Not to Be a Stick in the Mud, But…

I was at the park the other day and a lady arrived with a bouncy Cocker Spaniel. My heart sank as she picked up a stick and threw it for her beloved pooch to retrieve. You may think this is the best way to spend an afternoon – throwing a stick for your dog – but I can only see it as a potential road to disaster.

Stick injuries to the mouths and throats of dogs are a nightmare for the dog, for the vet and for the owner. The most basic and common injury is getting the stick caught on the roof of the mouth, between the upper teeth. This happens if the stick isn’t longer than the dog’s mouth or, more often, if the dog bites down too hard and breaks the stick, lodging the broken piece at the top of the mouth. A more serious injury occurs when the stick goes into the back of the mouth and the sharp end penetrates the lining of the pharynx. Often, even once the stick is removed, bits of bark or other foreign material can be left behind. It is extremely difficult to clean these wounds, even with the animal under anaesthetic and if any material is left behind it can cause inflammation (aka a foreign body reaction) or abscessation.

I treated one patient while at university whose oesophagus had been penetrated by the stick. It had to be referred to us at the university hospital for specialist surgery and ICU care during his recovery.

Another dog we treated at the local surgery had to have multiple anaesthetics to remove all of the bark that had become imbedded in his pharynx.

May I suggest rather than a stick, that a Frisbee, a bit of thick rope, or a sturdy rubber toy be employed to exercise your dog and that you leave the sticks for some one else.

The Cost of Animal Health

In the UK, we are blessed (or cursed depending on how you look at it) with a National Health Service. As a result, the humans rarely have any idea what it costs for them to see the doctor or spend a night in hospital. It comes as a bit of a shock when they come to the vet's and are asked to pay sometimes hundreds of pounds for treatment. There are three aspects of the price of veterinary medicine that I'd like to discuss:
(1) Getting an Estimate
(2) Insurance
(3) Prevention is Cheaper than Cure

(1) Before you even make your appointment you can get an idea of what it is going to cost you. Receptionists are used to people phoning up to find out the cost of a consultation (remember to ask how long the time-slot is -- a vet who does 20 minute consults may not be twice as expensive as one who does 10 minute ones so you may get more for your money). They will also give you an idea of costs for routine procedures like neutering and dental work. Once you have seen the vet and s/he has told you what is wrong and what needs to happen to fix it, it is a good idea to ask for an estimate. This gives you an idea of what kind of money you will be expected to hand over at the end of treatment and may help you make decisions as to which procedures to accept or decline. The estimate may be verbal or written. I prefer to give written estimates (I print out a copy for my clients to take home with them) so if there is a discrepancy at the end we can explain why it is different. If I do give a verbal estimate, I always make a note in the record. This reminds me to let the client know if the treatment is going to exceed what I initially thought. If your vet gives you a verbal estimate, I suggest you write it down yourself and make sure you have heard him correctly (50 rather than 15 for example). Please also realise that an estimate is only that. Once the vet is able to see the results of tests or the way your animal responds to treatment, the course of further treatment may change.

(2) I am always relieved when a client tells me they have insured their animal. I don't view this as a green light to spend lots of money on unnecessary tests, but rather as an equaliser. It allows me and the owners to do what is right for the individual patient rather than what the owner can afford (which may not be appropriate for the pet). Many people are sceptical of insurance companies, having found them unwilling to pay out for problems with their home or car. We have found them very accommodating so far and have had very few problems. For people who don't want their money to go to some large corporation, perhaps never to be seen again, I suggest opening a savings account just for the pet. I suggest finding out what the insurance premiums for your area are and saving that as a minimum amount. I do often suggest to clients who bring me new puppies/kittens for vaccination that they start a savings account, but take out insurance for the first couple years since this is when animals tend to be the most accident-prone and when the savings account will still be too small to cover the cost of a broken leg or retrieval of a swallowed toy.

(3) Please, please, please vaccinate your pets. If you decide you don't want them vaccinated, for whatever reason, at least bring them for an annual check up -- especially once they enter their geriatric years (over 8 years old for dogs and cats, over 5 for rabbits). Your vet can pick up subtle changes in your pet and can help curb problems before they become expensive. A toothbrush and tube of doggy toothpaste along with a demonstration of teeth brushing by the nurse is a lot cheaper than an anaesthetic for dental cleaning and extractions of rotten teeth. Kidney disease can be managed just with diet in the early stages, but may require multiple blood tests, blood pressure tests, fluids, tablets and hospital stays if not diagnosed until it is advanced.

