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Assessment and management in the foal
Stretch, Stretch Stretchâ€”Treating Muscle Injuries More Severe EIPH Means Less $$$ Technician Update: Phallectomy for Aggressive Squamous Cell Carcinoma
Vol 7 Issue 3 2017
Table of Contents
4 Managing Respiratory Issues in the Foal
Cover photo: Shutterstock/ Marie Charouzova
Rifampicin Penetration Good in the Lungs of Foals......................................................10 infectious disease
Antiinflammatories in EHV-1 Infection May Be Beneficial.........................................11 orthopedic
Stretch, Stretch, Stretch— Identifying and Treating Muscle Injuries...............................12 technician update
Aggressive Treatment for Squamous Cell Carcinoma............................................................16 News
More Severe EIPH Equals Worse Performance, Less $$$................................................ 3 New Start Receives $5,000 ......................................................................................................... 3 Owners Appreciate Convenience...............................................................................................15 Fire and Rescue Pioneer Receives NEF Award ......................................................................15 advertisers Merial.............................................................................. 5 Standlee Premium Western Forage ........................ 7
Merck Animal Health.................................................. 9 AAEVT............................................................................17
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Severe exercise-induced pulmonary hemorrhage (EIPH) negatively affects racing performance, but having less severe disease does not, according to recent research from the College of Veterinary Medicine, School of Veterinary and Life Sciences, Murdoch University in Western Australia. Guy Lester, BVMS, PhD, associate professor in large animal medicine, and his colleagues performed a prospective, observational study aimed to determine whether EIPH was associated with reduced performance in racing Thoroughbreds. They looked at more than 1,500 racehorses competing at three racecourses in Australia between 2012 and 2015. They performed endoscopy between 30 and 120 minutes after the race (3,794 exams in total) then two clinicians blinded to the horse’s identity and racing performance evaluated video recordings of these examinations. Approximately one-third of horses showed Grade 1 hemorrhage, 17% Grade 2, 5% Grade 3 and 1.2% Grade 4. The Grade 4 horses had a lower finishing position, were less likely to finish in the top three positions and earned less than those in the Grade 0 category. They also had a significantly slower average speed over the final 600 m and were more likely to be passed in the final 400 m. When compared with Grade 2 or
Courtesy of the Equine Veterinary Journal
More Severe EIPH Equals Worse Performance, Less $$$
Endoscopic view of the trachea of a Thoroughbred racehorse after exertion.
less, Grade 3 and 4 horses were faster over the early sections of the race, but were significantly slower over the final 600 m, more likely to decelerate over this distance and have a lower finishing position. The findings confirm that high grades of EIPH are significantly associated with poorer performance, but there were no differences in performance in horses with none or lower grades of EIPH. The authors acknowledged that many other factors that may affect individual performance. MeV
For more information: Crispe EJ, Lester GD, Secombe CJ, Perera DI. The association between exercise-induced pulmonary haemorrhage and race-day performance in Thoroughbred racehorses. Equine Vet J. 2017. Feb 17 (Epub ahead of print) http://onlinelibrary.wiley.com/doi/10.1111/evj.12671/full
New Start Receives $5,000 The Zoetis Equine Charity Sweepstakes awarded $5000 to New Start, the Pennsylvania Horsemen's Benevolence and Protective Association (PA HBPA) retired racehorse re-homing program, in Grantville, Pa. on behalf of nominating veterinarian, David Marshall, DVM, who practices at Penn National Race Course. “My responsibility at the racetrack, in part, is to secure the health and welfare of the horses that race here. While the career of a racehorse is limited, racehorses have many valuable years to give following their time at the track. That’s why I nominated New Start," Dr. Marshall said. New Start has helped rehome more than 350 former racehorses over the past three years. The program focuses on placing horses where they will succeed in second careers as show horses, barrel racers, eventers, polo mounts, pleasure horses and more. The Zoetis Equine Charity Sweepstakes was held at the 2016 AAEP Annual Convention in Orlando, Fla. Convention attendees nominated their favorite equine 501(c)(3) charity at the Zoetis booth, and one grand prizewinner was drawn at random following the show. ModernEquineVet.com | Issue 3/2017
Assessing and Managing
Respiratory Issues the
F o al
Courtesy of Dr. Nathan Slovis
One of the most frequent problems facing young foals is respiratory issues, explained Nathan Slovis, DVM, DACVIM, director of the McGee Medical Center at the Hagyard Equine Medical Institute, in Lexington, Ky. When assessing the foal, he suggested, don’t forget to also look at the environment because owners could either be inadvertently spreading B 4
Issue 3/2017 | ModernEquineVet.com
bacteria or viruses, or dust could be aggravating the condition. Use this time as an opportunity to teach owners about good biocontainment and hygiene in the barn, Dr. Slovis suggested. “When I go to the farm and as I do the exam, I wear personal protective equipment. I use gloves,” Dr. Slovis said, and he asks about the farm’s personal protective
measures and hand hygiene. Check the hay for excessive particulate matter, such as dust and mold. An animal with respiratory issues should avoid breathing in a lot of dust. A foal that is trying to recover from pneumonia will have a hard time getting rid of that cough in a dusty environment. In fact, Dr. Slovis recommended turning those animals out as much as possible. “You have to get rid of the dust,” he said. He discussed a case that was having respiratory problems for several weeks. They gave antibiotics, steroids and nebulizer treatments and the horse would do okay, but as soon as the steroids were stopped, he’d start to wheeze again. “I looked in the stall. There was sawdust, and I could smell ammonia,” he said. “It was wintertime, and they didn’t want to turn it out. They would put it on steroids, the horse would get better and then it would get worse again as soon as therapy stopped. He finally convinced the owners after the third round of steroids to turn the horses out 24/7 for a period, even if it snowed. However, he warned, be mindful of the weather—one would not want to put a young foal out in extremely cold temperatures, but a little cold usually won’t hurt a horse.
