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The essential publication for BSAVA members

companion
OCTOBER 2013
How To
Neurology Part II

P14
PROTECT Success
Poster impacts on
practice
P4
Global Outlook
BSAVAs world
vision
P12
PROTECT
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companion
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 beneft. Veterinary schools
interested in receiving
companion companion should
email companion@
bsava.com. 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 DPhil CertVR DSAM
DipECVIM-CA MRCVS
CPD Editor Simon Tappin MA VetMB CertSAM
DipECVIM-CA MRCVS
Past President Mark Johnston BVetMed MRCVS
CPD Editorial Team
Patricia Ibarrola DVM DSAM DipECVIM-CA MRCVS
Tony Ryan MVB CertSAS DipECVS MRCVS
Lucy McMahon BVetMed (Hons) DipACVIM MRCVS
Dan Batchelor BVSc PhD DSAM DipECVIM-CA MRCVS
Eleanor Raffan BVM&S CertSAM DipECVIM-CA MRCVS
Features Editorial Team
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
welcomed and guidelines for authors are
available on request; while the publishers will
take every care of material received no
responsibility can be accepted for any loss or
damage incurred.
BSAVA is committed to reducing the
environmental impact of its publications
wherever possible and companion is printed
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and can be recycled. When you have finished
with this edition please recycle it in your
kerbside collection or local recycling point.
Members can access the online archive of
companion at www.bsava.com.
3 BSAVA News
Latest from your Association
46 PROTECT Success
How the poster has impacted
practices
811 Clinical Conundrum
Sudden onset bilateral blindness
in a cat
1213 A Global Outlook
President explains plans
1422 How To
Perform the basic neurological
examination PART 2
23 PetSavers
Introducing the new co-ordinator
2427 Fundamentals in Diagnostic
Imaging
Introducing new BSAVA manual
2829 Welcome to the Future
What to expect from your new
website
3031 Congress News
Alice Roberts and Lecture Highlights
3233 WSAVA News
The World Small Animal Veterinary
Association
3435 The companion Interview
Mo Gannon
37 Letters from the Regions
News from your local groups
3839 CPD Diary
Whats on in your area
Additional stock photography:
www.dreamstime.com
Roman Samokhin; Fantasista; Fabio Camandona;
Vetkit Constantin Opris
EJCAP ONLINE
SUMMER ISSUE
NOWAVAILABLE
Dont forget that as a
BSAVA member you are
enttled to free online access to EJCAP
register at www.fecava.org/EJCAP
to access the latest issue.
Find FECAVA on Facebook!
n the October issue of JSAP, Kiviranta
and colleagues from the University of
Helsinki evaluate the efficacy and safety
of topiramate as an add-on therapy in
dogs with refractory idiopathic epilepsy.
The authors carried out a prospective,
open label, non-comparative clinical trial
of topiramate in dogs who had idiopathic
epilepsy and poor seizure control despite
therapeutic serum concentrations of
phenobarbital and potassium bromide.
The efficacy of topiramate was evaluated
by comparing seizure and seizure day
frequencies during a retrospective period
with a prospective short-term follow-up; an
additional long-term follow-up period was
conducted on dogs that responded to
topiramate therapy during the short-term
follow-up.
Ten dogs were included. Five
responded to topiramate therapy during
the short-term follow-up showing a
significant (P=0.04) decrease of 66% in
seizure frequency. Three of the five dogs
remained responders during the long-term
follow-up. Weight loss, sedation and ataxia
were the most common adverse effects of
topiramate therapy, but in dogs with
OTHER PAPERS IN THIS MONTHS JSAP
Conservatve management of fractures
of the third metatarsal bone in the racing
Greyhound
Computed tomographic morphometry
and characteristcs of thoracolumbar
extruded disc herniaton with and
without myelography
Inhaled budesonide therapy in cats with
naturally occurring chronic bronchial
disease
Efect of anatomic variaton in caudal
tbial plateau on the tbial plateau angle
in dogs
Statstcs: more regression models
Whats in JSAP this month?
Log on to www.bsava.com to access
the JSAP archive online.
Topiramate as an add-on
drug for treating refractory
canine idiopathic epilepsy
moderate sedation or ataxia, signs
subsided in a few weeks to few months to
mild sedation or ataxia.
The authors conclude that topiramate
may be effective as an add-on medication
in treating canine idiopathic epilepsy. Apart
from sedation and ataxia reported in some
of the dogs, topiramate was well-tolerated.
Adapted from Kiviranta A.-M. et al., JSAP 2013; 54: 512520
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Supporting Africa
T
hanks to support from BSAVA and its equivalent
association in the Netherlands, vets in Africa are
benefiting from first class CPD with the Sub
Saharan WSAVA Education Programme; though
they still have to deal with the occasional energy crisis.
A recent report from the WSAVA team told how Dr
Sarah Boyd from South Africa has been busy delivering
key lectures for African vets in June and July. Almost
50veterinary surgeons in Botswana and Zambia
gathered to hear her deliver stimulating sessions on
surgical topics. Despite the disruption of a power cut in
Botswana necessitating a change of room, her talks
were a great success.
Dr Jill Maddison says, WSAVA education in Africa
would not be possible without the generous support of
BSAVA and NACAM, and the hard work of Dr Lawson
Cairns who works tirelessly to deliver practical and
relevant CE in the region.
A full article about this programme will feature in
the November edition of companion. n
RCVS collection
gets small animal boost
T
he Royal College of Veterinary Surgeons was delighted to receive
a bust of the first President of BSAVA, Cecil Erskine Woody
Woodrow at a special presentation in August.
The bust was presented by Professor Michael Day to RCVS
President Neil Smith at Belgravia House, London, and is a replica of the
bronze original, which lives at BSAVAs office in Gloucester. The
presentation was attended by the three surviving founder members of
BSAVA: Nick Henderson, Bruce Vivash Jones and Brian Singleton.
The historical collection held by the RCVS reminds us of the journey
taken by those who went before us, and helps us to understand the
context of our profession in society today, said Professor Day. I am
delighted to present this statue of Woody Woodrow as a reminder of the
contribution made by our founder members back in 1957. They shaped
the future for companion animal vets in the UK and globally, through their
key role in establishing the BSAVA.
These pioneers were
ambitious about scientific
excellence and created a
supportive environment for
continual professional
development. It is thanks to
people like Woody
Woodrow, Nick Henderson,
Brian Singleton and Bruce
Vivash Jones that we have
access to a richness of
resources today. n
Anaesthesia
inAmerica
W
e were delighted to hear
recently that the BSAVA
Manual of Canine and
Feline Anaesthesia and
Analgesia, 2nd edition, is now cited
on the recommended reading list for the
American College of Veterinary Anesthesia and
Analgesia Board examinations. This manual is
one of the most highly-regarded publications in
clinical veterinary anaesthesia and is the top-
selling manual on our current list.
For further information on the manual visit
www.bsava.com/publications.
If you have a favourite BSAVA manual that you
do not think is covered in the relevant academic
reading lists, let us know email publications@
bsava.com. n
B
explore rabies and other disease risks from free roaming dogs
organized by the World Organization for Animal Health and the
WSAVA. For more information visit www.bsava.com/wsava. Places are
limited to 100 delegates. n
BVOA TRAUMATOLOGY
The Britsh Veterinary Orthopaedic Associaton has a
meetng in Manchester on 1517 November covering
fractures, wound management, analgesia and emerging
techniques. There will also be a one-day dry lab session
this year, preceding the Autumn Meetng. Aimed at the
novice orthopaedic surgeon, the programme will present
a mixture of lectures and practcals.
Find further details online at www.bvoa.org.uk.n
Bruce Vivash Jones, Brian Singleton and
Nick Henderson with the bust of their late
colleague Woody Woodrow
BSAVA extends
its global outlook
A
t the ECVIM Congress in Liverpool 1214
September, President, Professor Michael
Day, caught up with Paul Pion of the
Veterinary Information Network (VIN) and
agreed to provide VINs 42,000 members with
access to archival BSAVA material, directing users
back to the BSAVA website for access to the most
up-to-date resources. n
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success
S
itting in an NHS Accident & Emergency
Department will often provide a patient with
plenty of time for reflection. Ian Battersby
made good use of that opportunity when he
went to his local hospital for treatment of a cat bite that
had become painfully infected and the conclusion he
reached wasnt a particularly pleasing one for himself
or his fellow veterinary practitioners.
As he explained in an article for a special edition of
companion timed to coincide with the launch of the
PROTECT poster in October 2011, Ian realised that
human medics were much more careful than their
veterinary colleagues in deciding whether to prescribe
antimicrobial treatments. After questioning the duty
doctor, he discovered there is a strict protocol in place
within NHS hospitals on when, what and where to use
these valuable agents.
Ian went home and asked members of the
SAMSoc (Small Animal Medicine Society) discussion
group if they had introduced similar rules for their
practice in an effort to ensure that antimicrobials are
only used in appropriate situations. Only one practice
had taken this important step towards preventing the
emergence of antimicrobial resistance and so the idea
which culminated in the publishing of the joint
SAMSoc/BSAVA PROTECT poster was born.
Inspiring change
Ians rather humbling experience was more than two
years ago has anything changed in the interim?
Yes, it certainly seems to be the case that veterinary
practitioners are thinking much more carefully about
their prescribing policies and the majority of practices
now seem to have produced agreed protocols.
I think we have gone a long way towards closing
the gap that existed between human and veterinary
medicine in this country. The evidence may only be
anecdotal but I talk to a lot of first opinion vets and they
do know what they are supposed to do and they are
doing it. I like to think that the PROTECT poster has
been part of that process, said Ian, SAMSoc president
and a European diplomate in internal medicine with
Davies Veterinary Specialists in Hertfordshire.
One thing that hasnt changed is the attention
levelled by human medical practitioners towards the
prescribing habits of their veterinary colleagues.
There is the constant threat that the European
Commission will place further restrictions on what
molecules can be used in veterinary medicine in its
attempts to ensure effective agents will still be
available for human use. Itis also likely that the
pressure will intensify following statements like that
made by the governments new chief medical officer
Dame Sally Davies earlier this year. She said in her
annual report that antimicrobial resistance should be
ranked alongside terrorism and climate change on the
list of critical risks to the nation.
The professions response
Like others before him, Ian points out that there is no
evidence that veterinary use of antimicrobials is a
significant factor in the development of resistance
problems in human hospitals. Even so, we shouldnt
be taking any risks when prescribing these drugs. In
any case, we should recognize that for our own
patients sake, we should be careful. We dont want to
overuse these agents and find that they dont work any
more, as has happened for some of the key drugs
used in human medicine.
So from April 2012 the RCVS Code of Conduct has
included the following warning; Veterinary surgeons
must be seen to ensure that when using antimicrobials
they do so responsibly, and be accountable for the
choices made in such use.
That advice reflects concerns over the possibility
of food-borne transmission of resistant bacteria but
close physical contact between people and pets
The BSAVA and SAMSoc are planning to
update the highly successful PROTECT
poster, advising small animal practitioners on
the responsible use of antimicrobial drugs.
John Bonner finds out what has happened
since the poster was issued in 2011 and why
a new version is considered necessary
PROTECT
04-06 PROTECT.indd 4 20/09/2013 10:42
would offer a plausible alternative transmission route.
Hence from May of this year the RCVS Practice
Standards Scheme literature has included a notice that
A practice must be able to demonstrate that when
using antimicrobials and anthelmintics it does so
responsibly and is accountable for the choices made
in such use.
Pam Mosedale was formerly an inspector for the
RCVS Practice Standards Scheme and points out that
the PROTECT poster was one of the information
sources cited for those practices that need to look at
prescribing policies in order to conform with the
schemes demands. I think PROTECT is an excellent
template for practices to use to generate discussion,
look at the evidence and come up with a practice
policy or guidelines on antimicrobial use. As this is a
new part of the scheme, Royal College inspectors will
be helping practices and guiding them to useful
resources like PROTECT and the advice in the BSAVA
Guide to the Use of Veterinary Medicines.
An equine view
The British Equine Veterinary Association is another
organization that has found the PROTECT poster a
useful tool to help practices develop a sound and
consistent policy for deploying these essential
weapons in the veterinary armamentarium.
BEVA adapted the PROTECT guidelines and
released an equine toolkit to our members on
European Antimicrobial Awareness Day in 2012.
Itgreatly simplified the process of creating this
information, since we were able to adapt the concept
that had been widely publicized by BSAVA and
SAMSoc. We further built on the concept to identify
PROTECTed antimicrobials that should be avoided
as first line drugs using the WHO definitions of
critically important antimicrobials, said Mark Bowen,
an Associate Professor of veterinary internal
medicine at the Nottingham veterinary school and a
member of BEVA Council.
So far approximately 25 per cent of our members
have used this to develop practice based policies,
while a further third of the membership had already
developed their own policies. We will also be releasing
information for clients to reduce pressure to prescribe
in 2013, he added.
The BSAVA has similar plans to produce leaflets for
distribution to small animal clients explaining why the
veterinary surgeon may decide not to prescribe
antimicrobial agents to treat their pet.
Going global
The PROTECT poster has had a much wider impact
than Ian Battersby and his collaborators in BSAVA and
SAMSoc could have envisaged when they began work
on drafting the document.
This year the poster has gone global, said Ian
Mellor, Manager of BSAVA Publications. It has been
distributed in New Zealand by the Companion Animal
Society of New Zealand and the New Zealand
Veterinary Association. SAMSoc has arranged its
distribution in India and to other developing countries,
and the poster has also been translated into French,
German, Italian and Spanish and thousands of copies
of these versions are to be distributed throughout
Europe by Vtoquinol. Proceeds from any commercial
sales help to fund further distribution of the concept.
The animal health industry is an important ally for
the veterinary profession in spreading the word about
we have gone a long way towards
closing the gap between human and
veterinary medicine I like to think
that the PROTECT poster has been
part of that process
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PROTECT success
Keeping it relevant
So if the PROTECT poster has been so well received at
home and abroad, why is it necessary to produce a
new version? Ian Battersby explains that it is
necessary to keep pace with developments in the
underlying science. The guidance that we give in the
poster is designed to reflect the latest information and
as new studies are published we have to look at them
and see if we should adjust our advice accordingly.
There have also been a few new products licensed for
veterinary use over the past couple of years and we
want to make sure that we are recommending the right
products for any particular indication.
Ian will be part of a small team that will also include
Professor Ian Ramsay from the Glasgow veterinary
school and Dr Sally Everitt, scientific policy officer at
BSAVA which will begin work on revising the poster in
the autumn. Their discussions will also take account of
feedback from those who have used the document in
drawing up their own practice policies.
However, as Ian Battersby points out, restricting
the use of antibiotics to reduce the selection pressure
that would eventually lead to the emergence of
resistant bacterial strains is only half the story.
Medicines protocols have to be incorporated within a
comprehensive strategy that includes other infection
control measures such as strict attention to hygiene.
In practice
NorthWest Surgeons is a Cheshire-based referral
practice that has both looked very closely at the way it
deals with the resistance problem and also keeps
those measures under constant review. As Ben Keeley,
an orthopaedic surgery specialist with the practice,
describes in his blog, this involved setting up a
dedicated Infection Control Group (ICG) with the
overall aim of ensuring that their infection control and
antimicrobial use policies are soundly based on
current evidence and best practice.
That team is headed by one senior specialist
surgeon and one senior specialist physician. It
includes representatives of the nursing team and
reports to a committee consisting of all of the senior
clinicians. It develops and proposes policy
recommendations for standards of hygiene and
cleanliness and for proper antibiotic usage. Once
ratified by the committee of senior clinicians, these
policies covering all aspects of care from responsible
antibiotic use to hand washing and proper care of
catheters are issued to all staff members.
We have found that an important part of
implementing effective action from these written
policies is to enthuse, engage and empower the whole
team in the process. The ICG also has responsibility
for monitoring our infections and while such clinical
audit is still in its infancy in veterinary medicine, it is
something that we are continually looking to develop
and improve, he says.
Part of a package of support
The PROTECT poster forms part of a range of BSAVA
activities intended to ensure that future generations of
companion animal patients continue to enjoy the
benefits of effective antimicrobial agents. Advice for
members on appropriate use of these drugs is
included in the Small Animal Formulary edited by Ian
Ramsay. The Association also holds two dispensing
courses a year there has just been one in Exeter and
the next is in York in March 2014. In addition, the
BSAVA is part of an alliance of organizations including
Vtoquinol, the Bella Moss Foundation, Abbey
Veterinary Laboratories, CAPL and Medimark that
organized a webinar in August providing CPD for
practitioners on the use of cytology tests in the
diagnosis of infections in small animals. n
Your view on PROTECT
It is now two years since the PROTECT poster
was created and the team are looking to
review both the content and the format.
We have already brought out an eight page
A4 version for download from the website
www.bsava.com. If you have any further
suggestions for improving the PROTECT
poster please send your suggestions to
DrSally Everitt s.everitt@bsava.com .
04-06 PROTECT.indd 6 20/09/2013 10:42
For more information or to book your course
www.bsava.com
Learn@Lunch
webinars
These regular monthly lunchtime (12
FREE to BSAVA Members just book your place through
the website in order to access the event. The topics will
be clinically relevant, and particularly aimed at those in
first opinion practice. There will be separate webinar
programmes for vets and for nurses.
This is a valuable MEMBER BENEFIT
Coming soon
13 November Top 10 dental tips Webinar for vets
20 November Fluid therapy for nurses
4 December Foreign vets in UK practices.
DOs and DONTs
Book online at
www.bsava.com
Stock photography: Dreamstime.com. Vetkit
Chemotherapy
in practice: a life
changing experience
31 October
In small animals, chemotherapy plays a
critical role in the management of many
tumour types and can significantly increase
patient well-being and survival time.
SPEAKER
Iain Grant
VENUE
Best Western Premier Yew Lodge Hotel, Kegworth
