Learn and travel…a new story from Italy with Dr Marin Buchkov from Bulgaria

All-focus

Dr Marin Buchov, a veterinarian from Bulgaria has done his internship in clinica Lago Maggiore in Italy! We would like to express our gratitude to Dr Luca Formaggini.Dr. Mariangela De Franco and Dr Luigi Venco for making this posssible,as well to our partnern Blue Sky Commerce and Pamas Trading for supporting Learn and Travel with Vets on The Balkans.

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Dr Marin Buchkov are talking about his advanture:

In a rainy morning, after a long hours of driving I was welcomed by Dr. Amedeo Loss Pelle. He kindly prepared an Italian style coffee and gave me a tour around the clinic – well equipped and designed to be very practical. A clinic that can cover all the aspects of 21st century veterinary medicine – CT, Endoscopy, Ultrasound, Digital X-Ray, Laboratory and modern surgery rooms…

During the next days I met all the vets – Dr. L.Formagini, Dr. M. De Franco, Dr. S. Manfredini, Dr. M. Silvola. Dr. G. Saggin, Dr. V. Galli, Dr. A. Prolo, Dr. C.Ferrari and Alberto. As expected, Dr. Formagini was the most experienced vet, the leader in the clinic. He always explains to the younger vets what, how and when to do the right thing. Amazing vet and skillful surgeon. I like the way he tries to do his job easy and simply, most of all practically.
Dr. Mariangela De Franco is the leading ultrasonographer. We had the chance to examine some patients together and have a discussion about best possible treatment.
Dr. Manfredini and Dr. Silvola – I believe they’re the energy of the clinic – always running from room to room, smiling and ready to help the patients.
Dr. Saggin – its difficult to say if her heart belongs to the veterinary medicine or climbing mountains, but she’s good in both :)
Dr. Loss Pelle, Dr. Prolo, Dr. Galli, Alberto – charming young vets, very easy to work with. Thank you for the tips of ‘real Italian pizza’ and ‘how to cook pasta’ :)
Dr. Ferrari – thank you for helping me with accommodation.

I came all the way from Bulgaria mainly to see how Dr Luigi Venco extracts diroffilarias from CHW dogs. His colleagues from the clinic describe him as ‘genius’ and after a week of waiting to perform this surgery with him I can confirm – he is :) We had three patients from Hungary, all done in one afternoon. Professional job.
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Other impressive thing I saw – Cystoscopic‐Guided Laser Ablation of Ectopic Ureters in a young female dog. Together Dr Formagini and his team performed this procedure in the clinic.

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A lot of other interesting cases, but my favorite patient was Orazzio – english bulldog that had to say goodbye to what makes him ‘a man’ in order to urinate normally. After two cystotomy surgeries in the past (his bladder is so good in creating different types ot urinary stones..), a scrotal uretrostomy was performed. Even this way Orazzio is still charming and lovely :)

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It is for sure useful to see how other vets do their everyday job. One thing (even the most simple one) could be done in many different ways and knowing them is what makes you a good vet. You can say the same for being a good person too… :) Thank you guys for being so kind to me and speaking English all the time I was there. You’re very good team, don’t forget this. Hope to see you soon somewhere around the world. You’re all welcome to Bulgaria!

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Vets on the Balkans is such a good idea! Thank you Luba!learn and travel12814393_1673705086236432_1339900710371625092_n23316272_180060419216123_164154967085808895_n

Global Experts to Discuss WSAVA Research into Veterinary Wellness during World Congress 2019

logo-white-backgroundArtboard-1Experts from around the world will discuss the implications of research undertaken by the WSAVA’s Professional Wellness Group (PWG) into veterinary wellness in a panel session during WSAVA World Congress. The discussion, called ‘Shaping the Future:  Wellness in the Veterinary Profession’, will take place on 17 July, following a presentation of the preliminary results of a study of more than 4,000 veterinary professionals globally. They will be presented by PWG Committee Co-Chair Dr Nienke Endenburg, a human psychologist, who works at the veterinary school at the University of Utrecht, Netherlands.

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Dr Nienke Endenburg

Recognizing increased concern as to the impact on veterinary professionals of their demanding working environment, the PWG set out to assess professional wellness and the key factors which affect it globally when it launched its online survey in September 2018.  Dr Endenburg will present the findings before inviting panelists to respond and discuss their perspectives on the issue.  The panel members are:

  • Dr Marie Holowaychuk, a Canadian board-certified small animal emergency and critical care specialist and advocate for veterinary team wellbeing
  • Dr Jen Brandt, the American Veterinary Medical Association’s Director of Member Wellness and Diversity Initiatives
  • Dr Derick Chibeu, Co-chair of the PWG and Honorary Secretary of the Kenya Small and Companion Animal Veterinary Association
  • Dr Vicki Lim, who works in New Zealand and is the founder the Riptide Project, an international veterinary wellbeing initiative
  • Mr Elwin van Oldenborgh, President-Elect of the International Veterinary Students’ Association.

Commenting, Dr Endenburg said: “Veterinarians care for our animal companions but the question is, who is caring for them?  As a global community we wanted to gain a clear understanding of the challenges to their well-being faced by our members around the world and to find out both what they have in common and where their experience differs.

“The results of our research provide a unique global view of this important issue and we look forward to discussing these with our expert colleagues and exploring practical solutions that respect the regional, economic and cultural differences of our membership. It will be an important first step towards bringing about positive change and enhancing the wellbeing of veterinarians globally.”

The WSAVA works to enhance the clinical care and welfare of companion animals globally, representing more than 200,000 veterinarians around the world through its 110 member associations. Its core activities include the creation of Global Guidelines which set standards for veterinary care in key areas of practice, including nutrition, pain management and welfare.

 

WSAVA World Congress takes place in Toronto from 16-19 July.  The Professional Wellness presentation and expert panel discussion takes place at 11.40 am on 17 July.

Cerebrovascular accidents in dog

 

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Dr Svetoslav Penchev

United Veterinary Clinic

Varna,Bulgaria

 

 

Stroke or cerebrovascular accident (CVA) is the most common clinical manifestation of cerebrovascular disease, and can be broadly divided into ischemic stroke and hemorrhagic stroke. CVA are characterized clinically by a per acute or acute onset of focal, asymmetrical and non-progressive brain dysfunction. Next cases show the both type of CVA in dogs.

