Friends Newsletter Spring 2019

Better Together friends

SPRING 2019 NEWS STORY PROSTATE EMBOLISATION IN CONVERSATIONWITH RADIOGRAPHER FELICITY STRINGER A FOCUS ON OUR MULTI-DISCIPLINARY APPROACH REGULAR FEATURES CLIENT COLUMN & FITZ & PIECES

World-ClassVeterinary Medicine, Hope and Healing

fitzpatrickreferrals.co.uk

Welcome to the spring edition of the FRIENDS newsletter

EUROPE’S FIRST PROSTATIC EMBOLISATION AT FITZPATRICK REFERRALS

Innovation and routine expertise combine at Fitzpatrick Referrals Since 2005we have developed and undertakenworld- first procedures such as CDF (Cervical Distraction- Fusion) and LSDF (Lumbo-Sacral Distraction-Fusion) using patient-specific fixation devices forWobbler Syndrome andDegenerative Lumbosacral Stenosis. We have produced hundreds of custom implants, allowing bespoke solutions for patients thatmeet their specific anatomical and surgical needs.These include primary and revision partial or complete joint replacements, trauma and arthrodesis plates and spinal reconstruction devices. Prior to joining Fitzpatrick Referrals Gerard completed a Fellowship in Interventional Radiology (IR) at the Animal Medical Centre in NewYork. He is the only specialist in Europe to have undertaken this advanced training in IR. Prostatic embolisation in veterinary patients has only been performed in a small numbers of centres globally and not previously in Europe.The initial results from a study at the University of California Davis documented up to a 40% reduction in the volume of prostatic tumours following embolisation along with significant improvements in the patient’s quality of life (the ability to pass urine and faeces in particular). Prostatic embolisation can now be performed alongside targeted intra-arterial (IA) chemotherapy. IA chemotherapy has been administered to over forty patients with lower urinary tract tumours at Fitzpatrick Referrals in the past 24 months with excellent results (up to 30% reduction in prostatic size and improvement in clinical signs).The Interventional Radiology team at Fitzpatrick Referrals has extensive experience in embolisation techniques as they regularly perform chemo-embolisation of other non-resectable tumours including large hepatocellular carcinomas. Referrals Oncology and Soft Tissue) first carried out the procedure in December 2018 and has since performed it on two more patients. F itzpatrick Referrals is now offering arterial embolisation as a treatment for canine prostatic neoplasia – the first veterinary centre to do so in Europe. Gerard McLauchlan (European and RCVS Specialist in Small Animal Internal Medicine, Fitzpatrick

First and foremost I would like to thank all our referring vets for your ongoing support.Your trust, encouragement and friendship enables us to deliver the highest level of care and compassion for your patients and their families.

primary interest. This echoes the words of Charlie and Thomas Mayo, founders of The Mayo clinic in the USA in the early 1900s, which has since become the premier institution inAmerica for the evidence-based unprejudiced delivery of medical and surgical care in human medicine.The philosophy of Fitzpatrick Referrals is modelled on The Mayo Clinic. Of course, none of what we deliver as a team to animals and their guardians would be possible without your continued support. We welcome visits from any of our colleagues to interact and see us in action. I truly hope that we continue to work together as care partners to provide the best possible outcome through compassion and integrity. I have always considered the veterinary profession a vocation, as opposed to a job. It is this view that has given Fitzpatrick Referrals an unequivocal determination to provide all of the options with transparency and to support those who join us on our journey to help patients regain a pain free, functional quality of life.