FEES
BSAVA Member: 233.00 inc. VAT
Non BSAVA Member 350.00 inc. VAT
Surgical management
of soft tissue tumours
in practice
21 November
Surgery cures more patients with cancer
than any other treatment modality. Identify
the role that surgery plays.
SPEAKER
Stephen Baines
VENUE
Best Western Premier Yew Lodge Hotel, Kegworth
FEES
BSAVA Member: 233.00 inc. VAT
Non BSAVA Member 350.00 inc. VAT
Advanced airway
surgery
28 November
This course will cover initial emergency
management, diagnostic challenges and
decision-making in medical and surgical
management.
SPEAKER
Alison Moores
VENUE
Woodrow House, Gloucester
FEES
BSAVA Member:
233.00 inc. VAT
Non BSAVA Member
350.00 inc. VAT
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Clinical conundrum
Case presentation
A 21-year-old female neutered,
Domestic Short-hair cat,
presented for investigation of
blindness. The owner noticed
sudden onset blindness
approximately 4 weeks prior to
presentation. In addition, the
owner reported the cat was
drinking, urinating and eating
more, but had lost 500g in
bodyweight in 2 months.
Clinical examination findings
The cat had a poor body condition score (2/9), with
both poor muscle and coat condition. Mucous
membranes were pink and tacky, with a capillary refill
time of 2 seconds, and a mild skin tent. She had
moderate dental tartar and gingivitis. Her heart rate
was 212 beats per minute with hyper-dynamic but
synchronous femoral pulses. Cardiac auscultation
revealed a grade 2/6 left-sided systolic heart murmur
with the point of maximal intensity at the heart base.
Describe the abnormalities in Figure 1
Part of the retina is curved towards the front of the eye
indicating bullous retinal detachment of the left eye.
This is sometimes likened to a curtain descending
from the top of the eye or damp wallpaper coming
loose from a wall. There is one small haemorrhage
next to the optic disc in the 8 oclock position. The right
pupil was similarly dilated, as the right eye is also
suffering from retinal detachment.
Ophthalmic examination findings
Examination revealed bilaterally absent menace
responses, and although the pupillary light reflexes
were present, they were incomplete and sluggish.
There was no obvious dazzle reflex. There were no
eyelid, conjunctival or corneal abnormalities detected,
and the anterior chamber was clear. The lenses had
nuclear sclerosis (expected of a 21-year-old cat) and
prominent, non-cataractous, suture lines. Fundoscopy
revealed the presence of bilateral bullous retinal
detachment (left > right), with occasional retinal
haemorrhages. Intraocular pressures, measured by
applanation tonometry, were 9mmHg in each eye
(reference interval 1025mmHg). Schirmer tear tests
were 19mm/minute in each eye (reference interval
1520mm/minute).
Create a problem list
Bilateral blindness due to bilateral retinal
detachment
Weight loss despite polyphagia
Polyuria and polydipsia (PU/PD)
Dehydration
Tachycardia with a grade 2/6 heart murmur
Poor coat condition
Periodontal disease
Consider the differential diagnoses for
retinal detachment with haemorrhage
Systemic hypertension (primary or secondary)
Posterior uveitis (infectious (e.g. feline infectious
peritonitis, Toxoplasma or fungal), idiopathic or
secondary to systemic disease)
Neoplastic (e.g. lymphoma, other)
Blood dyscrasia
Which of these differential diagnoses
most likely explain the blindness?
Systemic hypertension would be the most likely
diagnosis based on the sub-acute history, ophthalmic
examination and other systemic clinical signs.
Posterior uveitis is possible but would be unusual,
especially in the absence of other ophthalmic signs of
uveitis, such as cellular debris within the vitreous, and
a lack of signs supportive of panuveitis such as
concomitant anterior uveitis (e.g. iritis, aqueous flare,
keratic precipitates and/or presence of anterior
chamber fibrin clots).
Negar Hamzianpour, an intern
at the Royal Veterinary College,
invites companion readers to
consider a case of sudden
onset bilateral blindness in a
Domestic Shorthaired cat
Figure 1: Indirect ophthalmic
examination of the left eye as observed
at initial presentation
Image courtesy of Rick F. Sanchez
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Fungal posterior uveitis usually presents with more
severe intraocular changes and sometimes systemic
signs, but is uncommon in the UK. Intraocular
neoplasia in the absence of anterior ocular changes is
also very rare. Blood dyscrasias, such as anaemia,
could explain the tachycardia and heart murmur, but
other concurrent clinical signs may be expected such
as weakness, collapse and mucous membrane pallor.
The other systemic clinical signs in this cat suggest the
retinal detachment is likely to be secondary, rather
than idiopathic.
Due to the high suspicion of systemic hypertension
it would be advisable to perform a blood pressure
check. The non-invasive (Doppler sphygmomanometry)
systolic blood pressure (SBP) in this cat was repeatedly
> 300mmHg. Blood pressure should be considered
according to the risk of developing target organ
damage (Table 1).
Consider the possible secondary causes
of the hypertension in this cat
Chronic kidney disease (CKD)
Hyperthyroidism
Primary hyperaldosteronism Conns syndrome*
Adrenal disease phaeochromocytoma*
*Considered rare differential diagnoses
At this point we have established that the cat has
retinal detachment secondary to systemic
hypertension. However, the cause of the hypertension
is unknown.
Construct a diagnostic plan
Complete blood count (CBC)
Serum biochemistry
Urinalysis (specific gravity, dipstick, sediment
examination) and culture
Total T4
You may also consider:
Ultrasound assessment of the kidneys and adrenal
glands
Echocardiography
Plasma aldosterone concentrations: primary
hyperaldosteronism (Conns syndrome) is an
infrequently diagnosed condition but should be
considered, particularly in those patients that
demonstrate persistent hypokalaemia and in which
an adrenal mass is documented. Approximately
50% of cats diagnosed with primary
hyperaldosteronism have concurrent systemic
hypertension. Ideally, assessment of plasma
aldosterone should be performed in conjunction
with evaluation of plasma renin activity in order to
confirm primary production of aldosterone. Primary
hyperaldosteronism was considered an unlikely
differential diagnoses in the current case given the
lack of appropriate electrolyte abnormalities
(outlined below).
What is your interpretation of the
laboratory results (Tables 2, 3 and 4)?
From the result of the total T4, we can diagnose this
cat as hyperthyroid. Hyperthyroidism makes the
assessment of renal function difficult, due to increased
renal blood flow and glomerular filtration rate (GFR),
which may mask underlying CKD. Thus, until the
hyperthyroidism is controlled, CKD cannot be
excluded in this patient.
The haematology is unremarkable. The elevated
urea concentration may be related to increased protein
catabolism in the hyperthyroid state, gastrointestinal
blood loss or could reflect a pre-renal component. As a
surrogate marker of GFR, the creatinine concentration
cannot be used to ascertain whether this cat will be
azotaemic following treatment of the hyperthyroidism.
Creatinine may also be influenced by the poor body
condition and muscle mass of this patient.
The urine specific gravity is inappropriate, especially
considering the cat is clinically dehydrated. It should be
at least > 1.035, although this is difficult to interpret in
the face of hyperthyroidism. Proteinuria is often seen in
untreated hyperthyroid cats, as a reflection of
glomerular hypertension and hyperfiltration, and may
resolve after treatment.
Risk
Category
Systolic BP Diastolic BP Risk of
future TOD
1 < 150 < 95 Minimal
2 150159 9599 Mild
3 160179 100119 Moderate
4 180 120 Severe
Table 1: Classification of blood pressure based on risk for
future target organ damage (TOD)
Adapted from: Jepson R. How to approach the hypertensive patient.
BSAVA companion, March 2012: p1219
08-11 Clinical Conundrum.indd 9 20/09/2013 10:46
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Clinical conundrum
However, if the cat remained proteinuric once the
hypertension and hyperthyroidism were controlled,
then a renal origin for the proteinuria should be
considered and a urine protein:creatinine ratio (UPCR)
performed. A UPCR would not be advisable at this
stage due to the potential for false elevation as a
consequence of the active sediment. Urinary tract
infections, as in this cat, are common in
hyperthyroidism and CKD.
Stress-related hyperglycaemia above the renal
threshold may be the cause of the glucosuria. The
cystocentesis sample was obtained using ultrasound
guidance at a later time point to sampling for
biochemical assessment, which may explain the initial
lack of stress hyperglycaemia. Repeat urine dipstick
evaluation using a free catch urine sample confirmed
glucosuria was not a persistent finding.
What do you suspect to be the cause of
the systemic hypertension?
The systemic hypertension diagnosed is likely to be
associated with the hyperthyroidism, although CKD as
a contributing factor in the pathogenesis cannot be
excluded at this stage. Approximately 10% of cats will
demonstrate systemic hypertension at the time
hyperthyroidism is diagnosed, whilst a higher
proportion (up to 20%) develop systemic hypertension
after achieving euthyroidism.
Systemic hypertension can lead to end organ
damage to the eyes, kidneys, cardiovascular system
and central nervous system. If this cat does have kidney
disease it is difficult to distinguish whether this is a
cause or consequence of the systemic hypertension.
The patient already has retinal detachment, indicative of
target organ damage secondary to systemic
hypertension, and may also have cardiovascular effects,
which are evident from the heart murmur. However, the
heart murmur may just be incidental as a result of the
tachycardia, induced by the hyperthyroidism.
How would you treat this case in view of
the above results?
Our first priority is to treat the systemic hypertension.
Our goal is a gradual but persistent decrease in SBP,
avoiding sudden fluctuations, sudden drops in SBP or
periods of hypotension. This can be achieved by
starting the cat on the L-type calcium channel blocker, LL
amlodipine. A suggested approach to management of
this is summarized in Figure 2.
Secondly, we should start treatment for the
hyperthyroidism. Of concern in this cat is that
restoration of euthyroidism may result in a decrease in
GFR, potentially unmasking CKD. Radio-iodine
therapy and thyroidectomy were therefore not
considered optimal treatment therapies at this stage.
In contrast, medical management is reversible and
was the preferred approach for this cat, allowing
careful assessment of renal function as therapy was
started. Currently, there are two authorized products
for the medical management of feline hyperthyroidism:
methimazole (starting dose 2.5mg q12h) and
carbimazole (starting dose 10mg q24h). Due to owner
concerns about administering tablets, carbimazole
therapy commenced.
Lastly, we need to treat the urinary tract infection.
The cat received amoxicillin clavulanic acid (15mg/kg
orally q12h) for 14 days. Subsequently the urine
sediment examination and culture confirmed resolution
of the urinary tract infection.
What long term follow up and treatment
would you advise for this case?
After achieving the target SBP (<160 mmHg),
regular monitoring of blood pressure every
23months
Regular total T4 monitoring: 3, 6, 10, 20 weeks
and thereafter every 3 months, adjusting dosage
as necessary
Regular CBC, biochemistry and urinalysis, at
least every 3 months, especially to check renal
function and for evidence of recurrence of
urinary tract infection
UPCR if inactive sediment and ongoing proteinuria
Test Result Range Units
16.6 5.519.5 10
9
/l
Neutrophils 12.28 2.512.5 10
9
/l
Lymphocytes 2.82 1.57 10
9
/l
Monocytes 0.50 01.5 10
9
/l
Eosinophils 1.00 01.5 10
9
/l
Basophils 0.00 00.4 10
9
/l
RBC 10.40 510 10
12
/l
HGB 14.00 815 g/dl
HCT 42.4 2445 %
MCV 40.4 3955 f
MCH 13.4 1317.5 pg
MCHC 33.1 3036 g/dl
RDW 20.0 %
PLT 251 200800 10
9
/l
PCV 43 2445 %
Plasma colour Unremarkable
Comment Diferentals confrmed on smear; platelet
clumping seen
Table 2: Haematology results (abnormal results in bold)
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CONTRIBUTE A CLINICAL CONUNDRUM
If you have an unusual or interestng case that you
would like to share with your colleagues, please submit
photographs and brief history, with relevant questons
and a short but comprehensive explanaton, in no more
than 1500 words to companion@bsava.com
All submissions will be peer-reviewed.
Guidelines for Clinical Conundrum submissions can be
found online at www.bsava.com/companion
Test Result Range Units
Total protein 77.2 6180 g/l
Albumin 34.2 2842 g/l
Globulin 43 2546 g/l
Sodium 153 153162 mmol/l
Potassium 4.8 3.85.3 mmol/l
Chloride 113 110121 mmol/l
Calcium 2.6 2.072.8 mmol/l
Inorganic phosphorous 1.81 0.922.16 mmol/l
Urea 19.3 6.112 mmol/l
Creatnine 161 74.5185.3 mol/l
Cholesterol 6.2 2.26.7 mmol/l
Total bilirubin 0 03 mol/l
CK 224 52506 IU/l
GGT 2 02 IU/l
ALP 42 1148 IU/l
Glucose 6.5 3.48.2 mmol/l
Total T4 81.2 1965 nmol/l
Table 3: Serum biochemistry results (abnormal results in bold)
Test Result
Specifc gravity 1.024
pH 6
Protein 1+
Glucose Trace
Ketones Negatve
Bilirubin Negatve
Sediment Leucocytes with intracellular cocci noted
Culture Enterococcus faecalis
Sensitvity to: Amoxicillin clavulanic acid, Ampicillin,
Oxytetracycline or Trimethoprim
sulphonamide
Table 4: Urinalysis and culture results from a cystocentesis
sample
Table 5: Serum biochemistry and urinalysis abnormalities at
re-examination
Parameter Result Reference
range
Units
SBP 150 See Table 1 mmHg
Urea 22.3 6.112 mmol/l
Creatnine 196.7 74.5185.2 mol/l
SG 1.022
SBP <160 mmHg; no evidence of progression
of hypertensive retnal detachment:
Maintain on amlodipine dose
Contnue to monitor BP every 23 months
SBP <160 mmHg or progression of end organ
damage (e.g. progression of retnal detachment
or development of neurological signs):
Confrm owner/cat compliance with treatment
Add ACE inhibitor
Re-check BP in 1014 days
SBP >160 mmHg or progression of hypertensive retnal detachment:
Increase dose of amlodipine to 1.25 mg orally q24h
Re-check BP in 714 days
Cat with systemic hypertension and retnal detachment
Start treatment with amlodipine (0.625 mg orally q24h)
Re-check blood pressure (BP) in 13 days
Figure 2: Flow
chart showing
how to treat a cat
with systemic
hypertension
and retinal
detachment
SBP = Systolic blood
pressure
Adapted from: Jepson
R. How to approach the
hypertensive patient.
BSAVA companion,
March 2012: 1219
Outcome
At a re-check 3 weeks later, the owner reported that
the cats vision at home appeared improved. This was
unexpected as the prognosis for vision return despite
retinal re-attachment is usually poor as photoreceptor
damage starts within 12 hours and progresses
rapidly over the first 2 to 3 days and is widespread.
However, despite this some patients may recover
some degree of vision after reattachment.
The SBP was controlled at 150mmHg. The total T4
was rechecked and found to be in the normal range.
The degree of azotaemia (Table 5) resulted in a
diagnosis of International Renal Interest Society (IRIS)
stage 2 CKD. As sucha prescription phosphate
restricted diet was introduced. It was noted that the
patient was now no longer proteinuric, following
elimination of the urinary tract infection.
Acknowledgements
The author wishes to thank the assistance of
Dr R. Jepson, Mr R. Sanchez and Dr S. Niessen, of the
Royal Veterinary College, for their help clinically with
this case and the review of this conundrum.
08-11 Clinical Conundrum.indd 11 20/09/2013 10:46
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A global
outlook
(418 members). These membership options provide
practising and future veterinary surgeons with ready
access to BSAVA online resources.
However, the presidential theme is not just about
business and expansion. As a well-established
Association that has worked hard to create a firm
financial footing and based in a country with a
relatively strong economy the global outlook also
has an altruistic dimension at its core.
BSAVA has readily engaged with initiatives
targeting developing countries in the past, and we
continue to support the WSAVA Sub-Saharan African
CE Programme (with recent annual donations of
10,000). Also, each year we sponsor delegates from
selected Eastern European countries to attend our
Congress. These activities are co-ordinated and
overseen by our International Affairs Committee,
presently chaired by Ross Allan.
The next phase of BSAVAs support for the
international veterinary profession is the introduction of
a developing country e-membership. The aim of this
new initiative is to share the BSAVA knowledge-base
with small animal veterinary surgeons in countries with
an emerging companion animal industry, where small
animal medicine and surgery is often taught at
postgraduate level because national curricula focus on
production animal science.
In such countries there is an enormous thirst for
knowledge and, as a speaker at various conferences,
D
uring my inaugural address at Congress
2013, Iproposed a Presidential theme of the
BSAVA Global Outlook. BSAVA has been an
inordinately successful national Association,
now representing some 8,500 veterinary, nursing and
student members, with a portfolio that includes our
manuals and publications, the worlds largest
companion animal congress, CPD that ranges from
local regional courses to the Postgraduate Certificates,
and our scientific and political representation.
It has become clear in recent years that in the
global veterinary community, many of our resources
have an international appeal. BSAVA manuals are
always popular when sold at overseas congresses and
indeed many have been translated into various other
languages. The Journal of Small Animal Practice will
appear on the shelves of most veterinary school
libraries, around 10% of our Congress delegates are
international visitors, and we already have enrolments
from other European countries onto the Certificate
programmes.
How and why
To help meet this increasing demand we now offer an
overseas e-membership category (currently with around
450 members) and more recently we introduced a
rapidly growing free overseas student e-membership
Ross Allan and
delegates from Belarus
at BSAVA Congress 2012
A firm financial footing and a
wealth of scientific knowledge
means that BSAVA is in an
ideal position to share its
resources with the
international veterinary
community. President Michael
Day explains how BSAVA is
doing that and why
12-13 Global Outlook.indd 12 20/09/2013 10:47
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WHY THIS PRESIDENTIAL THEME?
It may be a surprise to some BSAVA Members that their
56th President is also the frst Australian President, and in
fact the frst not from the United Kingdom or the Republic
of Ireland. Being born and raised in one of the most isolated
cites in the world (Perth, Western Australia) provides a
unique perspectve on the world and an inherent need to
look outward.
I am sure that this isolaton underpins the Australian love
of travelling and the rite of passage for young Australians
of the working holiday abroad. At the same tme, Australia is
also one of the most cosmopolitan countries on earth, with
almost one third of the populaton of 23 million now being
born overseas.
My own working holiday in the UK has now extended
over 26 years, during which I have been fortunate enough to
travel to many parts of the world, speaking to and meetng
veterinary colleagues in developed and developing countries.
My personal global outlook has led to my longstanding
involvement with the WSAVA global community of small
animal veterinary associatons. I am currently chairman of the
WSAVA Scientfc Advisory Commitee, the WSAVA Vaccinaton
Guidelines Group and the WSAVA One Health Commitee.
These groups have provided scientfc advice and
contnuing educaton to the developing countries most in
need of such support. The Vaccinaton Guidelines Group
is currently working on the vaccinaton requirements of
pets in Asia and the One Health Commitee has specifcally
targeted the impact of canine rabies virus infecton on human
communites in Africa and Asia. The success of these WSAVA
programmes has reinforced to me the potental major impact
that BSAVA could also have through more outward facing
actvity and the introducton of the developing country
e-membership category is a wonderful step towards this goal.
Ihave been fortunate to visit many areas of the
worldwhere there is great appreciation for the gift of
shared information.
Where and who
The initial challenge with this new scheme was
selecting countries that would benefit most. Starting
from the World Bank list of countries with a low or
low-middle income, the list of WSAVA member
