Companion November2012

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The essential publication for BSAVA members

companionNOVEMBER 2012

Diagnosing felinenasopharyngealdiseases

A dogs lifein prisonA pet project withoffenders P4

Clinical ConundrumUnilateral oculardiscomfortP8

How ToApproach the patientwith PU/PDP12


2/362 | companion

EJCAP ONLINE

Dont forget that as aBSAVA member you areentled to free onlineaccess to EJCAP register

at www.fecava.org/EJCAPto access the latest issue.

PETSAVERS FUNDED STUDY

Hair nicone concentraons indogs exposed to environmentaltobacco smoke (ETS)

This PetSavers-funded study found that

nicone concentraons in dog hair appear to

be strongly associated with reported exposure

to ETS, and the range and median were

similar to those reported in children. This

suggests that dog hair could provide a useful

method of determining the amount of ETS

exposure in environments common to pets

and children.

Analysis of 14,008 uroliths from dogsin the United Kingdom

This study found that associaons between

breed, gender, age and urolith formaon

were similar to those reported elsewhere.

However, temporal trends and novel breed

predisposions were idenfied.

Quesonnaire-based assessmentof owner concerns and doctorresponsiveness for caninechemotherapy paents

The authors conclude that quesonnaire-

based surveys appear to be an effecve tool

companionis published monthly by the BritishSmall Animal Veterinary Association, WoodrowHouse, 1 Telford Way, Waterwells Business Park,Quedgeley, Gloucester GL2 2AB. This magazineis a member-only benefit. Veterinary schoolsinterested in receivingcompanionshouldemail [email protected]. We welcomeall comments and ideasfor future articles.

Tel: 01452 726700Email: [email protected]

Web: www.bsava.com

ISSN: 2041-2487

Editorial BoardEditor Mark Goodfellow MA VetMB CertVR DSAMDipECVIM-CA MRCVSCPD Editor Simon Tappin MA VetMB CertSAMDipECVIM-CA MRCVSPast President Andrew Ash BVetMed CertSAM MBAMRCVS

CPD Editorial TeamPatricia Ibarrola DVM DSAM DipECVIM-CA MRCVSTony Ryan MVB CertSAS DipECVS MRCVSLucy McMahon BVetMed (Hons) DipACVIM MRCVSDan Batchelor BVSc PhD DSAM DipECVIM-CA MRCVSEleanor Raffan BVM&S CertSAM DipECVIM-CA MRCVS

Features Editorial TeamAndrew Fullerton BVSc (Hons) MRCVSMathew Hennessey BVSc MRCVS

Design and ProductionBSAVA Headquarters, Woodrow House

No part of this publication may be reproducedin any form without written permission of thepublisher. Views expressed within thispublication do not necessarily represent thoseof the Editor or the British Small AnimalVeterinary Association.

For future issues, unsolicited features,particularly Clinical Conundrums, arewelcomed and guidelines for authors areavailable on request; while the publishers willtake every care of material received noresponsibility can be accepted for any loss ordamage incurred.

BSAVA is committed to reducing theenvironmental impact of its publications

wherever possible and companionis printedon paper made from sustainable resourcesand can be recycled. When you have finishedwith this edition please recycle it in yourkerbside collection or local recycling point.Members can access the online archive ofcompanionat www.bsava.com.

3 BSAVA NewsLatest from your Association

46 Its a dogs life in prisonPioneering projects inside jails

811 Clinical ConundrumUnilateral ocular discomfort

1217 How ToApproach the patient with polyuriaand polydipsia

1822 Diagnosing felinenasopharyngeal diseasesExtracts from the new FoundationManual on feline practice

23 Congress FreebiesMaking the most of your eventbootie

2425 Congress Psychology inPractice streamAn example of the fresh newapproach being taken by BSAVA

2627 PetSaversNews, reports, and a chance to runin the London Marathon

2829 WSAVA NewsThe World Small Animal VeterinaryAssociation

3031 The companionInterviewAimee Llewellyn

33 Focus OnSurrey and Sussex Region

3435 CPD DiaryWhats on in your area

Additional stock photography Dreamstime.com

Indigofish; Katrinaelena; Soland; Steve Mann;

Virgil Naslenas; Vitaly Titov & Maria Sidelnikova; Vivian Seefeld; Vladyslav Starozhylov

Whats inJSAP

this month?Here are just a few of thetopics that will feature inyour November issue:

for communicang dog owners concerns

regarding chemotherapy and potenally for

monitoring a clinicians aenveness. Owners

expressed concerns at approximately half of

chemotherapy appointments.

A new method of compung thevertebral heart scale

This study compared a simplified VHS method

with the Buchanan VHS method. Providing

clinicians with precise guidance would

decrease variability and improve the reliability

of results.

Determining the cause of canineurolith formaon by advancedanalycal methods

The results of this study appear to confirm

the causave role of absorbable suture

material in the pathogenesis of hollowchannel structure in some canine

compound uroliths.

Log on to www.bsava.comto access

the JSAP archive online.


3/36companion | 3

Regions take

grass roots leadat strategy weekend

Representatives from all 12 of BSAVAs

regional committees got together in

Oxford in September to produce plans

for offering the very best CPD and

support to members in 2013.

The dedicated and energetic volunteers

that make up the regional committees

demonstrated how committed they are to

finding the most effective ways of

delivering high-quality low-cost

CPD. Ideas flowed freely during the

two-day meeting which takes place

twice a year so experiences can be

shared and new initiatives developed.

One of the big successes of 2012

has been the introduction of TurningPoint

voting technology to allow interactive

regional meetings. Attendees at Congress

will be aware of the great utility of this

technology, and how it can make for a much

more enjoyable lecture experience. This will

become an increasingly prominent feature in

the 2013 diary with more regions offeringinteractive events.

The central topic at all these biannual

meetings is a discussion about how BSAVA

can deliver even more to its members,

especially through regional committees.

Offering accessible CPD is a priority, of

course; however, if you have any other ideas

about how we can ensure we give you the

best possible support, then do please give

us your thoughts or even find out more

about becoming a regional volunteer.

Email Ben Dales at [email protected].

With a treasure chest of dedicated

resources the BSAVA invites vet nurses to

benefit from an expanded membership

package in 2013.

VN membership had a quiet launch in 2012

and since then BSAVA has listened to those who came

on board early and worked hard to create a package

that meets the needs of all VNs.

Improved benefitsVN Membership costs just one third of the general

membership fee. With the huge range of FOC CPD

this means that a BSAVA VN Member can get their

entire annual CPD, all from BSAVA, all for just 72.

Along with the nurse pocketbook, a collection of

vital info, stats and doses, that is being launched at

Congress, VN Members in 2013 will also get

complimentary subscription to companion, freelunchtime webinars, and hundreds of hours of

Congress lecture podcasts.

An especially welcome addition to the benefit

package is that VNs will also now be able to download

all the BSAVA Apps, including the Formulary (availableon iPhone and Android formats), and have access to a

brand new legal helpline.

VNs will of course be entitled to member discounts

too allowing a significant saving on all the Manuals,

CPD and four days at Congress from as little as 103

(in 2013). Of course VN Members also get exclusive

rights too. They can upgrade their Congress

registration to allow attendance at the veterinary

lectures as well as the nursing streams.

VNs to

benefit morefrom BSAVA

STOP THE PRESS NEW LEGAL HELPLINE

Watch out in your December issue for news of the new legal helpline for BSAVAmembers. Making your membership subscripon worth even more than ever before.

Response onanaesthesiaconsultation

In the October issue of companionwe invited members to comment onthe role of the vet nurse in monitoring and maintaining anaesthesia.

Thank you for the excellent responses we have already received. You

can still have your say until 30 November at www.bsava.com/

consultations.

Personal or practice investmentBSAVA is offering VN Membership to help nurses who

are keen to expand their clinical knowledge andachieve all their ambitions. So whether

its an investment in your own career

or is part of the training package

from the practice BSAVA

membership is the most

cost effective way to get all their

CPD requirements and a whole

raft of resources and benefits.

All VNs or practice principals

interested in VN Membership

can contact the BSAVA

membership team either

via www.bsava.comor

call 01452 726700.


4/364 | companion

Its adogs lifein prison

Strouds Digest on the Diseases of Birdsis the

first textbook that should be consulted by

anyone who wants to know about the

redemptive power of working with animals. It

was written by a violent career criminal who had been

sentenced to hang for the murder of a prison guard.

But while being held in solitary confinement he found

an injured bird which he nursed back to health. This

led to him being allowed to keep canaries in his celland he went on to become a leading authority on the

diseases of caged birds.

Robert Stroud, the famed Birdman of Alcatraz

died aged 73 in a medical centre for federal prisoners

at Springfield, Missouri. In contrast for the 18- to

21-year-old inmates of the Polmont Young Offenders

Institution near Falkirk the future may not be so bleak.

Rebecca Leonardi, a postgraduate student at the

University of Stirling is responsible for a new initiative

aimed at preventing reoffending.

