Veterinary Issue 11 Winter 2004 Veterinary News Editor: Hugh Edgar Design & Production: R & W Communications New senior clinician in equine cardio-respiratory medicine The is pleased to welcome Dr Eduard Jose-Cunilleras (Ed) as its new Senior Equine Cardio-respiratory Medicine Clinician. He comes to the Centre for Equine Studies at the AHT after seven years in the Equine Internal Medicine Service and Equine Exercise Physiology Laboratory at The Ohio State University. Ed earned his Veterinary Degree from the Autonomous University of Barcelona, Spain (1997). He went on to complete an Internship in Equine Medicine and Surgery, and Residency in Equine Internal Medicine, and became Diplomate of the American College of Veterinary Internal Medicine (Large Animal). He recently completed his PhD in Equine Exercise Physiology, and his main area of study was carbohydrate metabolism, and the relationship between exercise and diet in athletic horses. Ed joined us in the Equine Cardio-respiratory Medicine Service at the Animal Health Trust in October and is quickly settling in to his new role. His immediate goals are to maintain and enhance the state-of-the-art referral service of the Centre for Equine Studies by providing medical expertise in ailments of elite performance horses. Ed intends to develop the existing services dedicated to diagnostic and therapeutic procedures involving cardiovascular and respiratory conditions, as well as neurological, muscular and metabolic disorders of athletic horses. Specific diagnostic procedures of his interest and expertise include high-speed treadmill videoendoscopy, electrocardiography, echocardio-graphy, pulmonary scintigraphy, magnetic resonance imaging, as well as to introduce and promote non-invasive techniques to assess metabolic status and training adaptations by use of magnetic resonance spectroscopy analysis of muscle function and substrate storage. Ed is glad to return to Europe with his wife Sandra. They both enjoy spending time outdoors and are avid hikers and mountain climbers, and look forward to enjoying the country charm of East Anglia (well known for its mountainous terrain!). Ed enjoys the challenge of addressing the subtle and often multifactorial problems of racehorses that lead to decreased athletic performance. With the continual advancement in the field of Equine Sports Medicine, and more specifically Cardiorespiratory Medicine, he welcomes and encourages veterinarians to contact him for consultations through the Centre for Equine Studies at 08700 502430 or via e-mail at eduard.jose-cunilleras@aht.org.uk. Dear Colleague, I hope you will find this issue of Veterinary News of interest. It includes information on two important new services that we have introduced in the past year. The arrival of Jon Wray at the beginning of 2004 has allowed us to provide a comprehensive service in small animal internal medicine, adding to and complementing the important feline work already being undertaken by Andy Sparkes. On the equine side, Eduard Jose-Cunilleras brings important expertise to the cardio-respiratory group, and enhances our ability to investigate performance problems in horses. Both of these new services have been introduced in response to demand from you, our clients, and they also greatly help us to pursue our wider aims through clinical research. This Newsletter also contains case reports from three different clinical areas, all produced by clinicians undergoing further specialist training. They demonstrate the important role played by the Trust in producing our specialists of the future; I hope that you will also find them interesting from a clinical perspective. Our laboratory diagnostic area is an important part of the integrated service that we provide, and one that often links the clinical and research activities. The article on strangles has been included to show how tests now available in the laboratory can help with diagnosis. Finally, there is also general information on our services and prices for 2005, and details of CPD courses available. As ever, we depend on a supply of clinical cases and diagnostic material to carry out our research, and we are very grateful for your continued support. I hope that we can continue to provide you with a valuable service in the year ahead. In the meantime, I wish you a very happy and prosperous New Year. Hugh Edgar Director of Clinical & Laboratory Services Lanwades Park Kentford Newmarket Suffolk CB8 7UU Telephone: 08700 502424 Fax: 08700 502425 e-mail: info@aht.org.uk Web site: www.aht.org.uk Registered Charity No: 209642 CSAS NURSING TEAM The CSAS nursing team have celebrated a successful year of examination achievements. Notably, Nichole Hill achieved the highest marks this year in the DAVN Surgical exams and was awarded the BVNA DAVN Surgical Award and a 50 cheque. Rachael Vernalls, Jody Turner and Zowie Holland achieved the S/NVQ level III VN qualification. Paula Ross and Amy Pemberton achieved their S/NVQ level II VN pass and Sam Gould passed her ANA examinations.