associations, and personal contacts, we have now
selected the following eight countries from four
developing regions of the world:
Asia: India and Sri Lanka
Eastern Europe: the Ukraine and Albania
Central and South America: Guatemala and
Paraguay
Sub-Saharan Africa: Kenya and Mozambique.
Our target countries generally have an emerging
companion animal profession, a national small animal
association or strong individual professional leaders,
adequate internet access and a sufficient level of
understanding of the English language.
For the next three years, individual veterinary
surgeons in these target countries will be able to apply
for free developing country e-membership online and
then access a range of member benefits via the
website, including:
Visiting a small animal practice in Delhi, India, 2012
Congress lecture podcasts
Congress proceedings
Formulary and accompanying App
Procedures Guide
Journal of Small Animal Practice and companion
Discount on publications and UK-based CPD.
At the end of the three-year period, our list will be
revised and the scheme continued.
I am very grateful for the work that our Membership
Development Committee, chaired by Sheldon Middleton,
and our Woodrow House staff have put into developing
this new concept. I truly hope that the developing country
e-membership will continue to help colleagues globally
long after this Presidential year is ended.
12-13 Global Outlook.indd 13 20/09/2013 10:47
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How to perform the
basic neurological
How to perform the How to perform the
examination
basic neurological basic neurological
PART II
Cranial nerve tests hands-on
examination
Test for:
Visual tracking
Palpebral reflex
Corneal reflex
Menace response
Vestibulo-occular reflex
Positional nystagmus
Pupillary light reflex (PLR)
Nasal mucosal response
Gag reflex
Visual tracking
Visual tracking relies on the globe to
function (including the retina). Visual
sensory information is sent via the optic
nerves, through the lateral geniculate
nucleus, on to the visual cortex, which
processes this information (both the
last two parts of the anatomy are
included in the forebrain) (Figure 10).
To test this, drop cotton wool in front of
your patients eyes. The normal
response is to move the eyes (with or
without movement of the head) to follow
the cotton wool.
You can cover the contralateral eye
with a swab and tape if necessary.
If absent, you need to assess the
pathway described above further using
PLRs and an ophthalmic examination to
localize the deficit.
Palpebral reflex
The palpebral reflex relies on sensory
reception from the face that ultimately
travels to the trigeminal nerve and then
the brainstem and returns with motor
function via the facial nerve to allow the
facial muscles to function.
To test this, touch the medial and lateral
canthi of the eye and observe. The
normal reflex is to blink and close the eye.
The medial canthus is usually more
reliable than the lateral canthus for
eliciting this response.
In the event of a deficit you need to
ascertain which part of the anatomical
pathway is affected. Please note that
you can observe for other markers of a
facial nerve lesion (as outlined in the
September issue of companion with
facial droop etc), as well as test
trigeminal function further, with nasal
mucosal response or corneal reflex.
In Part II of their review of neurological assessment Jeremy Rose and Tom
Harcourt-Brown, of the University of Bristol, look at the hands-on examination.
Particular thanks are due to Jacques Penderis and Laurent Garosi who authored
the chapters describing neurological examination in the BSAVA Manual of
Canine and Feline Neurology. In the manual they outline the pragmatic logical Canine and Feline Neurology Canine and Feline Neurology
approach to neurological assessment around which this, and the previous
article, are structured
Figure 10: The visual pathways demonstrating
how each side of the visual field is represented
within the opposite occipital (visual) cortex. As
the degree of binocular vision in different
species decreases, so a greater proportion of
optic nerve fibres decussate at the optic chiasm
Picture courtesy and copyright of Jacques Penderis
P
art 1 of this How to perform the
basic neurological examination,
published in the September edition
of companion, concentrated on the
information that could be gathered through
observation of the patient.
Part II concentrates on the hands-on
neurological examination. The cranial
nerves, postural reactions and spinal
reflexes are assessed in turn.
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Corneal reflex
The corneal reflex relies on sensory
reception from the cornea that
ultimately travels to the trigeminal nerve
and then the brainstem and returns
with motor function via the facial nerve
(to allow blinking) and the abducens
nerve (to cause retraction of the globe).
To test this, lightly touch the cornea
with a soft apparatus (we use a
moistened cotton bud beware
corneal injury!). The normal response is
retraction of the globe and blinking.
Menace response
This is a response, which means it
involves the forebrain.
Anatomically this response relies on the
globe to function (including the retina).
Visual signals are sent via the optic
nerves to the forebrain (via the lateral
geniculate nucleus to the visual cortex
(i.e. same pathway as visual tracking
initially)). This then synapses to the
primary motor cortex via the brainstem
to the cerebellum. The cerebellum has
outputs to the facial nerve nuclei in the
brainstem, which transmit motor activity
via the facial nerve to the facial
muscles (Figure 11).
To test the menace response, tap the
patients orbital region with your open
hand a couple of times (to ensure they
are concentrating and believe you may
hit them). Then be sure you are not too
close (so that you avoid touching hairs/
whiskers or making a sudden air
movement that stimulates sensory
components of the trigeminal nerve) and
force your hand towards the face
quickly and stop abruptly. The normal
response is to retract the globe and
close the eye (Figure 12).
It is important to cover one eye as you
menace the other to look for asymmetry.
This is a learned response and may not
occur until 10 to 12 weeks of age in
puppies and kittens.
You should have already assessed
visual function using tracking and
PLRs, as well as the palpebral reflex, to
be able to localize the lesion further
within this pathway.
Vestibulo-occular reflex
The vestibulo-occular reflex relies on
sensory reception from the vestibular
portion of the vestibulocochlear nerve
that, via the brainstem, transmits motor
activity to the oculomotor, trochlear
and abducens nerves which move the
muscles of the globe.
To test for normal physiological
nystagmus, move the head side to side
and then up and down. As you move
the head to the right, the normal
response will be to move both eyes
abruptly in that direction. This tests the
abducens nerve in the right eye and
the oculomotor nerve in the left eye. On
moving the head back to the left, this
tests the abducens nerve in the left eye
and the oculomotor nerve in the right
eye. Only the oculomotor nerves are
tested when the head is moved in the
vertical plane.
When you stop moving the head the
physiological nystagmus should stop.
Positional nystagmus
Positional nystagmus relies on
challenging the vestibular-cerebellar
system further. As such it tests the
vestibulocochlear nerve and
brainstem/cerebellum.
To test for positional nystagmus, place
the patient in dorsal recumbency and
cover the eyes. Flex and extend the
neck in the dorsoventral plane a couple
of times and then uncover the eyes.
The normal response is to see no
nystagmus once the head is stationary
(Figure 13).
Localization to the cerebellar system is
further covered in the September issue
of companion.
Other signs of vestibular deficits
include head tilt, circling/falling, ataxia,
wide-based stance, and nystagmus/
strabismus. You will need to localize a
vestibular lesion to a peripheral (inner
ear/vestibulocochlear nerve) or central
(brainstem or cerebellum) location. The
major differences are that central
lesions will result in behaviour/
mentation changes and postural/tactile
placement deficits, whereas peripheral
lesions do not (Table1).
Pupillary light reflex
The PLR relies on the globe to
function (including the retina). Visual
sensory information is sent via the
optic nerves to the brainstem. Here
information eventually synapses in the
oculomotor nuclei and then returns
via the occulomotor nerve to the iris
(Figure14).
To test this reflex, initially hold a
pen-light on the midline over the nose
to look at pupillary size and determine
whether any anisocoria is present.
Then shine the light source in one eye
and observe for pupil constriction.
Figure 11: The menace response pathway a
lesion interrupting any part of the pathway may
result in a menace deficit
Picture courtesy and copyright of Jacques Penderis
Figure 12: A threatening movement towards
the eye should document a menace response
Figure 13: Place the head into abnormal
positions to try and elicit positional nystagmus
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How to perform the
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PART II
After observing the response in one
eye, quickly swing the light to shine in
the other eye. Observe the response
of the second eye and then swing the
light source back to the first eye. Keep
repeating this. In the normal patient,
the pupil will constrict rapidly and
symmetrically in the eye primarily
being tested and the contralateral eye.
Nasal mucosal response
This is a response, which means it
involves the forebrain.
The nasal mucosal response relies on
sensory reception from the nasal
mucosa that ultimately travels to the
trigeminal nerve and then the
brainstem and then runs to the
forebrain, which elicits an aversion
response (i.e. turning the head away
from the noxious stimuli).
To test this, cover the patients eyes
and then touch the medial nasal
septum. The normal response is to turn
the head from the noxious stimuli (not
to sneeze or wrinkle nose).
This is difficult to test in cats and if not
present, or reduced bilaterally, should
be interpreted in light of other findings
(i.e. in isolation in cats this may not
correlate to a lesion).
As above you can further test the
neuromuscular and trigeminal function
using the corneal or palpebral reflex.
Gag reflex
The gag reflex allows you to assess jaw
tone/pain, in addition to tongue
movement/symmetry.
The gag reflex relies on sensory
information from the back of the throat
to travel via the glossopharyngeal
(CNIX) and vagus (CNX) nerves to
the brainstem and then return in
the motor portions of the same two
nerves.
Jaw tone assesses the neuromuscular
part of the anatomical pathway (i.e
musculature, trigeminal nerve and
neuromuscular junction (NMJ)), as well
as the brainstem.
Tongue muscle symmetry and
movement is controlled by the
neuromuscular part of the anatomical
pathway (i.e musculature, hypoglossal
nerve (CNXII) and NMJ), as well as
the brainstem.
To test this, grasp the upper jaw with
one hand and pull down on the lower
jaw with the other hand opening the
mouth. Quickly look at the symmetry of
the tongue and then insert your finger
deep into the oropharynx. The normal
response is to feel jaw tone/resistance
to opening the mouth, closure of the
larynx and glottis, contraction of the
oropharynx and then licking/
movement of the tongue afterwards.
Deficits to these nerve functions may
also be apparent in the history from the
owner in particular dysphagia,
regurgitation or a change in bark/voice.
Table 1: Localization of a vestibular lesion
Test Peripheral lesion Central lesion
Mental status
and sensorium
Normal Usually abnormal
Cranial nerves Possible CN VII defcit Any possible (most commonly CN VXII) but
there maybe no other CN defcits
Possible Horners syndrome Horners syndrome rare
Nystagmus spontaneous or
positonal
Nystagmus spontaneous or positonal
Nystagmus usually rotary/
horizontal
Nystagmus may be rotary, horizontal or
vertcal and will ofen change directon when
performing positonal nystagmus test
Strabismus Strabismus
Posture/gait Head tlt Head tlt
Circling Circling
Falling Falling
Postural
reactons
Normal (not hopping) May be abnormal, in partcular paw
placement/tactle placement
Muscle mass Normal Normal
Muscle tone Normal Normal/increased
Spinal refexes Normal Normal/increased
Sensaton Normal Normal
Figure 14: The pathway of the PLR (divergence of
the conscious visual pathway is detailed in grey)
Picture courtesy and copyright of Jacques Penderis
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Postural reactions hands-on
examination
Postural reactions rely on receptors in the
joints, tendons, muscles and inner ear to
collect afferent data and transmit it via
various nerves to the ascending spinal
tracts, which travel to the forebrain via the
brainstem. The cortex then sends efferent
data via various descending spinal tracts
(i.e. the upper motor neuron (UMN)
segment) to the peripheral motor nerve
and skeletal muscles (i.e. the lower motor
neuron (LMN) segment). As a result,
deficits to these tests do not localize to a
specific region and any changes must be
be taken into account with the rest of the
neurological examination to localize a
lesion within a patient.
It is important to try and be as
symmetrical as possible in the way you test
a patients postural reactions so that you
do not make them appear to have deficits
in the face of a normal examination. It is
important for neuroanatomical localization
to decide if all four limbs are affected, just
the hind limbs, one side of the animal or
just one limb. Use this information in
conjunction with your findings on gait and
be aware that orthopaedic injury that could
cause changes to these tests if not
performed appropriately.
Test postural reactions with:
Paw placement
Hopping
Visual and tactile placement
Paw placement
It is important to try and have the
patient bearing the same amount of
weight on all four limbs.
Then support the majority of the
animals weight. This is to improve
sensitivity so that an animal with a
painful limb will still correct the defect.
Turn the dorsal surface of the paw over
on to the ground; it should quickly be
replaced to a normal position
(Figure15).
The animal has to want to turn over the
paw and this is not easy in cats. As a
result it is important to interpret this test
in conjunction with information from the
gait and other postural reactions.
Hopping
For the thoracic limbs, with a light
animal, lift the hind limbs off the floor
and then pick up one of the thoracic
limbs (only slightly flexing the elbow) so
that the animal is bearing weight on
one limb and hop the patient laterally.
As with all the hopping tests you should
see the limb reappear as soon as it
disappears from sight under the
patients body (i.e. as soon as the
centre of gravity has been moved).
Other deficits can be seen with paresis
(where the animal cannot support its
own weight when being hopped) or an
over exaggerated movement.
With heavy animals, do not lift the hind
limbs and brace your supporting
elbow on your thigh to avoid straining
your back.
To test the hopping response in the
pelvic limbs, with light animals, lift the
forelimbs from the floor surface and hop
the patient laterally, as for the forelimbs.
With heavy animals, stand beside the
patient facing its rear end and pick up
the caudal aspect of the stifle, flexing
the knee in the process. Then push the
dog away from you making it hop on
the opposite pelvic limb.
Hemiwalking patients can be very
helpful to exposure subtle lesions. This
is done by lifting the front and hind limb
of a patient on one side and then
pushing laterally.
Animals can be hopped or wheel-
barrowed on the front and then hind
limbs separately when supported. This
can allow subtle proprioceptive deficits
in these limbs to be revealed.
Hopping tests do not require
conscious co-operation and are a
more reliable test of proprioception
than paw placement.
Visual and tactile placement
Visual placement involves allowing the
patient to see, and then bringing them
up to, a table top.
The animal should move its limbs up
on to the table surface before the
edge is touched. This response
obviously involves the visual
anatomical tract (as discussed above)
in addition to the motor cortex and
postural reaction tracts as briefly
outlined in this section.
Tactile placement involves covering the
eyes and performing the same test.
As the animal is brought up to table
and the distal limb makes contact, the
patient should instantly lift the limb on
to the surface of the table.
Spinal reflexes hands-on
examination
The purpose in performing these tests is to
determine whether the reflexes are normal,
or that the LMN or UMN is affected. This, in
conjunction with changes in gait, posture
and postural reactions, allows localization
of lesions to specific areas of the central
nervous system (particularly for spinal cord
lesions) or the neuromuscular system. The
LMN is the efferent neuron connecting the
central nervous system to the effector
organ. The UMN is a neuron originating in
the central nervous system (brain,
brainstem, spinal cord) that synapses with
a LMN (Figure 16). As such, the LMN (or
LMNs) are in the grey matter of the
cervicothoracic intumescence (C6T2) for
the thoracic limbs and within the
lumbosarcal intumesence (L4S3) for the
pelvic limbs.
It is important to assess muscle mass
and tone during this stage of the
examination. In general, UMN limbs will
have normal to increased tone and
reflexes with normal muscle mass. LMN
limbs will have decreased to absent
muscle tone and reflexes with decreased
muscle mass. UMN limbs can lose muscle
mass with a chronic lesion due to mild
disuse atrophy.
Only the reliable spinal reflexes need to
be tested to localize a patients lesion:
Patella reflex
Withdrawal reflex
Perianal reflex/anal tone
Cutaneous trunci reflex
Test muscle tone using the spinal
reflexes by flexing/extending the limb.
This also allows an appreciation of the
Figure 15: Supporting the animals weight turn
the dorsal surface of the paw over to test
placement
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normal movement of the limb for this
animal (particularly where orthopaedic
disease may be a concern), which will
allow you to appreciate if the withdrawal
reflex is complete.
Patella reflex
This is the only reliable tendon reflex.
In dogs >10 years old it may be
absent, but watching gait can assess
femoral nerve function. Similarly, an
abnormal response may be seen with
stifle pathology.
The patient needs to be relaxed and,
ideally, in lateral recumbency. Holding
the stifle loosely in partial flexion, strike
the patellar ligament with a patella
hammer. The normal response should
be extension of the stifle (Figure 17).
A reduction/absence of the reflex
indicates a deficit in the sensory or
motor component of the femoral nerve,
the quadriceps muscle, the NMJ
between the two, or an L4L6 spinal
cord segments/nerve root lesion.
Presence or absence of the reflex is
the most important assessment that
can be made.
An increase in the patella reflex can
be a result of a UMN lesion in this
segment (i.e. cranial to the L4 spinal
cord segment), but other clinical
signs such as hopping deficits in the
hind limbs must be present to
confirm a UMN lesion. An increased
patella reflex in the absence of other
findings is irrelevant and cannot be
interpreted as abnormal. You will
occasionally see an increased
patella reflex in response to a lesion
at the L6S2 spinal cord segments
(or sciatic nerve lesion), given the
counteracting (flexing) muscles will
have less tone and therefore not
oppose the extension of the limb.
It is important to test the dependent leg
too, as you will often get a better
response in this limb.
Withdrawal reflex
This is the most reliable spinal reflex.
The patient needs to be relaxed and,
ideally, in lateral recumbency. Extend
the limb and then squeeze a digit
(usually digit 5) with enough pressure
to elicit the reflex in a normal patient.
Sometimes digital pressure may be
enough or you may need to use
forceps across the bone of a digit.
Assess for three reflexes and
responses: 1. flexion of all joints;
2. a pain response; and 3. look for a
crossed extensor reflex
A normal response is flexion of all
the joints with sufficient force. This
includes the hock/carpus and
digits. A patients range of flexion
will already have been ascertained
by manipulating the limb. In the
hind limb, this response requires
the femoral nerve (L4L6) for
flexion of the hip and the sciatic
How to perform the
basic neurological examination
PART II
Figure 16:
The spinal cord.
(A) Lateral view of the
whole cord showing
UMNs and LMNs.
(B) Cross-section of
the cord showing the
grey matter and spinal
ganglia
Figures drawn by
Allison Wright and
reproduced with her
permission
A