She is running Paws for Progress, a scheme which

offers offenders the opportunity to become involved in

training the dogs at a local rescue kennels so that they

are suitable for adoption by those wanting a well

behaved adult dog. The project, which began in August

2011, is a collaboration between the university, the

Scottish Prison Service and the Dogs Trust, and has thesupport of a number of organisations, including the

Society for Companion Animal Studies which promotes

the use of animals in improving human welfare.

Origins of an ideaThe idea behind the initiative is that through taking

responsibility for a dog, the behaviour of the young

men will also change; they will become involved with

the educational opportunities available and improve

their chances of getting a job on release.

Ms Leonardi is currently analysing data from the

first year of the scheme as part of her PhD thesis, and

the early indications are that it is achieving its goals.That is not surprising since the scheme is based on

Project POOCH (Positive Opportunities Obvious

Change with Hounds), a similar programme that has

been successfully changing the lives of young men

What do abandoned dogs and young offendershave in common? These two groups know onlytoo well what it feels like to be unwanted andcondemned to spend their days behind bars.In a pioneering Scottish project the inmates ofa young offenders institution and abandoneddogs living in welfare charity kennels are helping

each other to develop the behaviour and skillsthey will need to be accepted back intomainstream society. John Bonner reports


5/36companion | 5

and their canine charges at the MacLaren Youth

Correctional Facility in Woodburn, Oregon, since 1993.Project POOCH in turn was based on an initiative that

began 12 years earlier at Purdy Womens prison in

neighbouring Washington State. Similar projects have

since been launched at prisons in Australia, Canada,

South Africa and Spain.

This has been a mutually beneficial

project for all involved. The young men at

Polmont have enhanced their

employability and literacy skills and, as a

result of their involvement in Paws for

Progress, have even been awarded aScottish Qualifications Certificate. I look

forward to reading Ms Leonardis

findings in the future and seeing how this

research can be utilised to improve the

efficiencies of the prison estate.Kate Donegan, Governor at Polmont,

Scottish Prisons Service

Working with the probation serviceMany other prisons have attempted to calm prisoners

behaviour by allowing them contact with animals,

particularly cagebirds and fish that can be easilycared for in a cell. Liz Ormerod is a veterinary

practitioner from Fleetwood in Lancashire and

chairwoman of SCAS. She has studied the effects of

what has become known as Pet Facilitated Therapy

through her work with a former senior probation officer

for the county, Mary Whyham.

Together they surveyed the policies in place at 156

penal institutions around the UK and maintain that in

those places where prisoners had contact with animals

there were a number of very significant benefits. These

included better relationships between the prisoners

and their guards, a reduction in violence, fewer

incidents of self-harm and suicides, a reduction in drug

taking, and improved self-esteem among the inmates.If these effects are seen consistently in all

institutions that allow pet-keeping, then why is it the

case that less than one-in-three prisons surveyed have

such a policy? Liz Ormerod believes that there is

opposition from the public and within the prison

service to anything that smacks of pampering theprisoners. That does seem strange when they are

allowed to have a television but are not allowed to keep

a bird or fish in their cell, she asserts.

The hard cellThere have been a number of other objections

based on claims that bringing in animals would

provoke allergic responses in prisoners or staff, or

that larger animals brought in from outside the prison

could be serving as a drugs mule.

Security is certainly an issue because of the

continuing increase in the prison population.

Prisoners are being kept two or even three to a cellin facilities that were only designed for one. In some

cases, prisoners are kept locked up for most of the

day because there are not enough staff available to

oversee educational and training programmes like that

at Polmont.

Even in those places which have introduced

policies on pet ownership or to allow animals to visit

the institution, there is no guarantee that such

privileges will be maintained. Mary Whyham points out

that the attitudes of the prison governor and senior

colleagues are crucial, and many schemes have

foundered after key staff moved on to be replaced by

those with different views.


6/366 | companion

Its a dogs life in prison

Yet Liz Ormerod insists that maintaining such

policies would make the working lives of prison staff

much easier. It builds a different, more cooperative

atmosphere. Both the prisoners and the prison officers

start to see each other as better people. A pet gives

both sides something to talk about and the guards willoften bring in little treats for the animals. So the anger

that many prisoners feel starts to go away.

One obvious aspect to looking after an animal is

the time that it takes, an asset that inmates possess in

greater quantities than they would wish. Liz maintains

that it also fulfils a deeply held need to nurture another

living being, especially among the genuine hard

cases. At one prison I talked to a man who has stayed

up solidly for 72 hours looking after a sick budgie.

I wish I had that sort of commitment more often from

the clients that I had at my practice. But for some of

these men having a pet is the first time that they have

felt unconditional love.

Positivity in prisonSo pet keeping can help to improve the prisoners

behaviour in the short term but the goal of the dog

training projects is to produce permanent changes.

Joan Dalton established Project Pooch when she was

vice principal of the school connected to the MacLaren

Correction Facility for Young People. Her job was to try

to help her students gain the credit points that would

allow them to gain the high school graduation

certificates needed by most US employers. She

estimates that around 500 students and 600 dogs

have passed through the scheme since its inception.

Students could gain credits in subjects such asbiology and civics through their involvement with the

dog training project but, according to the students

own reports, the most important thing that they learned

was patience, she explains.

They discovered that they could only train the dogs

once they had built up a good relationship with the

animal, and that the necessary changes in canine

behaviour would only come about through positive

reinforcement. Generally the animals chosen for the

training programme are those that the dog pound finds

most difficult to re-home and few offenders fail to

appreciate the parallels between their dogs plight and

their own.

Joan believes that the educational qualificationsand improved self-esteem that participants gain from

the scheme help them to make a new life once they

are released. Usually many offenders will go on to

become regular clients of the prison service as they go

through their lives, but study by psychologist Sandra

Merriam found a zero recidivism rate among graduates

of the scheme. Indeed, many former students with jobs

outside do return but only to help the Project POOCH

organisers at fund raising events to help them continue

their work.

Properly run not a panaceaMary Whyham warns that dog training schemes are

unlikely to provide a panacea to the problem of youthoffenders. Moreover, a badly organised scheme with

the wrong choice of supervisors, trainers and dogs is

unlikely to produce the goods and may even do harm

by discrediting this work in the eyes of the prison

authorities.

Joan Dalton agrees that it is vital that the

schemes are properly organised and wonders

whether the eight-week training programmes

envisaged for the Polmont scheme will be enough for

every student and every dog. She points out that

under Project POOCH, some trainers and some

dogs have needed much longer periods of training

before they are ready to be released or re-homed.But once both sides are considered ready, they will

have been equipped with the skills that they will need

to survive in their new roles either as a family pet or as

a free member of society.

In Oregon state we do have something like 8 per

cent unemployment but our students can compete

successfully in the job market because they have

acquired skills that can be useful in a lot of fields, such

as doggy day care centres and pet shops. One recent

student has just started a dog grooming business and

another has plans to train as a veterinary technician,

says Joan.

The important thing is that by creating a

relationship with their dogs that is based on respect,they learn to respect themselves. They start to see

that they do have some value and will no longer think

of themselves as just some stupid criminal that

nobody wants. n


7/36

For more information or to book your course

www.bsava.com

Learn@LunchwebinarsThese regular monthly lunchtime (12 pm) webinars areFREE to BSAVA members just book your place throughthe website in order to attend. The topics will be clinical lyrelevant, and particularly aimed at vets and nurses infirs t opinion practice. There will be separate webinarprogrammes for vets and for nurses.

This is a great MEMBER BENEFIT.

Coming soon What to say to a grieving owner webinar for nurses,

14 November Cascade update webinar for vets, 5 December Dealing with nasty dogs webinar for nurses,

12 December

All prices are inclusive of VAT. Stock photography: Dreamstime.com. Alptraum; Alterf alter; Isselee

Surgery of the pelvis4 DecemberDesigned for general practitioners, offeringa clinically relevant approach to thediagnosis and decision making

SPEAKER

Kevin Parsons

VENUE

Woodrow House, Gloucester

FEES

BSAVA Member: 227.00Non BSAVA Member: 340.00

New, importantinformation onfeline viral disease15 JanuaryFirst talk in the Feline Mini-Modularprogramme covering the major andemerging viral infectious diseases of cats

SPEAKER

Andy Sparkes

VENUE

Hilton Stansted Airport

FEES

BSAVA Member: 233.00Non BSAVA Member: 350.00

Infectious diseasesof the rabbit20 NovemberA cutting-edge day course for veterinary

surgeons treating rabbits in practice

SPEAKER

Emma Keeble

VENUE

Woodrow House,Gloucester

FEES

BSAVA Member:227.00Non Member:340.00


8/368 | companion

Clinicalconundrum

Describe the abnormalities in Figure 1In the right eye no abnormalities were detected. In the

left eye there was a central stromal ulcer with

associated corneal oedema and peripheral corneal

neovascularisation. A periocular tenaciousmucopurulent discharge was also present.

