Equine Vet www.modernequinevet.com
Vol 9 Issue 10 2019
Endoscopy for Stallions Ask the Nutritionist? Feeding Stallions During Breeding Season Sedation and Anesthesia for Equine Dentistry Bistoury Hook Surgery for Epiglottic Entrapment Technician Update: Practicing in Qatar
NEW FEATURE: ASK THE NUTRITIONIST? YOUR NUTRITION QUESTIONS ANSWERED
TABLE OF CONTENTS
4 Using Endoscopy to Evaluate a
Stallion with Reproductive Issues Cover photo: Shutterstock/Osetrik
ASK THE NUTRITIONIST?
What are Some Nutritional Considerations for Stallions During Breeding Season?............................................................................................................... 3 DENTISTRY
Quiet and Still: Sedation and Anesthesia Techniques for Dentistry............................... 8 SURGERY
Bistoury Hook Surgery..........................................................................................12 TECHNICIAN UPDATE
Qatar–Raising the Bar in Veterinary Medicine..............................................19 MEV INTERVIEW
A Conversation With Dr. John Madigan............................................................17 NEWS
Something in the Way You Move Me.............................................................23 ADVERTISERS Purina Sponsored Content.........................................3 Merck Animal Health..................................................5 AVMA | PLIT....................................................................7 American Regent Animal Health/Adequan...........9 Shanks Veterinary Equipment................................10
Standlee Premium Western Forage.......................11 Heska............................................................................13 American Regent Animal Health/BetaVet...........15 AAEVT............................................................................19
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 10/2019 | ModernEquineVet.com
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SPECIAL ADVERTISING SECTION
DR. ROBERT JACOBS, PHD, EQUINE TECHNICAL INNOVATION MANAGER, 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 the Editor. For clinics looking for specific nutritional advice, visit purinamills.com/ask-an-expert.
What are some nutritional considerations for stallions during breeding season? A stallion’s nutritional needs are similar to other adult active horses, with consideration given to the increased requirements specifically related to breeding. A stallion actively competing, performing or training has elevated nutritional needs, which should be met while also accounting for incremental nutrition needed for breeding. The level of breeding activity will dictate nutritional modifications. Consider the number of mares booked, the number of collections per day and the method of semen collection. A highly active breeding stallion being collected three times per week could have 1.5 times the dietary energy requirements compared with a stallion that is only breeding a single mare per week. Similar trends hold true for other nutrients like protein, vitamins and minerals. Each stallion should be assigned a body condition score (BCS) before, during and after breeding season to monitor nutritional status. For most stallions, a BCS between 5 and 6 on a 9-point scale is ideal. Stallions with a lower BCS have been reported to have lower semen quality, while stallions at a higher BCS have
shown decreased libido or inability to mount the phantom or mare. Many diets can support a stallion’s nutritional needs. Start with good quality forage fed at a minimum of 2.0% body weight per day, and complement with a quality concentrate feed formulated to meet the needs of breeding stallions (check the label), like Purina® Strategy® GX, Omolene® 200 or Ultium® Competition horse feeds. Semen collection on top of other competition, performance or training can be stressful on a stallion, which may manifest as gastric discomfort. Use of a gastric support supplement, like Purina® Outlast® Supplement, can provide additional support for gastric health. Research on supplementing the stallion’s diet to improve semen quality is limited. Studies have primarily focused on increasing dietary fat or changing fat sources. Dietary additions of marine-derived omega-3 fatty acids, antioxidants and other additives have been explored, but study results vary. Overall, understanding a stallion’s nutritional needs and meeting them with a quality feeding program will help ensure the stallion has the necessary substrates to produce high-quality semen.
ABOUT THE AUTHOR Dr. Robert Jacobs is the Equine Technical Innovation Manager at Purina Animal Nutrition. He is responsible for conducting research aimed at better understanding how nutrition impacts various areas of equine physiology. SPONSORED BY PURINA ANIMAL NUTRITION
ModernEquineVet.com | Issue 10/2019
ENDOSCOPY to Evaluate a Stallion with Reproductive Issues B y
M a r i e
A urethroscopy can be useful
to evaluate a stallion that might be having reproductive issues related to the urethra, according to Charles C. Love, DVM, PhD, DACT, who spoke at the recent BEVA Congress 2019 in Birmingham, U.K. An endoscopy can help diagnose urethritis, seminal vesiculitis, cystitis, hemospermia and urospermia, as well as give the veterinarian a look at the bladder itself, according to Dr. Love, who is a professor in the Department of Large Animal Clinical Services at Texas A&M University, College of Veterinary Medicine in College Station.
