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Congress on Demand 2021: Internal Medicine
We are pleased to present a selection of lectures from BSAVA virtual Congress 2021 that cover internal medicine. This collection can be purchased as a standalone item, with a discount for BSAVA members. Visit our Congress on Demand information page for information about how to access the rest of our 2021 congress lectures.
Collection Contents
30 results
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A guide to the fundamentals of traumatic brain injury and spinal trauma
BSAVA Congress Proceedings 2021Author Tom CardyTom Cardy provides a guide to the fundamental aspects to be considered with traumatic brain injury and spinal trauma.
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A practical approach to jaundice in cats
BSAVA Congress Proceedings 2021Author Penny WatsonThe cat presenting with jaundice is rewarding to investigate because it already gives us a strong clue as to where its disease may be and there are a limited number of differentials for jaundice. Obviously, the cat is yellow because of increased circulating bilirubin. Considering the normal metabolism and pathway of bilirubin production and breakdown reminds us of pre-hepatic, hepatic and post-hepatic causes which need to be differentiated. Prehepatic jaundice is caused by increased production of bilirubin exceeding the capacity for hepatic excretion due to red blood cell destruction. It is distinguished from the others by a low haematocrit but icterus is very unlikely to occur unless anaemia is severe. Hepatic jaundice is associated with impaired hepatic uptake, conjugation or excretion into bile and occurs with hepatic disorders in which severe intrahepatic cholestasis develops, e.g. inflammatory liver diseases and feline hepatic lipidosis. Post-hepatic jaundice is associated with interruptions in flow in the extrahepatic bile ducts such as with choleliths; pancreatitis and biliary tract infection. Careful investigation with a combination of blood samples, ultrasonography, bile aspirates and (when indicated) liver biopsies should allow effective diagnosis and treatment.
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Acute kidney injury
BSAVA Congress Proceedings 2021Authors: Alix McBrearty and Caroline BoothroydMaking the diagnosis: Acute kidney injury (AKI) is a sudden fall in renal function and results in retention of uremic toxins and fluid, electrolyte, and acid-base imbalances. Classically AKI has been defined as a sudden (usually less than 1 week) increase in creatinine above the reference range, but because of the importance of obtaining an early diagnosis and the lack of sensitivity of creatinine in detecting a decline in GFR, more stringent criteria have been defined. AKI should be suspected in patients presenting with acute onset lethargy, anorexia, vomiting and diarrhoea regardless of their urine output. Critically ill and post-operative patients are at high risk and should monitored for AKI development. Physical exam findings often include dehydration and renal pain. Uremic halitosis, oral ulceration, hypothermia and bruising may also be present. The diagnosis is made based on an acute increase in creatinine and/or abrupt decline in urine output. Glucosuria (without hyperglycaemia), proteinuria, pyruria, microscopic haematuria and granular casts may be detected in on urinalysis. Further investigations should include a complete blood count, full biochemistry profile, urine culture, abdominal imaging and acid-base measurement (if possible). Other tests for underlying causes such as Leptospirosis, ethylene glycol toxicity and Lyme disease may be indicated.
Managing the patient: Acute kidney injury (AKI) is the rapid loss of kidney function leading to the accumulation of nitrogenous waste. AKI is potentially reversible either by resolution of the injury or by adaptation of the kidney or by both mechanisms. Management of the patient includes: correcting hypoperfusion, to the kidney, closely monitoring fluids ins and outs and adjusting intravenous fluid therapy as required, treating infections, such as pyelonephritis, leptospirosis and Lyme disease and alleviating blockages or repairing ruptures to the urinary tract. The holistic needs of the patient should be met: padded bedding in a warm, clean stress-free environment; time to rest and sleep; recumbency changed every four hours; water should be freely available, fresh and easily accessible; clinical examination at least twice a day; pain scores every four hours or as required; intravenous catheter care; consider a jugular catheter to facilitate fluid therapy and blood sampling; frequent toileting opportunity as likely high rates of fluid therapy. A urinary catheter would allow monitoring of urine output, oral hygiene, patients may develop painful ulcers on their tongue and oral mucosa. Suitable nutrition to meet the patients RER, a feeding tube should be considered.
