Les antibiotiques sont produits sous des formes pharmaceutiques telles que des pilules antibiotiques en ligne
elles permettent d'injecter la quantité de préparation strictement nécessaire.
Newsletter July 08
New Price List
NEW CONTACT NUMBER NOW IN USE
We have reviewed our price list (enclosed) and have made adjustments.
1300 VET QML (1300 838 765)
Our in-house tests have increased in line with CPI.
Our new QML Pathology Vetnostics contact number 1300 838 765 is now in operation.
Some of the increases in tests that
For a fast, efficient service, this number will take you directly to the following options:
have to be sent to external laboratories
1 - Results enquiries
have had more of an increase to
reflect the costs of transport (especially
3 - Speak to a Pathologist
frozen samples). Vetnostics still
4 - All other enquiries.
remains extremely cost competitive to other laboratories. As a policy we
Calls will be charged at local rates from landlines. Mobile charges may vary.
try to keep our send away tests as low-priced as possible (compared with our competitors) so as to allow
veterinarians to investigate their cases
As many of you are aware the ownership of Vetnostics has changed with the acquisition of Symbion
as comprehensively as possible.
Health by Primary Health Care Ltd. The commitment of Primary Health Care to the veterinary pathology business can be seen in the employment of additional pathologists and plans for further expansion of
This list which includes 95% of tests or our fully comprehensive list including
our existing services in Victoria and Queensland. This will ensure a major presence in all Eastern States
less frequently requested tests can be
as well as in WA through Vetpath. We will now have a team of 14 clinical pathologists and anatomic
emailed as an Excel file to you.
pathologists and two registrar pathologists undergoing training. We will continue with our internal veterinary medicine consultants.
Please contact Vetnostics Manager
During this year two new pathologists (Brett Stone, commenced June, David Taylor, starting 4 August)
Shaun Hickey on (07) 3121 4013
and a trainee pathologist (Matthew Silverstein, February) are expanding the Vetnostics team. As well
as supporting the training of future pathologists in-house, Vetnostics continues to support a resident in veterinary pathology at the University of Queensland.
The commitment to the veterinary profession will continue through our support of research projects within Universities as well as within our own laboratories using the enormous clinical case information available. We hope to continue our seminar program. We will continue supporting our testing of Delta Pet Partner dogs, the Port Macquarie Koala Hospital and offering a discount for staff for our regular veterinary users. Feedback has indicated that access to our medicine consultants is greatly valued in investigating and treating cases, as well as assisting in deciding whether cases can be adequately handled in-house or whether they should be referred on. We are therefore pleased to confirm that access to our internal veterinary medical consultants will be expanded.
New full time veterinary pathologist
at QML Pathology - Dr Brett Stone
Dr Brett Stone is now our full-time Veterinary Pathologist based at our Murrarie Laboratory in
Brisbane. This will ensure faster result turnaround times and Brett will be available to discuss
results. Please see page 3 for a full profile.
Newsletter July 08
New Tests & Test Alterations
(Continued from page 1)
We believe that Vetnostics is the longest serving laboratory. It has a tradition of aiming to provide
Canine Geriatric Profile
an ever improving service as evidenced by the continual expansion of available tests in-house and
Vetnostics has introduced a geriatric profile
employment of increasing numbers of pathologists. We have the most comprehensive range of
in addition to its wellness profile for general
in-house companion animal laboratory tests with competitive prices. Our excellent relationship with
health check in the older animal. Included in
university researchers and support of research programs is a further indication of our commitment to
the test profile: FBC exclusive of a differential,
the development of the profession and its ability to provide the best testing for animals in their care.
urea, creatinine, glucose, total protein,
For these reasons and our 7 days a week service, rapid turnaround of results and team of experienced
albumin, globulin, ALT, ALP, Ca, Phos and trig.
pathologists, we hope to remain or become your pathology provider.
Also in this Newsletter
We have an article on Mast Cell grading. This has been adapted by George Reppas from a recent
article by our colleagues at Vetpath.
After initial culture and an indication that one of these organisms is present, culture
Sue Foster has kindly updated and expanded a previous article on the use of the ACTH stimulation test
plates are sent to the National Mycobacterium
in diagnosis and monitoring treatment of hyperadrenocorticism. This excellent article answers many of
Laboratory for further identification and if
the questions we are frequently asked. If her advice is followed, considerable savings to your clients
required sensitivity determination.