1st case is about 9 years old female boxer. The dog was referring to the clinic with acute onset of seizures. The results of CBC and Biochemistry were normal and MRI was performed.

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MRI findings: Intra-axial right piriform lobe and hippocampus lesion with impression of moderate swelling of these portions is present. The cerebral falx is only mildly displaced to the left. There is corresponding low T1 signal intensity in these sections of the brain suggesting edema. There is no enhancement of the lesion after contrast administration. The findings suggest that there is a non-hemorrhagic cerebrovascular accident in right forebrain of the dog.

 

The 2nd case is about  a 8 years old male Cane corso. The dog was present in the clinic with unilateral fore brain deficits and history of epileptic seizures. Biochemistry and CBC were normal and MRI was performed.

 

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MRI findings : There is a well‐delineated T1 iso- to hypointense  and T2 hypointense  mass lesion with surrounding brain edema in right piriform lobe with a thin peripheral rim of contrast enhancement. There is a mass effect, displacement of the right lateral ventricle and midline shift to the left. This imaging feature is consistent with an acute to subacute intracranial hemorrhage.

 

Conclusion:

MRI features of Hemorrhagic infarction in dogs may not be distinguishable from hematoma caused by vascular disruption. Imaging characteristics will vary depending on the size, location, and chronicity ofthe hematoma.

Hyperacute – 24 hours   T1 isointense ; T2 hyperintense

Acute         1-3 days  T1 iso- to hypointense  ; T2 hyperintense

Early subacute   >3 days  T1 hyperintense  ; T2 hypointense

Late subacute    >7 days  T1 hyperintense ; T2 hyperintense

Chronic              > 14 days   T1 hypointense ; T2 hypointense

Secondary  features :  mass effect, surrounding edema, midline shift , ventricular displacement and compression .

 

MRI features of Nonhemorrhagic Infarction in dogs include mildly T1 hypointense and T2 hyperintense  lesion with minimal  mass effect involving both gray and white matter on unenhanced MR images. These changes seen in ischemic parenchyma rely on an increase in tissue water content. Gradually, during the acute stage, the T2-weighted image becomes more hyperintense in the ischemic region, particularly over the first 24 hours. These signal changes seen in the first 24-hours are best appreciated in grey matter and are well visualized in deep grey matter structures such as the thalamus or basal ganglia, in addition to cortical grey matter. Gadolinium enhances infarcts because of vascular rupture but does not enhance ischemia or edema.

 

Endometrial Polyps in a cat

IMG_20190115_141517Dr. Yavor Stoyanov, DVM    

 

Bomed Veterinary Clinic, Sofia, Bulgaria      

yavkata.ys@gmail.com

Abstract: Endometrial polyps from a 10 –year-old cat are described.The cat was presented in clinic due to vaginal bleeding. Few polypoid cystic masses pedunculated into the uterus lumen were found at the surgery. Sonographic, X-ray, cytology and histopathological examination revealed uterine polyp consisting mainly of endometrial fibrous tissue stroma and glands without invasive growth or atypical mitotic activity. Keywords: Endometrial polyp cats, Feline uterine polyps, Cystic uterine polyps in cat,Ultrasound endometrial polyps, Histology endometrial polyps, X-ray endometrial polyps

 

Introduction

Endometrial polyps in cats are a rare disease condition. Much of the available evidence being anecdotal1. There are only three more detailed reports for this condition in cats.    One from the archives of the International Registry of reproductive Pathology at the University of Illinois, US -14  cats1, one from Department of Obstetrics and Gynecology, Faculty of veterinary medicine, Kirikkale university, Kirikkale, Turkey-1 cat2 and one from School of Veterinary medicine, Azabu University, Kanagava, Japan -1 cat3.

Case History                                                                                                                  

A 10-year-old Persian cat was presented to Bomed Veterinary Clinic in Sofia, with history of acute vaginal hemorrhagic discharge. The cat was in good physical condition with normal temperature and behavior. Few bloody drops around the vulva. In middle to caudal abdomen was palpated some firm mases.                                                                                                                                               

Under clinical differentials diagnoses of pyometra, uterine adenocarcinoma or alimentary lymphoma was performed abdominal ultrasound. Sonographic examination showed a few cavernous structures cranial to bladder and caudal to kidneys.  The large one was about 4 cm in diameter. Caverns were dispersed in haphazard mosaic pattern.  Doppler sonography showed good blood supply of masses. On the base of ultrasonography pyometra was excluded of differentials diagnoses list.

Fig.1 Sonographic view of uterine polyps Fig 1 US-1

On the base of suspected uterine adenocarcinoma were performed two dimensional chest and abdominal X-ray.  Lungs and chest X-ray did not show indication of metastases.   Abdominal X-ray confirms sonographic findings about dispositions and dimensions of mases.

Fig.2 X-Ray view of uterine polypsFig 2 X-Ray

CBC and biochemistry was in normal limits.    On the base of the clinic and tests an exploratory laparotomy under general anesthesia was performed. During surgery uterus with abnormal asymmetric horns was found. Few mobile firm – elastic mases were palpated in uterine lumen. Two and smaller in the right horn, and a bigger one in the left horn. Ovaries looked normal except one little cyst nearby to right ovary.

After OHE the uterus was dissected. Evidence for an inflammation was not found.

Fig 3 Morphology

We found in left horn one big elongated egg-like structure pending on short narrow peduncle. It is about 5 cm long and 4 cm in diameter. The smallest one in the right horn was about 1 cm long and 0.6 cm in diameter starting nearby end of horn. The middle one was about 4cm long 2cm in diameter and partially entering in the cervix. Polyps had firmly –elastic consistency, easily bleeding, with small delicate cyst on the surface. Uterus wall had irregular thickening mostly because endometrial hyperplasia. On the luminal surface has similar small delicate cyst also. When we dissected one of the polyps many different sized caverns dispersed in haphazard mosaic pattern were found. They were full with translucent slightly mucinous secret. The stroma was tenacious.

