Practitioner Issue 1, 2017 by FVMA

Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 1 â&#x20AC;¢ 2017

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The President's Line Ruth-Anne Richter, BSc (Hon), DVM, MS - FAEP President

Dear Fellow Equine Practitioners, In this issue, we invite you to make sure you have the date saved and your plans made to join us for the 13th Annual Promoting Excellence Symposium (PES) program being held October 19-22, 2017. Our exceptional CE opportunity in the crown jewel of Florida’s Gulf Coast, Naples, Fla., offers the equine veterinary professional a breathtaking coastal destination where an impressive collective of expert speakers and industry partners will share knowledge and provide us all with a dynamic networking event. PES this year is offering a scientific program delivered by respected leaders in equine veterinary medicine, including Drs. Wayne McIlwraith and Sue Dyson, foremost authorities on lameness. Dr. Dyson and Dr. Lisa Fortier will conduct the FAEP news hour this year; our rehabilitation track team, Dr. Sheila Schils, Dr. Michael Butcher, Dr. Erica McKenzie and Dr. Jennifer Skeesick, will present a four-hour session; and other speakers, including Drs. Amanda House, Amy Johnson, Carter Judy and Meg Sleeper will present on diverse topics including Lyme disease, neck imaging, neurologic emergencies, compassion fatigue, equine asthma syndrome, and more. To round off an excellent curriculum, Ed Bayó, Esq., will present Dispensing Legend Drugs and Laws and Rules Governing the Practice of Veterinary Medicine, CE required for Florida license renewal. We are excited to be able to offer a comprehensive agenda encompassing a multi-disciplinary approach to the care of the equine athlete. We are proud that our symposium has evolved to establish itself as a worldclass CE provider, and we look forward to seeing you in Naples. Our issue’s center spread provides you with all the information about our program, as well as registration, rooming, and special activities we have planned for your relaxation, and pleasure. FAEP is grateful for the backing of our educational partners which enables us to offer quality CE events, and the work of the FVMA staff which makes them happen. We also appreciate your continued support of our conferences, and are very pleased to inform you that we have almost completed the preparations for the 55th Annual Ocala Equine Conference to bring you another exciting program that will include excellent laboratory sessions. Details of OEC 2018 will be presented in the next Practitioner. We welcome your questions, comments and suggestions and encourage you to make contact with our FAEP council members or the FVMA staff.

EXECUTIVE COUNCIL

Ruth-Anne Richter FAEP Council President

Corey Miller,

DVM, MS, DACT FAEP COUNCIL PAST PRESIDENT

Anne L. Moretta, VMD, MS, CVSMT marochel@aol.com

cmiller@emcocala.com

Armon Blair, DVM abeqdoc@aol.com

Jacqueline S. Shellow, DVM, MS REPRESENTATIVE TO FVMA EXECUTIVE BOARD jackie@shellow.com

Adam Cayot, DVM adamcayot@hotmail.com

Mr. Philip J. Hinkle EXECUTIVE DIRECTOR phinkle@fvma.org

Amanda M. House, DVM, DACVIM housea@ufl.edu

Opinions and statements expressed in The Practitioner reflect the views of the contributors and do not represent the official policy of the Florida Association of Equine Practitioners or the Florida Veterinary Medical Association, unless so stated. Placement of an advertisement does not represent the FAEP’s or FVMA’s endorsement of the product or service. FAEP | 7207 MONETARY DRIVE, ORLANDO, FL 32809 | PH: (800) 992-3862 | FAX: (407) 240-3710 | EMAIL: INFO@FVMA.ORG | WEBSITE: WWW.FAEP.NET

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EVERY VETERINARIAN

Can Take Good Dental Radiographs JACK EASLEY | DVM, MS, DABVP(EQ), DAVDC(EQ) Introduction:

For years, equine surgeons have found equine skull radiography to be a valuable tool in the diagnosis and management of dental disease. The excellent contrast between air, bone, soft tissue, and tooth substance make the head an ideal area for radiographic evaluation. Conventional or standard radiographic projections adequately image the lateral aspect of the reserve crown apices, lamina dura denta, alveolar space, and alveolar bones, as well as changes in the associated maxillary, mandible, and sinonasal structures. With these conventional closed-mouth radiographic projections, the erupted crowns and medial roots are obscured by superimposition of the crowns of the opposite dental arcades. Until recently, radiography has been of limited value in the assessments of lesions involving the gingival margins or evaluation of the exposed tooth crown. With the recent introduction of open mouth oblique radiographic views and digital and computer radiography, a more accurate diagnosis of lesions affecting the clinical crowns and entire apex of the cheek teeth can be made. A combination of intraoral and extraoral oblique projections are best at assessing the canine and incisor teeth. Several factors may limit the practitioner from acquiring good quality films (i.e., size of the horse, types of intensifying screens, and films and exposure capabilities of the portable x-ray machine). Some limitations can be overcome by reducing movement of the horse’s head and appropriate positioning of the x-ray cassette and x-ray machine while taking the radiography. The differences in tissue density and the increasing width of the horse’s head from rostral to caudal may require more than one radiographic exposure of the anatomical area to highlight the tissues to be evaluated. With DR and CR, the computer algorithms in the radiographic system can be adjusted to compensate for most variations in tissue thickness. A recent paper by Baratt has been published in the 2016 AAEP Proceedings (2016) on how to improve diagnostic quality of dental radiographs. In order to generate the required image, knowledge of skull anatomy and topographic landmarks is necessary to ensure correct positioning of the x-ray unit, cassettes, and horse’s head. The head is anatomically complex and the use of large cassettes -14“x 17“ (34 cm x 48 cm) – helps maintain spatial relationships when evaluating the radiograph. Coning down on the radiograph will allow better contrast and detail over a smaller area of greater concern. It is helpful to use both right and left projections in order to take advantage of image sharpness and magnification in the location of interest.

Because of age-related changes in the hypsodont teeth of the horse, it is beneficial at times to take lesion-orientated oblique views of the infected area and the opposite (normal) side of the skull to have a comparison film to evaluate. Good quality radiographs can be taken with a high-frequency portable x-ray unit capable of generating 80 kVp and 15 mA. Medium or regular speed rare earth cassettes with fast speed film without a grid can be used with a focal film distance of 60-100 cm. Most of the DR and CR systems on the equine market are well suited to head and dental radiography. A table or headstand with a flat surface (approximately 100 cm off the ground) is used to support the sedated horse’s head. Smaller cassettes are used for lesion oriented oblique films. Wooden or foam blocks are used to position the head and x-ray cassettes. These blocks are also used to support smaller cassettes and to elevate the cassettes to the height of the cheek teeth arcade. Bungee cords are useful to hold cassettes in position. A blindfold or towel placed over the horse’s eyes aids in restraint and helps avoid motion artifacts. Three different 10 cm long sections of PVC pipe can be used as mouth gags. A 7.5 cm diameter section of pipe is used on smaller horses and ponies. This diameter equates to 2 clicks on the standard McPherson mouth speculum. Sections of 9 cm diameter and 11.5 cm diameter PVC pipe are used to wedge the mouth open in larger horses. Two sections of 3 meter long x 0.5 cm diameter cotton or nylon rope are used to steady the horse’s head and/or put traction on the mandible. A cassette holder and suitable radiation protection equipment consisting of gloves, apron, and thyroid guards are used when taking the x-rays. Heavy sedation of the horse is necessary both to safely obtain skull radiographs and to facilitate separation of the maxillae and hemi-mandibles. A combination of xylazine hydrochloride @ .3-.6 mg/kg or detomidine hydrochloride @ 10-20 mcg/Kg with butorphanol tartrate 10 mcg/Kg provides 20-30 minutes of heavy sedation. This allows time for a comfortable and detailed oral examination and relaxed, motionless radiographs with the horse resting its muzzle on the table or headstand. Radiography is often the only imaging modality available and frequently yields an immediate diagnosis. On the other hand, further advanced imaging may be required in patients that are recalcitrant to medical therapy, require extensive surgical intervention, or have a disease that involves more than one tooth. As a general practitioner, it is important to

6 The Practitioner Issue 1 • 2017

understand the limitations of radiography to clearly diagnose equine dental disease. Advanced imaging may be employed to better characterize the extent and exact location of the abnormality, thus allowing a more effective treatment. When deciding whether to perform advanced imaging in dental cases, it is important to realize that CT and MR do not guarantee a precise diagnosis. On the other hand, it is also important to realize that advanced imaging is acceptable to perform even on cases where a confident diagnosis has been made through other modalities.

DENTAL RADIOGRAPHS VIEWS AND TECHNIQUE Lateral Radiographs This view is obtained with the cassette positioned in a vertical plane, as close as possible to the affected side of the head. The rostral aspect of the facial crest is approximately the center of the cheek tooth rows in most horses, and the horizontal x-ray beam should therefore be centered at this point. This view is easy to obtain and is useful for assessment of the paranasal sinuses for masses or fluid lines, which may be caused by empyema due to apical infection of the 3rd to 6th maxillary cheek teeth. The main disadvantage of this view is that the apices of the left and right cheek teeth are superimposed and it is therefore not possible to evaluate individual apices for radiographic changes. 30-45 degree Dorsolateral-Lateral Oblique Radiographs (maxillary cheek teeth apices) This oblique radiographic view separates the left and right maxillary cheek teeth rows, allowing evaluation of individual apices and the surrounding maxilla. The cassette is again positioned in a vertical plane, as close as possible to the affected side of the head. With the mouth opened, this view can also be used to evaluate the reserve crowns and occlusal wear patterns of the cheek teeth. The x-ray tube is positioned at a higher level on the opposite side, with the beam directed 30-45 degrees down from the horizontal and centered at the rostral aspect of the facial crest. The additional presence of slight 5-10 degree) rostro-caudal angulation allows better viewing of the interproximal spaces between cheek teeth.

