Equine Vet www.modernequinevet.com
Vol 9 Issue 1 2019
Ultrasonography Key for Lameness Diagnosis in Thoroughbreds
Do Intrasynovial Injections Cause Sepsis? The Microbiome and Obesity Technician Update: Cervical Stabilization Surgery
TABLE OF CONTENTS
Ultrasound in Thoroughbreds
4 Still Key for Lameness Diagnosis
Cover photo: Shutterstock/Cheryl Ann Quigley
UK Researchers Probe Link Between Equine Microbiome and Obesity..............................................................................................................10 TECHNICIAN UPDATE
Cervical Stabilization Surgery in a Thoroughbred Yearling....................................................................13 NEWS
Synovial Sepsis Rare Following Intrasynovial Medication ................................................................... 3 Urge Owners to Help Horses Lose Weight Now ........................ 8 Equine Rabies Found in New Jersey..............................................11 AVMA Combating Suicide Among Veterinary Professionals...................................................................12 ADVERTISERS Avalon Medical.............................................................3 American Regent Animal Health.............................5
Clarius Ultrasound.......................................................9 AAEVT............................................................................17
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Synovial Sepsis Rare Following Intrasynovial Medication The frequency of synovial sepsis appears to be pretty low when ambulatory veterinarians inject Intrasynovial medication. In a retrospective, cohort study, veterinarians from Rossdales Equine Hospital, Newmarket, United Kingdom, looked at a single large ambulatory practice. They reviewed the clinical records between January 2006 and December 2011 of all horses undergoing intrasynovial medication for treatment, not for diagnostic analgesia. They cross-referenced medication records against synovial cytology submissions and hospital admissions for synovial sepsis. They also reviewed which products were used and considered characteristics such as a horse’s age, gender and measurable attributes of risk. The hair overlying the injection site was not routinely clipped, but the site was prepared with chlorhexidine gluconate and surgical spirit. Sterile gloves and new vials of medication were used. The concurrent use of amikacin sulphate was left to the discretion of the clinician. A bandage was usually placed following the injection. The researchers studied 9,456 intrasynovial medica-
tions that were injected during 4,331 sessions. The most frequently used medications were: • corticosteroids (3,869/4,331), • hyaluronate (3,617/4,331) and • amikacin sulphate (4,044/4,331). Four cases (0.23%) of post-medication synovial sepsis occurred in 4 individual horses, with sepsis being detected 1–17 days post-medication. Synovial sepsis developed following middle carpal joint medication in 3 horses and following metacarpophalangeal joint medication in 1 horse. Two of these cases were medicated with polysulphated glycosaminoglycans and hyaluronate (1 of which also received concurrent medication with amikacin sulphate) and 2 were medicated with triamcinolone acetonide and hyaluronate. MeV
For more information: Smith LCR, Wylie CE, Palmer L, et al. Synovial sepsis is rare following intrasynovial medication in equine ambulatory practice. Equine Vet J 2018 Dec. 27 [Epub ahead of print]. https://onlinelibrary.wiley.com/doi/10.1111/evj.13063
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Ultrasonography is one of
the key tools for the diagnosis of lameness in Thoroughbred racehorses. One of its mainstay applications is the investigation of tendon and ligament overstrain injuries incurred at the track. While ultrasound is not the be-all, end-all of the lameness evaluation, Chris O'Sullivan BVSc, MS, DACVS, of the Randwick Equine Center, New South Wales, Australia, discussed how it can prove complementary to good, old-fashioned palpation and clinical examination skills, here at the 64th Annual AAEP Convention in San Francisco.
Photo courtesy of Chris O'Sullivan
STILL KEY FOR LAMENESS DIAGNOSIS B
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A quip bandied about at Dr. O’Sullivan’s practice states that tendon injuries in Thoroughbreds are like pregnancies: they’re either there or they’re not—and if present—like a pregnacy—will take at least 11 months to resolve. “That does apply directly to the core lesions that we see,” he explained. “I see some peripheral lesions that can be rehabilitated a little quicker than that, but for the core lesions in the tendon, that rings true.” In racing Thoroughbreds, the most common tendon injury is an overstrain of the superficial deep digital flexor tendon (SDFT). Typical presentation involves swelling, warmth on palpation and pain on palpation over the flexor tendons. “A work history is valuable to determine whether the horse worked at speeds typically associated with a tendon injury,” Dr. O’Sullivan said. Additional history should include questions about whether the horse has had recent bandaging on the affected limb. A “bandage bow” causes no real damage
The only dual ingredient injectable corticosteroid approved by the FDA for use in horses
The link between
RAPID ONSET and LONG-ACTING RELIEF of pain & inflammation1
BetaVet ® (betamethasone sodium phosphate & betamethasone acetate injectable suspension) is indicated for the control of pain and inflammation associated with osteoarthritis in horses. Learn more at www.betavetequine.com or call 1-800-458-0163. Please see Brief Summary of Full Prescribing Information on the following page.
INDICATION: BetaVet ® is indicated for the control of pain and inflammation associated with osteoarthritis in horses.
