Practitioner Issue 1 2014

Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 1 • 2014

Chronic and Post-Breeding Endometritis In The Mare

Maria Eugenia Cadario, MV, DVM, MS, DACT

What Is Equine Periodontal Disease Travis Henry, DVM

APPROACH TO EQUINE PASTERN Dermatitis Rosanna Marsella, DVM, DACVD

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The President's Line Suzan C. Oakley, DVM, Diplomate ABVP (Equine) - FAEP President I would like to wish everyone a great new year and thank the FAEP Council for the opportunity to serve as the 2014 president. Our Council is very excited to be celebrating our 10th anniversary and we have been hard at work putting together our educational programs for the coming year. We are continuing our tradition of providing equine-exclusive, international quality continuing education with a personal touch. Resort locations and smaller meeting size allow us to get acquainted and share our knowledge with the end goal of helping our noble friend, the horse.

I would like to thank our educational partners for their support. When you visit the exhibit halls at our conferences please thank them, because without their support it would not be possible to put on meetings of this caliber. I would also like to acknowledge our executive director, Phil Hinkle, and the FVMA staff for all that they do to make our meetings successful. We hope you will join us at one or all of our educational offerings in the coming year.

Our first meeting this year will be the 2014 Equine Foot Symposium in Orlando, Florida from June 13th to the 14th. The focus of the meeting will be on the hind limb. Mitch Taylor CJF, DWCF will be back by popular demand to present an anatomy dissection wet lab detailing hind limb structure. We have a great line-up of farriers and veterinarians speaking on topics that include the ever-important veterinarian-farrier relationship, shoeing for different surfaces, shoeing modifications for hind limb problems, and hoof wall defects. Please see the complete program line up in the center pages of this issue for details!

We also invite you to join us in beautiful Hilton Head, South Carolina from October 9th-12th, 2014, to celebrate the 10th anniversary of the FAEP Promoting Excellence Symposium. Our theme for the meeting is Achieving Peak Performance in the Equine Athlete. Our outstanding program includes a 4-hour Master Class on laminitis with Dr. Chris Pollit, the "FAEP News Hour" with Drs. Chris Kawcak, Rob MacKay and Margo Macpherson and more top-of-the-line speakers on the topics of lameness, surgery, imaging, medicine and reproduction in the athletic horse. We are offering an innovative Equine Sports Rehabilitation track, with Drs. Duncan Peters and Rob van Wessum addressing the rehabilitation of equine tendon, ligament and spinal/pelvic injuries. Dr. Jen Skeesick PT, DPT, SCS will discuss rehabilitation from a human physical therapy perspective and Dr. Shelia Schils will discuss the development of equine rehabilitation protocols.

The Ocala Equine Conference will be held from January 23rd-26th, 2015, in Ocala, Florida, so take a break from the cold or just drive over to Ocala and join us! We will be offering an ultrasound wet lab covering musculoskeletal, abdominal and thoracic imaging. Our Keynote speaker will be Dr. Sue McDonnell, who will discuss the many facets of equine behavior. Dr. Ted Stashak will present an outstanding case-based seminar on wound management that will deliver practical, “take home and use tomorrow” information. Other distinguished speakers include Drs. Steeve Giguere, Eric Mueller, Rich Redding and Karen Wolfsdorf discussing foal respiratory disease, GI issues, lameness, imaging, and reproduction.

Providing continuing education for the equine practitioner is only one of the duties of the FAEP. The FAEP Council is the equine-exclusive division of the FVMA, which gives the Florida equine veterinarian a voice in Tallahassee. We also act in an advisory capacity for all regulatory or legislative issues affecting the equine industry and equine veterinarians in the state of Florida.

My involvement with the FAEP has been a rewarding and enriching experience. Working with such dynamic, dedicated and innovative colleagues is inspiring and I invite you to join us on a committee or to submit articles to be considered for our publication, The Practitioner. We need ideas from our members to accomplish our mission, so please join us!

On behalf of the entire FAEP Council, I invite you to join us at one or all of our world-class meetings and experience our “Southern Hospitality.” I look forward to seeing all of you!

• EXECUTIVE COUNCIL • •

•

Corey Miller, DVM, MS, Diplomate ACT President-Elect

cmiller@emcocala.com

Anne L Moretta, VMD, MS

Mr. Philip J. Hinkle

FAEP Council Past President

phinkle@fvma.org

marochel@aol.com

Executive Director

Gregory D. Amanda M. House, DVM, Diplomate ACVIM BonenClark, DVM, Diplomate ACVS Representative to FVMA Executive Board gbonenclark@fevaocala.com housea@ufl.edu

Liane D. Puccia, DVM pucciavet@aol.com

Ruth-Anne Richter, Jacqueline S. Shellow, BSc (Hon), DVM, MS DVM, MS rrichter@surgi-carecenter.com docshellow@bellsouth.net

The Practitioner is an official publication of the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association.

4 The Practitioner

Issue 1 • 2014

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W hat I s E quine

P er i o d o n ta l D i sease ?

Travis Henry, DVM Periodontal disease is considered to be a painful condition in the equine oral cavity. Clinical signs include quidding, weight loss, bitting problems, and halitosis. Periodontal disease is used to describe an inflammatory process of the supporting structures of the dentition, and can be further broken down into gingivitis and periodontitis. Gingivitis is the inflammatory process of the gingiva, both free and attached, at the gingival sulcus. Periodontitis is the inflammatory process related to the alveolar bone and periodontal ligament. Gingivitis is considered in most species, the reversible component of periodontal disease and periodontitis the irreversible component. Therefore, if there is bone loss related to a periodontal lesion, the bone loss is permanent. If there is gingivitis related to a periodontal lesion and the cause of the lesion can be identified and successfully treated, the gingivitis will resolve.

In the horse, periodontal disease is related to food impacting between cheek teeth or diastema(diastemata plural) formation.

This ability for food to stagnate between teeth comes from a poor relationship with the interproximal spaces. Diastemata have been defined into 4 different classifications.1; 2 A. Primary diastemata are formed from the improper angulation in a mesial to distal orientation of the cheek teeth in a particular quadrant. Both excessive angulation or lack of angulation can occur.

B. Secondary diastemata are formed from overlong dentition, supernumerary teeth, hypodontia, linguoverted teeth, and buccoverted teeth.

C. Combination of primary and secondary diastemata such as improper angulation of the teeth in a mesial to distal direction with a linguoverted tooth. This is a common finding in mandibular quadrants of Arabian and Thoroughbred horses.

D. Senile diastemata caused by the normal tapering in of teeth in an apical direction, along with age-related loss of angulation of the 06s and 11s. This can be noted between the maxillary 08-09 teeth from a palatal to buccal direction as well.

Diastemata formation is also defined as open or closed. Closed is defined as having 40% or less of the width at the occlusal surface as compared to the width at the gingival margin. Open is defined as having a similar width from the occlusal surface to the gingival margin. There can be combinations of these as well.

Periodontal Evaluation on Oral Examination ■ Evaluate the periodontal tissue and gums of the incisive region to detect gingivitis, trapping of feed, calculus, discharge, bulbous enlargement, soft tissue masses, or draining tracts.

■ Normal depth of the gingival sulcus of the incisors is 3mm.

■ Palpate the gum of the interdental space for enlargements, painful areas, and unerupted wolf teeth.

■ The cheek teeth are normally in very tight apposition with barely perceptible interproximal spaces, and each row of teeth forms a single functional unit.

■ The gingival sulcus of the cheek teeth is normally quite 6 The Practitioner

shallow and does not pack with feed or bleed when probed (normal sulcus depth is 5mm or less for cheek teeth).

Indicators of periodontal problems include: ▶ Periodontal pocketing of roughage ▶ Gingivitis ▶ Pathologic diastema ▶ Gum recession ▶ Irritation & bleeding ▶ Odor ▶ Calculus accumulation ▶ When a periodontal pocket of feed is encountered, attempt to remove feed material from the sulcus with picks, forceps, and irrigation. High pressure irrigation and air abrasion can be used for cleaning and debriding the pocket. ◉ After cleaning, assess the degree of gingival recession, irritation, bleeding, etc. ◉ Measure the depth of the pocket using a periodontal probe. ▶ Manipulate affected teeth to determine tooth mobility – movement greater that 3mm and/ or if the tooth is depressible indicates advanced disease. ▶ Radiography is required to evaluate the extent of alveolar bone and tooth involvement.

