Friends of Vets on The Balkans- Dr Liliya Mihaylova

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Dr Liliya Mihaylova

Today we will present to you another friend of Vets on The Balkans, Dr Liliya Mihailova.

 

She is veterinary surgeon at the biggest veterinary clinic in Varna, Bulgaria. One of the most famous cardiologist in Bulgaria, teacher and friend of many many vets in Bulgaria and not only.

Let her friends and colleagues discribe her:

 

 

 

78508821_961764280857493_2739612204776030208_nLUIGI VENCO, DVM , SCPA, Dipl EVPC, Pavia, Italy

 

“When I first met Liliya Mihaylova, I immediately thought she was shy. Then working with her I realized that she is not shy at all. She is an incredibly sweet and respectful person. And the same sweetness and respect she puts into her profession and into relationships with the people around her. We had the opportunity to work together for months, we met each other at courses and conferences in every part of the world and she is always smiling. I was able to appreciate how brilliant she is as a veterinarian but if ask me if I prefer her human or professional aspect I can tell you that I prefer both and that if they are in the same person and if you’re lucky enough to be her friend , you’re very lucky, as I am”
 

61339937_10219962671486451_5841102552728338432_oDr Gergana Vitanova, veterinarian in veterinary clinic Albaitar, Ruse, Bulgaria

“Life meets you with different people. Some of them manage to provoke you to do your best with their example. Dr. Mihailova is exactly that. There is no way that you will not be infected by this difficult combination – uncompromising professionalism and the rarely found kindness.”

 

 

 

 

25442892_719068364966330_5338298658327192274_nFlorin Delureanu,DVM, MRCVS, veterinarian from Romania

“I met Liliya in the summer of 2017 through a veterinary medical event in Bucharest. During the lunch break she sat next to me and asked me where and for how long i work as a veterinarian and if the clinic where i work is a big one. Even though the discussion from that day was short, she left me a good impression. About 5 months later, in the winter of the same year, I decided to contact her with the intention of spending my winter holidays in the clinic where she works (United Veterinary Clinic-Varna) to develop even more my knoledge. I was pleasantly surprised by the speed and promptness with which she answered me, the answer being a positive one. After arriving in Varna, Liliya was very polite and intended to give me a lift from the bus station to the clinic. When i arrived at the clinic, i was very excited and wanted to help because there were so many patients waiting and Liliya was very open minded from day one and offered me the opportunity to participate with her in a few surgeries. She also had a pleasant attitude both at work and outside of work, was very friendly and gave me many tips. She has contributed a bit to my present by encouraging me and supporting me to move to another country (England) to develop myself. Because she is in a continuous development especially in the field of cardiology and endoscopy, i can say that she has given me many details, tips and tricks regarding this field! I have a lot of respect for Liliya, and i am grateful for the nice experience she offered me i am honored to know her!”

 

 

78608501_2993069480722815_5314071698566283264_oDr Spas Spasov, veterinarian at veterinary clinic Dr Antonov, Varna, Bularia

“What can I say about Lily.

We’ve known each other for almost 7 years.

She is one of the sweetest people I know, dedicated to her work and friends.

You can always count on her, both for work and if you just want to talk to her about things other than work.

Lily is a person who motivates us to be better professionals and people.

Her desire for continuous development is inspiring.

What else can I tell you about her … she’s always late, hahaha , she’s often quite distracted because she thinks about 100 things hahaha.

Big animal lovers: she has a dog, a cat, two parrots and a fish.

Quite often, she takes care of a wounded wild boar, for example, an owl, a gull, a sparrow, a pigeon, etc. .

When you go to visit her, you actually go to a small home full of friendly animals.

 

Of course, these things are not enough to describe the Lily as a person and a friend.

In conclusion, Lilia is a wonderful doctor and friend, and I am more than happy to have   her in my life”

 

THANK YOU Liliya for being such a good friend of Vets on The Blakans!59910676_10219811414505121_5136066701674151936_o

 

Friends of Vets on The Balkans- Dr Lea Kreszinger

Today we will present one of our friends, vet and friend who always support Vets on The Balkans, Dr Lea Kreszinger.

12507257_1321202834572913_5626344650040540301_nShe is an owner of 24 hours veterinary clinic in Zagreb, Croatia, she is also the head of Croation Small Animal Section, Director of FECAVA for Croatia and mother of 4 kids….. We can say just super woman.

Let’s her friends discribe more about her:

 

22007383_10159506036200531_1581377269244761437_nDr Wolfgang Dohne

Wolfgang is senior veterinary surgeon and founder of the Virginia Water Veterinary Clinic and Senior President of FECAVA

“Lea is one of the most extraordinary people I had the pleasure of meeting in my professional life. She manages to combine a fine interlect with both mental and physical strength. I see Lea as role model for a new breed of veterinary professionals – highly skilled with a constant appetite to improve her knowledge and her skills, but at the same time being acutely aware of the importance of physical exercise and wellbeing and a good work life balance. There are not a lot of people I know who can combine raising virtually singlehanded four children, running a successful veterinary clinic, competing in various sportsevents, organising nummerous CPD events and still finding time – and strength – to enjoy the finer things in life with her friends.”

 

31675106_10156528301028738_1797739977140862976_oDr Vladislav Zlatinov

Veterinary surgeon Central Veterinary Clinic

 

“Lea is unique and extremely strong woman character. I have been gifted with her friendship for many years. I have always been respected. How one woman could be an excellent surgeon, opinion leader in the area, successful practice manager, organizer of massive scale vet events, mother of four kids, traveling all the time, always studying and improving…? This must demands hell of an energy and qualities! And strangely, nevertheless the successes and her character is at least as proud as an lion, she still keeps her modesty. Just great!

 

I am sure that she is a shining example for many girls in the veterinary profession that strong will, good work and determination can bring them wherever they want, nevertheless any obstacles on your way. So Lea is a great inspiration for the young vets.

 

But before all Lea is just a true friend, that will not leave you behind because of simple interests or whatever. In the unfair world this is priceless, and deserves all the respect and admiration. These are he kind of people I would like to have around me. We love you Lea :)”

 

45342245_10156991837538738_4110675489188741120_oDr Nikola Bunevski

Lea’s emloyee

 

“I must to describe dr.Lea(my boss) in some words?

I met Lea 10 years ago as a student on postgraduate studies of surgery. And in that time  i say to myself”i think that i can learn alot from this women”

She is one of those unselfish bosses and colleagues who is sharing knowledge and stands by your site in time of  need.