Prepping the Stallion
sedate him usually with something like detomidine and butorphanol “to get the penis to drop down just low enough so that we can grab a hold of it and gently pull it down.” They clean up the tip of the penis and the urethral fossa, “which is the site of smegma and those beans that are so prominent in stallions and geldings. We don't want any of that material very close to the urethra where the endoscope is going to be introduced,” said Dr. Love, who also directs the Cytometer Laboratory at Texas A&M. He recommended lubricating the entire endoscope, not just the end. “We obviously don't want to obstruct the visual part of it, but we would want to make sure that the rubber part is lubricated because
M S we're going to be putting that endoscope all the way from the tip of the urethra all the way up to the bladder. And if we don't put lube on that, it can be a source of irritation to the urethra,” he said. It’s important to recognize the appearance of a normal urethra to avoid over diagnosing conditions like urethritis, he said. The normal distal urethra is a homogenous red looking structure. As one progresses up the urethra, it has a more clearly vascularized, linear appearance with wider paler areas in the middle of it; the proximal urethra has a lot of vasculature. The seminal colliculus can be seen from this vantage point, as well as the bladder sphincter. Although Dr. Love included
Photos courtesy of Dr. Charles C. Love
To prepare the stallion, Dr. Love’s team will put him in the stocks and
R o s e n t h a l ,
Distal urethra (normal)
Issue 10/2019 | ModernEquineVet.com
Middle urethra (normal)
Proximal urethra with seminal colliculus, bulbourethral gland openings, and urethral gland openings (normal)
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Photos courtesy of Dr. Charles C. Love
Urethritis with fibrin and inflammation
Cystitis showing ulceration and sediment attached to the bladder surface
urethritis as one of the conditions that can be diagnosed with an endoscope, he said it is rare. “Quite a few years ago, it was a fairly common diagnosis, at least in the United States.” One reason may have been because the normal patterns seen by endoscopy were misdiagnosed as urethritis. “So a stallion may have been presented for an unknown cause of subfertility or maybe a little blood in the ejaculate, and they decided to scope the horse, and they saw the normal patterns of the urethra but mistook it for inflammation.” It does occur, but it tends to be
caused by caustic solutions that inadvertently are put into the urethra, which is why it is so important to make sure that any cleaning solutions are removed before inserting the scope (see box). Rough endoscope handling can also cause urethritis, so try to avoid repeated scoping in a short period “You can’t just run the scope up and down a lot of times,” he said. “It’s a traumatic event. So, be cautious.” With urethritis, there will be fibrin, and the urethra has a very angry appearance. “A bladder stone that roughly
3 Steps to Cleaner Endoscopes Endoscopes can harbor pathogens that could be introduced into the reproductive tract, so it is important to sterilize them before use. “Preparation of the endoscope is critical because it is a potential space to harbor pathogens that we're not interested in introducing into the reproductive tract at all,” explained Charles C. Love, DVM, PhD, DACT, at Texas A&M University, College of Veterinary Medicine in College Station. “These endoscopes get used for many different reasons, such as passing into the lungs, into the stomach, a lot of normally highly infected areas, and we want to make sure that we don't invade an area such as the uterus or the urethra, which is normally a sterile environment. We don’t want to actually introduce a problem that may not have been there prior to our procedure itself,” he warned. He said that sometimes we forget about the flush fluid container, which is used to pass water over the visual surface at the endoscope to unclog it from things like fogging or mucus accumulation. “We want to make sure that this too is decontaminated and as close to sterile as we can get,” he said.
Soak the entire endoscope completely in an enzyme solution.
Scrub the ports with a brush and rinse them with alcohol, because those dark, moist areas can harbor some bad bugs like Pseudomonas.
Issue 10/2019 | ModernEquineVet.com
Rinse everything with sterile water.
rolls down the urethra can have a traumatic effect on the mucosa and that can be caused by cystitis as well. But in general, urethritis is a fairly uncommon cause of pathology in the stallion,” he said. Seminal vesiculitis also might be over diagnosed, according to Dr. Love. “And the reason for that is that often stallions are presented for fairly nonspecific cause of subfertility, and an immediate response may be to culture the stallion, and if something grows, which it commonly does, the animal is going to be put on antibiotics for a prolonged time. “This can have economic consequences, especially during breeding season, because often breeding will be discontinued until the 'infection' is cleared. “The correct diagnosis is really important. We like to see the presence of inflammatory cells or neutrophils in the ejaculate itself,” he said, before diagnosing seminal vesiculitis. “I think that it is important to have a positive culture, not just one or two colonies of a pathogen, but have a moderate to heavy growth of a particular pathogen. And probably the most common are going to be the usual ones, Streptococcus, Pseudomonas aeruginosa or Klebsiella pneumoniae.” An ultrasonography may show a thickened wall of the seminal vesicle. Prostatitis is rare in the stallion. To visualize the bladder with the endoscope, gently push through the bladder sphincter, but be careful, he warned. “One thing I'd caution you about as you do this whole procedure is to be aware of the air supply that you have and your endoscope. Make sure you don't put in a high pressure air supply of CO2 or air, because during this whole procedure you're going to constantly be gently tapping the air pressure to open up the urethra so you can see it.