Bilateral ulcerative keratitis in a Thoroughbred mare Miss Claudia Hartley, BVSc, CertVOphthal, MRCVS Schering-Plough Resident in Ophthalmology, describes this interesting case A mare was referred with a one-month history of bilateral ulcerative keratitis. Other horses on the stud farm and in the surrounding area had also had bilateral ulcerative keratitis which had resolved quickly on topical antibiotics. This case failed to respond to similar therapy and the referring veterinary surgeon took bacterial and fungal conjunctival swabs and made a cytological smear preparation. These cultures were negative and cytology revealed neutrophils and epithelial cell debris. After two weeks, there was no corneal fluorescein uptake and topical gentamicin therapy was discontinued in favour of Maxitrol. After another week, there was corneal fluorescein uptake present and treatment with plasma in EDTA and gentamicin was instituted tid. Five days later the eyes had deteriorated markedly and a referral was sought. Bacterial and fungal culture conjunctival swabs were taken from each eye. Under local anaesthetic, corneal scrapes were taken and smears made for cytology. Cytology revealed numerous neutrophils, many of which were degenerate. Bacterial cocci were present, both intracytoplasmic and within proteinaceous debris. No fungal hyphae were seen. This was consistent with a bacterial keratitis. Bacterial culture revealed a moderate growth of Streptococcus zooepidemicus from both eyes. Fungal culture revealed no growth. Right eye Day 11 Left eye Day 11 as no traumatic incident was reported. The simultaneously bilateral nature of the disease might also suggest a lack of traumatic involvement. The recent outbreak in the area is suspicious and fly vectors could be responsible for its spread. The mare s foal remained unaffected and bacteriology conjunctival swabs were clear. The bacterium may have been introduced by contaminated plasma given the rapid deterioration after introducing this treatment. Plasma or serum is primarily used topically to inhibit the action of matrix metalloproteinases (MMPs) and collagenases responsible for keratomalacia ( melting ulcer ) and there is some argument that it may also contain growth factors and other substances of benefit to epithelial healing. It should be autologous if at all possible and prepared using a sterile technique. It is best stored in the fridge and discarded after 72 h. There is a good argument for only utilising plasma or serum in hospital-based patients. Intensive topical antibacterial therapy is warranted and early surgical intervention should be considered where a bacterial ulcer is progressing. Topical steroids are contraindicated in ulcerative keratitis. They can potentiate fungal infections, promote the development of keratomalacia and greatly delay epithelial healing. Intensive topical therapy (chloramphenicol) was given every 2 hours to both eyes. Atropine was used as necessary to control ocular pain from ciliary spasm and pupillary constriction. Gut sounds were monitored as ileus is a recognised side-effect of topical atropine. Analgesia was provided by butorphanol as there was some concern over using NSAIDs in a pregnant mare. Morphine was contraindicated as she was lactating and it is sequestered in milk. Right eye Day 2 Left eye Day 2 The left eye progressed well and healed by 10 days post admission. Gentle debridement of necrotic corneal epithelium in the right eye was undertaken under local anaesthesia with a cellulose stick swab. It then healed well. Strep. zooepidemicus can be an aggressive pathogen once the epithelium is breached. The route of entry in this case was unclear Right eye Day 20 Left eye Day 20 References Brooks, D., Andrew, S.E., Biros, D.J., Denis, H.M., Cutler, T.J., Strubbe, D.T. and Gelatt, K.N. (2000) Ulcerative keratitis caused by beta-haemolytic Streptococcus equi in 11 horses. Veterinary Ophthalmology 3(2/3), 121-125. Sauers P., Andrews S.E., Lassalines M., Gelatts K.N. and Deniss H.M. (2003) Changes in antibiotic resistance in equine bacterial ulcerative keratitis (1991-2000): 65 horses. Veterinary Ophthalmology 6(4), 309-313. Barnett, K.C., Crispin, S.M., Lavach, J.D. and Matthews, A.G. (2004) Cornea. In: Equine Ophthalmology 2nd ed. Saunders, Oxford, pp 107-147. Strubbe, D.T., Brooks, D.E., Schultz, G.S., Willis-Goulet, H., Gelatt, K.N., Andrew, S.E., Kallberg, M.E., Mackay, E.O. and Collante, W.R. (2000) Evaluation of tear film proteinases in horses with ulcerative keratitis. Veterinary Ophthalmology 3(2/3), 111-119.
Managing anaesthesia in a dog with increased intra-cranial pressure By Colette Jolliffe, BVetMed, CertVA MRCVS Jack was a 7-year-old male neutered Jack Russell whose owners had noticed a change in personality over the previous 10 days. Normally a friendly family dog, Jack had become increasingly depressed, developed a stiff gait and had bitten his owner twice. By the time of referral, Jack had severe neck pain and was circling. At the Trust, the neurologist localised the lesion to forebrain and possibly cervical spine. He also suspected increased intra-cranial pressure (ICP). The plan was to image Jack s brain and cervical spine with magnetic resonance imaging (MRI) under general anaesthetic. Jack was too aggressive to examine properly. His aggression was probably due to pain, so he was given 0.2 mg/kg of methadone im. Methadone was useful in this case as it is a full µ agonist, similar in potency and duration to morphine, but does not cause vomiting, which can dramatically increase ICP. At clinical doses, opioids such as methadone, pethidine and buprenorphine are very unlikely to cause respiratory depression and thus can be used in animals with increased ICP. With careful handling, it was then possible to auscultate Jack s chest, assess his pulse and place an iv catheter. In an animal whose ICP is already raised, anaesthesia can tip the balance towards