Fig. 3 Morfology of uterine polyps. Polyps pedunculated from uterinw endometrium to uterine lumen. Many fine cysts are visualiseted on the surface of polyps. Uterine walls with irregular hyperplastic patern.

Many prints slides for cytolgy were made. We did not found inflamatory cells, evidance for adenocarcima or any proof for other malignasy. These polyps looked benign.

Fig 4 Cytology-1

Fig.4 Cytology from uterine polyp. Left- stroma    Ridht- cyst wall

Specimen for hystopatology was prepeared in 10% formalin and send to Pathology laboratory, at the same day.

Fig.5 Histology from uterine polyp. Up- Stroma and cysts.     Down- Left -Hyperplastic proliferation of  glandular epitelial cysts.  Down-right- Atrophyc epitelial wall of large cyst.       

         

Histology report:   Protocol 107,108,109,110/05.04.2019

Hystological spesimen representing uterine wall with presence of polypoid tumor formations.   Tumor origin is from endometrial surface, representing of stroma,  built from mature fibroses tissue with glands structures in thinly pattern within. Many of these glands structures are cystic dilated. They are covered with one row cubic epithelium with primarily basal situated nuclei. No signs for epithelium proliferation activity, atypical mitotic activity or invasive proliferation regarding the stroma. An endometrium and myometrium has typical histological structure.

Histological diagnosis: Atrophic endometrial polypsOn the base of clinical examinations, Ultrasonography, X-ray, morphology, cytology and histology report our diagnosis is as follows: Endometrial PolypsDiscussion

 

A diagnosis endometrial polyp of this case is according to the nomenclature in the Histological Classification of Tumors of the Genital System of Domestic Animals4. Main differential diagnoses are between endometrial polyps and polypoid form of cystic endometrial hyperplasia. The more exact differences between true endometrial polyps and polypoid endometrial hyperplasia are defined as that endometrial polyp have a vascular connective tissue stalk5 or contain a substantial connective stroma in addition to glands, and are pedunculated6.  Histology slides demonstrated changes in the different stages of cysts development. Focal cystic endometrial hyperplasia is the stimulus for formation of polyps. As hyperplasia progresses, out of synchrony with surrounding endometrium, the glands become larger and more numerous.  If the cystic endometrial glands have no external opening, they start to accumulate fluid. When the fluid pressure in the cysts increases, the gland cells covering their walls are compressed and start atrophic process.1      On the base of reports no breed, age or other predispositions were found1.No evidence that endometrial polyps are preneoplastic changes of the feline uterus except one a 16-year-old cat with metastatic carcinoma and five endometrial polyps1, 2. This probably reflects the rarity of endometrial neoplasia in cats as compared to women1. On the base of this data prognosis in this concrete case is excellent.  ConclusionEndometrial polyps in cats are very rare condition.It is difficult to classify this disease as gynecological, hormonal or oncological. On the base of the case studies OHE is choice of treatment with excellent prognosis.

Fig 6 Dara

Fig. 6 The lucky cat Dara.Acknowledgments:

 

The author would like to thank to team of Bomed Veterinary Clinic, Sofia, Dr. B. Rangelov, DVM for sonographic diagnostics, Dr. M. Lulcheva, DVM for anesthesia and Dr. J. Stojkov DM for histology report.

PSITTACINE BEAK AND FEATHER DISEASE (PBFD)

22789068_1470407493007067_8559896759169020355_n-e1509292305812Dr Daniela Drumea

Tazyvet

Bucharest, Romania

 

 

Psittacine circoviral disease (PCD) affects parrots and related species and is often fatal to birds that contact it. They can become infected through the oral cavity, nasal passages, and through the cloaca. High concentration of the virus are shed in feather dust from infected birds.

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Bobita, was one of those unfortunate birds. He is a juvenile male cockatiel, bought from a pet-shop about 3 months ago, when he was 4 months.

The owner noticed that the bird is singing more and more rarely, and when he does, the voice is hoarse. Beside this, he also noticed that the animal is losing his feathers. The owner thought it might be a hypovitaminosis, so he started to give him vitamins. When he noticed bleeding on the base of the feathers he scared and made the decision to bring him to the vet.

Clinical presentation:

During the consultation we noticed that the bird easily loses his plumage, he does not have any destructive feather behaviors or feather picking. He had a poor feather quality, they were more discolored than normal and the shape was abnormally (curved and stunting of the feathers). A part of the feathers on the head was lost. Feather dystrophy, hemorrhage within the pulp and circumferential constrictions of the feather shaft were observed. The beak started to pigment and there was a slight exfoliation, claws were longer than normal.

Differential diagnosis

Ectoparasites, viruses (circovirus [PBFD], polyomavirus), genetic conditions. Other factors that may negatively affect feather condition are low humidity, exposure to aerosols, cigarette smoke or other toxins, malnutrition and chronic systemic illnesses (hepatopathy, nephropathy).

Diagnosis

Microscopic examination of the pulp and feather were performed. In the examined samples there were no evidence of fungal, bacterial or parasitic infections. A PCR exam was performed from growing feathers pulp to detect PBFD virus DNA.

A positive PBFD- PCR result has been received.58004052_813644272342082_91552377580027904_n 58682417_2826329927441468_8642168322101608448_n 58629935_602178353581986_2865223522689482752_n

Treatment and prognosis

Because the disease is not in a very advanced stage supportive treatment focused on the stabilization of the immune system, a balanced diet and a stress free environment was recommended. The most important prevention is the hygiene of the cage and educating the owner how to disinfect, because they represent a risk   of spreading the disease.

Feather loss might be acceptable, but beak and claws changes are painful and usually a reason for euthanasia

Wound management part 2: The approach of traumatic wounds

 

 

51559132_952390804967417_8511078558653743104_nFlorin Delureanu

DVM, MRCVS

March 2017

 

Introduction

From a general point of wiev, a traumatic injury is defined as a physical damage caused by an external factor. Even if we talk about a road traffic accident, a burn or projectile injuries, all of them represents a trauma for the body. Because the first part of this series described the physiologic process of healing and how can wounds be recognized according to the phase in which they are, the second part will highlight how wounds can be addressed.