Rules Of Thumb For Classification Of Periodontal Disease (adapted from Klugh, D. Equine Periodontal Disease.

Clinical Techniques in Eq Prac, Elsevier Saunders, 2005, p 135-147) Stage

Attachment loss

Approx. Probe depth

0-Normal

none

<5mm

I-Gingivitis

none

<5mm

II-Early

<25%

5-10mm

III-Moderate

25%-50%

>10mm

IV-Advanced

>50%

>10mm

Index of Teeth Mobility Modified for equine dentistry 0

Mild

Normal

Represents the first distinguishable sign of movement greater than normal.

1 2

Moderate

Movement of up to approximately 3 mm (1 mm in man).

3

Severe

Movement > 3 mm in any direction and/or is depressible.

Klugh, D. O. (2005). "Equine Periodontal Disease." Clinical Techniques in Equine Practice 4(2): 135-147.

Issue 1 • 2014

Diagnostic Radiography Radiographs are obtained of all affected areas. Changes related to periodontal disease on radiographs are widening of periodontal ligament, vertical bone loss and horizontal bone Radiograph Demonstrating loss. With this information, Horizontal Bone Loss the degree of attachment loss can be formulated and the stage of the periodontal lesion determined. This is important information for determining the treatment plan for the horse. Teeth that have 50% attachment loss are candidates for extraction. Attachment loss in the horse changes with attrition and further eruption which is unlike brachydont teeth.

For instance a young horse with a 10 mm probing depth with 30mm Radiograph Demonstrating Vertical Bone Loss of reserve crown has 33% attachment loss. An aged horse with 10mm probing depth with 20mm of reserve crown has a 50% attachment loss. The bone loss with periodontitis is not reversible and such a periodontal lesion in a young horse that is not treated effectively could end in early tooth loss. Periodontal treatment without radiography can lead to ineffective treatment.

Periodontal Treatment The key to effective periodontal treatment in the horse first begins with identifying the underlying cause of the Radiograph Demonstrating disease process. For quadrants that have Increased Periodontal Ligament Width orthodontic problems with overlong teeth or diverted teeth, the first step is an appropriate occlusal adjustment (OA). The purpose of OA is to remove inappropriate forces that are applied during mastication.

For example, a mesial hook on a 206 with a periodontal lesion between 206-207 will be effectively treated if minimal bone loss is present, by reducing the overlong mesial component of the 206.

For quadrants that have closed diastemata, widening of the diastema to prevent food trapping has been demonstrated to alleviate clinical signs and healing. The aim of the treatment is to open the diastema at the occlusal surface and to have the walls of the interproximal space parallel. Long term follow-up of 202 cases demonstrated 72.6% remission of clinical signs over 20.8 month period1. Important considerations when performing this procedure is that inadvertent pulp exposure can happen. The live pulp is positioned closer to the interproximal spaces on the distal side of the tooth than the mesial side. Thermal injury must be avoided by liberal irrigation and not working the tooth for more than 5 seconds at a time3.

A shift in the bacterial population has been shown to happen www.faep.net

in the interproximal space when forage stagnates4. Debridement of the interproximal space to remove food matter and calculus is needed to remove bacteria that are pathologic. Many feel that placing a perioceutics in the interproximal space speeds the healing process. It stands to reason that debridement and preventing further food impaction would aid in the treatment process. A high-speed dental drill with water spray and a diamond fissure bur can be used to debride that interproximal space along with curettes. Polyvinyl siloxane impression material can be used to fill the interproximal space and prevent food impaction. Often, combinations of treatment strategies are needed to effectively treat periodontal pockets.

Periodontal lesions that achieve a depth severe enough to incorporate the apex of the tooth can lead to pulp death by formation of a perio-endo lesion. Because the periodontal disease process is often located in the interproximal space, it can affect adjacent teeth.

Incisor teeth can also be affected by periodontal disease. There is confusion that resorption and hypercementosis is a form of periodontal disease. Although it affects the periodontia, it is thought to be a separate disease process.

Conclusion Periodontal disease in the horse is a painful process that requires appropriate identification and diagnostics to effectively treat.

[1] Dixon, P.M., Ceen, S., Barnett, T., O'Leary, J.M., Parkin, T.D. and Barakzai, S. (2013) A long-term study on the clinical effects of mechanical widening of cheek teeth diastemata for treatment of periodontitis in 202 horses (2008-2011). Equine veterinary journal.

[2] du Toit, N. (2012) The problem with equine cheek teeth diastemata. The Veterinary record 171, 42-43.

[3] Dixon, P.M., Barakzai, S., Collins, N. and Yates, J. (2008) Treatment of equine cheek teeth by mechanical widening of diastemata in 60 horses (2000-2006). Equine veterinary journal 40, 22-28.

[4] Klugh, D.O. (2005) Equine Periodontal Disease. Clinical Techniques in Equine Practice 4, 135-147.

Travis James Henry, DVM Dr Henry grew up in Central Michigan where he learned to ride and show Quarter Horses. His love for horses continued through college where he attended Michigan State College of Veterinary Medicine.

In his 20-year veterinary career, he has focused on the care of the horse’s oral health. He owns and operates Midwest Equine Services in Elkhorn, Wisconsin providing all aspects of equine dental care. He also is employed in the Dentistry and Oral surgery Department at the UC Davis Veterinary Medical Teaching Hospital. He is currently working at the VMTH 1-2 weeks a month.

He is married to Amy and has two boys, Joshua and Noah.

They enjoy camping and many outdoor sports.

The Practitioner 7

2014 Equine Foot Symposium JuNE 13-14, 2014 • DoubleTree Resort by hilton orlando at seaworld

Event SCHEDULE

a r ia n & n i r e t e V g the Fo s t e r i n i e r R e l a t i o n s h i p Fa r r

Pre-registration

Information

Your Registration of

friday, JuNE 13, 2014 7:00 am - 8:00 am

Registration and Morning Coffee – Visit the Marketplace

8:00 am - 8:50 am

Fostering the Veterinarian and Farrier Relationship Scott Pleasant, DVM, MS, DACVS Travis Burns, APF, CJF, TE, AWCF

Includes:

$325

C.E Lectures

Friday Lunch Buffet

8:55 am - 9:45 am

Trimming and Shoeing: Back to the Basics Travis Burns, APF, CJF, TE, AWCF

Proceedings

Saturday Lunch Buffet

Anatomy Wet Lab

9:45 am - 10:30 am

Morning Break – Visit the Marketplace

All Social Events

Admission to the Marketplace

10:30 am - 11:20 am

Rear Hoof Imbalance and its Effect on Hind Limb Lameness Tracy Turner, DVM, MS, DACVS, DACVSMR

11:25 am - 12:15 pm

Comparative Anatomy of the Foot and Form and Function of the Hind Limb Jim Quick, CJF

12:15 Pm - 1:35 Pm

Lunch Break – Marketplace

1:35 Pm - 2:25 Pm

The Interaction of the Foot to the Surface: How Shoes and Different Shoe Sections Affect the Loading Phases of the Stride Mitch Taylor, CJF, DWCF

Take Advantage of the Discounted Pre-registration Fees and Special Room Rates Deadline is May 26, 2014

2:30 Pm - 5:30 Pm

Anatomy Dissection Wet Lab: Hind Limb Structure Mitch Taylor, CJF, DWCF

6:00 Pm - 7:30 Pm

Cocktail Reception in Marketplace

Symposium Host Hotel

Saturday, June 14, 2014 7:00 Am - 8:00 Am

Registration and Morning Coffee – Visit the Marketplace

8:00 Am - 8:50 Am

Rear Hoof Shoeing Modifications for Joint Pain Tracy Turner, DVM, MS, DACVS, DACVSMR

8:55 Am - 9:45 Am

Rear Hoof Shoeing Modifications for Upper Limb (Joint) Pain Tracy Turner, DVM, MS, DACVS, DACVSMR