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Approaches to weakness and collapse: a case based discussion
BSAVA Congress Proceedings 2021Authors: Holger Volk, Gerard MacLauchlan and Adrian BoswoodEpisodic weakness and collapse are common but frustrating clinical problems to investigate. They are frustrating because of the multitude of diseases that can manifest in this way and therefore the multitude of different organ systems that can be responsible for their development. Another challenging aspect of their investigation is that they are often intermittent, frequently occur in specific situations and are rarely observed by the clinician to whom the patient presents. If episodes are reasonably frequent asking the owner to video an episode and observe for specific changes in the patient can be very helpful. In a multidisciplinary hospital these patients can present to one of a number of different services and the initial challenge is often trying to decide which is the most appropriate service for which patient. Important clues can be obtained from the history and physical examination including: when do episodes occur?; is it at rest or on exertion?; does the patient seem to anticipate episodes, or do they occur out of the blue?; is the situation in which episodes occur always similar e.g. sprinting, barking at the postman or defecating?; does the patient lose consciousness?; how long do episodes last and what is the patient doing during the episode?; how rapid is recovery and how long does it take until the patient is back to normal?; is the patient completely normal between episodes?; do the signs seem to lateralise?; are any other clinical signs apparent? Careful physical examination may help to differentiate a patient with a neurological origin of their signs from one with cardiovascular or metabolic origins. Determining the system more likely to be responsible for the signs can allow more targeted diagnostic tests to be performed and prevent unnecessary expenditure on tests that are unlikely to be helpful. These points are illustrated during discussion of different case presentations.
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Catheter intervention or surgery?
BSAVA Congress Proceedings 2021Authors: Tobi Wagner and Poppy BristowCatheter intervention or surgery: cardiac interventions – when and how? This presentation gives an overview of cardiac conditions which can be treated or palliated via minimally invasive catheter techniques. The talk provides insight and general understanding how minimally invasive treatment works, and also demonstrates variations of common cardiac conditions to help with the understanding about limitations of catheter interventions.
Catheter intervention or surgery: cardiac surgery – when and how? Cardiac surgery in veterinary medicine has been slow to progress compared to other fields. It was previously thought that small dogs would not tolerate cardiopulmonary bypass (CPB) which severely limited potential case numbers, due to myxomatous mitral valve disease (MMVD) being the most common cardiac condition in dogs, and being primarily a disease of small breeds. Surgeries were therefore limited to congenital cardiac diseases as these are more commonly present in larger breeds e.g. pulmonic stenosis and double chambered right ventricle, and closure of patent ductus arterious. With the advent of interventional cardiology these surgeries are performed with decreasing frequency, and this presentation discusses when surgery may be considered preferable to an intervention for certain types of cases suffering with these conditions. In the past few years, mitral valve repair (MVR) surgery has been shown to be a highly successful management option for MMVD. For those centres performing cardiac surgery, MVRs now comprise the vast majority of cases and there are currently no interventional options available for this condition in dogs. The lecture also also touches on which cases make good candidates for this condition, success rates and the future for this disease management.
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Diagnosing seizures and other paroxysmal events
BSAVA Congress Proceedings 2021Authors: Tom Cardy and Holger VolkOdd episodes: when is a seizure not a seizure?: Dogs and cats presenting with abnormal episodes provide some of the most challenging and frustrating cases for veterinarians of all abilities. In veterinary neurology these episodes can be defined as ‘paroxysmal episodes’ with a defined start, defined end and relatively short duration. There are relatively few causes of paroxysmal episodes in dogs and cats including: seizures, syncope, vestibular syndrome, paroxysmal dyskinesia (movements disorders), narcolepsy/cataplexy, neuromuscular disease and idiopathic head tremors. Accurately classifying the paroxysmal episode is dependent on taking a thorough and systematic history that includes: a description of the event, the clinical status between episodes, asking if there is impairment or loss of consciousness, presence or absence of autonomic signs, description of muscle tone a lateralisation of presenting clinical signs. Where possible videos of the events should be reviewed with the owner. This lecture uses case examples and videos to review common paroxysmal episode presentations. Particular attention is given to seizures, syncope, vestibular syndrome and paroxysmal dyskinesia. We investigate the diagnostic approach to these conditions including genetic testing for certain breed associated conditions. Cases review the appropriate use of pharmacological or dietary treatments and highlight how the provision of accurate information to owners is critical in ensuring the optimal management of these varied conditions.
