Modernequinevet vol2no6

The Modern

Equine Vet www.modernequinevet.com

Vol 2 Issue 6 2013

Punky?

It may be lepto Coming to term ERAV more common than thought Compounding, rabies, Technician Update and more

Table of Contents

Cover story:

4 Punky?

It might be lepto Cover photo by Dhoxax/shutterstock

Reproductive Medicine

Helping horses come to term............................................................. 7 Infectious Diseases

"Common cold" common problem................................................10 technician update

Ali Fernandez: Expect the unexpected.........................................15

News

AVMA: New compounding policies ...............................................9 One health helps for burn victim................................................12 Equine rabies......................................................................................17

Reader Comment Thank you for emailing me The Modern Equine Vet. However, advertisements such as the MRI topic in the last issue should be more clearly identified as ads. Standing MRI's do not replace a high-field magnet exam under general anesthesia for detecting some lesions.

They also rely on well behaved horses who do not move. If the topic is presented as an article the downsides of standing MRI should be discussed along with the benefits. — Dr. M. Lunney Thanks for writing. The article was not a paid advertisement, but it was put together from company materials. — MeV

To contact us, email Marie Rosenthal LEGAL DISCLAIMER: The content in this digital issue is for general informational purposes only. PercyBo Publishing Media LLC makes no representations or warranties of any kind about the completeness, accuracy, timeliness, reliability or suitability of any of the information, including content or advertisements, contained in any of its digital content and expressly disclaims liability of any errors or omissions that may be presented within its content. PercyBo Publishing Media LLC reserves the right to alter or correct any content without any obligations. Furthermore, PercyBo disclaims any and all liability for any direct, indirect, or other damages arising from the use or misuse of the information presented in its digital content. The views expressed in its digital content are those of sources and authors and do not necessarily reflect the opinion or policy of PercyBo. The content is for veterinary professionals. ALL RIGHTS RESERVED. Reproduction in whole or in part without permission is prohibited.

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Issue 6/2013 | ModernEquineVet.com

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Equine Vet

Horse a little punky?

It might be lepto Leptospirosis more prevalent in horses than previously thought.

Dhoxax/shutterstock

Leptospirosis is more com-

mon in horses than previously thought, so it makes sense to keep it in the differential when evaluating a horse that is just a little punky. You just might catch an acute infection before more serious signs of disease occur.

“The dogma was that leptospirosis in horses was less prevalent than in other domestic species.

However, at least in some countries, it is clearly much more common than we thought,” said Ben Adler, PhD, of the Australian Research Council who recently wrote

B 4

a review of the disease with folks from Ross University and the University of Kentucky.

Adler did not know the incidence in the United States, but an analysis of aborting mares in North America published in 2011 found that 20 out of 21 were serovar positive for leptospirosis.

Some countries in Europe and South America that are looking actively for the disease have found a seropositive rate of 50% to 75% in horses.

Unfortunately, early indications of equine leptospirosis infec-

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tion are pretty vague — low-grade fever, listlessness and anorexia — and can signal many different problems.

Differential diagnosis “The acute signs are definitely not unique and could reflect pretty much any febrile illness or any illness with liver or kidney involvement,” said Adler.

More severe forms present with a range of signs, including conjunctival suffusion, jaundice, anemia, petechial hemorrhages on the mucosa and general depression,

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Cover Story

renal failure and spontaneous abortion, according to Adler.

Aborted fetuses will have histopathologic lesions and silverstaining organisms consistent with Leptospira, but the organism has not been recovered in culture from aborted fetuses.

Fortunately, the pulmonary hemorrhages seen in some human leptospirosis infection is not common in horses, according to the article, which was published in Veterinary Microbiology.

Recurrent uveitis or moon blindness is one of the hallmarks of the more severe form of the disease in horses. Experts think that the uveitis is an immune-mediate response to the antigenic cross-

reactivity between proteins in the Leptospira organism and the equine cornea. Although other species can suffer moon blindness, the condition is more common among equids.

PCR vs. Culture

The gold standard for diagnosing leptospirosis is still culture, but PCR also can be used and might be more convenient for treating veterinarians. “Acute infection can be treated with antibiotics,� Adler said.

However, the regimens have been extrapolated from other species without good data in horses.