Describe an appropriate ophthalmicexam

Menace response. This was positive in both eyes,

indicating that vision was present bilaterally.

Dazzle and direct pupillary light reflexes. These

were also positive in both eyes, indicating function

of the neurological pathway from the retina to the

facial nerve (cranial nerve (CN)VII) and the

oculomotor nerve (CN III).

Schirmer tear test 1 (STT 1). In the right eye the

result was over 15 mm/min, indicating adequate

levels of aqueous tear production. In the left eye

the STT reading was 0 mm/min. This test should

be performed before any topical medications

are applied.

Fluorescein dye test. There was no dye uptake on

the right cornea but there was fluorescein uptake

at the site of the ulcer present on the left cornea

(Figure 2). This pattern of uptake on the left eye

suggests that the ulcer is mid-stromal.

Slit lamp examination. This instrument is useful to

assess the depth of the ulcer in the left eye, which

was confirmed to be mid-stromal.

Fundic examination. Examination of the right eye

fundus using indirect ophthalmoscopy revealed no

abnormalities but was not possible for the left eye

due to the corneal pathology. Intraocular pressure measurements. IOP was

normal in the right eye (16 mmHg) but was not

measured in the left eye (due to the risk of further

damaging the cornea).

Andrew Lewin, an Intern at WillowsVeterinary Centre and Referral Service,invites companion readers to consider acase of unilateral ocular discomfort andredness in a young cross-breed dog

Case presentationAn 18-month-old male cross-breed dog

presented with a 2-week history of left ocular

pain and redness. A general physical examrevealed no other abnormalities. The dog had

been previously treated with systemic and

topical non-steroidal anti-inflammatory drugs

and topical ocular lubricant.

A

B

Figure 1: The right eye (A) and left eye (B) of an 18-month-old

male cross-breed dog at the time as observed of initialpresentation


9/36companion | 9

What is the significance of theabnormalities seen in Figure 3?The diagnosis in this case based on the findings so far

was keratoconjunctivitis sicca (KCS) and ulcerative

keratitis in the left eye. A physical examination revealed

unilateral crusting of the nares on the left hand side.

This indicates that the KCS may be of neurogenic

origin as both the lacrimal gland and the lateral nasal

gland share a common innervation. Other clinicalsigns which are occasionally observed with

neurogenic KCS include Horners syndrome, facial

paralysis and trigeminal nerve deficits, none of which

was present in this case.

What is the normal range for the STTtest and what is your interpretation of thevalues obtained in this patient?A STT test can be performed either with (known as

STT 1) or without (STT 2) a topical anaesthetic applied

to the cornea prior to placing the test strip in the lateral

half of the lower conjuctival sac. Performing the STT

without the aid of topical anaesthesia is preferred, as

this measures both basal and reflex tear production,

whereas only basal tear production can be measuredin the anaesthetised eye.

The normal value for STT 1 in the dog is over

15 mm/min, as was found to be the case in the right

eye of this patient. It is necessary to measure the

production of tears for a full minute as it has been

shown that the value will not rise in a linear fashion

during this time. A value of 614 mm/min indicates

mild to moderate KCS and a value of < 5 mm/min

indicates severe KCS, as was detected in the left eye

of this patient.

It is important to remember that occasionally

qualitative tear deficiencies can be present which

may present with a normal STT value. Qualitative

tear deficiencies can be detected using a tearbreak-up test, which is performed by applying a

drop of fluorescein into the eye and allowing the

patient to blink. The eyelids are then held open and

the corneal surface observed with the aid of a blue

A

B

Figure 2: The right eye (A) and left eye (B) after fluoresceinhad been applied bilaterally at the time of presentation.

There is no uptake of dye in the right eye and is an obviouscorneal defect in the central left cornea. Observation of thedefect using fluorescein is one method which the cliniciancan use to determine the depth of an ulcer

Figure 3: Nasal crusting observed on the left hand side


10/3610 | companion

Clinical conundrum

light source such as that found on a handheld slit

lamp. The time taken for the first dry spot to appearis noted and compared against normal values.

A normal tear break-up test time is 1525 seconds

and a value of 10 seconds or less is indicative of

tear film instability.

Which primary conditions cancause KCS?

Immune-mediated: this is the most common cause

of KCS in dogs.

Drug therapy: topical atropine and systemic

trimethoprim sulphonamides can both cause

reduced tear production. Infectious conditions such as distemper virus.

Acinar hypoplasia is a congenital condition

occasionally seen in toy breeds such as Yorkshire

Terriers, which can often present unilaterally

leading to KCS.

Iatrogenic KCS can be created by removal of the

tear gland of the nictitans membrane.

Systemic conditions including hypothyroidism,

diabetes mellitus and hyperadrenocorticism can

lead to reduced tear production.

Neurogenic KCS: this can be caused by a loss of

parasympathetic innervations to the lacrimal gland

(CN VII) or a loss of sensory innervation to cornea

(CN V). Loss of parasympathetic innervation can

be either idiopathic or due to middle/inner ear

disease. Neoplasia involving the nerves innervating

the lacrimal gland can also be responsible for

causing the condition.

Which further investigations may beuseful in the management of this case?Radiography (relatively insensitive), computed

tomography (CT) or magnetic resonance imaging

(MRI) can be used once a diagnosis of neurogenic

KCS has been reached, to try and determine an

underlying aetiology.

In this case CT was used to image the tympanicbullae and surrounding soft tissue, the region of the

left facial nerve and retrobulbar spaces. No pathology

was detected, so a final diagnosis of idiopathic

neurogenic KCS was reached. MRI is arguably a more

sensitive method of detecting neuritis than CT, but

was not used in this case as CT was deemedsufficient for ruling out neoplasia and middle ear

disease. There were also financial limitations with this

case which were partly responsible for the choice of

imaging modality.

Construct an initial treatment plan for theophthalmic problemsThe treatment plan for this dog had to address both

the ulcerative keratitis and the underlying idiopathic

neurogenic KCS. Despite the ulcer being mid-stromal,

a medical approach was adopted given the marked

associated corneal neovascular response.

The ulcer was treated with systemic analgesics(carprofen 4 mg/kg q24h), broad-spectrum systemic

antibiotics (cefalexin 15 mg/kg q12h) and topical

antibiotics (polymyxin B ointment applied four times

daily to both eyes)*. The neurogenic KCS was treated

with ocular lubricants (applied every 2 hours to both

eyes) and oral pilocarpine. Pilocarpine is a muscarinic

parasympathomimetic drug available in various

concentrations which was historically used for the

treatment of glaucoma.

Pilocarpine has a non-specific

parasympathomimetic effect, and so will not only

stimulate secretion from the lacrimal glands but will

also have systemic side effects. It is irritant when

applied topically so can be used diluted at 0.1% in this

way (based on anecdotal evidence) or used orally at

1% as was done in this case (1 drop/10 kg q12h orally).

The oral dose can be increased until signs of toxicity

are observed (hypersalivation, vomiting, diarrhoea and

cardiac arrhythmias). In some cases the pilocarpine

treatment can be stopped altogether after around six

months but in others it will need to continue as a

lifelong therapy.

Other treatments which were considered in this

case were bandage contact lenses to temporarily

protect the ulcer from further erosion and parotid duct

transposition. In this case medical management was

deemed sufficient without the need for surgery.

OutcomeAt a re-check appointment 9 days later, the right eye

was unchanged after therapy, with a good tear film

* Editors Note:

Readers are remindedthat the PROTECTposter (available atwww.bsava.com) hasguidelines on empericselection of antibioticsfor use in cases ofcorneal ulceration.


11/36companion | 11

AVAILABLE FROM BSAVA

BSAVA Manual of Small Animal

Ophthalmology2nd editon

Edited by: Simon Peterson-Jones and Sheila Crispin

This Manual provides a praccal, consulng room guide tosmall animal ophthalmology, but with suffi cient detail tosasfy those who wish to study this fascinang specialty ingreater depth. Features:

Surgical principles Chapters dedicated to exoc pets High quality full-colour photographs throughout

...an excellent book, clear and easy to read, and illustrated throughout withphotographs that aid clinical diagnosis. All praconers should own a copy...JOURNAL OF FELINE MEDICINE AND SURGERY

Member price: 55.00Non-member price: 85.00

CONTRIBUTE A CLINICAL CONUNDRUM

If you have an unusual or interesng case that you would like to share with yourcolleagues, please submit photographs and brief history, with relevant quesonsand a short but comprehensive explanaon, in no more than 1500 words to

[email protected]

All submissions will be peer-reviewed.

ACKNOWLEDGEMENTS

Thanks to Mike Rhodes for his help in the preparaonof this arcle and to Chrisne Heinrich for her kindpermission to use her photographs.