Finally, when you are thinking of bringing a new pet into your home, please remember there is more than just the purchase price to factor in. A £2.00 hamster can ultimately cost £200-300 with the cage, food, toys and veterinary care.

My Claim to Fame... or Not!

A different kind of post today: one of a more personal nature...

A new series started tonight on ITV (Channel 3 in the UK). It is called Prehistoric Park and is on Saturdays at 6:50pm. I imagine in a couple months it will air in the US on the Discovery Channel or Animal Planet or some similar channel.
(See the ITV website for more details)

My claim to fame, however, is that I auditioned for it, believe it or not. They had advertised in one of the vet mags for a female vet with acting experience. That's me, so I sent in an audition DVD. Unfortunately I wasn't chosen, so you can imagaine the eagerness with which I watched tonight's opening episode. The vet they've chosen is a woman named Suzanne and I don't know anything else about her. She only had a few short scenes in tonight's episode, so we'll see if she plays more of a role in the future ones.

Maggoty Bottoms -- No Thanks!

It has been hot in the UK for the last couple of days and the flies have been going wild. I noticed a maggot crawling out of one of my rubbish bags this morning as I put it out for collection. I even thought I saw one on my head of lettuce this morning while I was getting the sandwiches ready. If it was real, then the flies really are getting desperate.

These glimpses of the larval stage of the common housefly brought back vivid memories of previous summers full of maggoty bottoms. My heart sinks at this time of year if I’m consulting and a rabbit appears on my list as an extra “fit-in”. It usually happens about 4:30 in the afternoon when the owner has gone out to check on the rabbit and take it its evening meal. She’s either had to catch the rabbit up out of the run and notices them then, or the rabbit has already gone into shock and is flat out in the hutch.

Fly strike – the term applied to the process of a fly laying her eggs on an animal and the subsequent hatching of those eggs and the damage they cause – strikes fear into the heart of all rabbit owners (or it should!). The eggs look innocuous, just micro cream-coloured grains of rice arranged like a raft – it could be sawdust to the untrained or uninitiated. They hatch into tiny wriggling worm-like parasites whose goal is to eat as much as possible and grow as large as possible. If the rabbit (or other animal… see below) is wet or has faeces stuck to the underside of its tail, the maggots start there, but often keep going and can enter the rectum, vagina or urethra, or can burrow in through the skin and enter the abdomen.

It is often this faeces under the tail that attracts the flies in the first place, but any animal that is debilitated can be a target. If the animal is lying still long enough for the fly to land and lay the eggs, or if it is not grooming the eggs off after they are laid, it will be a target.

My rabbit clients probably get bored when I harp on about the importance of fibre in the diet and the importance of making sure you only ever see the hard round balls of faeces, not the soft smelly faeces (aka caecotrophs). I and my nurses have spent too much time picking maggots off the back ends of rabbits though! I want to put a stop to it!!

To prevent fly strike you MUST:
(1) Feed your rabbit properly. Make sure they have a high fibre diet (see previous post) with LOTS of grass and hay.
(2) Monitor the droppings daily. If you are seeing caecotrophs in the hutch more than once in a blue moon, get to your vet and get it sorted.
(3) Check your rabbit 2-3 times daily. Not just glancing in to see if he’s breathing, but physically picking him up and turning him over. Comb through the fur at the back if possible.
(4) Don’t allow your rabbit to become overweight. This makes it very difficult for them to groom properly and remove bits of faeces and fly eggs (they just can’t reach!).
(5) Remove faeces and urine along with any soiled bedding from the hutch daily. Flies have more sensitive “noses” than humans, so if it smells to you it will be heaven for a fly.
(6) Use mosquito-type netting over the hutch and run and keep them in the shade on hot days to prevent access by the flies and to prevent the rabbit from overheating and becoming debilitated.
(7) If you’re concerned about fly strike and have followed the previous 6 recommendations, there is a product that can help. “Rear Guard” is licensed for the prevention and treatment of fly-strike. It is a bit fiddly to use and to apply properly, but it does kill the maggots and prevent the eggs from hatching. It does not repel the flies, however, so it is not a replacement for good hygiene, diet, etc as listed above.