Common antibiotics used are streptomycin and/or penicillin, al-

Recurrent uveitis or moon blindness Photos courtesy of Dr. Dennis Brooks, http://largeanimal.vethospitals.ufl.edu/services/ophthalmology ModernEquineVet.com | Issue 6/2013

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One of the most striking signs of equine leptospirosis is recurrent uveitis, or moon blindness. The condition is painful and recurrent, according to Dr. Ben Adler, of the Australian Research Council, and is considered an immune mediated disease that is characterized by alternating periods of severe and low inflammation. Researchers believe that there is cross-reactivity between leptospiral and ocular proteins that contribute to the immunopathogenesis.

The ocular manifestations can develop months after a systemic infection. Early signs include miosis, blepharospasm, lacrimation, photophobia, edema of the eyelid and cornea, and swollen conjunctiva. Aqueous flare and hypopyon may also be seen in progressive disease. The repeated bouts of inflammation eventually can lead to cataract, anterior or posterior attachment of the iris, lens luxation, vitreous exudates and retinal detachment.

The best outcome depends on early diagnosis and treatment, which is aimed at reducing the inflammatory response. An intraocular device containing cyclosporine A has been effective.

Recurrent uveitis appears to be an immune-mediate response to the antigenic cross-reactivity between proteins in the Leptospira organism and the equine cornea.

Leptospira are spirochete bacteria, which are characteristically long, helically coiled (spiral-shaped) cells.

though many veterinarians do not give horses streptomycin because of potential toxicities. Tetracycline also can be used.

High doses of penicillin should be given to pregnant mares with

high titers to prevent spontaneous abortion.

No leptospirosis vaccine is indicated for equine use, although some people do use the cattle vaccine off label. However, Adler et al.

recommends against doing so because some of the antigens in the cattle vaccine may actually prime the horses for the development of uveitis and blindness. Adler did recommend vaccinating any animals for which there is a labeled vaccine. “Because there is no equine vaccine, prevention would involve eliminating rodents or reducing their populations as much as possible, and restricting contact with any infected horse, or any other animal species for that matter,� he said.

Good biosecurity is essential to prevent the spread of this infection. Clean up garbage and trash that attract rodents and isolate any infected animals.

MeV

For more information: Verma A, Stevenson B, Adler B. Leptospirosis in horses. Vet Microbiol. 2013 Apr 16. pii: S0378-1135(13)00215-0. doi: 10.1016/j. vetmic.2013.04.012. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/23647816 6

Issue 6/2013 | ModernEquineVet.com

Photos courtesy of Dr. Brooks

Moon blindness

Reproductive Medicine

Helping horses

come to term Immune system might affect birth rate of mares.

For women, the first trimester is the most risky time: many expectant women are reluctant to inform their friends or colleagues that they are pregnant until after this period has passed.

Horses suffer from similar problems, with a considerable number of pregnancies failing to progress beyond the first five weeks. Researchers do not know why the birth rate of horses is low with many pregnancies failing within the first few weeks after conception.

The reason is still unclear but may relate to a problem with the mare’s immune system, according to the latest work in the group of Christine Aurich, DVM, PhD, DECAR, at the University of Veterinary Medicine, Vienna (Vetmeduni) the Center for Artificial Insemination and Embryo Transfer.

The problem might be related to a particular class of blood cells, according to a online paper in the journal Reproduction, Fertility and Development.

The fertilized egg, or conceptus, obviously contains contributions from the mare and the stallion, which means it must avoid being recognized and attacked by the mare’s immune system as for-

eign material. Horse breeders talk about maternal tolerance of the conceptus and horses have a variety of mechanisms to enable fertilization and a successful pregnancy. Maternal tolerance probably depends on wide-ranging changes to the maternal immune response.

But what makes some mares better than others at adapting their immune systems?

There are indications from work in humans and mice that a particular class of immune cell, the so-called regulatory T cells or Tregs (pronounced “tea regs”), might somehow be important in

maternal tolerance. Aurich and her colleagues have now developed a highly sensitive assay to measure the proportion of Tregs in the blood of horses. They used their new technique to investigate more than 100 mares that were presented for artificial insemination, correlating the results with the outcome of the resulting pregnancies.

Of course, not all of the animals conceived. The scientists could find no association between the level of Tregs in the mares’ blood with the success of the insemination procedure. However, they did observe lower numbers of Tregs

Photo courtesy of Christine Aurich, DVM, PhD, DECAR

Self defense?