45-60 degree Ventrolateral-Lateral Oblique Radiographs (mandibular cheek teeth apices) This oblique radiographic view separates the left and right mandibular cheek teeth rows, allowing evaluation of individual apices and the surrounding mandible. For this projection, the cassette is again positioned vertically as close as possible to the affected side. The x-ray tube is positioned at a lower level on the opposite side, and the beam directed 4560 degrees up from the horizontal, centered on the affected tooth. Although increasing the angle gives greater separation of the left and right cheek teeth rows, increasing distortion of the apices also occurs, making dental evaluation more difficult. A larger angle is required to separate the cheek rows in smaller heads where the inter-mandibular distance is short. The thick masseter and pterygoid muscles overlay the caudal 2-3 cheek teeth and some degree of caudal obliquity and increased exposure is usually required to image these apices, as compared to the rostral 3-4 cheek teeth.

Left L45 degree V-LO open mouth

Dorso-Ventral Radiographs This radiographic view is obtained by positioning the cassette underneath and parallel to the hemi-mandibles (the horse’s head can be ‘rested’ on the cassette). The x-ray beam is directed perpendicular to the plate, centered in the midline, at the level of the rostra aspect of the facial crest. Positioning is very important when taking this radiographic view because any lateral distortion from a true DV will cause superimposition of the mandibular and maxillary arcades on

Right L30 degree D-LO open mouth showing apices of L maxillary and crowns of R max. and L mand. teeth

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one side. This view is most useful for evaluating the areas of the ventral conchal sinus (medial compartment of the rostral maxillary sinus), nasal cavity, and nasal septum. Laterally or medially displaced teeth can also be observed from this view; sagittal fractures, and advanced caries of the maxillary cheek teeth can also be detected. The mandibular cheek teeth are not as easily evaluated from this view because the dense cortical bone of the hemi-mandibles overlies their lateral aspects. Transverse fractures of the mandible, and occasionally maxillary bone fractures, may also be observed with this view. The lower jaw can be displaced to one side with the mouth open, allowing unobstructed viewing of the upper cheek teeth. Open-Mouthed Oblique Radiographs (15 degrees ventrolateral-lateral for maxillary erupted crowns, 10-15 degree dorsolateral-lateral for mandibular erupted crowns) These radiographic projections are useful for evaluating the erupted (clinical) crown of the cheek teeth, which are usually not visible on conventional views, due to superimposition of the opposing arcade. A Butler’s gag or hollow PVC pipe is placed between the incisors of the sedated patient to separate the maxillary and mandibular erupted crowns. The direction of the x-ray beam is the opposite of that used for conventional (closed mouth) views and the angle of incidence of the beam is also reduced (i.e., 10-15 degrees). Disorders such as coronal fractures, diastemata and disorders of wear can be well evaluated using these projections.

Intra-Oral Occlusal Radiographs of Incisor Teeth These projections are useful for evaluating the incisors and canines. A small cassette or non-screened film is placed between the incisors and canines, as far caudally as possible, and the x-ray beam is directed at 60-80 degrees to include the reserve crown and apices of the incisors.

Intra-Oral Radiographs of the Cheek Teeth This modified Gibbs technique utilizes a flexible 4”x 8” xray cassette or CR plate and a bisecting angle technique that was perfected by Dr. David Klugh. It provides evaluation of a single tooth from crown to apex. The horse is sedated and a full mouth speculum is used to hold the mouth open. The flexible cassette and film are introduced into the mouth and placed against the teeth to be evaluated. The x-ray beam is directed at a bisecting angle to the teeth and cassette to minimize image distortion. High-quality images of several teeth in a single arcade can be obtained with this technique without superimposition of the opposite arcade.

Inra-oral Radiographs of the cheek teeth

8 The Practitioner Issue 1 • 2017

Mandibular fracture could only be detected on intraoral V-D views.

(Gibbs and Lane, 1987 and Weller et al., 2001). Therefore, in early cases of periapical cheek tooth infection, even experienced clinicians may not be able to definitively identify lesions. Enamel is the densest material in the body. Therefore, the cheek teeth appear as strongly radiodense structures, within which the more radiolucent pulp cavities may be seen running longitudinally. The reserve crown of the cheek tooth is attached to the alveolar bone by the periodontal ligament. The periodontal ligament is evident radiographically as a narrow parallel radiodense rim of cortical bone, the lamina dura denta, which lines the alveolus. Although disruption of this structure is a sign of dental disease, the irregular contour of equine cheek teeth often hides the lamina dura denta of normal teeth. The area of the periodontal ligament may widen due to disease processes, but young horses with newly erupted teeth may also have slightly wider radiolucent areas adjacent to the lamina dura denta in the area of the eruption cysts. Foals are born with 3 deciduous teeth in each row, and these may be identified by their short, spickled roots. The dental sacs in the young horses are large, rounded radiolucent structures with a striated pattern which is due to partially calcified enamel formation. As the dental sacs develop into cheek teeth, their apical areas appear as round, radiolucent areas with a wide periodontal space (eruption cysts). The lamina dura denta is often not visible in the apices of the developing teeth. As the horse ages and the cheek teeth erupt, the true roots (i.e., enamel-free areas) develop and the apices change from rounded to pointed. Bearing in mind that the equine cheek teeth erupt between 1 and 4 years of age, it is a normal feature of young horses to have cheek teeth with variably appearing apical areas. For example, major differences are present between the apices of the third and fourth cheek teeth in a 4-year-old, because the 4th cheek tooth is 3 years older than the 3rd. Consequently, caution must be exercised when comparing the radiographic appearances of adjacent cheek teeth apices in younger horses.

Additional Radiographic Techniques The use of a small metal marker (e.g., paper clip or skin staple) placed over an area of maximal facial swelling can be useful when evaluating radiographic changes suspected to involve the cheek teeth apices, and to assess their likely significance. If an external sinus tract is present, a blunt, malleable metallic probe should be inserted into the tract and the appropriate lateral oblique radiograph taken. This procedure can provide irrefutable evidence of dental disease, identify the affected apical area of the tooth and provide a landmark for surgical approach to the apex. Lateral oblique radiographs often have a degree of rostro-caudal distortion; the horse lowering its head when sedated can cause this. Consequently, if the relationship of the angle of the probe to the angle of the tooth is not clear, a true lateral projection should also be obtained with the probe in situ. The injection of contrast material (e.g., Iohexol (Omnipaque)) into a draining tract can similarly provide valuable diagnostic and spatial information. Radiography of canine and wolf teeth is particularly useful if these structures are unerupted, displaced and/or abnormally angulated, or to provide information to the surgeon prior to attempting extraction. These views should be taken with the affected side next to the cassette and the x-ray beam angled at 10-15 degrees dorsolateral-lateral (to view the maxillary teeth) in order to separate the teeth on the right Radiographic Signs of Dental Disease and left sides. Early periapical infection of the cheek teeth causes the periodontal space to widen and the lamina dura denta beNormal Appearance and Age-Related Variation in comes thin or disappears. When periapical infection has Radiographic Appearance been present for many weeks, the infected apices develop The radiographic appearance of the equine cheek teeth, and lytic changes, especially in mature teeth where the roots are particularly their apices, varies markedly with age; and an well formed. appreciation of the normal variations is required for proper These manifest as periapical radiolucent ‘halos’ and the interpretation of dental radiographs. Most apical infections rounded or ‘clubbed’ appearance of the tooth roots are due occur in young horses when there can be marked differences to gross lyses and destruction of the root structures. In more in the appearance of the apical areas of the different cheek chronic periapical infections, a zone of radiodense sclerosis teeth. Although radiograph is a very specific diagnostic aid usually surrounds the periapical ‘halo’. This is due to new (95% specificity), it is not very sensitive (50% sensitivity), bone deposition around the lytic infected area.