She is asking and listening,teaching and giving path of your success especially in time when you grow as a veterinarian…she is not just a boss but a friend on which you can count on!!!

I think that Lea is a hardcore teacher and a leader that shows you how to never give up-on patient,on situation,on position,on life in general.

Even almost after 10 years i’m learning each day something new…

Cheers to friendship!Cheers to success!Cheers to you Lea ”

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Leishmaniasis associated to genital TVT in a dog

(case report)

Sofi SinadinovaDr. Sofiya Sinadinova

Blue Cross Veterinary clinic Blagoevgrad- Bulgaria

 

Introduction:

Canine transmissible venereal tumor(CTVT),also known as transmissible venereal tumor (TVT) or Stickers’s sarcoma, is a  transmissible cancer, that affects dogs. CTVT is spread by the transfer of living cancer cells between dogs, usually during mating. It’s normally localized at the external genitalia of male and female dogs, also at the oral and nasal cavities. Immuno-compromised and generally unhealthy dogs are predispose of leishmaniasis associated to genital TVT, and especially in a dogs living in Mediterranean region. CTVT  may also be transferred by licking, sniffing  or parturition. Clinically, CTVT lesions are red to tan, friable, verrucous to multilobulated masses, predominantly affecting genital organs, and are usually ulcerated and inflamed. Metastasis is uncommon ,but  is usually seen in regional lymphnodes. Other reported sites of metastasis include skin, subcutaneous, brain, eyes, spleen ,liver, musculature, lungs, anus, bones, kidneys ,testicles and  mammary glands.  Leishmaniasis is a vector-borne diseases with wide geographic distribution affecting humans, dogs and several wildlife species. Depending on the infecting Leishmania species and the immunocompetence of the host, the infection can result in visceral (CanVL), cutaneous or mucocutaneous disease.  CTVT and CanVL can overlap epidemiologically particularly in regard to their geographical distribution. In recent study was  found  that Leishmania sp.   has tropism for the canine male genital tract. CanVL has been previously identified concurrently with canine transmissible venereal tumor as well as Leishmania amastigotes within CTVT neoplastic cells.

Clinical case:

CASE REPORT-  A 10 yrs old mixed-breed female dog Lucky was presented in Blue Cross animal hospital  in Blagoevgrad on 01.04.2019 in a state of  prostration. The dog had been adopted from the street. On presentation Lucky was in a very bad body condition-cachectic  with pale mucosa membranes , muscle atrophy, onychogryphosis and two large cauliflower-like, ulcerated, hemorrhagic vaginal tumor masses. (Figure 1). The skin examination showed generalized alopecia with lice infestation and diffuse seborrhea. There wasn’t any lymphadenomegaly detected. Abdominal ultrasound examination didn’t show abnormalities in the spleen and other organs.

20190401_174353 20190401_174359

 

 

 

 

 

 

 

 

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Fig 1

21 04

Fig 1

Clinical diagnostic tests:

A  complete blood(cell) count (CBC), serum biochemistry profile were performed along with a Snap 4Dx test to screen for vector borne disease agents  Dirofilaria immitis (heartworm disease),Erlichia canis (ehrlichiosis) ,Anaplasma phagocytophilium (anaplasmosis) and Borrelia burgdorferi (Lyme disease)  and test  for Leishmania detecting antibodies. In addition, skin scrape of the few places on the skin and  fine needle aspiration cytology of the vaginal mass was done. The CBC revealed anemia, haemoglobinemia, Leukocytosis (lymphocytosis, granulocytosis).The serum biochemistry profile revealed hyperglobulinemia, hypoalbuminemia, low A/G ratio, hypocalcemia. The dog was positive for E.canis, A.phagocytophilium and Leishmania Ab. The skin scrape was negative for demodicosis and scabies. A fine needle aspiration cytology   of the vaginal mass revealed a neoplastic  round and ovoid  cell population with some inflammatory cells. Every cell is containing single ,large and  round  nuclei. The abundant cytoplasm was delicately granular and optically empty. The cells had an characteristic for transmissible venereal  tumor (TVT).(Figure 2)

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Fig 2

 

Clinical evolution:

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Fig 3

Treatment with doxycycline 10mg/kg,p.o. q12h for 30 days for ehrlichiosis and anaplasmosis was initiated. In addition Milteforan  2mg/kg,p.o. q24h  for 28 days and Allopurinol 20mg/kg,p.o.,q12h for 6 to 9 months was initiated for treatment of Laishmaniasis. The dog get   also every day, some supplement for the skin like omega 3 and omega 6 amino acids  and every 3th day topical treatment with shampoo with ketoconazole and chlorhexidine. The dog spent  20 days in the clinic, during that time Lucky get really improved (figure 3 ).

 

 

For the TVT treatment with vinciristine sulfate 0.6 mg/kg/m2, I.V., q7d for a total 8 treatments was initiated. The dog was monitored  with a CBC every week. Photographs of the vaginal tumors were taken at each follow up visit to monitor the progress. After the second vincristine treatment there was visible improvement. The mass had decreased in a size.(fig.4and 5)

first week

Fig 4-First week after vincristine treatment.

 

2 w

Fig 5-Second week after vincristine treatment.

3 w

Fig 5-3rd week after vincristine treatment.

 

 

 

 

 

 

 

 

 

 

 

5w

fig 6

By the f ourth week only a small remnant of the mass was visible(fig6).

 

 

 

 

 

 

7w

Fig 7- 7th week of the treatment

 

During the all treatment there was no decreasing of the  thrombocytes, CBC was completely normal. There was no side effects  of the vincristine treatment.

 

 

 

Conclusions:

The patient was fully recovered. The treatment with Allopurinol is stopped. Sixed months after the last vincristine treatment, Lucky was doing great, no TVT recurrence. Neutering of affected dogs can be beneficial to decrease distribution  of the vaginal tumors.

 

8w (1) 8w (2)

 

References:

1.Dermatopatolvet.it

2.Case report Leishmania sp. Amastigotes Identification in CTVT

3.Transmissible Cancer  Group

Department of Veterinary Medicine

University of Cambridge

 

 

SECONDARY ALIMENTARY HYPERPARATHYROIDISM and its complications – our approach

logoDepartments “Metabolic and endocrine disorders” and “Orthopedics” – veterinary clinics “Dobro Hrumvane”, Sofia, Bulgaria

The alimentary secondary hyperparathyroidism is not so rare as many specialists think. For period of only 9 months we diagnosed in our clinics 17 cases and had serious observations in other 9 cases (the owners didn’t agree to prove 100 % in Laboklin) in different stages of the problem evaluating. We present below our treatment protocol and two concrete complicated cases – both with healed patients but one not operated – and our consequences experience in cases with or without surgery.