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in the blood of horses that suffered an early loss of pregnancy compared with those that either aborted much later (for whatever reason) or gave birth to live foals.

The results suggest that high numbers of Tregs might somehow be required to suppress the mare’s natural immune reaction against the conceptus. In other words, low levels of Treg cells in mares might cause pregnancy loss in the five weeks after fertilization.

The differences in the levels of Tregs between horses in the “successful pregnancy” and the “unsuccessful” groups were too small to predict whether an individual mare is likely to suffer early pregnancy failure. Nevertheless, the results may help breeders solve the problem.

There is evidence from human medicine that estradiol

Many reasons have been proposed for early pregnancy failure, but new work suggests that a low level of regulatory T cells (Tregs), might be an important factor.

may enhance the function of Tregs during pregnancy. Treatment with this hormone could

possibly benefit mares prone to losing the conceptus. Another possible course would be to expose mares to the stallion’s semen before implantation, which might increase the number of Tregs in the blood and the animal’s tolerance to the conceptus, thereby, helping to avoid early pregnancy losses.

“A number of reasons have been proposed to account for early pregnancy failure in the horse but our work suggests that a low level of Tregs may actually be among the most important factors. It can only be a matter of time before we find out how to solve the problem,” Aurich said.

The work was undertaken in collaboration with staff at Certagen GmbH in Rheinbach, Germany and at Epiontis GmbH in MeV Berlin, Germany.

For more information: Aurich C, Weber J, Nagel C, et al. Low levels of naturally occurring regulatory T lymphocytes in blood of mares with early pregnancy loss Reproduction, Fertility and Development. http://dx.doi.org/10.1071/RD13012

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newsnotes

AVMA: New policies on drug compounding their office stock of drugs for urgent and The American Veterinary Medical emergent needs.

Association’s (AVMA) executive board The other two policies, which address recently approved three new policies to compounding from bulk unapproved provide guidance on compounding to substances, state that there are certain veterinarians and legislators. circumstances when bulk compounded “These policies are important to our drugs are useful and necessary. The members and the animals they treat policies establish clear differentiation bebecause veterinarians need compounded tween medically necessary compoundpreparations to provide treatments to ing needs in non-food animals from animals when drugs approved by the Food the very limited compounding in food and Drug Administration (FDA) cannot animals. be used,” said Douglas G. Aspros, DVM, Douglas G. Aspros, DVM The FDA and federal courts have president of the AVMA. held that compounding from bulk “Our staff in Washington is meeting unapproved raw active ingredients is with members of Congress to ensure that prohibited under federal drug law. The compounded preparations are available to AVMA’s two new policies on bulk compounding our patients when they need them. These policies will suggest how bulk compounding could be useful for help in that educational process, not only by providing veterinarians: guidance to legislators considering compounding issues • Compounding from Unapproved (Bulk) and legislation, but by informing our members on what Substances in Non-Food Animals states that is currently legal.” compounding from bulk is medically necesCompounded preparations are common in veterisary in certain situations and should be allowed nary practices and include mixing two injectable drugs, when the approved product is not commercially preparing an oral paste or suspension from crushed available (for example, during a drug shortage); tablets, or adding flavoring to a drug to get a patient to when the approved product cannot be used accept the medication. These compounds can be creto make the needed compound (for example, ated at the veterinary practices or through a prescripif the patient is allergic to the FDA-approved tion by a pharmacist. drug); or when there is no approved product from which to compound the needed preparaNon-food vs. food animals tion (for example, cisapride used for megacolon However, there is clear differentiation between therapy in cats). compounding that is medically necessary in non• Compounding from Unapproved (Bulk) food patients and the very limited compounding Substances in Food Animals states that comthat is used in food animal patients. pounding from bulk should be allowed specifiThe executive board passed one new general cally for and limited to euthanasia, depopulapolicy about veterinary compounding and two tion and poison-antidote compounding. If about compounding from bulk unapproved raw adequate scientific information is not available active ingredients. The new, general policy on veterito determine a clearance time it takes for a drug nary compounding advocates for additional uses of to adequately clear an animal’s system, the comcompounded drugs, but offers recommendations for pound cannot be used in a food animal or the compounding in a way that minimizes the risk for treated animal cannot enter the food supply. adverse events.

The new AVMA policies replace previous guidFor example, the new policy recommends alance on compounding.

