Internal Medicine
Osteomyelitis: Comprehensive Insights for Veterinary Professionals
Osteomyelitis, a multifaceted pathology characterized by inflammatory responses within bone and bone marrow, primarily emerges from insidious infections perpetuated by an array of pyogenic organisms.
Primarily, Staphylococcus spp and Streptococcus spp spearhead this microbial consortium, reinforced by the presence of Escherichia coli, Proteus spp, Pasteurella spp, Pseudomonas spp, and Brucella canis.
Depending on geographical location, fungal agents also manifest, exemplified by Coccidioides immitis, Blastomyces dermatitidis, Histoplasma capsulatum, Cryptococcus neoformans, and Aspergillus spp. The manifestation of these pathogens is supported by regional prevalence.
Diagnosing osteomyelitis involves a careful interplay between clinical experience and precise diagnostics. Clinical characteristics, delineating the spectrum of acute or chronic manifestations, encompass pain, fever, and anorexia.
Radiographic examination reveals an array of bone morphological alterations, including lysis, sequestration, periosteal reactions, implant detachment, and the intricate network of fistulous tracts. Simultaneously, the diagnostic arsenal employs deep fine-needle aspiration, cytological scrutiny, and judicious assessment of blood cultures.
Navigating the therapeutic possibilities for osteomyelitis requires finding the appropriate balance between pharmacological approaches and surgical expertise. Antibiotics stand as pivotal warriors in the battle against infections.
Noteworthy regimens entail administering clavulanic acid/amoxicillin at 15 mg/kg, twice daily; cefazolin at 30 mg/kg, twice daily; clindamycin at 11 mg/kg, twice daily; enrofloxacin at 15 mg/kg, twice daily; amikacin at 15 mg/kg, twice daily; and oxacillin at 22 mg/kg, three times daily.
Surgical management is characterized by debridement, lavage, and implant extraction. The surgical domain also encompasses the significant approach of open or closed wound drainage.
In cases of chronic presentation, consideration of limb amputation as a last resort comes into play.
The prognosis, embedded within factors such as infection intensity and timeline, shapes the patient's evolutionary path. Success is grounded in a triple foundation: expertise in individualized antimicrobial treatment, surgery, and follow-up.
Links:
- The Merck Veterinary Manual: OSTEOMYELITIS IN DOGS AND CATS
Do you have any feedback about the Quick Note?
We'd love to hear from you!
Feel free to send us a message
Don't forget to share with any friends who are also
preparing for the BCSE Exam.
Obstructive Urolithiasis in
Small Ruminants and Prevention
Urolithiasis in small ruminants, including cattle, sheep, and goats, leads to the formation of urinary calculi, resulting in obstructions that cause bladder distention, abdominal pain, and potential urethral complications. This condition, prevalent during winter, affects young feeder and mature breeding animals, often leading to severe outcomes like uremia or septicemia.
Winter conditions and high-grain diets worsen the issue, particularly impacting male goats. Urolithiasis, a major cause of urinary tract problems in small ruminants, significantly affects livestock, show animals, and pets globally. Urethral obstructions primarily target intact and castrated males at the urethral process and sigmoid flexure due to diverse factors like diet, age, sex, and genetics.
Factors such as water mineral composition and dietary imbalances contribute to urolithogenesis. Struvite, calcium carbonate, and calcium oxalate calculi exhibit distinct appearances, often affecting the distal sigmoid flexure of cattle and the sigmoid flexure and urethral process of sheep and goats.
Urolithiasis manifests in varying clinical signs influenced by obstruction severity, calculus composition, and location. While often calcium or phosphatic-based, diverse calculi types exist. Surgical intervention becomes essential when conservative measures fail, intensifying the complexity of management. Clinical signs range from blood-tinged dribbling urine in partial obstruction to severe manifestations like tenesmus, colic symptoms, and rectal prolapse in complete obstruction. Severe consequences encompass bladder rupture, urethral perforation, and hydronephrosis.
Ruminant urolithiasis, rooted in nutritional imbalances, primarily manifests as urethral obstruction. Notably, calves, lambs, and early-castrated kids subjected to high-grain diets with an imbalanced calcium:phosphorus ratio or excessive magnesium intake are prone to struvite and ammonium urate calculi. Grazing on silica-rich soil heightens the risk of silica urolith formation, while high-calcium plants like subterranean clover foster calcium carbonate uroliths.