We also have an article on phenobarbitone and its effects on triglyceride levels.
1. Initial culture (up to 2 months) $35.00
2. Identification of organism $60.00
Activated Clotting Time Tubes
3. Sensitivities $55.00.
Over the past few months we have had numerous requests for the supply of activated clotting time tubes. Unfortunately the manufacturer has informed us that supply has been discontinued. We are
Equine Health & Fitness Profile
presently investigating sourcing another supply of tubes for this test. As yet these tubes have not been validated for use in veterinary practice. They will also be considerably more expensive so free supply
Magnesium will now be included in this profile.
will no longer be possible. Availability of these will be notified through our website.
Equine Uterine & Clitoral SwabsA decreased cost has been introduced if
Requesting Tests not Listed on our Request Form
both samples are submitted.
These tests need to be requested in the space under OTHER TESTS and NOT as part of the history,
otherwise our touch typists may not enter the information as a specific requested test and the test will not be carried out.
Urine Cytology*As we have been receiving increasing
Discounts for Vets and their Staff
requests for cytological examination of urine
We believe that we offer very competitive discounts to veterinarians and their staff for their own pets.
samples we have introduced a Urinalysis plus
This will be maintained throughout 2008 and we will have a 50% discount except on referral tests
where a discount will not apply.
(All prices excl. GST)
*Preparation of smears/slides from concentrated unfixed
We will be looking to hold several seminars in late 2008 and would then like to continue these in
urine at the time of sampling minimises morphologic
2009. Seminars will be held in Brisbane as well as in regional areas.
changes, results in superior cell preservation and allows for a more accurate cytological assessment.
If you would like to discuss the possibility of holding a seminar in your region or would like to provide further information regarding topics you would like covered, please contact Dr Brett Stone at the Brisbane Laboratory on (07) 3121 4343 or firstname.lastname@example.org.
Newsletter July 08
Dr. Brett Stone
B.VSc(Hons) B.Biomed.Sc(Hons) MACVSc
Prior to commencing BVSc studies, Brett completed a Bachelor of Biomedical Sciences with Class I Honours at James Cook University, North Queensland. His honours research was in the field of Microbiology and Immunology and focused on the detection of Helicobacter pylori in domestic cats. Brett graduated as a veterinarian from the University of QLD with Class I Honours in 2001 and worked in mixed animal practice on the outskirts of Brisbane for two years before returning to the University of QLD to undertake an internship/residency funded by QML Vetnostics in veterinary pathology. As a pathology intern Brett also concurrently undertook a research masters project investigating the colonisation and excretion of E.coli serotype O157 in adult cattle. In 2006, after completing the internship, Brett lectured in clinical pathology at the University of QLD, was a contracted pathologist
at QML Vetnostics and attained membership qualifications with the Australian College of Veterinary Scientists in Veterinary Pathology. In 2007-2008, Brett worked as a diagnostic pathologist at Cytopath Ltd in the UK and commenced Fellowship training in clinical pathology. This practice run by ex-Australian pathologist Chris Belford has an extensive throughput of cytology, allowing Brett to gain extensive experience in this area as well as anatomic pathology. Brett‘s experience in cytology and interest in immunohistochemistry and microbiology will allow further development of these in QML Vetnostics.
Dr. David Taylor
BVSc, Diplomate ACVP
Dr. David Taylor, BVSc, Diplomate ACVP will join the pathology staff at Symbion Vetnostics in August. David received his BVSc from the University of Sydney in 1990. He spent the next few years in New South Wales and Victoria broadening his experience in private practice, university and government positions until he joined the Animal Health Laboratory in Launceston in 1998 as a veterinary pathologist. In 2001 David moved to the University of Florida for residency training in anatomic pathology. Following the two year residency he was appointed as a clinical assistant professor in
anatomic pathology and was board-certified in veterinary pathology in September 2004. While at the University of Florida David was a consultant pathologist for the dermatology and ophthalmology services, coordinated a dermatopathology biopsy service and served as anatomic pathology residency coordinator. His professional interests include dermatopathology, ophthalmic pathology and oncopathology. He also enjoys clinical research, writing and collaborating with clinicians on interesting and challenging cases. In his spare time he enjoys swimming, digital photography, digital retouching and art. With his wife Jacqui and children Hannah and Ben, he is looking forward to spending time with family and settling back into Australia.