MeV lowing veterinarians to maintain compounds in

For more information: AVMA policies, please visit http://www.avma.org/KB/Policies/Pages/default.aspx, and for more information about veterinary compounding, visit http://www.avma.org/KB/Resources/Reference/Pages/Compounding.aspx.

ModernEquineVet.com | Issue 6/2013

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Nasal secretions in a horse with ERAV. Photo courtesy of Dr. Viel.

‘Common cold’

common problem in horses Vaccinate to protect horses against equine rhinitis

By Marie Rosenthal, MS

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When researchers started

doing titers to see how much equine influenza there was, they found pretty high titers of rhinoviruses, which cause the common cold in people.

At a prevalence of around 75%, equine rhinitis A and B (ERA, ERB) are more prevalent in horses than anyone thought, according to Laurent Viel, DVM, MSc, PhD, professor of large animal internal medicine at the University of Guelph Ontario Veterinary College in Canada.

“In early 2,000, we were asked to look at respiratory outbreaks in

Canada and let the World Health Organization know when equine influenza appeared,” Viel explained. “People just weren’t vaccinating their horses. But we found not only influenza was prevalent, but so was rhinovirus A. We found that when you challenge a horse, it gets a substantial respiratory infection. Some of these outbreaks that people thought were influenza were actually rhinitis.”

Rhinovirus is a respiratory virus that causes flu-like symptoms in a variety of species, including people and horses.

“It is not a horse-specific vi-

Infectious diseases rus,” explained Nicola Pusterla, DrMedVeT, MedVet, professor of medicine and epidemiology at the University of California, Davis, School of Veterinary Medicine. “But it has been associated with outbreaks of the upper respiratory tract among horses. Infections occur generally in young horses, and there is a very good report from Canada that shows that it is one of the most common respiratory viruses associated with outbreaks at the race tracks.”

Rhinovirus is a fairly “new” virus in horses in that it was only recently recognized as causing substantial disease in equids, because people often attribute the clinical signs to herpesvirus or influenza, Pusterla said.

“You usually don’t die from a rhinitis virus, but it can cause significant respiratory illness,” added Viel. “We just don’t know a lot about the virus in horses.”

Young horses are at higher risk than older adults, but older horses can also be susceptible, although they usually have some partial immunity. Once infected, a horse does develop some natural immunity, but no one knows how long it lasts.

During the initial examination, a veterinarian would not be able to differentiate among the various respiratory diseases, so the gold standard for testing is serology and PCR rather than culture.

Young horses usually develop fever with a temperature of about 102° to 104° F and mild depression. They will develop nasal secretions that start out thin and eventually become thick and purulent, but they generally do not cough as much as they do with influenza. Their lymph nodes are usually swollen.

It is costly when the disease occurs in racehorses, because these horses must be kept from competition until they recover, and it can take months before

they are racing, again.

“There are no specific antiviral drugs to treat ERV A or B, so you must treat it symptomatically,” said Pusterla. “Treatment is the same as for other respiratory infections: address the fever, rest the horse, and confine the affected horse to prevent spreading the virus.

“You should not race or exercise any horse that is affected to prevent any secondary complications, such as bacterial bronchopneumonia,” he said.

Because there is no antivirals available for treatment, vaccination is the best course, they both said.

said Pusterla.

Viel believes that many horses show mild signs with substantial viral shedding before horses show more apparent clinical signs, which makes it a difficult virus to contain at tracks and on large farms, which is why he recommends vaccinating against ERA. “It is probably spread more from droplets and nasal secretions than from airborne spray and shared equipment fomites,” Viel said.

And can also be excreted from the urine, which will also make it harder to contain, according to Pusterla.

Regular vaccination with the new Equine Rhinitis A Vaccine (Boehringer Ingelheim Vetmedica) will prevent disease and minimize the shedding.

“The reality is that when we have outbreaks, we can find the cause in about 30-50% of outbreaks. The vaccine is a tremendous step in the right direction in improving the area of prevention for respiratory diseases in the equine field.

“You want to vaccinate before the show season, before horses get comingled, maybe even earlier in the winter when animals go to sales and training facilities,”

“There are no good experimental studies or a lot of longitudinal surveys of the disease. If you compare it to flu or equine herpesvirus, we need to assume that by the time the animal is febrile, it is almost at the peak of its shedding and the shedding can be variable, 6 to 10 days.