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FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 9

of moderate specificity (86%) (Weller et al., 2001). Because of the major short and long-term consequences of extracting the wrong cheek tooth, it is better to take a conservative approach in such cases if scintigraphy is not available, or if the combined results of these two imaging modalities are unclear. If there is any doubt as to weather a tooth needs to be removed, it is better to err on the side of caution by treating suspected dental infection with systemic antibiotics and re-evaluating radiographically in 4-6 weeks, where changes may have become more marked. References and Suggested Reading

Yearling

23-year-old

More marked sclerosis develops around the apices of all the mandibular and the first 3 maxillary cheek teeth than the caudal maxillary cheek teeth. This is because the mandibular and the first 3 maxillary cheek teeth are positioned in more dense bone than the caudal maxillary cheek teeth, which are situated in thin alveolar bone within the maxillary sinuses. External draining tracts are common with periapical infections of mandibular cheek teeth infections. Occasionally, external draining tracts will occur with rostral maxillary cheek teeth infections. Infections of the caudal maxillary cheek teeth rarely present with an external draining tract unless the teeth are laterally displaced. Soft tissue densities may be apparent in the sinuses if periapical infection of the caudal 3-4 maxillary cheek teeth has occurred. In early cases of dental disease, scintigraphy (which provides a functional image of bone) is proving a useful adjunctive tool to radiography, being highly sensitive (95%), but

Daken SG, Lam R, Rees E, Mumby C, West C, Weller R. Technical set-up and radiation exposure for standing computed tomography of the equine head. Equine vet. Educ. (2014), doi: 10.1111/eve.12127 Ingren CM, Townsend NB. The use of radiography for diagnosis of apical infection of equine cheek teeth Equine vet. Educ/AE. (2016), 448-454 Barakzai S. Radiology and scintigraphy, techniques and normal and abnormal findings. In Proceedings, Am Assoc Equine Pract, Focus on Dentistry, 2006 Baratt RM. How to obtain equine dental radiographs in ambulatory practice. In Proceedings, Am Assoc Equine Pract, Vol 53, 460-465, 2007 Baratt RM. How to improve the diagnostic quality of your dental radiographs. In Proceedings AAEP 2016. Orlando Barakzai SZ. Dental Imaging. In Easley J, Dixon PM, Schumacher J, eds Equine Dentistry 3rd ed, Edinburgh: Saunders/Elsevier, 199-230, 2010 Gibbs C. Dental imaging. In Baker GJ and Easley J, eds. Equine Dentistry. London: WB Saunders, 171-202, 2005 Klugh DO. Intraoral radiology in equine dental disease. Clin Tech Equine Pract, 4:162-170, 2005 Puchalski SM. Computed tomography and ultrasonographic examination of equine dental structure: normal and abnormal findings. In, Proceedings, Am Assoc Equine Pract, Focus on Dentistry, 2006 Salano M, Brawer RS. CT of the equine head: technical considerations, anatomical guide, and selected diseases. Clin Tech Equine Pract, 3:374-388, 2004 Tucker RI, Farrell E. Computed tomography and magnetic resonance imaging of the equine head. Vet Clin North Am, Equine Pract, 17: 131-144, 2001 Weller R, Livesey L, Nuss K, et al. Comparison of radiography and scintography in the diagnosis of dental disorders in the horse. Equine Vet J, 33:49-58, 2001 Veraa S, Voorhout G, Klein WR. Computed tomography of the upper cheek teeth in horses with infundibular changes and apical infection. Equine Veterinary Journal, 41(9):872-876, 2010 Henninger W, Mairi Frame E, Willmann M, et al. CT Features of Alveolitis and Sinusitis in Horses. Vet Radiology Ultrasound 2003;44(3):269-276

10 The Practitioner Issue 1 • 2017

OSPHOSÂŽ (clodronate injection) Townsend NB, Hawkes CS, Rex R, Boden LA and Barakzai SZ. Investigation of the sensitivity and specificity of radiological signs for the diagnosis of periapical infection of equine cheek teeth. Equine Vet J. 43, 170-178 (2011) El-Gendy SA and Alsafy. Nasal and paranasal sinuses of the donkey: Gross anatomy and computed tomography. J. Vet Anatomy, vol. 3 no.1, 2010: 25-41

Jack Easley, DVM, MS, DABVP (Eq), DAVDC (Eq) Dr. Jack Easley received a DVM degree from Tuskegee University in 1976. After completing a Large Animal Internship at Oklahoma State University, he served as an Associate Professor of Surgery at Kansas State University from 1978 to 1980 where he completed an Equine Surgical Residency and received a Masters Degree in Surgery. He was an Associate Professor of Surgery at the Virginia Polytechnic Institute, Virginia-Maryland College of Veterinary Medicine, 1980-1982. In 1982, he was certified as a Diplomate for the American Board of Veterinary Practitioners (Equine) and was recertified in 1992, 2002, and 2012. He most recently has become board certified by the American Veterinary Dental College as an equine dental specialist. Dr. Easley is currently a member of the American Board of Veterinary Specialists Specialty Organizing Committee for the new American Veterinary Dental College (Equine Specialty) and the chairman of the Equine Credentialing Committee for board certification. For over 40 years, Dr. Easley has lectured extensively on, and promoted equine veterinary dentistry throughout the world. He has written hundreds of articles for publication in professional, as well as lay equine journals, textbooks, and periodicals. He serves on the editorial review boards for Equine Veterinary Education, Equine Veterinary Journal, and the Veterinary Dental Journal.

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Dr. Easley resides in Shelbyville, Kentucky, where he owns a private practice emphasizing equine dentistry, oral and maxillofacial surgery, medicine and reproduction. He consults extensively in the areas of dental and maxillofacial surgery and accepts referrals from veterinarians seeking help in these areas.

Bisphosphonate For use in horses only. Brief Summary (For Full Prescribing Information, see package insert) CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: Clodronate disodium is a non-amino, chloro-containing bisphosphonate. Chemically, clodronate disodium is (dichloromethylene) diphosphonic acid disodium salt and is manufactured from the tetrahydrate form. INDICATION: For the control of clinical signs associated with navicular syndrome in horses. CONTRAINDICATIONS: Horses with hypersensitivity to clodronate disodium should not receive OSPHOS. WARNINGS: Do not use in horses intended for human consumption. HUMAN WARNINGS: Not for human use. Keep this and all drugs out of the reach of children. Consult a physician in case of accidental human exposure. PRECAUTIONS: As a class, bisphosphonates may be associated with gastrointestinal and renal toxicity. Sensitivity to drug associated adverse reactions varies with the individual patient. Renal and gastrointestinal adverse reactions may be associated with plasma concentrations of the drug. Bisphosphonates are excreted by the kidney; therefore, conditions causing renal impairment may increase plasma bisphosphonate concentrations resulting in an increased risk for adverse reactions. Concurrent administration of other potentially nephrotoxic drugs should be approached with caution and renal function should be monitored. Use of bisphosphonates in patients with conditions or diseases affecting renal function is not recommended. Administration of bisphosphonates has been associated with abdominal pain (colic), discomfort, and agitation in horses. Clinical signs usually occur shortly after drug administration and may be associated with alterations in intestinal motility. In horses treated with OSPHOS these clinical signs usually began within 2 hours of treatment. Horses should be monitored for at least 2 hours following administration of OSPHOS. Bisphosphonates affect plasma concentrations of some minerals and electrolytes such as calcium, magnesium and potassium, immediately post-treatment, with effects lasting up to several hours. Caution should be used when administering bisphosphonates to horses with conditions affecting mineral or electrolyte homeostasis (e.g. hyperkalemic periodic paralysis, hypocalcemia, etc.). The safe use of OSPHOS has not been evaluated in horses less than 4 years of age. The effect of bisphosphonates on the skeleton of growing horses has not been studied; however, bisphosphonates inhibit osteoclast activity which impacts bone turnover and may affect bone growth. Bisphosphonates should not be used in pregnant or lactating mares, or mares intended for breeding. The safe use of OSPHOS has not been evaluated in breeding horses or pregnant or lactating mares. Bisphosphonates are incorporated into the bone matrix, from where they are gradually released over periods of months to years. The extent of bisphosphonate incorporation into adult bone, and hence, the amount available for release back into the systemic circulation, is directly related to the total dose and duration of bisphosphonate use. Bisphosphonates have been shown to cause fetal developmental abnormalities in laboratory animals. The uptake of bisphosphonates into fetal bone may be greater than into maternal bone creating a possible risk for skeletal or other abnormalities in the fetus. Many drugs, including bisphosphonates, may be excreted in milk and may be absorbed by nursing animals. Increased bone fragility has been observed in animals treated with bisphosphonates at high doses or for long periods of time. Bisphosphonates inhibit bone resorption and decrease bone turnover which may lead to an inability to repair micro damage within the bone. In humans, atypical femur fractures have been reported in patients on long term bisphosphonate therapy; however, a causal relationship has not been established. ADVERSE REACTIONS: The most common adverse reactions reported in the field study were clinical signs of discomfort or nervousness, colic and/or pawing. Other signs reported were lip licking, yawning, head shaking, injection site swelling, and hives/pruritus.