IMPORTANT SAFETY INFORMATION For Intra-Articular (I.A.) Use in Horses.
CONTRAINDICATIONS: BetaVet ® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in cleft palate in offspring and in other congenital anomalies including deformed forelegs, phocomelia and anasarca. Therefore, before use of corticosteroids in pregnant animals, the possible benefits to the pregnant animal should be weighed against potential hazards to its developing embryo or fetus. Human Warnings: Not for use in humans. For use in animals only. Keep this and all medications out of the reach of children. Consult a physician in the case of accidental human exposure. PRECAUTIONS: Corticosteroids, including BetaVet , administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Due to the potential for exacerbation ®
of clinical signs of laminitis, glucocorticoids should be used with caution in horses with a history of laminitis, or horses otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, such as NSAIDs or other corticosteroids, should be approached with caution. Due to the potential for systemic exposure, concomitant use of NSAIDs and corticosteroids may increase the risk of gastrointestinal, renal, and other toxicity. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet ® (n=119) or a saline control (n=120) at five percent (5%) and above were: acute joint effusion and/or local injection site swelling (within 2 days of injection), 15% BetaVet ® and 13% saline control; increased lameness (within the first 5 days), 6.7% BetaVet ® and 8.3% saline control; loose stool, 5.9% BetaVet ® and 8.3% saline control; increased heat in joint, 2.5% BetaVet ® and 5% saline control; and depression, 5.9% BetaVet ® and 1.6% saline control. DOSAGE AND ADMINISTRATION: Shake well immediately before use. Use immediately after opening, then discard any remaining contents. RX ONLY References: 1. Trotter GW. Intra-articular corticosteroids. In: McIlwraith CW, Trotter GW, eds. Joint Disease in the Horse. Philadelphia: W.B. Saunders; 1996; 237–256.
BetaVet® and the Horse Head design are registered trademarks of American Regent, Inc. © 2019 American Regent, Inc. PP-BV-US-0021 1/2019
BRIEF SUMMARY OF PRESCRIBING INFORMATION (Betamethasone Sodium Phosphate and Betamethasone Acetate Injectable Suspension) 6 mg betamethasone per mL For Intra-Articular (I.A.) Use in Horses CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATION: BetaVet ® is indicated for the control of pain and inflammation associated with osteoarthritis in horses. DOSAGE AND ADMINISTRATION: Shake well immediately before use. CONTRAINDICATIONS: BetaVet ® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in cleft palate in offspring. Corticosteroids administered to dogs during pregnancy have also resulted in other congenital anomalies including deformed forelegs, phocomelia and anasarca. Therefore, before use of corticosteroids in pregnant animals, the possible benefits to the pregnant animal should be weighed against potential hazards to its developing embryo or fetus. Human Warnings: Not for use in humans. For use in animals only. Keep this and all medications out of the reach of children. Consult a physician in the case of accidental human exposure. PRECAUTIONS: Corticosteroids, including BetaVet ®, administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Appropriate examination of joint fluid is necessary to exclude a septic process. If a bacterial infection is present, appropriate antibacterial therapy should be instituted immediately. Additional doses of corticosteroids should not be administered until joint sepsis has been definitively ruled out. Due to the potential for exacerbation of clinical signs of laminitis, glucocorticoids should be used with caution in horses with a history of laminitis, or horses otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, such as NSAIDs or other corticosteroids, should be approached with caution. Due to the potential for systemic exposure, concomitant use of NSAIDs and corticosteroids may increase the risk of gastrointestinal, renal, and other toxicity. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet ® (n=119) or a saline control (n=120) were: acute joint effusion and/or local injection site swelling (within 2 days of injection), 15% BetaVet ® and 13% saline control; increased lameness (within the first 5 days), 6.7% BetaVet ® and 8.3% saline control; loose stool, 5.9% BetaVet ® and 8.3% saline control; increased heat in joint, 2.5% BetaVet ® and 5% saline control; depression, 5.9% BetaVet ® and 1.6% saline control; agitation/anxiety, 4.2% BetaVet ® and 2.5% saline control; delayed swelling of treated joint (5 or more days after injection), 2.5% BetaVet ® and 3.3% saline control; inappetance, 3.4% BetaVet ® and 2.5% saline control; dry stool, 1.7% BetaVet ® and 0% saline control; excessive sweating, 0.8% BetaVet ® and 0% saline control; acute non-weight bearing lameness, 0.8% BetaVet®and 0% saline control; and laminitis, 0.8% BetaVet® and 0% saline control.