“In healthy horses you can find ERA in the urine for weeks. The question is when does this virus transition from the respiratory tract to the urinary tract epithelium and how long does it stay in the urinary tract. I don’t think there are good studies to answer these questions.”.

MeV

Electron microscopy of ERAV Photos courtesy of Dr. Viel.

ModernEquineVet.com | Issue 6/2013

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news notes

One Health: Working to save equine burn victim

By Emily Caldwell The Ohio State University Pairing an equine veterinarian and a burn surgeon is providing a second chance for a horse that was doused in flammable liquid and set on fire late last summer.

No suspect has been identified in the case, but Pennsylvania law enforcement is pursuing this case.

The Ohio State University doctors and their teams have partnered to perform two skin grafts on Northstar, an American Paint, which suffered severe burns to almost half of his body.

The same instruments used for a human burn victim were used for the horse’s grafting procedures.

The clinicians removed ultrathin sheets of skin from Northstar’s chest and expanded them with a meshing tool before placing the grafts across an enormous wound spanning the horse’s back.

Northstar was burned down to the bone at the base of the neck

when he arrived in Columbus on Sept. 5, 2012, and his prognosis was not good. Skin damage extended from his neck to the base of his tail and along both of his sides.

Veterinarian and burn specialist apply human burn medicine techniques to rescue American Paint.

“There’s been a lot of trial and error with the challenges of how to bandage him, what the most appropriate antiseptic is for cleaning the wound bed, and the biology of burned tissue in a horse,” said Samuel Hurcombe, BSc, BVMS, MS, SACVIM, DACVECC, as-

sistant professor of veterinary clinical sciences and the leader of Northstar’s care team.

Veterinary experts got the healing off to a good start with relentless wound management, a series of smaller skin grafts and the implantation of cell cultures in the wound bed. These procedures were performed to bring top-layer skin tissue to the central area of the expansive wound bed on Northstar’s neck and shoulders, where all his skin had burned away.

To address the large wound across the horse’s back, Hurcombe consulted Larry Jones, MD, director of the burn center at Ohio State’s Wexner Medical Center.

The two observed one another’s surgeries and studied human- and veterinary-medicine journal articles before teaming to accelerate Northstar’s care.

Grafting

The thickness of the graft is different for a horse than a person,

Doctors who collaborated on surgery Dr. Samuel Hurcombe and Northstar Dr. Samuel Hurcombe (left) from The Ohio State University Veterinary Medical Dr. Samuel Hurcombe, BVMS from The Ohio State University Veterinary Medical Center comforts Center and Dr. Larry Jones (right) from The Ohio State University Wexner Medi- Northstar before surgery. The horse underwent two surgeries to repair burn wounds to his back. cal Center collaborated on the historic surgery for Northstar.

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according to Jones, who led the two larger skin graft procedures.

“We want to take the top layer of skin but we also need a portion of the second layer, the dermis,” he said. “I knew I had to take a graft that’s about twice as thick as one I would take if I were operating on a human.”

The team then ran the graft through a mesher that cut holes in the graft skin and allowed for expansion of the graft to about four times its original size. “When the graft takes, the holes will fill in from skin cells growing from the edges,” Jones said.

They dressed the wounds with bandages containing medicalgrade silver, which functions as an antibiotic, to speed healing of the grafts and the donor sites.

At this stage of the horse’s recovery, more than half of the initial wound is healed, with the repair resulting from both the various skin grafting procedures and normal closure along the edges of the damaged skin.

Just as human burn victims do,

Northstar will likely undergo a series of graft surgeries before he is healed completely.

“It’s a slow process but even in the time we’ve been caring for him, he has made remarkable progress,” said Hurcombe, a specialist in equine emergency and critical care. “From a welfare standpoint, his psychology is great and after what he’s gone through, the fact that he is still so trusting of people is pretty amazing.”

No dark horse

While he initially appeared to be a dark horse for recovery, Northstar persevered through weeks of daily cleansing and removal of dead and infected tissue followed by the application of antiseptics, honey, aloe and silver sulfadiazine cream, a common human burn treatment, to his damaged tissue.

