Equine Vet www.modernequinevet.com
Vol 10 Issue 1 2020
Managing Navicular Bone Disease Ask the Nutritionist? The Severely Malnourished Horse Radiographs for Stifle Injury Diagnosis Dental Case Studies Technician Update: Earning a Specialty Certification
CHECK OUT: ASK THE NUTRITIONIST? YOUR NUTRITION QUESTIONS ANSWERED
TABLE OF CONTENTS
4 Managing Navicular Bone Disease
Cover photo: Courtesy of Dr. Roger Smith
ASK THE NUTRITIONIST?
What Should the Refeeding Plan be When Rehabilitating a Severely Malnourished Horse?....................................................................... 3 ORTHOPEDICS
A Winding Road From Stifle Radiographs to Diagnosis............................ 8 DENTISTRY
Case studies: Listen, Look, and Radiograph for Proper Dental Care.........................................................................................10 TECHINICIAN UPDATE
The Road to VTS Certification...........................................................................15 NEWS
Horses With CMFC Less Likely to Return to Work.................................................................19 Laser Salpingopharyngostomy Useful for Clinical Guttural Pouch...............................19 ADVERTISERS Purina Sponsored Content.........................................3 American Regent Animal Health/Adequan...........9 Heska............................................................................11
American Regent Animal Health/BetaVet...........13 AAEVT............................................................17
Equine Vet SALES: Matthew Todd • Lillie Collett EDITOR: Marie Rosenthal ART DIRECTOR: Jennifer Barlow CONTRIBUTING WRITERS: Paul Basillo • Adam Marcus COPY EDITOR: Patty Wall Published by PO Box 935 • Morrisville, PA 19067 Marie Rosenthal and Jennifer Barlow, Publishers PERCYBO media publishing
Issue 1/2020 | ModernEquineVet.com
LEGAL DISCLAIMER: The content in this digital issue is for general informational purposes only. PercyBo Publishing Media LLC makes no representations or warranties of any kind about the completeness, accuracy, timeliness, reliability or suitability of any of the information, including content or advertisements, contained in any of its digital content and expressly disclaims liability of any errors or omissions that may be presented within its content. PercyBo Publishing Media LLC reserves the right to alter or correct any content without any obligations. Furthermore, PercyBo disclaims any and all liability for any direct, indirect, or other damages arising from the use or misuse of the information presented in its digital content. The views expressed in its digital content are those of sources and authors and do not necessarily reflect the opinion or policy of PercyBo. The content is for veterinary professionals. ALL RIGHTS RESERVED. Reproduction in whole or in part without permission is prohibited.
SPECIAL ADVERTISING SECTION
Nutritionist KELLY VINEYARD, MS, PHD, SENIOR EQUINE NUTRITIONIST, PURINA ANIMAL NUTRITION
Ask the Nutritionist is a new monthly column featuring questions answered by PhD equine nutritionists and sponsored by Purina Animal Nutrition. Have a nutrition question you want to see featured? Email Marie Rosenthal. For clinics looking for specific nutritional advice, visit purinamills.com/ask-an-expert.
What should the refeeding plan be when rehabilitating a severely malnourished horse? A complete veterinary exam is the first step to rehabilitation, including an assessment of liver, kidney and gastrointestinal function to check for underlying conditions. Following the exam, a refeeding plan that facilitates weight gain but avoids potential complications can be implemented. Remember to record initial body weight and take photographs of the horse to document current condition and future progress. REFEEDING SYNDROME Horses with a body condition score (BCS) under 3 are most susceptible to refeeding syndrome, a condition characterized by potentially fatal shifts in fluids and electrolytes that can lead to heart, respiratory and kidney failure. Symptoms include increased muscle weakness, neurologic dysfunction, and aggression. To reduce the risk of refeeding syndrome in emaciated horses, follow the 10-day feeding protocol outlined below. REFEEDING: THE FIRST 10 DAYS The first 10 days of refeeding are critical when rehabilitating a severely starved horse. For the average-sized horse (1,100 pounds), follow this plan in order to minimize the risk of complications: • Days 1–3: Offer approximately 1.3 pounds of leafy alfalfa every 4 hours around the clock. • Days 4–6: Slowly increase the amount of alfalfa and decrease the number of feedings. Work up to offering a total of 16.5 pounds of hay per day, offered in 3 meals at 8-hour intervals. • Days 7–10: Continue feeding alfalfa hay divided into 3 meals per day and monitor closely. • Throughout: If diarrhea appears or persists, consider replacing a portion of the alfalfa with good quality grass hay. Always provide free-choice access to water. After 10 days, re-evaluate the horse’s weight. If the horse has responded well to the 10-day refeeding protocol, begin twice-daily feedings with free-choice
access to alfalfa hay. Slowly introduce concentrate feeds, and evaluate the horse's deworming program and assess dental health. If the horse remains in a critical state after 10 days, continue providing 3 meals a day of alfalfa hay until the horse becomes stabilized. CHEWING OR INAPPETENCE If a horse cannot properly chew or ingest feed and/or forage, there are a few methods to encourage eating: • Alfalfa cubes or pellets soaked in water (on an equal weight basis) can substitute for hay during the initial refeeding period. • If a horse completely refuses alfalfa hay products, substitute with other types of hay, soaked non-molassed beet pulp or a complete, pelleted feed like Purina® Equine Senior® horse feed. • Enteral nutritional support with Purina® WellSolve® Well-Gel® supplement may be necessary in severe cases of inappetence.