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ULTRASOUND OF MUSCULOSKELETAL INFECTIONS: OSTEOMYELITIS & SYNOVIAL INFECTIONS MARY BETH WHITCOMB | DVM, MBA, ECVDI (LA-ASSOCIATE)

Horses with synovial sepsis and osteomyelitis are frequently encountered by equine veterinarians, and either condition can quickly become career-ending or life-threatening in the horse. If not treated appropriately, worsening infection or extension into adjacent structures can further worsen prognosis.1-4 Although multiple reports have not shown a correlation between time Figure 1: Severe synovial thickening (arrows) in two horses with synovial sepsis of the tibiotarsal joint to diagnosis and survival in (A) and tarsal sheath (B). Minimal effusion (asterisks) is visible in both cases. horses with synovial sepsis,1,2,4 prompt diagnosis and treatment are generally felt to of wound communication to vital structures. Ultrasound be in the patientâ&#x20AC;&#x2122;s best interest. The use of ultrasound to aid is used extensively in horses with wounds, suspect synoin the diagnosis of musculoskeletal injections has mainly vial sepsis, and osteomyelitis at UC Davis, especially when focused on synovial infections,5-8 but ultrasound can also be radiography is equivocal or in regions less amenable to radiographic evaluation. useful in horses with suspect osteomyelitis.5,6,9 Clinical signs of heat, swelling, pain and lameness are associated with musculoskeletal infections; however, each can Synovial Sepsis Extension of wounds to synovial structures is not uncomvary in severity and are not specific for either synovial sepsis mon with traumatic injuries; however, wounds or punctures or osteomyelitis. Evidence of wound communication with bone or synovial structures can be limited during contrast may be absent or not apparent on initial examination. Fluid fistulography, especially in cases where wounds have sealed leakage from a wound following synovial distention is indicover, or in acute cases where tracts are less well marginated. ative of wound-synovial structure communication; however, In cases of osteomyelitis, radiographically apparent bone lysis a negative result can occur in horses where wounds have generally requires 7-10 days for detection. In both instances, sealed over or become occluded. Since most affected horses ultrasound is often useful to detect changes consistent with also have concurrent cellulitis, distention of an infected syosteomyelitis and/or synovial sepsis and to detect evidence novial structure is often obscured on physical examination. This is particularly true in the carpus or tarsus, where multiple synovial structures are at high risk for contamination from wounds and lacerations.5 In such cases, ultrasound is beneficial to help differentiate between primary cellulitis or combined synovial sepsis and cellulitis. Ultrasound can help determine the need for synoviocentesis, prioritize sampling in regions with multiple synovial structures and select a sampling site that maximizes fluid retrieval while avoiding cellulitic regions (Figure 1). A high frequency (7-18 MHz), tendon Figure 2: Septic digital sheath tenosynovitis due to rope burn 3 weeks ago. Synovial membranes are severely inflamed (arrows) and show a lacey, edematous appearance (Image taken at P1C). format, linear transducer is best suited WWW.FAEP.NET |

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FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitionerâ&#x20AC;&#x201A; 13

to evaluate most synovial structures, although a rectal transducer can be used. Basic ultrasonographic parameters include the amount and cellularity of synovial fluid, and the degree and character of synovial thickening. Normal synovial membranes are thin and are often difficult to differentiate from adjacent soft tissues. In many cases, severe effusion is not a typical finding of septic synovial structures;5-7 however, large effusions have been reported.6-8 In our and others’ experience, the most common ultrasonographic feature Figure 3: Tract (arrows) from recent skin wound extends to palmar surface of deep digital flexor of synovial sepsis is severe thicktendon (DDFT) at proximal P2. Synoviocentesis confirmed septic digital sheath tenosynovitis. ening of synovial membranes.5,7,8 Thickened synovium is frequently hypoechoic compared with surrounding tissues and has wounds to underlying synovial structures is consistent with an edematous or lacey appearance (Figure 2). Horses with synovial sepsis or, at a minimum, synovial contamination chronic nonseptic synovitis will also demonstrate synovial (Figure 3). Tracts may not always be visible, especially in the thickening; however, synovial membranes tend to appear acute injury phase, when they can be convoluted and diffimore echogenic and less edematous than in horses with sepsis. cult to follow without careful examination. Tracts typically Synovial fluid is frequently anechoic in horses with sy- appear anechoic to hypoechoic and may contain gas echoes, novial sepsis. In one study, nearly 60% of septic structures especially if the wound tract has been explored or injected showed anechoic effusions.7 The lack of cellular appear- with radiographic contrast agents. It should be noted that ing fluid should therefore not be interpreted as negative for ultrasound can be performed in most horses with recent sepsis; however, echogenic effusions can also be found. The wounds, despite the presence of gas within the subcutaneous ultrasonographic appearance of septic synovial effusions tissues. Over time, tracts generally become more well-defined, can vary with cellularity and the presence of fibrin. Cellular which facilitates their visibility with ultrasound. Granulation -appearing effusions can also result from hemorrhage into tissue often creates concentric rings around older wound synovial structures. Horses with hemorrhagic synovitis tracts to aid in their visualization. Synoviocentesis is indicated in all cases with clinical signs can present with similar clinical signs as synovial sepsis, but or ultrasonographic features of synovial sepsis; however, this synoviocentesis is generally contraindicated. Ultrasonographic visibility of a tract extending from skin can be complicated by the relative lack of synovial fluid and

Figure 4: A) Scapular osteomyelitis in a foal showing thickened or “fluffy” infected bone (small arrows) with an anechoic layer (arrowhead) overlying normal (large arrow) & abnormal bone. B) Periosteal elevation creating a bilayered appearance in a foal with osteomyelitis of the greater tubercle.

14 The Practitioner Issue 1 • 2017

Figure 5 : A) Proliferative appearance (arrows) of infected bone is consistent with osteomyelitis while same day radiographs (B) show only a subtle lytic area at proximal P1 in a horse with severe lameness. Repeat radiographs 1 week later confirm osteomyelitis and appear similar to Day 1 ultrasound.

the presence of inflamed synovial membranes. This is not surprising given the difficulty often encountered when aspirating septic joints or tendon sheaths in the clinical setting. Ultrasound is extremely useful in such instances to identify the optimal location for synoviocentesis and to guide needles into small fluid pockets (see Figure 1).

(Figure 5). Treatment could be compromised in such patients if anti-microbials are not instituted until radiographic evidence of osteomyelitis becomes apparent. In more advanced cases, large destructive lesions may be seen as large, irregularly shaped cortical defects. Overlying abscessation may also be detected (Figure 6). Depending on anatomic radiographic visibility, ultrasonography is not typiOsteomyelitis cally necessary for diagnosis at this stage of infection; howUltrasound is useful to evaluate bone for evidence of os- ever, ultrasound-guidance is useful to obtain fluid samples teomyelitis and may be superior to radiography for its early for culture and sensitivity. Bony sequestra can sometimes detection. Radiographic evidence of osteomyelitis can be be difficult to distinguish from lone osteomyelitis, especially detected within 7-10 days, whereas ultrasound can detect in cases without significant distraction of the fracture fragperiosteal changes within a few days and even sooner if direct ment from the parent bone. Ultrasonographic localization wound-bone communication is apparent. Early ultrasono- of foreign bodies or bony sequestra can help to establish graphic evidence of osteomyelitis consists of a “fluffy” or a plan for surgical removal, with or without ultrasoundthickened periosteal surface. A thin anechoic layer is often guidance. In horses with upper limb infections, such as visible overlying abnormal bone and typically extends be- scapular osteomyelitis, open tuber coxae or tuber ischii yond the irregular bony surface (Figure 4A). Aspiration of fractures, ultrasound often has significant advantages over this layer can be attempted, but rarely yields fluid in the author’s experience. In some early cases, periosteal elevation can be detected that will create a bilayered appearance on ultrasound (Figure 4B). Subperiosteal or subchondral lysis may also be visible. In cases where concurrent radiography fails to confirm ultrasonographic findings, treatment should remain directed at controlling infection. In most cases, repeat radiography in Figure 6 : A) Proximal P1 sequestrum (arrow) with overlying abscess formation (arrowheads) in a foal with fet5-7 days will confirm the lock swelling. B) Ultrasound-guided aspiration yielded fluid that cultured positive for R. Equi. Arrows=needle. diagnosis of osteomyelitis WWW.FAEP.NET |

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FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 15

radiography, regardless of the stage of infection. Ultrasound Previously published in the ACVS Proceedings. is also surprisingly helpful with osseous infections involving the skull, where it can be difficult to obtain the proper angle References 1. Post EM, Singer ER, Clegg PD, et al. Retrospective study on skull radiographs to detect some bony lesions. of 24 cases of septic calcaneal bursitis in the horse. Equine Conditions that can be misinterpreted as osteomyelitis inVet J. 2003;35:662-668. clude traumatic periosteitis, callus formation during normal 2. Wereszka MM, White NA, Furr MO. Factors associated fracture healing and the normal appearance of cartilage and with outcome following treatment of horses with septic subchondral bone in immature animals. Foals have large tenosynovitis: 51 cases (1986-2003). J Am Vet Med Assoc. 2007;230:1195-1200. “cartilage caps,” especially of tuberosities, and thick cartilage in many joints. Cartilage has an anechoic appearance with pin- 3. Wright IM, Smith MR, Humphrey DJ, et al. Endoscopic surgery in the treatment of contaminated and infected point hyperechoic specks that could be mistaken for purulent synovial cavities. Equine Vet J. 2003;35:613-619. material. Additionally, the normal underlying subchondral 4. Walmsley EA, Anderson GA, Muurlink MA, et al. bone can show an irregular appearance and could erroneRetrospective investigation of prognostic indicators for ously be mistaken for infection (Figure 7A). Comparison to adult horses with infection of a synovial structure. Aust Vet J. 2011;89(6):226-31. the contralateral limb will readily clarify these findings. In 5. Whitcomb MB. Ultrasonography of the equine tarsus. In horses with healing fractures, callus formation can produce a Proceedings. Am Assoc Equine Pract 2006;13-30. “fluffy” appearance to bony surfaces at fracture sites (Figure 6. Whitcomb MB, le Jeune SS, MacDonald MM, et al. 7B). While this could also be misinterpreted as infection, Disorders of the infraspinatus tendon and bursa in three history and clinical signs should guide the diagnosis in such horses. J Am Vet Med Assoc. 2006;229:549-556. cases. Traumatic periosteitis may also create this appearance. 7. Young A, Whitcomb MB, Vaughan M, et al.