CLINICAL PHARMACOLOGY: Betamethasone is a potent glucocorticoid steroid with anti-inflammatory and immunosuppressive properties. Depending upon their physico-chemical properties, drugs administered intra-articularly may enter the general circulation because the synovial joint cavity is in direct equilibrium with the surrounding blood supply. After the intra-articular administration of 9 mg BetaVet ® in horses, there were quantifiable concentrations of betamethasone (above 1.0 ng/mL) in the plasma. EFFECTIVENESS: A negative control, randomized, masked field study provided data to evaluate the effectiveness of BetaVet ® administered at 1.5 mL (9 mg betamethasone) once intra-articularly for the control of pain and inflammation associated with osteoarthritis in horses. Clinical success was defined as improvement in one lameness grade according to the AAEP lameness scoring system on Day 5 following treatment. The success rate for horses in the BetaVet ® group was statistically significantly different (p=0.0061) than that in the saline group, with success rates of 75.73% and 52.52%, respectively (back-transformed from the logistic regression). ANIMAL SAFETY: A 3-week target animal safety (TAS) study was conducted to evaluate the safety of BetaVet ® in mature, healthy horses. Treatment groups included a control (isotonic saline at a volume equivalent to the 4x group); 1X (0.0225 mg betamethasone per pound bodyweight; BetaVet ®); 2X (0.045 mg betamethasone per pound bodyweight; BetaVet ®) and 4X (0.09 mg betamethasone per pound bodyweight; BetaVet ®). Treatments were administered by intra-articular injection into the left middle carpal joint once every 5-days for 3 treatments. Injection site reactions were the most common observations in all treatment groups. Injection site reactions were observed within 1 hour of dosing and included swelling at the injection site, lameness/stiffness of the left front limb, and flexing the left front knee at rest. The injection site reactions ranged from slight swelling (in many horses on multiple days in all treatment groups) to excessive fluid with swelling, pain, and lameness (4x group only). Injection site reactions were observed most commonly on treatment days, and generally decreased in number and severity over subsequent days. The incidence of injection site reactions increased after the second and third injection (number of abnormalities noted on day 10 > day 5 > day 0). In the BetaVet ® treated groups the number and severity of the injection site reactions were dose dependent. The 4X BetaVet ® group had the highest overall incidence of and severity of injection site reactions, which included heat, swelling, pain, bleeding, and holding the limb up at rest. The control group and 4X group (which received similar injection volumes) had a similar incidence of injection site reactions; however, the severity of reactions was greater in the 4X group. Absolute neutrophils were statistically significantly higher in the BetaVet ® treated groups as compared to the control group. Trends toward a decrease in lymphocytes and eosinophils, and an increase in monocytes were identified in the BetaVet ® treated groups after the initial dose of BetaVet ®. Individual animal values for white blood cells generally remained within the reference range. BetaVet ® treated horses also had a trend toward increased blood glucose after the initial dose. Some individual animals showed mild increases in blood glucose above the reference range. SHAKE WELL BEFORE USING NADA 141-418, Approved by FDA For customer care or to obtain product information visit www.betavetequine.com or call 1-800-458-0163. To report an adverse event please contact American Regent Animal Health at (800) 734-9236 or email firstname.lastname@example.org.
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to the tendon, but it can cause a form of peritendinous inflammation that appears as a bowed tendon. “Clinically, these are not as focally or discretely painful, and I’ll treat them similarly in the first phase of tendon injury therapy with aggressive anti-inflammatories. I’ll stop the horse from working until it’s been confirmed to be normal on ultrasound or until it is completely clinically resolved.” In an ideal world, if a likely SDFT injury is identified, a horse will undergo ultrasonographic evaluation after 7 days. “In the practice setting, it’s economically difficult to sit on a horse for any longer than 1 to 3 days,” he said. “That tends to be the general period when I will do ultrasound.” Prior to ultrasonographic examination, he will also start a fairly aggressive anti-inflammatory regimen, as well as discuss the merit of intertendinous therapies on a case-by-case basis. After the inflammation has resolved, a graded exercise program is initiated, which is then monitored by ultrasonography. For the ultrasound examination, the presence, position and severity of the tendonitis should be evaluated. A linear 10- to 14MHz probe with a standoff is ideal. The affected tendon and the contralateral clinically healthy tendon should be examined to provide a reference of cross-sectional area (CSA) and to identify subclinical ultrasonographic changes.
Suspensory branch injuries in Thoroughbreds are most common in 1- to 2-year-old horses. Presentation is similar to tendon overstrain injuries—swelling, pain and warmth on palpation, and variable lameness.