9:45 Am - 10:45 Am

Morning Break – Visit the Marketplace

10:45 Am - 11:35 Am

Management of Hoof Wall Defects: Toe Cracks and Quarter Cracks Scott Pleasant, DVM, MS, DACVS

11:40 Am - 12:30 Pm

Shoeing/Trimming Sport Horses in Work and Therapeutic Shoeing for Hind Limb Lameness Jim Quick, CJF

12:30 Pm - 2:00 Pm

Lunch Break – In the Marketplace

2:00 Pm - 2:50 Pm

Shoeing Sport Horses with Regards to Effects of Surfaces on Needs Vern Dryden, DVM, CJF

2:55 Pm - 3:45 Pm

How Surfaces Affect Injury and Shoeing Practices Vern Dryden, DVM, CJF

3:45 Pm - 4:00 Pm

Afternoon Break – Visit the Marketplace

4:00 Pm - 5:40 Pm

Difficult Cases: What Went Right and What Went Wrong

• •

Travis Burns, APF, CJF, TE, AWCF • Scott Pleasant, DVM, MS, DACVS •

Vern Dryden, DVM, CJF Tracy Turner, DVM, MS, DACVS, DACVSMR

Participants are invited to submit a difficult case on a jump drive for panel discussion (no more than 5 slides in powerpoint format)

To reserve your room at the Double Tree Resort Call 1-800-327-0363 Use promo code: FAEP2014 Special Group Rates: $99.00 Single Double Triple Quad

Reservation deadline is May 26, 2014

Hind Limb Dissection Wet Lab Featuring Mitch Taylor, CJF, DWCF Assisted by Our Distinguished Speakers • Dissection of the lower limb and foot • Comparison of different foot types • Dissect all tendons, ligaments and foot structures in relating the external hoof capsule to the internal soft tissues • Gain a better understanding of the morphology of the hind foot, the orientation and health of the coffin bone, with emphasis on internal foot structures.

Featured Topics • • • • •

Integrative Anatomy Hoof Wall Defects Shoeing for Joint Pain Veterinarian-Farrier Relationship Balanced Shoeing and More...

16

Distinguished Speakers • Travis Burns

• Jim Quick

• Vern Dryden

• Mitch Taylor

• Scott Pleasant

• Tracy Turner

APF, CJF, TE, AWCF DVM, CJF

DVM, MS, DACVS

CJF

Hours

CJF, DWCF

of Cutting-Edge

DVM, MS, DACVS, DACVSMR

Continuing Education

Continuing Education Credits

This program has been approved by  Florida Board of Veterinary Medicine, DBPR FVMA Provider # 31  New York State Sponsor of Continuing Education

This program has been approved for 16 hours of continuing education credits by the American & Canadian Associations of Professional Farriers (AAPF/CAPF). website - www.ProfessionalFarriers.com

American Association of Veterinary State Boards RACE Provider #532 This program has been submitted (but not yet approved) for 16 hours of continuing education credit, in jurisdictions which recognize AAVSB RACE approval; however participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education. Call Diana Ruiz, FAEP Meetings and Events Coordinator, at (800) 992-3862 for further information.

Visit the FAEP web site: www.FAEP.net

APPROACH TO EQUINE PASTERN DERMATITIS Rosanna Marsella, DVM, DACVD Pastern dermatitis is not a specific diagnosis, but the name used to describe a syndrome. This term is used to describe cutaneous lesions that affect the lower legs of horses that can be caused by a variety of diseases. Slang terms for pastern dermatitis include scratches, dew poisoning, greasy heel, mud foot, mud fever, foot rot, and cracked heels.

Differential diagnoses for pastern dermatitis include allergic (e.g., contact, food, insect allergy), parasitic (e.g. Chorioptes), bacterial (e.g., Staphylococcus, Dermatophilus), fungal (e.g., dermatophytes), immune-mediated (e.g., photo-activated vasculitis), and autoimmune (e.g., As many diseases can cause pastern pemphigus foliaceous). dermatitis, it is important to have a Since the list is extensive, it systematic and logical approach to is important to address the identify the primary disease. This secondary infections first approach starts with a thorough and treat the treatable, and history to include the age of onset, reassess once the infections the progression, the seasonality are resolved. It is imporand the life style of the patient. As tant to address pastern part of the history, it is crucial to dermatitis cases as early as know whether pruritus was primary possible, as in chronic cases, Pastern Dermatitis due to contact allergy and a (e.g., evident at the beginning) or it can be particularly diffisecondary staphylococcal infection. secondary (progressive over time once cult to diagnose the underlesions and secondary infections have lying cause. developed). Draft horses and horses Initial work-up of these cases with feathers on their lower legs are Depending on the results of prone to the development of pastern would include skin scraping, cytology dermatitis. Most horses have some and fungal culture. Frequently, a initial tests, treatment for secondary level of pruritus and discomfort at bacterial culture is also recommended, infections and for Chorioptes may be the time of presentation. Some cases particularly in chronic cases that have initiated. Chorioptes can be treated are mild and may only present with been treated with multiple courses of topically with lime sulfur dips (once erythema, crusting and scaling, while antibiotics. The best way to obtain weekly for 3-5 times) and systemically others may develop significant crusting, a bacterial culture is by skin biopsy. with ivermectin (0.3mcg/kg q 2 weeks oozing, edema, and pain. The swelling Simply swabbing the skin or a draining for 3 times) or moxidectin, although can be so severe that it can lead to tract may lead to culture of secondary the success of systemic therapy may lameness. Draining tracts can form contaminants while missing the not be complete, possibly due to and granulation tissue formation can main pathogen. For this reason, skin the surface habits of this mite.1 All become significant. Lichenification biopsy and culture of the tissue is animals in contact with the affected and hyperpigmentation are evident in the most appropriate way to culture one should be treated at the same time. chronic cases. these cases. Staphylococcus is a very Shampooing with an antibacterial common cause of secondary infection. product that will help remove the On physical exam, it is important This is typically treated with systemic crusts (e.g., benzoyl peroxide) may to note whether only the front limbs courses of potentiated sulfonamides, be done before the dip. Fipronil has are affected or whether all four legs although resistance is possible and also been reported to be effective, are affected. It is important to note should be considered in cases that although this is an extra-label use for whether only the depigmented limbs do not respond to standard therapy. this insecticide. It is also important are involved or whether lesions are Systemic therapy in chronic cases to implement some general changes independent of pigmentation. It is may be needed for extended periods in the management of these cases. If also important to know whether there of time. Suitable topical antibacterial feathers are present, it is advisable to are multiple horses affected in the herd therapy is in the form of antiseptics clip the legs to facilitate topical therapy or just one. (e.g., chlorhexidine, benzoyl peroxide, and to better visualize and clean the area. Also, if horses are kept in muddy oxychlorine) or antibiotics.

10â&#x20AC;&#x201A; The Practitionerâ&#x20AC;

Issue 1 â&#x20AC;˘ 2014

and wet conditions, this situation should be modified to allow more time in dry paddocks or clean stalls.

Many topical treatments have typically been tried in these cases, thus it is not uncommon for many patients to have also developed a contact dermatitis. It is therefore important to only use topical therapy that is needed and minimize the unnecessary use of topical products that may be irritating. If contact allergy to plants or shavings is suspected, confinement can be done as part of the diagnostic plan. This can be done by applying bandages to the area after thorough cleaning of the skin or changing the life style of the animal for 7-10 days (if no infection is present). For example, if the horse is on pasture, it can be stalled and only turned out in a round pen where there is no grass. If the animal is primarily in a stall with shavings, either a different type of shavings can be used or turn-out can be done to rule out contact allergy. If a case has contact allergy and completely resolves with confinement, re-challenge will lead to recurrence of the lesions within 24-48 hours after exposure. Contact allergy is best managed with avoidance. If this is not feasible, then protective gear, as well as oral pentoxifylline, can be implemented. Pentoxifylline is dosed at 10mg/kg 3 times daily.

If infections have been treated, the next step can be to biopsy for histopathology to identify the underlying disease. Vasculitis can be a cause of pastern dermatitis.