Figure 4: The right eye (A) and left eye (B) as observed 9 daysafter the time of initial presentation to the referral service.The right eye appears to be unchanged from the time ofinitial presentation. The left eye has markedly improved inappearance: the central corneal ulceration has resolved andsuperficial neovascularisation is visible in this region

A

B

and no signs of ulceration. The central ulcer in the

left eye had healed and there was superficialneovascularisation and associated corneal opacity

in this region (Figure 4). The left eye was confirmed

to be visual with a positive menace test. Both eyes

were comfortable and STT confirmed a reading of

> 15 mm/min bilaterally.

The dose of pilocarpine was increased gradually

until a side effect (hypersalivation) was observed. Atthis point the dose was reduced and treatment was

continued while monitoring STT levels, which remained

within the normal range in both eyes. One month after

initial presentation the dog was re-examined and

was found to have made excellent progress, and the

dose of pilocarpine was gradually reduced while

monitoring STT levels.

Eventually the drug was discontinued and one year

later the dog is continuing to do well without treatment.

It has been recently suggested that approximately half

of dogs with neurogenic KCS will not require

permanent treatment as they may have a self-limiting

underlying disease process.


12/3612 | companion

How to approach thepatient withpolyuriaand polydipsia

An animal that is drinking and

urinating more than normal can

be a diagnostic challenge. There

is a long list of possible

differential diagnoses (Figure 1) requiring

logical progression through the diagnostic

pathway. Investigation may very quickly

and simply give an answer (e.g. diabetes

mellitus) or may need extensive, and

possibly expensive, testing to achieve adiagnosis (e.g. partial central diabetes

insipidus). Owner education is key, as until

a diagnosis is made and correct therapy is

instigated the problem is likely to be

frustrating for both the owner and their pet.

Healthy animals drink 2070 ml/kg/day

and produce 2045 ml/kg/day of urine.

Animals, especially cats, fed a wet diet

may need to drink very little to maintain

hydration, as wet diets can contain up to

80% water. Animals fed a dry diet will often

drink a large proportion of their daily water

requirement within an hour or two of eating,

which can create unusual drinking patterns

if diet or feeding times are changed.

In normal animals urine concentration

is controlled by antidiuretic hormone (ADH,

also known as arginine vasopressin). ADHis produced in the hypothalamus and

stored in the posterior lobe of the pituitary.

It is released in response to changes in

serum osmolality and acts on the kidneys

to retain water by increasing tubular

permeability. Thirst is also important in

water balance but is stimulated at a higher

osmolality threshold than that needed for

ADH release.

PU/PDPolyuria (PU) and polydipsia (PD) usually

exist concurrently, with determination as towhich is the primary problem being one of

the major diagnostic challenges. Polydipsia

is usually defined as water intake of

>100 ml/kg/day and polyuria as urine

production >50 ml/kg/day. A large number

of disease processes can cause PU/PD,

and most affect the way ADH is produced

or exerts its action within the kidney.

However, as always, there are some

exceptions, for example osmotic diuresis

secondary to diabetes mellitus or a poor

medullary concentrating gradient

secondary to hepatic insufficiency.

Investigation starts with a detailedhistory to allow confirmation of the

presence of PU/PD and to rule out

misinterpretation of related clinical signs

such as dysuria or incontinence. Asking

the owner to measure water intake

definitively over a 24-hour period will helpconfirm the presence of PU/PD.

At the outset of investigations,

collecting multiple urine samples to

measure specific gravity (SG) can be very

helpful (Figure 2) as wide variations in

normal SG are reported (results in healthy

dogs range between 1.006 and 1.040).

Serial urine samples with an SG 1.030 support normal

urine-concentrating ability.

Careful clinical examination may also

help provide clues as to the origin of thePU/PD. Neutering status is important,

alerting the clinician to the possibility of

pyometra in the intact bitch for example.

In this condition E. coli toxins interfere with

the action of ADH within the kidney. Careful

examination of peripheral lymph nodes

helps to exclude lymphoma, and evaluation

of the anal sacs helps exclude anal sac

adenocarcinoma; both of which can cause

PU/PD through hypercalcaemia. Skin

changes such as bilaterally symmetrical

alopecia, thin skin and calcinosis cutis

suggest possible hyperadrenocortisim

(Figure 3).

Simon Tappin from Dick White Referrals helps usget to grips with this tricky presentation

Primary polydipsia (psychological/behavioural)

Central diabetes insipidus Nephrogenic diabetes insipidus Diabetes mellitus/primary glucosuria Hyperadrenocorcisim Chronic renal failure Hypercalcaemia Infecous focus (e.g. pyometra / sepsis)

esp. with Escherichia coli Hepac insuffi ciency Primary hyperaldosteronism Pyelonephris Hyponatraemia Hypokalaemia Hyperadrenocorcism Acromegaly Very low protein diets Hyperthyroidism Erythrocytosis

Iatrogenic drugs phenobarbital, potassium

bromide, glucocorcoids, diurecs(e.g. furosemide), lithium

Figure 1: Differential diagnoses for polyuria andpolydipsia in dogs and cats

Figure 2: Urinalysis and serial urine specificgravity measurements are essential early in theinvestigation of PU/PD


13/36companion | 13

Initial further investigations (Figure 4)

are aimed at excluding diseases that

interfere with the action of ADH within the

kidney (secondary nephrogenic diabetes

insipidus) and diseases which lead to

osmotic diuresis (e.g. renal failure and

chronic renal failure). Urinalysis (including

culture), haematology and full

biochemistry, including a bile acid

stimulation test are a good starting point,

before more focused investigations such

as adrenal function tests and imaging are

performed. If these investigations areunremarkable, and renal concentrating

ability has not been proven by random

urine samples, investigations then focus

on investigating the presence of diabetes

insipidus (central or nephrogenic) or

primary (psychogenic polydipsia).

Diseases leading to osmoticdiuresis

Diabetes mellitusDiabetes mellitus leads to elevated serum

glucose levels through the absolute or

relative deficiency of insulin. This elevationin glucose quickly exceeds the renal

tubules ability to resorb glucose and leads

to glucosuria. The presence of glucose in

the urine leads to an osmotic effect,

causing excessive water loss, primary

polyuria and hypovolaemia. This leads to

the stimulation of thirst, increased water

intake and a secondary polydipsia.Urinalysis and fasting glucose levels are

usually sufficient to diagnose diabetes;

however in cats, where stress-induced

hyperglycaemia is relatively common, the

measurement of fructosamine or

glycosylated haemoglobin can be helpful.

GlucosuriaPrimary renal glucosuria is an uncommon

disease which is most commonly seen in

Norwegian Elkhounds and the Basenji. It

results from the congenital inability to

resorb glucose from the renal tubules,

leading to osmotic diuresis in the same

way as diabetes mellitus. These dogs have

glucosuria but normal serum glucose

levels. Some dogs and cats may also have

glucosuria as a component of Fanconi

syndrome. This is a tubular disorder, which

results in increased urine concentrations of

glucose, potassium, phosphate,

bicarbonate and amino acids due toreduced tubular resorption.

Renal failureChronic renal failure (CRF) is caused by a

gradual reduction in the number of

functioning nephrons present within the

kidney. At compensation the remaining

nephrons increase their glomerular filtration

rate (GFR). This leads to an increased

amount of filtrate being presented to the

distal tubules and, as a result, less sodium

and urea are reabsorbed. This leads to

osmotic diuresis, which is worsened by a

reduced medullary concentrating gradient.

Animals with CRF usually have increased

serum urea, creatinine and phosphate

levels, as well as isosthenuric urine

(SG 1.0081.012).

Figure 3: A Yorkshire terrier withhyperadrenocorticisim with marked bilaterallysymmetrical alopecia

History and physicalexaminaon

Laboratoryinvesgaons

Urine and blood

PU/PD Abnormal?Suspect:Hyperadrenocorcism Pyometra Hyperthyroidism Hypercalcaemia

Specialist tests:Plasma osmolarity

Water deprivaon testDDAVP trial

Increased BAS or Ammonia?Suspect: Liver disease Portosystemic shunt

Hypercalcaemia?Suspect:Hyperparathyroidism Hypercalcaemia of

malignancy

ACTH stmulaton

Exclude:

AddisonsHyperadrenocorcism

Central diabetes insipidusPrimary polydipsia Nephrogenic diabetes insipidus

Glucosuria?Suspect:Diabetes mellitusRenal glucosuria

Normal if S.G.>1.025 Dogs>1.030 Cats

Azotaemia?Suspect renal disease

Figure 4: Diagnostic pathways for the investigation of PU/PDBAS = bile acid stimulation


14/3614 | companion

How to approach thepatient with polyuria and polydipsia

Acquired or secondarynephrogenic diabetes insipidusMany disorders interfere with the normal

interaction between ADH and its receptor

in the kidney or lead to reduced medullary

concentrating ability. These can appear

with marked PU/PD but the ADH sensory

and release mechanisms are present but

disease interferes with ADH action.

PyelonephritisPyelonephritis leads to inflammation of

the renal pelvis, which affects the

concentrating ability of the renal medulla.