Ultrasonographic features of septic synovial structures in 62 horses (2004-09). In Proceedings: Am Assoc Equine Pract 2010;56:238 8. Beccati F, Gialletti R, Passamonti F, et al. Ultrasonographic findings in 38 horses with septic arthritis/tenosynovitis. Vet Radiol Ultrasound. 2015;56(1):68-76. 9. Swinebroad EL, Dabareiner RM, Swor TM, et al. Osteomyelitis secondary to trauma involving the proximal end of the radius in horses: five cases (1987-2001). J Am Vet Med Assoc. 2003;223:486-91.

Figure 7 : A) Cartilage (IT) & subchondral bone (arrows) of the normal intermediate tubercle in a foal. LL=lateral lobe, ML=medial lobe of biceps tendon.

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

Figure 7 : B) Callus of a 30d scapular fracture in an adult horse. Neither should be mistaken for osteomyelitis.

Dr. Mary Beth Whitcomb received her DVM from UC Davis in 1996, completed an equine internship at Las Colinas Veterinary Clinic in 1997, and a fellowship in Large Animal Ultrasound & Cardiology at the University of Pennsylvania in 1999. She then returned to UC Davis to lead the Large Animal Ultrasound Service where she is currently an Associate Professor. Along with faculty colleague Dr. Betsy Vaughan and large animal ultrasound fellows, the Large Animal Ultrasound Service evaluates 1000-1300 equine cases annually and trains 20-30 equine veterinary students. The caseload at UC Davis ranges from high-level performance horses, to rodeo horses, to backyard pets, evaluated for lameness, surgical and internal medicine problems. Dr. Whitcomb is a Large Animal Associate Member of the European College of Veterinary Diagnostic Imaging, member of the ACVR Large Animal Diagnostic Imaging Society, and recently received her MBA from the UC Davis Graduate School of Management in 2013. She has delivered over 400 presentation at the national and international levels and is known for her creative use of 3D and 2D simulations to teach ultrasound to veterinarians of all skill levels. Dr. Whitcomb is author or coauthor of over 40 publications and book chapters on multiple large animal ultrasound topics.

16 The Practitioner Issue 1 • 2017

YOUR INVITATION

TO ATTEND THE

ANNUAL

PROMOTING EXCELLENCE

SYMPOSIUM

OCTOBER 19-22, 2017

NAPLES GRANDE BEACH RESORT NAPLES, FLORIDA

A MULTI-DISCIPLINARY APPROACH TO THE EQUINE ATHLETE

EDWIN BAYÓ JD

MICHAEL T. BUTCHER PhD

SUE DYSON MA, VetMB, PhD, DEO, FRCVS

LISA FORTIER DVM, PhD, DACVS

AMANDA HOUSE DVM, DACVIM

AMY JOHNSON DVM, DACVIM (Large Animal), DACVIM (Neurology)

CARTER JUDY DVM, DACVS

WAYNE MCILWRAITH BCSc, MS, PhD, DVM, DSc, DACVS, DECVS, DACVSMR

ERICA MCKENZIE BSc, BVMS, PhD, DACVIM, DACVSMR

SHEILA SCHILS MS, PhD

MEG SLEEPER VMD, DACVIM (Cardiology)

JENNIFER SKEESICK PT, DPT, SCS

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Dispensing Legend Drugs & Laws and Rules Governing the Practice of Veterinary Medicine Satisfy Florida’s Mandatory CE Requirements - Edwin Bayó, JD

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NEWS HOUR FRIDAY, OCTOBER 20 | 8:00 AM-9:45 AM

DISTINGUISHED PANELISTS Panelists will review published scientific equine clinical advancements of the past year in: ■ Lameness ■ Regenerative Medicine

Sue Dyson

MA, VetMB, PhD, DEO, FRCVS

Lisa Fortier

DVM, PhD, DACVS

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PRELIMINARY SCHED 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 13th Annual Promoting Excellence Symposium.

Friday, October 20 Time

8:00 a.m. 9:45 a.m.

Dr. Dyson and Dr. Fortier

A discussion of current topics on lameness and regenerative medicine. LISA FORTIER DVM, PhD, DACVS

9:45 a.m. - 10:30 a.m. Break - Visit the Exhibit Hall

Common and Uncommon Pathologies of the Digital Tendon Sheath and Fetlock Region Dr. Judy

Thursday, October 19 Time

NEWS HOUR

SUE DYSON MA, VetMB, PhD, DEO, FRCVS

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

Lisa Fortier, DVM, PhD, DACVS

Room 2

FAEP News Hour

Enjoy the interaction between our distinguished panel members: Sue Dyson, MA, VetMB, PhD, DEO, FRCVS

Room 1

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

The Complex Lameness Evaluation Dr. Judy

Breaking the Silence: Disclosing Medical Errors Dr. House Cough, Wheeze or Crackle: An Update on Equine Asthma Syndrome Dr. House

12:15 p.m. - 1:45 p.m. Complimentary Lunch in the Exhibit Hall

Room 1

1:45 p.m. 2:35 p.m.

Lyme Disease and Botulism in Horses - What Is the Clinical Relevance? Dr. Johnson

1:45 p.m. 2:35 p.m.

2:40 p.m. 3:30 p.m.

Options for Neck Imaging: Radiographs to Robotic CT - What Can We Learn? Dr. Johnson

2:40 p.m. 3:30 p.m.

Can We Determine the Presence of Musculoskeletal Pain in Ridden Horses by Facial Expression or Behaviour? Dr. Dyson Idiopathic Hopping-Type Forelimb Lameness in Ridden Horses Dr. Dyson 3:30 p.m. - 4:00 p.m. Break - Visit the Exhibit Hall

3:30 p.m. - 4:00 p.m. Break 4:00 p.m. 4:50 p.m.

4:55 p.m. 5:45 p.m.

Tips for Handling Neurologic Emergencies in the Field

4:00 p.m. 4:50 p.m.

How Do Stem Cells Work in OA?

Equine Rhythm Assessment

Dr. Fortier

Dr. Sleeper

4:55 p.m. 5:45 p.m.

Differences Between PRP, IRAP, and BMC - Implications for Clinical Application

Treatment of Equine Arrhythmias

Dr. Johnson Compassion Fatigue: Managing and Prioritizing Wellness

Dr. Fortier

Dr. House 5:45 p.m. - 7:00 p.m. Reception - Exhibit Hall

Dr. Sleeper

5:45 p.m. - 7:00 p.m. Reception - Exhibit Hall

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DULE AT-A-GLANCE Saturday, October 21 Time

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Sunday, October 22

Room 2

Time

7:00 a.m. 7:50 a.m.

Dispensing Legend Drugs Mr. Bayó (Satisfies Florida’s 1-hour CE requirement for Dispensing Legend Drugs)

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

Some Observations of WarmUp, the Approach, Take-Off and Landing in Showjumpers Dr. Dyson

Whole Horse Biomechanics and Kinesiology With an Emphasis on Equine Injury Prevention and Rehabilitation

Range of Motion of the Thoracolumbosacral Vertebral Column and Body Lean in Lame and Non-Lame Horses Dr. Dyson

Focus on What Current Research Has Shown About the Structure and Function of the Lower Limbs

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

(PROGRAM SUBJECT TO CHANGE)

Dr. Schils

Dr. Butcher

Room 1

Florida Laws & Rules Governing the Practice of Veterinary Medicine Mr. Bayó (Satisfies Florida’s 2-hour CE requirement for Florida Laws & Rules Governing the Practice of Veterinary Medicine)

7:00 a.m. 8:50 a.m.

Rehabilitation Case Studies I

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

Dr. Schils, Dr. Butcher, Dr. McKenzie, Dr. Skeesick 9:45 a.m. - 10:30 a.m. Break - Visit the Exhibit Hall

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

Rehabilitation Case Studies II

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

Rehabilitation Case Studies III

12:20 p.m. 1:15 p.m.

Rehabilitation Case Studies IV

9:45 a.m. - 10:30 a.m. Break - Visit the Exhibit Hall 10:30 a.m. 11:20 a.m.

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

Current Status of Conventional Treatments for Traumatic Joint Disease Dr. McIlwraith New Biologic Protein Therapies in the Treatment of Equine Traumatic Joint Disease Dr. McIlwraith

Exercise Physiology: The Importance of Warm-Up and Its Role in Injury Reduction Dr. McKenzie Current Topics in Human Physical Therapy and Rehabilitation and the Factors that Contribute to Injury Prevention and Decisions to Return to Sport After Injury Dr. Skeesik

Dr. Schils, Dr. Butcher, Dr. McKenzie, Dr. Skeesick

Rehabilitation CASE STUDIES

12:15 p.m. - 1:35 p.m. Complimentary Lunch in the Exhibit Hall 1:35 p.m. 2:25 p.m.

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

Soft Tissue Injuries of the Hock Dr. Dyson How Useful Is Nuclear Scintigraphy in the Diagnosis of Lameness or Poor Performance in Sports Horses? Dr. Dyson

The Development of Training Programs to Reduce Injury and of Specific Rehabilitation Protocols When Injury Occurs Dr. Schils Gait Mechanics and Locomotor Economy in Horses Dr. Butcher

3:20 p.m. - 4:20 p.m. Break - Visit the Exhibit Hall 4:20 p.m. 5:10 p.m.