Other causes: Patients presenting with a history of paroxysmal episodes or ‘fits’ can be a challenge for even the most experienced clinician. First, the patient presents usually in your practice when it is normal. Second, the identification of the nature of episode is heavily dependent on a good description from the person who witnessed the episode or a home-style video. Third, most of these paroxysms appear unpredictable and uncontrollable for the owner so their view of what has happened might be clouded. A meticulous history is essential before embarking on a diagnostic investigation. Syncope, narcolepsy/cataplexy, pain, compulsive behaviour disorders, vestibular attacks, certain movement disorders, neuromuscular weakness and seizures are paroxysmal events, which share commonalities in their clinical presentation. The inter-paroxysmal (inter-episodic) clinical examination can be completely unremarkable. If the animals present with inter-episodic deficits then this will guide your clinical reasoning and help you determine the body system involved. If you are ‘lucky’ then the patient will present during a ‘strange’ episode at your clinic, e.g. prolonged seizure activity (status epilepticus [>10min], cluster seizures [≥2 seizure/day]) or vestibular attack. This lecture covers the ins and outs of how best to differentiate the wonderful bouquet of paroxysmal neurological episodes.
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Diagnosis of congenital portosystemic shunts: the textbooks are misleading
BSAVA Congress Proceedings 2021Author Mike WillardCongenital portosystemic shunts are typically described as a disease usually found in relatively young animals that demonstrate abnormal mentation that have microhepatia and increased concentrations of serum bile acids. However, there are some animals that do not follow these “rules”. In fact, a surprising number of dogs with PSS are “atypical” and will not be diagnosed unless you are willing to take a closer second look.
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Epilepsy management: beyond conventional drugs
BSAVA Congress Proceedings 2021Author Holger VolkWhenever a neurologist gives a talk to breeders or owners of dogs with epilepsy the topic of diet and cannabis comes up. Just as in real life! Can diet or cannabidiol influence antiepileptic drug response or even have antiepileptic properties? Medium chain triglyceride enriched diets have been shown to improve seizure control, cognition and fear response in dogs with idiopathic epilepsy. Furthermore, there is some evidence for a positive effect of cannabidiol, lifestyle changes and avoiding seizure triggers. “Every little helps” to get back control in canine epilepsy. This lecture addresses how to manage epilepsy more effectively and in synergy with conventional drug therapy.
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For the whole team: we have an echo machine – what can we do with it?
BSAVA Congress Proceedings 2021Author Jo Dukes McEwanIf you have an echo machine, it is important to use it! An echo machine, rather than a general purpose ultrasound machine, should have sector transducers. It will almost certainly have cardiac software on it as well – for 2D and M-mode measurements and calculations. You might even have colour flow and spectral Doppler software. So, the machine has all the capabilities you need – what about you? Even if you are not confident or trained, as a first step, just with transducer on chest, you can do the following to triage patients: is there a pleural or pericardial effusion? Are there B-lines? These are radial, hyperechoic lines showing the lung parenchyma has a mixture of air and fluid – so pulmonary oedema (or other pulmonary infiltrate) is detected. Can you identify if the left atrium is dilated? (if not, respiratory signs are not likely to be associated with left sided congestive heart failure). To increase confidence, do attend a practical echo course. It is always difficult using a different type of echo machine to the one we know – so consider working with someone (or attending a course) with a similar machine, to learn how to use it well.
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Gasping for air: how badly is my patient affected?
BSAVA Congress Proceedings 2021Authors: Julia Riggs and Chris ShalesJulia and Chris will each provide a short presentation demonstrating practical tips on how best to assess these patients in order to decide how severely they are affected by Brachycephalic Obstructive Airway Syndrome (BOAS). Julia will use her wealth of experience to discuss the physical examination of these patients in the consultation room and Chris will then lead you through examination of the anatomy of the upper airway under anaesthesia.