Initial assessment of the patient

Due to various types of trauma, the patient should be treated according to the requirements. The patient can be unstable after a road traffic accident, after a fighting with another dog or can be bright, alert if superficial lesions are present (patients that develop wounds due to scratching). If the patient is not stable the plan must be focused first on stabilization by checking the major function (A- airway, B- breathing, C-cardiovascular, etc) followed by a good pain control and assess the life-threatening injuries. In an emergency situations is recommended to cover the wounds with sterile gauze or another type of sterile material to provide haemostasis and to protect against another contaminants that are considered already present in the wound.

Evaluation of the wound

When the patient became comfortable, a wound evaluation must be performed. There are some factors that can help the surgeon to take a decision regarding the local management. Therefore, the following should be considered:

  • the degree of contamination;
  • when the injury took place;
  • the degree of tissue ischaemia;
  • the amount of tissue loss;
  • type of wound (burn, snake bite, etc).

About the length of time between the production of the trauma and the presentation of the patient to the clinic and the degree of contamination, wounds are classified as clean, clean-contaminated, contaminated and infected (see details in part1).               Because every injury has as a result blood loss, the tissue exposed may have different aspect and can help with the prognosis. The first aspect of the wound may be misinterpreted due to colour and integrity of the surrounding tissues. Many times the skin is crushed due to a powerfull trauma and just small superficial wounds may be present. If at first presentation the skin looks normal and the small wounds have a clean aspect and the trauma happend in less than 4-6 hours not every time will be a good ideea to do a primary closure. Some wounds may have good viability but because the tissues are crushed can develop necrosis and some wounds may have an ischaemic aspect but if the surrounding tissues are not traumatised the evolution can be favorable. As a conclusion, not every time a primary closure will be a wright decision, sometimes wounds need 2-4 days to “settle” depending of the type of trauma.                The amount of tissue loss will guide the surgeon to use specific dressings according to depth and length if second intention healing will be elected.               Regarding wound type, some specific considerations must be taken. For example, bite wounds should be explored whereas for an early frostbite wound the patient must be rewarmed first.

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Fig1. Basic wound management in six simple steps (Atlas of Small Animal Wound Management and Reconstructive Surgery, 4th Edition Michael M. Pavletic, April 2018

As an approach, wounds can be managed by closure (primary closure, delay primary closure, secondary closure already described in part 1) or can be left for second intention healing.

Second intention healing occurs when a wound is left to heal by contraction and epithelialization. All wounds can be left to heal by second intention but this process may fail at a point or may end without providing a functional outcome. There are some reasons why not every time a complete healing by second intention (especially large wounds and in high motion area-joints, axillary, inguinal) is not recommended: the granulation tissue is very fragile and easly abraded; wound contraction, sometimes excessive, may impede normal function.

Some wounds may fail to completely reepithelialize. Open wound management is indicated in dirty, traumatized, contaminated wounds in which cleansing and debridement is necessary.

Wound preparation – cleansing

To prevent further contamination of the wound in the time of cleaning, all equipement must be sterile. Prior to application of topical treatments, the wound bed must be properly prepared. Initially the wound must be protected with a sterile lubricant (eg. K-Y sterile gel) or sterile gauze soaked in warm saline. After protection, the hair that surrounds the wound must be clipped. The hair represent one of the main foreign body that can imped wound healing in a clean wound. Next, lavage the wound with a proper solution under 7-8 psi to remove the surface contaminants and in the end dry the skin surrounding the wound. This may facilitate the adhesion of the dressing and also will prevent maceration of the skin if the wound is highly exudative.

  • Wound lavage: many lavage solutions are availabile. Most popular are
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Fig.2 Basic kit for wound lavage composed by seringe, 3 way-stop cock, 18G needle, intravenous tube and 500ml bag of sterile saline.

clorhexidine, betadine, Ringer’s and sterile saline. A study from human medicine compared tap water with sterile saline for wound irrigation and showed no difference in occurance of infection. Clorhexidine is availabile in many concentrations (4%, 2%, 0,5%) but for open wounds 0,05%  solution should be used. To obtain this concentration, 25ml of clorhexidine 2% must be mixed with 1liter bag of solution. Betadine may be a good option to use in wounds located on the face, particulary near eyes because clorhexidine have very toxic effect if will get in contact with the eyes. Betadine also must be diluted to a proper concentration (0,1%-1% solution). To obtain this solution, 1-10ml of 10% betadine must be mixed with 1 liter bag of solution. As a comparation, clorhexidine is not activated by anorganic matter while as betadine is inactivated by anorganic matter such as blood or exudate. Also a 0,01% clorhexidine gluconate with tris-EDTA solution was described for wound lavage. This combination help lyse Pseudomonas aeruginosa, Escherichia coli, and Proteus vulgaris. Recently polyhexanide/betaine (Prontosan), a solution or gel containing 0.1% of the antimicrobial agent polyhexanide and 0.1% of the surfactant betaine was described as a lavage solution in wounds with good results.

 

One of the key of this procedure is not necessarily the type of solution used, but the amount used. A copious lavage of 500-1000ml is recommended. The ideal pressure of 7-8 psi can be provided by different systems. The most cheapest way is to use an 18G needle, a 3 way stop cock, saline bag, 35-60ml seringe and an intravenous tube. Pressure cuff also can be attached to the solution bag and 300mm Hg pressure can be maintained to provide 7-8 psi in the time of lavage. If the pressure is too high, the healthy tissue can break; if the pressure is under 7-8 psi the surface contaminants may not be removed completely.

After cleansing, if the wound is not considered contaminated, primary closure is indicated. Most of traumatic wounds need also debridement.

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Fig. 3 Wet to dry bandage applied on a wound located on the ventral aspect of the metatarsal area in a cat as a nonselective form of debridement

Debridement: can be selective or nonselective. Usually chronic wounds needs debridement but also fresh wounds which present devitalized tissue. Surgical and mechanical debridement are considered nonselective forms. For surgical debridement different surgical instruments can be used (scalpel, scissors, etc.) and adherent bandages (wet-to-dry / dry-to-dry) are used for mechanical debridement.