In yet another application of human medicine, the team has treated Northstar with gabapentin (Neurontin, Pfizer), a medication used for human neuropathic pain,

Preparations before surgery The teams at The Ohio State University Wexner Medical Center and The Ohio State University Galbreath Equine Center work together to prep the horse for surgery. Northstar received skin grafts across his back in a historic surgery.

to treat the severe itching and nerve-related pain that is typical in burn patients as they recover.

Northstar, who turned 7 in January, is a “young, naughty boy” and would love nothing more than to toss himself to the ground and roll on his back to scratch that persistent itch, Hurcombe said.

So the horse is gently tethered to keep him standing, and he wears a cradle that immobilizes his neck several hours throughout the day.

He is also covered in bandages and wears a full-body “sleazy.”

The road ahead is a long one, both physicians acknowledge, but they hope Northstar has a complete layer of skin coverage by his eighth birthday. The location of his back wound is tricky to treat because the horse anatomy is such that Northstar’s every movement disturbs the grafted areas even with secure bandages from his neck to his tail.

Northstar’s owners live in northwestern Pennsylvania, where police have investigated the burning incident as a criminal case.MeV

Northstar recovers from burn wounds Doctors from The Ohio State University Veterinary Medical Center are currently treating Northstar with methods commonly used on human burn victims.

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AAEVT Membership

AAEVT* membership is open to US and international equine veterinary technicians, assistants, practice managers, and support staff employed in the veterinary industry. It is also open to students of AVMA/CVMA accredited programs

AAEVT Membership • • • • • • • •

Bi-Annual Newsletter Weekly “HoofBeats” email NEwsblast Full access to www.aaevt.org, including the Career Center and the Library Up-to-date information on the AAEVT Discounted registration for AAEVT Regional Meetings and the annual AAEP/AAEVT Convention NTRA, Working Advantage and Platinum Performance Benefits The opportunity to participate in the AAEVT Online Certification Program or to become a member of the AEVNT Academy-Specialty in Equine Veterinary Nursing • Scholarship opportunities.

• AAEVT’s Equine Manual for Veterinary Technicians (Blackwell Publishing 20% discount on purchase price) • Subscription to THE HORSE Magazine, compliments of Intervet Schering/Plough Opportunity to attend Purina’s Annual Equine Veterinary Technician Conference All Expenses paid!

AAEVT Objectives • • • •

Provide opportunities for CE, training, communication, and networking Educate the equine veterinary community and the public about our profession Inform Members of issues affecting our profession Assist in providing the best medical care to improve the health and welfare of the horse

AAEVT Online Equine Certification Program

• A three course, 10 module, equine-only online program offered through ACT • Geared toward Credentialed Veterinary Technicians, Assistants, Support staff, & Students • Areas of study include: equine medical terminology, anatomy and physiology, parasitology, laboratory, diagnostics, equine basics (breeds, wellness, husbandry,) diagnostic procedures, emergency medicine, restraint, pharmacology, surgical assistance and anesthesia, equine office procedures • A certificate of completion is awarded to those who: Successfully complete required courses Complete the list of required skills (per a supervising DVM who is an AAEP member) Attend an AAEVT regional CE symposium and participate in the we labs • Those individuals who successfully complete the programs will be recognized as AAEVT Certified Equine Veterinary Technicians / AAEVT Certified Equine Veterinary Assistants depending on their current designation. The certificate is recognized by the AAEVT and the AAEP but does not grant the credentialed status by the AVMA • For more information go to www.aaevt.4act.com or call 800-357-3182

AAEVT Mission Statement: To promote the health and welfare of the horse through the education and professional enrichment of the equine veterinary technician and assistant.

For more information visit www.aaevt.org

*American Association of Equine Veterinary Technicians and Assistants

technician update

Expect the unexpected — How to prepare your clinic for an inspection

By Ali Fernandez, BS Whether it be a routine random inspection or as a response to a complaint, your clinic can be inspected by numerous agencies at any time.

During the inspection, a licensed veterinarian or registered veterinary technician in good standing may request, and must be granted, access to all areas of your practice.

This article is designed to help you assess your preparedness for an inspection from The Board, as well as address other key issues to keep your practice in good standing. Please note that these are general guidelines. Check with your state and local agencies for specific regulations and acceptable types of compliance.

Overview of the Process

An inspection can take from 1 hour to all day. Inspectors will examine your physical facility and will commonly ask for access to pharmacies, medical records, etc.