LONG-TERM FEEDING PLAN After a successful 10-day refeeding period, the horse is ready for a long-term plan dictated by digestible energy (DE) requirements and the amount of weight gain needed. When introducing calorie-dense concentrate feeds, feed small amounts in multiple meals per day. Increase the daily quantity of concentrates slowly, by no more than a total of 0.5–1 pound per day, until you reach the desired feeding level (use feeding directions provided by the manufacture as a guide). Continue offering high-quality forage on a free-choice basis. Monitor the horse’s weight regularly, keeping in mind an increase of 1 BCS requires approximately 35–44 pounds of gain and can take up to 40–60 days.
UPCOMING TOPICS February: Developmental orthopedic disease (DOD) March: Foal nutrition April: Special needs of the competition horse
ABOUT THE AUTHOR Dr. Kelly Vineyard is a Senior Nutritionist, Equine Technical Solutions, with Purina Animal Nutrition. She provides expert technical nutrition advice and insights in a variety of areas, including new product innovation, product research, and veterinarian and customer technical support. SPONSORED BY PURINA ANIMAL NUTRITION
ModernEquineVet.com | Issue 1/2020
Navicular Bone Disease B y
M a r i e
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Images courtesy of Dr. Roger Smith
To optimize the treatment of the navicular bone,
Radiographs of navicular disease (arrows).
Issue 1/2020 | ModernEquineVet.com
one should not only pay attention to the navicular bone itself but also the surrounding soft tissue, because both can be involved in this region of the foot, Roger Smith, MA, VetMB, PhD, DEO, DipECVSMR DipECVS, FRCVS, explained at the BEVA Conference. “Making an accurate diagnosis requires localization of the lameness to the navicular region,” said Dr. Smith, which usually involves diagnostic analgesia and imaging. Although blocking will enable one to determine that the pain is in the foot, it’s usually not specific for navicular bone disease, according to Dr. Smith, who is a professor of equine orthopedics at the Royal Veterinary College. “We can localize it to the foot and while blocking the navicular bursa and the coffin joint may be a little bit more specific, it doesn't differentiate the soft tissue components from bony pathology. So ultimately we're going to require imaging,” he said. Radiographs can determine obvious signs of navicular disease and eliminate other causes of foot lameness, according to Dr. Smith. When looking at the radiograph, be careful not to over interpret the distal border fragments, he warned. “The significance of distal border fragments is questionable,” Dr. Smith explained. “They are more common in horses with lameness in this region, but can also occur in sound horses.” MRI can provide more information, because it can identify different abnormalities, such as deep flexor pathology and abnormalities of the navicular bone. “Successful treatment of that troublesome navicular bone requires defining the pathology, and I think MRI has made a big contribution to that,” Dr. Smith said. Early disease, which usually shows the presence of bone edema without obvious radiographic changes, has a better prognosis. If cases are found early, corrective farriery to reduce excessive biomechanical forces on the deep digital flexor tendon and navicular bone can be helpful. “The loading force of the navicular bone region and the deep flexor tendon is relatively low at the start of
There’s nothing else like it. Over the past 30 years, Adequan® i.m. (polysulfated glycosaminoglycan) has been recommended millions of times1 to treat degenerative disease, and with good reason. From day one, it’s been 2, 3 the only FDA-Approved equine PSGAG joint precription available, and the only one proven to. Restore synovial joint lubrication Repair joint cartilage Reverse the disease cycle Reduce inflammation When you start with it early and stay with it as needed, horses may enjoy greater mobility 2, 4, 5 over a lifetime. Discover if Adequan is the right choice. Talk to your American Regent Animal Health sales representative or call (800) 458-0163 to order. BRIEF SUMMARY: Prior to use please consult the product insert, a summary of which follows: CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATIONS: Adequan® i.m. is recommended for the intramuscular treatment of non-infectious degenerative and/or traumatic joint dysfunction and associated lameness of the carpal and hock joints in horses. CONTRAINDICATIONS: There are no known contraindications to the use of intramuscular Polysulfated Glycosaminoglycan. WARNINGS: Do not use in horses intended for human consumption. Not for use in humans. Keep this and all medications out of the reach of children. PRECAUTIONS: The safe use of Adequan® i.m. in horses used for breeding purposes, during pregnancy, or in lactating mares has not been evaluated. For customer care, or to obtain product information, visit www.adequan.com. To report an adverse event please contact American Regent, Inc. at (800) 734-9236 or email firstname.lastname@example.org. Please see Full Prescribing Information at www.adequan.com.