This can be triggered by a variety of antigens or it can be idiopathic. Effort should be placed in the identification of the triggering cause, if at all possible. Careful review of drugs, de-wormers and vaccinations should be done. Food trials can also be considered in the event that the suspected trigger is an ingredient in the horse’s diet. Pentoxifylline is also the drug of choice for vasculitis. This drug is safe for long-term use and is typically well tolerated. Topical glucocorticoid therapy is also frequently used to decrease inflammation. The use of systemic glucocorticoids is reserved for severe cases that are not responsive to other treatments. The potential for inducing laminitis should be considered before prescribing this form of therapy. It is also important to avoid insect exposure as some species of Culicoides preferentially affect the lower legs of horses.

Use of repellents such as 2% permethrin should be done daily in areas of greatest exposure.

In some draft horses (Shire, Clydesdale, and Belgian draft horses), a genetically inherited2 immune dysregulation leads to vasculitis and chronic progressive lymphedema. This condition is characterized by progressive swelling, hyperkeratosis and fibrosis of the distal limbs. This condition is thought to have a genetic component and is chronic-progressive3. The disease starts at an early age, progresses throughout the life of the horse, and often ends in disfigurement and disability of the limbs.

Antibodies against elastin have been detected in affected horses.4 Horses with clinical signs of chronic progressive www.faep.net

lymphedema have been found to have significantly higher anti-elastin antibody levels compared to clinically normal Belgian Draught horses and to healthy Warmblood horses.

These levels correlate with the severity of the lesions.

These antibodies could be used for early diagnosis of this condition and possibly to help with breeding programs to limit the breeding of individuals prone to this disease.

In summary, may different diseases can manifest as pastern dermatitis. Due to numerous possible underlying causes, a systematic and logical approach is crucial. History, careful physical exam and identification of primary lesions (when still present) are important in aiding the clinician to formulate the best diagnostic plan for each individual case. In most cases, secondary infections are present and complicate the evaluations; thus successful identification of the underlying disease will also depend on complete resolution of the secondary infections.

References

1. Rüfenacht S, Roosje PJ, Sager H, Doherr MG, Straub R, Goldinger-Müller

P, Gerber V. Combined moxidectin and environmental therapy do not eliminate Chorioptes bovis infestation in heavily feathered horses. Vet Dermatol. 2011 Feb;22(1):17-23.

2. Mittmann EH, Mömke S, Distl O.Whole-genome scan identifies quantitative trait loci for chronic pastern dermatitis in German draft horses. Mamm Genome. 2010 Feb;21(1-2):95-103.

3. De Cock HE, Affolter VK, Wisner ER, Ferraro GL, MacLachlan NJ. Progressive swelling, hyperkeratosis, and fibrosis of distal limbs in Clydesdales, Shires, and Belgian draft horses, suggestive of primary lymphedema. Lymphat Res Biol. 2003;1(3):191-9.

4. van Brantegem L, de Cock HE, Affolter VK, Duchateau L, Hoogewijs MK, Govaere J, Ferraro GL, Ducatelle R. Antibodies to elastin peptides in sera of Belgian Draught horses with chronic progressive lymphoedema. Equine Vet J. 2007;39(5):418-21.

Rosanna Marsella, DVM, DACVD Dr. Marsella is a graduate of the University of Milano (Italy, 1991).

After graduation, Dr. Marsella worked in private practice for a couple of years and then decided to pursue specialty training in dermatology.

She became a board certified dermatologist in 1996, and soon after accepted a faculty position at Virginia Tech University.

In 1997 she returned to Florida to join the faculty of the University of Florida, where she is a full Professor. Her special area of research interest is allergies and identification of new therapies.

Dr. Marsella is a horse lover and owner, and has a special interest in equine dermatology.

The Practitioner 11

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Achieving Peak Performance in the Equine Athlete

Laminitis Master Class

NEWS HOUR Distinguished Panelists

Christopher Kawcak,

Presented by

Christopher C. Pollitt, BVSc, PhD

DVM, PhD, DACVS, DACVSMR

Margo Lee

Macpherson, DVM, MS, DACT

Robert Mackay, BVSc, PhD, DACVIM

Panelists will review published scientific equine clinical advancements of the past year in: ■Surgery/Lameness ■ Reproduction ■ Internal Medicine

Distinguished Speakers

14 Nationally and Internationally Acclaimed Speakers Presenting 39 hours of Cutting-Edge Continuing Education

Thomas J. Divers, DVM, DACVIM, DACVECC

Melissa R. Mazan, BA, DVM, DACVIM

Alan Nixon, BVSc, PhD

Nicola Pusterla, Dr.med.vet., DACVIM

Sheila Schils, PhD

Jennifer Skeesick, PT, DPT, SCS

Duncan Peters, DVM, MS, DACVSMR

Rob van Wessum, DVM, MS, Cert Pract KNMvD (Equine)

Sarah M. Puchalski, BSc, DVM, DACVR

Mary Beth Whitcomb, DVM, MBA, ECVDI (LA-Assoc)

Preliminary

▶ Diagnostic Imaging

S chedu l

Lecture

Thursday, October 9 Time

Room 1

1:35 p.m. 2:25 p.m.

Neuro Case Studies Dr. MacKay

2:30 p.m. 3:20 p.m.

Neuro Case Studies Dr. MacKay

3:20 p.m. 3:50 p.m.

3:50 p.m. 4:40 p.m.

▶ Lamene

Friday, October 10 Time

Room 1

8:00 a.m. 8:50 a.m.

Room 2

News Hour Dr. Kawcak Dr. MacKay Dr. Macpherson

8:55 a.m. 9:45 a.m.

Break - Visit the Marketplace

What are we Talking About with Lower Airway Disease in Horses? Causes, Diagnosis, and Treatment Dr. Mazan

4:45 p.m. 5:35 p.m.

▶ Internal Medicine

▶ Equine Sports Rehabilitation

Sports Medicine Considerations for the Older Horse – How to Keep the Good Ones Going Dr. Mazan

NEWS HOUR Keep up with the published scientific equine clinical advancements of the past year through brief, yet specific reviews of selected papers presented by our Distinguished FAEP News Hour Speakers at the FAEP’s 10th Annual Promoting Excellence Symposium.

Enjoy the interaction between our distinguished panel members: Christopher Kawcak, DVM, PhD, DACVS, DACVSMR, is Professor in the Department of Clinical Sciences at the College of Veterinary Medicine and Biomedical Sciences, Fort Collins, Colorado.

Margo Lee Macpherson, DVM, MS, DACT, is Professor of Large Animal Reproduction at the University of Florida, Gainesville, Florida.

Robert Mackay, BVSc, PhD, DACVIM, is Professor of Large Animal Medicine at the University of Florida, Gainesville, Florida.

Hear what these well-respected and knowledgeable leaders of the equine profession have to say about the latest important clinical information that practitioners need to know. Many of the featured papers to be discussed are either too brief or too new to be included in this year’s scientific program. This is one news program you will not want to miss!

9:45 a.m. 10:30 a.m.

10:30 a.m. 11:20 a.m.

Break - Visit the Marketplace

Recent Advances in Regenerative Therapies Dr. Kawcak

11:25 a.m. 12:15 p.m.

Suppressing Undesirable Behavior in the Performance Horse Dr. Macpherson

Stifle Injury in the Horse: New Syndromes, Advanced Diagnostics, and Clinical Outcomes

Options for Pregnancy in the Performance Mare Dr. Macpherson

Dr. Nixon 12:15 p.m. 1:35 p.m.

1:35 p.m. 2:25 p.m.

Complimentary Lunch in the Marketplace

Perspectives on Pelvic and Lumbosacroiliac Ultrasonography Dr. Whitcomb

2:30 p.m. 3:20 p.m.

Diagnostic Imaging of the Back and Sacroiliac Region Dr. Puchalski

3:20 p.m. 3:50 p.m.

3:50 p.m. 4:40 p.m.

Newer Findings in Equine Liver Disease Dr. Divers

Equine Lyme Disease Dr. Divers

Break - Visit the Marketplace

Lameness Case Studies Dr. Kawcak

Old and New Challenges of Equine Infectious Respiratory Diseases Dr. Pusterla

4:45 p.m. 5:35 p.m.

5:40 p.m. 6:10 p.m.

