the health of the patient, or in
cases where bone imaging alone is required.
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What is MRI?
Magnetic resonance imaging (MRI) is
based on the use of strong magnetic fields
and radiofrequency pulses to generate
cross-sectional images. The patient is
placed into a large magnet and the powerful
magnetic field results in the alignment of
hydrogen atoms within the body. Different
radiofrequency pulses and additional
gradient magnetic fields are then turned on
and off to create a complex set of frequency
information that can be transformed into an
image. Unlike CT, images of the patient can
be acquired in any plane (sagittal, dorsal,
transverse, or oblique).
Magnetism is measured by means of a
unit, the Tesla (T). Two main types of MR
scanner are available: low field and high
field (Figures 1B and 1C). The low field
magnets have a smaller magnetic field
(0.20.5 T usually) and are open devices.
These are considerably cheaper than high
field magnets and have a smaller field of
view. The image quality especially of the
brain and head is usually good, though
sequences generally take longer to acquire
than with high field magnets.
High field magnets are supercooled with
liquid helium. They are larger, more
expensive structures with a closed gantry.
The images are quicker to acquire and of
high quality due to the higher signal-to-noise
part. This usually facilitates the choice of
CT or MRI, as there are some clearly
defined differences between the
modalities when considering specific
anatomical regions.
1. Central nervous system (CNS)
MRI is the imaging modality of choice for
the central nervous system due to its
superior contrast resolution. There are
many subtle changes that are seen on MRI
of the brain and spinal cord that simply
cannot be detected on CT. Also, CT has
limitations in evaluation of the brain and
spinal cord due to artefacts created by the
surrounding bone of the skull and
vertebrae. These artefacts create more of a
problem in canine and feline patients (due
to their smaller brain size and thicker skull
and overlying musculature), than they do in
human patients.
Specific MRI sequences can also be
used in the CNS and present additional
Figure 2: Transverse MR scan through
the caudal fossa of a 13-year-old dog.
This is a particular sequence called a
gradient echo (or T2*) scan, which aids in
the detection of haemorrhage. The
multiple lesions present are
haemangiosarcoma metastases
MRI Key features
No ionizing radiation
Relies on magnetic fields and radiofrequency pulses to generate an image
Creates a map of hydrogen atoms within the body
Equipment, setup and maintenance usually more expensive than CT
Two main types of scanner: low and high field strength
Can acquire images in any plane
Usually takes longer than CT
Much greater contrast between the soft tissues than in CT
Intravenous contrast medium (gadolinium) used in many examinations
Numerous advanced techniques can be performed (generally with a high field
scanner)
ratio compared to low field systems. High
field MR scanners are much more suited to
angiography and other advanced imaging
techniques than the low field scanners.
In MR imaging different combinations of
radiofrequency pulses and gradient
magnetic fields are used to create
sequences of images with different contrast.
Many different MRI sequences are
available. By utilising different sequences
and techniques and also by the
administration of intravenous contrast
medium (gadolinium) it is possible to be
very precise about the nature of a lesion.
For example, haemorrhage (Figure 2), fat,
proteinaceous fluid and pure water are
amongst substances that have very specific
imaging characteristics on MRI.
More advanced imaging techniques
are also available. These include: diffusion
weighted imaging (used in ischaemic
strokes); diffusion tensor imaging (used in
fibre mapping and demyelinating disease);
and functional MRI (identifies areas of
neural activity by evaluation of blood
oxygen levels).
Selecting an imaging modality
depending on the anatomical
region
Often a patient is sent for cross-sectional
imaging for evaluation of a particular body
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advantages over CT. These include:
gradient echo sequences for the diagnosis
of haemorrhage (Figure 2); diffusion
weighted imaging in the evaluation of
ischaemic disease; FLAIR sequences to
assist in diagnosis of perilesional oedema
and identification of pure fluid; and STIR
sequences to evaluate muscle, bone and
nerve root changes.
The use of CT alone to diagnose spinal
cord disease in the acutely paretic or
plegic patient is controversial. Extruded
mineralised disc material in
chondrodystrophoid patients is easily
visualized in non-contrast CT scans, but
CT myelography is necessary to identify
significant sites of spinal cord compression
or expansion. CT myelography does not,
however, allow detailed assessment of the
parenchyma of the spinal cord. The
presence of related, or unrelated,
intramedullary lesions is better recognized
on MRI without the inherent risks of
myelography (Figure 3).
The use of CT alone to diagnose brain
disease should be limited to situations
where MRI is not available. CT can be
used to identify an intracranial mass effect,
areas of severe oedema or acute
Figure 4: Transverse CT scan of the brain
after intravenous contrast medium. A ring
enhancing mass is present in the right
parietal lobe. CT can demonstrate large
contrast-enhancing mass lesions within
the brain, but subtle parenchymal lesions
will be missed. Note the lack of detail
seen within the remainder of the brain
parenchyma on a typical brain CT scan
Figure 3: (A) Sagittal T2W MR
scan through the cervical
spine of a 3-year-old
Rottweiler. The patient has a
subarachnoid cyst (red
arrow). MRI not only
demonstrates the presence of
the cyst, but also shows the
associated parenchymal
hyperintensity within the
spinal cord at C3 (blue arrow).
(B) Sagittal reconstruction
from a MDCT scanner of the
thoracic and lumbar spine
after lumbar myelography.
This patient is a 3-year-old
French Bulldog and also has a
subarachnoid cyst. CT
myelography demonstrates
the presence and location of
the cyst (yellow arrow), but it
is not possible to evaluate the
spinal cord parenchyma. This
patient also has multiple
vertebral abnormalities and a
kyphosis. Osseous vertebral
changes are clearly
demonstrated by CT
B
A
CNS Key features
MRI preferable in almost every situation for brain and spine imaging
MRI offers many significant advantages in terms of tissue contrast and special
sequences to identify particular pathology
CT can be used if MRI is not available:
To identify a mass effect, severe oedema, acute haemorrhage or contrast-
enhancing lesions in the brain or spinal cord
With myelography for the assessment of extradural compressive lesions in
acutely presenting paretic or plegic patients
CT is often useful in addition to MRI in:
Trauma
Skull and vertebral malformations
Degenerative lumbosacral stenosis
haemorrhage and contrast-enhancing
brain (Figure 4) or meningeal lesions. Brain
CT may overlook many subtle, but
significant brain lesions that would be
easily detected on MRI. Note that CT is not
generally suitable for assessment of
foramen magnum herniation.
Decide whether CT or MRI is
best for your patient
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There are many instances where CT is
complementary to MRI in evaluation of the
CNS these include skull and vertebral
malformations (Figure 3B), trauma cases
and lumbosacral stenosis. In some trauma
situations CT can be suitable for first line
imaging of the CNS to assess for fractures
and overt oedema/haemorrhage. This can
even be performed in non-anaesthetised
comatose patients due to the rapid image
acquisition of CT.