a fatal outcome. The cranium is a fixed volume chamber which houses 3 non-compressible components: brain tissue, cerebrospinal fluid (CSF) and blood. If the cranium contains a space occupying lesion, CSF and/or blood must be displaced or ICP will rise. Once CSF and blood are maximally displaced, any further increase on volume will force the brain to herniate out of the foramen magnum, ( coning ), resulting in compression of the brainstem and impending death. The anaesthetist has little control over the brain tissue or CSF volume, but can influence the volume of blood within the skull, by influencing cerebral perfusion pressure, arterial CO 2 and O 2 levels and cerebral metabolic activity. Because most of the blood in the cranium is venous, any obstruction to venous drainage of the head will increase ICP. Occlusion of the jugular veins should be avoided (eg pulling on a neck lead), as should any increase in central venous pressure, eg coughing, sneezing, vomiting or straining. Drugs which can cause vomiting such as morphine should be avoided. Intubation and extubation may cause coughing and hence a catastrophic increase in ICP. To try and prevent coughing, Jack was given 1 mg/kg lidocaine iv 1 min prior to induction. This has been shown to be effective in people, and in our experience it helps prevent the cough response to intubation in dogs. Thiopentone and propofol both exert a cerebroprotective effect by reducing cerebral metabolism. Cerebral blood flow is coupled to cerebral metabolism and agents such as ketamine, which increase cerebral metabolism, should be avoided. In this case, anaesthesia was induced with propofol given slowly to effect iv. Induction was smooth and Jack did not cough on intubation. Manual ventilation commenced immediately and continued mechanically during scanning. CO 2 is a potent cerebral vaso-dilator and raised arterial CO 2 caused by respiratory depression can be life threatening in patients with increased ICP. Therefore end tidal CO 2 was monitored and maintained within the low normal range (about 35 mmhg) by adjusting the ventilator. Anaesthesia was maintained with isoflurane in 100% oxygen using an Ayre s T-piece connected to the ventilator. Isoflurane causes Fig 1: T2W sagittal plane image of the brain. There is dilation of the lateral ventricles and severe subtentorial and tonsillar herniation. Within the cervical spinal cord there is focal accumulation of CSF due to syringohydromyelia which is secondary to the brain herniation. much less cerebral vasodilatation and disruption of flow metabolism coupling than halothane. Halothane and nitrous oxide should be avoided in these patients. Hypoxaemia causes cerebral vasodilatation and can be prevented by supplying oxygen. Jack also received Hartmann s solution iv at 10 ml/kg/h. In a normal conscious animal, the cerebral blood flow is autoregulated at mean arterial pressures of 50 150 mmhg. However, anaesthetic agents obtund this mechanism so blood flow may become directly pressure dependent. Therefore Jack s blood pressure was monitored using a non-invasive technique (oscillometric). The mean arterial pressure remained stable at about 70 mmhg. About 20 min after induction, with imaging well under way, Jack s heart rate dropped suddenly from 75 to 35 beats/min. The noninvasive blood pressure would not read. At the same time, the sagittal images of the brain were processed and showed dilation of the lateral ventricles, periventricular oedema, subtentorial and tonsillar herniation, and brainstem compression (see Fig 1), confirming the clinical suspicion of raised ICP. The dog was coning and the raised ICP had triggered the Cushing response: a massive sympathetic response resulting in marked peripheral vasoconstriction and reflex bradycardia. Jack was probably markedly hypertensive at this time. In an effort to reduce the ICP, mannitol (0.2 g/kg iv) was given over about 15 min. This osmotic diuretic reduces cerebral oedema by increasing plasma osmolarity, drawing water from the brain across the blood brain barrier. Jack also received 1 mg/kg frusemide iv. Frusemide acts synergistically with mannitol and reduces CSF production. Intermittent positive pressure ventilation (IPPV) was continued. Within 20 min, the heart rate had returned to 80 bpm. To achieve a definitive diagnosis, a lumbar CSF tap was taken. Tapping the cisterna magna would have been highly risky due to the increased ICP and lumbar puncture still posed a danger of precipitating brainstem herniation. Therefore Jack was hyperventilated manually during this procedure to reduce ICP by cerebral vasoconstriction. Recovery is a critical time for animals with increased ICP. Their arterial CO 2 levels must not rise above normocapnia, yet they must be weaned off IPPV. Coughing must not occur at extubation, and the recovery should be smooth and stress free to prevent haemodynamic instability. After turning off the isoflurane vapouriser, Jack was ventilated manually until he became light enough to breathe spontaneously. When he was breathing well, he was extubated early to prevent coughing. He had a smooth recovery and was up and about within 25 min. Sadly, CSF analysis showed that Jack was suffering from lymphoma. He was euthanased later that day, his owners having made the decision not to embark on chemotherapy. This case illustrates the importance of a basic understanding of physiology and pathophysiology when undertaking general anaesthesia, and the importance of appropriate monitoring, especially in high risk cases. For this dog, monitoring end tidal CO 2 was essential to prevent hypoventilation and resulting cerebral vasodilatation. Continuous heart rate monitoring with the pulse oximeter was invaluable in detecting the first signs of brainstem herniation. Understanding the underlying disease process enabled anticipation and prevention of adverse events, and appropriate treatment of serious complications.