Muscle and Bone Injuries Aside from tendons and ligaments, Dr. O’Sullivan will also use ultrasonography to investigate muscle injuries, and to work out whether an injury is caused by generalized inflammation or a muscle tear. The most common muscles involved include the hamstrings, gluteals and the brachiocephalicus. “Quite often, they also occur up at the tuber ischia attachment,” he said. “The horse may also have a bone injury that requires further investigation aside from ultrasound.” For horses with a suspected displaced pelvic fracture, Dr. O’Sullivan uses ultrasonography as a complement to scintigraphy. “[These fractures] in some cases are non-displaced and are like a crack in your windshield,” he said. “When you scan them on day 1, there will be no displacement. It’s just sitting there, and it can’t be identified on ultrasonography.” He finds it useful to perform follow-up scans over multiple days, as the fracture slowly starts to displace and become more obvious. “I find it a useful monitoring tool to help me convince the owner that the horse needs scintigraphy,” he added. “The reason I do scintigraphy is mainly to confirm the configuration, and to confirm my ultrasound findings.” “On the first day of the injury, the horse typically presents with a subtle grade 1-2/5 on the AAEP lameness scale, with swelling and edema,” Dr. O’Sullivan said. “The changing profile of the branch is typically obvious, and they will generally have discrete pain on palpation.” He will palpate these horses while weight-bearing to assess the size of the ligament and compare it to the opposite limb. To assess the horse’s level of comfort on palpation, he palpates while the horse is non-weight-bearing. “Similar to tendons, I’ll delay the scans for 1 to 3 days,” he added. “I always scan all 4 forelimb branches, because it is common to have pathology occurring in multiple branches in these horses.” Dr. O’Sullivan will also obtain radiographs of the fetlocks in these horses. Fetlock joint effusion is common with this type of injury, whether it’s due to the lesion extending into the fetlock joint or to a local inflammatory response around the damaged
suspensory ligament. Suspensory body injuries tend to have moderate swelling and general edema. A larger degree of edema is typically found on the medial side of the limb. A horse with an acute injury will often have a grade 2-3/5 on the AAEP lameness scale on presentation. “Interestingly, a lot of these horses will be presented as cellulitis by the trainer,” Dr. O’Sullivan said. “I think it’s important to carefully evaluate these horses, because a lot of the time they will subsequently be found to have suspensory body injuries after receiving treatment for some days.”
Digital Flexor Tendon Sheath
Soft tissue injuries involving the digital flexor tendon sheath (DFTS) often cause lameness, swelling, and an enlargement of the damaged structure within the sheath. The acute phase can see varying degrees of DFTS effusion, as well. “I radiograph a lot of these cases with DFTS effusion,” Dr. O’Sullivan said. “Clinical examiModernEquineVet.com | Issue 1/2019
nation findings will often identify them, but on occasion, we will see horses that have a small avulsion off of the back of P2.” Often, these injuries are quite obvious on ultrasound. They are present through the middle scutum, but also running up into the branches of the ligament.
In the past, curbs were predominately diagnosed based on clinical
findings of plantar hock swelling. During the past 15 years, ultrasound has shown great benefit in the investigation of curb swellings, and has allowed the injury to be identified as an overstrain of either the plantar ligament, SDFT, or DDFT. For horses with only a peritendinous or periligamentous inflammatory process, Dr. O’Sullivan will warn clients that a small percentage might develop an infection.
“They obviously bleed into the region—or at least that seems to be the case,” Dr. O’Sullivan explained. “Approximately, 1 in 10 will be taken away from the racetrack and then returned after about 8 to 10 days with an infection in that area. “A lot of the time, the horses need surgical debridement by the time they get back to me, and most of the time, there’s a blood clot present,” he said. MeV
Urge Owners to Help Horses Lose Weight Now
Photos courtesy of BEVA
In today’s domesticated environment with greater access to forage, hard feed, stabling and rugs, horses and ponies can quickly pile on dangerous excess pounds, according to the British Equine Veterinary Association, which increases the risk of serious diseases such as laminitis, as well as placing detrimental pressure on joints. Equine obesity is not a new problem, but it appears to be becoming more common, BEVA said. Studies have identified high levels of obesity in leisure horses and unaffiliated competition horses—especially those competing in showing and dressage. “Not only are many horses being unintentionally over-fed, over-rugged and under-exercised but, as perceptions of what constitutes a healthy weight have become distorted, overweight has become the norm,” said David Rendle, BVSc, MVM, CertEM, DECEIM, MRCVS from BEVA's Health & Medicines Committee. “A recent survey of more than 500 horse owners confirmed that owners have a poor ability to visually identify overweight animals and that perceptions
Ocko before and after weight loss
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of ideal weight for animals participating in showing classes was perceived to be significantly greater than for other equestrian disciplines,” said Dr. Rendle, an expert in pituitary pars intermedia dysfunction. “There seems to be a stigma attached to having a ‘fit’ or lean horse on many livery yards when, in fact, such a horse is highly likely to be healthier than its overweight neighbor,” added Lucy Grieve, MA, VetMB, MRCVS, chair of BEVA's Ethics & Welfare Committee. It is important for veterinarians to educate clients that this is not healthy. “Vets and owners need to work together as a team and monitor horses routinely. Taking steps to support weight control now and establish a healthy weight for your horse or pony is important to reducing the increased risks that come in the spring.” BEVA is developing information and tools to help veterinarians work with owners as a team to tackle equine obesity. MeV For further information visit www.beva.org.uk
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UK Researchers Probe Link Between
Equine Microbiome and Obesity A d a m
M a r c u s
The microbiome is human medicine’s hottest topic these days, so it’s not surprising that equine specialists also are exploring how ridealong microbes affect animal health. A new study has found evidence that the gastrointestinal tract of obese ponies have a markedly different microbial makeup from that of their lean or older stablemates. The research, published in Frontiers in Microbiology, does not offer any clinical guidance, but it does offer a baseline for future analyses of equine microbiota. “Although in the current study, our obese group of ponies were found to have some differences in the relative abundance of individual phyla and genera, it is impossible to speculate as to the cause and effect of this,’ said Philippa Morrison, PhD, an equine specialist at Scotland’s Rural College in Aberdeen, who led the research team. “It could be that these changes