If you discover that your rabbit (or other animal) has maggots it IS an emergency and they need to be seen by a vet immediately – even if it’s midnight. The maggots release substances as they feed that can send the animals into shock and kill them. Often the maggots are secondary and there is something else that is going to kill the animal first, so no matter what, if you see maggots, call the vet and then get down there ASAP. If you can’t be seen straight away, you can help your pet by starting to pick the maggots off yourself with a pair of tweezers. If your pet already shows signs of going into shock, try to minimise stress, wrap him up in a towel and put him near a warm radiator or under a warm lamp.

Also, rabbits are not the only animals that are affected at this time of year. Guinea pigs, dogs and cats are also susceptible. The saddest case I have seen was a dog who had had chronic diarrhoea but the owner had not been cleaning it away from the fur at the back end. The flies were having a field day. It was not a pretty sight.

Please don’t make me or my nurses clean up any more maggoty bottoms this year!

Thanks.

Further reading:
Glen Cousquer Case Report of an obese Lop-eared rabbit with fly strike. This is more for vets, but will give you an idea of the kind of work that can be necessary to repair the damage caused by the maggots.

A Word about UV

Everyone is uptight these days about avoiding Ultraviolet (UV) radiation exposure: stay out of the sun; put sun cream on; make sure you're protected against UVA AND UVB; UV causes skin cancer! All of these things are important to remember if you are a human, particularly one of Scottish descent (complete with reddish hair and freckles) like me.

If, however, you are a reptile, UV takes on a completely different significance. UV radiation allows a complex organism like an iguana, tortoise, snake, or, yes, a human, to make vitamin D which helps with calcium absorption and metabolism. When we avoid UV radiation we are preventing our bodies from making this useful molecule. This isn't a problem if you are a human drinking vitamin-D fortified milk and eating fish or eggs. If you are a vegetarian iguana or Spur-thighed tortoise, then to be deprived of sunlight or other source of UV light is to be deprived of normal bone growth and strength. This leads to deformed bones and can result in multiple broken bones.

Reptiles in captivity need to have regular access to unfiltered sunlight (sometimes a challenge in Great Britain, but make the most of it when you've got it!). When sun exposure isn't a possibility, then a good UV lamp is the next best thing. Unfortunately not all reptile owners realise a few key aspects of UV supplementation:

(1) There can be no glass or plastic between the animal and the light. If you are concerned about your pet breaking or burning himself on the light, then put a sturdy wire mesh in front of it, but no other barrier.
(2) The UV portion of the light only lasts 6-9 months. This is long before the actual light burns out, so be sure to mark on your calendar when to change the light - twice a year (it's easy if you remember to do it when the clocks change, for example). You don't have to throw the light away, you can use it elsewhere in your house as just a regular light.
(3) The UV portion of the light doesn't extend very far. Only 12-18 inches. It therefore needs to be positioned near where your pet likes to bask. For a tortoise or a snake this will be near the floor of the enclosure, for an iguana or chameleon this will be near the top of the enclosure.
(4) Be sure to buy a lamp for reptiles, not one simply marked "broad spectrum" or labelled for fish. These other lights won't necessarily have the wavelengths your pet needs.

Finally, the need for UV has been best documented in reptiles, but birds and small mammals do also benefit from a trip (in safe accommodation) into the back garden on a sunny day. It's best not to do this when the family is over for a barbeque, or the neighbourhood dog is barking his head off. Choose a quiet time when there isn't much of a breeze and gradually introduce your pet to the big wide world. Don't be surprised if they are a bit scared at first. There are a lot of predator smells/sounds that we won't necessarily pick up on. As they spend 10-30 minutes outside a couple times a week, you will hopefully notice an improvement in their health and well-being.

Bring on the summer sun!

Keep the Sandpaper Out of the Bird's Cage

If ever there was a bit of pet shop paraphernalia that was useless and potentially dangerous it would be the sandpaper perch covers and cage bottom sheets. They are touted as useful for wearing down the nails of budgies, canaries and other small caged birds. In truth, all they do is irritate the birds' feet and empty the owner's wallet!

As part of his normal preening activity, you should notice your bird nibbling his nails occasionally. This, along with the normal perching and climbing activity your bird should also be exhibiting, is enough for a normal, healthy bird to keep the nails at an appropriate length. Occasionally I will trim the sharp points off my birds' nails if they seem to be catching in nesting material or soft furnishings around the house.