Matthew completed his veterinary science degree in Queensland in 2002. After this time he worked in private small animal practice around NSW and Victoria over a two year period. Following this he pursued his interests in veterinary pathology by undertaking an internship at the University of Sydney Rural Veterinary Clinic in Camden. During this period he had a wide exposure to all facets
of pathology in small and large animals and valuable microbiology training. He then continued on to a training program at the University of Wisconsin-Madison in clinical pathology. This was a great opportunity to learn from very experienced people within this field and to experience life overseas. He has now become a registrar in veterinary clinical pathology at Symbion Vetnostics and is preparing for membership of the Australian College of Veterinary Scientists.
Newsletter July 08
OTHER SYMBION VETNOSTICS PATHOLOGISTS
(Further details on Vetnostics website www.vetnostics.com.au)
BSc(Vet)DVSc PhD MRCVS Clinical Pathologist and Chief Veterinary Pathologist
BVSc Dip. Vet Path MComm. AFAIM (Clinical Pathologist)
BVSc Dip.Vet Path. PhD (General Pathologist)
BVSc Dip.Vet.Path FACVSc (General Pathologist)
Dip. ECVP MRCVS (Anatomic Pathology)
Dr Terry Rothwell
DVSc PhD MACVSc (Consultant Anatomic Pathologist)
Prof. Rolfe C Howlett
BVSc PhD MACVSc MRCVS (Consultant Anatomic Pathologist)
Dr Ken Mason
BVSc MVSc FACVSc (Consultant Dermatohistopathologist)
VETERINARY MEDICAL CONSULTANTS
Dr Sue Foster
BVSc M.Vet.Clin.Stud. FACVSc (Feline Specialist)
Dr Martine Perkins
BVSc MACVSc (Canine Medicine)
Dr Richard Malik
DVSc PhD Dip. Vet Anaesth M Vet Clin Stud FACVSc (Feline Medicine) FASM
Veterinary Medical Consultant
Dr John Jardine
BVSc MMVet (Path) Dip ACVP MRCVS (Head, General Pathologist)
Dr Sue Beetson
BSc(Hons) BVMS PhD (Clinical Pathologist)
Dr Mary McConnell
BVSc Grad Dip Clin Path PhD (Clinical Pathologist)
Dr Leanne Twomey
BsC BVMS PhD DipACVP (Clinical Pathologist)
Dr Jenny Hill
BVSc DipACVP (Clinical Pathologist)
Newsletter July 08
Canine Mast Cell Tumours
Dr George Reppas
Specialist Veterinary Pathologist - adapted from article by Vetpath
Dr George ReppasSpecialist Veterinary Pathologist
Mast cell tumours (MCT) are one of the most common skin tumours in dogs and are lesions that are frequently encountered in clinical practice. These skin lesions have a wide variety of behaviours from small localised slow growing lesions with benign behaviour to multiple large and aggressive lesions with rapid growth and early metastasis to regional and distant sites.
A recent paper published in the Journal of Small Animal Practice (JSAP) has reviewed the recent literature and highlighted the advances in the diagnosis and management of cutaneous mast cell tumours.
"It appears then that this
Diagnosis of mast cell tumours is usually based on fine needle aspirate cytology or on histological
relatively simple test can
assessment. Grading of tumours on histological examination is currently regarded as one of the primary
provide very valuable
determinants of the prognosis. However, the reliability of histological tumour grading alone has been
information at no extra cost
questioned with significant inter-observer variation reported in recent studies.
to the client"
Much of the grading is based on cell morphology, mitotic activity, as well as growth patterns of the tumour. The published grading parameters are a little vague with grey areas between grades, and few hard and fast criteria.
Much research effort has been directed at increasing the reliability and repeatability of the cutaneous mast cell grading system. Although the JSAP article discussed recent advances in predicting individual MCT behaviour (e.g. staining for argyrophilic nucleolar organising regions (agNORs) or using immunohistochemical stains to detect proliferating nuclear antigen (PCNA) and Ki67 antigen, as well as assessing KIT expression in MCT with c-kit mutations), these tests are not currently applicable to routine diagnostic pathology.