An update from Professor Nick Bacon We have grown to become the largest and one of the few remaining independent multi-specialist practices in the UK. Our first practice, Fitzpatrick Referrals Orthopaedics & Neurology in Eashing, works hand-in-hand with our Oncology & Soft Tissue hospital in Guildford enabling us to offer a range of multi-disciplinary options, 24 hours a day, 365 days a year. From routine fractures, joint surgery and spinal emergencies to urgent cancer care and soft tissue When I built the first home for Fitzpatrick Referrals in 2005, my vision was to create an environment where it would be truly possible to marry compassionate care with excellence in veterinary medicine. I dreamed of building a facility where the diagnostic imaging, preparation areas, operating theatres, surgical equipment and implants, wards and rehabilitation would be world-class, and I took inspiration from hospitals all over the world. However, any building is only as good as the people within it, and I truly feel blessed to be surrounded by more than twenty highly-skilled specialists across two quality sites who are phenomenal at what they do. I’m also hugely honoured to work beside our nursing, theatre, ward and rehabilitation teams who are second-to-none and provide what I consider to be on par with the best level of care available anywhere in the world today.

surgery – our focus is on providing you and your client the best service as quickly as possible to help their animal family member. We aim to see all routine orthopaedic cases within 48 hours when clinical history, including imaging, is provided. We also aim to see all orthopaedic trauma and urgent spinal cases immediately. In the area of customised partial and complete joint replacements and spinal disc replacement and fusion, we offer more options than any other referral hospital in Europe. We also offer intra-articular injections for osteoarthritis with anti-inflammatory stem-cells and blood-based products.We adopt very strict quality control for such treatments and our gait assessment technology facilitates a stringent evidence-based approach. It is very important to us at Fitzpatrick Referrals that we provide all of the options without bias, including medical management or physiotherapy, regenerative medicine, minimally invasive or open surgeries, commercially available or custom implants depending on the circumstances. It is fundamental to our ethos that the welfare of patients is our principal concern and that the best interest of our patients and their guardians is our

We are extremely proficient at undertaking routine procedures to the highest standard, such as TPLO(Tibial Plateau Levelling Osteotomy) for cruciate ligament rupture of the stifle, and arthroscopic plus osteotomy treatments for developmental elbowdisease – both of whichwe have performed several thousand times. We have a dedicated oncology and soft tissue facility that was designed and purpose built to accommodate the specific physical andwellbeing needs of cancer patients. Cancer treatment is a journey, so our building and teamare 100%focussed on delivering best-in-the-world care every step of theway. Fitzpatrick Referrals is home to some of the world’s leading specialists in orthopaedics, oncology, neurology and soft tissue surgery.Whilst we take pride in our ability to perform routine surgeries for everyday conditions, we also strive to provide all of the options to our patients and their families through advanced treatments – developed by and performed at Fitzpatrick Referrals. By working closely with a team of researchers, biomedical engineers and in some instances surgeons in human medicine, we are able to provide innovative solutions for animals who would otherwise face a lifetime of medical management, loss of limb or euthanasia.

We hold Tumour Rounds every two weeks where all clinicians attend and discuss every new cancer patient we have seen; we share the decisions that were made for the patient and ask for input and feedback on future management.This benefits the patient by getting input from individuals with expertise in different areas from implant technology to chemotherapy to the most effective surgical techniques. It means the families can count on a world-class service, and it benefits you, the referring vet, as you can rest assured we are offering sound unbiased advice which puts the needs of the patient and the family first. We are continuing to work closely

2019 is already underway and it seems the changes within the veterinary profession show no sign of slowing down. Following all the recent well- publicised acquisitions within the referral world, our oncology and soft tissue hospital is now remarkably the only independent private oncology specialty centre in the UK. We are always looking towards our primary aim – to change oncology and try to help patients, whether they visit us or not.We appreciate this is not an easy path and it means committing to invest in people, projects, and ideas that are key to moving cancer care forward, but ultimately are financially altruistic. For example this year we are excited to be launching a tumour archiving BioBank – a repository for samples from spontaneous tumours in cats and dogs to help cancer researchers with investigative projects for decades to come.