This leads to PU/PD and eventual renalfailure. Bacterial toxins especially those

from E. coli, compete with ADH binding

sites within the kidney, which leads to

further polyuria. Pyelonephritis may be

very difficult to diagnose, needing a

combination of techniques such as

abdominal ultrasonography, looking for

evidence of subtle changes within the

renal pelvis (Figure 5) and pyelocentesis to

collect culture samples. In some cases this

may not be possible and is a sufficient

suspicion regarding pyelonephritis (e.g.

previous recurrent urinary tract infection)

then a trial treatment with a suitable

antibiotic (potentiated amoxicillin or a

fluoroquinolone) may be an appropriate

alternative. If this improves clinical signs,

antibiotics should be continued for

46 weeks.

Liver diseaseHepatic insufficiency and portosystemic

shunts both lead to PU/PD. The exact

mechanism is unclear; however, it is most

likely that reduced urea production leads to

a reduced medullary concentrating

gradient or that toxins alter the perception

of thirst. A bile acid stimulation test is the

best screening test of liver function.

HyperadrenocorticismHyperadrenocorticism, or Cushings

syndrome, is a relatively common cause ofPU/PD in middle-aged to older dogs. Signs

may be classic and associated with

polyphagia, skin signs and a pot-bellied

appearance (see Figure 3); however in

their absence hyperadrenocorticism

cannot be excluded and should be

considered as a possible differential.

Haematology will often reveal evidence

of a stress leucogram, mild thrombocytosis

and erythrocytosis are less commonly

documented. Biochemistry may reveal

increased alkaline phosphatase (seen in

approx. 9095% of cases) and cholesterol(seen in approx. 75% of cases). A urine

sample should be collected by

cystocentesis for culture, even if an active

sediment is not present, as 4050% of

dogs will have active urinary tract

infections at presentation.

An ACTH stimulation test is the most

commonly used screening test for

hyperadrenocorticism as it is least

affected by stress. The ACTH stimulation

test has a sensitivity of 85% in pituitary-

dependent and 65% in adrenal-dependent

disease (specificity of 8590%). A low

dose dexamethasone suppression test is amore sensitive and reliable test (sensitivity

100% in adrenal-dependent and

9095% in adrenal-dependent

hyperadrenocorticism) however it can be

affected by stress and cannot detect

iatrogenic hyperadrenocorticism nor beused for monitoring treatment. Once a

diagnosis is reached, further tests can

help discriminate between pituitary- and

adrenal-based disease.

HypoadrenocorticismHypoadrenocorticism leads to the inability

to concentrate urine through the absence or

insufficient levels of aldosterone.

Mineralocorticoid deficiency leads to

chronic sodium wasting and loss of

medullary tonicity. There is also some

evidence to suggest that decreased

aldosterone reduce the sensitivity of the

ADH receptors, furthermore the

hypercalcaemia associated with

hypoadrenocorticisim may also contribute

to the PU/PD. Treatment with synthetic

mineralocorticoids typically corrects this,

although some dogs may need additional

dietary sodium chloride to correct their

PU/PD. Differentiating hypoadrenocorticisim

from renal failure can be difficult on

biochemistry and sodium:potassium ratios

alone, so an ACTH stimulation test is

needed for definitive diagnosis.

HypercalcaemiaIncreased serum calcium concentrations

inhibit the action of ADH in the kidney,

leading to primary polyuria and secondary

polydipsia, and can lead to renal failure.

Other clinical signs include weakness,

vomiting and dull mentation. The

differentials for hypercalcaemia can be

remembered with the help of the

mnemonic HARD IONS (Figure 6). The

most common cause of hypercalcaemia in

an older dog is malignancy (lymphoma

followed by anal sac adenocarcinoma and

multiple myeloma).

HyperthyroidismHyperthyroidism is often associated with

PU/PD in both cats (common) and dogs

Figure 5: Ultrasound evaluation revealing mildpyelectasia. In this dog this was caused by thepolyuria and there was no evidence ofpyelonephritis


15/36companion | 15

(very rare


16/3616 | companion

How to approach thepatient with polyuria and polydipsia

Phase 1: Preparaon

1. Determine water intake in a 24-hourperiod with free access to water

2. Three to five days before the testgradually decrease water intake to100 ml/kg/day

3. Starve the animal for 12 hours before thebeginning of the test

Phase 2: Water deprivaon

1. Prior to starng test

a. Withdraw all food (12 hourspreviously) and water

b. Empty bladder completely consider aurinary catheter

c. Obtain exact body weight

d. Check urine SG

e. Check serum BUN and electrolytesf. Check hydraon and CNS status

2. During testa. Completely empty bladder every

60120 minb. Check urine SG

c. Check exact body weight every 60 mind. Check hydraon and CNS status at

each interval

3. End test if:a. Urine SG >1.030

b. Dog appears clinically dehydrated orunwell

c. Dog has lost 35% of body weight

4. At end of phase 2:a. Collect serum for endogenous ADH

determinaon

b. Empty bladder and recheck urine SG

Phase 3: Response to exogenous ADH

1. Administer 25 IU i.m.

2. Connue to withhold food and water3. Empty bladder every 30 minutes for

12 hours

4. Recheck urine SG5. Check hydraon and CNS status

Phase 4: End of Test

1. Introduce small amounts of water(1020 ml/kg) every 30 minutes for2 hours

2. Monitor paent for voming, hydraonand CNS status

3. If paent is well 2 hours aer the end ofthe test, return to ad lib water intake

Figure 8: Protocol for the modified waterdeprivation test

Classically a water deprivation test is

needed to differentiate CDI from NDI andPP. The water deprivation test (WDT) is a

long, time-consuming test which does

carry some risks to the patient if not

completed carefully. A full description of

how to perform a water deprivation test is

found in Figure 8. In a normal dog (or a

dog with PP) as water is withheld urine SG

will rise gradually as the kidneys work hard

to retain water. If ADH is not present (CDI)

or is unable to have an effect within the

kidney (NDI), there will be no increase in

urine concentration. Once the animal has

become 5% dehydrated synthetic ADH

(DDAVP) is administered by intramuscularinjection and the response measured. If

ADH is absent (CDI) then the urine SG

should increase quickly; however, if the

kidney is unable to respond to ADH (NDI)

then urine SG will stay constant (Figure 9).

An addition to the standard WDT is to

measure plasma osmolality and

endogenous ADH concentrations before

the administration of DDAVP. This can be

very helpful in eliciting whether ADH is

being produced and is especially useful for

the differentiation of partial CDI from CDI

(Figure 10).An alternative to a WDT is to consider a

DDAVP trial. This relies on the fact that NDI

is very rare and CDI should respond well to

DDAVP, whereas additional ADH in an

animal with PP will make little impact on its

PU/PD. Suggested treatment at home is

using oral DDAVP (absorption of tablets

can be variable however) with an empirical

dose: for a 20 kg dog, 0.1 mg three times a

day for about 7 days; for a 40 kg dog,

0.2 mg three times a day for about 7 days.

Animals with CDI will respond quickly to

this treatment and the response can be

substantiated using urine samplescollected at home by the owners. The dose

of DDAVP is then slowly tapered to reach

the lowest possible dose that controls the

animals clinical signs.

Nephrogenic diabetes insipidus

Nephrogenic diabetes insipidus describesconditions where the kidneys do not

respond to ADH to produce concentrated

urine as expected. Normally the

hypothalamus produces ADH in response

to increased serum osmolality. When

released ADH acts in the collecting ducts

to increase permeability, thereby retaining

water and the the production of

concentrated urine.

As described above, acquired or

secondary conditions which interfere with

the way ADH works in the kidney are

common (e.g. endotoxins from E. coli,

drugs such as glucocorticoids and

metabolic conditions such as

hypercalcaemia and hypokalaemia)

however primary or congenital NDI is very

rare. Congenital NDI is caused by a

deficiency of ADH receptors and clinical

signs usually develop at a very young age.

Signs are severe with very marked PU/PD

(urine SG 1.0011.005). Diagnosis is made

after excluding causes of secondary NDI

and a WDT showing failure to concentrate

after administration of exogenous ADH.

The animal should always have free

access to water and will always bemarkedly polyuric and polydipsic. Dietary

sodium and protein restriction will reduce

the amount of solute presented to the

kidney therefore reducing the amount to

excrete in the urine each day by about

2050%. The addition of thiazide diuretics

(hydrochlorothiazide 15 mg/kg orally

q12h) to dietary restrictions may further

reduce urine production by increasing fluid

uptake in the proximal tubules.