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Getting the basics right
BSAVA Congress Proceedings 2021Authors: Rebecca Geddes and Sophie McMurroughBlood tests in kidney disease – looking beyond: One of our biggest tools in evaluating the unwell patient is to run blood tests. Traditionally we look at urea and creatinine on our biochemistry panel to tell us if the patient has kidney disease. These parameters can tell us if a dog or cat is azotaemic or not, but how do we then decide if the azotaemia is pre-renal, renal or post renal? And which parameters can we use to help decide if the patient has acute kidney injury or CKD? Does a really high serum creatinine concentration always equal a poor prognosis? This lecture provides a quick, easy to follow overview of how to make the most of your blood tests when evaluating kidney function, and discusses how to make the most of your routine biochemistry panel, how haematology findings can help, and how to interpret SDMA concentrations.
Urine tests in kidney disease – beyond dipstick and USG: Renal disease is something we tackle every day in practice but how much do we know about the tests we have available? Urinalysis can tell us a lot about a patient’s renal function and it goes far beyond specific gravity and dipstick! Learn about the different tests we can utilise, how useful they are and what they can tell us about our patient. Urinalysis is a useful tool which complements bloodwork and together they can provide a well-rounded diagnosis.
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Health technology: the role of apps and devices in the future of cardiology – a personal perspective
BSAVA Congress Proceedings 2021Author Marc KrausTelecardiology – telehealth or telemedicine – are already showing considerable growth in the human medical fields. Telehealth is associated with lower mortality and emergency admission rates on the human side, driven by the need to provide lower health care costs; but can also be important and integral in providing optimal care for patients. This technology can also be applied to our animal patients. This lecture focuses on advanced technologies such as leadless pacemakers, micro-PDA occluders, smart phone ECGs, advanced mitral valve repair surgeries/devices and more.
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How do I take my basic heart scan further?
BSAVA Congress Proceedings 2021Author Jo Dukes McEwanYou can reliably obtain the standard 2D echo views and identify common cardiac pathologies. But you feel as if you are on a plateau and want to progress? If you are obtaining measurements from your echos, to compare with published reference ranges for species, breed or body weight of the animal, how repeatable are you with those measurements? A number of pitfalls are possible in measuring 2D and M-mode image and we will indicate how to avoid these. Obtaining reliable spectral Doppler is critical – you need to be able to optimise your 2D images to ensure your spectral Doppler cursor is parallel to blood flow. A thorough understanding of the pathophysiology of cardiac diseases is needed to problem solve if you identify an abnormality. Can you identify and interpret evidence of a volume overload or a pressure overload? You might have different levels of echo studies: triage in a patient with clinical signs; goal focused – e.g. staging a dog with myxomatous mitral valve disease; systematic Doppler echocardiography such as in a patient with a murmur with suspected congenital heart disease. This session identifies possible areas of echocardiography in which you can progress.
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How to approach neuro trauma in practice
BSAVA Congress Proceedings 2021Authors: Tom Cardy and Holly SmithHow to approach neurotrauma: a vet’s perspective – diagnosis and management: Neurotrauma, including traumatic brain injury (TBI) and acute spinal cord injury (SCI), is a relatively common emergency in small animal veterinary medicine that requires thorough patient assessment and a systematic approach to case management. Damage to the neuroparenchyma can be divided into primary injury directly associated with the trauma (e.g. contusion, compression, laceration and distraction) and secondary injury that occurs subsequently due to deficiencies in homeostasis and normal metabolic processes. Interventions are directed at addressing primary injury more so in SCI as well as minimizing the effects of secondary injury in both TBI and SCI. Initial investigations should be the same as any acute neurological case with a through history, physical examination and neurological examination. All patients should ideally have a minimum database performed with particular attention to electrolytes and glucose levels. Care must be taken to ensure the patient is systemically supported with a focus on airways, breathing and circulation. The level of intervention is patient dependent but can often be intense and hands-on. Prognosis for neurotrauma patients depends on the severity of injury, the site of the lesion, and the timing and efficacy of treatment, but with an appropriate response to initial management and stabilisation the outcomes of neurotrauma patients can be good.
How to approach neurotrauma: a vet nurse’s perspective – diagnosis and management: What you might expect, what to prepare for and complications in neurotrauma.
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Interactive cases with increased liver enzymes
BSAVA Congress Proceedings 2021Author Mike WillardA case-analysis of several cases ranging from mild disease to severe disease to things that look like liver disease but aren’t and things that look like other disease but are liver disease.