A very interesting recent development from UC Davis has been published in the May 2007 issue of Veterinary Pathology, which was not discussed in the JSAP paper. Their study uses the mitotic index (MI) as an indirect measure of the cell proliferation. MI is a simple measure of the number of mitotic figures in 10 standard high power fields. This is a simple and quick test to perform. In their study the
MI was shown to be directly correlated to the tumour grade.
1. Mitotic index is predictive for survival for canine
Furthermore the authors have shown that the median survival time for dogs with a MI of <5 was
cutaneous mast cell tumours. EM Romanski et
significantly longer (70 months) than for those with a MI >5 (2 months), regardless of tumour grade.
al. Vet Pathol 44:335-341 (2007)
Even in grade 3 MCT the dogs having tumours with a MI of <5 will have a long survival time compared
2. Cellular proliferation in canine cutaneous mast
cell tumours: associations with c-Kit and its role
to <2 months for dogs with a MI of >5.
in prognostication. JD Webster et al. Vet Pathol 44:298-308 (2007)
It appears then that this relatively simple test can provide very valuable information at no extra cost to the client. The case numbers examined in this study were significant but not enough to dispel all doubt.
3. Advances in the diagnosis and management
of cutaneous mast cell tumours in dogs. JM
More research is needed but may be slow to be published.
Dobson et al. Journal of Small Animal Practice 48,424-431 (2007)
In future QML Pathology VETNOSTICS will endeavour to provide a MI as well as the tumour grade in all mast cell tumour cases submitted for histopathology.
Newsletter July 08
The ACTH Stimulation
• screening test for spontaneous
• diagnosing iatrogenic hyperadrenocorticism
• monitoring efficacy of treatment with
mitotane (Lysodren®) or trilostane
Dr Sue Foster
• diagnosing hypoadrenocorticism.
Veterinary Medical Consultant
1. Screening Test for Hyperadrenocorticism
• take a 0h blood into a serum tube
• inject 5μg/kg Synacthen® IV
• only requires dog to be in clinic for 1hr (compared to 8hrs for the LDDST)
• take another blood sample 1hr later into a
• only requires two blood samples (not three as for the LDDST)
• detects iatrogenic hyperadrenocorticism
• QML Pathology Vetnostics' post-stimulation
• less affected by disease stress than LDDST (better specificity).
reference range and thus interpretation is based on this protocol.
This is the test of choice in an animal that has a reasonable chance of being concurrently affected by
Note: this dose has been validated in numerous studies
non-adrenal disease e.g. poorly controlled diabetes mellitus, renal disease, hepatic disease etc.
(Watson et al 1998, Kerl et al 1999, Frank et al 2000, Behrend et al 2006, Martin et al 2007)
• the ACTH stimulation test is usually reported as being less sensitive than the LDDST for both
• another frequently used protocol is to
pituitary dependent hyperadrenocorticism (up to 20% false negatives) and for adrenal tumours (up
administer 250μg Synacthen® IV or IM
to 40% false negatives) although some authors have found similar sensitivities on both tests (Van
with testing 1hr later. This protocol is more
Liew et al 1997). In the author's opinion, if dogs are carefully assessed for disease likelihood and
expensive for the client. In addition, it may
appropriate cut-off points chosen for the ACTH stimulation test results, then this test appears to have
produce higher post-stimulation cortisol
concentrations than the 5μg/kg IV protocol so if this protocol is used, you need to
• the test does not differentiate between pituitary dependent disease or that due to adrenal tumour(s).
indicate both dose and timing on your submission form so that they can be taken
2. Monitoring Test for Therapeutic Efficacy
into account when interpreting the result
a) Mitotane: test needs to be run 36 to 48 hours after any dose of mitotane.
• lower dose protocols with IV or IM
Synacthen® (see below).