The hyperparathyroidism is primary and secondary. The secondary could be renal – complication of chronic renal insufficiency, it is more often seen even in comparison to the primary – and alimentary: rarest but for sure not exotic. The alimentary variant is seen in young dogs and especially cats fed only or almost only with meat.  The low calcium levels and the inadequate calcium/phosphor ratio in meat starts a multi-vector pathological process evaluating for a couple of weeks to following clinical picture: unwilling for moving, lameness, stiff walking, spontaneous fractures, face edemas, easily teeth removing or teeth loosening, spontaneous neurological deficit  in different levels. The standard hematological and biochemical blood panels usually do not give any diagnose direction. It is common the right diagnose to be reached with delay because often the colleagues miss during the anamnestic phase to become well informed about the alimentary regime of the patient, X-rays are rarely made in the very beginning and usually the therapy starts with NSAIDS and general strengthening protocol.

This disease not rarely causes hind legs function insufficiency and neurological deficit, paradoxally not corresponding to and many times exceeding the found through imaging diagnostic bone (including vertebral) changes. It is not exotic OCD (even in cats) to be diagnosed later due to cartilage underlying bone and bone vessels malformation.

Most directing is the anamneses especially the alimentary regime of the young patient. Absolutely enough for 90 % sure diagnose is combination of anamneses, estimation of the bone geometry and density due to X-rays covering flat bones, spinal cord, mandibula, maxilla and blood levels of macro elements especially P. For 100 % sure diagnose we send blood hormon sample to Laboklin Germany. The differential diagnoses are not many and include some genetic or metabolic disorders.

Our newest therapeutic protocol, product of enough clinical experience and leading to fastest and completest healing includes:

  • Hospitalization of the patient in cage for maximal immobilization aiming to avoid pathological fractures and especially vertebral fractures.
  • Diet change to P-poor and Ca-rich: the variants are so many, ii is important the diet to be diverse and with enough vitamins. In most of the cases we start with renal diet combined with additional food components;
  • Calo-pet – zero P molecules and very adequate composition for this problem;
  • NEO-K9: not only because of the demonstrative bone healing stimulation but also very adequate against all cases of hyperphosphatemia – and in cases of alimentary hyperparathyroidism we have severe hyperphosphatemia as well as serious bone demineralization and decrease of their potential for resistance to physical forces and for healing;
  • Ipakitine – because of its ability to chelate and eliminate the phosphor
  • HyalOral – because of its adequate to the therapy (especially against intra-joints complications) composition and especially because of the gamma-oryzanol inside
  • NSAIDS – against pain and inflammation
  • Calciferol (Vitamin D3) in dosage 2 ng/kg/24h– please be very careful when using it because increases the resorption of calcium but also of phosphor. Should be added to the protocol only after the phosphor is already in normal blood levels or very close to them;
  • Sometimes after careful individual estimation – oral pure Ca human product for children or even injectable Ca vet product;
  • Often repeated biochemical including P and Ca blood monitoring (a big Thank you! to our trusted lab VetDiaLab for the precise and reliable work during the last 15 years), every-day neurological monitoring and checking the ability for urination, every-day check for rib and long bone fractures and regular (minimum every 8-10 days) X-ray follow-up of the geometry and healing of all fissures and fractures;
  • Therapy against the complications including the spontaneous fractures, eating difficulties because of jaw problems ets.

This algorithm leads to very fast and demonstrative health status improvement. Of course it is very important to estimate carefully when the patient is ready to get out of the cage. We recommend the bone fissues to be X-ray monitored every 5-10 days and all long-bone fractures to be operated especially those near the knee joints. The reason?: the long-bone fractures caused by SAHPT heal very often with malunion which is being well tolerated by young animals but many of them suffer when achieve adult/mature age. On the other hand we recommend vertebral fractures to be operated only in case of neurological deficit or pain. In all cases of eating difficulties esofageal probe and not manual assisted eating is recommendable.

Case 1: cat Darko, SAHPT complicated with two supracondylar femural fractures, operated with delay. We added Calciferol to the therapy protocol at the 7th day when the blood phosphor decreased to normal levels. The owners asked us not to operate and to wait but as usual despide the cage rest after a couple of days the fragments geometry get worse and the healing would lead to malunion and may be to patellar luxation. The owners agreed to operate, the surgeries with implants of Mikromed were fast and simple (peri-operatively: Clavaseptin) and the case result is 100% healthy and extremely mobil cat:

pic 1 pic 2 pic 3 pic 4

 

 

 

 

 

 

 

 

 

 

 

 

Case two: cat Pisi, SAHPT complicated with fissure and fracture, not operated. The X-ray fissure (left humerus) follow up showed no need to operate and healed without problems. Unfortunately we didn’t receive permission to operate the fracture and as usual the result is serious malunion:

pic 5 pic 6

 

Conclusion: strict cage rest, strict food and therapeutical protocol, strict clinical and paraclinical monitoring and careful surgery estimation = successful outcome.

Regulatory Convergence Key to Improve Access to Veterinary Medicines say Global Veterinary Associations

logo-white-backgroundArtboard-1Eleven global veterinary associations have signed a Position Statement calling for increased regulatory convergence and harmonization in order to ensure that veterinarians globally can access the medicines they need to treat their patients.  The Statement, initiated by the World Small Animal Veterinary Association (WSAVA), is the latest step in its campaign to secure more equal access to vital veterinary medicines for companion animal veterinarians around the world.

Restricted access to veterinary medicines because of regulatory issues in regions of the world including Eastern Europe, Africa and Asia, is a long-standing problem and limits the efforts of many veterinarians to provide optimal care to their patients.  Sometimes, even essential medicines, such as those required to properly manage pain, are difficult to access, causing immense and unnecessary suffering.

The WSAVA recently formed a Therapeutics Guidelines Group (TGG) to spearhead its work in this area and to campaign to ensure more open access to these medications.  Its new Position Statement is designed to raise awareness of the problems around regulation and to call on governments and regulatory bodies to act.  The Statement has been endorsed by:

It follows a 2018 Position Statement from the WSAVA outlining a range of factors which restrict global access to veterinary medicines and the significant impact on animal health and welfare this causes.  This statement also received wide support from the veterinary sector, including those associations listed above.