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Think about the environment when considering what is going inside the animal, he suggested.
The Work Up
The first consideration is whether or not the animal has a contagious disease. Is there just one sick animal or are several ill? The age and breed can give clues about the problem. A congenital condition is likely to show up pretty soon after birth, whereas diseases, such as bacterial pneumonia, are likely to occur from two weeks to four months. Weanlings tend to have upper airway and lower airway Streptococcus or rhinopneumonitis. Certain breeds are also more likely to have genetic issues that could cause respiratory conditions. For instance, Arabian or Quarter horse foals with chronic lung issues could have immunodeficiency syndromes. Both are more likely to have selective immunoglobulin M deficiency, while Thoroughbreds and Standardbreds are more likely to have agammaglobulinemia. If a genetic etiology is suspected, consider having the animal tested. Take a step back and really look at the animal, he suggested. Not just the chest, but also the face. Look at facial symmetry and patency of nares. Is there a discharge? It is not unusual for a foal to have sinus issues or a foreign body. “Keep an open mind when you approach these respiratory cases. It might not just be the lungs; it could be the sinuses,” he said. When auscultating the chest, use a re-
Hyperactive Airway Syndrome The foal might have hyperactive airway syndrome if it is in severe respiratory distress: huffing, puffing for every breath, nostrils flaring and has an abdominal lift. The ultrasonography might show consolidation and broad-based comet tails and inflammation, polyphonic crackles and wheezes that might be unresponsive to antibiotics. The animal is being hyperreactive to viral or bacterial pneumonia. Frequently, there is a lot of inflammation in the respiratory tract and exposure to dust in the barn just triggers more inflammation and a cascade of negative events. They tend to be weanlings, but some are older foals that are still on the mare. “I hit them with steroids and I hit them hard,” said Nathan Slovis, DVM, DACVIM. The goal of treatment is to resolve the compromised oxygen uptake. Use intranasal oxygen and bronchodilators, as well as the steroids to reduce the inflammation, he suggested. And ensure strict environmental controls.
For customer care or to obtain product information, including a Material Safety Data Sheet, call 1-888-6374251 Option 2, then press 1. ®MARQUIS is a registered trademark of Merial. ©2016 Merial, Inc., Duluth, GA. All rights reserved.
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breathing bag or cover the nares with your hands to cause hyperpnea, he suggested. “You don’t need a bag for a rebreathing exam. Put your hand over both nostrils, hold it off for a short period—don’t squeeze the nostrils just put your hand over them. Cup them. No need to squeeze. And after they resist, let go and start listening.” Try to better describe what you hear, he suggested. Don’t just use the term “harsh sounds,” it’s not specific enough. “As veterinarians, we should describe it. Is it polyphonic crackles or wheezes? Polyphonic is audible sound with a wide range of frequency that is characteristic of inflammation affecting the larger and smaller airways. It will sound like music,” he said. Is it tubular, a sign of significant consolidation where the air is only moving in the larger airways (main stem bronchi)? Are there increased bronchovesicular sounds, like rustling leaves in the wind? Bronchial sounds are louder than tubular sounds with a wide range of frequency. Do you hear crackles and wheezes? Crackles usually are associated with mucus or secretions; wheezes signal more bronchoconstriction. Consider all the clinical signs. Coughing, wheezing, respiratory rate, flared nostrils, abnormal breath sounds, discharge and fever are all common in foals with respiratory conditions. Look at the abdomen during inhalation and exhalation. Some veterinarians rely on radiographs, but Dr. Slovis does not find them as helpful as ultrasonography. “I don’t like to do ra-
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diographs too often [for respiratory illnesses] because it can be difficult for practitioners to distinguish the abnormalities.” An ultrasonographic examination can pick up smaller lesions, so one can diagnose the problems earlier. “Once the ultrasonographic lesions are 4 to 5 cm or larger, you can see them readily on a radiograph. Smaller lesions noted on ultrasound may look normal on radiograph,” he explained. He uses a multi-frequency 5.0 or 7.5 MHz linear transrectal transducer. The 7.5 MHz is perfect for the thoracic examination of a foal because it displays a depth of between 4 cm and 12 cm, according to Dr. Slovis. He does not clip the animals, but applies a good bit of alcohol, which provides a good contact surface for the transducer. Scan in a dorsal to ventral plane from the 16th to the third intercostal space, he recommended. To diagnose abnormal, one needs to understand normal, he said. The normal pleural edge of the lung appears as a horizontal line that moves with each breath. If the lung is not moving back and forth, there is consolidation, he said. More extreme pathology will show fibrin and lack of movement.