Mitotane interferes with cortisol synthesis in addition to causing adrenocorticolysis and as adrenal
Older textbooks recommend that this test
reserve is what is actually being monitored, direct mitotane effects on synthesis need to have worn off
be performed in the morning. As dogs do
(otherwise adrenal reserve will appear less than it really is).
not have a circadian rhythm for cortisol
For good control of hyperadrenocorticism, both pre and post-stimulation results need to be <75
secretion, there is no scientific justification
nmol/L. Poststimulation results 75-100 nmol/L tend to be associated with difficulty in achieving stable
for this recommendation. This test can be
control though some dogs do remain stable at this level of adrenal reserve.
run at any time. As fasted blood samples are preferable for chemiluminescence assays
Post-stimulation results > 100 nmol/L are usually an early warning of loss of control if adequate
(radioimmunoassays are unaffected by
induction results achieved. Clinical signs of loss of control are usually noticed by astute owners when
haemolysis or lipaemia), this means that when
post-stimulation cortisol concentration reaches 120-150 nmol/L. Less aware owners or owners of
performing an ACTH stimulation test in a
dogs that secrete less ACTH from their pituitary adenoma each day, may not notice loss of control until
diabetic dog with hyperadrenocorticism (e.g.
cortisol concentration reaches >200 nmol/L.
usually fed before coming to the clinic), the test can be run late in the day with no problems.
b) Trilostane: test needs to be run 4-6 hours after the morning-dose of trilostane to assess the peak
Note: Synacthen ® is only registered for IM use in humans
effect of trilostane on cortisol synthesis. As trilostane does not usually last for 24 hours, an ACTH
but does not seem to have caused problems in animals
stimulation test 12-14 hour post-dosing may be needed to assess duration of effect.
when given IV. A rare side effect, regardless of route administration, is acute adrenal necrosis!
Post-stimulation cortisol concentration with trilostane treatment should be 20-75 nmol/L.
Newsletter July 08
To Reduce the Expense of Frequent Monitoring
ACTH: adrenocorticotropic hormone
1) Reduce the amount of Synacthen® administered.
As Synacthen® is expensive, use a low dose ACTH protocol e.g. 5μg/kg IV for small dogs and 1 μg/kg
IV for large dogs and store the remaining sample for future monitoring. Both doses have been proven to produce maximal cortisol secretion in healthy dogs (Martin et al. 2007). If using really low doses,
LDDST: low dose dexamethasone suppression test
attention to timing of the post-stimulation sample is required. Timing needs to be PRECISELY one hour
post injection for doses of 1 μg/kg or less (Martin et al. 2007).
1. Behrend EN, Kemppainen RJ, Bruyette DS et al.
Intramuscular dosing with 5μg/kg has also been shown to cause maximal cortisol secretion (Behrend et
Intramuscular administration of a low dose of ACTH for ACTH stimulation testing in dogs. J Am
al. 2006). In the author's opinion, IV dosing is preferable unless patient difficulties preclude its use, as it
Vet Med Assoc 2006:229:528-530
ensures that the dose does reach circulation.
2. Frank LA, De Novo RC, Kraje AC, Oliver JW.
Only a small amount of Synacthen® is administered when using a 1- 5 μg/kg dose so freeze any
Cortisol concentrations following stimulation
remaining sample. Draw up the left-over Synacthen® in a 1 ml syringe (or draw up accurate doses
of healthy and adrenopathic dogs with two doses of tetracosactrin. J Sm Anim Pract
into multiple 1 ml syringes), leaving a small air space at the end of the syringe. Cap each syringe,
label it with dog name and date (frozen Synacthen® is stable for 6 months; Frank and Oliver 1998)
and place it in the freezer. When that dog needs another ACTH stimulation test, thaw it, draw up the
3. Frank LA, Oliver JW. Comparison of
serum cortisol concentrations in clinically
required dose and re-freeze the remainder. By doing this, multiple doses can be obtained out of one
normal dogs after administration of freshly
vial. This significantly decreases the cost of monitoring treatment: the owner can be billed for the whole
reconstituted versus reconstituted and stored
vial initially but thereafter, until another vial is required, there is no more cost for Synacthen®, just fees
frozen tetracosactrin. J Am Vet Med Assoc
for cortisol measurement and procedure.
4. Kerl ME, Peterson ME, Wallace MS et
2) Test only the post-stimulation cortisol concentration.
al. Evaluation of a low-dose synthetic adrenocorticotrophic hormone stimulation test
For monitoring efficacy, the important result is the poststimulation result as it indicates the extent of
in clinically normal dogs and dogs with naturally
cortical destruction (mitotane) or decrease in cortisol synthesis (trilostane) or both (mitotane, if testing
developing hyperadrenocorticism. J Am Vet Med
within 36 hours of dosing on suspicion of iatrogenic hypoadrenocorticism).