Diagnosis often employs ultrasound and radiographs to visualize bladder distention and stone presence, aiding in tailored intervention.
Treatment strategies encompass dietary adjustments, promoting urinary chloride excretion, urine pH reduction, and maintaining a balanced calcium:phosphorus ratio. Sodium chloride supplementation enhances urine solubility, and ammonium chloride acts as an acidifying agent. In cases of significant urolith issues, ration evaluation is pivotal, and specialized dietary supplements are available.
Advanced Surgical Approaches for Urolithiasis Management
-
Urethral Process Amputation: This procedure involves the removal of the short, constricted urethral process at the tip of the penis. While enabling uroliths within this area to pass, recurrence is possible if higher obstructions exist in the urethra.
-
Perineal Urethrostomy: Creating a novel urinary opening near the perineum allows urination akin to females. This intricate procedure may involve heavy sedation or general anesthesia, particularly for valuable animals, and aims to restore urinary flow following urolith-induced blockage or rupture.
-
Tube Cystostomy: In cases of urethral blockage or rupture, this approach diverts urine away from the compromised area, aiding tissue healing. A rubber tube is surgically placed in the bladder, often accompanied by urethral process amputation and urolith removal.
-
Prepubic Cystostomy: For recurrent obstructions, a permanent opening is created between the bladder and belly wall near the prepuce, enhancing urinary flow.
-
Urethral Translocation: A complex technique involving attachment of the urethra to the lower penis or prepuce section, often utilized to circumvent a ruptured or failed urethrostomy.
Given potential complexities, advanced urological procedures necessitate specialized training, especially for valuable or beloved animals. Veterinary referrals to skilled surgeons experienced in these intricate techniques, ideally those board-certified by the ACVS, offer the best chance for successful outcomes.
Prevention and Management of Urolithiasis in Small Ruminants
PREVENTION:
To thwart the onset of urolithiasis, several crucial measures have been identified:
-
Diet Management: Refrain from feeding horse grain to small ruminants due to inadequate diet balance, which escalates the risk of urolith formation.
-
High Grain Diets: Show animals on relatively high grain diets should incorporate salt (sodium chloride) at a rate of 2 to 5%, or alternatively, ammonium chloride at 0.5 to 1%, to boost urine production or acidify urine.
-
Calcium and Phosphorus Balance: High calcium diets might impede phosphorus absorption. Consult veterinarians before introducing supplements to the feed.
-
Urinary Chloride Excretion: For preventing struvite calculi, increasing urinary chloride excretion is crucial.
-
Urine pH Reduction: Lowering urine pH plays a significant role in struvite calculus prevention.
-
Calcium: Phosphorus Ratio: Maintaining a 2:1 calcium to phosphorus ratio in the complete ration is pivotal.
-
Concentrate Feeding: Intensive concentrate feeding, common in finishing programs, necessitates adequate calcium supplementation to deter urolith development and urethral obstruction.
-
Sodium Chloride Addition: Supplementary sodium chloride up to 4% of the total ration boosts sodium and chloride concentration in urine, encouraging water intake and mineral solubility.
MANAGEMENT:
In cases where prevention falls short, comprehensive management strategies include surgical and medical interventions:
-
Surgery: Surgical removal of uroliths and relief of obstruction are standard practices.
-
Medical Treatment: Initial management might encompass urine acidifiers, dietary modifications, and amputation of the urethral process. Surgical options are explored if medical approaches prove insufficient.
By diligently adhering to prevention measures and pursuing appropriate management strategies, the impact of urolithiasis on small ruminants can be significantly mitigated.
REFERENCES:
-
UROLITHIASIS IN SMALL RUMINANTS. American College of Veterinary Surgeons
-
Mejía, S. Small Ruminant Urinary Obstruction: decision trees for treatment. Journal of the American Veterinary Medical Association. Vol 260, Issue S2. 2022.
-
Aiello SE. The Merck Veterinary Manual. 11th ed. Merck & Co. 2016.
RECOMMENDED LINKS:
American College of Veterinary Surgeons: UROLITHIASIS IN RUMINANTS.
JAVMA: Small Ruminant Urinary Obstruction.
Do you have any feedback about the Note?
We'd love to hear from you!