Biosecurity in the Equine Practice Dr. Pusterla Emerging Outbreaks Associated with Equine Coronavirus in Adult Horses Dr. Pusterla

Continuing Edu This program has been approved by:  New York State Sponsor of Continuing Education  FL Board of Veterinary Medicine, DBPR FVMA Provider # 31

Pending Race Approval

- American Association of Veterinary State Boards RACE Provider #532

This program has been submitted (but not yet approved) for 39 hours of continuing educa certain categories and/or restrictions on certain methods of delivery of continuing educati

e

A t - A - G l ance

e Topics ▶ Neurology

ess Case Studies

▶ Regenerative Therapies ▶ Reproduction

Saturday, October 11 Time

Room 1

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LAMINITIS MASTER CLASS The Equine Foot: Normal Structure and Function

The Science Behind the Development of Rehabilitation Protocols

Dr. Pollitt

Dr. Schils

LAMINITIS MASTER CLASS Laminitis Theory: An Overview

Comparative Human/Equine Tendon and Ligament Rehabilitation Concepts

Dr. Pollitt

Dr. Skeesick

8:55 a.m. 9:45 a.m.

9:45 a.m. 10:30 a.m.

10:30 a.m. 11:20 a.m.

Room 2

Dr. Pollitt 11:25 a.m. 12:15 p.m.

LAMINITIS MASTER CLASS Chronic Laminitis – The Hidden Dangers Dr. Pollitt

12:15 p.m. 1:35 p.m.

1:35 p.m. 2:25 p.m.

2:30 p.m. 3:20 p.m.

Equine Tendon and Ligament Rehabilitation Concepts

Tendon and Ligament Rehabilitation Case Studies Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

Complimentary Lunch in the Marketplace

Foot MRI - Improving our Understanding of Foot Lameness

Comparative Human/ Equine Back and Neck Rehabilitation Concepts

Dr. Puchalski

Dr. Skeesick

A Clinical Perspective on MRI in Lameness and Surgery of the Foot and Ankle

Equine Back Rehabilitation Concepts

3:20 p.m. 3:50 p.m.

4:45 p.m. 5:35 p.m.

Time

Room 1

8:00 a.m. 8:50 a.m.

Practical Equine Tendon and Ligament Rehabilitation Protocols

8:55 a.m. 9:45 a.m.

Practical Equine Neck and Back Rehabilitation Protocols

Dr. van Wessum

Break - Visit the Marketplace

Ultrasound of the Carpus and Carpal Canal

Equine Neck Rehabilitation Concepts

Dr. Whitcomb

Dr. van Wessum

Carpal Tendon Sheath Diseases - New Syndromes and Approaches to Treatment

Back and Neck Rehabilitation Case Studies

Dr. Nixon

Dr. Peters

Dr. van Wessum

9:45 a.m. 10:05 a.m 10:05 a.m. 10:55 a.m.

Break - Visit the Marketplace

Rehabilitation Case Studies Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

Dr. Peters

Dr. Nixon

3:50 p.m. 4:40 p.m.

Sunday, October 12

Break - Visit the Marketplace

LAMINITIS MASTER CLASS Equine Laminitis – New Therapeutic Options

▶ Surgery

Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

11:00 a.m. 11:50 a.m.

Rehabilitation Case Studies Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

Rehabilitation Protocol Case Studies

Get involved! A panel of our rehabilitation speakers will present a series of case studies with videos. They will follow each horse from diagnosis through the completion of their rehabilitation protocols– what worked, what didn’t, what could have been tried? We want to hear about your experiences and we encourage everyone to participate!

In addition, one of the most distinguished clinicians currently in human rehabilitation will be on hand to discuss another perspective – what would the treatment be if this horse were a human?

Attendees will leave with some solid ideas on protocols that can be used in their practices!

ation credit in jurisdictions which recognize AAVSB RACE approval; however participants should be aware that some boards have limitations on the number of hours accepted in ion. Call Diana Ruiz, FVMA Meetings and Events Coordinator, at (800) 992-3862 for further information. A maximum of 25 credit hours can be earned at this conference.

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Revisiting the Diagnosis and Treatment Options for an Old Problem: Chronic and Post-Breeding Endometritis in the Mare Maria Eugenia Cadario, MV, DVM, MS, DACT One of the most common and frustrating challenges for the clinician during the breeding season is the diagnosis, management and treatment of endometritis. Clinically, endometritis in the mare can be divided into acute or chronic infections, and postbreeding/ post-mating induced endometritis. The most critical predisposing factors in chronic infections or post-mating induced endometritis are compromised integrity of anatomic barriers and insufficient physical clearance of uterine contents.

Repeated foaling and breeding can cause anatomical defects such as poor perineal conformation, incompetent vestibule-vaginal sphincter, vaginal stretching, incompetent cervix and pendulous uterus, all predisposing to chronic infectious endometritis due to re-infection. Mares that are unable to clear the by-products of insemination may quickly develop post-mating induced or acute endometritis. If endometritis is not promptly resolved, the inflammation can become chronic and difficult to overcome with conventional treatments.

Conventional treatments for chronic infectious and noninfectious endometritis are based on the physical elimination of uterine contents by uterine flushing followed by the administration of ecbolic drugs, microorganism control with antibiotics and/ or antifungal drugs, and the surgical correction of predisposing anatomical defects.

Persistent post-mating endometritis (PPME) results from insufficient mechanical uterine defense, including myometrial contractions, cervical relaxation and lymphatic drainage, to eliminate the by-products of inflammation. Their persistence stimulates pro-inflammatory cytokine release, exacerbating the endometritis. The recommended treatment for PPME is based on uterine lavages with lactated ringers solution (LRS) or saline solution in association with the administration of ecbolic drugs such as oxytocin or prostaglandins 4-8 hours post-breeding followed by reevaluation and treatment 24 hours later. In the presence of factors predisposing to infection such as poor perineal conformation and increasing age (> 12 years old), the inclusion of antibiotics in the uterine infusion is recommended.

Conventional treatments are not always successful in the elimination of infectious agents or by-products of inflammation due to: 1.

Reinfection caused by persisting anatomical/functional

defects predisposing to endometritis.

2.

Failure to isolate and identify the acting infectious agent.

3. Infection caused by multiple microorganisms with

different antibiotic sensitivity.

4. Excess of endometrial mucus production or

accumulation impairing the motility of endometrial

cilia necessary for drainage and precluding antibiotics

from reaching therapeutic concentration.

5.

Presence of a bacterial biofilm acting as a reservoir for

microorganisms and increasing their resistance www.faep.netâ&#x20AC;

to antibiotics. Bacterial biofilms consist of a complex bacterial population embedded in a sugar-rich matrix called glycocalix1, 2. The presence of bacterial biofilms is believed to cause a considerable increase in bacterial resistance to antibiotics.

The economic impact of endometritis-associated sub/infertility in the equine industry underscores the need for new methods of diagnosis and treatment.

Chronic Endometritis: New Methods of Diagnosis The diagnosis and successful treatment of chronic endometritis involves endometrial biopsy, low volume lavage for effective bacterial isolation, and the use of non-antibiotic anti-infective agents such as mucolytic agents, buffered chelator solutions, and immunomodulators in combination with targeted-antibiotic treatment. These agents enhance antibiotic penetration, dissolve the excess mucus or biofilm and reduce inflammation. One of the most important factors in perpetuating endometritis and promoting its progression from an acute to a chronic condition is the failure to identify (false positives or false negatives) the causative infectious agent. False positive cultures result from contamination when taking or processing the endometrial sample. Consequently, unnecessary treatment may lead to antibiotic resistance. On the other hand, false negative cultures are associated with inadequate sampling of the endometrial mucosa. It has been shown that only half of the cultures isolated from mares with infectious endometritis were deemed positive3, therefore, the endometrial cultures obtained by swab may be missing about half of the cases of infectious endometritis! Conceivably, microorganisms that are located focally or deeper in the most pendulous part of the uterus are not reached by endometrial swabs that only contact a small area (1 inch) in close proximity to the cervix (Fig. 1.A).

Some microorganisms stimulate excessive production of mucus, whereas others are embedded in a biofilm, commonly Gram negative bacteria such as Pseudomona

Fig. 1.A Methods for the collection of endometrial samples.Endometrial swabs only contact a small area (1 inch) in close proximity to the cervix (courtesy of Dr. Aguilar). Insufficient sampling may result in undiagnosed infectious endometritis.