1 Data on file. 2 Adequan® i.m. Package Insert, Rev 1/19. 3 Burba DJ, Collier MA, DeBault LE, Hanson-Painton O, Thompson HC, Holder CL: In vivo kinetic study on uptake and distribution of intramuscular tritium-labeled polysulfated glycosaminoglycan in equine body fluid compartments and articular cartilage in an osteochondral defect model. J Equine Vet Sci 1993; 13: 696-703. 4 Kim DY, Taylor HW, Moore RM, Paulsen DB, Cho DY. Articular chondrocyte apoptosis in equine osteoarthritis. The Veterinary Journal 2003; 166: 52-57. 5 McIlwraith CW, Frisbie DD, Kawcak CE, van Weeren PR. Joint Disease in the Horse.St. Louis, MO: Elsevier, 2016; 33-48. Adequan and the Horse Head design are registered trademarks of American Regent, Inc. © 2019, American Regent, Inc. PP-AI-US-0222 2/2019
Images courtesy of Dr. Roger Smith
stance and becomes maximal at the end of stance. And that's considered the normal loading pattern in this region. But in horses with navicular disease, the loading at the early part of the phase is increased both in the deep digital flexor tendon and on the navicular bone itself. And that's thought to be because of the tensing of the
Shoeing approaches for the troublesome navicular bone
Before and after corrective shoeing
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deep flexor tendon prior to the foot being placed on the ground, which is what we see as a flat or a toe first foot placement,” he explained. This produces excessive load on the navicular bone, “which we believe is one of the major drivers for the bony remodeling, and subsequently, the abnormalities that we see on the navicular bone itself,” Dr. Smith said. “When I was preparing this talk, I spoke to a few orthopedic specialists as to how effective they felt the corrective shoeing was. We had quite a wide variation of opinion from absolutely no benefit whatsoever to having some, or even very good effects. “I think it can be helpful and that's why I still undertake it, but it's not always a very predictable response. So we have to warn owners that the effects of that corrective shoeing may not be always as effective as we'd like,” he said. But studies have shown that the peak force inserted by the deep flex tendon on the navicular bone was reduced by 4% for every 1° increase in downward angulation of the distal phalanx (coffin bone) within the hoof. “So I think we can be confident that the concept of improving or increasing that downward angulation of the distal phalanx does have a significant effect of loading on the navicular bone, which we interpret as being helpful,” he explained. The question about the use of wedges depends on the severity of the lameness because ultimately long-term wedges can be counterproductive to heel growth. “We may want to use them in the early stages but probably not permanently,” he said. Nonsteroidals to reduce inflammation and provide pain relieve might help. Bisphosphonates, which are osteoclast inhibitors, provide beneficial effects in some studies in cases of early navicular disease where you have bone edema. They might help prevent bone remodeling, but the effect may be less of a therapeutic effect and more of an analgesic effect, he said. Reducing the level of exercise might help, although complete rest might not, he said. “For soft tissue pathologies, of course rest is important, although controlled exercise is important for rehabilitation. We know in many cases of navicular disease, however, rest is actually counterproductive,” Dr. Smith said. Addressing underlying soft tissue pathologies is essential for the management of lameness arising from the Continued on page 14.
In tra ora
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Imaging the Possibilities
A Winding Road From
Stifle Radiographs to Diagnosis
Images from Dr. Myra Barrett
M a r i e
R o s e n t h a l ,
Images 1 and 2: the left image is properly positioned and on the right, the joint looks narrow because of the angle. Image 3: medial cranial meniscal ligament enthesopathy
It’s a winding road getting from stifle radiographs to diagnosis, but a lot of indirect information can be had about the soft tissues from this diagnostic modality, according to Myra Barrett, DVM, at the BEVA Congress. The radiograph information added to clinical signs, history, ultrasonography and possibly arthroscopy will often get you there, said Dr. Barrett, who reviewed some things to look for when evaluating radiographs for stifle injuries. 8
Issue 1/2020 | ModernEquineVet.com
“I always like to start with radiographs, if possible,” she said, adding that it is important for the angle to be correct when taking them. “I just want to talk a little bit about positioning because it makes a big difference in how we interpret our radiographs,” said Dr. Barrett, associate professor, veterinary diagnostic imaging, Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University.
