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The author describes his path into and out of leading a large veterinary referral practice, and reflects on the challenges and rewards of leadership. Moving into a leadership role generally requires development of new skills and insight, and may mean old roles have to be passed on. The value of skills transferable from the clinic, such as listening, questioning, problem solving and trusting, are highlighted. The demands of task management, relationship management, external networking and change management are discussed. Reflecting from outside of the role, the importance of leadership development, self-care, daring, personal growth and change are acknowledged.

Members of Veterinary Humanities UK argue that the vet professions should move away from using the term 'gold standard care' and instead adopt 'contextualised care', which acknowledges that different treatment pathways are able to offer equally acceptable patient journeys in different contexts.

An 8-year-old female neutered domestic shorthair diagnosed with idiopathic hypercalcaemia and undergoing weekly treatment with alendronate presented to Davies Veterinary Specialists for progressive facial swelling and discomfort 12 months after commencement of bisphosphonate treatment. Progression of the pathology was documented through clinical history from the referring practice when the patient underwent dental treatment with dental radiographs and then subsequently CT evaluation of the lesions. Proliferative and lytic, multifocal bony changes to the jaw, with a strikingly similar radiographic appearance to that seen in humans suffering from bisphosphonate-related osteonecrosis of the jaw (BRONJ), were seen. BRONJ is a well-recognised side effect of bisphosphonate therapy in people undergoing bisphosphonate therapy for the management of malignant hypercalcaemia. The cat was eventually euthanised due to the development of an abdominal mass and declining quality of life.

Hypermanganesemia is commonly recognized in human patients with hepatic insufficiency and portosystemic shunting. Since manganese is neurotoxic, increases in brain manganese concentrations have been implicated in the development of hepatic encephalopathy although a direct causative role has yet to be demonstrated. Evaluate manganese concentrations in dogs with a naturally occurring congenital shunt before and after attenuation as well as longitudinally following the changes in hepatic encephalopathy grade. Our study demonstrated that attenuation of the shunt resolved encephalopathy, significantly reduced postprandial bile acids, yet a hypermanganasemic state persisted. This study demonstrates that resolution of hepatic encephalopathy can occur without the correction of hypermanganesemia, indicating that increased manganese concentrations alone do not play a causative role in encephalopathy. Our study further demonstrates the value of the canine congenital portosystemic shunt as a naturally occurring spontaneous model of human hepatic encephalopathy.

A retrospective study was performed to investigate the frequency of identification and characteristics of oesophageal disease in cats, including assessment of the utility of diagnostic techniques and clinical outcome. Thirty-three cats met the inclusion criteria, giving an in-clinic frequency of 33/2894 (approximately 1%) of feline referral cases. Vomiting and/or regurgitation were the most common presenting signs described, although a number of cats (6/33) showed neither. Useful diagnostic modalities included plain radiography, fluoroscopy, barium radiography and endoscopy. A wide range of diseases was reported including congenital disease, oesophagitis, foreign body obstruction, neoplasia, extraluminal compression and hypomotility disorder. Five of six cats with acquired oesophageal strictures had recently received doxycycline per os.