The Practitionerâ&#x20AC;&#x201A; 21â&#x20AC;&#x201A;

aeruginosa and fungi. Also, some bacteria frequently associated with endometritis (i.e. E.coli & Klebsiella Pneumoniae) impair PMNs uterine response and fluid production, further limiting the isolation of the causative microorganisms and endometrial diagnosis3, 4, 5.

Bacteriological and cytological (presence and number of netrophils) results obtained by endometrial biopsy are the most sensitive indicators bearing positive predictive value (a positive result is indicative of endometritis) compared to results obtained by endometrial swab. Thus, bacteriological and cytological results obtained by endometrial biopsy are considered the “gold standard” in the diagnosis of endoFig. 1.B Methods for the collection of metritis (Fig. 1.B). endometrial samples. Endometrial biopsy

as Streptococcus-β-hemolytic and E. coli in 70% of the cases. To obtain the precipitate, the sample is allowed to settle for at least 30-60 minutes or centrifuged at 400g for 10 minutes and all but 5 ml of the supernatant is discarded. The pellet is then sampled with a sterile cotton swab for culture and another for cytology.

Samples must be processed within 8 hours because saline does not preserve bacteria7. This technique readily identifies the presence of Gram negative bacteria, an advantage over other techniques.

The difficulty lies with the clinical presentation of the endometritis caused by these bacteria, i.e. weak influx of PMNs and decreased uterine fluid production. The cytological evaluation should not only include the presence of PMNs (1 PMN / 40X field is indicative of inflammation), but also the presence of epithelial cells, bacteria and debris to be considered an appropriate sample and to rule out false positive cultures due to contamination (Fig. 3.A).

for microorganism culture and cytology. This is considered to be the method of choice for an accurate diagnosis of infectious endometritis.

The use of low volume flush as a fast and accurate method to obtain endometrial samples for identification of mares with chronic or sub-clinical endometritis has been revisited6, 7. The low volume flush technique was twice as sensitive as endometrial swabbing and nearly as efficient (90%) as endometrial biopsy for the isolation of causative microorganisms in mares with infectious endometritis. This technique can be performed during estrus or diestrus by infusing the uterus with 60-150 ml of sterile saline or LRS. The uterus is massaged by transrectal palpation to distribute the fluid throughout the lumen, Fig. 2.A Low volume flush technique and subsequently, the (courtesy of Dr. LeBlanc). effluent is recovered The effluent from a low volume flush is recovered into a sterile container. into a sterile container (Fig. 2.A). If the mare is in heat and the fluid is trapped in the edematous endometrial folds, the administration of 10 IU oxytocin IV to stimulate uterine drainage through myometrial contractions is recommended.

The recovered effluent is evaluated for cloudiness (cloudy, clear or containing mucus strains) and the Fig. 2.B Low volume flush technique amount of mucus (Fig. 2.B). (courtesy of Dr. LeBlanc). The recovBoth parameters are highly ered effluent from a low volume flush is associated with the isolation evaluated for cloudiness and amount of of microorganisms such mucus.

22 The Practitioner

Fig. 3.A- Microscopic evaluation of endometritis The cytology evaluation when using low volume flush considers 1 PMN / 40X field as indicative of inflammation (courtesy of Dr. Aguilar).

New Strategies for Treatment of Chronic Endometritis Chronic endometrial inflammation/infection produces a uterine response characterized by mucus overproduction by the epithelial cells, transudation of plasma protein and influx of immunoglobulins and PMNs to the uterine lumen8. The persistence of these by-products of inflammation in the uterine lumen for 24-48 hours due to deficiencies in uterine clearance (pendulous uterus, incompetent cervix), may result in endometrial ulceration and secondary bacterial infection. These events are common in chronic and persistent post-mating endometritis. In both cases, the first line of treatment includes uterine lavage with LRS and the administration of ecbolic drugs. This treatment is followed by an intrauterine infusion of the antibiotic of choice for 3-7 days depending on the severity of the condition. Antibiotics are necessary in chronic infectious endometritis and optional in persistent post-mating endometritis (although antibiotics are recommended in mares older than 12 years and/or predisposed to endometritis).

Bacteria with multiple resistance patterns are more frequently isolated from mares previously treated with antibiotics. This finding supports the notion that mucus and biofilm may prevent antibiotics from reaching a therapeutic local concentration.

Therefore, new methods for the treatment of intrauterine microbial infections in the mare should include mucolytic drugs, buffered chelator agents, solvents and immune-modulators.

Mucolytic Agents It has been shown that in chronic obstructive pulmonary disease the chronic, persistent inflammatory process and associated mucus overproduction override the ability of the Issue 1 • 2014

epithelial cilia to mobilize, clear, and expel the mucus and debris. It is speculated that a similar process may occur in the mare’s endometrium with chronic (infectious or not), persistent inflammation (Fig. 3.B).

Fig 3.B- Microscopic evaluation of endometritis Chronic endometrial inflammation produces a uterine response characterized by mucus overproduction by the epithelial cells (courtesy of Dr. Causey).

Some of the new agents used in the treatment of chronic endometritis have mucoactive properties or the ability to alter the excessive mucus production in the uterine lumen9. Mucolytic agents (N-Acetyl-Cysteine), buffered chelator agents (EDTATris) and solvents (DMSO) have been added to the uterine lavage treatment in an attempt to dissolve exudates, mucus or bacterial biofilm. Although preliminary results are promising1, more mechanistic studies are needed.

N-Acetyl-Cysteine (NAC): This mucolytic agent decreases mucus viscosity by reducing the disulfide bonds between mucin polymers. It also has antioxidant and possibly antimicrobial properties. Recently, the local effect of this agent on the mare’s endometrium was evaluated10.

Reproductively normal mares received either a uterine infusion of saline or a solution of NAC at 3.3% on day 1 of the treatment followed by uterine lavage on days 2 and 3 with LRS. On day 4, a uterine biopsy was obtained from both groups. The amount of extracellular mucus decreased in mares treated with NAC compared to mares treated with saline solution1, 10. In addition, treatment with NAC did not compromise the integrity of the endometrium (based on the maintenance of the epithelial cell’s height). In sub-infertile mares, the uterine infusion of a 0.6% NAC solution either on the estrus previous to the estrus used for breeding, or just 48 hours before breeding, improved pregnancy rates 8.

The proposed protocol for the intrauterine therapy using this agent is the infusion of a 3.3% solution of NAC (30 ml of a 20% solution in 150 ml of saline or LRS) on day 1 of the treatment followed by uterine lavage 24 hours later. Removing debris, secretions, exudate, mucus and the potential disruption of the bacterial biofilm may expose otherwise inaccessible microorganisms, so culture of the effluent from this lavage is recommended. In my experience, a higher number of subclinically infected mares that are clinically suspicious, but have a history of false negative cultures, can be detected. In short, the treatment of mares with insufficient uterine clearance or chronic endometritis (with mucus overproduction) using a mucolytic agent as NAC, may help in the clearance of mucus and debris, and by altering the bacterial biofilm increase the level of antibiotic locally available. Of note, oral administration of NAC www.faep.net

does not reduce the viscosity of the uterine mucus, but elicits an anti-inflammatory effect including a decrease in PMNs and prostaglandin production in the endometrium of normal mares during estrus11.

Buffered Chelator Solutions or Agents: EDTA-Tris: Failure of antimicrobial therapy in chronic infectious endometritis could be due to the presence of biofilm, a protective sugar-rich (glycocalix) matrix produced by G- bacteria or fungi that confers microbial resistance 2, 12.

Pseudomona aeruginosa, a potent biofilm producer, is frequently isolated from mares with chronic endometritis. Other biofilm producing pathogens are Staphylococcus epidermis, E. coli, Enterobacter cloacae and some fungi. All these organisms frequently cause endometritis in old, pluriparous mares with anatomic defects. Some of these infections are refractory to the 3-5 days antibiotic treatment which results in subsequent colonization of the uterus with an organism highly resistant to the drug initially used. Buffered chelator agents, such as EDTA-Tris, may potentiate the antibiotic’s effect on the bacteria by increasing their permeability, dissolving exudates and breaking the biofilm.