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Medical and surgical options for portosystemic shunts
BSAVA Congress Proceedings 2021Authors: Gerard Mclauchlan and Chris ShalesThe lecture focuses on the medical management of portosystemic shunts both in the immediate emergency setting and also longer term. Attention is paid to the evidence for surgery versus medical management. There is also a brief introduction into the minimally invasive options available for managing an intrahepatic shunt. This talk will be available in the BSAVA Library until May 2023.
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Nephroliths - when are they a problem and what should I do next?
BSAVA Congress Proceedings 2021Authors: Isuru Gajanayake and Tim CharlesworthIdentifying kidney stones – incidental finding or the key to the patient’s problem? Nephrolithiasis can be an incidental finding or one that requires urgent action. In this session, the problem of kidney stones in dogs and cats is discussed. This will include an overview of the types of kidney stones that occur in dogs and cats, and the underlying medical conditions that can cause these. There is also a discussion about the imaging modalities used to confirm nephrolithiasis, as well as other diagnostics (e.g. laboratory testing) that help identify their composition.
Approach to calcium oxalate nephroliths: surgery, medicine or wait and see? Nephrolithiasis is becoming more frequently diagnosed but remains an uncommon condition. Historically, nephroliths have not been associated with increased rates of progression of chronic kidney disease (CKD) but newer evidence has suggested a relationship between the presence of nephrolithiasis and a more rapid progression of CKD. Although the nature of this relationship remains unclear, it has prompted reassessment of how we treat nephrolithiasis. Many cases of nephrolithiasis are discovered incidentally and it is clear that they do not all require treatment. It is now accepted, however, that intervention should be sought for “complicated” nephroliths such as: stones associated with partial or complete obstruction of the uretopelvic junction and progressive hydronephrosis; stones associated with renal parenchymal loss, and stones associated with persistent pyelonephritis despite appropriate medical management. All surgical interventions are associated with renal damage and subsequent loss of function. This has led to recent recommendations to be as minimally-invasive and minimally-destructive as possible. The risks and subsequent potential loss of GFR caused by any intervention need to be justified by the anticipated clinical benefit to the patient. Techniques employed to remove complicated nephroliths range from nephrotomy, pyelotomy to endoscopic nephrolithotomy and these are discussed.
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Now then, this is no ordinary dog: what should I be looking for?
BSAVA Congress Proceedings 2021Author Chris ShalesThis lecture considers these interesting patients from a slightly wider perspective including consideration of conditions that can accompany Brachycephalic Obstructive Airway Syndrome (BOAS). It covers a variety of topics including ophthalmic, dermatological, neurological and orthopaedic conditions in addition to aspiration pneumonia, lung lobe torsion, hypoplastic trachea and nasopharyngeal mucocoeles. This talk will be available in the BSAVA Library until May 2023.
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Nutrition: stretching your knowledge – the evidence base for dietary intervention in renal disease
BSAVA Congress Proceedings 2021Author Isuru GajanayakeNutritional therapy, like medical and surgical treatments, is recommended to manage many diseases. It is vital that these recommendations are based on a solid evidence base. In this session, the evidence behind nutritional recommendations to manage kidney disease, including protein restriction, phosphorus restriction and fish oil supplementation, are discussed. This includes ways to assess the evidence behind the recommendations and how to use these nutritional recommendations to improve patient outcome.
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Regurgitation and BOAS hiatal hernia: should this be treated surgically?
BSAVA Congress Proceedings 2021Author Rob WhiteDysphagia, ptyalism, vomiting and regurgitation are common clinical signs in brachycephalic breeds. Prevalence of gastrointestinal disease in brachycephalic dog populations, especially in the French bulldog, has been reported to be as high as 97%. The negative intrathoracic pressures generated by increased inspiratory effort is believed to be a major cause of the gastro-oesophageal reflux. Laxity of the phreno-oesophageal ligament and the presence of a sliding hiatal hernia are also recognised in the many brachycephalic breeds. The necessity of making a definitive diagnosis of a sliding hiatal hernia is controversial; in part, because the dynamic nature of the condition means that often it is not an easy diagnosis to make. Most commonly, regardless of the diagnosis of a sliding hiatal hernia, the gastrointestinal signs are managed medically (for example, with the administration of a proton-pump inhibitor, a gastric protectant omeprazole and the use of an appropriate feeding regime) and, surgically, with the improvement of airway function. This presentation explores the controversies, while providing a practical and rationale approach to a typical case. In addition, the surgical management options for non-responsive cases are considered.