Central diabetes insipidusCDI is caused either by the absolute

(complete) or relative (partial) deficiency ofADH. Complete CDI leads to the complete

inability to produce concentrated urine,

whereas in partial CDI ADH is released in

subnormal amounts often only at higher


17/36companion | 17

Urinespecificgravity

Primarypolydipsia

PartalCDI

CDI

NDI

Administraon

of DDAVP

Time

Figure 9: Expected results of the water deprivation test

Figure 10: Measurements of plasma osmolality and endogenous ADH at the end of the WDT can bevery helpful in diagnosing partial CDI as small, but inappropriate amounts of ADH are released inresponse to increasing plasma osmolarity

PlasmaADH

Plasma osmolarity

Normal

CDI

NDI

Primarypolydipsia

Partal CDI

osmolality than expected. Pituitary orintracranial neoplasia (e.g.

craniopharyngioma or meningioma) are

the most common causes of CDI. Thus,

once a diagnosis of CDI is made,

advanced imaging of the pituitary glandis recommended. Severe head trauma

may lead to clinical signs, with

spontaneous resolution possible due to

regeneration of disrupted axons. If no

aetiology is evident then idiopathic

disease is suspected. This is mostcommon in younger animals; however,

they may develop lesions during the

course of their life which were not initially

evident during the primary investigations.

Treatment revolves around the ADH

analogue desmopressin (DDAVP,

1-deamino, 9-D-arginine vasopressin); this

provides antidiuretic activity for about

8 hours. One drop (1.5 to 4 g) placed two

or three times daily in the conjunctival sac

sufficiently controls the polyuria in most

dogs with CDI. In the absence of neoplasia

the long-term prognosis is good, with many

animals remaining asymptomatic onappropriate therapy.

Primary polydipsiaPrimary polydipsia is largely thought to be

behavioural in origin and can be controlled

in most cases by gradual water restriction

to the high end of normal (6080 ml/kg per

day). If this not successful then behavioural

modification (e.g. increased exercise,

changed environment or seeking a

veterinary behaviourists opinion) may help.

ConclusionsAlthough common presenting complaints,

both polyuria and polydipsia represent

significant challenges to the small animal

practitioner. With careful history taking

and examination, followed by logical

investigations the cause should be

determined, allowing directed therapy

and realistic expectation of outcome for

the owner.

Note:Some of the medications

mentioned in this article are not

authorised for use in dogs and

cats. Readers are reminded to

follow the Cascade when

prescribing medication.


18/3618 | companion

Diagnosing felinenasopharyngealdiseases

Suspected nasopharyngeal neoplasia, polyp,

fungal granuloma (nasal discharge, epistaxis,

nasal asymmetry, stertor).

In cats amenable to oral examination while

conscious, it may be possible to get a view of the

nasopharynx by grasping the tongue with your fingers

and extending it rostrally, using the projecting lingual

papillae to help you get a firm grip on the tongue. The

soft palate develops a V shape and a momentary

glimpse of the nasopharynx can be obtained. This may

allow sight of a grass blade or polyp in the caudal

nasopharynx (polyps are usually situated more

caudally than nasopharyngeal lymphoma or fungal

granulomas). If there is a large mass lesion in the

nasopharynx, it is also sometimes possible to see a

bulging of the soft palate.Under general anaesthesia (see Box 1), the

nasopharyngeal region is palpated through the soft

palate. Normally, the soft palate gives on palpation,

but if a polyp, granuloma or neoplasm is present, it is

generally possible to appreciate the presence of a

mass lesion, which may then be sampled by fine

needle aspiration.

With the cat in dorsal recumbency, the soft palate

can then be retracted to allow visualization of any

foreign bodies or soft tissue masses. Further

evaluation is aided by simple adjunct tools such as a

laryngoscope (Figure 1), spay hook (Figure 2) or

forceps, and a dental mirror.

Effective feline practice is grounded in a

knowledge of the clinical approach to, and

management of, a wide variety of problems

likely to be seen in cats, while making the

veterinary clinic as cat-friendly as possible. Focussing

on gold-standard preventive healthcare and the

common areas encountered in the first opinion setting,the BSAVA Manual of Feline Practicewill be a best

practice guide. Where appropriate, guidelines will also

be given as to the best steps to take when there are

financial considerations.

While the Foundation Manuals are particularly

relevant to students and recently qualified vets, or

those returning to practice after a career break,

recommendations will be given that can be followed by

all vets seeing feline cases. As an added feature,

quick reference guides (QRGs) throughout the book

will highlight practical techniques and treatment in an

easy-to-follow step-by-step fashion, aided by clear

colour photographs.These QRGs will include: tips for taking and

interpreting a thoracic radiograph; performing a

neurological examination; tips for performing dental

extractions; enucleation; managing diabetic

ketoacidosis; performing early neutering; skin scrapes

and skin cytology; performing bronchoalveolar lavage;

thoracocentesis; taking a liver biopsy; placing a chest

drain to name just a few.

Examining the nasopharynx in a catNasopharyngeal examination may be required in cats

for a number of reasons:

Evaluation of stertor (most commonly caused bynasopharyngeal polyp, neoplasia or stenosis)

Suspected nasopharyngeal foreign body

(e.g. acute onset sneezing/gagging, facial

discomfort, nasal discharge)

The BSAVA Foundation Manual on feline

practice will be published next year. Here,one of the co-editors, Andrea Harvey, whowill also be speaking at BSAVA Congress inApril, gives us a taste of what is to come

BOX 1: ANAESTHETIC CONSIDERATIONS

General anaesthesia is almost always required for furtherinvesgaon or for removal of a foreign body or polyp.Cats with nasopharyngeal disease can be at high riskof upper airway obstrucon. This is usually due to thepresence of associated discharge. Smulaon of thenasopharynx will also oen result in excessive mucusand saliva secreon, in addion to ssue oedema/inammaon. It is therefore prudent to ensure thatall necessary equipment is prepared prior to inducinganaesthesia. This should include: sucon equipment;swabs and coon buds to help remove secreons; alaryngoscope; various sizes of endotracheal tubes; and

a dog urinary catheter in case of diculty intubang.The cat should be pre-oxygenated, and intubated withan endotracheal tube that is as large as possible. Pulseoximetry monitoring should be used throughout, andsucon equipment kept to hand throughout inducon,the procedure and recovery.


19/36companion | 19

Figure 1: This 6-year- old MN DSH cat was presented with anacute history of sneezing and pawing at the face, afterhaving been outside in the owners garden. He had no nasaldischarge or stertor. These signs, plus their acute onset,suggested a nasopharyngeal foreign body such as a blade of

grass. Allis tissue forceps were used to retract the softpalate, and a laryngoscope used to assist evaluation. A bladeof grass was seen in the nasopharynx and removed intactusing forceps

Figure 2: This 1-year-old FN DSH catpresented with a few weeks ofprogressively worsening stertor. There

was no nasal discharge or sneezing.Under anaesthesia, a firm bulging ofthe soft palate was palpable. The softpalate has been retracted rostrallyusing a spay hook and anasopharyngeal polyp can be seen (thered lesion just caudal to the tip of thespay hook). This was successfullyremoved by traction, using graspingforceps. This photo is taken with thecat in sternal recumbency, but theauthor prefers to conduct theprocedure with the cat in dorsalrecumbency

Diagnostic imagingPlain radiography, CT and MR imaging all provide a

measure of the extent of a lesion and its precise

anatomical location or the presence of a foreign body.

However, imaging does not negate the need for

direct visualization. Plain radiographs are the most

practical diagnostic imaging modality for general

practice, with the most useful views being an intraoral

dorsoventral view of the nasal cavity and a lateral view

of the skull and pharynx, with the patient extubated inorder to be able to assess the nasopharynx. In the

majority of cases, however, these are of limited value

in reaching a diagnosis, and extubating the patient

may not be desirable.

Advanced imaging is not usually required but may

be considered in some cases where a diagnosis hasnot been possible using other methods; this should be

discussed first with a specialist to determine whether

or not it is likely to be of value before proceeding.

Retrograde rhinoscopyIf a flexible endoscope is available (either a small

gastroscope or a bronchoscope) then a very good

view of the nasopharyngeal region can be obtained

(Figure 3). The endoscope is fully retroflexed into a

U shape and inserted into the mouth, hooking the free

end over the top of the soft palate. It is then rotated to

be in a midline position (look for the endoscopic light

pointing cranially through the soft palate to show thatyou are in the correct position) and pulled rostrally.

This technique is of particular value when a foreign

body or nasopharyngeal mass is suspected but

cannot be visualized as described above. Referral may

be required.

Figure 3: View of the nasopharynxobtained though retrograderhinoscopy. This was a 5-year-old MNDSH cat that had been presented witha chronic mucopurulent nasaldischarge and progressivelyworsening stertor. There is a fungal(cryptococcal) granuloma (arrowed)occluding the posterior nares. Thesoft palate is at the top of the photo;its location can be determined bypushing on the soft palate with afinger during the procedure


20/3620 | companion

Diagnosing feline nasopharyngeal diseases

IndicationsNasal ush only: Where a foreign body is suspected or

has been identied and ushing isrequired to attempt to dislodge it

Where a mass has been identied or issuspected, and nasal ushing issuccessful in dislodging enough tissuefor histopathology (this can occur with

fungal granulomas and nasal lymphoma) In chronic rhinitis, to ush out tenacious

secretions (this can be therapeutic).