Not having the right beam angle can create an artifact that makes the joint look narrower than it is. “If it's a pretty abnormal stifle and you're also trying to decide if it's narrowed, then you have to be more diligent in your interpretation.” One of the most common problems in taking stifle radiographs is that people tend to shoot too steep with the beam, especially if they are being taken on a squarestanding horse. For a square standing horse, the angle should be about 10° to 15°. If the limb is angled behind the horse, the technician will have to adjust for that angle. “And that’s important for a couple of reasons. One is it's going to open up the joint space and give us the most accurate interpretation. The other is that it’s also going to help us be tangential to the area on the weightbearing surface of the medial femoral condyle where we’re most likely to see surface defects,” Dr. Barrett said. The location of the tibia on the radiograph can help you determine if the angle is correct. If the medial tibial condyle looks somewhat curved on the caudal cranial view, the angle is incorrect. “You always want to look for it to be flat and relatively super imposed. The other check you can use is to look at the angle of the tibial crest. The tibia crest should be about a centimeter below the lateral tibia condyle,” she explained. “Remember that when we have our radiographs, we are super imposing cranial and caudal,” she said. “We tend to see our primary problems on the medial aspect of the joint,” she said. One place to begin looking for abnormalities is the meniscal ligament. The medial cranial meniscal ligament should tether the medial meniscus to the tibia. “We have to be very diligent because there's some super imposition of the caudal meniscal ligament fossa that can happen, which can make us overinterpret changes here,” she warned. If one looks at the caudal cranial radiograph, one may see a dip or decreased bone density in the tibia, which is caused by bone resorption, where the cranial meniscal ligament attaches. A corresponding ultrasound image
will show bone loss at the attachment. Whereas on a normal radiograph, there will be a nice, smooth, round or square shape. “We start to see bone loss and that's usually the most common thing that goes under the ligament. It resorbs that bone and it dips. And then you also get bone irregularity and that helps you see the sclerosis. “You want to see those two things together. If all you see is a lucent area and no sclerosis around it, then it's a good chance that you're actually seeing super imposition [of the fossa],” she said. Another sign is shape. Are the cystic lesions perfectly round? “We tend to see more irregular bone resorption,” she explained. “If it's perfectly round and superimposed, you're probably just seeing the caudal fossa.” Before diagnosing joint space narrowing, make sure it was a well-positioned radiograph and there are other signs of disease, such as articular cartilage and meniscal damage. Is there a medial lateral balance? If it's crooked from medial to lateral, the narrowness could be an artifact. The lateral cranial meniscal ligament is much less frequently damaged than the medial, but it’s worth viewing. “The day you don't look is the day something happens,” she warned. The medial collateral ligament is not damaged very often, but it can occur. “I don’t think in my clinical experience that I tend to see a lot of somewhat insidious medial collateral ligament injuries, unlike people and dogs that often will get that triad of medial disease. We just don't tend to see that as often in our equine population,” she said. The equine cases she has seen tend to be associated with a more severe lameness and often are due to trauma. When looking at the medial collateral ligament, sometimes stressed views will help. Stressed views occur when pressure is applied to the lateral side of the leg. Before taking a stress view, take a pre-stress view for comparison with the stressed view. “And then I really like to compare it with the opposite limb, especially in places like the fetlock because that can vary in how much it opens up,” she said. If you put pressure on the lateral side and the stifle opens significantly, but you don’t see that opening on the other side, it confirms a collateral ligament injury. This is especially useful if ultrasonography is not available. “This is a great way to check whether you have a collateral ligament injury,” she said. Remember, however, that advanced osteoarthritis can result in bone production in the tibia due to medial buttress formation, which can be confused with medial collateral ligament injury, she said. MeV ModernEquineVet.com | Issue 1/2020
Listen, Look, and Radiograph for Proper Dental Care B y 10
P a u l
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oral care is to listen to the horse owners and trainers to get a full picture of the complaint, according to Jack Easley, DVM, DABVP-EQ, DAVDC-EQ, owner of Easley Equine Dentistry in Shelbyville, Ky. “A horse that is losing weight and that has bad teeth is not necessarily losing weight because of the bad teeth,” he said here at the 54th Annual AAEP Convention in Denver. “A horse with a biting issue that has a couple of wolf teeth isn’t necessarily biting because of the wolf teeth.” While a great deal of owner concerns can be addressed through dentistry, it is important to remember that there is a horse attached to all of those teeth, Dr. Easley reminded. After obtaining a thorough history, including review of the signalment, a complete oral exam with sedation, speculum, good light and a dental mirror or oral endoscope is a must. After that, it’s time to start the radiographs. “Back when we used conventional radiographs, you’d go out in the field and take 10 x-rays, come back to the clinic to develop them, and maybe two would have no motion and be diagnostic,” Dr. Easley said. “With digital radiography, we can do a much better job. As I’ve started taking more radiographs, I’ve diagnosed more pathology, I understand the pathology better, and I’m better able to treat the horse.” Dr. Easley presented a couple of cases to demonstrate the importance of radiography.