Canine Internal Medicine Mr J D Wray BVSc CertSAM MRCVS, Miss S Davies BVSc MRCVS This service accepts referrals in all aspects of canine internal medicine. It benefits from a multidisciplinary approach, so vital in internal medical cases, frequently involving the excellent Imaging and Soft Tissue surgical facilities as well as our other disciplines. Referrals in endocrinology, dysphagia, vascular/haemostatic disorders and cardio-respiratory conditions are especially welcome. The service benefits from excellent diagnostic facilities including use of minimally invasive diagnostic equipment (such as flexible and rigid endoscopy) and comprehensive imaging facilities and expertise (radiography, ultrasonography, fluoroscopy, scintigraphy and magnetic resonance imaging [MRI]). Highly-qualified 24 h nursing care, excellent monitoring facilities and on-site diagnostic clinical pathology and histopathology support allows comprehensive and expedient case management. Long term case support and re-evaluation of chronic medical cases is encouraged. We are happy to discuss cases in advance of referral and to see emergencies as a matter of priority. Please note that in certain cases, prior therapy (especially use of corticosteroids) may substantially interfere with diagnostic evaluation and we would be happy to discuss withdrawal of medication before referral appointments. Consultation 150.00 Re-examination 75.00 Out of hours emergency consult 220.00 Bronchoscopy 85.00 (plus anaesthesia) Endoscopy Combined GI 232.00 Upper GI 155.00 Lower GI 155.00 (plus anaesthesia) Investigation of coughing 500.00-700.00 Investigation of chronic diarrhoea 600.00-1200.00 (includes diagnostic imaging and endoscopy) Dermatology Dr S C Shaw BVetMed PhD CertSAD MRCVS Miss J C Coatesworth MA VetMB CertVD MRCVS Referral Prices for 2005 The Dermatology Unit accepts canine, equine and feline referrals including systemic and endocrine diseases with dermatological manifestations. It has considerable experience in the investigation and management of allergic patients and has associated clinical research programmes, particularly relating to canine atopic dermatitis. In-house support from internal medicine, surgery and neurology allows care of complex cases including severe disease of the ear and nails. Cases that are likely to require allergy testing at the first consultation should be discussed with a dermatologist to allow drug withdrawal and appropriate appointment time. In addition, where needed appointments can be arranged out of standard working hours, but will attract higher than normal charges. Further advise about cases can be obtained by telephone, fax or e-mail (dermatology@aht.org.uk) Consultation - small animal 145.00 - equidae 150.00 Re-examination 95.00 & 70.00 Investigation of patients with: Allergic disease from 660.00 Auto-immune disease from 840.00 Out of hours emergency (add) 75.00 Neurology/Neurosurgery Mr S R Platt BVM&S DipACVIM DipECVN MRCVS RCVS, European and ACVIM Specialist in Veterinary Neurology Dr J Penderis BVSc MVM PhD CVR DipECVN MRCVS RCVS & European Specialist in Veterinary Neurology Dr L Garosi DVM DipECVN MRCVS RCVS & European Specialist in Veterinary Neurology Dr Alberta de Stefani DVM MRCVS - Vetoquinol Resident in Neurology/Neurosurgery Dr Lara Wieczorek DVM MRCVS Resident in Neurology/Neurosurgery Mrs J Freeman BSc (Hons) - Research Assistant A comprehensive referral service for canine and feline patients with medical and surgical neurological problems or myopathies. The excellent facilities, including onsite MRI, electrodiagnostics facilities and neurosurgical operating equipment, with related oncology and surgical services, allows a standard of investigation and treatment matched by few other locations in Europe. The service can receive intracranial and spinal emergencies on a 24-hour basis and prides itself on its congenital deafness-screening programme in a variety of at-risk breeds. Consultation 170.00 Re-examination 28.00-90.00 Spinal disease investigation from 1150.00 (including MRI, CSF analysis, electrodiagnostics and hospitalisation) Spinal surgery from 1350.00 Intracranial disease investigation from 1150.00 (including consult, MRI and CSF analysis) Brain surgery (excluding MRI and intensive care) from 2200.00 Out of hours emergency consult (add) 80.00 Deafness screening (per puppy) 24.00 Oncology Mrs S Murphy BVMS MSc (Clin Onc) MRCVS Ms A Hayes BVMS CertVR MRCVS, Mr G Maglennon BVMS MRCVS Comprehensive cancer management in dogs and cats. Diagnostic investigations performed include fine needle aspirate cytology and histopathology, radiography and ultrasonography. For tumours at complex anatomical sites such as the head and neck, brain and pelvic canal, MRI can be used for diagnosis and treatment planning. The treatment of choice depends on tumour type and clinical stage; many cancers are SMALL ANIMAL CENTRE best treated with multi-modality therapy, eg surgery with adjuvant radiotherapy or neoadjuvant chemotherapy then surgery. Oncology, together with other services, represents one of only a few comprehensive cancer therapy groups in Great Britain. Consultation 155.00 Re-examination 84.00 Consult & diagnostic work up ~ 480.00 Adjuvant chemotherapy Dependant upon protocol please enquire Adjuvant radiotherapy from 850.00 Feline internal medicine Dr A H Sparkes BVetMed PhD DipECVIM MRCVS European Specialist in Internal Medicine, RCVS Specialist in Feline Medicine Miss E Mardell MA VetMB CertSAM MRCVS A comprehensive referral service for feline internal medical disorders backed up by extensive diagnostic abilities including a full laboratory service, endoscopy, radiography, ultrasonography, scintigraphy and MRI. Feline patients are hospitalised in a dedicated ward with 24 hour nursing care. The Trust is one of the few centres offering radioactive iodine therapy for hyperthyroid cats. Referrals of all natures are accepted, and we are happy to discuss cases and give telephone advice prior to referral. Consultation 90.00 Re-examination 50.00 Bronchoscopy (plus anaesthesia) 85.00 GI endoscopy (plus anaesthesia) 