5:15 p.m. 6:05 p.m.

eing available for the subject

anagement/ dictions which ts

Mesenchymal Stem Cells – Appropriate Use in Equine Joint Disease

Muscular Causes of Poor Performance: Evaluation, Rehabilitation and Prevention

Dr. McIlwraith

Dr. McKenzie

Interactive Lameness Panel

The Multi-Factorial Approach to Human Sports Medicine Rehabilitation and How it Relates to Equine Athletes Dr. Skeesick

Dr. McIlwraith and Dr. Judy In part by

Case studies will be presented by each speaker which will follow the progression from diagnosis through the rehabilitation process. The focus will be on the following: 1. Preventing injury and improving poor performance. 2. Science-based rehabilitation protocols when injury occurs.

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

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13TH ANNUAL PROMOTING EXCELLENCE SYMPOSIUM

OCTOBER 19-22, 2017

OCTOBER 19-22, 2017 • NAPLES GRANDE BEACH RESORT, NAPLES, FLORIDA

th ANNUAL PR O M O T I N G E XC E L L E N C E

OCALA IS KNOWN AS THE HORSE CAPITAL OF THE WORLD. WE CALL IT OUR BACKYARD.

North Central Florida is home to over 600 horse farms. And the University of Florida College of Veterinary Medicine is right in the middle of it. Our large animal hospital in Gainesville offers everything from advanced imaging modalities, such as MRI and CT, to evaluating poor performance and comprehensive lameness of the equine athlete, to neonatal intensive care staffed by board-certified veterinarians 24 hours a day, seven days a week. For more than 40 years, weâ&#x20AC;&#x2122;ve been making a difference in the health of animals, humans and the environment. To get the full story, visit vetmed.ufl.edu and watch our Challenge Accepted video.

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Equine Infectious Endometritis – Diagnosis and Treatment PATRICK M. MCCUE, DVM, PHD, DACT; RYAN A. FERRIS, DVM, MS, DACT Bacterial Endometritis

Diagnosis of Bacterial Endometritis

Bacterial endometritis is a significant cause of decreased reproductive performance in mares due to failure of conception or early embryonic loss. Mares with acute endometritis may exhibit a premature return to estrus after ovulation, due to a shortened luteal phase, secondary to early release of prostaglandins from the inflamed endometrium. A majority of young mares rapidly eliminate bacterial contamination of the uterus following mating, parturition, intrauterine manipulations or other events. In contrast, some older multiparous mares may be unable to eliminate pathogenic organisms from their uterus and are considered to be ‘susceptible’ to infection. Factors predisposing mares to uterine infections include contamination at breeding, pooling of urine in the anterior vagina and uterus, trauma from parturition or breeding, and failure of natural uterine defense mechanisms. Poor perineal conformation, decreased muscular tone of the vulva and cranial displacement of the anal sphincter may lead to aspiration of air, fecal material and bacteria into the reproductive tract. Physical barriers to infection of the reproductive tract of the mare are the vulva, vestibule-vaginal fold and cervix. A compromise in the integrity of any of these barriers will predispose mares to a uterine infection. Uterine defense mechanisms of the mare include phagocytotic elimination of bacteria by neutrophils, local uterine antibody-mediated immunity, and physical clearance of bacteria and inflammatory products from the uterus.

Cytologic examination of an endometrial swab or brush sample may reveal an increase in neutrophils (>5 neutrophils per high power field or more than 1 neutrophil per 10 endometrial epithelial cells) and may reveal the presence of bacterial organisms (Figure 1). Mares with a Streptococcus sp. infection are more likely to have a significant uterine inflammatory response than mares infected with Escherichia coli. A uterine culture can be used to detect the presence of a specific organism and antibiotic susceptibility tests can subsequently be determined. In general, microbial growth occurs on approximately 30 % of uterine cultures. Of the positive cases, a mixed growth of more than one organism occurs about 20 % of the time. The most common bacterial organisms cultured from mares with chronic endometritis are Streptococcus equi subspecies zooepidemicus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and possibly Staphylococcus aureus. Anaerobic infections of the equine uterus have also been described. S. zooepidemicus is the most common organism associated with equine endometritis. E. coli infections are often associated with anatomic defects that predispose a mare to pneumovagina and fecal contamination. Pseudomonas and Klebsiella are most commonly recovered in susceptible mares that have been repeatedly treated with intrauterine antibiotics. The most common anaerobic organism cultured from the equine uterus is Bacteroides fragilis. It is becoming more common for veterinary practices to

Figure 1. Double-guarded uterine cytology brush (left image) and a uterine cytology sample stained with Diff-Quick showing chains of cocci (arrow) and inflammatory cells (right image).

22 The Practitioner Issue 1 • 2017

A Caslick procedure should be performed to prevent reinfection if either the perineal conformation is poor or the muscular tone of the labia is inadequate. An empirical choice of antibiotics may be made initially, but further treatment should be based on culture and in vitro sensitivity tests. Antibiotics are often diluted to a volume of 20 to 50 ml in sterile saline or sterile water to enhance distribution through the uterine lumen. The duration of local antibiotic treatment depends on the severity of the disease and the response to Figure 2. Microbial culture of Streptococcus equi subspecies zooepidemicus (left image) and treatment. Protocols range from Escherichia coli (right image) on Quad Plates. Note the growth of blue colonies on the Grama single infusion to a 3 to 5 day positive chromogenic agar (black arrow) for S. zooepidemicus and the growth of pink colonies course of daily treatments (Table on the Gram-negative chromogenic agar (red arrow) for E. coli. 1). It should be noted that the commercial enrofloxacin product (Bayperform their own in-house uterine cultures. The primary tril® 100, Bayer HealthCare LLC, Shawnee Mission, KS) advantages are a faster determination of the status of the should not be infused into the uterus of a mare, due to mare (i.e. ‘clean’ culture vs. presence of bacteria) and earlier the propensity for causing severe inflammatory reaction possibility of appropriate intervention on infected mares. in the uterus. Adding a small microbiology laboratory can also be a profit Systemic antibiotic administration may be used alone or center for a practice. It is our recommendation that uterine in conjunction with intrauterine administration of antibiotculture swabs be applied to each quadrant of a ‘Quad plate’ ics, uterine lavage, etc. for the treatment of bacterial endo(Spectrum- Duo Gram Selective Culture System, VETLAB, metritis. The most commonly administered systemic antiPalmetto Bay, FL) consisting of TSA blood agar, MacConkey biotics are ceftiofur crystalline free acid (Excede®, Zoetis agar, and both Gram-positive and Gram-negative chromo- Inc., Kalamazoo MI) and enrofloxacin (Table 2). Possible genic agars (Figure 2). alternatives for susceptible organisms are trimethoprimAn additional advantage of an in-house microbiology sulfamethoxazole or a combination of penicillin and an laboratory is the ability to perform an antimicrobial sus- aminoglycoside, such as gentamicin. ceptibility test (AST) if an organism is detected. An AST Other treatments for infectious endometritis have should ideally be performed on all Gram-negative isolates included intrauterine infusion autologous plasma, DMSO, as susceptibility patterns are not always predictable (Figure disinfectants, antiseptics, peroxide, povidone-iodine, ozone, 3). Polymerase chain reaction (PCR) analysis may be help- Tris-EDTA, antimicrobial peptides, and other substances, ful in the detection of DNA from microbial organisms in as well as systemic administration of Propionibacterium uterine samples. It is likely that PCR will be commonly acnes as an immunostimulant. used in the future as a primary means to detect the presence or absence of microbial DNA in the uterus. Genetic profiling may eventually be useful in predicting antimicrobial susceptibility patterns for equine pathogens. A lowvolume uterine lavage can be helpful in providing samples for culture, cytology or PCR analysis, in the event that standard uterine swab samples are unable to detect the presence of bacteria or inflammation in a mare suspected of a uterine infection.

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Treatment of Bacterial Endometritis Numerous protocols exist for treatment of endometritis. The general principles of a treatment regimen are to remove the source of infection, aid in physical clearance of the uterus, eliminate pathogenic organisms by local infusion with antimicrobial agents or systemic administration of antibiotics, and reduce future contamination by enhanced reproductive management. WWW.FAEP.NET |

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Figure 3. Antimicrobial susceptibility test for Pseudomonas aeruginosa. The organism was most sensitive to ciprofloxacin and not sensitive to gentamicin or amikacin.