Feel free to send us a message
Don't forget to share with any friends who are also
preparing for the BCSE Exam.
Radioactive Iodine (I-131) Treatment for Feline Hyperthyroidism: Mechanism, Response, and Monitoring
Radioactive iodine (I-131) therapy is an effective treatment for hyperthyroidism in cats, with a success rate of around 95%. It involves the administration of I-131, which is actively taken up by hyperplastic and neoplastic thyroid cells. Beta particles emitted by I-131 cause cell necrosis and inflammation, leading to the resolution of hyperthyroidism. The treatment primarily affects functional thyroid tissue, sparing surrounding structures.
Advantages of I-131 therapy include its high success rate, minimal side effects, and no need for general anesthesia. However, the disadvantages are the requirement for special licensing, isolation of the cat post-treatment, and varying regulations regarding the duration of isolation. The goal is to restore euthyroidism with the smallest possible single dose while avoiding hypothyroidism, which is generally uncommon but may require thyroid hormone replacement in some cases.
Dose determination methods include tracer studies, serum thyroxine concentration, and a fixed dose. All methods have shown high success rates and low incidence of hypothyroidism. Tracer studies are now rarely performed. The choice between dose determination methods requires further study to assess potential benefits in reducing hypothyroidism incidence, hospitalization time, and radiation exposure to personnel.
The action mechanism of radioactive iodine (I-131) therapy in the treatment of hyperthyroidism in cats is as follows:
-
Uptake by Thyroid Cells: Radioactive iodine (I-131) is administered, either intravenously (IV) or subcutaneously (SC). Thyroid cells actively concentrate I-131, similar to stable iodine.
-
Incorporation into Thyroglobulin: The I-131 that is taken up by the thyroid gland is incorporated into thyroglobulin, a precursor molecule for thyroid hormone synthesis.
-
Emission of Beta Particles: I-131 emits beta particles, which are high-energy electrons. These beta particles have a short range of action, traveling only about 1 to 2 millimeters in tissue.
-
Cell Necrosis: The ionizing effects of the beta particles lead to cell necrosis within the hyperplastic and neoplastic thyroid follicular cells. This cell necrosis is histopathologically manifested as cell death and inflammation.
-
Resolution of Hyperthyroidism: The destruction of thyroid follicular cells results in the resolution of hyperthyroidism. As the affected thyroid cells are no longer overproducing thyroid hormones, the thyroid hormone concentrations normalize over a period of days to weeks.
-
Preservation of Surrounding Tissues: Beta particles have a limited range of action, sparing surrounding tissues such as the parathyroid glands and atrophic thyroid tissue.
Overall, the mechanism of action of radioactive iodine therapy is targeted destruction of overactive thyroid cells, leading to the resolution of hyperthyroidism while preserving adjacent tissues. It is considered an effective and precise treatment for feline hyperthyroidism.
The response to radioactive iodine (I-131) therapy in cats is generally favorable:
-
Success Rate: Radioactive iodine therapy has a success rate of approximately 95% in both cats and humans, effectively resolving hyperthyroidism.
-
Hypothyroidism Incidence: Post-treatment hypothyroidism is generally uncommon, occurring in about 2-7% of cases. Fewer cats require thyroid hormone replacement.
-
Transient Hypothyroidism: Most cases of post-treatment hypothyroidism are transient, and clinical signs are rare.
-
Long-Term Hypothyroidism: In one study, up to 30% of cats were hypothyroid three months after treatment, but only about 56% of these hypothyroid cats showed clinical signs requiring thyroid hormone supplementation.
-
Overall Euthyroidism: The primary goal of therapy is to restore euthyroidism, and for the majority of cats, this is achieved with a single treatment.
These statistics suggest that radioactive iodine therapy is highly effective in managing feline hyperthyroidism, with a low incidence of long-term hypothyroidism and clinical signs. However, it's important to advise owners about the possibility of transient hypothyroidism, especially in cats with concurrent kidney disease.
Monitoring and laboratory follow-up are crucial to evaluate the response to medication and ensure the well-being of cats receiving treatment for hyperthyroidism. Here's what veterinarians typically consider for follow-up:
-
Thyroid Hormone Levels: Serial measurement of thyroid hormone levels, particularly total thyroxine (T4) or free thyroxine (fT4), is essential. Initially, frequent monitoring may be necessary to assess the response to medication. The goal is to achieve euthyroidism.