 

Surgical debridement must be performed in layers, step by step until the necrotic/ devitalized tissue has been removed and blood can be visible from the wound edges or from the bed. An en block surgical debridement can be performed but this can be limited due to location and size. The wound margins should be closed with suture material or towel clamps can be applied for a temporary closure and after the entire wound is excised, including a margin of healthy tissue. Wound irrigation is also considered a nonselective debridement.There is no strong evidence that cleansing wounds increases healing or reduces infection, but it is almost universally recommended.

Three forms of selective debridement are described: enzymatic, autolytic, biosurgical/ biotherapeutic.

 

 

  • Enzymatic debridement – includes proteolytic enzymes that break down the necrotic
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Fig.4 An example of ointment with papain and urea used for enzymatic debridement

tissue. Papain, trypsin, chymotripsin, fibrinolysine, collagenase, urea are the most common enzymes used for enzymatic debridement. Castor oil, balsam of Peru, desoxyribonuclease are also described.

 

As an advantage, they will not damage healthy tissue. This type of debridement is used less and less nowadays in wound management because is less effective and needs a long period of time to have the proper effect. Surgical debridement may facilitate enzymatic debridement.

  • Autolytic debridement – is the most preferate selective debridement. Is less painfull in

compare with the other types. This method involves maintaining a moist environement on the wound so that natural enzymatic “phenomens” can take place. Hydrogels, hydrocolloids and foams are very common used to support autolytic debridement and will be described later as moisture retentive dressings. Due to their high osmolarity, honey and sugar can also be used also for autolytic debridement. They attract the fluid and will keep a moist environement.

 

  • Biosurgical debridement – refers to usage of maggots (Lucilia Sericata, Phaenicia

Sericata) and have and FDA approval since 2004. The maggots produce enzymes that dissolve the necrotic tissue and don’t interact with healthy tissue, that’s why the debridement is selective. They are applied in the wound as larva stage (4-7 days of life) and can be left in place 3-4 days. At the moment of application the larvae have 2-3 mm and in 4 days grow until 10-15mm. The optimal activity of the maggots depends on the wound pH. They don’t survive in an acidic environment. An 8.5 pH in the wound is preffered. Each maggot may consume up to 75mg of necrotic tissue every day. They cannot penetrate dry necrotic tissue or eschar therefore are not indicated for this situation.

 

 

Moisture retentive Dressings (MDR’s)

Transepidermal water loss represents the the amount of fluid lost by the normal skin. In humans with intact skin the transepidermal water loss is 4–9 g/m2/h. In partial and full-thickness wounds the water loss increase up to 90 g/m2/h. Dressings that have a low moisture vapor transmission value, less than 35 g/m2/h, are considered moisture retentive. In humans was found that the dressing with a water vapor transmission rate of 2028.3 ± 237.8 g/m2/24h was able to maintain an optimal moisture content for the proliferation and regular function of epidermal cells and fibroblasts in a three-dimensional culture model.                The process of wound healing can be accelerated by a moist environment. MDR’s retain water and hydrate the tissue and facilitate natural autolytic debridement. All wounds need to be covered with a specific dressing to maintain a proper moisture until full epithelialization otherwise the granulation tissue will get dry and eschar will occur. MDR’s are availabile on the market in various sizes, shapes, thicknesses, with or without adherent margins. They must be applied on top of the wound as a first layer and after can be covered with the second (absorbent layer) and third layer (protective layer).

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Fig.5 Lateral view of a polyurethanic foam. Noticed the convex shape that the foam acquired after beign moistened. Due to this particularity this dressing have a good contact with the wound bed.

Polyurethane foams: is a porous nonadherent dressing that can be used in moderate to high exudative wounds. It absorb several times it’s weight. Is recommended to be used in sterile wounds and regularly must be changed every 3-5 days. With time, the period in which the dressing must be kept in place will change according to the amount of exudate. Some articles described that can be used also over infected wound bed but must be changed every 24 hours.

 

Can or cannot have adhesive borders and does not transform in gel. It is contraindicated in wounds with low exudate and not recommended in areas with bony proeminence because is very soft and cannot protect the damaged area. In compare with hydrocolloids and alginates, foams are less effective for autolytic debridement.

Alginates (calcium alginate): have high absorbtive properties. It absorbs 20-30 times its weight in fluid. In contact with the exudate, alginates transforms in gel. Is derived from brown seaweed and is recommended in high exudative wounds. It promotes haemostasis and Ca2+ stimulates macrophages and fibroblast activity. Is not recommended to be used in low exudative wounds.

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Fig.6 Calcium alginate appearance. Left picture represents calcium alginate sheet applied on dorsal and ventral aspect of metatarsal area in a cat with a degloving injury after surgical debridement; Right picture represents the aspect of calcium alginate 24 hours later in the same patient; Note the transformation from dry fibers in gel and the proximal area in which the dressing was absorbed (yellow arrow).

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As a presentation form, alginates are used in flat sheets and can be applied even in narrow cavities. On the market alginates can be found in combination with silver, zinc or honey.

Hydrogels: are indicated in low exudative wounds. They donate fluid to wound but can also absorbe it. Can be found in two presentation forms-sheet and gel. Contains 60-95% water and the cooling effect may decrease pain. Is not indicated in high exudative wounds because maceration can occur. Overgranulation has been reported after usage of hydrogels in excess. In cavitary wounds the gel form is inficated due to better contact. Hydrogels can also be used to soak the dry necrotic tissue.

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Fig.7 Left picture describes hydrogel sheet used on the lateral aspect of digit IV in a dog with and abrasion wound. The wound had partial epithelialization and a small area with granulation tissue and the level of exudate was low. In the right picture gel shaped hydrogel is placed on Primapore.

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Various forms of hydrogels combinations are availabile: with hyaluronic acid, alginate, collagen, etc. Can be left in place 3-4 days in non-infected wounds. They are permeable to gas and water and have proven to be a less effective bacterial barrier than occlusive dressings.

 

 

 

 

 

Hydrocolloids: have in composition may constituents like sodium arboxymethylcellulose,

gelatin, pectin, and polyisobutylene. Gelatin, pectin, elastomers, alginates, silver, and other materials can be added to these substrates. In contact with exudate it transform in gel and maintain a moist environment. Hydrocolloids are indicated in wounds with low to moderate exudate.