160.00 Radioiodine therapy from 900.00 Out of hours emergency consult 180.00 Soft tissue surgery Ms J Ladlow MA VetMB CertVR CertSAS DipECVS MRCVS European Specialist in Veterinary Surgery Referrals of soft tissue disease are welcomed from laryngeal paralysis and gastric outflow obstruction to anal furunculosis. We offer a complete surgical oncology service via our imaging and medical oncology units and provide essential critical care required for surgical treatment of conditions such as portosystemic shunts and thoracic disease. Our nurses are fully qualified, providing 24 hour post-operative care supplemented by 24 hour veterinary attention for the more critical patients. Consultation 102.00 Re-examination 51.00 Oral tumour excision from 800.00 Upper Airway surgery from 475.00 Ectopic ureter surgery from 950.00 Portosystemic shunt from 1100.00 (including consultation, pre-operative investigations, surgery, post-operative care & histopathology) Out of hours emergency (add) 70.00 Ophthalmology Miss J Sansom BVSc DVOphthal FRCVS DipECVO European Specialist in Veterinary Ophthalmology Mr D Donaldson BVSc(Hons) CertVOphthal MRCVS Ms K M Smith BVetMed CertVOphthal MRCVS Miss Claudia Hartley BVSc CertVOphthal MRCVS, Schering-Plough Ltd Resident Consultant: Dr K Barnett OBE MA PhD BSc DVOphthal FRCVS DipECVO European Specialist in Veterinary Ophthalmology The Unit of Comparative Ophthalmology offers a fully comprehensive referral service in the medical and surgical treatment of ophthalmic disorders across the species. We encourage early referral and offer a 24 hour service 7 days a week. We are always happy to see ophthalmic emergencies the same day. Consultation 90.00 Re-examination 45.00 Check up 35.00 ERG 48.00 Cataract extraction from 1050.00 Conjunctival flap from 600.00 Eyelid surgery (2 lids) from 600.00 Out of hours emergency 160.00 (above fees include general anaesthesia, hospitalisation [2 nights + drugs] For giant breeds anaesthesia and consumable costs may be higher) S Support services Anaesthesiology Dr J C Brearley MA VetMB PhD DVA DipECVA MRCA MRCVS European Specialist in Veterinary Anaesthesia Dr F Corletto DVM CertVA MRCVS DipECVA European Specialist in Veterinary Anaesthesia Ms E A Leece BVSc CertVA MRCVS DipECVA European Specialist in Veterinary Anaesthesia Ms L Clarke BVMS CertVA MRCVS DipECVA European Specialist in Veterinary Anaesthesia Mr L Novello Medico Veterinario (MedVet) MRCVS Miss C Jolliffe BVetMed CertVA MRCVS, Mr P Franci CertVA DVM MRCVS Staffed by vets specialising in anaesthesia, this Unit is responsible for all anaesthetics and sedations in the Clinics. It also provides support for intensive care cases and pain control. Each patient is cared for on a one-to-one basis with particular emphasis on perioperative pain relief and maintaining homeostasis. Vital signs monitored routinely include temperature, heart rate, arterial blood pressure, respiratory rate and respiratory gases. In more complex cases, neuromuscular function, renal function and central blood pressure will also be monitored. Advice is available to veterinary surgeons on anaesthetic and related problems including practice visits if requested. Our clinicians are happy to receive requests for advice or to discuss potential referrals. We will aim to call or fax the referring clinic with a brief update on the day of the initial appointment, a further update on the day of discharge, followed by a full referral letter within a week.
Sedation 35.00 General anaesthesia from 65.00 to 250.00 (depending on patient size/duration. Highly complex procedures may incur extra charges) Blood transfusions from 95.00 to 200.00 Written advice/reports on anaesthetic problems from 25.00 Practice visits from 500.00 plus travel Hospitalisation Hospitalisation per day Cat 24.15 Dog 29.00-37.00 Additional high dependency nursing fee may be applied ~ 16.00-68.00 per day Day case fee 21.00 Diagnostic imaging Mrs R Dennis MA VetMB DVR DipECVDI MRCVS RCVS & European Specialist in Veterinary Diagnostic Imaging Mr F J Llabres Diaz DVM DVR DipECVDI MRCVS RCVS & European Specialist in Veterinary Diagnostic Imaging Mr J F McConnell BVM&S DVR DipECVDI MRCVS RCVS & European Specialist in Veterinary Diagnostic Imaging Ms A Petite DVM DVDI MRCVS Referral Prices for 2005 Radiology provides diagnostic imaging services for the other clinical disciplines. These include radiology, ultrasound, magnetic resonance imaging (MRI) and scintigraphy. A radiographic film reading service for practitioners is also offered. A high-field (1.5 Tesla) MRI scanner is on site, and over 1000 small animal patients are examined each year, including many emergencies. Typical indications for MRI include brain & spine scanning for neurological disease, assessment of tumour extent prior to surgery or radiotherapy, investigation of orbital and nasal disease and location of foreign bodies and draining tracts. The AHT is approved by the Feline Advisory Bureau (FAB) as a centre for ultrasonographic screening of cats for polycystic kidney disease (PKD) Radiography from 65.00 Contrast studies from 85.00 MRI (including anaesthesia/consumables) 440.00-650.00 Ultrasonography 50.00 to 170.00 PKD Screening 25.00 to 35.00 Reporting practice films 25.00 EQUINE CENTRE The Equine Centre offers a comprehensive referral service for orthopaedics, neurology, cardiology, upper airway investigation and performance-related disorders, together with anaesthesiology and surgical facilities. A referral service is also available for equine dermatology and ophthalmology in collaboration with the Small Animal Centre. The Equine Centre office is manned from 08.30 until 17.00, and our clinicians can provide telephone advice to veterinary surgeons between 08.30 and 18.00. Orthopaedics Dr Sue Dyson MA VetMB PhD DEO FRCVS Dr Rachel Murray MA VetMB MS PhD MRCVS DipACVS DipECVS Barbara Maulet DVM CertES(Orth) MRCVS Acute and chronic orthopaedic (including surgical) cases undergo comprehensive clinical examination by appointment or as an emergency admission. Many lameness and poor performance cases require hospitalisation