2. Nasal cavities and sinuses
Both CT and MRI are extremely useful in
assessment of the nasal cavities and
frontal sinuses. CT and MRI are effective in
the assessment of turbinate, maxillary and
palatine destruction (Figure 5), mass
lesions, presence of fluid, osteomyelitis,
and contrast-enhancing lesions. Whilst CT
and MRI are both able to detect cribriform
plate destruction, rostral meningeal/brain
enhancement or mass lesion, MRI has the
advantage that it may also demonstrate
T2W meningeal hyperintensity surrounding
the olfactory lobes in cases of nasal
neoplasia. The cause of this finding is, as
yet, unknown but it may represent
micrometastases, secondary meningitis or
an accumulation of fluid. It has not been
shown to have an effect on neurological
deficits or survival time.
CT can be used to guide fine needle
aspiration (FNA) and biopsy if required. CT
of the thorax can easily be performed at
the same time as nasal CT in order to
evaluate for metastatic disease.
3. External, middle and inner ears
CT and MRI are both able to detect the
presence of fluid or mass lesions within the
tympanic bulla and external ear canal,
sclerosis or erosion of the bulla wall,
associated retropharyngeal or para-aural
lesions and regional lymphadenopathy
Nasal cavities and sinuses
Key features
Both CT and MRI are very useful
Both can demonstrate cribriform
plate invasion and rostral brain
involvement in nasal neoplasia
MRI may show additional meningeal
changes surrounding the olfactory
bulbs in nasal neoplasia
CT can be used to guide FNA
or biopsy
CT can be used for thoracic
metastatic screening
Figure 5: Transverse CT scan through
the nose of a 6-year-old dog with
aspergillosis. CT provides exquisite detail
of the nasal chambers and demonstrates
severe left-sided turbinate destruction
A
Figure 6: (A) Transverse CT scan (bone algorithm) at the level of the tympanic bullae in
a 7-year-old Weimaraner with chronic otitis media. The right tympanic bulla wall is
thickened and irregular, and both bullae contain abnormal material. (B) Transverse
T1W/C transverse MR scan through the tympanic bullae of a cat with severe chronic
ear disease and clinical signs of otitis interna. In addition to the abnormal material
within the bullae, MR also demonstrates contrast enhancement of the right
vestibulocochlear nerve (purple arrow) and suspected meningeal enhancement
around the brainstem (yellow arrow)
B
(Figure 6A). MRI has an additional
advantage in enabling evaluation of the
facial and vestibulocochlear nerves for
thickening and enhancement (Figure 6B)
and also allows visualization of the fluid
signal within the cochlea and semicircular
canals. Associated brain disease is also
best assessed by MRI, but may be
recognized on CT.
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CT can be used for thoracic metastatic
screening if aural/para-aural neoplasia is
suspected.
External, middle and inner ears
Key features
CT or MRI can be used
MRI can also assess cranial nerves
VII and VIII, the cochlea and
semicircular canals and the
adjacent brainstem
CT can be used for thoracic
metastatic screening
4. Thorax
The inherent variation in densities within the
thorax makes the chest ideally suited to CT
evaluation (Figures 7 and 8). Conversely,
the low signal from the air-filled lungs and
the presence of artefacts means that MRI is
far less suited to assessment of the thorax.
Overall, CT is the preferred modality for
assessment of the thorax, though MRI can
be useful in the assessment of the thoracic
wall, mediastinal masses, the pleural space
Figure 8: Dorsal MDCT reconstruction of
the thorax (at the level of the tracheal
bifurcation) in a young dog. The right
caudal mainstem bronchus is dilated and
contains an abnormal structure. This was
found to be a Holly leaf at bronchoscopy
and surgery was required for removal
Figure 7: Transverse CT scan (lung
algorithm) through the mid thorax of an
11-year-old mix breed dog. A large
left-sided lung mass is present. Thoracic
CT provides excellent pulmonary detail
and also enables assessment of regional
lymph nodes and a search for pulmonary
metastases. Post-contrast images were
also acquired (soft tissue algorithm)
Figure 9: Dorsal T2W MR scan of the
ventral part of the thorax of a 3-year-old
dog with chronic pyothorax. The scans
were obtained prior to surgery (CT was
not available) to locate loculated fluid and
to assess for possible foreign material.
The areas of high signal represent fluid
pockets. The low signal structure is the
apex of the heart
Thorax Key features
CT is definitely the modality of choice
Extremely useful in the evaluation of pleural, mediastinal, bronchial, pulmonary
parenchymal and thoracic wall lesions
Superior metastatic screening when compared to radiographs
MRI can be used for thoracic imaging in some situations
Useful for mediastinal masses, thoracic wall masses and the pleural space
Respiratory and cardiac gating techniques are usually required
Cardiac MRI can be performed with extremely advanced MR scanners
(Figure 9) and, with a suitable scanner and
compatible equipment, the heart. Images
using either modality should be obtained
during periods of apnoea. With rapid CT
machines this can usually be achieved by
hyperventilating to an apnoeic state or by
the use of remote ventilation and breath-
hold techniques. Respiratory and cardiac
gating techniques are usually required for
MRI of the thorax.
5. Abdomen
CT provides excellent images of the
abdominal organs and peritoneum
(Figure 10). Contrast should always be
administered (see CT Key features,
page 14) and with helical CT (particularly
MDCT) it is also possible to obtain
exquisite angiographic studies. Contrast
CT is extremely useful for CT excretory
urograms, portosystemic
Decide whether CT or MRI is
best for your patient
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HOW TO
potential for cartilage imaging, but
powerful scanners are required for this
level of detail.
Shoulder Key features
MRI has great potential for the
assessment of muscular, tendinous
and ligamentous shoulder injury
CT is much less useful overall and is
reserved for osseous disease
Elbow Key features
CT usually recommended
Quick and provides excellent
osseous detail
Ideal for the diagnosis of common
elbow conditions (medial
compartment disease, IOHC, OC,
elbow incongruity)
Complementary to arthroscopy
MRI may also be used and could
provide additional information
concerning bone oedema and
cartilage
Abdomen Key features
CT is the current modality of choice,
providing good quality images and
being much easier to perform
MRI can be used but requires
special sequences and expertise
In the future MRI may be used more
for the characterization of abdominal
masses and nodules in veterinary
patients
Pelvic region Key features
Either CT or MRI may be used
MRI may hold a slight advantage
with its benefits of additional soft
tissue contrast
6. Pelvic region
Both CT and MRI are suited to evaluation
of the pelvic region. This area is not prone
to movement artefact, and therefore MRI
may hold the advantage over CT given its
superior soft tissue contrast and the ability
to assess the adjacent CNS structures
more readily.
8. Shoulder
MRI offers significant potential for the
evaluation of muscular, ligamentous and
tendinous shoulder injuries in adult dogs.
Some of these conditions are not seen
arthroscopically and hence may be
underdiagnosed. MRI is also well suited to
the diagnosis of brachial plexus disease.