-
Clinical Signs: Regularly evaluate the cat's clinical signs. Improvements in signs such as weight gain, reduced appetite, and decreased thirst and urination can indicate a positive response to medication.
-
Physical Examination: Conduct regular physical examinations to assess body condition, heart rate, and overall health. Improvement in these parameters can be indicative of a positive response.
-
Renal Function: Monitor renal function, especially if concurrent kidney disease is present. Hyperthyroid cats may have underlying kidney issues that can be unmasked or exacerbated when hyperthyroidism is treated.
-
Blood Pressure: High blood pressure (hypertension) is common in hyperthyroid cats. Regular blood pressure monitoring can help detect and manage this condition, which might persist after successful hyperthyroid treatment.
-
Monitoring Side Effects: Keep an eye out for side effects or adverse reactions to the medication, and adjust the treatment plan accordingly.
-
T3 Levels: In some cases, measuring total triiodothyronine (T3) levels can provide additional information about the cat's thyroid status.
The frequency and duration of follow-up assessments will vary depending on the specific medication used, the cat's response, and any concurrent health issues. In some cases, long-term management of hyperthyroidism with medication may be necessary, while others may eventually require alternative treatments like radioactive iodine therapy or surgery. Veterinary guidance is crucial to determine the most appropriate follow-up schedule for each individual cat.
References:
-
Feldman, EC. Canine and Feline Endocrinology. Elsevier. 4th ed. 2015.
-
Bruyette, D. Clinical Small Animal Internal Medicine. Wiley Blackwell. 2020.
Recommended Links:
-
AAHA. 2023 AAHA Selected Endocrinopathies of Dogs and Cats Guidelines
-
Veterinary Merk Manual. Hyperthyroidism in Animals.
-
Journal of Feline Medicine and Surgery. 2016 AAFP Guidelines for the Management of Feline Hyperthyroidism
-
PennVet. University of Pennsylvania. Feline Hyperthyroidism & I-131
-
ScienceDirect. Radioactive Iodine Overview
Do you have any feedback about the Quick Note?
We'd love to hear from you!
Feel free to send us a message
Don't forget to share with any friends who are also
preparing for the BCSE Exam.
Heartworm Disease Antigen Diagnostic Tests in Animals
Dogs:
-
Antigen Tests: These tests are specific and sensitive, detecting heartworm antigen from adult worms. They are nearly 100% specific but can produce false-negative results with low female worm burdens, immature infections, or occasionally due to antigen-antibody complexes.
-
Microfilaria Testing: Recommended alongside antigen testing to improve diagnostic accuracy, as dogs can be antigen-negative but microfilaria-positive.
-
Heat Treatment: Improves the sensitivity of ELISA tests in suspected false-negative cases by dissociating immune complexes.
-
False-Positives: Rare, but possible in low heartworm incidence areas.
Cats:
-
Challenges: Diagnosis in cats is complex due to often absent clinical signs, low infection incidence, and the prevalence of male-only or immature infections.
-
Antigen Testing: Less useful in cats due to low worm burdens, male-only infections, and immature infections. False-negative results are common, with sensitivity varying based on worm burden and gender. Heat treatment can increase sensitivity.
-
Antibody Testing: More effective than antigen testing in cats, detecting exposure to heartworms and aiding in the diagnosis of heartworm-associated respiratory disease (HARD). However, it's less specific for mature infections.
-
Diagnostic Imaging: Thoracic radiography and echocardiography can assist in diagnosis but are not specific to heartworm disease.
-
Wolbachia Antigens and PCR: Emerging diagnostic tools showing promise in detecting feline heartworm infections.
Ferrets:
-
Diagnostic Approach: Similar methods as used in dogs and cats are likely applied, adjusted for ferrets' physiological differences. This may include both antigen testing and diagnostic imaging such as echocardiography.
General Considerations:
-
Role of Clinical Signs and History: A high index of suspicion is necessary, especially in areas with high heartworm prevalence or in animals with unclear prevention histories.
-
Combining Tests: Using multiple diagnostic methods increases the likelihood of accurate detection, especially in challenging cases.
-
Time Factor: The timing of testing is crucial, as it can take months for an animal to test positive following infection.