half of the 2018 class of surgical interns have now moved onto surgical residencies and in March our recent oncology intern started a medical oncology residency at the University of Edinburgh.The surgical residency program has been running for several years now with the residents rotating through both Guildford and Eashing, treating patients at both sites. Both (ex) residents who sat the Board examinations this spring are now Surgery Specialists and Diplomates of the European Surgery College. We are a few weeks away from seeing our 5000th patient and I hope that every family we see, every patient we treat, ultimately makes the landscape better for those that follow. Warm wishes to you all.

with the University of Surrey Veterinary Cancer Research Programme and The Rumba

Foundation who support many of our technical innovations.We also remain committed to training junior clinicians – we are very pleased that

To find out more information about both our advanced and routine procedures, visit fitzpatrickreferrals.co.uk

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Client Column | Tully

IN CONVERSATIONWITH...

Felicity Stringer, radiographer at Fitzpatrick Referrals Orthopaedics and Neurology and Fitzpatrick Referrals Oncology and Soft Tissue, offers an insight into life working across both centres and multi-disciplines.

Communication was a big change for me at first, my animal patients can’t directly tell me how they are feeling and where the pain is, so getting used to interacting with my furry patients definitely took a bit of getting used to! In addition, there was also the challenge of anaesthesia to incorporate into the imaging process. Most of our veterinary patients will undergo either general anesthesia or sedation during diagnostic imaging and with this comes a whole variety of different factors to take into consideration. Anatomy was another huge subject to get my head around – for instance a dog’s elbow joint structure is very similar to that of a human, the same bones, ligaments and tendons are all designed to move the joint in the same way. But the huge difference of course is that in dogs, the elbow is a weight bearing joint which creates a very different type of elbow pathology to that which is seen in humans.Also the development and metastasis of cancer - there are so many similarities in how cancer progresses and presents in all species - human or animal, and so therefore a lot of the imaging methods we use in veterinary are the same as if we were scanning humans. But with such a variety of breeds, each imaging protocol needs to be tailored and adapted to each patient in order to attain the very best diagnostic images.

1.What made you make the move from human radiography to veterinary radiography? After graduating from the University of Exeter with a degree in Medical Imaging (Diagnostic Radiography), I worked in the NHS for seven and a half years – at the Royal Surrey County Hospital, where I was fortunate enough to learn both CT and MRI. I found this really fulfilling, it gave me a range of skills and a lot of perspective to take into a veterinary role. When I was at university, I attended a lecture on veterinary radiography and I became fascinated by it, I love animals and the urge to make the move into the veterinary field was always in my mind. My dream came true in early 2015 when I was offered a radiographer post at Fitzpatrick Referrals and I have not looked back since! 2. How does working in veterinary radiography differ to human radiography? There are so many similarities yet at the same time so many differences! My journey from when I started at Fitzpatrick Referrals has been, and continues to be, a huge learning experience.

By Lance Plunkett

Tully is an eight year old Australian Sheepdog who I’ve had since he was eight months old. He is extremely loyal, loves a cuddle and is super well behaved.

Tully having his re-check

3.You work across both Fitzpatrick Referrals hospitals.What are the differences between the two practices and how do the two complement each other? The hospitals offer very different specialties and for the radiographers that means that imaging requirements can be different. However there are always cases that cross over between the different disciplines and the two hospitals constantly work together to provide world-class care with every option possible available to patients. The limb salvage pathway is a great example of this – patients with suspected osteosarcoma will be referred to the oncology centre, see a specialist and undergo imaging to confirm the diagnosis.The clinician will then go through the treatments available, one of which being limb salvage surgery, a technique pioneered by Professor Noel Fitzpatrick at our orthopaedic centre whereby the cancerous part of the bone is cut out and replaced with an endoprosthesis. I love working between the two sites because not only does it give me a huge range of patients and pathologies to image, but it also allows me to follow the patients on every part of their journey.To see a patient enjoying a good quality of life again is so rewarding and to feel that I have been a small part of that process makes me very happy in my job. 4.Talk us through a typical day across both hospitals There really is no such thing as a typical day!We see all sorts of patients for all sorts of different conditions.At our orthopaedic and neurology site, a day’s work may include seizuring patients who need an MRI brain scan, lame patients who need a CT elbow scan or patients who have lost use of their limbs who need an MRI spine scan.At our oncology and soft tissue site we may see patients with suspected tumours who need a CT to confirm and stage the disease, patients with stick injuries who need a CT scan to assess soft tissue damage and patients undergoing interventional procedures where x-ray guidance under fluoroscopy is needed.You never really know who you will end up imaging and just when you think you have seen it all, a patient arrives with a something you have never seen before. The radiographers all rotate between the two sites allowing us to work with a variety of patients and pathologies.We stay in communication with each other, often imaging will need to be sent between the two sites so that the vets with different clinical specialties can assist in reviewing the images in order to provide the best options for the patient and their family.We are lucky to have two radiologists who report on all sorts of images, providing advice and support to the imaging team. No two days are ever the same, every patient presenting a different set of challenges to overcome in order to achieve a diagnostic image and every day a learning day, that’s one of the things I really enjoy about my job.