CT of the shoulders is generally much
less useful. Osteochrondrosis lesions in
young patients are usually seen
radiographically and assessed and
treated arthroscopically. CT may be helpful
in fracture assessment and can also be
used for assessment of suspected
neoplasia with the addition of a thoracic
metastatic scan.
Expertise and experience are essential to
obtain the most relevant information from
abdominal MRI.
7. Elbow
CT has been the most widely reported
cross-sectional imaging technique in the
assessment of canine elbow disease.
CT is ideally suited to the osseous changes
of medial compartment disease,
osteochondrosis (OC) lesions and
incomplete ossification of the humeral
condyle (IOHC). CT and arthroscopy have
been shown to be complementary
techniques, with CT identifying some
lesions not seen on arthroscopy and vice
versa. CT has also been used quantitatively
in the assessment of elbow incongruity.
More recently MRI has been
advocated in the detection of subtle
intramedullary abnormalities such as bone
oedema. MRI also theoretically holds the
shunt diagnosis, presurgical assessment
of abdominal masses, and many other
indications. It may even be preferable
to abdominal ultrasonography in large
obese patients.
MRI of the abdomen allows excellent
evaluation of the parenchyma of the organs
due to the good soft tissue contrast. Body
MRI is used widely in people for the
assessment of hepatic, splenic and renal
nodules and masses and also for prostatic
disease. Once again, rapid sequences
and/or gating are usually required.
9. General skeleton
CT offers the advantage of superior
multiplanar and volume rendered 3D
reconstructions which are extremely
beneficial in the planning of fracture repair
Figure 10: Dorsal MDCT reconstruction of
the abdomen after intravenous contrast
medium administration. This 11-year-old
dog has a large heterogenous right-sided
liver mass (black arrow), which can be
seen displacing the portal vein (white
arrow) to the left. CT was used to perform
a full assessment of the mass, regional
lymph nodes, other abdominal organs
and the thorax
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HOW TO
Conclusion
Veterinary practices now have
unprecedented access to cross-sectional
imaging modalities. In many situations
CT and MRI can be used interchangeably
and the decision on which to choose may
be mostly affected by cost and availability.
There are, however, some important
situations where the correct choice is
extremely important and the wrong
modality may make the study non-
diagnostic for the disease process
in question.
for the same purpose. The CT studies are
quick to acquire if MDCT is used, whereas
special protocols are required for fast MRI
screening techniques. All of these types of
studies take a long time to read, but
certainly are useful in detecting previously
unrecognized metastatic disease. In these
whole body techniques the emphasis is
generally on contrast rather than spatial
resolution and MRI holds the advantage in
the detection of bone marrow changes,
lympadenopathy, soft tissue lesions and
CNS lesions. CT remains beneficial in
metastatic lung and bone imaging, but the
latter is probably better assessed using
bone scintigraphy.
In the future, positron emission
tomography (PET) may become
increasingly important in cancer staging.
PET/CT or PET/MRI may eventually
become the gold standard of cancer
imaging in our canine and feline patients.
Patients with metallic implants
CT or MRI?
Metallic implants create problems for both
CT and MR examinations.
In MRI non-ferrous implants may be
placed into the magnet, but can create
serious artefacts and hence non-
diagnostic studies. The magnitude of these
artefacts differs depending on the MR
sequence used.
The artefacts identified on CT
examinations in patients with metallic
implants can also prevent interpretation,
but on occasion the gantry can be angled
to avoid the metallic region and certain
slices and reconstructions can limit their
effect on the final image.
CT and MR angiography
Both CT and MR have a role in
angiography in our small animal patients.
Current applications include evaluation of
portosystemic shunts, assessment for
General skeleton Key features
CT useful for angular limb
deformities, fracture repair planning
MRI advantageous in neoplastic
disease (such as mandibular or
maxillary tumours)
pulmonary thromboembolic disesase,
planning of vascular mass resection and
many others. For CT angiography a helical
scanner is required and a rapid injection
pump is preferable (Figure 12). For MR
angiography the best results are achieved
with high field scanners and special
techniques such as parallel imaging.
and other orthopaedic surgeries such as
angular limb deformity correction (Figure
11). MRI is more advantageous where
neoplastic invasion into bone is
suspected. In this scenario the altered
intramedullary bone signal may be seen
long before lytic changes are recognized
on a CT examination.
Whole body MRI and CT for
metastatic disease?
Recently protocols for whole body MRI
screening for the diagnosis and staging of
neoplastic disease have been reported.
Some institutions are also routinely
performing whole body CT examinations
Figure 11: 3D CT reconstructions can be
useful to assess the overall alignment of
osseous elements of the axial and
appendicular skeleton for surgical
planning
Figure 12: CT angiogram performed with
an MDCT unit and a rapid injection pump.
The image is displayed as a Maximum
Intensity Projection (MIP) which is a
useful way to view contrast-enhanced
vessels or mineralized lesions
Decide whether CT or MRI is
best for your patient
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CPD
T
he ultimate goal of this course is
to provide the busy practitioner
with the necessary clinical tools
to take on the challenge of a
neurological examination and to tackle
common neurological complaints
encountered in daily general practice.
The vet in general practice will learn
to develop a logical step-wise
approach to common neurological
complaints and to take home some
realistic management plans that can be
easily applied in practice. We really
want this course to be useful for
veterinarians at any stage of their
career, and will take delegates from the
common clinical presentations of
neurological cases (on video) to the
World-class speakers Simon Platt and Laurent
Garosi will be taking their neuro know-how on the
road to four locations in November. Here they talk
about their aims for the course and their passion
for communicating their specialist subject in
innovative ways
Neurology
to turn heads
NEUROLOGY
ROADSHOW FOR
BUSY PRACTITIONERS
Derby 18 November
Yorkshire 19 November
Cardiff 22 November
Surrey 23 November
Member fee: 203.28 inc. VAT
Non-member: 304.91 inc. VAT
Specific topics covered:
Is it spinal?
Working up the weak: neuromuscular
diseases of the dog and cat
Rock and roll: the many faces of vestibular
disease
Seizures behaving badly
Headaches: dealing with head trauma
Dropped jaw, lockjaw and droopy faces
Visit www.bsava.com or email
administration@bsava.com or call
01452 726700 for more details.
work-up and treatment options
available whether or not advanced
technology and unlimited finances are
on hand. We hope to take away the fear
factor from these cases and discuss
treating for the treatable.
Each clinical presentation will be
illustrated by videos and interactive
case studies. Indeed, the programme
is mostly video-based which will make
the course more interactive, engaging
and practical. The hope is that
delegates will return to their practice
with more confidence to manage those
common neurological complaints such
as weakness, loss of balance,
refractory seizures, paralysis or head
trauma.