In a survey of its members conducted by the WSAVA during 2016-2017, 75% of respondents confirmed that that problems in accessing veterinary medical products hampered their ability to meet the needs of their patients and 20% assessed the impact of this issue as resulting in a severe restriction on their ability to provide a high level of care.  During its 2019 World Congress in Toronto, Canada, in July, the WSAVA’s Therapeutics Guidelines Group convened a summit meeting of global veterinary associations and stakeholders to discuss potential solutions.  The new Position Statement was one of the outputs from this meeting.

Dr Walt Ingwersen

Dr Walt Ingwersen

Commenting, Dr Walt Ingwersen, WSAVA Past President, said: “Difficulty in accessing therapeutics to treat patients is a critical issue for companion animal veterinarians in many parts of the world.  It causes huge frustration and means that many, if not most, companion animals globally do not receive optimum care.  It’s a situation which requires urgent change and, working in partnership with our colleagues across the veterinary sector, we are focused on bringing this about.

“While a number of issues impact the supply of veterinary medicines, duplication of the regulatory medicines approval process in various regions of the world is one of the biggest and the focus of our Joint Position Statement on Regulatory Convergence. The WSAVA Therapeutics Guidelines Group has been working hard on the issue of access to and availability of veterinary medicines and will shortly be announcing the first of a set of practical tools to support veterinarians and their associations to lobby their own governments and regulatory bodies.

“To support them, we, as a global veterinary community, will continue to demand change at a global level and our Position Statements are proving effective in increasing understanding and prompting action.”

He added: “We thank our colleagues in other veterinary associations for standing with us and we will continue to collaborate closely to ensure that all veterinarians have access to the drugs they need to treat their patients.”

The WSAVA represents more than 200,000 veterinarians worldwide through its 113 member associations and works to enhance standards of clinical care for companion animals.  Its core activities include the development of WSAVA Global Guidelines in key areas of veterinary practice and lobbying on important issues affecting companion animal care worldwide.

Histiocytic Ulcerative Colitis in French Bulldog

21034264_1857657530915739_9210069975642627612_nDr Mila Kisyova,

veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

  1. Introduction

Histiocytic ulcerative colitis (HUC) is an inflammatory bowel disease that causes tenesmus, hematochezia, and profound weight loss. The disease is most commonly described in young Boxer Dogs but it has also been reported in other breeds of dogs, including Mastiff, Alaskan Malamute, Doberman Pinscher, French Bulldogs. One cat with HUC also has been described. HUC differs from other forms of inflammatory bowel disease in dogs because it is characterized histologically by periodic acid-Schiff (PAS)-positive macrophages; it is more likely to be associated with mucosal ulcerations; it is less responsive to therapy, and has a poorer long-term prognosis. HUC in Boxer Dogs was 1st described by Van Kruiningen et al in 1965. Since that time, the gross histopathologic and ultrastructural findings have been well characterized. The pathognomonic lesion of HUC is the accumulation of distinctive, PAS-positive macrophages (indicative of glycoprotein within the macrophages) in the lamina propria and submucosa of the colon with loss of the associated epithelial surface. The PAS-positive material may be derived from remnants of bacterial cell wall glycoprotein, and accumulation of PAS-positive material in macrophages may occur because of abnormal lysosomal activity, exhaustion of lysosomal activity, or inhibition of lysosomal activity by toxic substances. The cause of HUC has yet to be determined. Early studies proposed an infectious etiology on the basis of the presence of chlamydia-like organisms in macrophages on electron microscopy and clinical improvement after chloramphenicol therapy. In a subsequent ultrastructural study, organisms were not conclusively demonstrated. Attempts to create the disease experimentally by mycoplasma infection failed. Management of HUC consists of various combinations of the following: dietary modifications; antibiotics such as chloramphenicol, metronidazole, and tylosin and anti-inflammatory or immunosuppressive drugs such as sulfasalazine, prednisone,cyclosporine and azathioprine. Response to treatment is generally poor, frequently resulting in euthanasia of affected animals

pic 11

 

 

Representative histologic images in the dog (HE, bar = 50 μm). A: Lymphocytic-plasmacytic colitis. Note the interstitial diffuse pattern of infiltrate represented by a large amount of lymphocytes mixed with plasma cells and some macrophages; B: Lymphocytic-plasmacytic colitis (follicular variant); C: Histiocytic colitis. Severe mucosal abnormalities with loss of crypts and diffuse infiltration by large macrophages (arrows) that in the insert (PAS stain) are shown as the main cells infiltrating the lamina propria; D: Eosinophilic colitis. Note the presence of a large number of eosinophils (arrows).

pic 12

  1. Report and history of the patient

We had a patient dog, named Robin, French Bulldog, male, noncastrated, 2 years old, vaccinated, with chronic diarrhea dating back about a year and a half. Everything started with minor episodes of diarrhea when the dog was about 6-7 months old, the owners also mentioned itching and licking of paws. Аll tests for infectious diseases were negative (CPV/CCV/Giardia) and blood samples were normal. The faecal sample was negative for any parasites. At that time, the patient was treated with probiotics, chemotherapeutics and sulphonamides, gastrointestinal and hypoallergenic diets  without any effect. During this time, the owners refused colonoscopy or diagnostic laparotomy combined with a histopathological examination аnd a test for pancreatitis (Idexx cPL).

On April 12, 2019, the dog came to the clinic again with complaints of persistent diarrhea accompanied by blood and tennesms. Robin’s condition had become more serious since the owners had given BARF at their discretion. On the same day we did the CBC and biochemical blood tests and ultrasound of the abdomen. The ultrasound examination showed a high degree of thickening of the layers of the colon and some of the small intestine divisions, as well as enlarged mesenterial limph nodes.

pic 13pic 14

We placed an intravenous catheter and included fluid therapy NaCl 55 ml/h, antiemetics (famotidine and pantoprazole), vitamins (vit C, B- complex, arginine ,ornithine, citrulline), antioxidants (duphalyte, amynoplasmal), probiotics (Fortiflora and Pro-kolin paste), painkillers (buprenorphine), haemostatic drugs (Vit K1 and etamsylate)  and tylosinum  25 mg/kg/24h/p.o. Аfter 3 days we took blood tests, which again showed low-grade anemia, leukocytosis and neutrophilia. We also added injectable erythropoietin to therapy.