for in-depth examination, including local analgesic techniques, radiography, ultrasonography, thermography, nuclear scintigraphy and magnetic resonance imaging (MRI). Horses may be referred for comprehensive clinical evaluation including scintigraphy which is not be performed within 7 days of multiple regional local analgesic techniques and horses are hospitalised for at least 3 days. Images can only be interpreted in the light of results of other diagnostic techniques, and both qualitative and quantitative image assessment are used and combined with the results of other investigative techniques. MRI of the distal aspect of the forelimbs and hindlimbs can be performed in anaesthetised horses. To ensure that appropriate sequences are obtained to maximise information about suspected lesions, it is essential that maximum clinical information has been obtained before scanning, and we prefer to combine MRI with scintigraphy to facilitate both of these and image interpretation. Prices for a typical case would be: Lameness investigation or back examination (including clinical examination, radiography, nerve blocks, scintigraphy, and hospitalisation) from 1160 Arthroscopic surgery (including surgery, general anaesthesia, drugs, dressings, and hospitalisation) from 1320 MRI (including general anaesthesia) from 1345 (Please note this excludes clinical examination, hospitalisation and any other diagnostic procedures which may be required) Opinions will also be given on referred radiographs, scintigraphic and ultrasonographic images. Cardiology Dr Lesley Young BVSc PhD DVA DipECVA DVC MRCVS The complete cardiology service includes colour flow Doppler echocardiography and measurement of heart rate and rhythm during strenuous exercise by radiotelemetry. Cardiology forms part of the diagnostic service for performancerelated disorders and fitness assessment. The service also handles primary referrals for evaluation of cardiac murmurs detected at pre-purchase examinations, and for investigation and treatment of horses with suspected cardiac rhythm disorders. Prices for a typical case would be: Heart murmur investigation (including clinical examination, echocardiography, exercising ECG, hospitalisation) from 330 Fitness and performance evaluation and upper airway investigation Dr Eduard Jose-Cunilleras DVM PhD Dip ACVIM(LA) MRCVS Dr Lesley Young BVSc PhD DVA DipECVA DVC MRCVS Dr David Marlin BSc(Hons) PhD, Dr Chris Deaton BSc(Hons) PhD We are equipped to evaluate abnormal respiratory noise at exercise, fitness and performance in horses using either treadmill or field exercise tests. Evaluation includes measurement of heart size by echocardiography, assessment of heart rate, and blood lactate responses to exercise. Treadmill evaluation allows acquisition of more detailed information such as measurement of maximum oxygen uptake and examination of the upper airway by videoendoscopy. Field tests are also of value for assessment of multiple horses in a single yard, or for screening individual animals. The opportunity for surgical treatment of upper airway disorders is available at the Equine Centre in combination with the local referral practices. Prices for a typical case would be: Treadmill test and endoscopy (including clinical examination, treadmill training and exercise testing, videoendoscopy at rest and exercise, and hospitalisation) from 715 Complete performance evaluation (including clinical examination, treadmill training and exercise testing with exercising videoendoscopy, echocardiography, measurement of maximal oxygen uptake, laboratory investigations and hospitalisation) from 870 Surgical treatment for dorsal displacement of the soft palate (including general anaesthesia) from 1100 Neurology Dr Sue Dyson MA VetMB PhD DEO FRCVS Dr Eduard Jose-Cunilleras, DVM PhD Dip ACVIM(LA) MRCVS Dr Rachel Murray MA VetMB MS PhD MRCVS DipACVS DipECVS Barbara Maulet DVM CertES(Orth) MRCVS Simon Platt BVM&S DipACVIM DipECVN MRCVS Acute and chronic neurologic cases undergo comprehensive clinical examination and diagnostic evaluation. We handle referrals for examination of neurologic gait abnormalities, and investigate manifestations of central neurologic disease (seizures, narcolepsy, altered mentation and behaviour, cranial nerve deficits). Head MRI is a valuable diagnostic tool, and studies are routinely performed in adult horses. Spinal ataxia (including clinical examination, radiography +/- lumbosacral spinal tap) from 550 Brain disease (including clinical examination, head MRI under general anaesthesia, and atlantooccipital spinal tap) from 1905 Other services In conjunction with the Small Animal Centre, services in ophthalmology and dermatology are also provided: Ophthalmology Miss J Sansom BVSc DVOphthal MRCVS DipECVO Dr K C Barnett OBE MA PhD BSc DVOphthal FRCVS DipECVO David Donaldson BVSc(Hons) CertVOphthal MRCVS Examination from 155 Dermatology Dr S Shaw BvetMed PhD CertSAD MRCVS Examination from 150 The prices in the examples are typical, but they may vary according to the severity or complexity of the case. All prices quoted are exclusive of VAT Lanwades Park Kentford Newmarket Suffolk CB8 7UU Tel: 08700 502424 Centre for Small Animal Studies Tel: 08700 502540 Fax: 08700 502541 Answering Service Tel: 01223 257436 e-mail: smallanimal.centre@aht.org.uk Centre for Equine Studies Tel: 08700 502430 Fax: 08700 502431 Answering Service Tel: 01223 257436 e-mail: equine.centre@aht.org.uk