One of the most important steps for thorough
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-0027 5/2019
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 email@example.com.
A Division of American Regent, Inc. 5 Ramsey Rd. | Shirley, NY 11967
5/17/2019 9:15:15 AM
Courtesy of Dr. Jack Easley
Lateral incisors with equine odontoclastic tooth resorption and hypercemtosis (EOTRH).
A 25-year-old female horse was “not acting normal” around other horses or when handled by the owner. Physical exam, complete blood chemistry (CBC), serum chemistry and endocrine testing were all within normal limits, so a dental exam was requested. “She was a little long in the tooth, but her incisors looked pretty good,” Dr. Easley explained. “There was a little plaque accumulation at the gingival margin, and she had a little gingival recession.” Prominent juga were noted, as well as some gingival hyperplasia at the corner incisors. “I probed a little and found a little black spot on the tooth, which is a subtle sign,” he said. “She also had a few red dots on the gums, but overall the gross exam looked pretty good.” The horse’s owner was a small animal veterinarian, who was quite familiar with resorptive lesions, so she requested radiographs. The dorsoventral image of the upper and lateral incisor teeth showed severe odontoclastic tooth resorption lesions and mild hyperplasia that was especially prominent in the incisors. After extracting the incisors, the horse was back to normal within months and had improved body condition at 2 years. “Without radiographs, the crowns of these teeth looked fine,” he said. “This is always a radiographic diagnosis in a horse.”
An 11-year-old Saddlebred gelding was presented for routine dental examination. The horse had mild epiphora, and the groomer in the barn said that the horse usually has a “runny right eye.” On examination, a slight indentation was found
Lower incisors with EOTRH
on the side of the horse’s face. No other abnormalities were noted. The horse had no recent history of injury or trauma. “The horse had cupped out upper 108 and 109 teeth that looked like senile attrition,” Dr. Easley said. “The infundibulae was gone, and there was a small 408/409 occlusal wave pattern. They just look like old teeth—the type you'd see in 20-year-old horse, not in an 11-year-old horse.” Radiographs showed an expired 608 deciduous tooth without a permanent tooth present, and an expired 109 tooth with a blunted apex surrounded by condensed bone. “We didn’t have to do anything special in this horse, except for keeping down the wave pattern in the lower arcade,” he explained. “But at least we can tell the owner that the horse is going to have to be maintained this way throughout his life. We put the horse on a 6-month dental schedule instead of an annual schedule.” The most likely cause was a slight crushing injury sustained as a weanling or yearling. The bones of the face healed, but the dental buds inside the mandible may have been crushed, which can cause dysplastic, displaced or absent teeth later on.
The owners of a 24-year-old Dutch Warmblood gelding noticed the horse had been losing weight and had some intermittent green discharge from the left nostril during the past few months. The farm veterinarian had prescribed antibiotics, but the discharge persisted. The horse had been started recently on pergolide (Prascend, Boehringer Ingelheim/Vetmedica) for pituitary pars intermedia dysfunction (PPID). The physical examination was within normal limits for a geriatric ModernEquineVet.com | Issue 1/2020
Courtesy of Dr. Jack Easley
Upper incisors withe EOTRH.
horse, but it had a body condition score of 3. Oral examination showed diastemata between the
upper 08s and 09s on both sides. The 211 had an expired crown with an area of forage packing. “When I flushed the area and got the probe to clean out the food, fluid started running out of the left nostril,” Dr. Easley said. “That’s pretty pathognomonic for a fistula between the mouth and the sinus.” Radiographs revealed the 211 had expired, as well as 2 firmly attached root fragments and a bony defect in the dorsal aspect of the shallow alveolus. The left paranasal sinuses were filled with fluid and dense material. Instead of removing the 211 and creating a bigger opening between the mouth and sinus, Dr. Easley took some dental acrylic and created a sort of washer on either side of the hole to seal it up. He was then able to clean the sinus. After 2 years, the patch is still in place, and the horse has a dry nose. “Any time you see something that you don’t understand on the oral exam, take a set of x-rays,” Dr. Easley said. “It’s always worth it. It’s the best way to spend the owner’s money instead of chasing a problem with antibiotics for months before you finally figure it out.” MeV
Images courtesy of Dr. Roger Smith
Managing Navicular Bone Disease continued from page 6.