Kirkland, et al. demonstrated that a “first generation” solution of 3.5 mM of EDTA and 0.05 M of Tris, reduced the in vitro MIC (minimum inhibitory concentration) of a Pseudomonas aeruginosa strain isolated from a mare with endometritis12. A “third generation” solution of the buffered chelating agent (Tricide®) potentiates the effect of antimicrobials against fungal keratitis13. The mechanism of action of these solutions is not completely known, however, it is speculated that they may alter the cell wall integrity after removal of bivalent cations (Ca++ and Mg++) from the outer bacterial membrane increasing the permeability to antibiotics.

Recent studies suggest that intrauterine treatment with EDTATris for 24 hours does not harm the endometrium or affect pregnancy rates in normal mares13. This is important because the volume of infusion should be enough to fill the uterine lumen (250-1,000 ml based on the size) so that microorganisms are reached within minutes. The treatment-induced accumulation of bacterial/cellular debris should be cleared from the uterus by uterine lavage within 24 hours14. The recommended protocol for treating mares with chronic endometritis consists of uterine lavage using LRS followed by uterine infusion with 250-1,000 ml of the buffered chelator solution. It is advised to repeat the lavage 12-24 hours later to remove cellular debris and dead bacteria1, 13.

It is recommended to mix the appropriate antibiotics with the buffered chelator solution in the days following the first treatment (if the post infusion lavage is intended to be used for culture) or from the first day (if bacteria have already been identified). This treatment can be repeated on subsequent days of the same estrus.

Treatment during the same estrus used for breeding may result in pregnancy15, although limitations include increased likelihood of early embryonic death. How long should the treatment last?

Duration of the treatment depends on the chronicity/severity of the case, but it is usually administered for 2-5 days. During the first two days the solution can be used alone and from day 3-5 the antibiotic is infused with or without the solution.

Note: - A buffered chelator solution (EDTA-Tris) can be prepared by following the directions from reference #13.

The Practitioner 23

Commercially prepared: - Tricide TM, Molecular Therapeutics, LLC, Athens, GA. - Tricide Solution (TRIS EDTA for equine use). Rood

and Riddle Veterinary Pharmacy, Lexington, KY. Solvents: Dimethyl sulfoxide (DMSO): This agent is soluble in water and organic material which makes it an excellent solvent. It also has anti-inflammatory and bacteriostatic properties, having bactericidal properties when the concentration is > 10%. Open, sub-fertile mares (n=16) treated post-breeding with an infusion of DMSO at 30% had higher pregnancy rates than those treated with saline solution16. It was also reported that this therapy boosts uterine health by improving endometrial biopsy classification. When solutions of DMSO (25%, 50%, or 75%) were infused into the uterus of clinically normal mares, the examination of serially obtained biopsy specimens revealed epithelial ulceration and stromal inflammation that were proportional to the DMSO concentration infused. In all mares, the endometrium had returned to normal by day 21 after DMSO infusion. The recommended concentration for intrauterine treatment with DMSO solution is at 30% (33 ml of DMSO at 90% in 64 ml of saline solution).

New Strategies for the Treatment of Post-breeding or Post-mating Endometritis The traditional treatment for post-mating endometritis aims to improve uterine clearance through uterine lavage with LRS or saline, followed by the administration of oxytocin (10-25 UI EV or IM) or cloprostenol (250 µg IM) between 4 and 8 hours post-breeding. New strategies consider the inclusion of carbetocin for uterine contractions, cloprostenol and misoprostol for cervical relaxation, and immunomodulator agents for controlling the endometrial inflammatory reaction.

only improves the conditions for breeding, but also favors the drainage of the by-products of post breeding inflammation.

Steroids and immuno-modulators Glucocorticoids: Most therapies to treat post-mating endometritis are directed at stimulating uterine drainage through uterine contractions and cervical dilation. These therapies are not always successful and alternatives that may further control fluid production by modulating the inflammatory and immune uterine response are being investigated. Recent studies have shown that glucocorticoids and immuno-modulators administered around the time of breeding increase pregnancy rates.

The administration of prednisolone acetate (0.1 mg/ kg every12 hours) to mares with a history of post-mating endometritis, beginning 48 hours before breeding and continuing until ovulation, increases pregnancy rates (20).

Another study showed that a single dose of dexamethasone (50 mg IV) administered 1 hour after breeding in combination with traditional post-breeding treatments (uterine lavage, ecbolic drugs) increased the pregnancy rate in mares having 3 or more risk factors for susceptibility to endometritis21. These risk factors included: history of post-mating endometritis, > 2 cm of intrauterine fluid pre-breeding, history of or a positive uterine culture, abnormal perineal conformation, abnormal cervix, and > 2 cm of intrauterine fluid present 36 hours postbreeding. Ferris and McCue (2010) reported a high incidence of ovulatory failure using multiple doses of dexamethasone during estrus22. A retrospective study to determine if the administration of 50 mg of dexamethasone at breeding interfered with the response to hCG administration was conducted23. Analysis of the data showed that a single dose of dexamethasone does not impair hCG-induced ovulation.

In another study, mares with a history of post-breeding fluid accumulation were administered 10-20 mg of dexamethasone IV at 6-12 hours post-insemination (in combination with traditional treatments) and the resulting pregnancy rates were evaluated24. The pregnancy rate did not increase with this treatment, a finding suggesting that factors such as dose, time, and risk factors for endometritis affect the efficacy of steroid supplementation in mares with post-mating endometritis.

It is expected that the administration of glucocorticoids will help restore homeostasis following uterine inflammation by reducing the overproduction of inflammatory cytokines, modulating endometrial fluid and mucus production1, 25. This treatment is only recommended in mares with a negative culture since glucocorticoids have an immunosuppressant effect that would exacerbate microbial infection.

Oxytocin and Prostaglandin Analogs Carbetocin: (175 µg IV or IM), a synthetic analog of oxytocin, has a half-life of 17 minutes, 2.5 times longer than oxytocin (half-life: 6.8 min,19). It is recommended for mares that accumulate intrauterine fluid pre and post-breeding and respond poorly to the 45 minutes of uterine contractions provided by the administration of intravenous oxytocin (10-20 IU IV). Carbetocin is available in Canada, Mexico and Europe (even approved for animal use), but not in the United States.

Cloprostenol:(250-500 µg/500 Kg IM- Estrumate®) is a synthetic analog of prostaglandin E2 which has utero-tonic properties. It is frequently used to lyse the corpus luteum (CL) and bring the mare back into heat. Cloprostenol is used to expel the intrauterine fluid through a poorly dilated or inefficient cervix (i.e. older maiden mares) by smooth and sustained Immunomodulators: uterine contractions. Another advantage is that its effect lasts On the other side of the spectrum of immunomodulators, longer than oxytocin (4 hours versus 45-60 min). Strong, tonic, there are 2 products in the market (MCW - Mycobacterial oxytocin induced contractions are ineffective in the majority cell wall extract for acronym in English / Settle ® and of these cases. Cloprostenol can only be administered up to 36 EqStim ®) composed of extracts from bacterial cell wall which hours post ovulation without affecting the CL and pregnancy. are believed to induce and increase cell-mediated immunity.

Synthetic Prostaglandin E1: (Misoprostol® 200 µg/3ml A study showed that mares with Streptococcus zooepidemicus ointment) is used for cervical relaxation8. This ointment should induced endometritis, cleared the infection more quickly be applied on the cervical mucosa 2-4 hours before breeding. It when treated with an extract of Mycobacterium phlei (Settle®; is believed that it keeps the cervix relaxed for 8 hours which not Bioniche Animal Health, Bogard, GA) as compared to 24 The Practitioner

Issue 1 • 2014

the untreated group of mares26. Mares with cytological diagnosis of persistent endometritis treated with an extract of Proprionibacterium acnes (EqStim ®; Neogen choir, Lexington, KY) and conventional treatment had higher pregnancy rates and percentage of live foals compared to mares treated with conventional treatment only27. The mechanism of action by which these immune-modulating agents improve pregnancy rates remains undetermined.

Conclusion: There is no silver bullet for treating chronic or post-mating endometritis, and clearly, one size does not fit all. The new diagnostic and treatment methods being developed are to complement, more than replace, the long-established ones.