Nasal ush and biopsy: Where a soft tissue mass has been

identied or is suspected, and has notbeen dislodged with vigorous nasalushing

Where a cause (e.g. foreign body orpolyp) of the clinical signs has not yetbeen identied; ushing can be used tocollect samples for cytology, and nasalbiopsy samples obtained forhistopathology.

Equipment Suitably sized mouth gag Gauze swabs Gauze bandage Throat packs: these can be made by

rolling up a small piece of gauze swaband tying a gauze bandage around it;the swab can be packed into the throat,whilst the bandage remains outside themouth to allow easy retrieval.Alternatively, a small sponge with a tieattached can be used

Laryngoscope

Suction equipment Lidocaine Allis tissue forceps and/or spay hook Dental mirror 35 mm diameter tip (or smaller)

endoscope

Quick Reference Guide: Nasal ushing and biopsyby Andrea Harvey and Richard Malik

Cotton buds Small bowl of tap water 2 formalin pots 1 plain collection tube 1 or 2 EDTA collection tubes 0.9% saline 2 x 10 ml syringes and needle for

drawing up saline Suitable nasal biopsy forceps e.g.

alligator forceps with sharp cupped tips,otoscope biopsy forceps or endoscopic

GI biopsy forceps. The bigger theforceps that can be inserted, the largerthe samples that can be retrieved.

parameters (PCV and platelets) shouldbe checked and found to be normal priorto taking biopsies. The authors do notroutinely assess coagulation timesunless the cat has any other systemicabnormalities (e.g. liver disease).

General anaesthesia is required andanaesthetic considerations areimportant (see Box 1). With nasal ush biopsy, there is the additional concern

of even more risk of upper airwayobstruction and aspiration, because ofthe nasal ush uid and haemorrhagefrom biopsy. In addition to havingsuction equipment and gauze swabsand cotton buds to hand, the pharynxshould be packed (see below) andconsideration given to using a cuffedendotracheal tube.

Performing a nasalush

1With the cat anaesthetized and with an

ET tube in place, the pharynx is packedwith gauze swabs or small pieces of spongeattached to a tie.

Throat pack

Alligator forceps

Patient preparation The nasopharynx should be evaluated

prior to performing nasal ush or biopsy. Since nasal biopsy can cause signicant

haemorrhage, haematological


21/36companion | 21

2

One of the authors (AH) prefers to

have the cat positioned in sternalrecumbency, with the head and neckfacing ventrally over the edge of the table,to encourage uid to drain out rostrallyafter ushing.

3 Two to four 10 ml syringes are lled withsterile 0.9% NaCl that has been warmedto 38C. The end of the syringe iswedged into one nostril.

One hand is used to hold the syringe inplace and to occlude the contralateralnostril, while injecting 10 ml saline as fastas possible using the other hand.

A collection dish is held underneath thecats head to collect any material thatdrains from the nose or pharynx.

Unless a foreign body has beendislodged and thus the cause alreadyidentied, uid is then transferred to anEDTA tube for cytological assessment.

The procedure is repeated for the otherside of the nose.

Routine bacterial culture of ush uid is

rarely helpful, but in cases of chronic rhinitisculture can sometimes be useful in directingantibiotic therapy if a resistant infection isidentied (culture of tissue collected bybiopsy is more helpful).

The other author (RM) prefers cats to bepositioned in dorsal recumbency. Firm tapecan be used to hold the cats head inposition against the table top using themaxillary canine teeth as points ofanchorage (not shown here). Gauze tapecan be hooked around the mandibularcanine teeth to open the jaws (not showhere) or, if a third person is available, it isideal if they can hold the tongue (as shownhere) and endotracheal tube up and awayfrom the palate.

4After ushing, the throat packs can beremoved and examined for any foreign

material, or dislodged tissue. Usually foreignbodies and many mass lesions will bedislodged within two or three attempts.

Portions of dislodged tissue can be:

Used to make impression smears for

cytological assessment Placed in formalin for histopathology Retained for fungal culture if fungal

infection is suspected on the basis ofgross appearance, or suggested bycytology or histopathology.

5Following the procedure the pharynxshould be examined, and any

remaining secretions or uid suctioned out.

Performing nasalbiopsy

1The anaesthetized cat, with ET tube inplace, is positioned in sternal

recumbency with new throat packs placed(so that any blood resulting from biopsy isnot aspirated). Care must be taken not torisk penetrating the cribriform plate:forceps can be pre-measured from the

nares to the medial canthus of the eyeand a piece of tape used to mark theforceps at this point. The forceps must notbe inserted beyond this. WARNING: Thetape must not be allowed to get wet andslip during the procedure.


22/3622 | companion

Diagnosing feline nasopharyngeal diseases

ANDREA HARVEY AT

CONGRESS 47 APRIL 2013

Thursday 14.0514.50

Feline jaundice 15.0015.45

Feline pancreas Sunday

14.3515.20Conspaon/Obspaon

OUT IN SPR ING 2013

Edited by AndreaHarvey and SverineTasker, the BSAVAManual of FelinePractce: A Foundaton

Manual will be availablein Spring 2013.

Cat-friendly pracce ps Problem-oriented clinical approach

Common presentaons Management opons Praccal step-by-step guides

For more details and to register your interestemail [email protected]

20.10.2 ml of 1% lidocaine is instilledinto the nares via a cannula and a few

minutes allowed for this to take effect.

3The forceps are inserted anterogradeinto the ventral meatus. The forceps are

opened and then lodged up against anyarea of resistance, before closing andretracting them. The head should bedirected slightly ventrally, to encourage anyblood to fow cranially to the nostrils ratherthan caudally into the pharynx. Gauzeswabs and cotton buds should be on handto help stop any haemorrhage, whichinevitably occurs.

reserved in a plain pot on a moistened

sterile gauze swab, for bacterial andfungal culture.

Both sides of the nose should besampled, with at least six samplescollected from each.

Note: It is important to remember towash the forceps in water after eachsample has been placed in formalin(using the forceps), prior to insertingthem into the nose again to avoidformalin entering the nose.

Pre-measuring the forceps. This cat has a mouth gag

in place because retrograde rhinoscopy had just

been performed; a gag is not necessary for nasal

biopsy

5Following the procedure, the throatpacks should be removed once

haemorrhage appears to have ceased.The pharynx should then be carefully

examined and any remaining blood orblood clots removed with swabs or cottonbuds, and any secretions suctioned, prior torecovering the cat from anaesthesia.

The pharynx should be evaluatedcontinually for any ongoing haemorrhageprior to extubation, and anaesthesiashould be maintained until anyhaemorrhage has ceased.

The cat should be monitored very closely

in the recovery period, ensuring that suctionequipment, laryngoscope, ET tubes andintravenous anaesthetic agent are keptclose to hand until the cat is fully recovered.

Analgesia should be provided for at least24 hours following biopsy.

Typical samples collected from nasal invesgaons.

From le to right: nasal flush fluid in EDTA tube for

cytology; secreons from nasal flush on a gauze

swab for bacterial and fungal culture; ssue

samples from the le and right sides of the nose in

formalin for histopathology

4 Tissue collected is placed in formalin

pots (labelled with the side collectedfrom). A small amount of tissue is also


23/36companion | 23

Congress 47 APRIL 2013

scientificproceedings

veterinaryprogramme

47 April

The ICC/ NIA Birmingham UK

www.bsava.com

47 April

scientificproceedings

nursing programme

The ICC/ NIA Birmingham UK

www.bsava.com

All the fun of the freeYou know youll come away from Congress with moreknowledge and confidence thanks to the science, butyoull also come away with plenty of treats thanks to anabundant treasure chest of freebies in the NIAExhibition heres your guide to Congress booty

Stay cool with your

free daily tub ofdelicious ice cream

available from booths

in the NIA.

Sponsored by Petplan.

Smoothies are

one of the mostpopular rewards

and a quick way

to get in one of

your five a day.

Sponsored by

Virbac.

Stay hydrated all day with freebottles of water available at

the catering points in the NIA.

Sponsored by National

Veterinary Services.

Invaluable resources

to support your attendance at lectures

not only do you get the abstracts in the free

Proceedings book, members also get

access to all the lectures online after the

event. This means you can listen again, or

catch up on the ones you missed.

Help yourself to a cuppa

(tea or coffee) any time of

the day in the NIA youmight need that caffeine

to help you keep going.

Sponsored by Willows.

Early birds can also get

a hot drink in the morning

in the ICC & NIA.

Sponsored by VetPlus.

The first item youll pick up will

probably be your Congress bag from

the big blue container outside the NIA.

This will give you somewhere to put

all the rest of your goodies.

Sponsored by Royal Canin.

Not only does every delegate get a free

lunch bag each day (sponsored by

Norbrook Laboratories), this year you need

to look out for the equivalent of Willie

Wonkers golden ticket, with a winning

ticket in one of the packs the prize being

a trip to WSAVA Congress in South Africa

in 2014.