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occurred as an adaptation to their metabolic state but it could be that these changes occurred prior to the development of obesity. “An interesting finding in our study was that the bacterial community of those animals in the aged group that were also obese—we did not set out to recruit obese and aged animals; it was just impossible to source enough lean aged ponies— clustered with the obese animals as opposed to the aged animals, suggesting in the current study that obesity had a stronger impact on the microbiome than age,” Dr. Morrison told The Modern Equine Vet. Further studies would be required to identify whether the fecal microbiota is associated with an altered propensity to obesity and weight-loss, she added. “Additionally, there is a lack of data regarding
The researchers found no differences in total bacteria in the 3 groups of horses. However, obese ponies had significantly greater microbial diversity than the lean or aged animals (P=0.02)—a finding that was at odds with previous studies that looked at the question. “The relative abundance of Bacteroidetes, Firmicutes and Actinobacteria was significantly greater in obese compared to control animals, whilst the relative abundance of Proteobacteria was significantly greater in the aged group compared to the control group,” the researchers wrote. Another species, Fibroacteres, were particularly common in the control ponies compared with the 2 other groups. This species was the most abundant family of microbes overall.
Obese ponies had a significantly greater microbial diversity than the lean or older animals. the function of the individual bacteria and further studies investigating the metabolism of individual bacteria may aid in our understanding of their function in the horse.” Dr. Morrison and her colleagues regularly analyzed fecal samples from 35 Welsh pony mares over a 2-year period. Of the animals, 11 were aged (average age 25 years), 12 were of normal weight and 12 were obese (average weight, 293.83 lbs.) at the start of the study.
“The current study has identified that host-phenotype has a major effect on the structure of the microbial population of equine feces. However, clear biomarkers of animal phenotype were not identified in either the fecal microbiome or metabolome,” the researchers reported. “Further studies are needed to confirm whether this is a result of the relatively small number of animals used in this study or a consequence of the functional redundancy within gut microbial population.” MeV
For more information: Morrison PK, Newbold CJ, Jones E, et al. The equine gastrointestinal microbiome: impacts of age and obesity. Front Microbiol. 2018;9:3017. Published online 2018 Dec 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293011/
NJ Horse Found Positive for Rabies A 20-month-old from New Jersey colt is a sad reminder that horses are at risk for rabies and should be vaccinated against this disease and receive boosters periodically. “Vaccination of livestock and other domestic animals is the most effective strategy to protect animals against this disease,” the New Jersey Department of Agriculture (NJDA) said in a statement. A Cape May County, New Jersey, horse was found positive for rabies. The horse, which was on a farm in a rural part of the county, was being treated at a referral facility and was tested for rabies because it showed neurologic symptoms. The 20-month-old colt was previously vaccinated, as were all other horses on the property. There was no word on how long ago he was vaccinated. The exposed surviving horses have since received a booster vaccination and are under observation for 45 days. Exposed, unvaccinated animals have been quarantined for 6 months. The NJDA Division of Animal Health encouraged everyone to speak with their veterinarians about vaccinating their animals against rabies. If unvaccinated livestock are suspected of having direct contact with a rabid animal or are suspected of contracting rabies, it may be necessary for the entire premises to be placed under quarantine. Rabies is endemic in New Jersey and is often detected in bats, raccoons, foxes, skunks, cats and—to a lesser extent— domestic livestock. Transmission is almost always from the bite of a rabid animal. The virus is shed in the saliva several days before the onset of clinical signs. The disease is fatal once clinical signs appear. Suspect cases should be handled with care and isolated from other animals. Rabid animals of all species usually exhibit typical signs of central nervous system disturbance with owners first noticing their animal “doesn’t seem right.”As the illness progresses, nervous system impairment becomes more obvious. Affected animals may or may not show signs of aggression, but may show signs, such as slight depression, walking in circles, eating non-edible items, “star gazing,”or not acting normally, according to the NJDA. No word when we posted as to which people had to MeV received rabies prophylaxis. ModernEquineVet.com | Issue 1/2019
AVMA Combating Suicide Among Veterinary Professionals According to a 2016 CDC report, 45,000 Americans aged 10 or older died by suicide, which is the 10th leading cause of death in this country. And its incidence is increasing. Veterinarians are not immune. In fact, female veterinarians were 3.5 times as likely and male veterinarians were 2.1 times as likely to commit suicide than the general population, according to research done by the CDC and the American Veterinary Medical Association. The AVMA and other groups are partnering to study this sad statistic and see what they can do to help their colleagues. “Too many of our colleagues have either contemplated, attempted or died by suicide,” said John de Jong, DVM, AVMA president. “And one suicide is clearly too many. Working with our colleagues throughout the veterinary community will help us find solutions more quickly. “As medical professionals, we need to understand and learn about the clinical signs associated with suicide and work with other medical professionals to confront and combat this serious problem,” he said. The AVMA and partners are creating and developing resources, not only for those in distress, but for
those who want to help those who are suffering. A key program available to help veterinarians identify and refer at-risk colleagues, is QPR (Question, Persuade, Refer) training. The AVMA offers this 1-hour, online “gatekeeper training” free to every member and veterinary student. It teaches people without professional mental health backgrounds to recognize the signs that someone may be considering suicide and helps them to establish a dialogue. “Oftentimes people may suspect someone is suffering but they don’t know what to say, or they worry that what they say may make the situation worse,” said Jennifer Brandt, PhD, AVMA’s director of member wellbeing and diversity. “It is my goal to have every veterinarian complete the QPR training. It provides guidance on what to say and ways in which you can enhance a sense of belonging and help alleviate the sense of fear that some may have about being a burden to their friends, family or colleagues.” “This truly is a profession-wide concern,” Dr. de Jong said. “We know that we don’t have all of the answers but there is strength and hope in such a strong industry-wide collaboration." For more information visit avma.org.