“If you have a high pressure source of air, that air can only go one place. It doesn't come back out because you've got a firm grip on the end of the penis and the only place it's going to go is into the bladder. You want to make sure that you don't end up rupturing the bladder,” Dr. Love said. Most often, urine has to be removed from the bladder so that the surface can be seen. Blood in the urine may come from the kidney, and it can be sporadic. The cause can be difficult to ascertain, he said. “It's usually not life threatening, and the cause many times is unclear. But that's one thing you could look for when you're evaluating the ureters. You can evaluate the patency of the urethra opening.” The bladder sphincter can be
dysfunctional allowing urine to dribble out of the bladder as the horse is at rest and may also result in urospermia. The bladder muscle can also be dysfunctional, and a horse might not be able to empty his bladder (atony). This might lead to a thickening of the bladder wall on ultrasound and a fairly thick, dark sediment in the bladder. “If you evaluate these areas in the bladder with the endoscope, it can be fairly diagnostic. You'll see a very red surface that has ulcerations in it as well as thick mucus concretions stuck to the surface of the bladder. And so it's a fairly straightforward diagnosis,” he said. If the bladder doesn’t evacuate fully, that sediment is going to be retained instead of being pushed
out with a complete evacuation every time the stallion urinates. So the veterinarian will see an increase in sediment, which here can lead to cystitis. Sometimes the cystitis is associated with pathogenic bacteria. Sometime they're relatively sterile conditions or they may have nonpathogenic bacteria that have colonized the bladder due to the sediment retention and inflammation. Treatment for these conditions are quite difficult, according to Dr. Love, who recommended flushing the bladder frequently to remove the sediment, as well as determine if medications to enhance bladder evacuation are effective. The horse can also develop calculi or bladder stones, but these will be fairly obvious either on ultrasound or endoscopy. MeV
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QuietSedation andand Anesthesia Still: Techniques for Dentistry
Sedation and local anesthesia go hand in hand in equine dentistry. “It is absolutely evident that
Images courtesy of Dr. Andy Fiske-Jackson
local anesthesia is vital,” said Andy Fiske-Jackson, BVSc, MVetMed, FHEA, DECVS, MRCVS, at the 2019 BEVA Congress in Birmingham, U.K. “You can’t sedate a horse
Providing sedation and anesthesia before dentistry.
Issue 10/2019 | ModernEquineVet.com
P a u l
B a s i l i o
to the point where it can no longer feel pain” However, a reaction can be reduced greatly with sedation. “Ethically, we should not be subjecting horses to painful stimuli,” he said. While there is a relatively small number of drug classes to choose from for everyday sedation and anesthesia, it can be useful to try new combinations and techniques, he suggested. “I think we can all get stuck in a routine—we use this one thing and then we use it forever,” said Dr. Fiske-Jackson, who is a senior lec-
turer in Equine Surgery at the Royal Veterinary College in the United Kingdom.