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The asymptomatic patient
BSAVA Congress Proceedings 2021Authors: Adrian Boswood and Jose Novo MatosAsymptomatic patients: I am hearing a heart murmur for the first time in an adult dog. What should I do? Incidentally discovered heart murmurs in adult dogs are common. Degenerative (myxomatous) mitral valve disease (DMVD) is by far the most common cause of acquired murmurs in dogs. Other possible causes would include dilated cardiomyopathy, bacterial endocarditis, previously undiscovered congenital heart disease and non-cardiac causes such as haemic murmurs and flow murmurs. In dogs with an appropriate signalment, a murmur with timing and location consistent with mitral regurgitation makes DMVD very likely. Factors that might make this less likely (or rule it out altogether) would include; the finding of a murmur that is audible continuously or in diastole, finding a murmur in a large breed dog or the presence of clinical signs indicative of significant systemic disease e.g. pallor or pyrexia. The single best diagnostic test to determine whether or not a murmur is caused by cardiac disease and to characterise the specific cause of a murmur is echocardiography. In some circumstances, echocardiography may not be possible due to cost or lack of access to appropriate equipment or expertise. In a patient suspected of having DMVD it is important to stage their disease as accurately as possible to ensure appropriate treatment can be instituted if appropriate.
Asymptomatic patients: I am hearing a heart murmur for the first time in an adult cat. What should I do? Cardiomyopathies are the most common heart diseases in cats with hypertrophic cardiomyopathy (HCM) being the most prevalent form. HCM affects 15% of apparently healthy cats. Cardiac auscultation in cats is challenging as it lacks both sensitivity and specificity. Cardiomyopathies may not cause a heart murmur, thus some cats with clinically significant heart disease have a normal cardiac auscultation. Conversely, a murmur may be present in some cats with structurally normal hearts. Thus, absence/presence of murmurs may not always help in determining which cats have heart disease. However, the majority of cats with a murmur do have structural heart disease, especially older cats with loud (≥3/6) murmurs. In HCM, murmurs are commonly caused by dynamic LV outflow tract obstruction. Normal cats can have murmurs due to dynamic RV outflow tract obstruction (clinically benign). NT-proBNP is increased in cats with moderate-severe asymptomatic cardiomyopathy, thus it may be used as a first-line test to assess the likelihood of heart disease in a cat with a murmur. But echocardiography is required to confirm the presence of heart disease, and most importantly to assess for risk factors associated with increased risk of CHF and ATE (e.g. left atrial size). Systemic diseases that may cause a murmur should also be excluded, i.e. check blood pressure, haematocrit and T4 (cats >6 years). Normal and HCM cats may have heart murmurs, but a loud murmur in a cat >6 years is more likely to be associated with HCM and further investigations are recommended. Early interventions in cardiomyopathic cats may reduce the risk of serious complications, thus early detection of occult cardiomyopathies is paramount.
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The ethics of managing heart disease in pets
BSAVA Congress Proceedings 2021Authors: James Yeates, Tobi Wagner and Poppy BristowThere are always going to be ethical questions and concerns when introducing new treatment modalities, and rightly so. As veterinarians we must always have animal welfare at the forefront of our decision making. Heart disease is a very common disease in dogs and can have a huge impact on quality of life, a subject that until recent years has been largely unresearched in veterinary patients. When considering any treatment option we must always consider its likely effect on quality of life; expected detrimental effects weighed up against potential improvements, in addition to quantity of life expected to be gained. This is particularly challenging in veterinary patients when assessment of quality of life and decision making has to be made by proxy. Maintaining a good health related quality of life (HrQOL) is just as important as survival to most humans in chronic heart failure (Lewis et al. 2001) and is also more important than quantity of life in owners of cats and dogs with cardiac disease (Oyama et al 2008, Reynolds et al. 2010). It is imperative that with any intervention, be they medical or surgical that owners are fully informed of potential risks and consequences, and presented with the most up to date and accurate information candidly.