People who meet Tully always love him - he greets everyone with a waggy tail and genuine look of happiness on his whole face. Even before his operation he was a special dog whom everyone loved, and now he is extra special with his three legs. In November 2014,Tully started to show a slight lameness in his front right leg.A local vet first thought he had pulled a muscle in his shoulder and recommended resting him from walks.We tried that for a month and the symptoms slightly improved but there were still small signs of lameness. Unfortunately we had a six week trip toAustralia planned so Tully stayed with a friend who was going to rest him.When we returned in January his lameness had not gotten any better, so we returned to the local vet who took some x-rays and saw what he thought was a cancerous tumour in Tully’s shoulder and he was immediately referred to Fitzpatrick Referrals Oncology and Soft Tissue hospital. discussed treatment plans. I was extremely worried about Tully being on three legs and seriously considered having his leg removed. However, after much research and talking to other people with three legged dogs and weighing up all the pros and cons, I decided amputation was the best route. Tully was seen by Nick Bacon who diagnosed an osteosarcoma and we

After the leg and tumour were removed, Tully had chemotherapy. I wasn’t concerned about this, as I had discovered through research that it doesn’t affect dogs like it does humans.Tully had both intravenous and oral chemotherapy and neither affected him at all. He is still on chemotherapy today. Once his strengthwas built together and I let himdowhat hewanted. Dogs on three legs do not need to bewrapped up in cottonwool andmy philosophy was that hemight as well enjoy the days he has left asmuch as he could.  He loves swimming, racing along the beach, chasing balls, jumping onto boulders and going for runs with me.  Tully’s life now is identical to what it was before the operation and chemotherapy: he runs, swims, jumps and chases balls with all the vigour that he did when he had four legs. He is the alpha dog in the family and keeps up with his younger sisters Hiccup and Meadow without difficulty. He even insists on lifting his leg to pee still, balancing on only two legs. up, I treated himas I did before;wewent for runs

It has worked so well with the local vet and Fitzpatrick Referrals sharing Tully’s care.  The communication between them and Fitzpatricks has been seamless and both have worked really well together to help Tully. It couldn’t have been an easier or better process. I cannot speak highly enough of the team at Fitzpatrick Referrals – they are friendly, nice, talented and genuine people with the animal’s welfare at the heart of their job. I’ll forever be grateful to them for keeping my best mate alive for a lot longer than was expected… and he’s still going!

Tully after surgery

5.What skills do you feel you have developed as a result of working across both hospitals? I think working between the two sites has allowed me to build my knowledge and create a deeper understanding of how the different specialties work and how they all fit together to create the overall result for the patient, just like how all the pieces of a puzzle fit together. This has helped me develop the way I carry out my own work in imaging, especially if it is apparent that a patient will benefit from a multidisciplinary approach to treatment. We usually only have one opportunity to acquire all the appropriate images so it is important that we get exactly what the clinicians need to make a diagnosis and working alongside all the different specialties has given me a huge appreciation of what is expected in imaging. I think it has also given me a tremendous sense of team work, everyone contributing their own part to get the best outcome for the patient.