The first cortisol concentration really acts as a check on the endocrine assay. Whilst it is ideal to know
5. Martin LG, Behrend EN, Mealey KL et al. Effect
of low doses of cosyntropin on serum cortisol
the basal cortisol concentration as it can enable both practitioner and laboratory errors to be detected,
concentration in clinically normal dogs. Am J Vet
it is often better for the client to be able to afford two good tests than one perfect test.
6. Van Liew, CH, Greco DS, Salman MD.
Comparison of results of adrenocorticotropic hormone stimulation and low-dose dexamethasone suppression tests with necropsy findings in dogs: 81 cases (1985-1995). J Am Vet Med Assoc1997;211:322-325
7. Watson ADJ, Church, DB, Emslie DR, Foster
SF. Plasma cortisol responses to three corticotrophic preparations in normal dogs. Aust Vet J 1998;76:255-257
Newsletter July 08
Phenobarbitone and Effects on Triglyceride Levels
Over the past four years Symbion Vetnostics Laboratory has been running concurrent triglyceride (TG)
levels with each phenobarbitone (PB) assay in dogs. This was a background study as part of a PhD
research project conducted at Sydney University, which was aiming to determine the following:
• The prevalence of epileptic dogs on chronic PB with hypertriglyceridaemia
• The mechanism/s behind hypertriglyceridaemia
• The significance of hypertriglyceridaemia.
From this research, approximately 30% of dogs studied on chronic PB had elevated fasting TG's. In addition, three dogs with normal fasting TG's prior to PB use developed severely elevated fasting TG's (> 40 mmol/L) within 1 month of initiating PB therapy. Although the exact mechanism for this is unknown, it is likely due to an increase in hepatic TG production due to PB induction, which in some dogs appears transient. Many dogs on PB are also overweight, which can lead to insulin resistance, another cause of increased TG levels. Obesity in combination with an increased hepatic TG production is the likely cause for the fasting hypertriglyceridaemia seen in many dogs on PB therapy.
As we suspect PB has a direct effect on raising serum TG levels, baseline fasting TG levels prior to commencing PB and regular monitoring of TG with PB drug levels throughout therapy should become a standard part of treatment in epileptic dogs. In most epileptic dogs with elevated TG levels and no evidence of concurrent disease, weight loss (if overweight) and a low fat diet should be sufficient to lower TG levels. Hypertriglyceridaemia in dogs can lead to vomiting, diarrhoea, abdominal pain, pancreatitis and even seizures, although it is unlikely this is the underlying cause for idiopathic epilepsy.
In dogs that have been fasted for approx. 14-16 hours, the reference range for fasting triglycerides is 0.3 – 1.7 mmol/L. There are many factors such as diet and concurrent disease (e.g. hyperadrenocorticism, hypothyroidism, diabetes) that influence both fasting and post-prandial TG levels in dogs, however as a rough guide, peak TG levels after eating should not exceed 5.0 mmol/L.
If you require further information or wish to discuss specific cases please contact the researcher involved Elissa Kluger 0410 572 966 or email@example.com.
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For any further information please contact the Vetnostics Department at QML Pathology on
(07) 3121 4013 or visit the QML Pathology Vetnostics website www.qml.com.au/vetnostics.asp
arturO martOS fOSeLathe Fitting of Five Straumann® roxolid implantsin the maxillary anterior Sextant, using an immediateloading protocol General Anamnesis Clinical Examination the patient is a 50-years old Caucasian woman, non-smoker the x-ray exam revealed a destructive loss of bone contactand in a good general state of health. She had suffered in the teeth of the maxillary anterior sextant and the presencebreast cancer with infiltrating ductal carcinoma of the right of periodontal pockets in the posterior sector. moderate tobreast, which required the breast to be removed, chemo- severe periodontal disease was found in the upper maxil-therapy, radiotherapy as well as subsequent anti-estrogen lary. tooth mobility was diagnosed in teeth 11, 13, 21 andtherapy1. She is still undergoing anti-hormonal treatment up 22. there was no mobility in the teeth in the posterior sectorto the present day.
Summary Care Records A QUICK REFERENCE GUIDE What is a Summary Care Record? When should I use the SCR? The Summary Care Record (SCR) is a ‘read only' electronic patient summary containing key clinical When dispensing an Times when you would information. It has been created with information emergency supply (at the want to ask the GP practice request of the patient)