Sheets, powder and paste are the form of presentation. In compare with alginates, foams and hydrogels, the contact face of hydrocolloids is adherent but just on the skin, not on the granulation bed. Regarding permeability, hydrocolloids are semi-permeable to water vapour and oxygen but not permeable to bacteria and other contaminants. Is not recommended in infected wounds. May cause overgranulation.

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Fig. 8 Different aspects of hydrocolloid dressing. (a) Fresh hydrocolloid applied on a mild exudative wound in a dog; the dressing have is brown and opaque. (b) View of the dressing 5 days after application on the dorsal metacarpal area in cat. Note the brown dark colour that hydrocolloid achieved. (c) Dressing removal in the same patient in the same day. Note the yellow, gelly and bright aspect due to granulation bed contact.

 

 

Miscellaneous dressings

Honey – called also natural dressing, they are composed by glucose, fructose, sucrose, maltose, amino acids, vitamins, minerals and enzimes. Honey is the most popular product used as a topical treatment for wounds; have an antimicrobial effect due to low pH (3-4.5 ), release of small amounts of hydrogen peroxide or the presence of methyglyoxal. Honey promotes autolytic debridement and reduce oedema due to high osmolarity. It was demonstrated that honey have effect against a multitude of bacteria including Pseudomonas spp., MRSA and E. coli. Composition of honey does vary according to the geographical source. Many types of honey are availabile, from raw honey to medical grade. Manuka honey (Leptospermum scoparium) that originates from New Zealand is the most common used in humans and animals for wound care. Medical grade Manuka honey is recommended despite raw honey because raw honey may contain bacteria and fungal contaminants including anaerobic spore‐forming organisms. Recently was developed a new type of honey was developed which is not manuka honey. SurgihoneyRO is an antimicrobial wound gel utilising bioengineered honey to deliver Reactive Oxigen and is superior to Manuka honey. It cames in a variety of form such as gels, sheets, in combination with alginates or simple gauze. Honey is recommended in wounds that needs debridement and is not recommended to be applied over the granulation tissue. Despite the multitude of benefits, the quality of the evidence is variable.

Silver dressings– should be used when infection is suspected. Has been shown that silver ions have an antibacterial effect in contact with the exudate. Because silver ions are activated by a moist environment, is not indicated to be used in wounds with moderate-to-low exudate. There are some evidence that suggest delay healing if silver dressings are used in acute wounds. Is available as gel, sheets, impregned in alginates, foams and hydrocolloids and can be left in contact with the wound up to 7 days. Silver is a broad-spectrum antimicrobial agent that is effective against bacteria, fungi, viruses, and yeast. It has also been proven to be active against MRSA and vancomycin-resistant enterococci (VRE) when used at an appropriate concentration. Silver destroy bacteria due to multiple mechanisms: disrupts bacterial cell walls, inactivates bacterial enzymes, and interferes with bacterial DNA synthesis. Therefore bacterial resistance has yet to be documented, although reports of isolated Escherichia coli and Pseudomonas aeruginosa have shown resistance to silver in vitro.  Despite the benefits, some articles concluded that is still a lack of evidence about usage of topical silver and silver dressings for treatment of infected or contaminated chronic wounds.

Collagen dressing: are available in different forms such as granules, powders, sheets, pastes, gels. The collagen from these products derived from bovine, porcine, equine, piscean or avian source. Collagen has been widely used in cosmetic surgery, as a healing aid for burn patients for reconstruction of bone. Is the main structural protein in the extracellular space. Is resistant against bacteria and in this way it helps to keep the wound sterile. Platelets interact with the collagen to make a hemostatic plug. Collagen based dressings need a secondary dressing layer to maintain a moist environment. Products that contain collagen promotes angiogenesis and stimulates fibroplasia. Recently, usage of Tilapia skin fish in veterinary medicine and blue shark skin in human medicine for burns were described with promising results.

Silicone dressings– are used mainly in humans to reduce the hypertrophic scar. The mechanism of action of silicone dressings is not fully understood. It is believed that silicone due to occlusive effect, decrease the oxygen of the tissue until anoxia, environment in which fibroblasts cannot have a normal function and undergo apoptosis. In humans has been shown to help reduce trauma and pain. Silicone dressings were tested in rabbits, rats and horses. Silicone dressings are nontraumatic and the contact surface is adherent but just on the skin surrounding, not to the granulation bed. A comparison between silicone dressing and silicone gel in a controlled trial for treatment of keloids and hypertrophic scar. Compared to the untreated controls, all of the measured parameters including scar size and induration were reduced in both silicone and nonsilicone-treated groups. In 2005, silicone dressing was used with good outcomes in horses with exuberant granulation tissue. In 2017, a review of silicone gel sheeting and silicone gel for the prevention of hypertrophic scars and keloids concluded that was statistical significance in the effectiveness of both of them but most of the trials had poor quality with high or uncertain risk of biases.

Borate glass nanofiber – was developed in 2010 by human engineers and is recognized to have regenerative properties on bones and soft tissues due to stimulation of angiogenesis and osteogenesis. Two borate glasse with (1605) or without (13-93B3) CuO and ZnO were studied along with the silicate-based glass, 45S5 for the potential effect on vascular endothelial growth factor. The study demonstrate that silicate glass is inferior to borate glass. Copper and zinc ions together with calcium, phosphorus, magnesium, etc., stimulate the proliferation of human endothelial and osteoblast-like cells, promote angiogenesis, and stimulate vascular endothelial

growth factor secretion. Osteogenesis is encouraged because the fibers convert to hydroxyapatite.

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Fig.9 Borate based glass nanofiber. Macroscopic aspect, “cotton-candy” like (left picture) and electron microscopy (right picture).

In 2017, borate glass nanofiber was evaluated for treatment of full thickness wounds in six dogs. The study had many criteria: wound cause and location, type and duration of previous wound management, time to granulation tissue formation, time to complete wound healing, subsequent procedures if applicable, outcome, and complications associated with treatment. With a “cotton candy” aspect and soft texture, the borate glass can be applied to any defect, even in deep wounds can be packed. Is not expensive and did not require hospitalization. A veterinary product was developed and is available (RediHeal) for cats, dogs and horses. Because promotes bone growth, the product can be packed also in the defect which result after dental extraction. After application, the fibers degrades at a controllable rate and release ions.