A
lliso
n
2011

A
lliso
n
2011
Sensory input
to brain
UMN
Dorsal horn of
grey matter
Spinal
ganglion
Sensory
fibre
LMN
Motor fibre
Ventral horn of
grey matter
Descending
UMN tracts
Ascending
sensory tracts
B
Figure 17: Striking the patella ligament with the
limb partially flexed tests the patella reflex
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nerve (L6S1/2) for flexion of the
stifle and hock/digits (Figure 18).
Flexion of the joints in the forelimb
is mediated through the median,
ulnar, musculocutaneous and
axillary nerves (C6T2). We do not
normally expect a dog to kick out
or vocalize before completing the
movement as this usually indicates
a deficiency. Presence of this
reflex indicates the above nerves,
relevant muscles, the NMJs
between the two, root and spinal
cord segments all to be intact. It is
different from the ability to feel
pain or a crossed extensor reflex.
Assessing for a conscious pain
response is achieved by applying
force to the digit. You need to
observe turning, trying to bite or
vocalizing to ensure this is present.
Please note, once again, that the
pain response is different from the
withdrawal reflex!
The crossed extensor reflex is
assessed after performing the
withdrawal reflex, when the
uppermost limb is in its fully flexed
position. Take the dependent limb
(which should be extended at this
point) and apply pressure to the
5th digit of this limb. A crossed
extensor reflex is present if the
uppermost limb extends rigidly as
the dependent limb flexes. This
indicates an UMN lesion to the
intumescence where this is being
tested. This is a weak sign if found
in isolation.
Note that if you squeeze digits 1 and 2
in the hindlimb, sensory information
may travel via the femoral nerve rather
than/as well as the sciatic nerve.
Perianal reflex/anal tone
The tail should be moved to assess the
tone of the muscles.
The perianal reflex is assessed by
lightly applying pressure to the anus or
perianal skin. The normal response
should be tail flexion with anal
sphincter contraction (Figure 19).
This reflex relies on the muscles, NMJs,
pudendal nerve (S1S3) and caudal
nerves (and their associated spinal
cord segments) to be intact.
If you are unsure about the presence of
the reflex, you may perform the
bulbo-urethral reflex by squeezing the
bulbo-carvenosus portion of the penis
and looking for tail flexion and anal
sphincter contraction in male animals.
It is important to check anal tone at the
same time. This is best done digitally in
dogs and with forceps in cats. Generally
speaking, you should not be able to
open up 2 fingers within the dog.
Please note with tail pull injuries/
trauma just the sacral nerves/S1S3
spinal segments may be affected. In
this instance is can be useful to
assess bladder size, tone and ease of
expression to help decide if there is a
lesion affecting LMN innervation of
the bladder.
Cutaneous trunci reflex
This test relies on sensory receptor
function from the dermatome of the
skin being pinched, peripheral nerve,
spinal cord C8T1 (where it synapses
with the motor portion provided by the
lateral thoracic nerve), NMJ and
cutaneous trunci muscle.
To test this reflex pinch the skin on the
dorsum, just lateral to the dorsal
spinous processes, with forceps. It is
often better to pluck hairs with cats
(although it can be impossible to elicit
the reflex in this species). Start at the
level of the L5 vertebral body
(approximately level with cranial edge
of the wings of the ileum) and work
forward until found. The normal
response is to see contraction of the
cutaneous trunci muscle (causes a
rippling of the flank).
If the reflex is present at L5 you do not
need to test further dermatomes (unless
looking for a sensory arm deficit).
If absent, it may have no implication
without other clinical signs of disease
localized to that area.
It is particularly helpful in defining
where you may find a T3L3 lesion or
helping define a C8T1 lesion (i.e.
brachial plexus injuries).
Please note that T3L3 lesions do not
all have a cutaneous trunci cut off, but
if found it can support evidence that
the lesion is there.
Finally palpate your patient for pain.
This is usually done by applying dorsal
and transverse pressure to the vertebrae,
and performing lateral and dorsoventral
flexion of the neck. Look for a
physiological or behavioural response that
may indicate pain (i.e. trying to bite,
vocalizing, etc.). Pain is a poor localizer
given the number of anatomical structures
present that could cause pain in any
specific area. For example, in the neck,
subcutaneous or soft tissue injuries, as
well as muscular, bone, joint capsule,
disc, and meningeal injuries, may cause
pain. As such we suggest using pain as a
supportive indicator of a lesion.
Completed neurological
examination
Once you have completed the
neurological examination you should be
able to assimilate the information present
and decide whether the problem is indeed
neurological and, if so, the lesion
localization. Tables 2 to 11 tabulate the
possible changes that may be noted on
examination with each neuroanatomical
localization (not all will be seen in every
patient). Tables 12 and 13 outline the
clinical findings that would be expected
to be found with a LMN and UMN lesion,
and which signs (either LMN or UMN)
will be evident with the differing
neurolocalizations.
Figure 19: Squeeze the skin around the anus to
test the perianal reflex
Figure 18: A normal withdrawal reflex
documents flexion of each joint
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How to perform the
basic neurological examination
PART II
Test Abnormalites Side defcit seen
relatve to lesion
Mental status Altered mental status Either
Sensorium* Altered behaviour
Cranial nerves Blindness Contralateral
Decreased menace response
(with normal PLR)
(Facial paresis)
(Miosis)
Posture/gait Normal gait
Head turn Head turn ipsilateral
Head pressing
Pacing
Circling Circling (usually)
ipsilateral
Postural reactons Normal to decreased Contralateral (but can
afect all four limbs)
Muscle mass Normal
Muscle tone Normal/increased
Spinal refexes Normal/increased
Sensaton Hypoalgesia (weak sign) Contralateral
Other Seizures Hemi-neglect
Contralateral
Hemi-neglect
Dyskinesia (movement
disorder)
Cataplexy (diencephalon)
Table 2: Clinical signs caused by lesions in the forebrain
Test Abnormalites Side defcit seen
relatve to lesion
Mental status Altered mental status Either
Sensorium* Usually severe
Cranial nerves CN III to XII afected
Horners syndrome very rare
Ipsilateral (ofen
bilateral)
Posture/gait Abnormal Gait usually bilateral
(i.e. afects all four
limbs) but possible
ipsilateral
Opisthotonus
Decerebrate
Postural reactons Decreased Usually afects all four
limbs but possibly
ipsilateral
Muscle mass Normal
Muscle tone Normal/increased
Spinal refexes Normal/increased
Sensaton Normal
Other Respiratory and
Cardiac abnormalites
Table 3: Clinical signs caused by lesions in the brainstem
Test Abnormalites Side defcit seen relatve
to lesion
Mental status Normal
Sensorium*
Cranial nerves Menace defcit with
normal vision + normal
facial movement
Ipsilateral (usually)
Possible vestbular signs
(Anisocoria)
Posture/gait Intenton tremor Gait usually bilateral
(i.e. afects all four limbs)
but possible ipsilateral
Hypermetria
Truncal ataxia
Decerebellate possible
Postural reactons Normal
Muscle mass Normal
Muscle tone Normal
Spinal refexes Normal
Sensaton Normal
Other (Increased mituriton)
Table 4: Clinical signs caused by lesions in the cerebellum
Test Abnormalites Side defcit seen relatve
to lesion
Mental status Normal
Sensorium*
Cranial nerves Possible CN VII Ipsilateral cranial nerves
Possible Horners
syndrome
Nystagmus fast phase away
from lesion
Nystagmus Nystagmus usually rotary/
horizontal
Strabismus
Posture/gait Head tlt Ipsilateral
Circling
Falling
Postural reactons Normal (not hopping) Usually afects all four
limbs but possibly
ipsilateral
Muscle mass Normal
Muscle tone Normal
Spinal refexes Normal
Sensaton Normal
Table 5: Clinical signs caused by lesions in the peripheral
vestibular system
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Test Abnormalites Side defcit seen relatve
to lesion
Mental status Abnormal but may be
normal