Haematology and biochemistry screens were also performed as a baseline prior to drug therapy and revealed a sole mild elevation of alkaline phosphatase. The BAL showed chronic active bronchitis characterised by mixed inflammatory cell population (macrophages, small numbers of neutrophils, reactive small lymphocytes and rare mast cells). There was no evidence of inhaled foreign material or parasites. Culture of the fluid was negative. Pending BAL results Angus improved on a combination of theophylline (Corvental D, Novartis) 200 μg q 24h and doxycycline (Ronaxan, Merial) 120 mg q 24h. CASE Angus was a nine year old male neutered West Highland White Terrier who presented with a history of progressively increasing panting and coughing on exercise/excitement. On examination, resting respiratory rate and effort were very slightly increased. Cardiac auscultation revealed no heart murmurs, a heart rate of 90 beats per minute and an obvious respiratory sinus arrhythmia. The most dramatic findings were very harsh inspiratory and expiratory crackles over all lung fields, loudest towards the hilus. There was also an intermittent, occasionally productive, cough. Although the presentation was consistent with fibrosing alveolitis, further investigation was strongly advised because frequent coughing does not, typically, accompany simple fibrosis unless there is concomitant small airway disease (Corcoran et al., 1999). Angus was anaesthetised for a CT scan of his chest. This showed a generalised increase in soft tissue density with a ground glass appearance and obvious dilation and thickening of some of the major airways (Fig. 1). Overall these findings were consistent with pulmonary interstitial disease (fibrosis) and Clive M Elwood MA VetMB MSc PhD MRCVS CertSAC Dip ACVIM Dip ECVIM Nathaniel T Whitley BVMS PhD MRCVS CertVC Dip ACVIM Dip ECVIM DAVIES VETERINARY SPECIALISTS LIMITED MANOR FARM BUSINESS PARK HIGHAM GOBION HERTS SG5 3HR Fibrosing alveolitis and pulmonary arterial hypertension in a West Highland White Terrier

Background: Trilostane is a recognized treatment for canine pituitary-dependent hyperadrenocorticism (PDH); however, its efficacy in dogs with adrenal-dependent hyperadrenocorticism (ADH) is unknown. Objectives: To examine factors that might influence survival in the medical management of ADH, with particular emphasis on treatment selection. Animals: Thirty-seven animals referred to 4 centers over a period of 12 years that had been diagnosed with ADH and treated with either trilostane (22/37), mitotane (13/37), or both (2/37). Methods: Retrospective analysis of clinical records. Results: There was no statistically significant difference between the survival times of 13 dogs treated only with mitotane when compared with 22 dogs treated only with trilostane. The median survival time for animals treated with trilostane was 353 days (95% confidence interval [CI] 95–528 days), whereas it was 102 days (95% CI 43–277 days) for mitotane. Metastatic disease was detected in 8 of 37 dogs. There was a significantly lower probability of survival for dogs with metastatic disease when compared with those without metastatic disease (P < .001). Conclusions and Clinical Importance: The choice of medical treatment for ADH may not have a major effect on survival times. However, the presence of metastatic disease considerably decreases survival time regardless of the choice of medical treatment.

This report describes recurrent respiratory distress following vincristine administration to a cat with chronic lymphocytic leukaemia. The cat was treated with a combination of vincristine, chlorambucil and prednisolone with initial success. After approximately 4 months, dyspnoea developed within 6 h of vincristine administration. Emergency therapy was instituted resulting in a full recovery. Further vincristine was administered; dyspnoea was similarly noted after all but one of these treatments. Dyspnoeic episodes were not attributable to alterations in vincristine dose or method of administration. The repeated temporal association was consistent with a suspected adverse drug reaction to vincristine.

DISORDERS associated with regurgitation and failure of oesophageal function can be difficult to define and frustrating to treat. Aspiration pneumonia is a common and potentially life‐threatening sequela and, for this and other reasons, every effort must be made to define the disorder and institute appropriate management as early as possible. Often, various treatments may need to be tried and tested to determine which is most suitable for an individual patient. This article provides guidance on diagnostic approaches and treatment options for the clinician presented with a dog with suspected oesophageal disease.

VOMITING is a common presenting complaint in canine clinical practice and dogs seem particularly prone to vomiting without much encouragement. It is part of the clinician9s role to determine whether vomiting is frequent enough or associated with other clinical signs that indicate a need for treatment or further investigation. Ultimately, a correct diagnosis and appropriate management depend on good clinical practice and, as discussed in this article, a logical approach to the investigation. At each stage, careful assessment is required to ensure that diagnostic tests are suitably discriminatory. Results must be critically appraised and related back to the clinical presentation of the patient at all times.

IN 2006, Gerry Polton and Clive Elwood described how an infection control group was set up in their practice to investigate infection risks and improve hygiene practices (In Practice, October 2006, volume 28, pp 548-550). The practice duly saw improvements in the incidence of hospital-acquired infections. However, infection control is an ongoing process and here they report further on what has been learned from their experiences.