When an inspection is complaint driven, the inspector may be accompanied by members of a task force or other government agency and may interview employees. They may also focus on a particular aspect of the clinic. The person who files the complaint, as well of the details of the complaint remain anonymous and no specifics will be disclosed to the staff.

After the inspection is completed, the examiner will go over his/her findings and point out any deficiencies with the practice owner and/or an appropriate representative. Inspectors will forward their information to The Board, who will then determine what, if any, actions need to occur to address any correction to meet minimum standards of operations.

General

Your facilities must be clean and organized. Your office and/or waiting room should be separate from any examination areas. Food for human consumption should be kept in a separate refrigerator from vaccines and refrigerated medications and should never be brought into an exam area.

Have your exit ways clearly marked and always have an appropriate amount of fire extinguishers serviced and ready for use.

Signage

Make sure that all mandatory notices are easily accessible to your clients. This will include a veterinary and/or premise permit, as well as the registration for your radiology equipment. If your clinic is not open to clients 24 hours, you must make sure that clients seeking services after hours are directed to a facility that can assist them. This information must be both on your answering machine and in writing at your clinic's entrance.

Radiology

Remember to have the appropriate signage at the entrance of your radiology room/area. Minors and women who may be pregnant should not be exposed to any radiation. Staff members performing radiology should have both the proper personal safety equipment and a personal radiation monitoring badge. Many states also require that any nonregistered staff be properly trained and the training record be sent to the state prior to participating in radiology. All training documentation and radiology registration and information must be properly maintained and available for viewing.

Mobile units

Mobile veterinarians and their vehicles have become a hot topic. Although the type of vehicle is not regulated, as a minimum, it must contain hot and cold water as well as have access to 110-volt power.

The Drug Enforcement Administration currently prohibits veterinarians from transporting, using or distributing any controlled substance from a location other than the physical address on their DEA license. Although there is a bill aimed at amending the Controlled Substances Act, it is important to remember that your veterinarian can still be cited for having these items in the vehicle.

Surgery

If your facility performs surgery, it must have its own distinct area within the clinic. It should be as aseptic as possible, and have no windows, doors, etc. leading directly to the outside. It should have proper ventilation and heating to ensure the comfort of both the staff and their patients. Emergency/ back up power and lighting should also be available for this area.

Make sure that your equipment is cleaned after ModernEquineVet.com | Issue 5/2013

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technician update each use. Proper anesthetic monitoring equipment should be available at all times during surgery. All of your surgical tools should be kept sterile. Although there is no expiration date for sterility of a packaged product, many inspectors will ask about a protocol for monitoring and/or re-sterilizing tools.

Controlled Substances

Many of the drugs used daily are classified as a controlled substance. Substances are classified on their likelihood to be abused. Because of this, controlled substances, such as butorphanol, ketamine and diazepam, should be closely monitored. The substances should be kept in a double-locked area only available to the staff. Their use should be properly recorded, including ID number/address, patient, directing veterinarian, recording staff member, amount used/wasted and a total of the drug on hand. The on hand amount should relate to a total within the open bottle so your zeroed tally should correlate with an empty bottle. Any new shipments entered into your records should also include the name and address of the distributor.

Record Keeping

Proper record keeping is key in any business.

Medical records should include any possible details regarding your clients, patients and their care.

Drugs, dosages, routes of administration, etc. are all important details to remember. Most states have a minimum time frame for keeping records (i.e. three years, seven years, etc.), although it can be in your interest to keep them longer. Although the records and diagnostic images are the property of the veterinary clinic, the information contained in them must be made readily available to clients if requested.

MSDS Sheets

Any chemicals used in your business should have an associated Material Safety Data Sheet. These sheets must be available to staff at all times. A recently adopted policy requires that new MSDS conform to an international format. These new sheets will be required to be in use by the year 2016.

Medications

It is important to monitor your drug inventory regularly. Any expired medications should promptly be removed from the main pharmacy area and marked as expired. There are a number of ways to properly dispose of these medications such as reverse distribution, destruction programs, etc.

When repackaging a medication, such as breaking down a bulk order for individual clients, be sure 16

Issue 5/2013 | ModernEquineVet.com

to check with your local agencies regarding proper re-labeling. Compounded medications can be used when there is no FDA approved formulation for that client's need. If you need to dispense a compounded medication, you may only give the client an amount equal to no greater than three days of treatment. If a larger amount is needed, the client should be directed to order from the compounding pharmacy with a prescription for the medication. When dispensing any kind of medication, it is important to maintain a veterinary-client-patient relationship.