Simon and Laurent bring over 20 years
of combined experience dealing with
neurology cases on a daily basis. Both
are RCVS recognised specialists in
veterinary neurology. Laurent is a
diplomate of the European College of
Veterinary Neurology and currently
company director and head of neurology
service at Davies Veterinary Specialists,
UK. Simon is a diplomate of both the
European College of Veterinary
Neurology and the American College of
Veterinary Internal Medicine,
subspecialty Neurology. He is currently
associate professor at the College of
Veterinary Medicine at the University of
Georgia, USA.
Both speakers have written
extensively on veterinary neurology
subjects, from brain tumours to strokes,
in scientific articles in the most respected
veterinary journals, in textbooks and the
veterinary press. Simon is a co-editor of
the BSAVA Manual of Canine and Feline
Neurology. As speakers they are known
for their comprehensive knowledge and
passion for their subject, providing
delegates with tools for the quick-thinking
that is required for dealing with
neurological cases.
Little known speaker facts
Laurent enjoys
anything to do
with planes and
flies in his spare
time.
Simon coaches his
3 daughters to
swim and all three
are USA state
champions.
ABOUT THE SPEAKERS
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PUBLICATIONS
B
rachycephalic breeds are popular in
the UK, and include British and
French Bulldogs, Pugs, Pekingese
and Boston Terriers. The term means
short-headed or broad-headed and
refers to the characteristic appearance of
the head. These dogs may also have
dyschondroplastic development of the
limbs, resulting in relatively short, bowed
legs. The breed characteristics depend on
breeding selectively for those offspring
with abnormal development of the bones of
the skull such that the head is shortened,
but of a normal width. The soft tissues
develop normally and, consequently, the
majority of these dogs have some element
of upper respiratory tract noise, including
snoring and stridor due to obstruction and
pharyngeal folds and occasionally
hypoplastic trachea) and the subsequent
secondary problems (eversion of the
mucosa of the lateral laryngeal saccules
ventricles and laryngeal collapse).
Presentation
Most dogs present in the first 3 years of life,
with English Bulldogs and Pugs presenting
at a younger age than other breeds.
Typical presenting complaints include
more snoring and stridor than expected for
the breed, coughing, reluctance to exercise,
and dyspnoea when hot or excited.
Marked respiratory distress, cyanosis
and collapse may occur in those dogs
where owners have failed to recognise, or
ignored, the clinical signs. Typical
scenarios include exercising in hot
weather or stressful trips to their veterinary
practice where they may collapse in the
waiting room.
Some dogs may have difficulty
breathing on recovery from anaesthesia for
another condition.
Diagnosis
A provisional diagnosis is made in affected
breeds with a typical history and
supportive physical examination findings.
In some cases the dog may not show
any respiratory effort or distress on
examination, in which case the owners
description becomes very valuable.
Clinical examination may confirm that the
nares are stenotic, with reduced airflow at
rest when the mouth is shut. Auscultation
of the thorax may be impossible due to
referred stridor from the upper airways.
The definitive diagnosis is based on
examination of the pharynx and larynx
under a light plane of anaesthesia, such
that the dog is able to demonstrate
movement of the larynx. However, in
severely affected cases, these patients
may pose problems for recovery from
Airway problems in
brachycephalic dogs
Obstruction of the upper respiratory tract is a
problem in many brachycephalic breeds. Alison
Moores and Davina Anderson from Anderson
Sturgess Veterinary Specialists in Winchester,
outline the clinical approach to this disease
Figure 1: Stenotic
nares in a French
Bulldog
Reproduced from the
BSAVA Manual of Canine
and Feline Head, Neck and
Thoracic Surgery
oscillation of the redundant soft tissue.
Most dogs will not have clinical
problems, although many owners limit
exercise, especially in hot weather, to avoid
the risk of collapse episodes. Breed
websites suggest that these dogs are at
abnormal risk of heatstroke, indicating a
general acceptance of the fact that upper
respiratory obstruction is a fact of life for
these breeds. Brachycephalic airway
obstructive syndrome or disease (BAOS) is
the clinical presentation of upper airway
obstruction due to a combination of the
anatomical abnormalities in the upper
respiratory tract of brachycephalic dogs
and some cats. It comprises primary
problems (stenotic nares (Figure 1),
elongated soft palate, redundant
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PUBLICATIONS
anaesthesia and they should not be
anaesthetised unless facilities are available
to treat the condition or place a
tracheostomy tube if necessary.
The difficulty is that most
brachycephalic dogs will have some or all
of the primary problems that define BAOS
to a certain extent. However, most dogs
with clinical signs have extreme anatomical
abnormalities and may have secondary
erythema and oedema of the mucosa,
suggestive of turbulent airflow.
Anatomical abnormalities
Up to 85% of brachycephalic dogs are
found to have an elongated, and often
thickened, soft palate, which is seen to
obstruct the rima glottidis. The tip of the
palate can often be seen vibrating on
inspiration and may get sucked into the
glottis. The palate can be assessed by
fluoroscopy (which avoids anaesthesia),
or by an accurately positioned lateral
skull radiograph.
In the normal dog, resistance to airflow
is primarily (76%) in the nasal cavity and
the larynx contributes very little (4%).
However, in the brachycephalic dog the
extreme negative pressures required to
draw air through the nasal cavity frequently
exert sufficient pressure on the larynx to
cause secondary changes, which then
significantly increase air flow resistance in
the laryngeal area as well.
Examination of the larynx is often
hampered by the long soft palate, but can
be achieved by use of a long laryngoscope
to gently lower the epiglottis ventrally and a
second laryngoscope or wooden tongue
depressor to lift the palate dorsally. The
lateral laryngeal ventricles lie rostral to the
vocal folds, and eversion of the mucosal
lining may occur secondary to chronic
negative airway pressures in the pharynx
and larynx. This should be assessed prior
to intubation as restoration of normal
pressures often allows the mucosa to
return to the ventricles. The mucosa
causes obstruction of the ventral rima
glottidis and in extreme cases can occlude
half of its functional area.
Redundant pharyngeal folds cause a
generalised narrowing of the pharynx that
is unaffected by surgery and can only be
managed by weight loss and reducing the
dynamic effects of forced inspiratory effort.
Finally, the dog is assessed for laryngeal
collapse (Figure 2), a consequence of
chronic negative airway pressures. This is
more common in dogs that are older on
first presentation, even if their clinical signs
are milder, reflecting the time it takes for
collapse to manifest.
Treatment
Surgical treatment is ideally performed
immediately after diagnosis, under the
same anaesthetic, as it may be more
difficult to recover the dog from
anaesthesia without definitive surgery.
Surgical management of these dogs aims
to reduce the high resistance to inspiration
in the nasal part of the upper respiratory
tract, which involves nasal and palate
(Figure 3) surgery. Whilst there are reports
that only 50% of BAOS dogs have stenotic
nares, the majority have a smaller nostril
than normal dogs and these authors
consider that all affected animals will
benefit from surgery to widen the external
nares and improve airflow. More recently,
there have been reports of removal of nasal
turbinates, but this involved specialist
techniques and facilities.