 

Wet-to-dry Vs MDR’s

 

·         Wet to dry bandages: first they overhydrate and after dessicate the wound bed. As

a result, cells involved in the healing process will lose their function. Because is a nonselective debridement form, when wet to dry bandages are removed normal cells (WBCs, macrophages, granulation tissue) are pulled off with the surface contaminants. The environmental bacteria can penetrate the gauze.

 

Because is adherent, in the time of removal will be not comfortable for the patients due to pain sensation. Small gauze fibers can remain in the wound bed, will act as a foreign body and will extend the inflammatory phase. They are not expensive but if are used as a sole treatment for wounds, the cost may increase semnificatively due to delay healing and daily replacement.

 

·         Moisture retentive dressings: during the inflammatory phase, support selective

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Fig.9 Characteritics of an ideal dressing

autolytic debridement and promote healing because will keep a moist environment. They are nonadherent and nonpermeable for bacteria  so the infection rate is lower in compare with wet to dry bandages. They also require replacement every 3-6 days (depends on the product and the wound appearance) therefore decrease the costs for total wound care. Because MDRs are occlusive or semioclusive in nature, they decrease the pH and oxygen tension in wound and, as a result, WBCs are attracted, angiogenesis and collagen formation are stimulated and inhibit bacteria. MDRs are comfortable  not painfull for the patient when are removed from the wound bed. Also they prevents dessication and necrosis.

There is no dressing that meets all the conditions and cannot be considered that one is better than the other. The aim is to use the correct dressing according to the needs of the wound. Therefore, the physiology of wound healing needs to be understood. As an example, even if gauze (wet-to-dry) have many negative consequences, it can be used for debridement as part of wound management and is very effective but contraindicated in the proliferative phase while calcium alginate (MDRs) is less effective and can dessicate the wound bed when is applied on dry wounds.

 

Regarding moisture, a simple general rule is considered: exudative wounds need dressing that will absorb the fluid and dry wounds need dressings that will deliver moisture. It is detrimential to assess the volume and the appearance of the exudate each time the bandage is changed. A wound with a favorable evolution will produce less and less exudate with a clear clear aspect.

Alternative therapies

 

            Wounds have different behavior and the evolution depends on many factors (localization, degree of contamination, size, etc.). In particular situations, wounds may not heal by second intention or they may decrease in size in the time of treatment but in some cases the proliferation may stop. If surgical closure cannot be achieved, alternative therapies may be considered. As an example, vaccum assisted closure (negative pressure therapy), laser therapy or platelet-rich plasma (PRP) should be considered.

Pink teeth in a 10 months old Cane Corso

 

30595139_1823183557733595_5657871534119714816_nDr Elena Carmen Nenciulescu

Bucharest, Romania

 

 

 

Hera, a 10 months old female Cane Corso, was presented on the 15th of October 2018 for a dental consultation. She had pink teeth, a strong halitosis, „wasn’t eating like she used to” and showed signs of pain (didn’t let anyone touch her mouth or look at her teeth).

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Crown fracture with pulp exposure 304 and 404

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Image 1 – Abnomal density of the cortical bone

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Image 3 – X-ray of the rostral maxilla

 

 

 

 

 

 

 

 

 

 

 

 

 

X-rays showed a very large pulp cavity in all teeth, very thin dentin and enamel, crown fracture with pulp exposure in 304 and 404 (Image 2), but also an abnomal density of the cortical bone in the mandible (Image 1) . The owner reported that the deciduous teeth were pink too.

 

 

 

 

 

 

 

 

 

 

 

 

The dog previosly had 2 surgeries in both elbows in another clinic (bilateral elbow dysplasia). Hera is also blind with both eyes (there is no vascularization in the eyes).

Antibiotics (amoxicillin with clavulanic acid 20 mg/kg/12 h) and analgesia (meloxicam 0.1 mg/kg/day) were immediately started and the patient was scheduled for a dental procedure a week later.  CBC and routine biochemistry were normal.

The dental examination under aneshesia revealed 6 crown fractures with pulp exposure (109, 110, 209, 210, 304, 404). We extracted these teeth and tried to seal  with the remaining ones. The dental extractions were very difficult, but the healing was good (as you can see in the images from the second dental procedure).

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Image 4 – Complicated fracture 304

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Image 5-404 pulpar granuloma and 404 extraction

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Image 6- 404 pulpar granuloma and 404 extraction

At this first dental procedure (Images 4 – 11), we took a blood sample to see what were the vitamine D3, calcium and parathoyroid hormone levels. When results came, we found out that Hera had hypoparathyroidism (PTH level was 1.2 pg/ml, almost 16 times lower then the physiologic range) and recomanded a thyroid ultrasound, which is not availiable unfortunately.

Also Vitamine B12 was low, so the patient recieved treatment for that too.

 

 

 

 

 

 

 

 

After the first procedure, the recovery was fast, the dog started to eat the next day, but only very soft food.

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Image 8- Clinical view of the right maxilla

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image 9-Clinical view of the right maxilla

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Image 10 – Clinical view of the right mandible

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Image 11 – Clinical view of the left maxilla

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Image 12 – Clinical view of the right maxilla and mandible – tooth wear of all teeth is more pronounced

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Image 13 – Clinical view of the lower incisors that are even „pinker” then the first time

The second dental procedure (Images 12 – 16) together with  the ovariohysterectomy took place on the 23rd of February 2019, when we performed extractions of 208 and 209 retained roots and full 405 was extracted for histopathological examination (that will be performed at Histovet by Dr. Teodoru Soare). The recovery was even better than the first one. Hera received clindamycin 11 mg/kg/day, 7 days and meloxicam 0.1 mg/kg/day, 4 days. Unfortunatelly, because a second set of radiographs were not available for this dental intervention.