Sensorium*
Cranial nerves Any possible but maybe
none (usually CN VXII)
Usually ipsilateral (can be
contralateral)
Horners syndrome rare Horizontal, rotary or
vertcal possible
Nystagmus Changing directon
indicatve of central
Strabismus
Posture/gait Abnormal (possible normal) Gait usually bilateral
(i.e. afects all four limbs)
but possible ipsilateral
Postural
reactons
Possible abnormal
(decreased paw placement)
Usually ipsilateral but
possible contralateral
Muscle mass Normal
Muscle tone Normal/increased
Spinal refexes Normal/increased
Sensaton Normal
Table 6: Clinical signs caused by lesions in the central vestibular system
Test Abnormalites Side defcit seen relatve
to lesion
Mental status Normal
Sensorium*
Cranial nerves Possible Horners syndrome Ipsilateral
Posture/gait Abnormal Gait usually bilateral (i.e.
afects all four limbs) but
possibly ipsilateral
Postural
reactons
Decreased Usually afects all four limbs
but possibly just ipsilateral
Muscle mass Normal
Muscle tone Normal/increased
Spinal refexes Normal/increased Afects all 4 limbs
Sensaton Possible spinal pain If loss of pain sensaton =
dead (usually)
Other UMN bladder
Table 7: Clinical signs caused by lesions in the spinal cord (C1C5)
Test Abnormalites Side defcit seen relatve to
lesion
Mental status Normal
Sensorium*
Cranial nerves Possible Horners
syndrome
Ipsilateral
Posture/gait Abnormal Gait usually bilateral (i.e. afects
all four limbs) but possibly
ipsilateral (or monoparesis)
Postural
reactons
Decreased Usually afects all four limbs but
possibly just ipsilateral
Muscle mass Normal HL
Decreased FL
Muscle tone Normal/increased HL
Decreased/absent FL
Spinal refexes Normal/increased HL
Decreased/absent FL
Sensaton Possible spinal pain If loss of pain sensaton = dead
(usually)
Other UMN bladder
Absent cutaneous
trunci refex
Table 8: Clinical signs caused by lesions in the spinal cord (C6T2)
Test Abnormalites Side defcit seen relatve
to lesion
Mental status Normal
Sensorium*
Cranial nerves Normal
Posture/gait Abnormal HL Gait usually bilateral HL
but possibly ipsilateral
Normal FL
SchifSherrington
possible
Postural
reactons
Decreased HL Usually bilateral HL but
possibly ipsilateral
Normal FL
Muscle mass Normal HL
Normal FL
Muscle tone Normal/increased HL
Normal FL
Spinal refexes Normal/increased HL
Normal FL
Sensaton Possible spinal pain
Reduced/absent
cutaneous trunci refex
Hypoalgesia HL
Other UMN bladder
Paraplegic animal has to
be T3L3
Table 9: Clinical signs caused by lesions in the spinal cord (T3L3)
Test Abnormalites Side defcit seen relatve
to lesion
Mental status Normal
Sensorium*
Cranial nerves Normal
Posture/gait Abnormal HL Gait usually bilateral HL
but possibly ipsilateral
Normal FL
Possible tail paresis
Postural
reactons
Reduced/absent HL Usually bilateral HL but
possibly ipsilateral
Normal FL
Muscle mass Decreased HL
Normal FL
Muscle tone Decreased/absent HL
Normal FL
Anal sphincter dilataton
Spinal refexes Decreased/absent HL
Normal FL
Sensaton Hypoalgesia HL/perianal/
tail

Possible spinal/lumbosacral
pain
Other LMN bladder
Table 10: Clinical signs caused by lesions in the spinal cord (L4S3)
KEY TO TABLES: FL = forelimb; HL = hindlimb; * = Sensorium is an
assessment of the patents percepton of its environment
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Test Abnormalites
Mental status Normal
Sensorium
Cranial nerves Any, but CNs VII, IX and X commonly involved in
generalized neuromuscular signs
Posture/gait Flaccid paresis all four limbs OR
Stf or exercise intolerance (myopathy)
Postural reactons May be normal/abnormal in all four limbs
Muscle mass Decreased most commonly but can be increased/
normal
Muscle tone Decreased most commonly but can be increased or
normal
Spinal refexes Decreased/absent most commonly but can be normal
Sensaton Decreased/normal
Can have hyperaethesia of the muscles
Table 11: Clinical signs caused by lesions in the neuromuscular system
Test LMN UMN
Posture Cannot support weight
Plantgrade/palmigrade
Crouched gait
Ofen normal
Knuckling
Abnormal limb positon
Paralysis
SchifSherrington
Gait Short stride
Collapse
Stf
Ataxic
Delayed protracton
Motor Flaccid paresis Spastc
Refexes Decreased/absent Normal/increased
Muscle tone Decreased/absent Normal/increased
Limb fexion Decreased resistance Increased resistance
Muscle
atrophy
Yes severe (startng
~7 days)
Yes late onset with mild
disuse
Table 12: Clinical signs caused by lesions in the LMN and UMN
Lesion Forelimbs Hindlimbs
Brain UMN UMN
Brainstem UMN UMN
C1C5 UMN UMN
C6T2 LMN UMN
T3L3 Normal UMN
L4S3 Normal LMN
Peripheral nerve LMN LMN
Table 13: Clinical signs expected in the LMN and UMN as a result of lesions
in each of the major anatomical areas of the nervous system
Acronym Diseases
D Degeneratve, developmental
A Anomalous
M Metabolic
N Neoplastc, Nutritonal
I Infammatory (including immune-mediated), Infectous,
Idiopathic
T Toxic, Trauma
V Vascular
Table 14: Aetiology of neurological diseases according to the
DAMNITV mnemonic
Clinical signs Diseases
asymmetrical signs
Degeneratve
Neoplastc
Infammatory/Infectous
Acute onset with progressive
symmetrical signs
Metabolic
Nutritonal
Neoplasm
Infammatory/Infectous
Toxic
Acute onset, non-progressive Idiopathic
Trauma
Vascular
Chronically progressive with
symmetrical signs
Degeneratve
Anomalous
Metabolic
Neoplasm
Nutritonal
Infammatory/Infectous
Toxic
Chronically progressive with
asymmetrical signs
Degeneratve
Neoplastc
Infammatory/Infectous
Table 15: Possible aetiology using the DAMNITV mnemonic and
progressiveness and symmetry of clinical signs
How to perform the
basic neurological examination
PART II
Having localized the lesion, your aim is now to form a
differential list and refine this list using diagnostic procedures.
Toform your differential list requires knowledge about the onset,
progression, response to medication and symmetry of the
disease in combination with signalment and localization. In basic
terms, differential diagnoses should be headed under each
category of the mnemonic DAMNITV (Table 14). Within these
differential categories, diseases often have a similar onset,
progression and symmetry of signs (Table 15). This will allow you
to order your differential diagnoses and therefore chose your
diagnostics appropriately.
Figures 10, 11, 14 and 16 reproduced from BSAVA Manual of Canine and Feline Neurology,
4th edition
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PetSavers
welcomes new
co-ordinator
H
aving had experience in
organizing charity events and
having recently graduated in
Events Management from the
University of Plymouth, Emma Sansom,
PetSavers new co-ordinator says, I am
really excited about taking on the role and I
am also looking forward to working
alongside vets and practices to come up
with some wonderful new ways to raise
funds for PetSavers.
In 2012, charitable organizations saw a
20 per cent drop in donations, even though
9.3billion was donated people are still
giving, but there are over 180,000
registered charities within the UK
competing for their altruism.
PetSavers is one many small animal
charities struggling to compete with the
huge publicity campaigns and budgets of
bigger organizations. Yet this doesnt daunt
Emma, she says PetSavers has an
invaluable advantage it has a very strong
relationship with the veterinary profession
which appreciates the invaluable work the
charity does to fund vital research into
companion animal diseases.
Emma also realises that the charity has
another invaluable asset its volunteers;
PetSavers has benefited from the goodwill
of the volunteers on our two committees
since it was founded 40 years ago. We
have a good mix of academics and
practitioners who have given us their
knowledge and insights into the veterinary
profession. Without them our work would
be impossible.
Let us help you to help us
With so many good causes and animal
charities demanding attention, PetSavers
has to work very hard to maintain its
profile within the profession let alone be
recognized by animal lovers. Emma has
plans in this area; We are creating a
great fundraising guide that will help
practices set up an event, which will both
help raise funds for the charity and will
also help share our aims with members of
the public too.
The PetSavers Fundraising Pack is a
step-by-step guide on how to plan and
implement an event, giving useful
information for promoting and maximizing
an events potential. In the past
PetSavers has concentrated mainly on
one annual public fundraising event, The
British London 10k, says Emma. This
We are pleased to announce that Emma
Sansom has been appointed the new
PetSavers co-ordinator, and she brings great
enthusiasm and big plans
has proven to be an important source of
income and for this we are grateful, but
at the same time we need to create a new
portfolio of events and maximize the
power of social media and our contacts
to galvanise participants in all kinds
of events.
The events that Emma is planning
already will be organized and aimed at all
ages and abilities, from sponsored dog
walks to sporting challenges. I have
already secured ten places for the Bath
Half Marathon next March and we are
looking at cycling, triathlons and extreme
sporting events like the Iron Man. Next
year at BSAVA Congress, PetSavers will
be celebrating its 40th Anniversary and
we all know the old saying life begins at
40 so it seems right to launch our new
fundraising pack and events diary at this
special occasion.
PetSavers is keen to hear from any
individual, practice, or organization that
would like to get involved with our new
events or would like to contribute to animal
welfare. For fundraising ideas or
information about supporting PetSavers
email e.sansom@bsava.com or visit
www.petsavers.org.uk. n
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Fundamentals in
diagnostic imaging
T
he first edition of the BSAVA
Manual of Small Animal Diagnostic
Imaging was published in 1989
and introduced a structured
approach to radiographic interpretation
that assisted many practitioners. There
are now three imaging manuals which
cover in great depth thoracic, abdominal
and skeletal diseases, reflecting the
advances in knowledge and techniques
in diagnostic imaging over the past
few decades.
In the new BSAVA Manual of Canine
and Feline Radiography and Radiology we
have attempted to focus on the basic
principles and fundamentals of radiology,
using classic Rntgen (also Roentgen)
signs to present a systematic approach to
radiological interpretation. The physics and
principles of radiography (including digital
radiography) are also covered. In addition,
we have been fortunate in that the
availability of digital radiographs has meant
that we have been able to provide the
images on an accompanying CD. This
allows the reader to view the images in a
more realistic manner and at better quality
than is possible in a print-only book.
Advances in the field
The past 25 years has seen huge changes
in radiographic image acquisition and
processing, and the introduction of new
modalities brought about by the digital
revolution has radically changed the
The BSAVA Manual of Canine and Feline
Radiography and Radiology is the latest addition to
the Foundation Manual series. Editors Andrew
Holloway and Fraser McConnell introduce
companion readers to this new title
landscape of diagnostic imaging. Some of
these advances include:
The technical challenge of producing
diagnostic films by chemical
processing has been replaced by
digital acquisition of radiographic
images by computed radiography (CR)
and direct digital radiography (DDR).
Digital radiographic systems are more
forgiving the increased sensitivity of
the systems has widened the range of
exposures over which diagnostic
studies can be obtained, limiting the
need for repeat imaging. Digital studies
are easily sent over high speed internet
links for interpretation
Abdominal radiographic studies have
been superseded, in some cases
exclusively, by ultrasonography and in
large dogs by computed tomography
(CT)
The limitations of thoracic radiography
have been overcome by cross-
sectional evaluation using rapid, high
resolution CT and endoscopy
Many contrast studies, particularly of
the gastrointestinal tract, have been
replaced by endoscopic examination
Echocardiography has revolutionized
the assessment of cardiac structure
and function
Myelography has been replaced by
magnetic resonance imaging (MRI) as
the technique of choice.
Most of these techniques provide
minimally invasive, specific and accurate
diagnostic information and in many
instances conventional radiographic
studies are not the technique of first choice
or sometimes not even second or third
choice. It is arguable that there is now less
focus on the skill and subtleties of
radiographic diagnosis compared with
previously when conventional radiography
was the only technique at our disposal and
decision-making had to be based on
radiographs alone. As such we are less
practised at radiographic interpretation
and, when faced with challenging or
presumed normal radiographic studies, we
should resist the temptation to recommend
or proceed to advanced imaging
techniques before making the most of the
radiographs already at our disposal.
Nevertheless, radiography remains
relevant in clinical practice. Whether in
general, referral or emergency practice,
radiographs are rapid, repeatable,
inexpensive and can be easily reviewed.
Radiographic interpretation remains a
valuable skill, but one which requires
practice. The discipline and good habits
acquired from developing this skill serve
as an important foundation for all aspects
of diagnostic imaging.
It is reasonable to remind ourselves of
the strengths and weaknesses of
radiographic studies and to reappraise our
approach to radiographic interpretation.
Expectations of the radiographic
study
Radiographic texts tend to imply a degree
of diagnostic certainty that is not replicated
in the clinical setting. Thus, our
expectations of a radiographic study must
be realistic. We must accept that there are
some things that radiographs are very
good at:
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Providing an overview of the thorax and