Surgery is more difficult to perform in
certain breeds, most notably the English
Bulldog in which the soft palate is markedly
thick and long; and cut and sew techniques
without the use of haemostatic clamps can
be associated with brisk haemorrhage.
More recently, alternative procedures have
been described which debulk the muscle
of the hypertrophied palate as well as
achieve shortening of its length. If the
lateral laryngeal ventricles are everted,
these may be removed at the same time in
order to facilitate anaesthetic recovery,
although they will recede if sufficient
improvement to airflow has been achieved.
Some surgeons also remove the tonsils if
they are grossly enlarged.
Laryngeal collapse is generally treated
conservatively, but the collapse will
continue to contribute to airway obstruction
and may progress. It has been suggested
that laryngeal lateralisation (tieback) may
Figure 2: Severe laryngeal collapse. The
cuneiform and corniculate processes
meet in the midline, closing both the
ventral and dorsal glottis
Reproduced from the BSAVA Manual of Canine and
Feline Head, Neck and Thoracic Surgery
Corniculate
process
Cuneiform
process
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Airway problems in
brachycephalic dogs
be beneficial for dogs with extreme
collapse, although this is unproven, with
permanent tracheostomy considered as a
last resort.
The abundant pharyngeal folds mean
that the pharynx may continue to look
very narrow despite palatoplasty, and
owners should be encouraged to keep
these dogs on the slim side to reduce the
impact of these folds. Clinically this may
manifest as ongoing upper respiratory tract
obstruction during recovery from
anaesthesia. Recovery should therefore be
slow and quiet, with the endotracheal tube
left in place for as long as the dog tolerates
it. The head can be supported on a
sandbag and the tongue extended to aid
breathing, but most dogs will breathe
normally by the time they are conscious.
Postoperative swelling of the mucosa is
rarely a problem if the technique is
performed by an experienced surgeon.
Associated conditions
Whilst most BAOS dogs respond well to
surgical management, other contributory
factors may affect the long-term outcome.
Brachycephalic dogs treated for BAOS
may also have bronchial stenosis, although
it is not thought to affect surgical outcome.
Nasopharyngeal turbinates are present in
20% dogs with BAOS, especially Pugs,
and unless facilities are available to resect
them, they may continue to affect the level
of nasal airway resistance. Epiglottic cysts
and laryngeal granulomas are also
described in English Bulldogs.
Finally, recent reports have shown an
association between BAOS and
gastrointestinal disease, with 50% of dogs
having dysphagia and vomiting.
Abnormalities (including hiatal hernia)
and inflammatory disease are commonly
found during upper gastrointestinal tract
endoscopy and biopsy, and there is a
relationship between the severity of
respiratory disease and gastrointestinal
signs. Affected animals benefit from 23
months of treatment with a histamine
(H2) inhibitor and prokinetic, with
prednisolone for cases with severe
inflammation/fibrosis and an antacid and
surface protector if there is oesophagitis.
Long-term therapy is required in 25% of
dogs, and owners should be aware that
this may be a significant factor in the
postoperative outcome.
Summary
The aim of surgery is to reduce airway
obstruction such that collapse episodes do
not occur. It is rare for affected dogs to
have quiet respiration and most will still be
unable to tolerate exercise in hot weather.
Owners should remain conservative in their
expectations and should continue to avoid
exercise in hot weather. However, the
majority of dogs recover without
complication and achieve an improved
quality of life. Brachycephalic breeds are
charming and entertaining household pets
and are likely to increase in popularity;
however, the likelihood of the conformation
defects being improved are slim and it
would appear that veterinary involvement
in these breeds is here to stay. n
References are available upon request.
SOFT TISSUE SURGERY
The Manuals of Canine and Feline
Abdominal Surgery, Head, Neck and
Thoracic Surgery, and Wound Management
and Reconstruction highlight the most
commonly performed techniques.
Procedures undertaken by surgeons with
more experience are also discussed, so
that practitioners can better inform their
clients. Step-by-step Operative Techniques
detail the common procedures, with notes
on patient positioning and preparation,
instrumentation and postoperative care. Member price 49 Member price 44 Member price 49
Figure 3: Soft palate resection. (A) Allis tissue forceps are used to grab the centre of the soft palate and pull it rostrally. The grasped
area will be removed. (B) A clamp is applied and used as a guide for cutting the soft palate. (C) The palate is oversewn loosely
around the clamp, which is then removed. The larynx is now visible
Reproduced from the BSAVA Manual of Canine and Feline Head, Neck and Thoracic Surgery
A B C
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PETSAVERS
Improving the health of the nations pets
P
etsavers produces a range of
products specifically designed to
meet the requirements of small
animal practice. By buying Petsavers
veterinary products you can ensure that
all the profit goes directly back to
Petsavers, helping to support the important
work that Petsavers does in awarding
grants to vets both in academia and
practice to research the many conditions
and illnesses that affect pets.
Heated pads
Petsavers heated pads are designed to
keep small pets warm in hospital and are
also effective in minimising perioperative
hypothermia. The pads are cheaper than
an incubator and are less hassle than hot
water bottles. The pads
are easy to clean and
run on a low voltage
so that they can be
left on constantly. A
plug-in lead means it
can be easily
passed through the
bars of a cage.
Protective collars
Assembly of the protective collars is easy
and they are attachable to regular collars.
The collars come in packs of ten and are
available in a range of sizes starting at
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Petsavers veterinary
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We are pleased to announce that Petsavers
veterinary products, previously available only
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PETSAVERS CHRISTMAS CARDS
An order form for Petsavers Christmas cards is included in this edition
of companion, with a special offer price of 3 for a pack of 10. These
cards can also be ordered through www.petsavers.org.uk where
you can also see the extended range of Petsavers Christmas cards.
Recovery blankets
Petsavers recovery blankets are made of
metalized polyester, which means these
blankets are tough and also retain 95% of
radiated body heat. The blankets are ideal
for preventing hypothermia in the
perianaesthetic period and are also
radiolucent, which means that diagnostic
radiographs can be taken while the animal
remains in the blanket. They are especially
useful for trauma patients or hypothermic
cases. The blankets are 2.14 m x 1.42 m
and can be cut to fit smaller animals.
Pet carriers
Petsavers
wire carriers
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The hinged lid
allows full
access to the
interior of the
carrier, so its easy to get pets in and out.
Petsavers also features inexpensive
cardboard carriers that are popular with
clients and easy to store.
25 Petsavers.indd 25 24/09/2010 12:33
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The challenges of
vaccination in Asia
T
he WSAVA Vaccination Guidelines Group (VGG)
was established in 2006 following recognition by
the WSAVA Board and Scientific Advisory
Committee (SAC) of the need for globally applicable
recommendations on best practice for the vaccination
of dogs and cats. During its first phase of activity
(200607) a substantial guidelines document was
produced which was published (Day et al., Journal of
Small Animal Practice 2007; 48: 52841) and made
freely available on the WSAVA website (latterly with
Spanish and Polish translations). This document
included a set of invaluable fact sheets related to the
major canine and feline vaccine-preventable infectious
diseases and a set of frequently asked questions
(FAQs) related to vaccination practice.