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The team approach to the brachycephalic patient
BSAVA Congress Proceedings 2021Authors: Julia Riggs, Chris Shales and Lydia SmithThis is a recording of a session giving Congress delegates the opportunity to ask questions and discuss practical tips and techniques used by three experienced team members to manage their busy BOAS clinics. The session complement the pre-recorded seminars and other live sessions that form part of this stream and gives a very useful exchange of ideas and experiences in this challenging but rewarding area.
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The value of a good hepatic biopsy
BSAVA Congress Proceedings 2021Author Penny WatsonThe results of blood and imaging tests are non-specific in liver disease, so a liver biopsy is usually indicated to give a diagnosis and allow most effective treatment. Certainly, steroids or copper chelators should never be used without justification from a liver biopsy. The clinician must decide the best way to perform this biopsy considering how stable the patient is, the financial resources of the owner and the relative reliability of the results obtained with different methods. There is also little point in taking a biopsy which is not representative of the underlying disease – if the sample is too small, or from the wrong place, or only from one of a number of organs affected with disease, it may lead to the wrong conclusions being drawn and the wrong, or incomplete, treatment protocols. Fine needle aspiration (FNA) cytology is not strictly a biopsy but a potential alternative to more invasive biopsies but beware becoming ‘liver FNA happy’ for fear of false diagnoses and wasting the client’s money. FNAs are only helpful in a small number of cases, predominantly for bile aspirates and to rule out feline hepatic lipidosis or lymphoma. Wedge biopsies taken at laparotomy or laparoscopy are the most reliable diagnostically.
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Update on current ACVIM consensus statements: MVD and HCM
BSAVA Congress Proceedings 2021Authors: Jose Novo Matos and Kieran BorgeatKieran Borgeat and Jose Novo Matos discuss an update on the current ACVIM consensus statements for MVD and feline cardiomyopathy.
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Update on current ACVIM consensus statements: MVD and HCM – case studies
BSAVA Congress Proceedings 2021Authors: Jose Novo Matos and Kieran BorgeatFollowing on from their lecture ‘Update on Current ACVIM Consensus Statements MVD & HCM’ Kieran and Jose discuss and challenge over two case studies. Watch Kieran and Jose put each other to the test, discuss their thought process around the cases and compare notes on their experiences of managing heart disease.
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What is the current thinking on feline triaditis: does it even exist?
BSAVA Congress Proceedings 2021Author Penny WatsonThe term ‘triaditis’ is used to refer to concurrent pancreatitis, cholangiohepatitis and inflammatory bowel disease (IBD) in cats. It was first reported in a case series in 1996 in which an association with nephritis was also found. The disease associations were controversial for many years, but more recent clinical, post mortem and imaging studies provide strong evidence for concurrent disease in two or three of the gut, pancreas and liver in a significant number of cats. The reason for these associations remain speculative. It is very likely that cats suffer from not one but several different biliary tract diseases, some of which may be associated with pancreatitis and/or IBD and some of which might not. The relative involvement of bacteria, immune-mediated disease or sphincter of Oddi dysfunction remain unclear, the optimal treatment is unknown and even studies on the long term follow up of cases are lacking. Many questions still remain and future studies hope to characterise the disease better including advanced imaging of the biliary tract and the role of feline autoantibodies. Ultimately, we need better understanding to allow more effective diagnosis and treatment of cats in the future.
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What should we advise owners about mucocoeles: surgery, medicine or ignore?
BSAVA Congress Proceedings 2021Authors: Mike Willard and Chris ShalesWhat are the medical options for mucocoeles? First, one must identify those animals whose gall bladder mucocoeles are suitable for medical management because medical therapy of mature “kiwi fruit” mucocoeles may result in substantial morbidity and even mortality. After selecting the appropriate cases, one should next look for co-morbidities (especially endocrine) that are believed to increase the risk of mucocoele, and if found need to be treated. Finally, choleretics (especially high doses of ursodeoxycholic acid) are used to help liquify the gall bladder contents, must like a diet designed to dissolve uroliths.