The new strategies for the treatment of chronic endometritis include the addition of buffered chelating agents to enhance antibiotic penetration, infusions with solvents or mucolytic agents to dissolve the excessive mucus or biofilm, and the addition of antioxidants (such as NAC) to the solutions to reduce inflammation.

Even though the main treatment for post-mating endometritis is still based on improving uterine drainage, administration of immunomodulators appears to increase pregnancy rates through the modulation of the inflammatory response and fluid production.

16- Ley WB, Bowen JM, Sponenberg DP, et al. Dimethyl sulfoxide intrauterine therapy in the mare: Effects uppon endometrial histological features and biopsy classification. Theriogenology. 1989;32:263-276.

17- Bracher V, Neuschaefer A, Allen WR. The effect of intrauterine infusion of kerosene on the endometrium of mares. J Reprod Fertil 1991;44 (Suppl):706-707.

18- LeBlanc MM, McKinnon AO. Breeding the problem mare. In McKinnon AO, Squires EL, Vaala WE, et al editors. Equine Reproduction. Chichester (UK): WileyBlackwell;2011: p 2620-2642.

19- Schramme AR, Pinto CR, Davis J, et al. Pharmacokinetics of carbetocin, a long acting oxytocin analogue, following intravenous administration in horse. Equine Vet J 2008;40:658-661.

20- Papa FO, Dell’aqua Jr JA, Alvarenga MA, et al. Use of corticosteroids therapy on the modulation of uterine inflammatory response after artificial insemination with frozen semen. Pferdeheilkunde 2008;24:79-82.

21- Bucca S, Carli A, Buckley T, et al. The use of dexamethasone administered to mares at breeding time in the modulation of persistent mating induced endometritis.

Theriogenology 2008;70:1093-1100.

22- Ferris RA, McCue PM. The effects of dexamethasone and prednisolone on pituitary and ovarian function in the mare. Equine Vet J. 2010;42(5):438-43.

23- Bucca S, Carli A.Efficacy of human chorionic gonadotropin to induce ovulation in the mare, when associated with a single dose of dexamethasone administered at breeding time. Equine Vet J Suppl 2011;43 Suppl 40:32-4.

24- Vandaele H, Daels P, Piepers S, et al. Effects of post-insemination dexamethasone treatments on pregnancy rates in mares. Anim Reprod Sciences 2010;121(Suppl 1):110-112.

25- Balsamo R, Lanata L, Egan CG. Mucoactive drugs. Eur Respir Rev 2010;19:127-133.

26- Rogan D, Fumuso EA, Rodriguez E, et al. Use of Mycobacterial cell wall extract (MCWE) in susceptible mares to clear experimentally induced endometritis with Streptococcus zooepidemicus. J Equine Vet Sci 2007;27:112-117.

27- Rohrbach BW, Sheerin PC, Cantrel CK, et al. Effect of adjunctive treatment with intravenously administered Propiobacterium acnes on the reproductive performance in mares with persistent endometritis. J A Vet Med Assoc 2007;231;107-113.

Bibliography

1- Lyle SK. Incorporating non-antibiotic anti-infective agents into the treatment of equine endometritis. Clinical Theriogenology 2012;Vol4;3: 386-390.

2- Sedlacek MJ, Walker C. Antibiotic resistance in an in vitro sub gingival biofilm model. Oral Microbiol Immunol 2007;22:333-339.

3- Nielsen JM. Endometritis in the mare: a diagnostic study comparing cultures from swab and biopsy. Theriogenology 2005;64:510-518.

4- Nielsen JM. Troedsson MHT, Pedersen MR, et al. Diagnosis of endometritis in the mare based on bacteriological and cytological examinations of the endometrium: comparison of results obtained by swabs and biopsies. J Equine Vet Sci 2010;30: 27-30.

5- Burleson MD, LeBlanc MM, Ridle WT, et al. Endometrial microbial isolates are associated with different ultrasonographic and endometrial cytology findings in Thoroughbred mares. Equine Reproduction X Proceedings, International Symposium on Equine Reproduction 2010;S103.

6- Ball BA, Shin SJ, Patten WH, et al. Use of low volume uterine flush for microbiologic and cytologic examination of the mare's endometrium. Theriogenology 1988;29:1269-1283.

7- LeBlanc MM. How to perform and interpret findings from a low volume uterine flush. AAEP Proceedings 2011;57:32-36.

8- LeBlanc MM. New treatment strategies for chronic endometritis and post mating endometritis. Clinical Theriogenology 2009 9- Causey RC, Miletello T, O’Donnell L, et al. Pathologic effects of clinical uterine inflammation on the equine endometrial mucosa, in Proceedings. Annual American Association of Equine Practitioners 2008;276-277.

10- Gores-Lindholm, A., Ahlschwede, S., Causey, R., Calderwood-Mays, M. and Le Blanc, M.M. Effect of intra-uterine infusion of diluted N-acetylcysteine on equine endometrium. In: Proceedings of the American Association of Equine Practitioners, 2009; p 326.

11- Witte TS, Melkus E, Walter I, et al. Effects of oral treatment with N-acetylcysteine on the viscosity of intrauterine mucus and endometrial function in estrous mares.

Theriogenology 2012;78(6):1199-208.

12- Kirkland KD, Fales WH, Blanchard TL, et al. The in vitro effects of EDTAtris, EDTA-tris lisozyme, and antimicrobial agents on equine genital isolates of Pseudomona aeruginosa. Theriogenology 1983;20:287-295.

13- Lyle SK, LeBlanc MM, Staempfli SA, et al. How to use a buffered chelator solution for mares with chronic endometritis. Proc Annu Conv Am Assoc Equine Pract 2011;p 16-18 14- B.W. Ritchie. Personal comunication 2009.

15- Lyle SK. Umpublished observations 2012.

www.faep.net

Dr. Maria E. Cadario, MV, DVM, MS, DACT Dr. Maria E. Cadario received her DVM from the National University of Rio Cuarto and practiced equine reproductive medicine in her native Argentina during the initial years following her graduation. Dr. Cadario completed a residency in Theriogenology at the University of Florida, received board certification from the American College of Theriogenology in 1995, and a Master of Science degree from the University of Florida in 1996. She was certified by the Educational Commission for Foreign Veterinary Graduates from the American Veterinary Medical Association in 2000 and was a faculty member in the Department of Large Animal Clinical Sciences, University of Florida, from 1998-2002.

In 2002, Dr. Cadario started an ambulatory practice “Equine Reproduction Specialty Practice” that specializes in Equine Reproduction Veterinary Services and serves the Ocala area in central FL. Dr. Cadario is currently a courtesy faculty for the Practice Based Equine program of the University of Florida.

The Practitioner 25

There is

NO GENERIC ® ADEQUAN Get the facts at www.nogenericadequan.com BRIEF SUMMARY : Adequan® i.m.: For the intramuscular treatment of non-infectious degenerative and/or traumatic joint dysfunction and associated lameness of the carpal and hock joints in horses. There are no known contraindications to the use of intramuscular Adequan® i.m. brand Polysulfated Glycosaminoglycan in horses. Studies have not been conducted to establish safety in breeding horses. Each 5 mL contains 500 mg Polysulfated Glycosaminoglycan. WARNING: 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. Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian.

Adequan® I.A.: For the intra-articular treatment of non-infectious degenerative and/or traumatic joint dysfunction and associated lameness of the carpal joint in horses.

Inflammatory joint reactions and septic arthritis have been reported following administration of Adequan® I.A. Joint sepsis, a rare but potentially life threatening complication, can occur after intra-articular injection. Use only in the carpal joint of horses. Each 1 mL contains 250 mg Polysulfated Glycosaminoglycan.

WARNING: Do not use in horses intended for human consumption. Keep this and all medications out of the reach of children. Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian.

SEE PRODUCT PACKAGE INSERTS FOR FULL PRESCRIBING INFORMATION. Adequan® is a registered trademark of Luitpold Pharmaceuticals, Inc. ©LUITPOLD PHARMACEUTICALS, INC., Animal Health Division, Shirley, NY 11967. AHD 010, Rev. 2/2014

26 The Practitioner

Issue 1 • 2014

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