The ideal drugs for sedation will be reliable, reversible if possible, and predictable in onset and duration. Combinations are typically more effective than either sedative alone. Acepromazine While it’s rarely sufficient for sedation on its own, acepromazine is a useful drug to have on board. It provides mild-to-moderate se-
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
dation, a background anxiolytic effect, and a long duration of action. Food does not need to be withheld, which is another plus. Acepromazine does have a reputation for priapism and paraphimosis. Although Dr. Fiske-Jackson noted that the risk is small, he said that use of the drug would be difficult to defend if these adverse events did occur in a breeding stallion. One important point is that increasing the dose only increases the duration of the effect, not the intensity. “Equally, topping it up during the procedures is not useful,” he said. The alpha-2s The three most common alpha-2 agonists are xylazine, detomidine and romifidine. “I find that when sedating for different procedures, such as scintigraphy, CT, dentistry, etc., some of these
drugs seem to appear more effective in one horse versus another,” Dr. Fiske-Jackson said. “If you’re finding that you constantly have to give a lot of detomidine, for example, it may be worthwhile switching to xylazine or romifidine.” The drugs are reliable and have a quick onset, but Dr. Fiske-Jackson cautioned that it is important to allow time for the peak effect. “The peak effect will take a few minutes,” he said. “Do let that time elapse. It’s always tempting when you top it off during an extraction to get cracking, but it is definitely worth letting the drug take effect before proceeding.” In addition, horses that appear to be heavily sedated can still kick and injure staff. He warned that a sedated horse should not be misread as a “safe” horse. Alpha-2s can also cause sweating and polyuria. While mostly an annoyance for dental procedures, the horse may object to their urine splashing off of the hard floor. Placing a bucket under the horse to catch the urine can help to keep it relaxed while under sedation. Opioids Opioids have a synergistic effect with alpha-2 agonists— the addition of opioids can allow for up to a 50% reduction of the alpha-2 dose. Cons include excitement, head shaking, pacing and gastrointestinal hypomotility. Butorphanol is typically the go-to drug, with morphine often used as an alterative. “The drug I’ve been particularly impressed with recently is methadone,” Dr. Fisk-Jackson said. “I have used it in horses that have sedated poorly [with butorphanol] for something like a CT scan, and I’ve gotten a good level of sedation. It’s a controlled drug, but worth considering.”
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Issue 10/2019 | ModernEquineVet.com
There is no substitute for a good nerve block in equine dentistry. “Do not try to just sedate them more,” he said. “It will not work. The infraorbital nerve block is a particularly useful block that will desensitize the upper incisors, canines, wolf teeth and upper 06s. Dr. Fiske-Jackson recommends using a 21-gauge, 40mm needle, and starting with a bleb as the horse can react sharply, once this has taken effect” You can insert the needle and get the local anesthetic into the ventral aspect of the canal; it will move caudally in the confines of the infraorbital canal and remove sensation to the rostral cheek tooth,” he said. “However, if I am extracting a rostral cheek tooth, I will usually use maxillary block to make sure [it’s desensitized].” Continued on page 14
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Hook! Bistoury hook
The study assessed the racing performance of 32 horses in Sin-
A d a m
M a r c u s
gapore that underwent surgical correction of epiglottic entrapment using a curved bistoury hook between 2012 and 2013. The researchers evaluated the animals’ racing finishes before and after the procedure, and compared them with those for a group of untreated, but healthy, horses. Most of the treated horses were geldings (25). The researchers found that correcting the epiglottic entrapment significantly improved the animal’s racing performance. “One horse did win [a race] with the condition present, but
Images courtesy of Dr. Daniel J. Shaw.
surgery to repair epiglottic entrapment don’t lose a step on animals that have never had the throat problem, researchers have found. A new study by equine veterinarians in Asia showed that horses that undergo surgical correction of epiglottic entrapment using a curved bistoury hook race faster than before the procedure—and just as fast, if not faster, than horses without a history of the condition. The surgery is brief and generally safe, although it requires general anesthesia, according to the researchers.
Images courtesy of Dr. Daniel J. Shaw.
Horses that undergo minor
Bistoury Hook Surgery for Epiglottic Entrapment Improves Race Performance
Issue 10/2019 | ModernEquineVet.com
Immediately post-surgery. The granulation tissue is common but normally resolves.
In tra ora
LD WOR ’S FI
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Imaging the Possibilities
overall horses racing with epiglottic entrapment perform very poorly. Once the surgery is done, they have normal racing careers,” said Daniel J. Shaw, BVSc, MRCVS, Cert AVP(ES-O), MSc, an equine veterinarian at the Singapore Turf Club Veterinary Hospital, who led the research. The bistoury hook procedure is widely available and relatively simple, Dr. Shaw added, and most horses return to work in a few days.