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Image 14 – Closer look of the right maxilla

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Image 15 – Left upper premolars

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Image 16 – Left maxilla and mandible

 

 

 

 

 

 

 

 

 

 

 

The dental pathology of this patient might be a very rare congenital dental condition called „shell teeth”, in which teeth have large pulp chambers and insufficient coronal dentin. The treatment of this dental disease is full mouth extractions, but given the very high level of difficulty of the extractions, we chose to extract only the fractured teeth. It may be a consequence of a congenital hypoparathyroidism, which would also explain the other pathological signs (blindness, bilateral elbow dysplasia).

Hera is a very interesting case with high didactic value. She remains supervised for evaluation of her clinical evolution.

Both interventions took place at QincyVet and were performed together with Dr. Raluca Zvorasteanu.

Broncholithiasis in cats

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Dr Svetoslav Penchev

Unites Veterinary Clinic

Varna, Bulgaria

 

 

 

 

 

 

3 years old male, not castrated British shorthair cat with history of tetraparesis was referred to the clinic for Computed Tomography. Mineral-attenuating endobronchial lesions were detected in Thorax as accidental finings in spinal CT. The finding is specific for broncholitiasis.

CT  :

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CT features: Multifocal mineral-attenuating endobronchial lesions in cranial and middle right and cranial left lung lobe are present. There is mild generalized thickening of the bronchial walls and consolidation of right middle lung lob with regional bronchiectasis

 

 

 

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X-rays

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X-ray features: Multiple mineral opacity nodules with irregular margins are present within left and right cranial and right middle lung lobe. The largest of which lies within the right middle lung lobe and interstitial patter in this region is present.

 

 

 

Broncholithiasis is very rare condition in cats and is defined as the presence of calcified or ossified material within the bronchial lumen. Only four cases of broncholithiasis in cats have been reported in the veterinary literature. Normal this condition is associated with lower airway inflammation, but in this case the owner does not report for respiratory problems. Broncholithiasis is an uncommon condition, which should be considered as a differential diagnosis for cats with chronic respiratory disease. Affected cats may develop broncholithiasis secondary to a diffuse inflammatory lower airway disease with mineralisation of secretions in the airways.

 

 

 

 

 

 

Vet Business Academy, an amazing association, open to give us the knowledge and help us to make our life better

24909813_388955481530328_7583228791966007145_nWe are really happy that more and more veterinarians are aware of the needing, to improve our knowledge in a field that is really far of our medical way of thinking, because if we are aware or not, we are managers of our own business. So, we should be open and to start learning how to improve this field.

 

And we are lucky because we have the sources and the people who can teach us.

One of these opportunities is Vet Business Academy, an amazing association, open to give us the knowledge and help us to make our life better.

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Dr Cristian Marinescu-the president of Vet Business Academy

VET BUSINESS ACADEMY

  1. What is our desire?

 

  • Create a vet business community and provide access to business education.
  • Provide knowledge and increase vets’ competencies in areas like:
    • People management, Communication, Marketing-merchandising, Financial knowledge.

 

  • Improve vet the efficiency of vet clinics by providing better services to clients and improving internal processes.

 

 

  • Training and workshops to improve vet competencies in business areas.

 

  • Vet consultancy in the business field.

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Why us and why now?

 

  • Practical experience in vet clinic management

 

  • Experience in vet industry , local and international.

 

  • Experience in fields like: marketing, communication, planning, business administration and people management.

 

  • Good relationship with KOLs, Universities and local authorities.

 

  • Knowledge of vet legislation and experience in the prediction of future vet business trends.

 

  • Coaching, Leadership, Critical thinking.

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OUTCOME

  • Become more than a Vet clinic
    • Provide a consultative relationship model
    • Build effective TEAM
    • Become preferred Vet Clinic for Vets & Pet-Owner’s
    • Differentiate in a crowded market

 

In 2018 the association has organized plenty of events in Romania.

  • Workshops : Communication , People Management, Merchandising , Financial intelligence
  • Class – “Mastering Public Speaking”
  • Management presentations on AMVAC Congress –Dr.Lowell Ackerman
  • Provide the management string in different vet events

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If we realize or not, we are part of the economically world, we sale service and together with our love to the animals and our professional, we are responsible about our employers, for their financial comfort and work environment. So, it is time to start learning to be good in this as well

Learn and Travel-Dr Renata Jelic from Serbia in Central Vet Clinic in Sofia, Bulgaria

 

53835429_2559867640708543_1925608025490456576_nDr Renata Jelic from Serbia has done her externship in Central Vet Clinic in Sofia, Bulgaria

learn and travel

 

 

 

 

Lets see what she said about it:

 

“I would like to start by thanking Dr. Luba Gancheva and Vets on The Balkans for giving me a wonderful opportunity to spend a week in one of the best veterinary clinic on the Balkans. received_625044874599015Together with my colleague I was warmly welcomed by Dr. Ranko Georgiev, the head of Central Veterinary Clinic in Sofia, a great expert and an exceptional man who provided accommodation for us and, more importantly, gave us free access to all parts of his clinic. And what a clinic it is. It spreads on three levels, all well organized and fully equip, in order to provide the best possible comfort and care for pet patients. Dr. Georgiev when out of his way to make sure that I used my time efficiently, constantly encouraging me to ask and participate. His help is immeasurable. Central Veterinary Clinic is the best vet clinic I ever had a chance to be a part of, even for a short while. One week is certainly not enough to experience and learn all that the great and professional staff was willing to teach me, but the knowledge and experience gained will sure help me improve as a veterinarian. One vet that I would like to give a special thanks to is Dr. Hristina Shukerova,received_555494404860695 received_2472585622815978 a person I spend most time with. She was always there for all my questions, she answered them professionally but with a touch of human emotion which made me fell as a part of the group, as a part of their team. As Dr. Shukerova’s field of expertise is cardiology, a field I wish to specialize in, she was able to help me greatly improve my knowledge in this area of veterinary practice. I will conclude this short look back on my week spent at Central Veterinarian Clinic in Sofia by sending my love and lots of smiles to all the staff working in this clinic, with a special big “Thank you” to Dr. Ranko Georgiev, Luba Gancheva and Vets on The Balkans for making this externship possible.”received_398377974256240 received_445330466039904

We would like to express our gratitude to Dr Ranko Georgiev and the whole team of Central Vet clinic for make this possible!