Your drinks voucher can beexchanged for an alcoholic

or soft drink at the bar.

Sponsored by

Hills Pet Nutrition.

As well as all the BSAVA

treats, our Exhibitors

provide plenty of great

give-aways on their

stands and yourExhibition Voucher

Booklet contains thousands of

pounds worth of benefits (almost 17k

worth of vouchers in 2012!).

Discounts

SpecialOffers

Competitions

TheICC/ NIA Birmingham UKwww.bsava.com

47 April

exhibition

vouchers

Welcome drinks come and enjoy

complimentary canaps, wine, beer

and juice as we celebrate with our

exhibitors in the NIA on Thursday at 5.Sponsored by VetPlus.

The sweet shop on the concourse

brought to you by Mrialwill provide

you with a sugary treat to keep your

energy up over the four days.


24/36


Delegates at Congress 2013 will hear of research intomental health, wellbeing and mentoring which shouldhelp in avoiding the problems that can get the betterof us in practice

Best practice isall in the mind

Important studyRosie is studying for a PhD in the universitys College

of Medicine examining mental health and wellbeing

in veterinary students. This involves following a

complete annual cohort of graduates from each UK

school, looking at how they adapt to life in practice

and the factors affecting their psychological state and

its effect on their job satisfaction and performance.

So in Birmingham she will describe progress in this

project and other research supported by various

veterinary institutions including the BSAVAs own

charity, PetSavers.

The first months in practice are known to beamong the most stressful periods that new graduates

are likely to face in their career. This is reflected in the

numbers of inexperienced practitioners that hand in

their notice and even go looking for new jobs outside

the profession that they have worked so hard to join.

The turnover rate for new graduates can be quite

high and that is probably linked to a disparity between

their expectations and the reality of life in practice.

They are certainly not lacking in the technical skills

needed for their work, the problem appears to be

mainly due to failings in confidence and

communication.

The best possible startWhile there may been some practice principals who

feel that being thrown into the deep end is the best

way for new graduates to develop the additional skills

that they will need to succeed, many others recognise

that young colleagues benefit from receiving

guidance from a senior colleague. In one of her three

presentations, Rosie will be looking at the concept of

monitoring and how it can help smooth the transition

from vet school to practice.

There are lot of practice owners and senior

veterinarians out there who support the idea of

mentoring but they dont know where to start with it orthey have struggled with it in the past, she explains.

So she will offer practical insights gained from her

investigations of mentoring systems employed both

within veterinary practice and in sister professions.

Rosie Allister from the University of Edinburgh

will be looking at the professions work in

tackling the mental illness issues that affect an

unacceptably high proportion of its members

in her talks at BSAVA Congress. She will explain how

researchers, like herself, are gathering the information

on the relative effectiveness of different interventions in

preventing depression and other mental

health problems and so allow

vets to begin looking after

their own.

24 | companion


25/36companion | 25


Learning from othersThe corporate practices will often have more advanced

support systems for their junior staff than a smaller

practice. We can learn from the way that doctors are

trained and mentored at the beginning of their careers.

Of course, veterinary practice may be unable on

economic grounds to allow staff to spend any

extended period shadowing a senior colleague.

Vets should be looking at the strategies that work in

other areas and adapting them for their own

situations, she says.

This is important not only to help the new

graduate but also to improve the efficiency of the

whole business. To work effectively as a team,

you need everybody to be well and coping with theirjob. As soon as one person begins to struggle, then

that can have knock-on effects on all of their

colleagues, she notes.

We arent all the same

One factor that makes it difficult for senior staff to

provide better help for their colleagues is that every

new graduate is different and so the support that they

need in their work may vary. Rosie is hoping to obtain

funding to develop a training programme for senior

vets in mentoring skills. This is intended to identify

what a new graduate needs to help them adapt to

practice life, and show how the practice can providethem with the most appropriate support.

Although we often think of new graduates needing

special support, the problem of poor mental health

can affect vets at all stages of their career. In this, as in

most situations, prevention is much better than cure

and so those attending this stream on psychology in

practice will also hear from Brian Faulkner, managing

director of Frontfoot Consultancy and 2008 Petplan Vet

of the Year.

Brian will be presenting some ideas gained

from the developing field of positive psychology

to improve the way that colleagues deal with

problems. He will raise questions about the typicalmindsets of veterinary surgeons and whether their

attitudes help or hinder them in developing the

psychological resilience needed to achieve

success in a veterinary career.

Psychology in Practiceat Congress

In your Congress programme you will see various icons. This

one indicates that the talk includes electronic voting. By popular

demand, this will be available in more sessions in 2013 than

ever before including the Psychology in Practice stream with

Rosie and Brian.

Using personal keypads delegates can answer questions posed to the

whole audience. This helps establish common opinions and experiences and it is all totally anonymous, so you can be as frank as you like.

Questions might be case-based in some instances, such as:

What do you think is the best test? Or you might be asked an

opinion-based question, like Do you agree with this statement?

The answers (always anonymous!) are presented on screen in

a graphical format that can be used as a basis for discussion

by the speaker.

This technology has been employed at Congress

for several years, and also in BSAVA CPD courses

across the country. If you havent attended one

before it really does help add to your

engagement in the talk and makes the whole

experience more interactive. For more

details about the programme visitwww.bsava.com, or email

[email protected] you

would like us to send you a

programme.

Electronic Voting

Thursday 4 April

8.309.15: Understanding and managing values,beliefs and opinions as the basis of leadership.Brian Faulkner

9.2510.10: What is emoonal intelligence and howcan we use it to delivery customer sasfacon?Brian Faulkner

10.5511.40 Psychology of confidence, achievementand success in veterinary pracce. Brian Faulkner

11.4512.30: Wellbeing in the vet profession: what dowe know and why does it maer? Rosie Allister

13.5014.40: New graduates: approaches to reducingarion and improving performance throughunderstanding wellbeing. Rosie Allister

14.4015.35: Mentoring in pracce. Rosie Allister


26/3626 | companion

Calling all runners have you always wanted

to do the London Marathon but never got

around to applying for a place? Or perhaps

youve been disappointed in the ballot and

missed out. We can help you and you can really

help PetSavers.

By choosing to be the 2013 PetSavers Marathon

runner you could not only achieve a personal

ambition, but also contribute to the wellbeing of pets

throughout the world. Your sponsorship will be used

to fund vital research in one of the designated

PetSavers grants areas.

What to doGet in touch today tell us why you want to do the run

and how much you think you can raise. Applications

need to be in by 30 November and the minimum

sponsorship you would be expected to achieve is in

the region of 2000. We will help with lots of publicity

and ideas to make sure you can reach your target.

What we will doThe successful runner will hear from us before

Christmas and we will provide lots of help with

fundraising. Youll even get a PetSavers running

vest or T-shirt to inspire your training. Email

[email protected] call Gemma on

01452 726723.

Getting a spot on the start line for theLondon Marathon can be almost as difficultas running it we have a place on offer are you up for the challenge?

Marathon place

could be yours

PetSavers heated pads are ideal for keeping your

small pets warm this winter. The pads run on a low

voltage and can be left on constantly, even

underneath an animals favourite blanket. They

are safe, robust and easy to clean. The pad surface can

be easily wiped clean and be rolled up for storage when

not in use.

If you work in a practice, the heated pads are ideal for

minimising perioperative hypothermia, or just to keep them

warm in hospital. PetSavers pads are much cheaper than an

incubator and less hassle than hot water bottles. The plug-in

lead can be passed easily through the bars of a cage.

Heated pads are available to buy from the website at

www.petsavers.org.ukfor just 40.00 (including VAT).

Feelingwarm

all over


27/36companion | 27

PETSAVERS FUNDING

To find out more about how PetSavers fundsessenal research that ulmately helps vetssave pets please visit www.petsavers.org.uk or email [email protected] you wouldlike to find out how you can support thisimportant work.

Funding forstudy of urinalysisRachel Burrow of the University of Liverpool tells usabout her recently funded Clinical Research Projectentitled Comparison of non-validated in-house methodof urinalysis with the reference laboratory method

A

nalysis of urine is a commonly

performed and relatively simple

test that can help to investigate

diseases of the urinary system

and also many other body systems of bothdogs and cats.

Traditionally, urine was submitted to a

commercial laboratory where it would be

centrifuged to separate the cells and other

particles from the liquid part of the sample

by a standardised technique. Both parts of

the sample would then undergo various

tests and the results obtained would be

compared with well established standard

(normal) values.

In-house testsMany veterinary practices now havegreater in-house laboratory facilities,

including small bench-top centrifuges, and

are able to prepare urine samples

themselves. This is usually more cost-

effective and allows results to be obtained

much more quickly, which is of great

benefit to owners and their pets.

The technique is not standardised,

however, and it is not known if the results

obtained in a commercial laboratory are

directly comparable to th

Companion November2012

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Transcript of Companion November2012