Courtesy of Dr. Nathan Slovis
Ultrasound image showing consolidation of the foal's lung below the horrizon.
Take pharyngeal or nasal swabs. Transtracheal washes, which collect specimens from the trachea, can be diagnostic if there is a lot of deeper pathology. They require percutaneous or guarded endoscopic sampling, according to Dr. Slovis. When preparing the slide for the lab, do a slide smear: Put the sample on one slide, put the other slide on top and pull it a bit. The leading respiratory cause of morbidity and mortality in foals is pneumonia, and it is often bacterial, although some older foals develop bacterial pneumonia, secondary to a viral infection, such as equine herpesvirus 4. He recommended culture and cytology of the transtracheal
wash if the client can afford it. The cytology can give the veterinarian an idea of what is causing the illness before the culture results come back to better manage these patients. This information can help choose an appropriate antibiotic. Look at the causative agent. The common grampositive agents in foals are Rhodoccus equi and Streptococcus zooepidemicus; common gram-negatives are Actinobacillus equuli and Pasteurella sp. Fungal infections tend to be rare in foals, unless they have a concurrent diarrhea. Before choosing an agent, also look at susceptibility patterns in your area, consider host factors and the pharmacokinetics of the drug. Older foals with an uncomplicated pneumonia can be treated with a narrow-spectrum drug that is active against gram-positives; increase the spectrum if there is no response. If the animal is septic, consider a broadspectrum drug from the get-go. Bronchodilators and antiinflammatory drugs can improve breathing until the antibiotics start to heal the infection. Make sure the environment is managed. Some animals will require pleural drainage to remove exuMeV date and debris, he said.
Biosecurity Barns were not created for biosecurity and hygiene, but the environment is important to keep animals healthy. There tend to be a lot of issues that owners don’t even think about, according to Nathan Slovis, DVM, DACVIM. For instance, are they reusing personal protection equipment, disposable gowns, boots, etc.? That could be a source of contamination to uninfected animals. Hand hygiene is always a problem because barns are not designed for hand washing. He suggested asking owners to tie hand wipes right outside the stall, so people can sanitize their hands before and after they care for a sick animal. What sink are they using to mix drugs? The same sink they clean the mop and dump other things in? There should be a clean sink just for mixing drugs and other activities that should be done in a sterile environment. And it should be cleaned before and after the activity. Do they use the same mop or are they changing mops between healthy and unhealthy animals? Get the owner to do a biosecurity assessment before an outbreak, because after is definitely leaving the barn door open … 8
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Good in the Lungs of Foals
Although rifampicin is used
in young horses, there is a lack of data about its pharmacokinetic and pharmacodynamic properties in foals, so researchers from Germany decided to measure serum concentrations to get a better idea of the drugâ€™s penetration. Werner Siegmund, Dr. Med. Habil, of the department of pharmacology at the University Medicine of Greifswald in Germany, and his colleagues measured serum concentrations in six healthy Warmblood foals at intervals of up to 48 hours following an IV bolus of 10 mg/kg rifampicin. Following a seven-day washout period, foals randomized to groups were treated either with 10 or 20 mg/kg of rifampicin once daily for 10 days. Serum concentrations were measured at intervals up to 24 hours after the last dose. Bronchoalveolar lavage (BAL) was performed on foals 24 hours after the last oral dose. Liquid chromatography tandem-mass spectrometry was used to determine
levels of rifampicin and its active metabolite in plasma, lavage fluid and BAL cells. They found that at all doses tested, plasma concentrations were significantly higher than the minimum inhibitory concentration (MIC) required. The half-lives of rifampicin were significantly lower following oral dosing compared with IV dosing, and there was a significantly longer half-life following the 20 mg/ kg dose compared with the 10 mg/ kg dose. Systemic exposure to rifampicin was greatest with the IV dose, followed by 20 mg/kg and then 10 mg/kg dose. Concentrations of rifampicin in BAL fluid and cells were slightly lower than plasma levels measured at the same time. More research in this area should focus on clinical outcomes for this dosing regimen when combined with a macrolide antibiotic for the treatment of Rhodococcus equi infections, the researchers suggested. MeV