Strangles : the use of laboratory tests in its diagnosis Strangles, caused by infection with the bacterium Streptococcus equi (S. equi), remains one of the most commonly diagnosed and feared infectious diseases of horses worldwide. The disease is initially characterised by a raised temperature and associated depression and loss of appetite. This is then followed several days later by profuse nasal discharge and swelling of the lymph nodes ( glands ) of the head and neck, which burst discharging highly infectious pus (Fig 1). The swelling of the glands in the head and neck may, in severe cases, restrict the airway and it is from this feature that the term strangles arose (Fig 2). Fig 1: Discharging lymph node abscess during strangles in a pony The S. equi bacterium rapidly invades the horse s lymph nodes and often cannot be detected until an abscess ruptures. Scientists at the Trust s diagnostic facilities offer the use of haematological techniques to monitor animals exposed to S. equi for increases in their neutrophil and fibrinogen levels, indicative of abscess formation. By using these techniques those animals most likely to develop severe abscesses can be identified and carefully monitored for administration of ameliorative therapy. This complements the typical microbiological investigations for Strangles culture and our Diagnostic Laboratory Services specific PCR, which is helpful in identifying both affected and carrier animals. These microbiological tests can be carried out on nasopharyngeal Fig 2: Respiratory obstruction ( strangles ) in a foal with S. equi infection swabs and washes as well as washes of the guttural pouches. Although most affected horses recover uneventfully over a period of about a week, some animals can become extremely ill for several days and fatal complications are not unusual. The more severe cases will take 3 4 weeks to make full clinical recoveries. In the first of a series of case reports to be included in Vet News, one of our Iams interns, Mark Graham describes a case presented during his medicine rotation. The AHT small animal clinic intern programme provides hospital care and discipline specific training to six recently qualified veterinary surgeons who spend time in each small animal discipline as well as providing continuous on-site veterinary care overnight and at weekends. We are very grateful to Iams for their generous sponsorship of our intern programme. Physeal dysplasia with secondary fractures and avascular necrosis of the femoral neck in cats A 2-year-old British short-haired male neutered cat was presented to the internal medicine unit. He was heavy for his size at 5.4 kg. He was confined indoors and had developed lethargy over a 2- week period associated with a wobbly, bunny-hopping gait in the hind limbs. The owner was unaware of any trauma. Previous investigations had included haematology, biochemistry, radiographs of lumbar spine, hips and pelvis and echocardiography. Results were unremarkable and aspirin and steroids had been used without effect. The cat was in good body condition but with muscle wasting over the hind limbs. Femoral pulses appeared normal. There was a moderate left hindlimb lameness and marked extension of the hocks. No neurological problems were detected on examination of the hind limbs and no orthopaedic abnormalities were detected on examination/manipulation of the phalangeal, tarsal or stifle joints. Both coxo-femoral joints were mild to moderately painful on manipulation and occasional crepitus was felt in the left coxo-femoral joint. Differential diagnoses included traumatic fracture of proximal femur, hip dysplasia, osteomyelitis, spontaneous femoral neck fracture, femoral thromboembolism and neoplasia. Repeat haematology and biochemistry were performed in combination with urine analysis. The results were unremarkable except an elevated creatinine kinase 111 iu/l (21-56). Review of the radiographs revealed changes consistent with bilateral femoral neck fractures with separation or slippage of the
capital epiphyses and osteolysis of the femoral necks. The left proximal femur was more severely affected but the lesions were subtle, appearing similar to normal open growth plates pre-physeal closure. Physeal dysplasia, with secondary fractures and avascular necrosis of the femoral neck, was diagnosed. Treatment initially involved femoral head excision of the left hip. Recovery from surgery was uneventful and the patient was weightbearing on the left hip three days post surgery. Six weeks later the right femoral head was removed with a similarly uneventful recovery. A syndrome of spontaneous femoral neck fractures in young male cats has been reported in several studies but there seems to be no overall consensus on pathophysiology and nomenclature. Perez-Aparico and Fjeld (1993) first described the syndrome in detail. A similar condition was described as femoral neck metaphyseal osteopathy (Queen et al. 1998). It was then considered that a primary bone resorption resulted in secondary fracture of the femoral neck. It now seems more likely that dysplasia or delayed closure of the capital epiphysis results in pathological weakening and secondary capital fracture across the weakened physis. Osteolysis and remodelling of the femoral neck/ metaphysis seem to develop later perhaps as a result of avascular necrosis of the neck region due to disruption of the vasculature. This is supported by evidence from several cases presented to the Trust. Where these had initially been managed conservatively, radiographs of early disease show minimal femoral neck changes with capital epiphyseal separation (fracture) whilst the femoral neck develops osteolysis in later stages. A similar syndrome was also described as physeal dyplasia with slipped femoral capital epiphysis (Craig 2001) and spontaneous femoral capital epiphyseal fractures (McNicholas et al. 2002). In all the studies most cats were male neutered adult cats, under 2 years old. They were also often overweight, with an indoor lifestyle. Commonly there was no history of trauma. They presented with unilateral or bilateral signs, although individuals with unilateral disease often went onto develop bilateral disease. There seemed to be no clear breed disposition though Siamese were overrepresented which paradoxically were then much leaner than other breeds. There is also anecdotal evidence that the syndrome is more common in British Blues. Many hypotheses exist regarding aetiology/pathophysiolgy but delayed physeal closure due to early castration is often proposed with an increased tendency for neutered males to then gain weight when kept indoors. A similar syndrome is described in adolescent overweight boys. However a minority of affected cats in the studies were entire males or female. The high proportion of male neutered cats may simply reflect the high proportion of male cats which are neutered. Physeal dysplasia may be a result of prolonged chondrocyte survival due to absence/low levels of necessary growth factors for differentiation, leading to an open disorganised physis. Once diagnoses is made, response to simple surgery, as described, is excellent, although staged bilateral femoral head excision arthroplasty is often required. References Craig, L.E. (2001) Physeal dysplasia with slipped capital femoral epiphysis in 13 Cats. Vet. Pathol. 