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Table 1. Dosages of antibiotics used for intrauterine infusion. Medication

Dosage

Amikacin sulfate

1 to 2 grams; buffer with 10 to 20 mls sodium bicarbonate (8.4 %) then q.s. to 50 to mls with sterile saline

Ampicillin

1 to 2 grams, reconstitute in 50 mls sterile saline

Ceftiofur

1 gram, reconstitute with 20 to 50 mls sterile water

Ciprofloxacin

400 mg, reconstitute in 50 mls sterile saline

Gentamicin

1 to 2 grams; buffer with 10 to 20 mls of 8.4 % sodium bicarbonate; qs to 50 mls sterile saline

Penicillin (Potassium)

5 million units; reconstitute in 50 mls sterile saline

Penicillin (Procaine)

15 mls; dilute to 50 mls in sterile saline

Ticarcillin / Clavulanic acid

3.1 grams; reconstitute to 50 mls with sterile saline

Table 2. Systemic antibiotics used in the treatment of bacterial endometritis. Medication

Dosage

Route and Frequency

Ceftiofur crystalline free acid (CCFA)

6.6 mg/kg

IM; q 4 days

Ceftiofur sodium

1.1-2.2 mg/kg

IV or IM; q 12 h

Enrofloxacin

5 mg/kg (IV) 7.5 mg/kg (PO)

IV or PO; q 24 h

Gentamicin

6.6 mg/kg

IV: q 24h

Penicillin (Procaine)

22,000 IU/kg

IM; q 12h

Trimethoprim-Sulfamethoxazole

30 mg/kg

PO; q 12h

A major area of concern is the ability of certain bacteria to produce a biofilm which protects the bacteria against the host immune system and therapeutic agents. The clinical consequence of a bacterial biofilm is often a chronic infection that does not respond to traditional antimicrobial therapy. Local infusion of substances to reduce or eliminate biofilm may be an important component in the overall treatment strategy for infectious endometritis. Recent research has shown that addition of Tris-EDTA or DMSO to certain antibiotics enhances bacterial killing and disruption of biofilm, as compared to treatment with the non-antibiotic agent alone, or the antibiotic alone. Acetylcysteine should not be mixed with antibiotics. It should be noted that an antimicrobial susceptibility test should still be performed and an antibiotic selected that exhibits

in vitro susceptibility against the cultured organism. Our current recommendations for treatment of chronic uterine infections associated with a biofilm are: 1. Culture the mare to identify the bacterial organism 2. Perform an antimicrobial susceptibility test to determine the optimal antibiotic 3. Perform a uterine lavage, as needed to remove as much inflammatory debris, etc. as possible 4. Combine an appropriate antibiotic with a non-antibiotic agent, such as Tris-EDTA or DMSO, in the same syringe (see the Table 3 below) a. TRIZEDTA, Dechra Veterinary Products b. DMSO 99 % purity, FWI, Inc 5. Infuse the combination once per day for 3 consecutive days

24 The Practitioner Issue 1 • 2017

Table 3. Instructions on preparation of antibiotic plus Tris-EDTA or DMSO for treatment of equine uterine bacterial infections associated with a biofilm. Tris EDTA

 Final concentration in the syringe should be 50 mM Tris and 3.5 mM EDTA  Tris-EDTA and Tricide are similar; however Tricide is not equivalent to Tris-EDTA in regards to bacterial killing

 To make Tris-EDTA: 16oz bottle of Dechra Triz-EDTA crystals; add 8 oz of sterile water (this is different than the bottle instructions).  The 2x concentration of Tris-EDTA solution will be further diluted by the antibiotics below to the proper final concentration.

Antibiotic

Drug Amount

Tris EDTA

Final volume

Notes:

60 mls

10 mls of 8.4% sodium bicarbonate should be added to the amikacin

Amikacin (250 mg/ml)

4 mls (1 gram)

30 mls

16 mls sterile fluid (Saline, LRS, Sterile H2O)

Ceftiofur (1 gram reconstituted in 20 mls)

20 mls (1 gram)

30 mls

10 mls sterile fluid (Sterile H2O)

60 mls

Ciprofloxacin (10 mg/ml)

40 mls (400 mg)

40 mls

80 mls

Split between two syringes

Notes:

DMSO

 30 % final concentration in the syringe  Start with a 99 % stock solution for calculations below

Antibiotic

Drug Amount

DMSO

Final volume

Ceftiofur (1 gram reconstituted in 20 mls)

20 mls (1 gram)

20 mls

20 mls sterile fluid (Sterile H2O)

60 mls

Ciprofloxacin (10 mg/ml)

40 mls (400 mg)

20 mls

60 mls

Fungal Endometritis Fungal organisms are reported to occur in 1 to 5% of all mares diagnosed with infectious endometritis, and the most commonly cultured organisms are Candida spp., Aspergillus spp., and Mucor spp. Physical conditions such as pneumovagina, urovagina, decreased uterine fluid clearance, cervical defects, immunosuppression, and perineal

defects may predispose mares to uterine fungal infections. It has also been hypothesized that the use of intrauterine antibiotics may increase the incidence of uterine contamination with fungal organisms from repeated breach of the cervix or may alter the normal bacterial flora of the caudal reproductive tract and facilitate fungal colonization of the vaginal vault, clitoral fossa, and clitoral sinuses.

Figure 5. Endometrial cytology with hyphate fungal organisms (Aspergillus fumigatus; arrow) visible.

Figure 4. Endometrial cytology with yeast organisms (Candida albicans; arrow) and white blood cells visible.

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Table 4. Intrauterine medications used in the treatment of fungal endometritis.

Medication

Dosage, Route, Frequency

Amphoteracin B (50 mg/vial)

100 to 200 mg reconstituted in 50 to 100 mls sterile saline

Clotrimazole

500-700 mg in 50 to 100 mls sterile saline

Fluconazole (200 mg/tablet)

100 to 250 mg in 50 to 100 mls sterile water; to reconstitute, add 5 mls DMSO to 1 gram (5 tablets) of fluconazole to dissolve; divide into 4 aliquots of 250 mg each; qs to 50 to 100 mls with sterile water

Lufenuron (Program®) (270 mg/packet)

540 mg in uterus suspended in 60 mls sterile saline, 270 mg applied to vaginal vault and clitoral area

Miconazole (1,200 mg insert)

1,200 mg insert deposited into uterus

Nystatin (100,000 USP units/ gram; 30 gram vial)

5 grams suspended in 50 to 100 mls sterile water; or 0.5 to 2.5 million units

Table 5. Systemic medications that may be used in the treatment of fungal endometritis.

Medication

Dosage, Route, Frequency

Fluconazole (200 mg/tablet)

14 mg/kg, PO, loading dose, followed by 5 mg/kg q 24h

Itraconazole (3 grams/packet)

3 - 5 mg/kg PO q 24h for 2 to 3 weeks or longer

Table 6. Uterine lavage therapies that may be used in the treatment of fungal endometritis.

Medication

Dosage, Route, Frequency

N-Acetylcysteine solution (20 %) (200 mg/ml)

30 mls (6 grams) diluted into 150 mls sterile saline infused into uterus

Dimethyl sulfoxide (DMSO) (99%)

50 ml DMSO per liter saline; may repeat as needed; follow with lavage with 1 liter saline or LRS

Hydrogen Peroxide (3 %)

60 to 120 mls infused into uterus; follow the next day with lavage using sterile saline or lactated Ringer’s solution (LRS)

Lactated Ringer’s Solution (LRS)

1 to 4+ liters; repeat lavage until effluent fluid is clear

Povidone-Iodine (Betadine® Solution) (1 %)

10 -15 mls added to 1 liter sterile saline

Saline (0.9 %)

1 to 4+ liters; repeat lavage until effluent fluid is clear

Tris-EDTA (Tricide)

250 to 500 mls infused into uterus; then lavage uterus with lactated Ringer’s solution (LRS)

Acetic Acid (Distilled White Vinegar) (2 %)

20 – 100 mls added to 1 liter sterile saline

26 The Practitioner Issue 1 • 2017

Diagnosis of Fungal Endometritis A crucial factor in development of an effective therapeutic plan for fungal endometritis is accurate identification of the etiologic agent. Currently, the standard techniques for detection of fungal infections are mycological culture, microscopy evaluation of endometrial cytology or biopsy samples, and detection of fungal DNA by polymerase chain reaction (PCR) analysis. Mycological culture often requires a significant time period to allow for the long growth phase of mycotic organisms and requires considerable laboratory expertise for accurate identification. Specific media (i.e. Sabouraud’s agar) designed for culture of fungal organisms are recommended. Cytology samples may be obtained by either traditional uterine swab or brush or by low-volume uterine lavage. Mares with fungal endometritis usually, but not always have inflammatory cells in the cytology sample. Fungal agents are often easiest to detect in smears made after centrifugation of uterine effluent in a low-volume lavage. Yeast are typically 5 to 8 μm in diameter with a distinct cell wall (100 to 200 nm) that forms a clear ‘halo’ around the organism (Figure 4). The ‘halo’ may be especially evident if the organism is surrounded by debris or other cells. Hyphate fungi are typically 3 to 5 μm in width and 8 μm in length (Figure 5). These individual cells are commonly linked together in long branching chains. In many instances, detection of a fungal organism on cytological examination may be the only evidence of fungal endometritis, as organisms may not always grow on culture. Diagnosis of mycological infections by in vitro amplification and detection of fungal DNA using molecular techniques (i.e. PCR) is now available in some areas. Molecular assays have the advantages of potentially being more sensitive than other assays and are more rapid than culture. Prompt identification of a mycological infection allows for rapid institution of antimicrobial therapy, which could potentially improve the clinical outcome. For instance Candida albicans is typically sensitive to fluconazole while Candia krusei and C. glabrata are inherently resistant to fluconazole. Unfortunately, qPCR assay cannot be used to determine antimicrobial susceptibility for fungal organisms. Treatment of Fungal Endometritis Therapy for fungal endometritis is directed at a combination of correction of predisposing factors, uterine lavage with dilute acetic acid or dilute povidone-iodine, plus systemic administration and/or intrauterine infusion of antifungal agents. Treatments with more than one anti-fungal agent may be indicated in refractory or recurrent clinical cases. Uterine lavage is indicated to remove retained fluid, eliminate or kill fungal organisms, and remove biofilm. It may also be beneficial to apply topical antifungal medication to the vagina and clitoris as these areas may act as a reservoir or nidus for reinfection. Ideally, selection of an antifungal agent would be based on results of susceptibility tests for the specific fungal organism. Unfortunately,