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A FOCUS ON Our multi-disciplinary approach Fitzpatrick Referrals prides itself in its ability to offer patients all of the options and this often means that we treat patients across multiple specialisms and across both hospitals.We are home to a team of world-class specialists who provide round the clock care to every patient – especially those with complex needs. Discover some of our case studies across these pages.

Neurology and Soft Tissue Two-year-oldWest Highland Terrier Louie Simpson was admitted to Fitzpatrick Referrals Orthopaedics and Neurology after a suspected head trauma following an accident with a stepladder. After his altercation with a stepladder, Louie was taken to his local primary vet the next day after developing signs of hyperactivity, drooling and a vacant expression. He was also unresponsive when called, hitting obstacles and circling around a perimeter of a room.

Suspecting brain swelling as a delayed complication of head trauma, his local primary vet treated him with a mannitol infusion and a low dose of intravenous fluids. He initially recovered but a couple of days later, Louie deteriorated. He presented with further signs such as difficulty drinking, panting, compulsive walking and walking into obstacles and had a lowered head posture.

Sensei at Fitzpatrick Referrals post treatment

high 190 - suggesting Louie did not have a normal functioning liver and was unable to deal with neurotoxic compounds produced by gut bacteria as a normal part of a digestive process. Clare became suspicious of a hepatic portal shunt - whereby a blood vessel “shunts” the blood coming from the gut past the liver whereupon the neurotoxic compounds affect the brain. She recommended a referral to our oncology and soft tissue centre in Guildford, a low protein diet, lactulose at 5mls three times daily (adjusted to achieve soft faeces) and Synulox™ 50mg twice daily.” Louiewas then referred to Fitzpatrick Referrals Oncology and Soft Tissue instructed a CT angiogram – showing the presence of a large portocaval shunt. Whilst he was still under anaesthetic, Laurent performed surgery to localise and dissect the shunt.The procedure was a success and Louie recovered without problems from anaesthesia. He remained in hospital for another two days to recover and was sent home to continue his medical treatment. hospital where Senior Clinician Laurent Findji

Louie was immediately referred to Fitzpatrick Referrals Orthopaedics and Neurology where he was examined by Chief Neurologist Professor Clare Rusbridge.Whilst Clare found him to be relatively responsive, she detected a ventral lateral strabismus in his right eye – a cause for concern, as she suspected intracranial pressure and possible intracranial herniation. AnMRI scan later revealed symmetrical changes that were consistent with a metabolic encephalopathy with high signal through the corona radiata and also through the brain stem nuclei. This posed a number of explanations but Clare couldn’t rule out inflammatory disease and obtained a sample of cerebrospinal fluid to test for meningitis and encephalitis. A urine sample was obtained for organic acid urinalysis because this appearance could have been consistent with L2 hydroxyglutaric aciduria (a rare inherited metabolic disease inWest Highland Terriers). In-house blood work prior to anaesthesia showed that the alanine aminotransferase (ALT) was slightly elevated. Preprandial bile acids were low suggesting normal liver function but suspecting that there may be a liver problem Clare retested them but after feeding Louie, the bile acids rose to an extremely

CT angiogramshowing the prescence of a large portocaval shunt (highlighted)

AnMRI scan revealed a soft tissuemass close to Sensei’s hip and pelvis

Orthopaedics, Oncology and Soft Tissue

Sensei was presented to our orthopedic and neurology hospital as an emergency, and was seen by Surgical Resident Dr Diogo Miraldo. This was as a result of having experienced progressive left pelvic limb lameness. His family said this had started over the Christmas period.