abdomen
Evaluating areas with high subject
contrast (e.g. thorax and appendicular
skeleton).
However, radiographs may be less
informative when evaluating areas of low
subject contrast (such as the abdomen)
and lack specificity for the underlying
cause as many diseases may result in
similar radiographic changes. The only
realistic conclusion that may be reached in
some cases is that an alternative
technique may be required to reach a
definitive diagnosis.
Limitations of the radiographic
study
The radiological interpretation of many
studies is hindered by technical or patient
factors. The challenges associated with
wet processing and automatic developers
are, fortunately, a thing of the past for
many clinicians. However, digital imaging
is not problem-free and technical factors
associated with image acquisition, data
processing and archiving pose their
own challenges.
Although CD/DR imaging is widely
available, the number and quality of the
display monitors used to view the images
are often not adequate for radiographic
interpretation within a busy practice
setting. The size and number of monitors
may limit the ability to view images in
real-size, compare images side-by-side or
to compare current and previous studies
concurrently. The benefits of digital
imaging, in particular the wide exposure
latitude and ability to manipulate images
electronically, mean that structures with
considerably different attenuation can be
viewed on the same image without the
need for multiple exposures.
Digital radiography is not a panacea
for all radiographic faults and does not
reduce the need for good radiographic
technique. Problems associated with
inadequate patient immobilization,
positioning, incorrect selection of
exposure factors and insufficient inflation
of the lungs are unfortunately still
commonplace. Hence, radiographic
studies should be planned carefully and
the limitations of the study considered
before the images are acquired.
Appraisal of the radiograph
The evaluation of the radiograph should be
systematic and changes should be
assessed to determine whether they
represent:
A feature of normal anatomy
A composite shadow caused by
superimposition
An artefact caused by inaccurate
positioning or poor technique
A pathological lesion.
The specific approach to image
interpretation must be adapted according
to the area being assessed. For example,
in the appendicular skeleton comparison
with the contralateral limb is essential to
allow subtle changes to be recognized
(Figure 1).
Figure 1: (AB) Mediolateral and (CD) craniocaudal views of the right and left elbows of a dog with right forelimb lameness due to a periarticular soft
tissue mass invading the bone. This case emphasizes the importance of comparing the affected limb with the contralateral limb on the same display
monitor. The subtle lysis (white arrows) of the right humeral condyle is more apparent when compared with the same area of the left limb (black
arrows). Note the enlargement of the supratrochlear foramen (dashed white arrows) and the lysis (
*
) of the proximal radius on the craniocaudal view of
the right elbow. Radiographic interpretation cannot substitute for the limitations imposed by inadequate technique: for appendicular studies, the
contralateral limb should be radiographed, orthogonal views should be obtained and the viewing conditions should allow for both limbs to be assessed
and compared alongside one another
A B C D
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Fundamentals in
diagnostic imaging
Radiographic interpretation
Rntgen signs are descriptive features of
the radiographic image used to
characterize changes. They allow the
clinician to develop a consistent approach
to assessing radiographs. Developing a
good, consistent technique will limit the
number of errors. The Rntgen signs used
in radiographic interpretation relate to size,
anatomy (location and number), geometry
(shape and margination) and X-ray
attenuation (opacity). There is a tendancy
to describe lesions only in terms of opacity.
Overreliance on opacity to the exclusion of
the other Rntgen signs will limit the benefit
of the descriptive features.
Size
Changes in size are frequently subjective
and difficult to distinguish from normal.
This is especially true when assessing the
cardiac silhouette, or structures such as
the stomach or bladder which can change
in size quite markedly due to physiological
function alone. The assessment of size is
more reliable when comparing symmetrical
structures (skull, ribs, vertebrae, long
bones) (Figure 2), evaluating the intestinal
diameter for obstruction, or assessing the
significance of changes in the lungs. It is
also important to remember that changes
in size can be due to benign causes (cysts)
and do not necessarily represent
significant disease.
Location
Normal structures are constantly used as
landmarks when evaluating radiographic
changes. This is particularly important
when assessing the significance of
thoracic lesions in order to localize
changes to the thoracic wall, lung or
mediastinum. Within the abdomen,
changes in the location of the viscera are
crucial for localizing the origin of
abdominal masses.
Number
Failure to visualize a structure in a normal
location, such as the bladder or stomach,
is often a key feature in diagnosing
conditions such as herniation or rupture.
However, it is easy to overlook the absence
of normal structures. When assessing the
lungs or skeletal structures (bones and
joints), the number of lesions or structures
affected is crucial when determining the
differential diagnoses (i.e. solitary versus
multiple lung lesions and monostotic
versus polyostotic changes). The
evaluation of the radiograph should not be
suspended as soon as the first lesion is
identified, otherwise additional lesions may
be overlooked.
Margination and contour
Benign changes frequently have smooth
borders, whereas irregular or poorly
circumscribed margins are more
significant, particularly when assessing
bone to characterize changes as
aggressive versus non-aggressive
disease. For some structures, such as the
cardiac silhouette, a change in shape is
often a more reliable indicator of disease
than size. Failure to appreciate the border
of a normal structure, known as border
effacement, is usually a significant finding
indicating a mass, an infiltrate or
abdominal or pleural fluid.
Opacity
Focal masses are usually not difficult to
recognize, but evaluation of opacity is
often most usefully employed to identify
pleural and abdominal effusions,
particularly when associated with
effacement of the margins of structures.
Subtle changes in opacity should be
searched for actively (e.g. gas in the soft
tissues or mineralization in unexpected
locations, using a bright light, magnifying
the image or using a magnifying glass).
Figure 2: (A) Lateral and (B) magnified views of
the thoracic spine of a 7-year-old Staffordshire
Bull Terrier presented with acute onset,
non-ambulatory paraparesis following a fall
during aggressive play with another dog. The
expectation is that MRI is necessary for a
definitive diagnosis, but, as the initiating
incident was traumatic, a vertebral fracture is a
consideration. Thus, although traumatic
intervertebral disc disease is the most likely
differential diagnosis, the expectation of the
radiographic study is to assess for vertebral
fractures and other concurrent traumatic lesions
prior to general anaesthesia. The radiographic
quality of not optimal as the images have been
obtained without a grid (the dog is strapped to a
spinal board to avoid movement of the
potentially unstable spine) and the dog is
panting. Despite this, the T10 vertebral body
(solid double-headed arrow) can be seen to be
reduced in length (due to a compression
fracture) compared with the adjacent normal
vertebra (dashed double-headed arrow).
Therefore, in this case, the Rntgen sign of
reduced size/length is the most important
feature. Speculation about the opacity of the
bone is possible (the dog had multiple myeloma,
hence the compression fracture recognized is a
pathological fracture), but is a less reliable
Rntgen sign than length in this case
A
B
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Errors in radiographic
interpretation
An understanding and appraisal of the
errors that lead to mistakes in radiographic
interpretation is often helpful.
Under-reading
Failure to identify a lesion can be due to:
Lack of a systematic approach
Failure to assess all parts of the
radiograph
Suspending the search of the
radiograph as soon as the first lesion is
identified, leading to other related
(metastatic) or more important lesions
being missed or overlooked.
Over-reading
Over-reading films and faulty reasoning of
radiographic changes are normally closely
associated:
Mistaking artefacts for pathology
Classifying incidental findings as
significant abnormalities
Failure to correlate radiographic
changes with clinical signs
Misinterpreting normal anatomy for
pathology.
Differential diagnosis
Many diseases have a similar appearance
on radiographs and it may not be possible
to reach a specific diagnosis. The
purpose of a differential diagnosis list is to
summarize the possible causes based on
radiographic findings and allow further
investigations and/or therapy to be
considered. All Rntgen signs should be
assessed, but not infrequently a single
Rntgen sign provides the information
critical for a considered list of differential
diagnoses (Figure 3).
Conclusion
Radiography may be less appealing and
attractive than the other modalities that
currently dominate diagnostic imaging, but
dedicating time to, and effort in, acquiring
good habits when evaluating radiographs
will result in the valuable rewards of
technical consistency and professional
confidence.
Figure 3: (A) Right lateral, (B) dorsoventral (DV) and (CD) magnified
thoracic views of an elderly Lurcher presented for episodes of
vestibular disease. MRI of the brain was unremarkable. A
radiographic study of the thorax and abdomen was performed to
evaluate for concurrent disease, which could account for the
vestibular signs. A nodular mass is clearly evident on the lateral
radiographs cranial to the cardiac silhouette. The DV view should be
used to localize the change to the chest wall, the lung or the cranial
mediastinum. The mass is not visible on the DV view, thus a
reasonable assumption is that the mass lies within the cranial
mediastinum. However, more careful scrutiny reveals that, although
it is primarily of soft tissue opacity, there are several small gas
pockets within the mass (white arrows), suggesting that it is in fact a
pulmonary mass lesion. This is reinforced by the slightly uneven
margin, which would be unusual for a discrete mediastinal mass, and
its location immediately cranial to the cardiac silhouette, which is
also unusual as most mediastinal masses arise further cranially
(although large masses can efface with the cardiac silhouette). On
re-evaluation of the DV view, it is perhaps easier to recognize that the
mass may lie just to the right of the midline (black arrows) by
applying our knowledge of anatomy the right cranial lung lobe
extends across the midline, displacing the cranioventral mediastinum
to the left. Thus, lesions within the most medial part of the right
cranial lung lobe may be superimposed on the spine of the DV or
ventrodorsal view. This case demonstrates the importance of
applying all Rntgen signs, integrating radiographic interpretation
and correlating the changes to clinical signs
A B
C D
AVAILABLE FROM
BSAVA
The BSAVA Manual of
Canine and Feline
Radiography
and Radiology: A
Foundaton Manual
is available later this
month.
Visit www.bsava.com/
publicatons to register
your interest or
purchase your copy.
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Welcome to the future
its just arrived
C
arole Haile, BSAVAs Customer
Support Manager, has been
listening to our members for over
a decade. She has been pivotal
in the decision to implement the new
membership system and ensuring it
matches the requirements of the
membership both now and in the future;
At the end of 2012 BSAVA took the
decision to replace its existing customer
relationship management tool and we
chose Silverbear, as this best met our
business requirements.
Silverbear will provide an improved
and efficient service, working in harmony
with the new website, ultimately making it
quick and easy for members and
volunteers to update their details online.
Also, with Silverbear we will have capacity
to grow as our business processes change
and develop, so not only does it completely
satisfy our current requirements, but it also
has the capacity to grow to meet future
business needs.
IT that works for you
The BSAVA IT team, who have managed
both these technical projects, have
ensured that the business requirements of
the two new systems have been met, whilst
also making sure members see the benefit
at the front end of the website.
Emma Hayes, IT Manager, comments
on the work done by her team; Feedback
from our members highlighted the
limitations they were experiencing with the
existing website in terms of speed and
explains, With these new systems we
are able to offer a wealth of new features
and functionality to our members, but it
will not stop there as we will continue to
enhance and expand our online offering
once the website has been launched
watch this space!
So with all these changes happening
at once, what does the IT department
consider to be the main benefits that
members should look out for when
visiting the new website for the first time?
Ryan Hallett, Web Developer, says,
The website will look completely
different, be far quicker and simpler to
use. Content will also be completely
overhauled with a cleaner layout and
more accessible information.
This cleaner layout and the concise
information on the new website is down to
the work of the BSAVA marketing
department, who have reduced the
number of overall pages on the new site.
Alison Ferry, Marketing Manager,
With the launch of the new BSAVA website and
membership system both taking place this month,
key staff at BSAVA HQ whove been involved in the
developments explain how they will benefit members
navigation, and that it was not providing
the additional levels of functionality they
required. So we decided to replace our
existing membership system and upgrade
the website at the same time. We worked
to a brief that not only should we provide
a range of new features and functionality
for members, but also that the new
website should have fresh design,
intuitive navigation and enhanced
search capabilities.
As with the Customer Relationship
Membership (CRM) system, Silverbear,
the new website has been developed
with future growth in mind, as Emma
The BSAVA IT Department. (LR) Ryan Hallett, IT Manager Emma Hayes, and Chris Bird
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KEY BENEFITS OF YOUR
NEW BSAVA WEBSITE
myBSAVA
The enhanced myBSAVA functon is a key
tool for users of the website. This will
allow you to quickly access and update
your own account informaton, view
your purchase and payment history, view
your CPD learning record, renew your
membership, access the Knowledge Vault,
book an event and buy manuals.
The Knowledge Vault
This is a new secton that will be available
to members within myBSAVA and will be
a central gateway to provide quick access
to downloadable content such as forms,
documents, MP3s and videos.
Improved member benefts secton
Not sure if you are taking advantage of
all your BSAVA membership benefts, or
want to know more? Why not visit the
improved member benefts secton to
make sure you dont miss out.
Job opportunites
This secton of the site gives you access
to veterinary profession jobs across the
UK. Members can also post vacancies
at their own practce free of charge.
Nonmembers can register on the new
website to view vacancies and can
advertse by paying a fee.
Blog
Our resident BSAVA Policy Ofcer Sally
Everit will launch our new online blog
look out for surprise guest bloggers
planned for the future.
Interactve news
You can now post comments and share
your views with other members on the
new interactve news secton.
Social media feeds
Follow BSAVA posts via our Twiter and
Facebook feeds live on the homepage.
comments, One of the major issues we
had with the old BSAVA website was the
volume of information, some of which was
repeated in several locations. Weve
streamlined the navigation and reduced
content on each page, improving the
speed by which members can find the
information they need, and weve tried to
anticipate some of the most common
questions they might have in new
frequently asked questions sections.
Your website
What about myBSAVA, how will this feel
different for members on the new website?
Ryan explains, myBSAVA will be a key tool
and members will discover an enhanced
functionality. For example, not only does it
allow quick access to their own account
information, where they can view their
payment history and renew their
membership, but it will also remember
preferences and recommend products or
services just like youd experience on the
Amazon website.
Emma continues, myBSAVA will also
give members access to the new
Knowledge Vault which will operate as the
gateway to search for and download
resources such as member publications,
information and policy documents, and
MP3s. These can be accessed in one area
rather than having to search individual
sections of the website.
What other new features will members
find when logging on to the website? For