Screwing a fractured navicular bone
navicular region and can resolve sympathetic navicular bone edema, he said. Some clinicians inject deep digital flexor tendon lesions with stem cells, but it is quite challenging to get them accurately into the lesion site, he said. “It may be helpful in some cases, but I'm not wildly enthusiastic about that approach,” Dr. Smith said. If conservative management fails, a neurectomy can be undertaken to resolve the lameness, but soundness tends to last longer for navicular bone disease than deep 14
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digital-flexor-tendon pathologies, he said. If the navicular bone is fractured, screw repair might negate the need for a neurectomy and have a better outcome. “I think in the end, the decision-making is quite simple. You either repair it or you’re doing a neurectomy. We are quite a fan of repairing them,” he said. Data suggest that repair can be effective in returning a horse to soundness, but it requires special equipment and intraoperative imaging to insert a 3.5 mm screw accurately into the center of the navicular bone. MeV
The Road to VTS Certification By Sue Loly, LVT, VTS-EVN Attaining a specialty that is recognized by the Veterinary Technician Specialty Academy is not easy, but is well worth it for anyone who thinks being an equine technician is not just a job, but a calling. Increasing your skills and job opportunities are two good reasons for being certified but the networking and friends I’ve made through this experience have been invaluable. Some employers recognize the achievement and offer a raise or stipend, but not all do, so making more money should not be the main reason for getting a specialty certification.
First Things First
grandfathered into the profession. Provide proof of graduation and VTNE completion with your application. A curriculum vitae (CV) might sound intimidating, but it is really a form of professional resume. There are plenty of examples you can find online. Only include work history that is related to your application. (Include all of your professional affiliations, awards or recognitions at work [I won the idea of the month a few times.]). You may also include a list of special skills, lectures or presentations you’ve done or any articles you’ve published. Be sure to check the CV guidelines for any other requirements from the specific academy for which you are applying. Letters of recommendation are either due before or at the time of your application. Be aware that recommendations can only be made by a current VTS, a veterinarian or a veterinary diplomat; getting a recommendation from someone related to the specialty could carry more weight so try to have the highest-qualified references possible. The letter can be either an actual letter or a fill-in form. Make sure to follow through and confirm that your reference sent the letter on time. As we all know, this often means chasing after your veterinarian a few times. In most circumstances you don’t see the recommendation, and it goes directly to the review committee so make sure you choose someone that you know will give you a glowing recommendation. Each academy has a set amount of required work that is related to the specialty. The absolute minimum is 3 years of full-time work. Most require 4,500–5,000 experienced work hours in the specialty. You must provide employment history to prove your experience. The work history should be current proceeding the application, so it doesn’t count if you worked doing the specialty 10 years ago and no longer practice it. The work history hours must also be credentialed hours— so if you worked for 4 years uncredentialled and just 1 year credentialed, you will have to do at least 2 more years of credentialed work before applying. The surgery specialty requires a much longer work history but only a portion of it is required to be in the specialty.
Attaining a specialty recognition is not easy, but well worth it for anyone who thinks being an equine technician is a calling.
Every academy requires you to submit a letter of intent, which is your introduction to the review committee, so make it professional. It doesn’t need to be long, but introduce yourself and include an explanation about why you want to join the academy. You will make a stronger impression if you include an actual letter as a separate attachment, rather than just an email. The letter of intent should include details about which year you plan to apply. There is no consequence for backing out later or delaying your application. Most academies will also assign a mentor after receiving your letter of intent. Take advantage of this valuable resource. All technician specialties require applicants to be credentialed, either RVT, LVT or CVT. You need one of these credentials even if your state does not require them. You should include proof of initial certification and continued maintenance because the work experience related to your application needs to be done by a credentialed vet tech. Some—but not every—academy requires applicants to be a graduate of an accredited program; others will accept if you just challenged the VTNE and then were
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Case histories represent the largest portion of your application and allow you to demonstrate your skill set.