A sandpaper perch cover only serves to give a rough place for the bird to perch. At best this is unnecessary, and at worst may predispose the bird to bumble foot (a sore area on the weight-bearing surface of the underside of the foot and subsequent infection). The sandpaper floor covers are the same. I also worry if your bird is like my lovebirds and shreds the paper at the bottom of the cage -- it can't be nice to accidentally ingest!

If your bird's nails appear to be overgrowing, there are a couple reasons this could be happening. A parasitic infestation or painful condition could be altering the bird's preening routine. Malnutrition - either due to not being offered the right food, competition for food, or selective feeding - can also cause nails to overgrow.

The best types of perches for your bird are natural branches. These can either be collected from your own fruit trees (i.e. apple, cherry, pear trees), or they are commercially available at good pet stores with bolts and washers to connect them to the sides of the cage (see photos – these are the perches from my budgie’s cage). The benefit of these more natural perches is the variation in diameter which allows the bird to choose where he is most comfortable; they also allow him to exercise his feet and vary the pressure points throughout the day. They also look nicer than plain wooden dowels or plastic perches! A branch that isn't attached at both ends will also swing/sway a bit when the bird lands on it mimicking tree branch movement in the wild and helping with balance and muscle coordination.

The floor substrate you should use will depend a bit on the activity of your bird. If he spends time shredding the paper, then paper kitchen towel or plain, unprinted paper will be best. If he never goes down to the floor, you can use newspaper or similar. I encourage my clients to change the paper regularly (as often as daily sometimes) to monitor the droppings – their number and consistency – and maintain good hygiene.

Let’s only use sandpaper to tidy the ends of our natural branch perches; it has no other use in a bird’s cage!

Walk Through the Grass at your Peril

You wouldn't think something as simple as taking a walk would be painful or life-threatening. And it rarely is immediately. There is, however, a hidden danger in the long, uncut grass on the verge, or in the field, or in the park, or even in your own garden. The Brits call them "grass seeds"; the Americans call them "foxtails".

The San Francisco Dog Owner's Group has produced a document which includes some good pictures of the species of plants involved.
http://www.sfdog.org/do/foxtails.pdf

I always dread seeing canine patients from July through September since this is what we call "grass seed season". This is the time when the warm sunshine of late summer induces the grasses to put up their seed heads. As the seed heads dry out the seeds (or "awns") are dispersed. A dog brushing against the seed head as he runs through the field will later find multiple awns caught in his fur. Because of the arrow-like shape of the awns they can only migrate in one direction and if that direction is "into the dog" it then becomes a fight to get them out again.

The dog breeds that have the most trouble with grass seeds are the spaniels and other hunting breeds. These dogs have longish hair and dangly ears -- perfect for collecting grass seeds. The seeds can penetrate the skin and most often do so between the toes. They can also get caught in the eyes (especially behind the 3rd eyelid), in the ears, and inhaled or swallowed. They are initially simply irritating -- the eye becomes red and weepy, the ear is itchy and produces copious amounts of wax, the skin develops a red raised area that can become infected -- often the owner is alerted to a problem when the dog starts limping or licking the foot or shaking his head.

The seeds become life-threatening if they are not removed. Infection is just the tip of the iceberg. They can migrate up a leg slowly month after month and eventually end up in the chest -- one was reportedly removed from a lung.

They are notoriously difficult to find. They are not visible on xray, so at times it is like searching for a needle in a haystack. We use long thin forceps (alligator/crocodile forceps) to probe the sore area of the foot in an effort to blindly retrieve the foreign object. In the ear, an otoscope makes the procedure a bit easier as you can sometimes visualise the seed, but then retrieving it without puncturing the ear drum or pushing the seed further in can be nerve-wracking!

An ounce of prevention in the case of grass seeds is worth pounds and pounds of cure! Firstly, in your own garden, mow the lawn frequently enough to prevent the seed heads from maturing (they are not dangerous when the are green). Petition your local authorities to maintain public parks and other areas for the same reason. Obviously in fields and wooded areas, areas that are allowed to go a bit wild for the wildlife, the frequent mowing isn't going to be an option. If you take your dog to these areas, check him CAREFULLY when you get home. Brush his coat thoroughly and examine his paws. When you look between the toes, part the hair so you can see the skin at the top-most part. Check the ears with a torch/flashlight and pull down the eyelids (if you dog will let you) to be sure no seeds have gone in. I often recommend to owners who have dogs with fluffy feet to have a groomer shave the feet to just below the carpal pad -- a "poodle cut" – during this part of the year. Trimming hair around the eyes and shaving/plucking the hair from around the entrance to the ear canal also makes a big difference.