-
Continuous Improvements: Diagnostic techniques and test sensitivities are evolving, necessitating ongoing awareness of the latest developments in heartworm diagnostics.
REFERENCES:
-
Côté, E. Côté’s Clinical Veterinary Advisor Dogs and Cats. 4th Ed. Elsevier. 2020.
-
Ettinger, SJ. Textbook of Veterinary Internal Medicine. 8th ed. Elsevier. 2017.
-
American Heartworm Society. "Heartworm Diagnostics: Antigen Tests Alone Aren’t Enough." Available at: .
-
American Heartworm Society. "The Truth About Testing in Cats."
-
Courtney, Charles H., and Qi-Yun Zeng. "Comparison of heartworm antigen test kit performance in dogs having low heartworm burdens."
-
Canine heartworm and heat treatment: An evaluation using a well-based enzyme-linked immunosorbent assay (ELISA) and canine sera with confirmed heartworm infection status."
Do you have any feedback about the Note?
We'd love to hear from you!
Feel free to send us a message
Don't forget to share with any friends who are also
preparing for the BCSE Exam.
Infectious Bovine Rhinotracheitis (IBR)
Bovine Herpesvirus 1 (BoHV-1): A Comprehensive Guide
Introduction
Bovine Herpesvirus 1 (BoHV-1), an alphaherpesvirus, is a major cattle pathogen causing infectious bovine rhinotracheitis (IBR) and other diseases. This virus has a significant impact on cattle health and international trade, necessitating comprehensive management strategies in veterinary practice.
History and Epidemiology
BoHV-1, initially identified during outbreaks in the US during the 1950s, has since gained worldwide distribution. The prevalence varies, with herd level prevalences up to 85% in regions with established cattle enterprises. The disease's impact within herds is unpredictable, making vigilant monitoring crucial.
Clinical Manifestations
BoHV-1 infection ranges from severe and fatal to mild and subclinical. Common symptoms include respiratory distress, decreased milk production, and, in some cases, abortions. The variability of these infections is influenced by viral, host, and environmental factors. Subclinical infections are widespread, and the severity of the disease is often exacerbated by secondary bacterial infections.
Transmission and Survival
Transmission primarily occurs through direct contact with infected cattle or re-excreted latent virus. The virus can survive in the environment under specific conditions, including low temperatures and high humidity, posing a risk of transmission between farms.
Pathogenesis
BoHV-1 replicates in the upper respiratory tract, leading to clinical symptoms like pyrexia and nasal discharge. The virus can also enter the central nervous system (CNS) without necessarily causing clinical signs of nervous disease. In reproductive tract infections, BoHV-1 is introduced through natural mating or artificial insemination and does not arise from viraemia from respiratory infections.
Immune Response and Latency
An efficient immune response, involving interferon production and both humoral and cellular immunity, contributes to recovery. However, every bovine animal with BoHV-1 antibodies has a lifelong latent infection, posing a continuous risk. Reactivation from latency can occur under stress or corticosteroid induction.
Diagnostic Approaches
Diagnosis often requires laboratory confirmation in addition to clinical observations. Virus detection is highest during the early stages of infection, and serology is an essential tool for diagnosis and control. Understanding the vaccinal history of animals is crucial in interpreting serological tests.
Vaccination Strategies
A range of vaccines, including marker vaccines, is available for BoHV-1. Marker vaccines allow differentiation between infected and vaccinated animals, essential in control and eradication programs. Vaccines are effective in preventing clinical disease and reducing virus spread but do not completely prevent infection.
Control and Eradication
Control and eradication of BoHV-1 are feasible with the availability of excellent diagnostic tools, understanding of the virus biology, and effective IBR marker vaccines. Several European countries have initiated control and eradication programs, highlighting the potential for long-term eradication.
Conclusion:
For veterinary professionals, managing BoHV-1 requires a multifaceted approach involving accurate diagnosis, effective vaccination, and herd management strategies. Understanding the disease's variability, transmission risks, and the role of stress in reactivation is vital. Continuous research and application of these insights are essential in managing BoHV-1 effectively and protecting cattle health and productivity.
This article aims to provide veterinary professionals with a comprehensive understanding of BoHV-1, emphasizing the importance of a strategic approach in managing this significant cattle pathogen.
References
-
Muylkens, B. "Bovine Herpesvirus 1 Infection and Infectious Bovine Rhinotracheitis.” Vet. Res. 38 (2007), 181-209.