 

On April 16, 2019, we performed a diagnostic laparotomy with full thickness biopsy of thr large and small intestine. The material taken was prepared and sent for patho-histological examination in Laboklin Germany. The result was sent by email on May 24, 2019 :

Diagnosis:
1: moderate to severe mixed cell colitis with

PAS-positive macrophages and ulceration
2: mild to moderate lymphoplasmocytic enteritis
Critical report:
The histological findings (PAS-positive macrophages) in context with the reported breed indicated a histiocytic and ulcerative colitis(HUC).This form of colitis develops especially in

boxer dogs and french bulldogs. Single cases are described forother breeds.A HUC is associated with an infection of certain strains of Escherichia coli. Clinical signs are weight loss, anorexia andpoor condition.A colitis with epithelial lesions and PAS-positive macrophages are typically found in histology.“

pic 15

On the same day we started methilprednisolon 2 mg/kg/12h/i.v, ampicillin/sulbactam 15 mg/kg/8h/i.v, ceftriaxone 35 mg/kg/12h/i.v in addition to all other therapy.

On April 25, 2019 we only took complete blood count, which established increase of leukocytes and neutrophils, as well as deepening anemia. Clinically, the dog continued to have severe and watery diarrhea with tenesmus, most of which were mixed with blood. Robin began to lose weight progressively and refused to eat at his own will. He was fed by force, following a hypoallergenic diet of “Hill’s z/d cans” and “Royal Canin Hypoallergenic cans”. After a few days Robin felt better and started to eat dry hypoallergenic food.

On April 30, 2019 we took blood for a full blood count where the levels of leukocytes and neutrophils had dropped, but the levels of red blood cells were still low, so an ultrasound examination of the colon was carried out – the wall had begun to decrease in size

pic 16

Robin’s condition was beginning to improve, the stools were getting better. After a few days, the patient was given home therapy (amoxicillin/clavulanic acid for 5 weeks, marbofloxacin for 6 weeks, prednisolone by scheme with start dose 3 mg/kg/12h/p.o for 7 weeks, b-complex liquit, legaphyton 200 tabl).

On May 09 2019 we took blood for a full blood count – the leukocytosis were even fewer, but still out of norm; the hematocrit, the hemoglobin and the number of red blood cells were still low. We sent another blood sample to Laboklin Germany for TLI (Tripsin-like-immunoreactivity) + Vit B12 + Folic Acid.

“Trypsin-like-Immunoreactivity (TLi) – CLA
TLI:

Result                  36.8  µg/l             > 5

Inretation:
TLI values < 2.5µg/l are indicative for exocrine pancreas
insufficiency (EPI).
With values of > 5.0 µg/l a EPI is most unlikely. 2.5 to 5.0 µg/l
is considered to be a questionable; a control measurement should be considered after 2 3 months time according to the clinical sings.
Reasons for questionable values are:
– acute phase of chronic pancreatitis
– sampling time within 12 hours post feeding
TLI values > 35 µg/l are indicative for pancreatitis. Renal
insufficiency can result in retention of TLI and thus falsely
elevated TLI resp.
                                               Vitamin B12 Concentration – CLA
Vitamin B12          748    pg/ml       300-800
Folic Acid Concentration – CLA
folic acid           5.73 ng/ml         3.0-10.0”

The ultrasound study showed high-grade meteorism and reactive patch plaques. No increased mesenteric lymph nodes were detected. Clinically, diarrhea was accompanied by tenesmus and fresh blood.

pic 17

Based on TLI levels, we included metronidazole 7,5 mg/kg/12h/p.o for 5 weeks.

On May 23, 2019 We took blood for a full blood count – the leukocytes and neutrophils were at baseline according to the reference values. However, the hematocrit, the hemoglobin and the red blood cells levels were still low. The condition of the patient had worsen after eating food from the rubbish bin.  The ultrasound study showed high-grade meteorism and reactive patch plaques; the wall of the colon had begun to decrease in size; corrugation of the colon appeared. We placed an intravenous catheter and included fluid therapy NaCl 55 ml/h, antiemetics (famotidine and pantoprazole), vitamins (vit C, B- complex, arginine ,ornithine, citrulline), antioxidants (duphalyte, amynoplasmal), probiotics (Fortiflora and Pro-kolin paste), haemostatic drugs (Vit K1 and etamsylate), metronidazole, amoxicillin/clavulanic acid, enrofloxacin 5%.  We chose to stop the prednisolone and try budesonide sachet in dose 2 mg/kg/24h/p.o. The dog continued to weaken progressively.

Pic 18

*) abdominal ultrasound from 23.05.2019

 

 

On May 30, 2019 we took blood for a biochemical profile, which showed the following results – elevated bilirubin, elevated ALT, AST, ALP, low creatinine. On the same day, we reduced the prednisolone (1 mg/kg/12h) to include ciclosporin. Clinically the dog continued to weaken and lose muscle mass progressive. The owners started adding veterinary ciclosporin liquit in dose 5 mg/kg/24h/p.o. Three hours after the intake of cyclosporine the dog’s condition deteriorated dramatically, began to vomit and defecate only fresh blood. Unfortunately, we hospitalized the dog again.

The condition of the colon was getting worse.

Pict 19

*) abdominal ultrasound from 02.06.2019

We started intravenous methylprednisolone again in combination with the rest of the therapy to stabilize the patient. He didn’t want to eat alone again.

On June 04 we took blood for a biochemical profile, which showed the following results – improvement in liver enzymes as well as in pancreatic lipase levels and normal creatinine. Two days later, Robin stopped vomiting and received the rest of the therapy. We fed him three times a day with hypoallergenic food (Royal Canin Hypoallegenic cans).

On June 08 the dog felt better; body temperature was in norm; Robin started to eat with appetite again. Diarrhea continued to be abundant and watery, accompanied by blood and tenesmus. We started budesonide, and stopped methylprednisolone.Pic 20

 

Despite the applied complex therapy, diarrhea was unaffected. Defecation continued to be extremely frequent with blood and tenesmus. The patient continued to lose weight and muscle mass progressively. On 11 June Robin was discharged from the clinic with home therapy of budesonide and cyclosporine only. The owners had been offered euthanasia.

Pict 21

The wall of the column progressively hyperplasia.