Upper respiratory endoscopy is the current gold standard for diagnosing epiglottic entrapment. “These horses can make a respiratory noise, but it can also be an incidental finding,” Dr. Shaw told Modern Equine Vet. “The purpose of the paper is to help vets and owners make an informed decision on what to do once the condition is diagnosed, especially in asymptomatic horses. “The main complications can be some granulation tissue ob-
served at the site of the transection on follow-up endoscopy,” Dr. Shaw said. “This normally resolves. In some horses the condition will recur and a second surgery is required.” In the future, Dr. Shaw predicted, more clinics will invest in laser equipment to do the procedure standing—as the Singapore Turf Club recently did—avoiding the risk of a general anesthesia. The results should be the same, he said. MeV
For more information: Shaw DJ, Rosanowski SM. Race-day performance of horses with epiglottic entrapment, and following surgical correction using intra-oral curved bistoury hook in anaesthetised horses. Vet J. 2019;250(8):24-27 DOI: 10.1016/j.tvjl.2019.06.003 https://www.sciencedirect.com/science/article/pii/S1090023319300644
Quiet and Still: Sedation and Anesthesia Techniques for Dentistry continued from page 10 Maxillary Nerve Block
The mental nerve
This is a deep one, so aseptic preparation and a bleb are critical. “I had one horse develop an abscess there, and it was not a pleasant experience,” he added. The block desensitizes the maxillary teeth and lining of the maxillary sinuses. There are several approaches to this nerve block, starting with the caudolateral approach. “You’re looking to find the region just below the lateral canthus,” Dr. Fiske-Jackson said. “You can feel the zygomatic process, and place your local anesthetic below that. You can also place your needle a little further back and direct it caudorostrally until you hit bone.” There is a risk of striking the maxillary artery or vein, resulting in a hematoma and swelling of the supraorbital fossa. It’s not a desirable outcome, but it usually resolves in 24 or 48 hours. A 20-gauge, 9-cm needle should be satisfactory. The lateral approach involves going just below the lateral canthus and directing the needle perpendicularly rather than rostrally, but it does come with a slightly greater risk of arteriopuncture.
the lower incisors, canines and wolf teeth.
Issue 10/2019 | ModernEquineVet.com
Mental Nerve Block
The mental nerve block desensitizes the lower incisors, canines and wolf teeth. The nerve sits in the space just rostral to the 06s of the lower arcade. "Under the depressor labii inferioris muscle,” Dr. Fiske-Jackson said, “I’ll put the bleb in first. Bending the needle can be useful to get the anesthetic up the foramen.”
Mandibular Nerve Block
The mandibular (inferior alveolar) nerve block will take care of the mandibular teeth. An aseptic prep is recommended. There are several approaches, but Dr. Fiske-Jackson tends to use the ventral approach. “I can feel the abaxial margin of the upper cheek teeth and follow it caudally on the outside of the face,” he said. “I will also look for the temporomandibular joint. I normally go into the junction between where the curved part of the ventral aspect of the mandible hits the horizontal part, and I will direct the needle on the axial aspect of the mandible to a point halfway between the lateral canthus of the eye and the temporomandibular joint. I’ll draw a little line, measure the needle, and walk it up with a bevel pointed out so it doesn’t the periosteum.” MeV
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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.
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5/17/2019 9:15:15 AM
A Conversation With Dr. John Madigan
All images courtesy of UC Davis School of Veterinary Medicine
John Madigan, DVM, MS, MeV: UC Davis is known for being DACVIM, DACAW, is a distinat the forefront of equine veterinary guished professor of medicine medicine. What are some of the proband epidemiology at the UC Dalems you and your colleagues are tryvis School of Veterinary Mediing to solve at the moment? cine, a clinician in equine mediDr. Madigan: One area I am focused on cine at the Veterinary Medical is the transition of consciousness at Teaching Hospital, and co-leader birth. We determined that foals with of the Comparative Neurology the condition known as the “dummy Research Group at UC Davis. foal syndrome,” have a persistence Caring for animals and improvof the hormones which keep them ing their lives has been his life’s work, asleep in the womb. These hormones and he has made many groundthen act on the brain after the foal is breaking discoveries and inventions born and prevent normal behavior that have helped him with this goal, such as bonding with the mare and including the Madigan Foal Squeeze nursing. We are looking comparaProcedure for neonatal maladjusttively at a possible similar syndrome John Madigan, DVM, MS, DACVIM, DACAW ment syndrome, which occurs in 3% in infants and possible effects of these to 5% of live births. hormones on neurodevelopment. He has responded to numerous floods, fires and Dr. Monica Aleman, in the Equine and Comparative other disasters in California and nationally and deNeurology Research Group, is working on many things velops curricula to train first responders in the safe including equine-trigeminal-mediated headshaking, handling of distressed animals and humane animal cervical pain and spinal cord issues of the warmblood rescue. He designed state-of-the-art slings for horses performance horse, epilepsy in horses, sleep disorders in and cattle using the animal’s skeletal system. He has horses, and many more. authored more than 250 articles and proceedings and two textbooks on foal care. MeV: You direct the UC Davis International Animal WelHe was honored to be the recipient of the Amerifare Training Institute (IAWTI), which was launched in can Veterinary Medical Association animal welfare 2008. How have the mission/activities of the program award in 2006 and the UC Davis School of Veterinary evolved over the past decade? And are you seeing any imMedicine Alumni Achievement award in 2007. portant recent shifts?
John Madigan responding after a wild fire in California.