For more information: Berlin S, Kirschbaum A, Spieckermann L, et al. Pharmacological indices and pulmonary distribution of rifampicin after repeated oral administration in healthy foals. Equine Vet J 2017 Feb. 25 (Epub ahead of print). http://onlinelibrary.wiley.com/doi/10.1111/evj.12662/full 10
Issue 3/2017 | ModernEquineVet.com
EHV-1 Infection M ay Be Be n eficial
Pro-active use of anti-inflam-
• The first experiment used immortalized equine carotid artery cells. The degree of infection and subsequent cell lysis was detectable as a plaque, allowing cell infection to be measured by plaque count per well. All five anti-inflammatory drugs resulted in significantly
Courtesy U.S. Department of Agriculture (USDA)
matories in the early stage of equine herpesvirus-1 (EHV-1) might be beneficial, according to a new in vitro study. In this study, researchers from several universities in the United States and Germany set out to determine the effects of several antiinflammatory drugs on endothelial cells infected with EHV-1. They tested acetylsalicylic acid, lidocaine hydrochloride 2%, firocoxib, flunixin meglumine and dexamethasone sodium disphosphate at therapeutic concentrations. Peripheral blood mononuclear (PBM) cells were infected with EHV-1, and three experiments were performed.
a restricted 24-hour period on infected PBM cells alone, brain endothelial cells alone or both together. Lidocaine and firocoxib significantly reduced plaque counts when both types of cells were incubated together. This effect was not seen when only one cell type was infected, with the exception of dexamethasone, which significantly decreased plaque counts in PBM cells.
Snotty nose is a sign of EHV-1.
decreased plaque counts compared with untreated monolayers. • The second used brainderived endothelial cells, which resulted in significant reduction in plaque counts in monolayers treated with lidocaine, firocoxib and dexamethasone. • The third experiment evaluated the effect of the drugs over
These results provide evidence that infection of the central nervous system with EHV-1 appears to occur by contact between PBMC and endothelial cells. Infection of endothelial cells in vitro is reduced by exposure to anti-inflammatory medications, including commonly used nonsteroidal anti-inflammatories. However, more information is needed to determine whether antiinflammatories result in reduced infection rates in clinical cases of disease, the researchers said. MeV
For more information: Goehring LS, Brandes K, Ashton LV, et al. Anti-inflammatory drugs decrease infection of brain endothelial cells with EHV-1 in vitro. Equine Vet J. 2017 Jan 17 (Epub ahead of print). http://onlinelibrary.wiley.com/doi/10.1111/evj.12656/full ModernEquineVet.com | Issue 3/2017
Stretch, Stretch, Stretch—
Identifying and Treating Muscle Injuries Muscle injuries are poorly recognized as a cause of lameness and poor performance in horses, despite the near-constant exposure to predisposing factors such as cold weather, insufficient warm up and fatigue, according to Tracy B y 12
Issue 3/2017 | ModernEquineVet.com
A. Turner, DVM, MS, DACVS, DACVSMR. When injuries are identified, it is important to lay out a comprehensive plan to strengthen the muscle, increase the range-of-motion (ROM), and slowly return the
P a u l
horse back to full activity to avoid the pitfalls of re-injury. Dr. Turner discussed his three rehabilitative goals for muscle injuries at the 62nd Annual AAEP Convention: 1. Improve flexibility and conditioning; 2. Strengthen; and 3. Return to full activity. “Flexibility starts with stretching,” he said. “Start stretching on day one, except in cases of a complete muscle tear or active bleeding.”
B a s i l i o
Courtesy Dr. Tracy A. Turner
Dr. Turner recommended stretching three times weekly, at a minimum, to begin to increase (ROM). “I think horses stretch best while walking in a long and low frame,” he said. “I like to get people in the saddle as soon as possible. The horses tend to be under control with a rider, and it also gets the rider off of your back. The rider just needs to be told that the horse needs to walk.” The movements should not be forced, and the horse should only be allowed to do what it can. Stretching should be limited to what can be tolerated without pain. Dr. Turner prefers to use carrot stretches when possible, noting that the horse will typically work as much as it can to follow the food. Massage is another useful modality to improve flexibility, especially in cases where the goal is to loosen tight muscles. “It’s typically most effective after 48 hours,” said Dr. Turner, owner of Turner Equine Sports Medicine and Surgery in Stillwater, Minn. “You want to prevent scarring by using the kneading motion. There are umpteen different techniques, but the basic goal is to work in the direction of the muscle, not against it. That can induce spasms.”