The 2007 WSAVA vaccination guidelines had major
global impact as assessed by a survey conducted of
WSAVA member organisations in 2009. The availability
of the guidelines, accompanied in some instances by
local public pressure, led to many countries either
formally adopting the WSAVA guidelines as national
policy, or using the WSAVA guidelines as a basis for
formulation of a national policy document. It is clear
that the controversy surrounding small companion
animal vaccination has not diminished and that there
is an urgent requirement to educate veterinary
practitioners in this area. The members of the VGG are
actively engaged in delivering national and
international lectures to help address this demand.
The VGG was reconvened in
2009 for a second phase of activity
which concluded in June 2010.
During Phase II the initial task was
the above-mentioned assessment of
the global impact of the 2007
guidelines. The second major task
was the production of an updated
2010 version of the guidelines. The
document has been prepared and
published (Day et al., Journal of
Small Animal Practice 2010; 51: 33856). The revised
document includes much new background information
which was included following the feedback from the
2007 version. In addition, there is a new infectious
disease fact sheet related to rabies virus and the
number of FAQs has almost doubled. As a
supplement to the revision we also make available a
set of images, related to the major vaccine-preventable
infectious diseases, that may be used by veterinary
surgeons in their consultation room to emphasise the
importance of vaccination to clients. The final outcome
of Phase II was the release of a substantial information
document for the owners and breeders of small
companion animals in June 2010.
VGG Phase III: focus on Asia
During 200809, the chair of the VGG was privileged
to lecture on the vaccination guidelines in Japan,
The WSAVA Vaccination
Guidelines Group is reconvening
for a new phase of activity, which
will focus on the challenges
related to infectious disease
control in dog and cat
populations in Asia
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WSAVA NEWS
Thailand, Singapore and India. These visits also
provided unique opportunities to discuss with local
practitioners, academic experts and officers of
professional associations the issues and challenges
related to vaccination in Asia.
The developing Asian countries provide particular
challenges related to infectious disease control in dog
and cat populations. The relevant issues include:
Stray animals: There are vast populations of stray
animals within these countries and a lack of
infrastructure to control these animals. There is a high
prevalence of infectious disease within these stray
populations diseases that are well controlled by
vaccination in developed countries are commonplace
in these areas.
Rabies: Rabies is a major cause of human
mortality in these countries. Mandatory vaccination of
the canine pet population is not routine and control is
particularly challenging in the stray population.
The economics of pet ownership: Although in some
burgeoning economies, such as India and China,
greater affluence has led to increased pet ownership
and a clientle prepared to finance this activity, the
majority of owned animals in developing nations will
not receive regular veterinary attention. The affluent
clientle also has a distinct preference for particular
small breeds of dog (e.g. the Pug in India, the
Dachshund in Japan) and in some instances there is
unregulated cross-border importation of stock (e.g.
from Thai puppy farms) that frequently carry
infectious disease. In most Asian countries, the dog is
the companion animal of preference, although there is
a slow increase in the keeping of pet cats.
The inadequacy of education of veterinary
surgeons in small animal practice: In many of these
countries, a number of veterinary schools teach to a
national curriculum that is entirely directed towards
production animals. Small animal medicine
practitioners rely on CE events for their education.
There is inadequate knowledge of small animal
infectious disease, immunology and vaccinology. It is
also challenging to bring high-quality CE to these
nations, even the more developed countries, as the
small animal practitioner population might be relatively
small and geographically dispersed and opportunities
are limited. The WSAVA CE programme has been very
successful in achieving this goal.
The lack of laboratory diagnostic infrastructure: In
some countries there are no commercial pathology
laboratories able to service the small animal sector.
Laboratory diagnosis, including of infectious disease,
is unavailable other than through rudimentary in-
practice testing or the use of human medical
laboratories without veterinary specialist input.
The lack of availability of vaccines: Many
developing countries are (correctly) regarded as very
small markets by manufacturers and so only limited
product ranges are available, often via secondary
distributors. In terms of vaccines, this means that
monovalent or restricted component products are
unavailable making it impossible for veterinary
surgeons to adopt new vaccination guidelines.
Manufacturers are also slow to introduce extended
duration of immunity (DOI) products into these
countries, again impeding the uptake of new
guidelines. Additionally, within some countries there
are local vaccine manufacturers that dominate the
market with products that are sometimes of low
efficacy relative to internationally used vaccines.
Political pressures: In many Asian countries the
national professional organisations are highly political,
very persuasive and well respected by the local
veterinary community. These organisations may not be
fully aware of the new vaccination guidelines.
A number of these points come together in the
situation regarding the uptake of extended DOI
vaccines in some developing Asian nations.
Practitioners correctly recognise a high local
infectious disease pressure on companion animal
MEMBERS OF
THE VGG
Professor Michael J. Day, UK
(Chairman)
Professor Ronald D. Schultz,
USA (Member)
Professor Hajime Tsujimoto,
Japan (New member)
Professor Richard Squires,
Australia (New member)
Professor Marian Horzinek,
The Netherlands (Past Member
of VGG Phase I/II)
The work of the VGG would not have been possible without the generous
sponsorship of Intervet/Schering-Plough Animal Health and WSAVA.
(LR): Professors Ronald Schultz,
Marian Horzinek, Michael Day
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WSAVA NEWS
populations and will not be convinced that an
appropriately vaccinated animal will be afforded
protection for three years following use of an extended
DOI product.
This collection of facts clearly highlights an urgent
need for evaluation of the Asian situation with respect
to companion animal vaccination. The proposed aim
for Phase III of the WSAVA VGG is therefore to take an
Asian focus and address this specific need.
Phase III plan
The established mode of operation for the VGG is to
work over a cycle of 12 months, with face-to-face
meetings and electronic communication between
these meetings. This tested model will be applied to
Phase III, which will run from 2011 to 2012. Within this
framework, the aims of the VGG for Phase III will be:
WORLD CONGRESS
2011 KEY FACTS
What:
36th World Small Animal Veterinary Association
World Congress 3rd Federation of Asian Small
Animal Veterinary Associations Congress 21st
Korean Animal Hospital Association Congress
When:
Friday 14 to Monday 17 October 2011
Where:
International Convention Center Jeju, Korea
Lectures:
Confirmed 80 keynote speakers, 31 streams
Organisers:
World Small Animal Veterinary Association
Federation of Asian Small Animal Veterinary
Associations Korean Animal Hospital
Association Korean Society of Veterinary Clinics
Korean Society of Veterinary Science Korean
Association of Education for Veterinary Clinics
Please visit the official website
(www.wsava2011.com) for more information.