When and how should we intervene surgically with mucocoeles? This talk compliments the medical perspective regarding treatment of this disease and tries to explore some of the challenges in decision making that surgeons can face when managing this interesting condition. This talk will be available in the BSAVA Library until May 2023.
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Where do I start? Keys to cost-effective neuro diagnosis
BSAVA Congress Proceedings 2021Authors: Tom Cardy and Holger VolkAn introduction to the neurological examination: Neurology cases are a common presentation for veterinarians in general practice but can frequently seem overwhelming. In many patients it can be challenging to establish a neuroanatomical localisation making attempts to generate a list of focused differential diagnoses and determine a management plan feel like a lost cause. This lecture aims to provide a simple and logical approach to the neurological exam that works within general practice. Participants will learn the skills to determine if a neurological abnormality exists and develop the knowledge and confidence to interpret their findings in order to localise the lesion to a specific anatomic region of the nervous system. We also examine how the ‘Five-Finger Rule’ considers elements from the patient signalment, onset, progression, lateralisation and pain of the presenting condition to improve clinical reasoning in neurology cases to generate a list of prioritised differential diagnoses.
Key diagnostic tests: In the past decade there has been an exponential increase in diagnostic tools in veterinary medicine fueled by an even faster developing toolkit in human medicine. The developments of diagnostics, especially in advanced imaging and genetics, have not only improved our clinical diagnostic abilities, but also enhanced our understanding of their pathophysiology and treatment. The rapid development of the new diagnostics paralleled with an increase in costs. The development of diagnostics for veterinary medicine, especially in the field of imaging, will be slowed by the increase in costs, if we are not careful. Taking this into account and the current financial climate, inappropriate use of diagnostics leads to unnecessary cost to the owner and frustrations (which might end up in complaints) and potentially morbidity to the patient. Many of the advanced techniques used in veterinary neurology are invasive, require an anaesthetised or sedated patient, therefore a logical clinical reasoning approach is essential to ensure the correct body part is looked at, the lesion is accurately and correctly identified and one is not hijacked by an incidental finding. Using the five-finger rule (Onset and course of the disease, symmetrical or asymmetrical, painful or non-painful, neuroin conjunction with the signalment will determine a handful of differentials which can then be verified by using your diagnostic toolkit. This lecture covers when, why and how you should use the various diagnostic tests which can be grouped into 1. Clinical pathology, 2. Assessment of structure using diagnostic imaging techniques and 3. Functional assessment (mainly electrodiagnostics).
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Why and how should we do more liver biopsies in practice?
BSAVA Congress Proceedings 2021Authors: Mike Willard and Penny WatsonWhy should we do more? Many clinicians view the liver as a “black box” that is difficult to understand and which has diseases that are only treated with basic supportive therapy. Hence, they see no reason to do something invasive like a biopsy. Or, perhaps they have been “burned” in the past by doing a biopsy incorrectly or at the wrong time, resulting in therapeutic failure and an upset client (outcomes that they want to avoid ever experiencing again). In fact, a lot of chronic hepatic diseases can be cured or controlled if diagnosed in a timely fashion. However, the only way to definitively diagnose most chronic hepatic diseases is by histopathology. Furthermore, it is extremely rare that a properly performed hepatic biopsy results in morbidity or mortality.
How should we do more? Taking a liver biopsy is central to diagnosis and effective treatment in most canine and feline liver diseases. I explain to the owner that the results of the biopsy will help treat their animal more effectively and that treatments such as copper chelators or immunosuppressives cannot be used without histology. Owners usually want the least invasive option, but a poor, unrepresentative sample is worse than useless. It is important to explain to them the strengths and limitations of different techniques and the value of taking larger, representative wedge biopsies. Fine needle aspirates are only indicated for bile culture and cytology and to help diagnose lymphoma or hepatic lipidosis, but even then have to be viewed with caution. Ultrasound-guided trucut biopsies are often poorly representative of the disease as a whole and carry an increased risk of bleeding. I discuss the benefits of wedge biopsies in making a more reliable diagnosis, allowing more effective treatment. I am lucky to have access to laparoscopic biopsies which we made cost effective by matching the price of ultrasound-guided biopsies so that owners do not make a decision based on finances. Wedge biopsy at laparotomy is a good alternative but owners can be harder to persuade because it is more invasive.
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