Programs and Tools Available to Address This Issue • The AVMA has collected and developed resources to help veterinarians combat moral/ ethical distress from the empathy that develops with patients that causes them to take on the burden of an ill or dying patient. • The AVMA offers financial planning resources, including a personal financial planning tool, salary calculator and tips on student loan repayment because the average student debt loads are rising. • AVMA has developed an online wellbeing and peer-assistance toolkit because the potential for drug abuse and addiction is higher among medical professionals than in other workplaces. • The MyVeterinaryLife.com website is aimed at students and veterinarians in their early careers to help them navigate wellbeing, finances and career concerns. • AVMA's 100 Healthy Tips to Support a Culture of Wellbeing offers strategies and practice steps a person can take at work and at home to support healthful living and create a positive work environment. • Veterinary peer-assistance programs are available around the country. • Veterinary Wellbeing Summits provide an opportunity to discuss steps that should be taken to support enhanced wellbeing throughout the profession. • AVMA is working with the Royal College of Veterinary Surgeons in the United Kingdom, and the World Small Animal Veterinary Association to improve the health and wellbeing of all of those in veterinary medicine. 12
Issue 1/2019 | ModernEquineVet.com
Cervical Stabilization Surgery in a Yearling A bay, Thoroughbred, yearling colt was born at a Scott County farm in Central Kentucky on March 16, 2017. In late May to June 2018 this colt, and his 2 field mates, had a few management changes in preparation for a late 2018 sale. Their time in the paddock was decreased to allow stall time during the heat of the day, exercise, and then they were separated into different paddocks when turned out. The colt has always been taller than his herd mates; he had also recently undergone a growth spurt. After this management change this colt became noticeably less coordinated after being in the stall. His signs of ataxia and weakness were more obvious in the hind limbs and worsened when his head was raised or he walked on an incline. There was evidence of circumduction of the pelvic limbs when circling. His thoracic limbs would knuckle occasionally when walking. His cranial nerve function was normal. Standing films of his cervical spine were taken at the farm on in June 18, 2018 after being videoed for a full neurologic examination. His standing films were uploaded and measured in efilm to gain the intra-vertebral sagittal ratio (Hudson. et al. 2005). Dr. Steven Reed considers <50% at C 4, 5, 6 and <52% at C 7 as an indicator of narrowing. His intra-vertebral caudal C-spine ratio at C5-6 (35%) was narrow (Figure 2). The joint at C 6-7 was difficult to evaluate on the field radiographs due to the quality of exposure; attempts to alter the contrast and measure the sagittal
ratio suggested that it would be <52%. This is indicative of cervical vertebral stenotic myelopathy (CVSM). The decision was made to bring him to the clinic for a myelogram on June 22, 2018. CVSM is most commonly seen in male Thoroughbreds and Quarter horses, often in those with longer necks and rapid growth. On the way to the clinic, he lost his balance and was down in left sternal recumbency upon arrival. Lacerations were evident on his chin, left front fetlock, knee and elbow. The colt was able to stand on his own with encouragement and the support of the trailer wall; he was taken to a stall for assessment. None of his injuries necessitated delaying the myelogram, but the deepest laceration to the fetlock did require exploration, flushing and sutures under general anesthesia. A bandage was placed over the fetlock laceration, a 14 g Mila catheter was placed in the LJV and pre-anesthesia bloodwork was pulled. Once the bloodwork results were back (WBC 8,700, PCV 35.7%, TP 6.3 and fibrinogen 300 with a normal differential) he was started on Kpen, gentamicin, phenylbutazone and given tetanus toxoid. A second brief neurologic examination was performed on the way to radiology. The colt was noticeably weaker and more ataxic in the pelvic limbs. Circumduction of the pelvic limbs was pronounced on circles; he was walking and standing base wide with a periodic â€œhitchâ€? to the right hind. When halted, he would lean backward on the thoracic limbs and would rush when starting to walk again. Using the Mayhew scale he was graded by Steve Reed, DVM, DACVIM, and Bonnie Barr, VMD, DACVIM, as a 2 in the thoracic limbs and a 3 in the pelvic limbs. His fall could be considered to be grad-
FIGURE 1. Colts field radiographs 6/18/18
FIGURE 2. C 6-7 radiographic quality
All photos courtesy of Andrea Whittle
By Andrea Whittle, BS, LVT, VTNE
ModernEquineVet.com | Issue 1/2019
Cervical vertebral “Wobbler syndrome” and its possibly hereditary nature has been researched for many years. A published study in 1985 (Wagner. et al., 1985) bred 12 known CVSM mares with 2 known CVSM stallions; they did not diagnose any of the offspring with CVSM in their first year of life. Anecdotally there is evidence to suggest that there is a genetic link and as genetic testing advances we may be closer to proving this. Janes (2014) states that her genome wide association study showed results that were consistent with the understanding that CVSM is influenced by both genetic and environmental variables. One section of this research looked at 8 individual horses within a single family that showed a higher-than-normal incidence of the disease.