If, as so often happens, you come home from work after the vet's has closed for the night and find your dog has been licking his foot all day, it is not a life-or-death emergency; you do not have to call the vet out that night (unless your dog is in extreme pain). Examine the foot to see if you can see the end of the seed poking out from the skin. Pull it out if you can see it. If not, and you are comfortable doing so, trim the hair way from the sore part of the foot. Soak the foot for 10 or 15 minutes in a chlorhexidine solution (if you have it) or a saline solution (1 teaspoon table salt in 1 pint of warm water). If your dog is keeping you awake licking it you can put an Elizabethan/Buster collar on or put a sock over the foot.

When you see the vet the next day, be prepared for the possibility of your dog needing an anaesthetic. Retrieving grass seeds is a painful process and unless your vet is very lucky to find it on the first probe or your dog is very laid back, they often need a bit of "chemical restraint".

Feeding Guidelines for Pet Rabbits

(This information was originally published as part of a "New Bunny Pack" I put together for clients of Downes and Partners Veterinary Surgery in 2004. I have modified some of the wording for this forum.)

There have been many recommendations over the years as to the best diet for rabbits. Much of this has been based on what has been fed to laboratory rabbits kept in small cages with little to no exercise and a very short life span.

Today, pet rabbits can live up to 12 years so we are trying to feed them a more natural diet. Wild rabbits spend most of their day grazing on fibrous meadow grass and then select a few tastier morsels as they are available such as roots, bark, branches, flowers and leaves. This diet is very high in fibre, low in protein and fat, and requires a lot of chewing!

Diets that are deficient in fibre cause a number of problems. Dental disease is the most common result of a grass-deficient diet. Diarrhoea, soft stools and flystrike are also problems resulting from low-fibre diets. Diets too high in sugar and fat can cause obesity, which also contributes to dirty bottoms and flystrike!

I recommend, whether your rabbit resides indoors or outdoors, that hay and fresh grass should make up the main part of his/her diet. The grass is best picked by the rabbit himself while grazing in a protected run. The hay should be good-quality, bagged, meadow or timothy hay. Alfalfa hay is also available. This can be fed ad lib to growing animals and pregnant or lactating does, but should be fed only in small quantities to fully-grown rabbits.

Once daily you may supplement this diet with a very small amount of a concentrated pelleted or extruded food. In the UK, I recommend Oxbow Bunny Basics, Burgess Super Excel Lite, or Supreme Science Selective. I do not, under any circumstances, recommend a mixed or muesli-type food of any make or brand. A concentrated food, if fed, should be fed at a maximum rate of 10-20g food per kg rabbit per day. Pregnant and lactating does, ill animals, and animals recovering from surgery may have extra requirements and your rabbit vet can advise you if your pet falls into this category.

Weeds, such as dandelion, chickweed, and nettles are often enjoyed by rabbits along with branches from fruit trees such as apple and pear. Fresh green leafy vegetables, such as cabbage, spring greens, kale and broccoli are also delicious treats. Many rabbits also enjoy herbs such as mint and parsley. If you have a question about any food or plant item, please feel free to ask your vet.

Please remember, that ANY change to your rabbit’s diet must be made slowly over a week or so to allow his/her gut to adjust to the new foods. Any sudden change, even swapping to a new bag of his regular food, can cause an imbalance in the gut flora and subsequent bloating, release of bacterial toxins and possibly death. Even if you are just feeding a new bag of your regular food, mix some of the old and new bags together to allow a gradual change-over.

The final word: Rabbits eat GRASS!!

The Cat is Getting Old

It has happened so many times. A client brings in a thin, scraggly 14 or 15 year old cat. She has been with the family for years and they love her dearly. They say the cat has been losing weight over the last couple months, but has been eating well, so they didn't think anything of it. They just thought she was getting old. She is now skin and bones so they think she may need to be put down, but look hopefully at me to see if there is anything that can be done.