Dr. John Madigan and students feed a horse they found on a search-and-rescue mission in Sonoma County. ModernEquineVet.com | Issue 10/2019
Dr. John Madigan leads horses to safety on a search-and-rescue mission in Sonoma County.
Dr. John Madigan with CalFire.
Dr. Madigan: The IAWTI institute has a focus to bring awareness to our students and veterinarians on important issues of welfare in multiple species. The awareness of the importance of welfare in veterinary medicine has emerged worldwide. The American Veterinary Medical Association recognized the discipline of animal welfare as a specialty just a few years ago, forming the American College of Animal Welfare. I am pleased to be a founding member of that organization. Some of our initial funding and focused area was training first responders and veterinarians in improving the preparedness, response and care and sheltering of animals in disasters and large-scale emergencies. For example, IAWTI brought in Dr. Rick Arthur to speak about welfare issues at Santa Anita Race this summer. MeV: The fires last year in Northern California were a major human disasterâ€”and a veterinary disaster, as well. Can you describe how the work of the IAWTI helped to mitigate the harm to the horses and other animals caught up in the fires? Dr. Madigan: By having a program here for response, we 18
Issue 10/2019 | ModernEquineVet.com
Dr. John Madigan views the Valley Fire.
Dr. John Madigan with Valley Fire cat at VMTHsearch-and-rescue mission in Sonoma County.
were able to respond to a request for mutual aid from the office of emergency services for helping animals. We deployed over a dozen veterinarians and over 30 students over several weeks to assist in the care of animals. Our VMTH received over 40 burned animals and provided treatment at no cost thanks to generous donations. MeV: How should community equine veterinarians best take advantage of the resources of training/research institutions such as UC Davis? Dr. Madigan: We are in the process of creating a mixture of online and hands-on courses leading to certificates of training for veterinary students and veterinarians. Itâ€™s a work in progress. We will be hosting a conference here at UC Davis in the Spring to deliver lectures and wet labs. I am speaking at the American Association of Equine Practitioners on use of the loops in equine practice situations, rescue and emergencies. We have developed a train-the-trainer program and will be graduating students who can teach equine rescue methods upon graduation to horse owners, veterinarians and first responders. MeV
Qatar—Raising the Bar in Veterinary Medicine “I’m moving to the Middle East!” was something I never dreamed I would be telling friends and coworkers, but that’s exactly what I did in January 2018. I’ve always been up for travel and adventure and had a lifelong passion for Arabian horses, so I couldn’t believe I was getting the opportunity to do both. I began doing as much research as I could about Qatar—its people, culture and customs—and attempted to find out more about equine veterinary care in the country. People always ask me, “How did you hear about the opening?” And “How were you able to leave your stateside home and career and move 7,000 miles away?” I saw the nursing position posted on the American Association of Equine Veterinary Technician’s Facebook page. The job description piqued my interest, citing an attractive, tax-free salary, full health and life insurance coverage, annual airfare allowance, stipends for housing and transportation, and 37 paid vacation days per year! At that point in my life, I felt I had reached a plateau and needed a change, both professionally and personally. Over the previous 11 years, I had been serving as a nurse, part-time, at Virginia Tech’s Marion duPont Scott Equine Medical Center in Leesburg, Va. In addition, for 18 years I had been working with many local veterinarians as a registered dental technician, traveling around Virginia and West Virginia. While both roles were rewarding, I wanted to learn more and use my skills in a greater capacity. In my personal life, I was recently divorced and had lost both of my elderly parents, for whom I had been a care-giver. The only things holding me back were the responsibilities of my small farm, which included my four Arabian horses and Australian Cattle dog. With help from relatives, friends, farm-sitters and hires, I was able to leave the animals and farm maintenance in capable hands. I even rented out my home through Airbnb! After applying for the position in Doha, Qatar, in spring of 2017, I was invited to visit the Equine Veterinary Medical Center (EVMC) in July, and interviewed with the then-director, Mats Troedsson,
DVM, PhD, DACT, DECAR. The EVMC was still under construction, but I could see how important the vision was to open a high-caliber facility for the horses of Qatar. The nation is very small, about the size of Connecticut, but is both geographically and politically isolated (thanks to an ongoing blockade from neighboring Gulf countries). The only in-country surgical facility previously available was immensely outdated and lacked the ability to handle modern post-operative care or to tend to critical medical cases. Many farms employ their own veterinarians, but often with limited resources. The EVMC was built on the campus of the Qatar Foundation, next to the world class equestrian facility, Al Shaqab, known best for its Arabian breeding and show horses. It was envisioned as a state-of-the-art complex that could provide needed veterinary services and could also serve as a research and educational facility. I worked in Qatar from January 2018 until August 2019, and I was the first veterinary nurse with a permanent indefinite contract hired at the EVMC. It was exciting and challenging to start from the ground up. I assisted with a range of responsibilities: writing hospital standards of operations; unpacking and organizing equipment, drugs and consumables; and even showing the veterinarians how to install fluid hangers and lines. We had to set up HVMS Equine Veterinary Management Software from the beginning, establishing realistic prices for items that were often purchased at an unreasonable markup,
Image courtesy of Amanda Compton
By Amanda Compton, EDT, LVT
The group photo consists of vet assistants and techs, from left to right, Jayson Chubang, Asim Shaikh, myself, Courtney Ziegler, Chantal Dube, Sophie Sigrun, Mohammed Iftikar, Andrea Shepley and Arshad Ali. ModernEquineVet.com | Issue 10/2019
Image courtesy of Amanda Compton
EVMC nurses Amanda Compton, EDT, LVT, and Andrea Shepley, LVT, IAED/C
Ms. Comptom feeding the foal.