TWO years ago, in response to concerns about the nosocomial infection rate in its veterinary hospital, Davies Veterinary Specialists set up an infection control group to investigate infection risks and improve hygiene practices. As Gerry Polton and Clive Elwood explain, this has led to tangible improvements in the incidence of hospital‐acquired infections and has also had significant spin‐offs in terms of improved patient care and enhanced staff morale.

(1994). The Approach to the Small Animal Poison Case. Veterinary Nursing Journal: Vol. 9, No. 3, pp. 79-85.

Diseases of the urogenital system can lead to problems with fluid balance, metabolic derangements, pain/discomfort, infection, dysuria, incontinence (with the potential for urine scalding) and inhibition of voiding behaviours. Appetite may be affected and specific nutritional therapies may be appropriate. Case examples: Chronic kidney disease in a cat; Chronic pyelonephritis in a dog; Protein-losing nephropathy in a dog; Bladder transition cell carcinoma in a dog; Urethral sphincter mechanism incompetence in a dog; ‘Idiopathic’ cystitis in a cat; Acute urinary obstruction in a cat; Urolithias in a dog; Prostatitis in a dog.

Clive Elwood and Celia Marr argue that there is a need to improve the definition and regulation of specialists to avoid confusion among the profession and the public THE Lowe Report (2009) on veterinary expertise in food animal production states: ‘Information about what counts as specialisation is unclear and confused … the profession’s concept of specialisation is inward-looking and orientated towards fellow professionals rather than aimed at informing the customer.' Although Lowe was primarily interested in food animals, this assessment is applicable across the species and disciplines. Unfortunately the term ‘specialist’ is not protected and is used, at times, to imply a level of expertise that is not justified, leaving the customer unable to make truly informed treatment choices. As specialisation has developed within the profession, so have specialist-level treatments and facilities, with referral an accepted option for many cases. Referral practices are not specifically regulated, however, nor are there universally accepted standards of clinical governance and audit. There is a clear need to improve the definition and regulation of specialists …

Small intestinal bacterial overgrowth (SIBO) was diagnosed by quantitative bacterial culture of duodenal juice samples obtained endoscopically in 41 of 80 dogs that were admitted with chronic diarrhea, vomiting, or weight loss. Thirteen dogs had aerobic bacterial overgrowth, most frequently comprising Escherichia coli, staphylococci, and enterococci, and 28 dogs had mixed anaerobic overgrowth, most frequently including Clostridium and Bacteroides spp. Affected dogs comprised 23 breeds, including 10 German Shepherd Dogs and median age at diagnosis was 2 years (range, 6 months to 11 years). High serum folate and low serum cobalamin concentrations had fair specificity (79 and 87%, respectively), but low sensitivity (51 and 24%, respectively) in detecting SIBO. Histologic examination of duodenal biopsy specimens did not reveal abnormalities (26/41 dogs), or revealed mild to moderate lymphocytic (12/41) or eosinophilic (2/41) infiltrates, or lymphosarcoma (1/41). Oral antibiotic treatment was effective in 77% (23/30 dogs), but prolonged treatment (4 weeks) was required to control signs and prevent recurrence in 50% (15/30). Corticosteroids were used alone in a dog with eosinophilic enteritis and in combination with antibiotics in 4 dogs with marked gastrointestinal lymphocytic/plasmacytic infiltrates. This study suggested that SIBO may be observed in dogs of many breeds, without an obvious primary cause, and that, although results of indirect tests may be suggestive of SIBO, bacterial culture of duodenal juice samples remains necessary for definitive diagnosis.

CLINICAL IMMUNOLOGY OF THE DOG AND CAT, 2nd edn Michael Day. 464 pages, hardback, £95.00. London, Manson Publishing. 2008. ISBN 978 1 84076 098 9 ![Figure][1] HAVING reviewed the first edition of this book, published in 1999, I jumped at the chance to

Manual of Veterinary Dietetics Tony Buffington, Cheryl Holloway, Sarah Abood Published by Elsevier, 2004. Paperback, 251 pages Price £29.99. ISBN 0-7216-0123-5