the first time, the BSAVA website will feature
job opportunities. This will give members
access to veterinary profession jobs across
the UK and members will also be able to
upload their own vacancies free of charge.
Jobs and blogs
President Michael Day, who has been
involved in developing this aspect of the
site, comments, An online jobs board is
something our members have requested
for some time. The Silverbear system now
allows us to launch this exciting new
member benefit. Practice vacancies will
now be accessible by over 8,800 BSAVA
vet, nurse and student members
ensuring that your advertisement has wide
exposure throughout the profession.
There will also be a new blog page,
with the first post by BSAVA policy officer,
Sally Everitt. It is planned to invite other
bloggers to post over the coming months.
Also, members will notice an improved
interactive news page where you can
post views and share comments with
other members.
Getting access
So are there any other changes
members need to be aware of? Emma
Hayes says, Yes, members will be sent
an email in early October (to their current
registered email address) asking them to
pre-register with the new website by
clicking on the link contained in the
email. Once registered, members will be
able to login and access myBSAVA and
be able to access their account
information, view their BSAVA member
benefits, and purchase products from
the BSAVA Store.
And finally, we asked BSAVA General
Manager, Stephen Torrington, for his
thoughts on the launch, he says, The
team at BSAVA have done a terrific job in
ensuring that the two new systems improve
and enhance services to members. It has
been a challenging but worthwhile project,
and Im confident that once members
log on to and start using the new website
they will start to reap the benefits straight
away. However, the member developments
dont stop there; weve already started
work on enhancements to our online
publications, so watch this space for
further information.
The new BSAVA website
goes live late October
look out for your
membership email.
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Congress 36 APRIL 2014
Professor
Alice Roberts
at Congress
T
he BSAVA Lecture at Congress is renowned
for featuring prestigious and engaging
speakers who give their audience something
to think about. Having welcomed Lord
Robert Winston, Simon King, Monty Halls and
Richard Dawkins in recent years, 2014 looks set to
continue this tradition as BSAVA welcomes Professor
Alice Roberts to deliver the keynote Lecture at
2014 Congress.
Alice Roberts is Professor of Public Engagement
in Science at the University of Birmingham, helping to
promote the Universitys academics and their
research to the general public, and inspiring people
about science. She studied medicine and anatomy at
Cardiff University, qualifying in 1997, and went on to
work as a junior doctor in South Wales before
becoming a lecturer at Bristol University where she
taught anatomy on the medical course for over ten
years. Professor Roberts developed a research
interest in biological and physical anthropology,
looking at what ancient skeletons can tell us about
human evolution and the diversity of the human
species. She has a PhD in Palaeopathology.
Author and broadcaster
Alongside her academic work, Professor Roberts has
written four popular science books and writes a
regular science column for The Observer. Two of her
books were written to accompany the television series
Dont Die Young (an introduction to human anatomy
and physiology) and The Incredible Human Journey
(about the ancient colonization of the world), while
themes of anatomy and human evolution are further
explored in two illustrated volumes, The Complete
Human Body and Evolution: the Human Story.
Her television debut came as a human bone
specialist on Channel 4s Time Team in 2001. Part of
the original team of presenters on BBC2s Coast, she
went on to present a range of other programmes on
BBC2, including Dont Die Young, The Incredible
Human Journey, Wild Swimming, Digging for Britain
(stating during this programme that We might be a
small island but weve got a big history. Everywhere
you stand, there are worlds beneath your feet),
Horizon (Are we still evolving?), Origins of Us, Woolly
Mammoth and Prehistoric Autopsy. She is also a
regular presenter on Radio 4s environment
programme, Costing The Earth.
Professor Roberts talk will take place on the
Thursday at 4pm in Hall 1 of the ICC. This event is free
to all with a Congress registration simply show your
badge to gain admission. The Exhibition will remain
open during this talk. n
ALICE SAYS
Science is so important to our economy, to politcs and
educaton, but perhaps more than anything, Im keen to
promote science as an integral part of our culture.
Trying to decide if two populatons really are diferent
enough from each other to be labelled as separate species
is more difcult than it seems.
As a doctor and an anatomist, its my job to know where
the organs are and how they work. But I also want to
know how our organs cope with the challenges of life and
what we can do to look afer them.
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Congress 36 APRIL 2014
Controversy lectures
These Advanced level lectures are
designed to challenge and inspire chaired
by a leader in the field who will provide a
brief overview of the topic and then pose
questions to two other key experts. The
subjects cover controversies in
endocrinology and orthopaedics and
include the best international speakers.
John Bonagura
BSAVA are very proud to be welcoming
probably the most well-known veterinary
cardiologist in the world with a huge wealth
of clinical and teaching experience and one
of the finest CPD lecturers. John Bonagura
is a previous winner of the Bourgelat Award,
author of numerous scientific papers, and
editor of Current Veterinary Therapy.
Medicine on a budget
So you know what you want to do and what
you should be doing, but what happens
when you cant do it because the owner
thinks it costs too much? Budgets and
finances are more relevant than ever these
REGISTRATION
Registraton will open on 21 October with a
new and improved online registraton system
at www.bsava.com.
The full Programme will be in your
November issue of companion and is
available online.
Clinical Research
Abstracts
Clinical research is a valued and
integral part of Congress and
presentations will run concurrently with
the main scientific programme. We are
inviting the submission of abstracts
(oral or poster) concerning current
clinical research and management
and nursing practice for presentation
at BSAVA Congress. Prizes will be
awarded in five categories and details
for these are available on the BSAVA
website. Submit your abstract online
from 15 October 7 November 2013.
Further information is available
from www.bsava.com/cra. n
days and everyone is tightening their belts,
including pet owners, so make sure you
come to the Medicine on a Budget stream
to see how the experts handle this situation.
Am I up to date?
Need a quick update to make sure you are
up to date? Then I would recommend the
What has changed in the treatment of...
stream. Topics include heart disease and
heart failure, seizures, spinal disease, liver
disease, IBD and renal failure.
Neurology without an MRI
Is neurology only for those with fancy MRI
equipment? Not so come along to
Neurology without an MRI to hear how to
confidently diagnose these cases without
using a big machine. Speakers include
Alberta de Stefani and Jacques Penderis.
Interactive case based medicine
This is a welcome return for this popular
stream, with talks on Feline pancreatitis by
Vanessa Barrs and Calcium disorders by
Richard Mellanby. n
Anaesthesia) to talk to us about how they
do things in America and to see the
differences and similarities between us.
Nursing wildlife
For the first time since 2011 there will be
a stream dedicated to nursing wildlife
and we are sure this will be a highly
entertaining stream with Simon Cowell
and Lucy Kells providing a double-act!
Using your qualification to
perform minor surgeries
With Schedule 3 reform for VNs hot
on the agenda, Paul Aldridge will be
reminding us of the ways that VNs
can use their qualifications to perform
minor surgeries. n
Nursing
Highlights
Samantha Fontaine and
Louise ODwyer from the
Congress Scientific
Programme Committee
give us their Nursing
highlights for 2014
Controversial topics
Marge Chandler and Steve Dean will be
tackling topics such as The raw meaty
bones diet and Fit for function
responsible dog breeding.
The nurses role today
In order to highlight the evolving role of todays
vet nurse, we will be running a bite-size
stream where VNs will discuss the different
ways that they have used their qualification.
How do nurses do things on the
other side of the Atlantic?
We are delighted to announce that we will
have two very engaging speakers from the
US in Liz Hughston (VT ECC & Internal
Medicine) and Susan Burns (VT
Tips from the top
Professor Ian Ramsey, Congress
Scientific Programme Chairman, gives
us some of his own subject and
speaker highlights on offer in 2014
3031 Congress Alice Roberts.indd 31 20/09/2013 10:59
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T
he WSAVA Vaccination Guidelines Group
(VGG) has completed the final of three visits to
Asian countries. With its fact-finding activities
now complete, it will distil the information
obtained during this and earlier visits to Japan and
India before producing advice and recommendations
for Asian small animal practitioners. It aims to publish
this information in early 2014.
The VGG began its visit in Beijing, where it met with
veterinary practitioners, academics and government
officials and visited three veterinary practices in the
city. A one-day continuing education programme was
attended by 100 veterinarians. In Shanghai, the VGG
held further meetings with practitioners, academics
and representatives of industry and visited three further
veterinary practices. Eighty veterinarians attended the
continuing education event in Shanghai. It then moved
to Bangkok where a round of similar meetings was
held, followed by a third continuing education event
attended by 80 veterinarians.
In each city, a questionnaire was circulated by the
VGG to provide further information on the local
situation. 150 responses to the survey were received in
China while 267 responded in Thailand.
Professor Michael Day, Chairman of the VGG,
said: This two-year project in Asia has been
enormously successful and we now have a much
greater understanding of the particular challenges
faced by Asian practitioners. During our visits we have
provided continuing education to over 800
veterinarians, spoken with dozens of local opinion
leaders and obtained survey data from almost 800
first opinion practitioners. Our visits to a wide
spectrum of veterinary practices have been
particularly informative, enabling us to see at first hand
the challenges faced by our Asian colleagues. n
Final visit of WSAVA
Vaccination Guidelines
Group to Asia
The VGG has completed the
last of three visits to Asian
countries as part of its project
to examine small animal
infectious disease and
vaccination practice
Members of the VGG
at the Bangkok
Continuing Education
Event. Left to right:
Professor Richard
Squires (James Cook
University, Australia),
Professor Michael Day
(Chairman; University
of Bristol, UK) and
Professor Hajime
Tsujimoto (Tokyo
University, Japan)
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33
Update from
the President
WSAVA President Jolle
Kirpensteijn on our global
veterinary community
A great WSAVA veterinarian
A look back at the
contribution of John
Holt to the WSAVA
and beyond
D
r John Holt, a pioneering
veterinarian from Australia and
former president of the WSAVA,
died peacefully on 24 June aged
82, leaving behind his devoted wife Mary.
John built a group of six practices in
Sydney during the 1960s, setting new
standards at a time when most practices
were small and poorly equipped.
Later, believing that Australian small
animal practitioners needed an
organization to better represent their
interests, he and a group of like-minded
practitioners established the group that
became the Australian Small Animal
Veterinary Association. He also funded
and edited the Australian Veterinary
Practitioner publication until it could stand
on its own feet.
In 1986 John became President of
WSAVA, so far the only Australian to have
held that position. He was an inaugural
member of the WSAVA Foundation Board
of Directors.
Among the awards he received are the
inaugural ASAVA Practitioner of the Year
Award in 1973, the WSAVA Award for
Service to the Profession in 1998 and a
special award for Meritorious Service to the
ASAVA which was presented at the 2007
WSAVA Congress in Sydney. In 2007, the
annual ASAVA Distinguished Service
Award was renamed to honour and
acknowledge Johns contribution to the
ASAVA and is now the John Holt
Distinguished Service Award.
At a personal level, John represented
Australia in the shooting team at the 1960
Rome Olympics and competed as an
elite level rifle shooter for many years.
He was always ready to back his
beliefs with action and financial support
and was a lifelong conservationist and
animal rights supporter. In his later years
he became very passionate in his
support of the campaign against live
animal export. John always held strong
views and was prepared to work for what
he felt was right.
Few people have changed the lives of
others and, in particular, our profession in
the way John did, although he would
never have thought about it in that way.
He was a shy and modest man who
avoided the limelight and was
uncomfortable when his achievements
were recognized. He will be sadly missed
and hopefully never forgotten. n
I
recently attended seven events on behalf of the
WSAVA in six countries. The common thread is
our passion for enhancing veterinary care and it is
only by working together at an international level
and sharing our resources that we have the
opportunity to achieve this at a truly global level. We
are one global veterinary community that is serious
about finding solutions for companion animal
problems all over the world.
A good, practical example is the Mission Rabies
project that the WSAVA Foundation is supporting. Its
team of volunteers is doing pioneering work in India
and aims to vaccinate 50,000 street dogs against
rabies in the country during September a step which
will, of course, benefit the human population as well as
the dogs. You can find out more about its work and
how you can help at www.missionrabies.com.
Speaking of pioneering work, it was with great
sadness that I learned of the passing of a truly great
veterinarian and WSAVA advocate, Dr John Holt. When
I first joined the WSAVA, I was at an Assembly meeting
when someone said: There is John Holt. He is a very
special person. As he entered the room, he was
greeted with respect by everyone and emanated a
friendly, caring aura. I was lucky enough in later years
to meet John and his wife Mary many times. He gave
me a great deal of wise advice and became a great
friend. I will miss him very much.
I would like to thank him personally for helping me
to see that we are all part of a global veterinary
community and I would like to thank him on behalf of
all of us for being such a passionate supporter of the
work of the WSAVA. n
Jolle
Left to right, Ben Albabas, former WSAVA
representative from Greece, John Holt, Brian
Romberg, Honorary Treasurer of WSAVA
Foundation
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Mo Gannon was born in Sheffield. She went to Notre
Dame High School and then studied at Sutton
Bonnington, graduating in 1991 with a degree in
Animal Science. She did a PhD at Nottingham
looking at the energy balance of pigs outdoors and
then worked in the veterinary industry at Willow
Francis (which became Fort Dodge) and Boehringer,
before finding her dream role as an agricultural and
veterinary market researcher. She is now Director at
Mo Gannon & Associates and has been
commissioned to work on BSAVAs research project
to help identify the needs of members in the coming
years. Mo is a violinist in a symphony orchestra and
counts her greatest non-career achievement as
Dragon Boating for Great Britain.
the companion interview
Mo Gannon
You are now working with BSAVA on its
latest research tell us about the
process and why members participation
will be valuable.
In the past, people belonged to
organizations so that they could meet other
people with a common interest, make
contacts, share information and learn from
each other. These associations helped
their members achieve this by holding
conferences, producing publications for
the profession and creating networking
opportunities. With the advent of social
media and advanced internet technologies
coupled with more difficult economic
times, membership organizations need to
ensure they are continuing to deliver value
to their membership in order to retain and
build loyalty. As a forward-thinking
organization, BSAVA not only wishes to
retain its membership going forward but
also aims to offer more value to more of the
profession.
BSAVA has commissioned us to work
with them to help uncover what members
value about the current offering and what
could be offered in the future that would
add value. This might be in terms of new
products and services or how current
products and services are made available.
The programme will start with qualitative
research to ask the members and
Q
Tell us how your career got you to