Gadgets and Gizmos
Therapeutic ultrasonography is often employed in both human and veterinary medicine. The modality has the potential to speed the healing process and decrease pain two ways. First, the absorption of soundwaves into the tissue provides thermal relief. Second, the generation of movement as the soundwaves move through tissues provide a sort of micromassage. “Even when you’re doing an ultrasound [imaging] examination, a horse with a relatively acute
injury will act a little sensitive,” Dr. Turner said. “You’re sending soundwaves through that are moving tissues that may be painful.” Bigger soundwaves, known extracorporeal shockwave therapy, can also reduce pain and speed healing, but the exact physiologic mechanisms are not entirely understood. Electrical stimulation (ie, TENS, functional electrical stimulation, and pulsed electromagnetic field
therapy) causes muscles to contract, and can be a useful strength training, rehabilitative or preventive tool. Benefits include pain relief, improved ROM, reduction of swelling, reduction of scar tissue, re-education of muscle functioning, and a decrease in rehabilitation time. Pulsed electromagnetic field therapy has been used often in bone healing, but it also has some benefit in muscle injuries.
(On page 12) Left pelvic/thigh region of the horse showing increased heat over the left biceps femoris muscle, this is consistent with overuse or strain of this muscle. (Above) A croup from above showing increased heat over the body of both left and right gluteal muscles, this is consistent with gluteal muscle strain. Lower image is a dorsal (front) image of the left stifle showing an abnormal stifle pattern with increased heat over the middle and lateral patellar ligaments, as well as increased heat over the quadriceps just above the patella, this is consistent with quadriceps muscle injury
ModernEquineVet.com | Issue 3/2017
Bodybuilding and Beyond
Strengthening muscles can help avoid re-injury. Dr. Turner explained that ground poles and Cavalettis are some of the easiest ways to do it. “You can do them on the ground or you can do them with someone riding,” he said. “The idea is to get the horse moving again. Gait transitions are also a great way to start building strength. Therapeutic banding and underwater treadmills have also been shown to build strength, but Dr. Turner offered his personal opinion that strength training is best achieved through time in the saddle. Strength training is typically done daily in the early stages. Start slowly by having the horse walk over poles. As the intensity increases, the number of sessions can be reduced to three per week.
Dr. Turner typically prescribes a 60-90 day progressive work schedule, depending on the injury and the horse. Stretching should always be performed before and after exercise. “Muscle injuries are gifts that keep on giving,” he said. “That muscle can tighten back up, so make
Thermal Imaging Thermal imaging detects infrared radiation and produces a pictorial representation of the surface temperature of an object, which can be useful to clue in to an underlying injury. It is a highly accurate imaging modality when combined with a thorough physical examination, but there is interpretation involved. Many people may not understand how to use it. “Thermography is not a tricorder from Star Trek,” Dr. Turner said. “It is not going to magically find stuff for you. It’s not a lameness locator.” In the case of a caudal thigh injury, for example, a thermal imaging of the semitendinosus and semimembranosus muscles of each leg can be performed. If there is a marked difference in heat between legs, an inference of increased circulation and inflammation can be made. “Can you tell for certain that it’s an injury? No,” he explained. “But it gets me to a location where I need to look more closely. Horses will have specific patterns. The idea is to learn the patterns and how they change to give you the clues that you want, but it won’t tell you the nature of the injury.”
sure you maintain that stretch. The contraction of the muscle will change the range of motion.” Returning to full activity is a gradual progression. Dr. Turner typically prescribes a 60-90 day progressive work schedule, depending on the injury and the horse. “I tell my clients that they need to work the horse 6 days a week, and then I’ll give them a day off,” he said. “The work may just be an hour of walking, but they need to get out there and move the horse. Most of the exercise may end up being warm up and stretching.” As the work becomes easier at any gait, Dr. Turner recommended slowly increasing to a slow trot, and then gradually increasing speed and stretching again. “During this time, keep doing anything that you’ve already been doing to help the muscle to keep from contracting again,” he explained. “You have to look at the whole horse, including hoof balance, front and rear. If the horse has lost some muscle, look at the saddle fit. If the horse isn’t happy with it, then that’s a problem.” For horses that have been on stall rest, Dr. Turner typically will not let the horse out in the pasture unless it’s been ridden at cantor for 20 minutes without issues. “When they get turned out, the only thing I can guarantee is that they’ll do something stupid,” he MeV said.