Additional Helpful Hints

There have been numerous reports of businesses being targeted for violations of the Americans with Disabilities Act, and the veterinary world is no exception. It is important to have proper signage in and around your facility. An accessible route in and out of the office, exam area, bathroom and any other public area must be properly marked and maintained. An accessible parking space and loading zone must also be marked with specific colors, wording and signage.

Check with your local government's building department for regulations regarding specific requirements for accessible spaces. Although this may require some renovation of your practice, it can more than pay for itself in the long run.

Employee Records

Documenting employee training and job descriptions can be very useful to protect the liability of the practice. Most states have specific regulations relating to the approved jobs and duties for different classifications of staff. It is important to properly document any employee performance reviews, or any disciplinary actions taken against them. It is an unfortunate truth that employee fraud is becoming increasingly common in the work place. It can be helpful to create a system of checks-and-balances between employees. This can be as easy as having records available for viewing by any employee, or having multiple employees working on a shared project."

MeV About the author Ali Fernandez graduated in 2009 from the University of California at Davis with a BS in Animal Science, with an equine emphasis. In 2011, she joined Los Caballos Equine Practice in Galt, Calif., and has been working there as a veterinary assistant and office manager. In addition, she volunteers her time to the American Association of Equine Veterinary Technicians and Assistants as a Pacific area Regional Contact.

news notes

Equine rabies confirmed With 12 cases of equine rabies already confirmed in 2013, veterinarians should be vigilant about making sure owners vaccinate their horses against this fatal zoonotic disease.

Although the incidence of equine rabies is low, it has considerable public health significance. Therefore, the AAEP recommends that rabies vaccine be a core vaccine for all equids.

The equine cases are among the hundreds of cases discovered this year in other species, including bats, cats, dogs, cows, foxes, raccoons and skunks.

Animal Rabies Cases, U.S. Besides the cases in horses, in the past several years, there have been

thousands of incidents of animals with confirmed rabies, 92% of which were in wildlife:

2009 – 6,694 2010 – 6,155 2011 – 6,037

signs are similar to other diseases affecting the horse’s nervous system, but in the case of rabies, become so severe, the horse is euthanized or dies within days.

There is no way to diagnose rabies in live animals, and veterinarians who suspect rabies must send the horse’s brain to a diagnostic laboratory where it is examined for the presence of characteristic lesions.

Because it is zoonotic and just as lethal to people, any person who came in contact with the infected equid would require rabies prophylaxis.

“Horse owners have significant emotional and financial resources invested in their horses over long periods of time and consider their horses to be family,” said Green. “Their vision for the animal’s end of life tends toward retired days grazing in green pastures – not convulsions, paralysis and a painful death. MeV

Staying Informed with Oubreak Alert Veterinarians can use Merial’s Outbreak Alert program, launched in June 2011, to find out which infectious disease are occur and where. It is a good tool for evaluating risk, especially when traveling.

The program features a website with maps indicating the presence of confirmed cases in all species, including the carriers of rabies, West Nile Virus, Eastern Equine Encephalitis, Western Equine Encephalitis, Influenza, Potomac Horse Fever and Equine Herpes Virus. Free, printable information about each of the diseases, their clinical signs and treatments, is also available on the site. MeV

“In 2011, which is the last year for which we have complete data, there were 44 confirmed cases of rabies in horses. But what really should be a concern for horse owners is the number of cases in wildlife as most horses are kept in areas near wildlife habitats,” said Megan Green, DVM, equine specialist in large animal veterinary services at Merial Ltd, which makes IMRAB rabies vaccine for horses.

“I’m sure every barn owner has seen skunks, foxes, raccoons and the occasional bat in and around their barns.”

Mammals contract rabies through exposure to infected secretions, usually through a bite from an infected animal, typically a wildlife source, such as raccoon, fox, skunk, or bat. Bites to horses occur most often on the muzzle, face and lower limbs. The virus migrates via nerves to the brain where it initiates rapidly progressive, invariably fatal, encephalitis.

Clinical signs include, but are not limited to going off feed, depression, excessive salivation, difficulty swallowing, lack of coordination, aggressive behavior, hyperexcitability, colic, convulsions or paralysis. These ModernEquineVet.com | Issue 6/2013

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