Your continuing education (CE) should reflect veterinary topics related to your specialty, but you can also usually submit some general veterinary technician topics like compassion fatigue that relate to everyone in the profession. Most academies require the CE to be RACE-approved or the equivalent, and proof of attendance documents are required. Equivalent CE may include a presentation by a VTS or diplomate that isn’t officially RACE approved. When in doubt, check with the application committee to see if a specific event will be accepted. The number of CE hours varies from group to group but averages 40–50 hours over the 3 years preceding the application. The type of CE may also be restricted; for example, usually in-house CE is limited because the review board wants to see that you are learning from various sources and perspectives. Online CE also tends to be limited. Each academy has its own list of advanced skills. The number and type of skills vary and usually focus on advanced skills related to the specialty, although some also include core basic skills. Some groups have fewer required skills with a higher number of proficiencies required and others may have more skills with less proficiency required. Regardless of the quality of the rest of your application, if you haven’t fulfilled the required skills, your application will most likely be rejected. Each skill needs to be signed off by a VTS or diplomate preferably, or an experienced veterinarian. Some academies also require that each skill correlates and is
Costs HERE IS A RUNDOWN OF SOME OF THE COSTS: To sit the exam: Letter of intent: Free Application Around $100 submission: $50 (non-refundable) Once you’ve passed the exam and been accepted into an academy, you need to work on maintaining your new credentials. Recertification is done every 3–5 years. Most groups have an annual membership fee, so remain a member in good standing. Recertification requires you to continue earning CE credits—traditionally through attending CE events, points for mentoring new applicants, holding board positions with the VTS or a state association, and/or presenting and publishing. There is usually also the option to retake the exam if you failed to maintain the requirements. The biggest cost is time. Don’t forget to factorthis in. Your time is valuable, and the time put into this process means time away from other parts of your life. 16
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referenced to a case log in the application. Just like the letters of recommendation, its recommended to use a strong reference for the skills list.
A Case in Point
Case histories represent the largest portion of your application. The first are brief case logs. You must follow the application guidelines specific to each academy regarding the dates you can collect your skills. In most cases you can only use cases that occurred in the 12 months prior to your application. This is one reason that you can’t apply if you are not actively working in that specialty at the time of the application. It is important to follow the recommended or required format. Not doing so tells the review committee that you don’t follow directions and makes it harder for them to evaluate you. If they ask you to list them in chronological order, make sure you follow that detail. Brief case logs should include basic patient signalment, history, diagnosis, treatment and most importantly, the skills from your list that you perform or assisted with. The number of brief case logs required varies, but average around 40–50 acceptable cases. You can usually submit extras to make sure you have enough in case any are declined. There is usually a limit, but it is pretty high, often about 75 cases. The second requirement is detailed case logs, which should be chosen from your compilation of brief case logs. The number required vary from 3–5 detailed cases and usually also have character limits—such as 1,500-3,000 words or 15,000 characters. There are rarely minimums but keep in mind that if your report is too short, you probably have not adequately demonstrated your skill set. When possible, pick cases that vary and highlight a variety of skills. Again, follow the required format, font, type size, margins and present the case information so that it flows nicely for the reader and accurately presents the case from presentation to the end. When writing the detailed case logs, you want to do more than just report the facts—you want to display your understanding of the complexities of the case. Of course, all case reports need to be original work. For any part of your application, the review committee may check your sources to verify information. Include details like bloodwork values, drug dosages and units, etc., when creating the detailed case reports. All abbreviations you use should be spelled out
• Present yourself as a professional. • That means your letter of intent should be a formal business letter sent as an attachment. • Find the best people for your references. • Make sure your case histories are also professionally presented. Invest in an American Medical Writers Style book to make sure you use the proper terms and abbreviations. • Follow all directions. • Y our biggest “expense” is your time. Make the most of it.
initially or include an abbreviation reference list. Don’t frustrate the review committee by using unclear abbreviations and short cuts. For example, if you say the patient received IV fluids at maintenance rate, that could mean different things to different individuals so include the specific rate and type of fluids, as well as if you used a gravity dial system or pump. List medications by generic names only. Most importantly, make sure you finish and submit your application on time! I highly recommend asking someone to review your application before submitting. This doesn’t necessarily need to be a professional in the field, sometimes a friend or family member can provide helpful insight, such as catching spelling and grammatical errors and letting you know if the informa-
these websites for information about attaining a specialty.
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tion flows well or something doesn’t make sense. Most academies are now accepting applications electronically, either through Dropbox, Google drive, website upload, or jump drive. The review committee typically takes 2–4 months to review all the applications before letting you know if it has been accepted or not.