OvaMed New Name for Altresyn Bimeda Inc. recently rebranded altrenogest, a medication used to control estrus, from Altresyn to OvaMed. “The trade name OvaMed more closely aligns with Bimeda’s brand identity and is a key step in the integration of the recently acquired equine products within our portfolio and global brand,” said Emmanuelle Lemaire-Galliot, marketing manager for Bimeda North America. Late last year, Bimeda Inc. acquired the marketing rights to Ceva Animal Health’s portfolio of equine products in the United States, including altrenogest. OvaMed is currently shipping to Bimeda’s distributors to fulfill veterinary orders. 14
Issue 3/2017 | ModernEquineVet.com
Owners Appreciate Convenience A treatment regimen that is convenient is more important than the cost of care to many horse owners, according to a recent survey of owners and veterinarians. Compliance is also important, according to Mark Crisman, DVM, MS, DACVIM, equine technical services veterinarian, Zoetis, which sponsored the survey. In the unpublished study, horse owners were given the choice of two anti-infective treatment regimens: 1. Intramuscular (IM) injection ceftiofur crystalline free acid (Excede, Zoetis) Sterile Solution administered by the veterinarian four days apart; or 2. Oral trimethoprim-sulfonamide (TMS) tablets twice daily for 10 consecutive days given by the client.
Most owners picked two doses of ceftiofur given by the veterinarian over twice-daily TMS for 10 days given by them. Horses were examined on day four to evaluate treatment response, administer the second IM dose to horses being treated with ceftiofur and, in the case of the oral therapy group, to verify compliance with the regimen. The study examined 27 veterinarians from 11 equine practices in various regions of the country, treating a total of 137 horses, Dr. Crisman explained. Overwhelmingly, 93.1% of horse owners selected two doses of ceftiofur over twice-daily oral TMS treatment for 10 days, he said. The average treatment response scores for both anti-infective regimens were comparable at days zero and 10. However, 100% of the horses treated with ceftiofur achieved full treatment compliance compared with 75% of horses treated with oral tablets. There was a wide variation in the veterinarian’s pretreatment cost estimates, with the estimated cost of ceftiofur more than double that of the oral medication. However, the pretreatment estimate differed markedly from the actual costs incurred, he said. The average cost of treatment with ceftiofur was just $20.80 more than the oral treatment. In a posttreatment survey, convenience was judged more important than price in the horse owner’s perception of value, with mean scores of 4.3 versus 3.5, respectively. The item with the greatest score differential
was convenience, where ceftiofur had a near-perfect average score of 4.8 versus 3 for the oral medication. Overall client satisfaction when ceftiofur was selected had a mean score of 4.7, approaching the maximum possible score of 5. Excede is contraindicated in animals with known allergy to ceftiofur or to the beta-lactam group (penicillins and cephalosporins) of antimicrobials. Do not use in horses intended for human consumption. The administration of antimicrobials in horses under conditions of stress may be associated with diarrhea. Click here for full prescribing information. MeV For more information: To learn more about the study or EXCEDE, talk with your Zoetis representative or visit www.EXCEDE.com.
Fire and Rescue Pioneer Receives NEF Award Jim Green, pioneer of equine emergency rescue methodology and training received the Sir Colin Spedding Award at yesterday’s National Equine Forum (NEF) in the United Kingdom. As a member of the Hampshire Fire and Rescue Service, Mr. Green has been at the forefront of response to animal rescues in Hampshire and led the implementation of animal rescue methodology, training and equipment that is now standard throughout the UK Fire and Rescue Service. Mr. Green, together with Josh Slater, BVM&S, PhD, DECEIM, professor of Equine Clinical Studies at the Royal Veterinary College, helped to set up Safer Horse Rescues, an equine rescue initiative, launched by the British Equine Veterinary Association (BEVA) and the UK equine industry in 2007. He is co-founder and codirector of the British Animal Rescue and Trauma Care Association (BARTA). Mr. Green has been keynote speaker at conferences in the U.K., United States, Turkey and Australia, and was rescue advisor to the Veterinary Services Team at the London 2012 Olympic Games. He is spending 12 months in the United States, developing animal rescue and disaster response capabilities, working for the Center for Equine Health at the University of California. Dr. Slater accepted the award on Mr. Green’s behalf. He will deliver the Memorial lecture at the National Equine Forum 2018. ModernEquineVet.com | Issue 3/2017
Aggressive Treatment for Squamous Cell Carcinoma
By Brandi Larsen, CVT
Squamous cell carcinoma (SCC) is all too common in the equine veterinary world. Sometimes it can be treated without surgical intervention, however, this approach is not suitable for all patients affected and more aggressive treatment is needed to improve the quality of life. A 17-year-old paint gelding presented following a routinely scheduled wellness appointment with his regular veterinarian for a rapidly growing mass on his penis. Upon arrival, the mass, which the owner noted had been there for about six months, was extremely large, ulcerated and prevented the patient from retracting his penis completely and comfortably. He was treated multiple times over the previous 6 months by the referring veterinarian by surgically debulking the mass in the field. The veterinarian also submitted a biopsy for histopathology of the mass, which resulted in a confirmed diagnosis of SCC. On presentation, a thorough history of the patient was taken from the owner. She stated that she has owned the horse since he was 2 years old and used him for trail riding. She noted that he had no
Issue 3/2017 | ModernEquineVet.com