ed as a 4, although he was being trailered at the time of the fall. Grade 2: Mild neurological deficits but apparent at all times/gaits
FIGURE 3. Circumduction seen on a small circle
Issue 1/2019 | ModernEquineVet.com
Grade 3: M oderate deficits at all times/gaits that are obvious to all observers regardless of expertise Grade 4: Severe deficits noted at the walk and may fall or nearly fall at normal gaits The colt was sedated with xylazine in the induction stall, induced with ketamine and midazolam, intubated and hoisted onto the myelogram table. He was maintained on a GKX drip for the 35 minute procedure. His head was elevated and after a sterile prep an AO tap was performed (18 g 3" BD spinal needle) with 30 mL CSF drawn and 50 mL Iohexol (Omnipaque) injected. After 5 minutes to allow for the flow of contrast, his head was lowered to the table. His front legs were drawn back and his down eye padded well with the halter off. Three neutral position cervical spine images were taken, 3 with the neck hyperextended and 3 flexed with the colts nose tucked between his knees. The yearling was hoisted off the myelogram table onto a surgery table and moved to a transfer area to repair the LF fetlock laceration. The myelogram was independently called by an internist and surgeon as being compressed at C6-7. The dorsal column of dye is absent at the site of compression. His cervical stabilization surgery was scheduled for June 26. This surgery fuses the vertebrae causing the compression and prevents further, repetitive, damage to the spinal cord. Antibiotics were continued with LF bandage changes every 2 days. His diet was adjusted from
FIGURE 4. Myelogram image of C^-7—neutral head position
sweet feed to a ration balancer. Pre-operative bloodwork was submitted (WBC 9,500, PCV 35.6%, TP 5.5 and fibrinogen 500) and his morning dose of phenylbutazone was increased; this was given just prior to surgery. After sedation, induction and intubationâ€”following the same induction protocol as for the myelogramâ€”he was placed in dorsal recumbency (Figure 6.), clipped and prepped for a ventral midline incision of the caudal neck. A nasal tube is also placed in these surgeries to ensure continual airflow in recovery post extubation; being dorsal for the duration of the surgery can predispose the patient to the accumulation of edema. Positioning of the head and neck in these patients is key and takes time. Marker needles are placed under the skin prior to the first set of radiographs to identify the correct joint and correct approach prior to the first incision. The joint between C6-7 is exposed, a small amount of bone is removed with an osteotome and mallet, and a core saw and drill bits of varying sizes are used to make room for the implant. The hole is then tapped and a half-threaded titanium basket implant is placed between C6 and C7; the implant is packed with bone material saved from drilling. Placement, depth, angle and security of the basket were verified with multiple intra-op radiographs. The incision was closed and stapled, he was then moved to a padded recovery stall for an assisted recovery. He was under anesthesia for a total of 1 hour and 50 minutes. His recovery was assisted by 2 recovery tech-
nicians and went smoothly; he was able to walk back to the stall with just tail support. Our nursing staff saw him lie down to rest and get back up on his own early the next morning. He remained on stall rest at the clinic with continued antibiotics and phenylbutazone for 5 more days. On June 28, he needed a little encouragement and assistance to get up in the stall and seemed to be guarding his neck more. A firocoxib (Equioxx) loading dose was given alongside the phenylbutazone and then given PO SID (Equioxx paste) for several days. A post-op radiograph to assess the placement of the implant was taken on June 29; he walked willingly and comfortably to radiology. He was discharged to the farm's care on July 1. The initial rehabilitation plan was 30 days (from surgery) of stall rest, continuing the ration balancer feed and NSAIDS as needed for comfort. The staples on the ventral incision were removed 10 days post-surgery. After the 30 days he started hand walking for a further 30 days, ground poles were gradually introduced into his regime to encourage him to step up and over them cleanly. At the 60-day mark he had another follow-up radiograph taken to check the placement of the implant and was allowed to have small, round pen turn out; he was initially sedated to go outside. After this period he has progressed to a small paddock for turn out and was continuing with strengthening exercises in hand; this included cavaletti poles
FIGURE 5. Patient in dorsal recumbency for surgery
FIGURE 6. Identification and marking of vertebral joints
FIGURE 7. Half-threaded titanium implant
FIGURE 8. Intra-operative radiographs