I ask my usual questions as I examine her. The answers are familiar: yes she is always hungry, yes she seems to have a lot of energy for her age, yes she occasionally throws up but we thought it was hair balls, yes she is restless at night. The exam reveals bad teeth, bright eyes, a racing heart rate, a heart murmur, severe muscle wastage and no body fat... and a large lump in the neck to one side of the trachea.

I inform the client that I will need to do some tests to confirm, but that I suspect the cat is getting old and is suffering from one of the most common "old-cat diseases": hyperthyroidism. Fortunately it is completely treatable and often carries an excellent prognosis.

I find the three most common "old-cat diseases" are kidney disease (failure/insufficiency), hyperthyroidism and cancer (various types). Each of these diseases can be treated if they are caught early enough and managed to maintain the quality of life of your beloved moggy for many years after diagnosis.

Hyperthyroidism is caused by an over-active thyroid gland. The gland is shaped like a butterfly and is located on either side of the trachea (windpipe) on the front of the neck. Often one side overacts first and the second side follows a year or two later. Because thyroid hormone regulates the metabolic rate of the cat, too much thyroid hormone makes them burn calories much faster than they can take them in. They become very hungry and very active/restless. Because they can't take in enough calories, they start to burn all their fat reserves, and when those are gone, they start to burn muscle.

Thyroid hormone also increases the heart rate. A normal cat who is nervous in my exam room will have a heart rate of between 160-200 beats per minute. I have counted heart rates of 240-260 in some hyperthyroid cats. The heart starts to wear out from all the hard work it is doing. Initially you just hear a murmur, but eventually the cat can go into heart failure and this is usually what kills the cat if the thyroid is left untreated.

I diagnose hyperthyroidism with a simple blood test. I always test the kidney and liver enzymes as well and monitor these throughout treatment. The high blood pressure associated with a rapid heart rate can mask an underlying kidney disease. This then becomes apparent once the heart rate and blood pressure are brought down to within the normal limits.

I start treatment with tablets given once, twice or three times per day depending on how high the thyroid levels are. I always check the patient 2 weeks after starting treatment to make sure they are not suffering any adverse side-effects (dramatic loss of appetite, lethargy, vomiting or itchy skin for example) and to adjust the dose accordingly. After a further 2 weeks, I check the thyroid hormone level and kidney values. Once the patient is stabilised we discuss further options. Cats, if they tolerate the tablets, can stay on them indefinitely. I prefer to surgically remove the overactive thyroid since most cats do not reliably take their tablets! There is also the option to use radioactive iodine to irradiate the thyroid tissue, but I have yet to have any clients take me up on this option. (It requires the cat to be hospitalised for a month since her urine and faeces are radioactive for this length of time after the treatment. It also costs over £1200, while the surgery is more like £250 per side and only requires an overnight stay in hospital).

I have only ever had to start 1 patient on thyroid supplementation after removing the thyroid and I have only ever had one patient experience the most serious side effect of surgery which is damage to the parathyroid and subsequent hypocalcaemia (resulting in fits/seizures which resolved with calcium supplementation). If you do opt to have your cat’s thyroids removed, please be aware that they can still be hyperthyroid. Some cats seem to make thyroid tissue elsewhere in the body. These cats can only be treated with tablets or radioactive iodine. Sometimes the thyroid is also located in the chest rather than the neck. These cats cannot have the operation.

So the long-and-the-short of this post is... if the cat seems to be getting a bit old and thin, get her checked sooner rather than later -- she'll thank you for it!

Please note: prices vary widely in different parts of the country and world. The prices mentioned here were examples from two veterinary surgeries in the Southeast of England.

Introduction

As I go through my day consulting with my clients and treating my patients, I often wish I could shout to the pet-owning public bits of information that would help them look after their beloved pets better. The birth of the blog is a great opportunity to do just this.

I am a small animal veterinarian, but I do have some knowledge of farm animals and equids. I will be publishing basic information about husbandry and healthcare of certain species and tips for recognising when your pet needs to see a vet. I will not be able to comment about specific cases or diagnose a problem via email. If you have questions about a specific disease or condition, I can do my best to address it in a general sense. My experience is limited to diseases and medicines available in the USA and the UK, but much of this is transferable to the rest of the world.

If you think the information I have published is inaccurate, I am not so proud as to not accept correction, so please correct me -- preferably including a source for your information (such as a journal article or personal experience).

Thanks!