history of previous illness or SCC and was current on all vaccinations, deworming and routine dental care. He had no history of injury or steroidal joint injections, and up to this point, he has been relatively healthy and low maintenance. She mentioned that she had observed uncomplicated urination and that the lesions seem to have not affected that function. Following the history, the referral clinician performed a physical examination of the patient, which resulted in an unremarkable conclusion. He had an abundance of unpigmented skin around the eyes, mouth, perineum and genital areas, which is a common predisposer for SCC. The patientâ€™s skin was thoroughly examined and no further evidence of SCC was found. Following the physical examination, the patient was sedated with IV detomidine and butorphanol to promote a more comfortable and safe thorough examination of the SCC lesions present on the penis. Detomidine is the most potent non-narcotic sedative of the alpha-2 agonist drugs and produces profound sedation following administration with some analgesic properties. It may cause bradycardia, cardiac arrhythmias (specifically atrioventricular and sinoatrial block) and tachypnea. Butorphanol is a centrally acting, synthetic, narcotic agonistantagonist analgesic that has the ability to decrease gastrointestinal motility. Following the onset of the IV sedatives, his penis was gently extended for examination. Most of the SCC lesions encompassed the distal one-third of the penis, including a large portion of the glans. The lesions were extremely ulcerated with an abundance of desiccated coagulum, which when even lightly touched, fell away exposing open tissue and further ulceration. The clinician discussed his findings with the owner and offered several options
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the first being the most conservative, which was another attempt at debulking the masses with chemotherapy injections and cryotherapy. He explained that since this has been attempted several times already, and due to the advanced nature of the lesions, it was not likely going to have lasting effects. The next and most promising option was a partial phallectomy (penis amputation) that could be performed without general anesthesia accompanied by multiple cisplatin injections and aggressive cryotherapy. Cisplatin is a platinum-containing chemotherapy drug that produces cross links in deoxyribonucleic acid (DNA). It would be injected with sesame oil intralesionally postoperatively and the patient would need to return for subsequent cisplatin injections every two to three weeks. Following the partial phallectomy, the lesions would be subjected to cryotherapy with liquid nitrogen prior to the cisplatin injections.
Due to the advanced nature of the lesions, another debulking was not likely to have lasting effects. Cryotherapy is the controlled use of liquid nitrogen to freeze and destroy undesirable tissue while causing minimal damage to the surrounding healthy tissue. It is best performed by rapid freezing, slow thawing and a minimum of three freeze cycles. After discussion, the owner decided to go forward with the partial phallectomy, cisplatin injections and cryotherapy, which would be an outpatient procedure barring any procedural complications.
Following the decision to proceed with the partial phallectomy, the surgery technician prepared the surgical area for the procedure by gathering the supplies and equipment needed to perform the procedure and a cryogun was carefully filled with liquid nitrogen in preparation for cryotherapy. Following setup an over the needle IV catheter was placed in the jugular vein, an initial dose of antibiotics and pain management drugs were administered, as well as a tetanus toxoid vaccine. At this time, the initial IV sedation had begun to wear off, and the patient was administered a subsequent dose of detomidine and butorphanol IV, and a 18
Issue 3/2017 | ModernEquineVet.com
dose administered IM for lasting effect. When the patient became sedate, the affected area was aseptically prepared to facilitate local and regional anesthetic nerve blocks. The clinician injected mepivicaine circumferentially around the penis proximal to the incision site. He also decided to anesthetize the pudendal nerves to facilitate urinary catheter placement and retained protrusion of the penis. To perform pudendal nerve blocks, a 1.5 inch by 20 gauge needle is inserted on the left and right sides of the penis where it curves around to the ischium. Angling the needle medially and aiming for a point on the ischium slightly lateral to midline, the needle is advanced until contact is made with the ischium and mepivicaine is injected at each site. Once the block began to take effect, the penis protruded within 5 minutes of local anesthetic injection and a technician used gentle traction to extend the penis and again, aseptically prepare for a urinary catheter. Using sterile technique, a 28 French by 150 cm silicone Foley catheter with a 5 cc balloon was lubricated and gently advanced into the urethral opening and up to the urethral sphincter where mild resistance was met; 30 mL of air and 10 mL of lidocaine 20% was administered to facilitate relaxation of the sphincter, which allowed the gentle passage of the urinary catheter through the urethral sphincter and into the bladder, confirmed by the presence of free flowing urine. Once placement was confirmed, the balloon on the Foley catheter was filled with 5 mL sterile saline to secure it in the bladder. Following placement of the urinary catheter, the area was prepared using sterile technique and gentle downward traction was applied on the penis to extend it as much as possible while the clinician tied a latex penrose drain around the penis proximal to the incision site to reduce intraoperative hemorrhage. He opted to use Vinsotâ€™s Procedure for the partial phallectomy. He began by excising a triangular section of tissue that included the epithelium, bulbospongiosus muscle, and corpora spongiosum penis from the ventral aspect of the penis just proximal to the planned transaction location. The clinician then incised the exposed urethra along its midline from the apex to the base of the triangle. He then sutured the right and left margins of the urethral incision to the epithelial border of the triangle and included the tunica albuginea of the corpora spongiosum penis. He then created a urethral stoma by making an incision into the urethral lumen and suturing the edges of the urethra and the integument while incorporating and compressing the corpora spongiosum penis. The partial phallectomy was completed without hemorrhage or complication.