FIGURE 9. Closing the incision
FIGURE 10. Rehabilitation using ground poles ModernEquineVet.com | Issue 1/2019
FIGURE 11. 60-day post-operative radiograph
and gradual hill work. From this point on, his increasing coordination and comfort dictated the rehabilitation. His strength and coordination has improved solidly to this point; his significantly increased range of motion in his hind legs can be seen well in Figure 12. The long-term plan for this colt is to be trained and to go to the track as a racehorse; he has been named through the Jockey Club. The dam of this colt is a Thoroughbred who also underwent cervical stabilization surgery in 2007 to fuse
FIGURE 12. Paddock turn outâ€”October 2018
C6-7. Of her previous 6 foals, 4 made it to race track and 2 were winners. Her only filly is now a broodmare with a 2017 foal on the ground. MeV
About the author
Andrea Whittle is an internal medicine technician at Rood and Riddle Equine Hospital in Lexington, Ky. The year 2019 will be her 20th foaling season between Kentucky and New Zealand. Her favorite patient groups are intensive care neonates, neuros' and long-term hospitalized patients.
For more information: Hudson NPH, Mayhew IG. Radiographic and myelographic assessment of the equine cervical column and spinal cord. Equine vet. Educ. 2005;17:(1) 34-38 Janes J. (2014) The roles of orthopedic pathology and genetic determinants in equine cervical stenotic myelopathy. University of Kentucky, Theses and Dissertations â€“ Veterinary Science. Mayhew IG, deLahunta A, Whitlock RH, et al. Spinal cord disease in the horse. Cornell Vet. 1978;68(Suppl 6):1-207 Power B, Stashak T, Nixon A. Pathology of the vertebral column of horses with cervical static stenosis. Veterinary Pathology 1986;23:392-399 Reed SM. Cervical Vertebral Stenotic Myelopathy. Personal communication and document sharing. Rush BR, Grady J. Cervical Stenotic Myelopathy. Compendium Equine 2008;3:8. Wagner P, Grant B, Watrous B. A study of the heritability of cervical vertebral malformation in horses, In: Proceedings of the annual convention of the American Association of Equine Practitioners (USA). 1985 16
Issue 1/2019 | ModernEquineVet.com
AAEV T M E M b E r s h i p Membership in the AAEVT is open to all veterinary technicians, assistants, support staff and those employed in the veterinary health care industry worldwide. Student membership is open to those currently enrolled in an AVMA/CVMA accredited veterinary technology program.
AAEVT Membership • • • • • • • • • • •
Bi-Annual Newsletter Weekly “HoofBeats” Email Newsblast Full access to www.aaevt.org, including the Career Center and the Library Up-to-date information on the AAEVT Discounted registration for AAEVT Regional Meetings and the annual AAEP/AAEVT Convention NTRA, Working Advantage and Platinum Performance Benefits The opportunity to participate in the AAEVT Online Certification Program or to become a member of the AEVNT Academy-Specialty in Equine Veterinary Nursing Scholarship opportunities. AAEVT’s Equine Manual for Veterinary Technicians (Blackwell Publishing 20% discount on purchase price) Opportunity to attend Purina’s Annual Equine Veterinary Technician Conference - All Expenses paid!
AAEVT Objectives • • • •
Provide opportunities for CE, training, communication, and networking Educate the equine veterinary community and the public about our profession Inform Members of issues affecting our profession Assist in providing the best medical care to improve the health and welfare of the horse
AAEVT Online Equine Certification Program
• A three course, 10 module, equine-only online program offered through ACT • Geared toward Credentialed Veterinary Technicians, Assistants, Support staff, & Students • Areas of study include: equine medical terminology, anatomy and physiology, parasitology, laboratory, diagnostics, equine basics (breeds, wellness, husbandry,) diagnostic procedures, emergency medicine, restraint, pharmacology, surgical assistance and anesthesia, equine office procedures • A certificate of completion is awarded to those who: Successfully complete required courses Complete the list of required skills (per a supervising DVM who is an AAEP member) Attend an AAEVT regional CE symposium and participate in the we labs • Those individuals who successfully complete the programs will be recognized as AAEVT Certified Equine Veterinary Technicians / AAEVT Certified Equine Veterinary Assistants depending on their current designation. The certificate is recognized by the AAEVT and the AAEP but does not grant the credentialed status by the AVMA • For more information go to www.aaevt.4act.com or call 800-357-3182
AAEVT Mission Statement: To promote the health and welfare of the horse through the education and professional enrichment of the equine veterinary technician and assistant.
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