Even though the care at EVMC could increase their horses’ prognoses, owners in Qatar are not used to paying for equine care.
due to the lengthy procurement process and importation from suppliers. Unbelievably, equine veterinary services—both emergency and elective—had been provided free from the only other facility available to horse owners. Having to pay for procedures, diagnostics and treatment was a new concept for the equine clientele, even though the EVMC— with a more modern facility and trained staff—could increase the chance for a more favorable outcome for patients. Client communication and education were paramount in changing the status quo and justifying the charges for services rendered. We had multiple training sessions of staff for all the new equipment installed in the hospital: new anesthesia machines, digital radiography (both portable and ceiling-mounted), ultrasonography, 3-Tesla magnetic resonance imaging, 20
Issue 10/2019 | ModernEquineVet.com
128-slice computed tomography and MIE scintigraphy units. Using the latest cutting-edge equipment was often new to some of the technicians and veterinarians, who had no experience using it at their previous practices. The images were amazing and of great value diagnostically, even if we were constantly working with the computer folks to address glitches in the systems and the ability to send to the picture archiving and communication (PACS) system. Many of the support staff had never worked in the veterinary profession. I taught common equine terminology and explained veterinary procedures as well as the importance of understanding and recording data in the patients’ medical records. Language was a big barrier, but fortunately we had staff members who could not only speak English, but Arabic and Hindi. I joke I can speak English and bro-
Because of the desert heat, trailering horses to the hospital usually meant they were very sweaty with raised vitals on arrival.
ken English very well now! Our front desk translator would spend countless hours explaining verbal and written discharge instructions from the doctors. Grooms and nursing assistants, both in the hospital and on the farms, usually hailed from India and were indispensable, hardworking men who always offered their assistance with the horses. Many of them had left their home country to better provide for their families by taking jobs—sometimes for decades—in Qatar. The extreme heat of the desert environment means that the busy season runs November through March, when the average temperature is 78˚F. Summer temps can reach 130˚ F with up to 90% humidity. Qatar has a thriving equestrian scene, which includes flat racing for Arabians and Thoroughbreds, jumping, dressage, and endurance and involves a very large number of Arabian show and breeding horses. Many farms have air-conditioned stables but trailering the horses to the hospital usually meant they would arrive very sweaty with raised vitals. Surprisingly, I didn’t see an abundance of exertional rhabdomyolysis. Sand colics were treated commonly at the hospital though, and we routinely did abdominal radiographs on any patient with a history of reoccurring colic or diarrhea. Turnout time is limited for many horses, which could be a factor in the number of chronic and severely acute cases of laminitis and other maladies. The veterinarians routinely see sports medicine and lameness cases. Good nutrition is an area that needs more attention to help prevent issues and address others, but again can be limited by the availability of feeds and hay imported to the country. I created the dentistry program for the EVMC and worked with local veterinarians at Al Shaqab and other farms. There is a dire need for quality, modern dentistry in Qatar and 95% of the horses seen had dental abnormalities. The limited turnout and grazing affected the balance on both incisors and cheek teeth of the horses we examined. In addition, the Arabians often had a higher prevalence of caudal hooks due to the breeding practices which valued an extremely dished face. The internal medicine service quickly became swamped with critical neonates during foaling sea22
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son, with some farms foaling out as many as 200 mares a year. The EVMC’s ICU, along with the separate isolation unit, were instrumental in treating cases, such as failure of passive transfer, hypoxic ischemic encephalopathy, prematurity, dysmaturity, diarrhea, sepsis and juvenile idiopathic seizure disorder in Arabians. We provided 24-hour care, monitoring, fluids, treatments, etc.—practices which helped save the lives of many foals. Biosecurity and disease surveillance are both areas the EVMC is hoping to improve for the country. Statistics are difficult to find on many equine diseases, due to the lack of reporting and record keeping. We began doing peripheral blood smears on many of the horses seen by the hospital for piroplasmosis and found a surprising infection rate. The laboratory—although expensively equipped—could be limited in providing results back to the doctors. Proper sanitation of stalls, equipment and handling of potentially infectious patients had to be taught to the grooms and assistants working in the hospital and helping on local farms. Many of the materials and methods commonly known in equine veterinary hospitals in the United States were new to the people with whom we were working. Despite many challenges, I felt that I contributed a wealth of knowledge and experience to the EVMC, to the people, and the horses while I was in Qatar. It was a phenomenal cultural experience, where I made many new friends from all over the globe, all of us brought to the desert together by a common passion for horses and veterinary medicine. I am thankful for those veterinarians and technicians who encouraged me to go, and those who supported me while I was there! I hope to return in the future, or as they would say, “Inshallah!” MeV
About the Author
Amanda Compton, EDT, LVT, is currently selfemployed and manages Amanda Compton Equine Dentistry, LLC, coordinating with multiple veterinarians & practices. After being in Qatar, she is back on her Virginia farm with her four Arabian horses, two rescued Salukis, and one Australian Cattle Dog.