38, 92-97. McNicholas, W.T. et al (2002) Sponatenous femoral capital physeal fractures in adult cats: 26 cases (1996-2001). JAVMA 221-12, 1731-1736. Perez-Aparico, F.J. and Fjeld, T.O. (1993) Femoral neck fractures and capital epiphyseal separations in cats. JSAP 34, 445-449. Queen, J. et al (1998) Femoral neck metaphyseal osteopathy in the cat. Veterinary Record 142, 159-162. A heartfelt thank you!! We would like to take this opportunity to pass on special thanks to those of you who support the Trust, either through our referral centres or by contributing to fundraising activities. As illustrated in the feature on our new Canine Internal Medicine service, despite charging for referral and diagnostic services at competitive prices, we must rely on charitable income in the form of donations and legacies to fund the purchase of specialist equipment and much of our veterinary research programme. Securing research grants looks set to become increasingly difficult and the Trust will depend even more on the generosity of you and its many supporters. To strengthen this area, our Fundraising Team will contact you during 2005 to discuss ways in which you and your clients might help us; from simply displaying our leaflets and collection boxes in waiting areas, to supporting future capital appeals and events. If you have suggestions as to how we can improve our fundraising success, we would love to hear them. Please contact the Fundraising Department: 08700 502380 or email info@aht.org.uk
New canine internal medicine service Jon Wray recently joined the Trust to establish a Canine Internal Medicine service. This will complement established disciplines of Feline Medicine, Oncology, Neurology, Ophthalmology, Diagnostic Imaging, Dermatology, Soft Tissue Surgery and Anaesthesia. After working in mixed practice in Bath, Jon completed a residency in Small Animal Internal Medicine at Bristol Veterinary School in 2001 before moving to Willows Referral Service in Solihull where he established an internal medicine service. His clinical interests are cardiorespiratory medicine, endocrinology, diagnostic imaging and diagnostic and therapeutic endoscopy. Specific interests include the diagnosis and management of megaoesophagus and other causes of dysphagia, Angiostrongyliasis, insulinoma and episodic weakness and collapse in dogs. The Canine Medicine service has proved to be in much demand and the case load has been challenging and variable. This has led to the appointment of Sian Davies as the Canine Medicine Junior Clinical Training Scholar. Sian will work closely with Jon towards her Certificate in Small Animal Medicine.Canine Medicine thrives in an environment where a multidisciplinary approach is possible, and in many cases, this is essential to diagnosis. Canine Medicine cases require much diagnostic input and support from other disciplines. Having a wealth of expertise and a first rate Clinical Pathology and Histopathology team on site makes a huge difference to what can be achieved in complex medical cases. This is CPD 2005 11th March: Practical Neurology British Racing School, Newmarket Course Organiser: Mr Simon Platt Registration: 150.00 For further information, or an application form, please contact Karen Bond on 08700 502540 or by e-mail: karen.bond@aht.org.uk BEVA/AHT Day courses 5th May: Practical Equine Cardiology, Newmarket Course Organiser: Dr Lesley Young Registration: 300.00 BEVA members, 315.00 for non members Registration via BEVA Tel: 01223 836970 or e-mail info@beva.org.uk. Delegate numbers will be limited to maximise exposure to case material and demonstrators 6th May: Practical Equine Cardiac Ultrasound, Newmarket augmented by round the clock nursing care from a dedicated and professional group of nursing staff. Referring vets are increasingly aware that, although there is an expanding choice of referral services, there are distinct advantages in the multidisciplinary approach offered by the Trust. Jon s arrival and increasing caseload has produced a need to expand existing facilities, particularly the endoscopy facilities, which already allow comprehensive gastrointestinal and respiratory tract investigation. Thanks to a generous donation from the Dalmatian Rescue Service, the existing range of fibreoptic and video endoscopes will be complemented by a flexible urethrocystoscope facility. This will allow minimally invasive examination of the male and female urethra and bladder and we may be able to offer such services as non-surgical urolith removal or even non-surgical management of urinary incontinence by endoscopic procedures. Dalmatians are predisposed to urate urolithiasis due to their unique purine metabolism. Thanks to the generosity of the Dalmatian Rescue Service, Dalmatians and other breeds will be able to benefit from earlier diagnosis and therapeutic intervention. Course Organiser: Dr Lesley Young Registration: 350.00 BEVA members, 365.00 for non members Registration via BEVA Tel: 01223 836970 or e-mail info@beva.org.uk Nurses Club Evening Programme 23rd February: 26th April 5th Sept 19th Nov Ocular Emergencies David Donaldson BVSc(Hons) CertVOphthal MRCVS Cushings Syndrome Jonathan Wray BVSc CertSAM MRCVS Approach to the cancer patient Sue Murphy BVM&S MSc(Clin Onc) MRCVS Phobias Sally Ann Sore For further information, or an application form, for the Nurses Club, please contact Karen Felton at the AHT on 08700 502540 or by e-mail: karen.felton@aht.org.uk the science behind animal welfare