where you are now.
A
When I finally left academia, Phil
Sketchley (current Chief Executive
at NOAH) gave me my first
permanent job as a territory manager for
Willows Francis which then became Fort
Dodge Animal Health. Phil has always
been very supportive and helpful
throughout my career and I remain most
grateful. After sales, I moved to product
marketing at Boehringer where I got to
commission and use market research and
saw the value of what it could do. I
persuaded the company who Id
commissioned to take me on in what was
clearly the perfect role for me.
Two years ago, I took the exciting step
of setting up Mo Gannon & Associates as
sole director. MG&A provides market
consultancy within agriculture and animal
health. I was very fortunate to keep with me
the core team with whom I had worked for
the previous 10 years people who I
respect a great deal for their work and
even more as people. I am very lucky to be
able to say I genuinely love my job and the
people with whom I work.
What has been your involvement with
BSAVA?
Ive been a Congress attendee for the past
15 years, and an exhibitor for some of
those years. I wouldnt miss it for the world.
It is a great opportunity to catch up with
many people in the industry and also
network with a few new ones.
34-35 Interview October.indd 34 20/09/2013 11:03
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35
would-be members broad-reaching
questions about BSAVAs current
economic, functional and emotional
offering and about what BSAVA could offer
in the future. This will then be followed up
by larger scale quantitative research with a
wider audience so we ensure that the
initiatives of most value to the profession
are developed. The research, both
qualitative and quantitative, will be carried
out in the latter half of this year. If you are
contacted to take part in the research, we
would ask you to take part and make a
difference in building your Association.
What, in your opinion, are the key
challenges that face the veterinary
profession today?
There are a few old challenges that the
profession faces regularly:
The importance of a professional and
welcoming receptionist with a want-to-
help attitude. I have met some
shockers in my day!
The importance of vets charging for
their expertise rather than putting
higher mark-ups on medicines. This
will be a slow migration but is
becoming increasingly more
important as internet shopping in
general and internet pharmacies in
particular take hold. Although
undoubtedly the first port of call in an
emergency, we need to continue to
develop the practice as the first port
of call for any pet health enquiry.
This then leads on to offering
transparent pricing and discussing
options with associated costs up front
to avoid owner surprises and avoid
generating a fear of coming in to the
practice to get general advice;
preferring to go to the pet shop or
Googling it.
Be seen to add value boosters seem
like an expense for no visible benefit.
In times of hardship, it would be very
easy for owners to cut back on routine
healthcare, especially for older pets.
Explaining what is being checked
during the booster vaccination
appointment as it is being done e.g.
ears, heart, weight etc is important to
help owners understand the value of
the service. It never ceases to amaze
me, when researching life-long pet
owners, that despite the millions spent
on education by various vet pharma
companies, how very little they know
about the basics of fleas, worms, what
the vaccinations cover and why they
remain important, not to mention the
importance of diet and being a
healthy weight.
And there are a few newer challenges:
The challenge for smaller practices to
complete with the 5+ man practices
and corporates in terms of providing
24/7 care within the working time
regulation and provision of equipment
and services of a comparable standard
to the larger practices.
With the relaxing of the pet travel
scheme rules, how do we keep the non
endemic diseases (some of which are
zoonotic) out of the UK? How do we
train the profession to ask the right
questions before and after travel and
how do we diagnose these non
endemic diseases which may remain
dormant for many months after travel,
especially when the pet (or rescue
animal) presents as apparently healthy
on landing? How do we get the
message across to the pet owning
public about the importance of these
diseases to man and pets?
Formal market research is not within
easy reach of all veterinary practices
but what would you say practices can do
for themselves?
It is easy for us all to assume that we
know what people want especially in an
area that we know well. This, however,
can be a costly mistake to make as the
first time we realise there is a problem, it
has already cost us emotionally and
financially. The old adage that it is
cheaper to retain customers than attract
new ones is certainly true, as is the
adage that a happy customer will tell one
person and an unhappy customer will tell
seven! Ideally, all practices should
conduct a customer satisfaction survey
amongst its clients periodically.
This would:
Confirm or challenge commonly held
views in the practice.
Highlight any awareness issues e.g.
most owners may not be aware of
certain facilities or specialisms offered
by the practice. Simply promoting
these areas could build loyalty by
confirming a good buying decision to
use the practice and gain new clients
through word of mouth (we know pet
owners come from a family of pet
owners and discuss their pets whilst
walking the dog).
Ensure that your clients feel they are
getting a professional and caring
service from stepping through the door
to going home and throughout the life
stages of their pet from kitten / puppy
until the inevitable loss.
Identify what clients want more of, or
want less of. For example, the
importance of always seeing the same
vet, separate waiting rooms (or
appointment slots) for cats and dogs,
highlighting any areas that could be
introduced such as a practice open
day, any specific nurse clinics for
puppies and kittens, obesity, senior
pets, fleas and worms etc.
Identify what makes / could make your
clients feel valued.
The only way to be certain a practice
can answer these questions is to ask the
users of a product or service your clients.
You may be surprised by what they tell you
and even more surprised to find out
ultimately how it affects your bottom line.
You may also find that some veterinary
pharmaceutical companies may sponsor
this service. It may be worth asking your
territory manager.
I am very lucky to be able to say
I genuinely love my job and the
people with whom I work
For more information or to order
www.bsava.com
BSAVA reserves the right to alter prices where necessary without prior notice.
Got this on
your shelf?
BSAVA Manual of Small Animal
Practice Management
and Development
A daily reference for veterinary surgeons, managers and the
whole practice team to aid with the organization and delivery
of clinical veterinary care in companion animal practice.
WHAT THEY SAY
this book is for everyone everyone with an interest in
improving clinical standards a must-have management
reference with a tremendous amount of informaton
EUROPEAN JOURNAL OF COMPANION ANIMAL PRACTICE
Got this in your
practice library?
BSAVA Manual of Canine and Feline
Reproduction and
Neonatology
2nd edition
This Manual provides a practical approach and covers:
The reproductive cycle
Infertility
Pregnancy and parturition
Neonatology
WHAT THEY SAY
...an indispensable tool...
VETERINARY RECORD
BSAVA Publications
COMMUNICATING VETERINARY KNOWLEDGE
BSAVA Member Price: 55.00
Price to non-members: 85.00
BSAVA Member Price: 45.00
Price to non-members: 75.00
e-BOOK ALSO AVAILABLE
TO MEMBERS: 25.00
companion offerof the month
Exclusive offer for companion readers
call BSAVA on 01452 726700 and
quote companion offer Wounds
20% discount off member price
BSAVA Manual of
Canine and Feline
Wound Management and
Reconstruction
2nd edition
WHAT THEY SAY
I have no hesitaton in recommending this manual
JOURNAL OF FELINE MEDICINE AND SURGERY
Offer is available to BSAVA Members only.
Ends 31 October 2013. Free P&P on
telephone orders for UK and Eire delivery;
online rates of P&P apply for overseas
orders.
companion offer:49.0039.20
Price to non-members: 75.00
e-BOOK ALSO AVAILABLE
TO MEMBERS: 29.00
Last chance
to buy
BSAVA Manual of
Rabbit Medicine
and Surgery
2nd edition
This popular Manual reflects the increased
understanding of rabbit health and disease.
New titles
BSAVA Manual of
Rabbit Surgery,
Dentistry and Imaging
Available from mid-October 2013.
BSAVA Manual of
Rabbit Medicine
Due Spring 2014.
BSAVA Member Price:
49.0035.00
Price to non-members:75.00 75.0055.00 55.00
S
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f
f
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37
Letters from the Letters Letters Regions
Small furries problems solved
Charlotte Clough, Southern Region
PS
A practical approach to skin disease
and otitis
Krista Arnold, Southern Region
PS
Whats your gut feeling
about gastroenterology?
For more information on all
regional meetings visit
www.bsava.com or email
administration@bsava.com
Find out more
38
|
companion
CPD diary
EVENING MEETING
WEST MIDLANDS REGION
Thursday 3 October
Feline medicine: the evidence base
Speaker: Rachel Dean
The Barn Beefeater and Premier Inn,
Stratford Road, Hockley Heath, Solihull,
West Midlands B94 6NX
Details from westmidlands.region@bsava.com
DAY MEETING
Thursday 10 October
Ascitic Alsations, bradycardic
Boxers, coughing Cavaliers and
panting Pugs: everything you need
to know about canine cardiology
Speaker: Nuala Summerfield
BSAVA Headquarters
Details from administration@bsava.com
DAY MEETING
Friday 11 October
Haematological disorders in dogs:
from pallor to pred
Speaker: Polly Frowde
BSAVA Headquarters
Details from administration@bsava.com
DAY MEETING
Saturday 12 October
Canine case-based liver and
pancreatic disease
Speaker: Jon Wray
BSAVA Headquarters
Details from administration@bsava.com
DAY MEETING
Wednesday 23 October
Behaviour
Speakers: Sophie Oestreich
Holiday Inn, Taunton
Details from administration@bsava.com
EVENING MEETING
SOUTH WEST REGION
Wednesday 16 October
Managing diabetes mellitus
Speaker: Grant Petrie
Kingsley Village, Fraddon, Cornwall
Details from southwest.region@bsava.com
DAY MEETING
SOUTH WEST REGION
Tuesday 15 October
Feline geriatric medicine
Speakers: Angie Hibbert and
Joanna Murrell
Westpoint Arena, Exeter EX15 1DJ
Details From southwest.region@bsava.com
DAY MEETING
Thursday 31 October
Chemotherapy in practice:
a life-changing experience
Speaker: Iain Grant
Yew Tree Lodge Best Western Hotel,
33 Packington Hill, Kegworth,
Derby DE74 2DF
Details from administration@bsava.com
EVENING MEETING
SOUTH WEST REGION
Thursday 31 October
The responsible use of
antibicrobials in practice
Speaker: Jill Maddison
Langford Vet School
Details from southwest.region@bsava.com
EVENING MEETING
EAST MIDLANDS REGION
Tuesday 15 October
Diagnosing and managing
fish/reptile diseases in practice
Speaker: Peter Scott
Yew Tree Lodge Best Western Hotel,
33 Packington Hill, Kegworth,
Derby DE74 2DF
Details from eastmidlands.region@bsava.com
EVENING MEETING
WEST MIDLANDS REGION
Tuesday 5 November
Dermatology of small animals
Speaker: Sue Paterson
Yew Tree Lodge Best Western Hotel,
Wolverhampton Medical Institute, New Cross
Hospital, Wolverhampton, WV10 0QP
Details from westmidlands.region@bsava.com
LUNCHTIME WEBINAR
Wednesday 9 October
13:0014:00
Dealing with nasal tumours
Speaker: Jackie Demetriou
Online
Details from administration@bsava.com
October 2013
LINKED WEBINAR
Tuesday 22 October
20:0021:00
Canine haematological disorders
Speaker: Polly Frowde
Online
Details from administration@bsava.com
EVENING WEBINAR
Tuesday 15 October
20:0021:00
Wound healing
Speaker: Laura Owen
Online
Details from administration@bsava.com
LUNCHTIME WEBINAR
Wednesday 16 October
13:0014:00
Hospitalizing small mammals
Speaker: Frances Harcourt Brown
Online
Details from administration@bsava.com
LINKED WEBINAR
Monday 21 October
20:0021:00
Canine cardiology
Speaker: Nuala Summerfield
Online
Details from administration@bsava.com
LINKED WEBINAR
Wednesday 23 October
20:0021:00
Canine liver and pancreatic
disease
Speaker: Nuala Summerfield
Online
Details from administration@bsava.com
Register at www.bsava.com
or call 01452 726700
Speakers: Diane Addie, Sarah Caney,
GerryPolton and Elise Robertson
Bridgewood Manor Hotel,
Kent ME5 9AX
Feline medicine
weekend in Kent
Saturday 12 October
Sunday 13 October
FECAVA EUROCONGRESS
25 October
Dublin, Ireland
Visit www.fecava2013.org or email
info@fecava2013.org for more details.
November 2013
38-39 CPD Diary October.indd 38 20/09/2013 11:06
companion
|
39
EXCLUSIVE FOR MEMBERS
Extra 10% discount on all BSAVA
publicatons for members atending any
BSAVA CPD event.
All dates were correct at tme of going to print; however, we
would suggest that you contact the organizers for confrmaton.
DAY MEETING
NORTH EAST REGION
Sunday 10 November
Diarrhoea
Speaker: Dan Batchelor
Holiday Inn, Newcastle
Details from: northeast.region@bsava.com
DAY MEETING
SOUTH WEST REGION
Tuesday 19 November
Champagne, canaps and an
update on Vaccination
Speaker: Michael J Day
RSPCA Clinic, 48 Albert Road, St Philips,
Bristol BS2 0XA
Details from southwest.region@bsava.com
DAY MEETING
NORTH WEST REGION
Tuesday 12 November
Spinal surgery
Speaker Turlough ONeill
Venue: Haydock Holiday Inn
Details from northwest.region@bsava.com
DAY MEETING
EAST ANGLIA REGION
Sunday 24 November
Fracture fixation
Speaker: Michael Hamilton
Animal Health Trust
Details from eastanglia.region@bsava.com
EVENING MEETING
METROPOLITAN REGION
Wednesday 6 November
All you need to know about rabbits
in 2 hours!
Speaker: Jill Pearson
Royal Veterinary College, Hawkshead
Campus, Hawkshead Lane, North Mymms,
Hatfield AL9 7TA
Details from metropolitan.region@bsava.com
EVENING MEETING
SOUTHERN REGION
Tuesday 12 November
Recognition of the emergency
patient
Speaker: Kath Howie
Venue: Sanctuary Vet Hospital,
Mountbatten Estate, Jackson Close,
Farlington, Portsmouth PO6 1UR
Details from: southern.region@bsava.com
EVENING MEETING
EAST MIDLANDS REGION
Wednesday 13 November
The evidence for/against surgical
and medical options for the
management of hip dysplasia
Speaker: Mark Morton
Yew Tree Lodge Best Western Hotel,
33 Packington Hill, Kegworth, Derby DE74 2DF
Details from eastmidlands.region@bsava.com
LUNCHTIME WEBINAR
Wednesday 13 November
13:0014:00
Top 10 dental tips
Speaker: Peter Southerden
Online
Details from administration@bsava.com
LUNCHTIME WEBINAR
Wednesday 20 November
13:0014:00
Fluid therapy
Speaker: Louise ODwyer
Online
Details from administration@bsava.com
LINKED WEBINAR
Thursday 7 November
20:0021:00
Chemotherapy in practice
Speaker: Iain Grant
Online
Details from administration@bsava.com
EVENING WEBINAR
Thursday 14 November
20:0021:00
Applications of minimally
invasive surgical techniques
in practice
Speaker: Rob White
Online
Details from administration@bsava.com
EVENING WEBINAR
Wednesday 20 November
20:0021:00
Management of brachycephalic
airway syndrome
Speaker: Alison Moores
Online
Details from administration@bsava.com
DAY MEETING
Thursday 21 November
Surgical management of soft
tissue tumours in practice
Speaker: Stephen Baines
Yew Lodge, Kegworth
Details from administration@bsava.com
DAY MEETING
Thursday 28 November
Advanced airway surgery
Speaker: Alison Moores
Details from administration@bsava.com
DAY MEETING
Friday 29 November
Gastrointestinal surgery
Speaker: Daniel Brockman
Details from administration@bsava.com
DAY MEETING
Saturday 30 November
Fix the leaks and unblock the
pipes lower genital plumbing
Speaker: Jane Ladlow
Details from administration@bsava.com
EVENING MEETING WEST
MIDLANDS REGION
Tuesday 3 December
Diagnosis and management of
chronic small intestinal disease in
dogs
Speaker: Roger Batt
The Barn Beefeater and Premier Inn,
Stratford Road, Hockley Heath, Solihull,
West Midlands B94 6NX
Details from westmidlands.region@bsava.com
December 2013
OTHER UPCOMING BSAVA CPD COURSES
See www.bsava.com for further details
Metropolitan Region
Tuesday 3 December
Medical and surgical oncology
Leading Edge VNMA Educaton
Tuesday 3 December
Blood products when and how
should we use them in surgical patents
North West Region
Wednesday 4 December
Cardiac disease including practcal
ultrasound
North East Region
Wednesday 4 December
Demodex and other skin parasites
Cymru/Wales Region
Wednesday 4 December
Clearing up the canine cornea
South East
Wednesday 4 December
Cytology
East Midlands Region
Tuesday 10 December
Maximizing the use of cytology for skin
cases in practce
38-39 CPD Diary October.indd 39 20/09/2013 11:06
Heres what some of
our 2013 attendees
had to say

Lots of streams to pick


and choose from...

Ive come every year since


Igraduated 6 years ago
social events are a good place
to meet up with old friends
from University...

Like feeling like Im a part of


the big vet community...

The BSAVA is better than


other events as there is a real
buzz about it and you can get
all your CPD hours completed
over the four days...

36 April 2014
The ICC / NIA Birmingham UK
www.bsava.com/congress
Download the 2014
Scientifc Programme at
www.bsava.com
Get practical, valuable knowledge for
theentire practice
Choose from over 300 lectures by
worldclass speakers
Extensive Management Programme
Access the expertise of over 250 exhibitors
Great networking opportunities
Registration opens on
Read more inside
Vets Nurses
Practice Managers
Congress is for
the whole team whole whole