Current research shows that equine gait analysis has many practical applications beyond lameness assessment—to help support and improve equine health and performance. The Equine Veterinary Journal is providing a virtual issue this month about the latest information on equine locomotion. A special focus section on biomechanics is also planned for publication in November and most of the papers will be free. Gait evaluation now involves more than subjective assessment by eye. Quantitative gait analysis involves the use of electronic sensors, enabling the assignment of numerical values to motion, with the application of kinetics and kinematics. “We have now reached a stage in which technical developments have permitted the introduction of userfriendly quantitative gait analysis techniques in clinical practice,” said Paul René van Weeren, PhD, of the Utrecht University, who jointly edited the collections with Dr. Constanza Gómez Álvarez, DVM, MRCVS, PhD, FHEA, CVA, CCRT, of the University of Surrey. “Accuracy and reliability of these techniques have increased to improve our performance in the assessment and monitoring of equine locomotor performance. However, these developments also urge us to reconsider our position as clinicians and pose new challenges in terms of interpretation of the data that are generated he said. Practical uses of quantitative gait analysis is a substantial collection of 15 of the latest research papers on gait analysis. This virtual issue will be free until Oct. 4, 2020. Among the issues explored are: • Combined influence of expertise and fatigue on riding strategy during endurance races · Head and pelvic movement asymmetry during lunging · Determination of vertebral range-of-motion using inertial measurement units in 27 Franches-Montagnes stallions · Evaluation of a wireless activity monitoring system to quantify locomotor activity in horses in experimental settings · Objective assessment of gait in xylazine-induced ataxic horses · Validation of distal limb mounted inertial measurement sensors for stride detection in Warm-
Credit Drs. Constanza Gómez Álvarez and Professor René van Weeren
Something in the Way You Move
blood horses in walk and trot · Does ‘hacking’ surface type affect equine forelimb foot placement, movement symmetry or hoof impact deceleration? · A simple method for equine kinematic gait event detection · Head, withers and pelvic movement asymmetry and their relative timing in trot in racing Thoroughbreds in training · Kinematic discrimination of ataxia in horses facilitated by blindfolding · Quantification of the effect of instrumentation error in objective gait assessment in the horse on hind limb symmetry parameters · Repeatability of gait analysis measurements in Thoroughbreds in training “The breadth and substance of this research shows how far we have advanced with equine quantitative gait analysis. It has moved far beyond solely being a tool for objective lameness assessment and continues to develop as an exciting method for the support of equine welfare and performance,” said Celia Marr, BVMS, MVM, PhD, DEIM, DECEIM, FRCVS, an equine specialist at Rossdales Equine Hospital and Diagnostic Center and editorin-chief of EVJ. Dr. Constanza Gómez Álvarez continued: “Today, objective, quantitative gait analysis in the horse has outgrown the laboratory and is infiltrating all horse-related activities,” Dr. Constanza Gómez Álvarez said. MeV
For more information: Gomez Alvarez C, Van Weeren PR (editors). Practical uses of quantitative gait analysis. Equine Vet J. 2019 Oct 4 [Epublished]. https://onlinelibrary.wiley.com/doi/toc/10.1111/(ISSN)2042-3306.Practical_uses_of_quantitative_gait_analysis ModernEquineVet.com | Issue 10/2019
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