I apply some photos of the dog on the day of euthanasia:logo

pic 22

CAT KNEE ARTHRODESIS -SERIAL CASE REPORT

logoOrthopedic Department of Veterinary clinics “Dobro hrumvane” – Sofia, Bulgaria

Every cat knee arthrodesis is an orthopedic challenge. Cats have relatively long bones, crista tibia is narrow and even sharp most cranially, and they are very active animals with common post-op serious vertical efforts, for example jumping to and from furnitures and even refrigerators. The arthrodesis of their knees requires maximal stability of the fixation, freedom for intraoperatively estimation for usage of different screws on one and the same plate – from 2.0 mm to 2.7 mm thick, a serious attention to the fixation of the plate to crista tibiae and the underlying tibia. And, of course, maximal level of aseptic and antiseptic procedures and algorithms: by every orthopedic surgery the possibility for post-op infection is proportional to the implants surface in sq mm and during arthrodesis we use wide and thick plate with serious surface and many screws sometimes even wires with serious surface too.

During the last 16 years we passed through different variations of the arthrodesis technique with different implants systems – at the beginning non-locking, later locking. Fortunately finally we found not only the best for us technique variant but also the most reliable for us implanst system and achieved constantly excellent results in 9 cats.

All 9 surgeries were very smilar with approximately equal percentage of covering of femurs as well of tibias. By all of them we used one and the same system – Mikromed locking 2.4 with one and the same plate – symmetrical limited contact straigth locking plate with “bridging” area in the middle (without hole for screw). In all 9 cases this bridging segment was positioned in the area of the femuro-tibial connection. In all cases we used on one and the same plate different screws – locking Mikromed 2.4 mm (in the tibia) and 2.7 mm (in the femur and in the bigger cats in the tibia as well) and non-locking (2.0 mm, 2.4 mm and 2.7 mm). In all cases before the tibial plating we took away with Rounger curette the most cranial 1-3 mm wide part of crista tibiae which procedure should be made very carefully and doesn’t compromise the fixation because in cats crista tibiae is build by bone compacta more caudally in comparison to dogs (that why we recommend in case of transposition of crista tibiae to cut the osteotomy into the tibia as caudal as possible – of course not damaging the menisci – in order not to compromise the healing process; but this is another story for another technique).

The patients and their individual stories before the surgery were not similar, however the results were equal: constatnly 100 % excellent. Here we present two different cases: Cat Gosho, under 4 kg, allowing manipulations without problems, with trauma not more than 2 weeks before the surgery, without muscle atrophy; and Cat Aksel, over 6 kg, very difficult to be manipulated and with “specific” temperament, which trauma happened before approx 2 years and as result the patients leg had severe muscle atrophy and weakness of the ahilea tendon.

The only difference in the approaches to both patients was the fact that because of the weight and the temperament of Aksel we left both situational wires in comparison to the surgery of Gosho where we removed them after finishing the plating process.

As in all orthopedic surgeries in cats we do not loose intra-operatively time for plate bending – more time means bigger risk of anesthetic problems and infection. We have a big collection of cat bones (cat bones are very similar, the dog bones aren’t) from cats of different weight including “arthrodesed” femur+tibia combinations. We use these models before autoclaving the implants for perfect contouring the plate to the bones and bnes combinations and for preparation of the perfect screws combination.

We recommend the dynamic compressive screw to be not in the femur but in the tibia this means to fix the plate with locking screws first to the femur and after that to start fixing it to the tibia. We recommend two non-locking 2.0 mm cross-screws in both holes nearest to the plate middle. We strongly recommend to take off the most cranial 1-3 mm slice of the tibial (crista tibiae) silhouette with Rounger for better contact between plate and bone and respectively best stability. And, of course, do not forget to take off all the cartilages, menisci, cruciate ligaments and the patella and to compress tibia to femur as strong as possible.

The nine cases prove that there is not any need of longer plates covering bigger percent of the femural and tibial length. We monitored all the 9 cats for period between 2y4m to 1 m after the procedure and there aren’t any signs of problems including fissures or fractures of bones at the plate edges.

Video of Gosho 10 m post-op:

As usually the goal is the patient to start using the leg very soon. In the first 2-5 weeks some hyperextensy of the hook and abduction of the leg are normal.

Cat Aksel 96h post-op:

Conclusion: the presented at the X-ray pictures below variant of cat knee arthrodesis with lockig system Mikromed 2.4 guarantees constantly excellent result.

Gosho X-Ray pictures:

pic 1

Pre-operator

pic 2

post operator

 

 

 

 

 

 

 

 

 

 

Aksel X-Ray pictures:

pic 3

pre operator

pic 4

post operator

„Slow Kill” – adulticide protocol in heartworm treatment! Can we use it? When to use it? How to use it?

13549281_10207110414020766_1752592814_oTodor Kalinov DVM

 

veterinary clinic “Vitalis”, Plovdiv, Bulgaria

drkalinov80@gmail.com

 

 

 

Heartworm disease is caused by Dirofilaria immitis. The disease is widely distributed throughout Europe. Species susceptible to infection are dogs, wolves, foxes, coyotes, cats, ferrets, muskrats, sea lions, and humans. The parasite is transmitted by over 70 species of mosquitoes.

Adult heartworms reside in pulmonary arteries and in cases of severe infections in the right ventricle. Mature female parasites produce microfilariae and release them into the circulation. The feeding female mosquitoes ingest these microfilariae, and they undergo two molts, L1 – L2 – L3, over an 8 to 17 dаy period. This process is temperature-dependent (at least 18 C are needed). The L3 are infective and are transmitted by the mosquito to the hosts. In the subcutaneous, adipose, and skeletal muscle tissue L3 molt to L4 for 1 to 12 days and L4 molts to S5 – immature adults, for 2 to 3 months. The Immature adults enter the vascular system, migrating to the heart and lungs, where final maturation and mating occur. Under optimal conditions, completion of the life cyclе takes 184 to 210 days.

The adult worms cause the following through mechanical, immune-induced, and through toxic substances: inflammation and proliferation of the pulmonary arteries, pulmonary thromboembolism, pulmonary hypertension, and right-sided heart failure. Clinical signs of the disease are weight loss, exercise intolerance, lethargy, poor condition, cough, dyspnea, syncope, abdominal distention.1

According to the guidelines of the American Heartworm Society2 treatment of the heartworm infection consists of doxycycline 10 mg/kg BID for 28 days, monthly use of macrocyclic lactones, and melarsomine at days 60, 90 and 91.