WSAVA CE UPDATE
October 2010
Costa Rica: Emergency Medicine (Dr Luis Tello)
El Salvador: Emergency Medicine (Dr Luis Tello)
Panama: Emergency Medicine (Dr Luis Tello)
Poland: Interdisciplinary (various speakers)
Cuba: Cytology
November 2010
Czech Republic: Vaccination Guidelines (Dr Ron Schultz)
India: Internal Medicine & Surgery (Dr Lappin & Dr McPhail)
Sri Lanka: Internal Medicine & Surgery (Dr Lappin & Dr McPhail)
Estonia: Feline Medicine and Behaviour
Albania: Soft Tissue Surgery
To undertake a fact-finding exercise in Asia with
view to further defining and understanding the
issues and problems (listed above) that are unique
to this area
To formulate a summary document that makes
recommendations to Asian veterinary professional
groups, governments and veterinary schools as to
how some of these issues may be addressed
To produce a concise practitioner-facing document
that offers simple recommendations for best-
practice vaccination in this geographical area and
to encourage national organisations to translate this
To develop core education modules in small
companion animal infectious disease, immunology
and vaccinology, and to make these available to
practitioners and veterinary students
To begin to deliver vaccinology CE in the region.
26-28 WSAVA News.indd 28 24/09/2010 12:34
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29
THE companion INTERVIEW
Sandy
Trees
Sandy Trees was born in Middlesborough in 1946. At the age of three, his
family moved to Scunthorpe where his father worked as a chemical engineer
in the steelworks. An only child, Sandy developed an interest in natural history
and outdoor activities such as mountain climbing as a pupil at Brigg
Grammar School. He was accepted to the Edinburgh veterinary school where
he graduated in 1969. He spent just over a year in mixed practice in Derby
before returning to Edinburgh as a researcher at the Centre for Tropical
Veterinary Medicine. After completing his PhD, he went into industry spending
three years in Rome as Elancos veterinary adviser for the Middle East and
Africa. In 1980 he was offered a lectureship at Liverpool and has remained
there for the rest of his career. He was elected president of the RCVS in 2009.
Q
What was your abiding memory of your
time at Edinburgh?
A
That must be meeting the woman who would
become my wife at a third year party. At that
time there werent many females in the
veterinary faculty and you had to look further afield to
meet any girls. Frances was in her first year of a
modern languages degree and so we graduated at the
same time. On a more flippant note, my clearest
memory is of walking home through the city in the early
hours taking in the pungent smell of the local brewery.
Is there anything that you know now that you wish
you had known then?
There is a great line in the Bob Seger song Against the
Wind that says Wish I didnt know now what I didnt
know then. But the answer is really no I have no
regrets. I lived life to the full then, just as I try to do now.
Did you go into practice on qualification?
No, I went on a postgraduation expedition with five
classmates. We offered our services and were given
the incredible privilege of working on the first field trial
on an experimental vaccine for East Coast Fever in
cattle, which had been developed at the Kenyan
national veterinary research institute at Muguga. We
raised 5,000 for the trip, which was quite a lot of
money in those days. It paid for our airfares, two
secondhand Land Rovers and our living costs for six
months spent looking after the vaccinated cattle out in
a tick-infested area of savannah.
What do you consider to be your most important
achievement during your career?
In my scientific career there are three things that I am
proud of. One is the work that my colleagues and I
have done over the years on onchocerciasis, using
the worms found in cattle as a model for the infection
that causes river blindness in people. We showed that
antibiotic treatment kills these worms by knocking out
bacteria that the worms depend on. That story is still
unfolding, with trials in humans who have
onchocerciasis or elephantiasis with tetracycline
antibiotics. In addition to that, I think we have done
good work in helping to unravel the story behind
Neospora as a disease agent in cattle and dogs and
in drawing attention to the risks of new parasitic
diseases arriving here following the relaxation of the
quarantine rules.
29-30 Interview.indd 29 24/09/2010 12:20
30
|
companion
THE companion INTERVIEW
one should never
let regrets and
bitterness triumph over
optimism and hope
THE companion INTERVIEW
... and outside the lab?
I was Dean of the Liverpool faculty from
2001 to 2008 and during that time the
school went through some tremendous
changes. With the help of a very
supportive Vice Chancellor and senior
colleagues, it grew significantly in terms of
student and, particularly, staff numbers.
We improved the infrastructure and built a
wonderful new small animal hospital.
During that period, we also celebrated
the schools centenary, which was a
great occasion.
What has been your main interest
outside work?
That has to be my family. Frances and I
have one daughter, Katie, now 33. There is
one grandchild and another on the way.
Mountaineering and the great outdoors has
been a lifelong passion, although I dont
have as much time for those things as I
would like.
When and where were you happiest?
Now, I suppose. But I have been lucky
and can say in all honesty that I have
enjoyed all the different phases and facets
of my career.
Who has been the most inspiring
influence on your professional career?
I remember two wonderful lectures that I
attended as an undergraduate. One was
on ticks by Dr Alan Campbell, a
parasitologist at Edinburgh, which probably
stimulated my longstanding interest in
tick-borne disease. The second was by Sir
Alexander Robertson, one of the great
figures in the vet school at that time. He
gave tremendous support to my friends
and me in organising our postgraduate trip
and also helped me greatly during my PhD.
to both small and big issues. Ultimately,
our success in dealing with the worlds
big problems like climate change and
overpopulation will depend on
individuals, corporations and governments
acting responsibly.
Which historical or literary figure do
you most identify with and why?
There are two former Prime Ministers that I
admire Winston Churchill and Margaret
Thatcher. I think history will show that she
was the greatest post-war Prime Minister.
In other areas, I admire Ernest Shackleton
for his leadership in saving his men on their
Antarctic expedition in 1916. We make
heroes in this country of glorious failures
he wasnt one and he did amazing things
in bringing his people home.
If you could change one thing about
your appearance or personality, what
would it be?
You will have to ask Frances; she has to
look at and listen to me more than
anyone else.
What is your most important
possession?
Assorted memorabilia. I am not one for
gadgets and gizmos but there are some
things like photographs which are simply
irreplaceable.
What would you have done if you hadnt
chosen to work in the veterinary
sphere?
In deciding to apply for a university place,
it was a toss-up between human and
veterinary medicine. Because I love the
outdoors, I decided to try for veterinary
school. There are some aspects of human
medicine which I find fascinating such as
psychiatry and the power of the human
mind. Being based in the School of
Tropical Medicine, I have been fortunate in
being able to work in areas of veterinary
medicine that have been relevant to the
interests of a wider society. n
What is the most significant lesson you
have learned so far in life?
Be positive and see the upside of every
situation. One should never let regrets and
bitterness triumph over optimism and
hope. It is also important to stand up for
key principles while recognising that there
are some battles that are unwinnable.
What do you regard as the most
important decision that you have made
in your life?