If at First You Don’t Succeed
While it is incredibly disappointing to find that you did all that work and your application was not accepted, remember you can try again. If you were declined, be sure to find out details about why you didn’t pass, so you can remedy them. If you were accepted, then it’s time to prepare for the exam during a national conference, such as AAEP, ACVIM, IVECCS, etc. The format for the examinations vary among groups, most are written, a few include a practical portion as well. Exams include true/false and multiple choice questions, and sometimes longer responses. Be prepared for drug dosage and fluid rate calculations as well. The typical exam runs about 2 to 3 hours. Results for the exam can vary from same day for some of the smaller academies, to a month or more for bigger academies that have more exams to review. If you fail an exam, you usually can retake it once or twice more without having to resubmit your entire application. Once you achieve your certification, don’t forget to congratulate yourself! Getting certified is a remarkable achievement. It really is a special accomplishment. MeV
About the Author
Sue Loly, LVT, VTS-EVEN, has a long career as an equine technician. Currently, she teaches veterinary students at the University of Minnesota, College of Veterinary Medicine.
Horses with CMFC Less Likely to Return to Work The prognosis is not great for a horse with chondromalacia of the cranial medial femoral condyle (CMFC), according to a study out of the United Kingdom. The researchers found that CMFC is associated with a decreased likelihood of the horse returning to ridden work after long-term follow up. In this retrospective cohort study, the researchers wanted to document the occurrence and significance of CMFC in adult horses with stifle lameness. They reviewed medical records and arthroscopic surgical videos from horses with unilateral or bilateral lameness localized to the stifle that subsequently underwent arthroscopy of the cranial medial femorotibial joint at a single equine referral hospital between 2009 and 2014. The arthroscopy video recording for each was reviewed by 3 board-certified surgeons for the presence or absence of CMFC. Surgical intervention and post-
operative rehabilitation varied based on the pathology and surgeon preferences. Regular exercise was not resumed for at least 6 months post-surgery. Follow-up information was obtained by talking with owners on the phone, with a satisfactory outcome being defined as a horse being in ridden work without requiring ongoing anti-inflammatory medication. A total of 104 horses were included in the study; 79 (76%) had CMFC, of which 54 had CMFC in combination with other pathology and 25 had CMFC alone, and 25 (24%) had other pathology. At 12 months, 62 (59.6%) horses had a satisfactory outcome. The only variable that showed any significant effect on outcome was CMFC; with horses with CMFC being 9.9 times more likely to have an unsatisfactory outcome at the 12-month follow-up period compared with those without CMFC. MeV
For more information: Croxford AK, Parker RA, Burford JH, et al. Chondromalacia of the cranial medial femoral condyle; its occurrence and association with clinical outcome in a population of adult horses with stifle lameness. Equine Vet J. 2019 Nov (Epub ahead of print). https://beva.onlinelibrary.wiley.com/doi/10.1111/evj.13205
Laser Salpingopharyngostomy Useful for Clinical Guttural Pouch Disease Laser salpingopharyngostomy into the guttural pouch may be useful in clinical cases of guttural pouch disease where alteration of the environment may be beneficial, according to a recent study. Six adult Standardbred horses free from endoscopic evidence of guttural pouch abnormalities were included in the study. A stab incision was made ventral to the sternocephalicus tendon and a customized trocar inserted into the into the floor of the right medial guttural pouch compartment under standing sedation. Baseline (Day 0) temperature, humidity, oxygen (O2) and carbon dioxide (CO2) levels were recorded. A 2 cm x 2 cm salpingopharyngostomy was created into the dorsocaudal pharynx abaxially off midline into the floor of the right medial guttural pouch compartment. The gut-
tural pouch environment was re-evaluated at 7 and 14 days post-operatively. All horses underwent upper respiratory tract and guttural pouch examination by endoscopy at 3 and 12 months after sampling was completed. The guttural pouch environment was altered by the laser salpingopharyngostomy, with considerable variation among horses and during the sampling period. The level of CO2 post laser salpingopharyngostomy appeared to be linked directly to the horse's respiratory pattern, and the variation in CO2 was significantly different at Days 7 and 14 post laser salpingopharyngostomy compared to baseline levels. O2 levels were also more varied during sampling compared with baseline. There was no change in humidity or temperature during the study. MeV
For more information: Jukic CC, Cowling NR, Perkins, NR, et al. Evaluation of the effect of laser salpingopharyngostomy on the guttural pouch environment in horses. Equine Vet J. 2019 Dec 10 (Epub ahead of print). ModernEquineVet.com | Issue 1/2020
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