-
Nettleton, P. F. "Update on Infectious Bovine Rhinotracheitis”. In Practice. June (2017). Volume 39, 255-272.
Do you have any feedback about the Note?
We'd love to hear from you!
Feel free to send us a message
Don't forget to share with any friends who are also
preparing for the BCSE Exam.
Primary Canine Glaucoma
Glaucoma in animals is a critical condition marked by increased intraocular pressure (IOP), leading to retinal and optic disc damage. It results from impaired outflow of aqueous humor, either through the trabecular meshwork or uveoscleral network. The condition can be primary, often inherited, or secondary to other ocular diseases. In dogs, primary breed-predisposed glaucoma is notably common, and in cats, it's mostly secondary to conditions like anterior uveitis. Diagnosis involves tonometry and ophthalmoscopy, with gonioscopy and high-frequency ultrasonography being helpful for prognosis. Treatment varies, ranging from medical management with drugs like miotics and carbonic anhydrase inhibitors to surgical interventions in more severe cases.
References:
Veterinary Merk Manual. Glaucoma in Animals.
Do you have any feedback about the Note?
We'd love to hear from you!
Feel free to send us a message
Don't forget to share with any friends who are also
preparing for the BCSE Exam.
Environmental Diseases in Aquatic Systems
Environmental diseases affecting aquatic systems and aquatic domestic animals are diverse and influenced by a variety of factors including water quality parameters like salinity, temperature, chlorine/chloramine levels, dissolved gases, and the presence of toxicants such as hydrogen sulfide and heavy metals. These diseases can have significant impacts on a wide range of aquatic species, from fish to invertebrates, and understanding their causes, effects, and treatments is crucial for veterinary professionals working in aquaculture or managing aquatic ecosystems.
Poor water quality is a leading cause of environmentally induced diseases in aquatic animals. Factors such as low dissolved oxygen and high ammonia levels can directly lead to fish mortality. Additionally, the toxicity of other parameters, such as ammonia, can increase with rising pH levels. Temperature plays a critical role as well, where inappropriate temperatures can be linked to fungal diseases in fish, for instance, Fusarium solani infections in bonnethead sharks can be managed by maintaining the water temperature above 80°F (27°C).
Chlorine and chloramine, often used in municipal water treatment, are highly toxic to aquatic organisms. These substances can cause acute and chronic health issues in fish and other aquatic animals, with symptoms ranging from ragged fins and excess mucus to lethargy and mortality at very low concentrations. Effective management involves testing and treating water to remove these compounds before introducing it to aquatic systems.
Hydrogen sulfide, resulting from anoxic conditions in poorly maintained tanks or sediments, and heavy metals like copper and zinc from plumbing or environmental contamination, can also cause significant health problems. Strategies to mitigate these risks include regular tank maintenance, water testing for toxic substances, and the use of specific filtration systems to remove or neutralize these compounds.
Dissolved gases, particularly oxygen, are vital for the health of aquatic systems. Fluctuations in oxygen levels, often due to photosynthesis, respiration, and other natural processes, can lead to stress and mortality among aquatic animals. Monitoring and managing dissolved oxygen levels are essential to prevent hypoxia and ensure the well-being of aquatic life.
The U.S. Geological Survey (USGS) and other organizations conduct research and surveillance on aquatic animal health, focusing on the identification of pathogens, understanding their impacts on hosts and ecosystems, and developing mitigation strategies. This work includes the study of diseases in a variety of aquatic environments and is aimed at promoting the health of aquatic ecosystems and the sustainability of aquaculture industries.
For veterinary professionals, staying informed about the latest research findings and disease management strategies is crucial. Engaging with scientific literature, attending professional workshops, and collaborating with research institutions can enhance their ability to diagnose, treat, and prevent environmental diseases in aquatic systems effectively.
References:
Environmental Diseases of Aquatic Animals in Aquatic Systems - Exotic and Laboratory Animals. Merck Veterinary Manual.
Diseases of Aquatic Organisms | U.S. Geological Survey.
Aquatic Animal Health and Disease | U.S. Geological Survey
Do you have any feedback about the Note?
We'd love to hear from you!
Feel free to send us a message
Don't forget to share with any friends who are also
preparing for the BCSE Exam.