Following the procedure, the patient was still moderately sedated and relaxed. The clinician then sutured the penile stump by ligating the vessels in the fascia on the dorsal and lateral aspects of the penis proximal to the planned site of transection and removed the diseased portion of the penis distal to the ligatures with a wedge shaped incision. Sutures were placed through the tunica albuginea of each body to compress the corporeal bodies and the penile integument was also sutured in a similar pattern to close the incision. The modified tourniquet was removed with no evidence of hemorrhage and the clinician opted to leave the urinary catheter in place for three days following the procedure to decrease the risk of urine induced, contact dermatitis of the pelvic limbs. Once the tourniquet was removed, cryotherapy was performed on the remaining tissue that contained evidence of mild SCC. Three freeze/thaw sessions were administered, allowing each round to thaw slowly and completely before beginning the next. With the consideration of the local and regional nerve blocks, the patient tolerated cryotherapy well despite the mild state of sedation he was displaying at that point. The final step was the injection of cisplatin in sesame oil to the areas of concern left over from the partial phallectomy. The clinician, who was wearing personal protective equipment, including gloves and safety goggles, due to the toxic nature of this drug, injected it subcutaneously into the remaining portion of the penis, which would be repeated every 2-3 weeks. The patient was put in a stall for recovery and placed on close observation for the next 24 hours. Once he was safely in the hospital stall, the amputated portion of the penis was submitted for histopathology. The patient stood quietly in his stall and his mentation was dull immediately following the procedure. He was not offered any grain or hay to avoid aspiration into his lungs due to the lasting effects of sedation. He was administered a subsequent dose of antibiotics by a night technician and despite an unremarkable physical examination, he was uninterested in hay or grain when offered later. The following morning after surgery, the patient was displaying signs of agitation from the urinary catheter and the clinician decided to remove it to prevent the patient from causing trauma to the area. Mild hemorrhage mixed with urine was observed when the tip of the urinary catheter came out of the urethra, which was an expected mild complication of a partial phallectomy. This hemorrhage is usually originated at the corpora spongiosum penis and may continue for several days at the end of urination.
The patient was returned to his hospital stall and appeared much more comfortable for the remainder of the day, even developing an appetite for alfalfa hay. The patient received routine physical examinations twice daily while hospitalized following surgery, which were all unremarkable. No evidence of infection or fever was seen. He received additional doses of antibiotics and analgesics for his health and comfort. On the fifth day of his hospitalization, he was discharged to his owner and was urinating without complication.
The most promising option was a partial phallectomy with chemotherapy and cryotherapy. Follow up
The patient returned 10 days post operatively for his next injection of cisplatin in sesame oil on the remaining tissue. On examination, the incision had healed well and the gelding had no urinary postoperative complications. The clinician did confirm the original diagnosis of SCC based on the histopathology results sent back from the lab. His physical exam was again within normal limits. Although he had returned for only a cisplatin injection, the remaining lesions were responding so well after the first treatment with cryotherapy, it was decided that a repeat cryotherapy treatment would be beneficial before injecting the cisplatin. The patient continued to improve postoperatively and had no lasting complications from the partial phallectomy procedure. He received a third and final round of cryotherapy and cisplatin injections and was instructed to come back in 6 months for a recheck. His owner was thrilled and the patient had almost zero evidence of SCC at his third appointment. MeV
About the author
randi Larsen, CVT, is an independent B consultant in Weatherford, Texas. She has piloted and implemented custom veterinary training programs in large animal practices in Texas as well as lent her knowledge as a speaker at veterinary conferences nationwide. ModernEquineVet.com | Issue 3/2017
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