In other publication3, the authors suggest administration of melarsomine on day 30 , 60 and 61, to make the protocol shorter, and to better comply with the owner’s financial resources.

 

In certain circumstances, melarsomine dihydrochloride could be contraindicated, unavailable, or not affordable to the owners. In this situation the practicing veterinarian could use the so-called “Slow kill” or “Soft kill” protocol.  It consists of the use of macrocyclic lactones in prophylactic doses with and withоut doxycycline to kill adult heartworms4–6. In most of the studies, the results are not satisfactory. L. Venco et al.6 used ivermectin – 6mcg/kg, monthly and had 100% microfilaricidal efficiency after 7 months, and 71% adulticidal efficiency after 24 months. The authors do not recommend this treatment regime in patient with clinical, radiographic or echocardiographic signs. G. Grandi et al.4 used doxycycline – 10 mg/kg/sid for 30 days and ivermectin-pyrantel – 6mcg/kg-14mg/kg every 15 days. By day 90 one hundred percent of the dogs became negative for microfilariae, and 72.7% became antigen-negative by day 300.

The study of Savadelis et al.7from 2017 had results similar to melarsomine treatment for a relatively short period of time. They used topical moxidectin 2.5%+imidacloprid 10% monthly with combination of doxycycline 10mg/kg/bid for 30 days. All treated dogs became negative for microfilariae at day 21. Ten months after the beginning the adulticidal efficacy was 95.6%. Hence, the conclusion of the authors is that this treatment regimen is a relatively quick, reliable and safe option to treat canine heartworm infection as compared to other treatment regimens involving macrocyclic lactones, when the approved drug melarsomine dihydrochloride is unavailable, contraindicated or declined by an owner unable to afford the more costly treatment or concerned about the potential side effects”.

I used this protocol numeral times with very good results. Most of the dogs were with class 4 heartworm disease and caval syndrome. Probably the most severe case was a 10-year-old Bulgarian shepherd dog. At presentation, the dog was cachectic, could not walk, did not eat for several days, and had ascites. Blood work revealed slight leukocytosis, neutrophilia, and thrombocytopenia, slightly increase in ALAT, ASAT, BUN, decrease in albumin, and the test for HW antigens was positive. Echocardiographic examination revealed severely dilated right atrium and right ventricle, with heartworms in the tricuspid valve region(video 1).

photo2

photo 2

The left atrium and ventricle were collapsed due to severe pulmonary hypertension. Of course, in this situation surgical extraction of the worms is the first choise8, but this option was declined by the owners. So we started treatment with doxycycline 10 mg/kg/sid, moxidectin+imidacloprid topically, and sildenafil 1mg/kg/bid. Several days after the start of the treatment the dog was in better condition, and on the echocardiographic examination we found that the left ventricle is relatively dilated, compared with the previous exam, the number of worms in the tricuspid valve region was subjectively lower. However, on m-mode, the systolic motions of Interventricular septum and left ventricular free wall was weak(photo 2). Therefore we suggested that the dog has subclinical dilated cardiomyopathy, which contributed to the development of the caval syndrome. We added pimobendane – 0.25mg/kg/bid and benazepril – 0.5 mg/kg/bid and prednisolone – 0.5mg/kg/sid to the therapy for thromboembolism prophylactic. On the next control examination, the dog was feeling better, there were no heartworms in the right atrium and ventricle and in the pulmonary artery(photo 3,4).

photo4

photo 4

photo3

photo 3

photo 5

photo 5

After a month from the diagnosis we stopped the doxycycline and continued with other pimobendane, benazepril, topical moxidectin+imidacloprid, sildenafil, and prednisolone – 0.5 mg/kg/48h. After two more months we gradually stopped the prednisolone. Six months after diagnosis the antigen test for heartworms was negative. The dog still had severe pulmonary hypertension, exercise intolerance and coughed occasionally. We continued treatment with pimobendane, benazepril and sildenafil and monthly moxidectin+imidacloprid for heartworms prophylactic. The dog lived for two more years and died from noncardiogenic reasons. I have similar results with two other large-breed dogs, also with caval syndrome, with complete resolution of clinical signs and withdrawal of all drugs, only continuing with moxidectin+imidacloprid for heartworm prophylactic. A small-bred dog developed severe pulmonary hypertension and tricuspid valve granuloma after the third month probably due to damages of the tricuspid valve from heartworms(photo 5), and untreatable right-side heart failure. Soon after the dog was euthanized.

The “slow kill” protocol is arguably more suitable for large and giant breed dogs, where the surgical extraction is more challenging, and the treatment with melarsomine is more expensive. In caval syndrome, the worms could be moved back in the pulmonary artery with a combination of pimobendane and sildenafil. Sildenafil is a phosphodiesterase 5 inhibitor, and pimobendane is a phosphodiesterase 3 inhibitor. The combination leads to more profound reduction in pulmonary artery pressure. The pimobendane has positive inotropic effect, hence the combination of improved myocardial function and lower pulmonary artery pressure helps in movement of the heartworms from right heart in pulmonary artery9(photo 6, 7 – before and after administration of pimobendane and sildenafil).

photo 6

photo 6

photo 7

photo 7

In small and medium dog breeds the surgical extraction, when possible, is the best choice, however, do not exclude the use of macrocyclic lactones and melarsomine.

In conclusion, when we treat a dog with dirofilariosis, we should first rely on the American heartworm society guidelines2. When we decide to use the Slow kill protocol, the macrocyclic lactone of choice is topical moxidectin. It has a unique pharmacokinetic, establishing a peak several days after application, long half-life about 28 days, and steady-state levels after four monthly applications, ensuring constant and high exposure of the parasites to the drug10,11. Of course doxycycline is also mandatory for adulticide therapy. Last but not least, we always have to think of the patient, we have to treat the patient rather than the disease, and to ensure good quality of life to them.

FECAVA announced Didier-Noël Carlotti Award Laureate: Assistant Professor Dr. Bogdan-Alexandru Vitalaru from Romania

23131883_1723169741051257_1944002556383533163_nThe Didier-Noël Carlotti Award (DCA) is named after a veterinary surgeon who initiated, planned and inspired FECAVA and who served as its first President for four years. The Didier-Noël Carlotti Award is presented annually for ‘outstanding service in the fields of inter-professional communication and/or continuing education for companion animal veterinarians in Europe’.Capture d’écran 2017-09-05 à 15.30.43

In 2019, the DCA award will be received by Assistant Professor Dr. Bogdan-Alexandru Vitalaru from Romania.