Due to the diagnosis being of oncological nature, Sensei was

On his initial assessment Sensei was bright and alert, but was completely non-weight-bearing on his left pelvic limb. Diogo noticed that he could feel a hard swelling behind Sensei’s left hip. It was noticeable that Sensei was in discomfort and after discussions with Sensei’s family, it was decided that initial diagnostic tests needed to be carried out so the teamcould have a diagnosis. These investigations took place the same day, and an MRI revealed the presence of a soft tissue mass, which seemed to arise from the sciatic nerve. Fine-needle aspirates of the mass were taken under ultrasound guidance.These produced too few cells to be conclusive, which raised the suspicion of a soft tissue sarcoma. Diogo discussed potential surgical options with Sensei’s family.

transferred for treatment at our oncology and soft tissue hospital under the care of Dr Laurent Findji. Sensei arrived at our oncology and soft tissue hospital and a full CT was performed for complete tumour staging before surgery.After reviewing the CT, Laurent recommend an amputation and hemipelvectomy, which Sensei’s family agreed to. Sensei underwent surgery the next day. Sensei recovered incredibly well from surgery, and was walking around and wagging his tail within less than 24 hours of surgery! The team have sent off samples of the tumour and will await the results to determine whether any additional treatments will be needed. Sensei has now returned home to continue recovery with his family.

IN AN EMERGENCY To discuss a case or for any urgent or emergency referrals, please call us

For oncological and soft tissue emergencies 01483 668100 For orthopaedic and neurological emergencies 01483 423761

Fitzpatrick Referrals Orthopaedics & Neurology Halfway Lane, Eashing, Surrey GU7 2QQ Tel: 01483 423761 | Fax: 01483 527590 enquiries@fitzpatrickreferrals.co.uk

Fitzpatrick Referrals Oncology & Soft Tissue 70 Priestley Road, Guildford, Surrey GU2 7AJ Tel: 01483 668100 | Fax: 01483 454724 guildford@fitzpatrickreferrals.co.uk

For more information visit fitzpatrickreferrals.co.uk

Company Registration: Fitzpatrick Referrals Limited 5287667 Fitzpatrick Referrals Oncology and Soft Tissue Limited 08627448

World-Class Veterinary Medicine, Hope and Healing

Louie post treatment

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Fitz & Pieces

CPD dates for your diary EASHING 26th March

Sarah Girling: Coxofemoral joint replacement – is it worth it? Susan Murphy: Collateral damage: management of tarsal and distal limb injuries Clare Rusbridge: Spinal signs - cage rest or should I be referring? Intervertebral disc disease conservative versus surgical management Miguel Solano:Wobbly knee caps - the ins and outs of treating patellar luxation

30thApril

21st May

25th June

GUILDFORD 4thApril

Laurent Findji: How do I close this? Jon Bray:Top tips for cancer surgery

2nd May 6th June

Gerard McLauchlan and Nick Bacon: Could this dog have a portosystemic shunt and what should I do about it?

To book visit fitzpatrickreferrals.co.uk/CPD

A hat-trick of newly qualified specialists at Fitzpatrick Referrals We’re pleased to announce that registrars Pádraig Egan, Susan Murphy, and anaesthetist Enzo Minghella have passed their board exams first time round to become EBVS® European Specialists. Enzo is now a Diplomate of the European College of Veterinary Anaesthesia and Analgesia (ECVAA) and Pádraig and Susan join the European College of Veterinary Surgeons (ECVS). Congratulations, Enzo, Pádraig and Susan!

Physiotherapy evening clinics Our physiotherapy team is now offering two evening clinics a week. The clinics will run on Monday and Thursday evenings from 4-8:30pm and are available to all current and future clients – whether referred internally or directly from their primary care vet. For more information about this service, please contact enquiries@fitzpatrickreferrals.co.uk

VETERINARY EDUCATION TOMORROW

7-8 June 2019 | Loseley Park, Surrey

INSPIRING CPD LEADING BRANDS LIVE MUSIC

REFRESHINGLY DIFFERENT WORLD-CLASS SPEAKERS

The ONLY outdoor CPD event – breaking the mould of veterinary education Book now: www.vetfestival.co.uk

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