Apart from asking Frances to marry me,
I suppose it was choosing an academic
career, focussing on teaching and
applied research.
What is the most frustrating aspect of
your work?
I dont get frustrated very often because I
see most problems as a challenge to be
overcome. But in management it is a
constant battle to ensure that bureaucracy
and rules are servants of progress and
action rather than inhibiting them. Also as
president of the Royal College, I became
aware and concerned about the time and
resources that are devoted to just a few
disaffected members of the profession.
That effort could be better spent in
helping promote the interests of the
thousands of hard working, well
intentioned and contented members of
this great profession.
If you were given unlimited political
power, what would you do with it?
I think the key word is responsibility. I think
it is important to ensure the individuals
and organisations that behave responsibly
are supported by the political system
and those that behave irresponsibly do
not benefit from their actions. This applies
29-30 Interview.indd 30 24/09/2010 12:20
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CPD diary
Visit the CPD section at www.bsava.com to find dates for local courses.
All dates were correct at time of going to print; however, we would suggest that you contact the organisers for confirmation.
EVENING MEETING
NORTH WEST REGION
Wednesday 13 October
Cruciates, curse or blessing?
Speaker: Turlough ONeill
Holiday Inn, Haydock
Details from northwestregion@bsava.com
EVENING MEETING
SOUTH WEST REGION
Friday 22 October
An approach to flexible endoscopy
Speaker: Philip Lhermette
Plymouth University
Details from southwestregion@bsava.com
EVENING MEETING
SOUTH WALES REGION
Wednesday 27 October
Angiostrongylosis, the Celtic
worm: everything you wanted
to know
Speaker: Ronan Fitzgerald
Shepherds Veterinary Surgery,
Bridgend CF31 2BF
Details from southwalesregion@bsava.com
EVENING MEETING
SURREY AND SUSSEX REGION
Thursday 28 October
Heart murmers in cats
Speaker: Virginia Luis Fuentes
Leatherhead Golf Club, Kingston Road,
Surrey KT22 0EE
Details from surreyandsussexregion@
bsava.com
ADDITIONAL CPD COURSES
Visit www.bsava.com for full details
DAY MEETING
Tuesday 2 November
Medicine, surgery and emergency care of
cage birds and raptors
Speakers: Simon Girling and Romain Pizzi
DAY MEETING
Tuesday 2 November
Backyard poultry: problems and
solutions. Includes chickens, turkeys,
pheasants, peafowl and waterfowl
Speaker: Victoria Roberts
EVENING MEETING MIDLANDS REGION
Wednesday 3 November
Getting the most from your practice ECG
Speaker: Rachel James
DAY MEETING SOUTH WEST REGION
Thursday 4 November
Physiotherapy and rehabilitation in small
animal practice
Speaker: Helen Mathie
DAY MEETING
Thursday 4 November
Advanced surgical nursing: taking the
trauma out of nursing the trauma patient
Speakers: Mickey Tivers & Alison Young
EVENING MEETING
SOUTHERN REGION
Thursday 7 October
Behavioural problems in cats
and dogs
Speaker: Kersti Seksel
Potters Heron Hotel, Romsey SO51 9ZF
Details from southernregion@bsava.com
DAY MEETING MIDLANDS REGION
Wednesday 13 October
Essentials of small animal
ophthalmology
Speaker: John Mould
Yew Tree, Kegworth, Derby DE74 2DF
Details from midlandregion@bsava.com
DAY MEETING SCOTTISH REGION
Sunday 24 October
Abdominal surgery, techniques
and case study for vets
Speaker: Kathryn Pratsche
Dunkeld Hilton, Dunkeld PH8 0HX
Details from scottishregion@bsava.com
DAY MEETING SCOTTISH REGION
Sunday 24 October
Radiology for vet nurses
Speaker: Martin Sullivan
Dunkeld Hilton, Dunkeld PH8 0HX
Details from scottishregion@bsava.com
DAY MEETING
Thursday 28 October
Advanced feline nursing day
Speaker: Andrea Harvey
BSAVA Headquarters, Gloucester GL2 2AB
Details from administration@bsava.com
EVENING MEETING KENT REGION
Thursday 21 October
Managing the reptilian inpatient
Speaker: Martin Lawton
Best Western Russell Hotel, 136 Boxley
Road, Maidstone ME14 2AE
Details from kentregion@bsava.com
DAY MEETING
Thursday 14 October
Essential dispensing course
Speakers: Phil Sketchley, Steve Dean,
Fred Nind, John Hird, Pam Mosedale
and Mike Jessop
Village Hotel, Cardiff, Coryton CF14 7EF
Details from administration@bsava.com
DAY MEETING
Thursday 7 October
How to keep this cornea clear
Speakers: Christine Heinrich and
Claudia Hartley
Kettering Park Hotel & Spa,
Northants NN15 6XT
Details from administration@bsava.com
DAY MEETING
Tuesday 19 October
Haematology
Speaker: Clare Knottenbelt
BSAVA Headquarters, Gloucester GL2 2AB
Details from administration@bsava.com
DAY MEETING
Thursday 21 October
Oncology II
Speaker: Rob Foale
Thorpe Park Hotel & Spa, Leeds LS15 8ZB
Details from administration@bsava.com
DAY MEETING
Wednesday 13 October
Wound Management Road Show
Speakers: Geraldine Hunt
and Ronan Doyle
Novotel, Ponteland Road,
Kenton, Newcastle Upon
Tyne NE3 3HZ
Details from administration@bsava.com
DAY MEETING
Friday 15 October
Wound Management Road Show
Speakers: Geraldine Hunt
and Ronan Doyle
Holiday Inn, Huntingdon,
Cambridge CB24 9PH
Details from
eastanglia.region@bsava.com
DAY MEETING
Monday 18 October
Wound Management Road Show
Speakers: Geraldine Hunt
and Ronan Doyle
Chilworth Manor,
Chilworth, Southampton,
Hampshire SO16 7PT
Details from administration@bsava.com
DAY MEETING
Wednesday 20 October
Wound Management Road Show
Speakers: Geraldine Hunt
and Ronan Doyle
Thistle Hotel, Brands
Hatch, Fawkham,
Longfield DA3 8PE
Details from administration@bsava.com
31 Diary.indd 31 24/09/2010 12:20
54th Annual Congress 31 March 3 April
The ICC / NIA Birmingham UK
2011
British Small Animal Veterinary Association
Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley, Gloucestershire GL2 2AB, UK
For further information please email congress@bsava.com
n Book online at www.bsava.com
to save 5% on your registration
n The largest small animal congress in Europe
n Created by the profession for the profession
n Offers more choice than any other conference in Europe
n Over 40 streams and more than 100speakers
n Simultaneous translation into Spanish and Polish
1 veterinary stream each day (Hall 1)
n Over 200 exhibitors offering expertise and discounts
32 OBC.indd 32 24/09/2010 12:14