He was selected for the Award by the DCA Committee and will receive it at the opening ceremony of the 25th FECAVA EuroCongress in St. Petersburg.

Assistant Professor Bogdan Alexandru Vitalaru graduated the Faculty of Veterinary Medicine of Bucharest in 2004, PhD since October 2009, and he has participated since then in numerous national and international conferences, both as a doctor and as a lecturer. Since January 2016 he became Assistant Professor at the Faculty of Veterinary Medicine of Bucharest.

Over the years he has written more than 100 scientific papers on topics related to oncologic surgery, dialysis, hemodialysis and emergencies. His 4 books about emergencies were sold in more than 2000 copies in Romania in the last 4 years. His last book it is completely dedicated to peritoneal dialysis in small animals and it has been released also in English in Italy, Bulgaria, Turkey, Greece, Croatia, Ukraine and Poland starting February 2018.28471893_1212686848867718_2541073989731187894_n 49848433_2438242006214507_5459535691056676864_n

Since January 2014, in collaboration with BBraun Romania, within the Faculty of Veterinary Medicine, he opened the first Veterinary Hemodialysis Clinic in Romania and one of the few in Eastern Europe.

Starting 2013, he established the Romanian Association of Veterinary Nephrology, Hemodialivet, who’s Chairman he is.

In the last 10 years, Dr. Vitalaru has been a lecturer for Hills Romania and KTL in Romania and Europe regarding urology, nephrology and renal replacement therapies. He is also leading the Emergency Department of the Faculty of Veterinary Medicine of Bucharest since 2015.22154250_1512540295490310_2300870383746233502_n

Starting 2014, Dr. Vitalaru has initiated a program of workshops and seminars regarding renal patients all over Romania (București, Iași, Cluj, Timișoara, Brașov, Constanța), Bulgaria (Varna, Stara Zagora), Poland (Krakow, Warsaw), Croatia (Zagreb), Italy (Perugia, Pisa) and in Turkey (Istanbul, Ankara, Antalya). He was awarded with the Continuing medical education prize – AMVAC/RoSAVA, Sinaia 12-14 November 2015 and SPEAKER OF THE YEAR – Romanian College of Veterinarians, Bucharest, 17 December 2015. He is a member within the board of some of the most prestigious publications in Romania: Cat life, 2015, Romanian Journal of Veterinary Orthopedics and Imagistic, 2015, Romanian Journal of Veterinary Medicine & Pharmacology, 2016, Romanian Cardiology Review. In 2016, Dr. Vitalaru has received the Special Prize for the best veterinary initiative of the year in Romania – Innovation in Health.39515211_2117230608311833_1547971329477574656_n 55811478_2440517709316453_3635058829533642752_n

Since November 2017 he is a board member of AMVAC (Small Animal Romanian Practitioners Association), FECAVA Director for Romania and since October 2017, Dr. Vitalaru is FECAVA Ambassador and ROVECCS Ambassador (Romanian EVECCS partener).

His passions are mountain hiking, fishing and nature and as a result of this, he has initiated in 2017 a Vet Camp in the Romanian mountains with vets all around Romania.

The greatest achievements of his life are Silvia his wife and his two beautiful daughters: Natalia and Sofia.40082786_10216876652047378_4749508800241729536_n 57384291_2505251306176426_5657680386600206336_n

Learn and Travel ….. story from vets

67509335_393199464955171_7827241570955952128_nDr Elena Nenciulescu from Romania has done her externship with Ana Nemec, DVM, PhD, Dipl. AVDC, Dipl. EVDC at our project LEARN AND TRAVEL with Vets on The Balkans.

We would like to express our gratitude as well to The University of Ljubliana, Faculty of Veterinary Medicine in Slovenia for the opporunity!

 

Let her tell us her story:

Last week I had the amazing opportunity to assist Dr. Ana Nemec during dental procedures and dental consultations. It really was AMAZING!learn and travel

I arrived in Ljubljana on Sunday, July 27th. I had a little rest and the next day my journey in the Slovenian world of veterinary dentistry began. The weekly schedule is usually like this: Monday, Tuesday, Thursday and Friday are for dental procedures (2-3 cases per day) and Wednesday is only for consultations.

On the first day, Dr. Nemec showed me the clinic (very well equipped, with ultrasound machine, X-ray machine and CT). What really impressed me was the dentistry room. It is fantastic: dental unit, dental X-ray machine, dental table (custom made) and all dental instruments and materials that you need for dental materials for exodontics, endodontics, orthodontics, orthopaedics and oral surgery. It was like heaven for me!

All the dental procedures that I assisted had the following steps:

  1. Dental consultation under anaesthesia and filling the dental chart (using the periodontal probe, every tooth was examined – mobility, gingival retraction, furcation exposure, gingivitis, periodontal depth)
  2. Full mouth dental X-rays and interpretation
  3. Sonic scaling and polishing
  4. Surgical extractions (the teeth were extracted based on the clinical and radiological findings)

It is important to perform all steps correctly and not to miss any of them. 90% of dentistry cases in general practice are periodontal patients that need periodontal therapy, so this is what all vets should learn to do properly.

Dental chart for cats Dental table prepared for the patient Dental unit, dental table, intraoral X-ray and equipment for anaesthesia

I had the chance to see a wide range of cases: mild to severe periodontal disease, stomatitis, tooth resorption, tooth avulsion, crown fractures, chin eosinophilic granuloma, peripheral odontogenic fibroma, intraosseous squamacell carcinoma, endodontic treatment re-check, but also cases of no dental disease that came in only to learn oral homecare which is also a big must for maintaining the oral health of our pets. All cases were discussed in detail.

Dr. Nemec is such a positive person, teaching dentistry is something natural for her. She answered all my questions (and there were many of them). I consider myself very lucky to be given this opportunity. I learned a lot!

But it was not all dental work for me last week, I also visited the city. Ljubljana is beautiful: the castle, the city centre, the museums, the Tivoli Park. It is worth visiting. I enjoyed my stay there very much. On Saturday, August 3rd I traveled back home.

Vets on the Balkans and Luba Gancheva, thank you for giving me this opportunity. Learn and Travel is a fantastic chance to grow professionally. Dr. Ana Nemec, thank you so much sharing all you knowledge with me! I am really grateful for this experience.

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