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antifungal susceptibility tests are not readily available to most practitioners and a significant time period may occur from sample submission to obtaining test results. Empirical choices of antifungal drugs based on published susceptibility patterns can be made in the initial treatment of fungal endometritis while awaiting organism identification and susceptibility testing. It is common for a moderate to heavy growth of a bacterial organism such as Streptococcus equi subsp. zooepidemicus to be detected in mares by uterine culture following treatment of fungal endometritis. Consequently, it is often necessary to treat for bacterial endometritis along with or after treatment for fungal endometritis. Several anti-fungal agents are available for intra-uterine therapy (Table 4) or systemic therapy (Table 5). Fluconazole and itraconazole are available as oral formulations, and fluconazole is the most cost effective therapy for use in the horse. Oral administration of an antifungal agent can provide long term anti-mycotic activity and may be an important component of a multimodal treatment program for fungal endometritis in a mare. Lufenuron was also reported to be an effective treatment in mares with fungal endometritis by inhibiting chitin synthesis in the cell wall. This treatment may not be effective in all cases, as not all fungal organisms have chitin in their cell walls. Additional therapies are presented in Table 6.

Patrick M. McCue, DVM, PhD, Diplomate, American College of Theriogenologists, Iron Rose Ranch Professor of Equine Theriogenology Dr. Patrick McCue graduated from veterinary school at the University of California, Davis, in 1986. He subsequently completed an internship in Large Animal Medicine and Surgery at the University of Pennsylvania and a residency in Equine Reproduction at the University of California, Davis. He received a PhD in Comparative Pathology, with an emphasis on reproductive endocrinology and ovarian pathology in the mare, from UC-Davis in 1992, and joined the faculty at Colorado State University in 1994. Dr. McCue coordinates the Clinical Stallion, Broodmare, Foaling and Embryo Transfer Services at the Equine Reproduction Laboratory, Colorado State University. He also attends to dystocias, high risk pregnancies and other equine reproduction cases at the university’s Veterinary Teaching Hospital. He is the author or coauthor of 5 books and over 200 refereed publications, textbook chapters, scientific proceedings chapters and abstracts. In addition, he writes a monthly column called ‘The Breeding Shed’ for the American Quarter Horse Journal.

FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 27

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FACTS AND MYTHS ABOUT MEDICAL TREATMENT OF COLIC DAVID E. FREEMAN | MVB, PHD, DACVS The Treatment Plan for Medical Colic 1. Remove food, allow water. This is extremely important but rarely done. Additional food will only contribute bulk to the impaction and make it more difficult to remove. 2. Give laxatives and water by nasogastric tube. 3. Monitor progress. 4. Give analgesics as indicated, without masking changes. 5. Repeat laxatives if necessary. 6. Give IV fluids if necessary. 7. Only allow food when impaction has fully resolved, as evident by passage of feces. 8. Evaluate management, dentition, diet.

Flunixin Meglumine Facts 1. Flunixin meglumine (Banamine) is a nonsteroidal anti inflammatory drug (NSAID) that blocks the production of prostaglandins. 2. Benefits are pain relief, inhibition of endotoxin effects, and improved cardiovascular status. 3. The dose of flunixin meglumine is 1.1 mg/kg IV (SID or BID).

Flunixin Meglumine Myths 1. Flunixin meglumine can mask signs of surgical colic. Untrue; most veterinarians can recognize the need for surgery in a horse treated with flunixin meglumine. This concern emphasizes the need for close observation of a horse with colic. 2. Flunixin meglumine can be given IM or IV. Analgesia Untrue. The IM route is not recommended because it Control of pain is crucial in horses with colic (flunixin can cause severe and fatal myositis in the injection site. meglumine and/or xylazine). Pharmacologic control of pain 3. Flunixin meglumine can interfere with mucosal repair can be supplemented, as indicated, by other procedures, such and cause endotoxemia. as decompression of the stomach by nasogastric tube and coUntrue. Recent studies have examined the recovery of lon/cecum by enterocentesis (on extreme occasions and then intestine that was subjected to ischemic injury in vivo, with full regard for possible complications). Handwalking comparing the effects of different NSAIDs. Flunixin megluis used to prevent rolling and associated injury to the horse mine delayed functional recovery of mucosal barrier and and others. Owners will walk horses endlessly because this allowed low molecular weight markers of permeability to interrupts the signs of colic and gives them the false sense traverse the ischemic-injured mucosa, including endoof security that it is of benefit, when it is really only masktoxin. NSAIDs with a more COX-2 selective profile (e.g. ing signs of a persistent or worsening problem. All forms of firocoxib) could support repair of mucosal barrier defects pain control should be interrupted so that progress can be compared with flunixin meglumine. The major limitation monitored repeatedly and frequently. Persistent pain under of the preceding studies on the equine small intestine any circumstances indicates a need for referral. The goals of is that the failure to prevent leakage in flunixin-treated pain control are (order of importance varies with each case): tissues was shown in vitro with doses of endotoxin that 1. To provide restraint. would not be relevant in vivo. Also, any endotoxin that 2. To prevent self mutilation, injury to personnel, and would gain entry across the mucosa would be removed by damage to equipment. the liver, which could explain why horses with ischemic 3. To provide brief, pain free periods for observation and small intestine that is not resected do not demonstrate evaluation of disease progress. any clinical evidence of endotoxemia. In the equine pelvic 4. To provide pain free periods to allow other medication flexure, FM does not inhibit barrier recovery. to take effect (e.g. laxatives). 5. To provide humane care. Alpha2 Agonists and Sedatives Facts 6. To treat intestinal spasm (can only assume if present). 1. Xylazine (0.2 1.1 mg/kg IV or IM) is sufficient for most 7. To confirm or refute the diagnosis of colic. cases and detomidine (5 20 micrograms/kg IV) might 8. To facilitate transport to a clinic for further treatment. be required for severe pain. 9. To facilitate administration of IV fluids. 2. Xylazine can be given repeatedly in low doses as needed. 10. To distinguish between medical and surgical types 3. Xylazine has a short duration of effect - allows almost of colic. continuous assessment of progress. WWW.FAEP.NET |

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FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitionerâ&#x20AC;&#x201A; 29

Alpha2 Agonists and Sedatives Myths The ability of xylazine to reduce intestinal blood flow and motility could be of clinical importance in impaction colics. This is untrue and xylazine might relieve spasm, which could help with removal of the impaction. Also the motility effect is short-lived.

This demonstration fails because the oil in the colon does permeate colon contents under the massaging effect of abdominal contractions during breathing and other activities in the live horse. Also at surgery, oil can be found deep within the impacted mass. Water might be absorbed by the colon and not reach the impaction in the volume infused. 2. Mineral oil should not be given to a horse that might go to surgery because it increases the risk of contamination and peritonitis if the intestine has to be opened. This is untrue because current methods for emptying the colon are very effective and clean.

Opioid Analgesics 1. Butorphanol (Torbugesic, 0.02 to 0.08 mg/kg IV) is usually used with xylazine. 2. At recommended doses, side effects include inhibition of motility. 3. The duration of effect is short and its effects on motility Magnesium Sulfate 1. Magnesium sulfate is classified as a saline laxative, appear to be site and dose-dependant. assumed to increase fecal bulk and water content 4. Side effects can be minimized by continuous infusion through an osmotic response to the poorly-absorbed of 23.7 μg/kg/hr, after a loading dose of 17.8 μg/kg. magnesium ion. 5. Morphine or meperidine should only be used in ex2. Magnesium sulfate at a dose of 1 mg/kg (1 lb to a 1000 treme cases. lb horse) reflexly stimulates equine colonic function, possibly through the gastrocolonic reflex. Laxatives 3. Can be given once or twice daily for 23 days with little Laxatives should be given every 12 hours. Sometimes, risk of a toxic effect. reflux through the stomach tube makes it impossible to give 4. Repeated doses can cause weakness, collapse, and laxatives and can signify another problem or a longstanding tachycardia from the absorbed magnesium ion, espeimpaction (check for gastric reflux before giving any laxacially if it is administered with DSS (see below). tive). The horse colon accounts for a greater proportion of its 5. Treatment of toxicosis is diuresis with IV fluids and total body weight than does the human colon, and so human IV calcium. doses for laxatives on a body weight basis are underdosing for horses. However, increasing the dose, increases toxicity. Dioctyl Sodium Sulfosuccinate Facts 1. DSS is an anionic surfactant that has been classified Mineral Oil Facts as a wetting agent, irritant laxative, or fecal softener. 1. Mineral oil (half to 1 gallon to a 450 kg horse) is an 2. DSS can increase mucosal permeability (increases Mg effective fecal softener. absorption if given with magnesium sulfate), cause 2. Its presence on the perineum, tail, and hind limbs, surface damage and inflammation. usually 12 to 24 hours after administration, indicates that the intestinal tract is partly or completely patent. Dioctyl Sodium Sulfosuccinate Myth DSS is an effective fecal softener. 3. Mineral oil can pass around some obstructions without In one study in horses, DSS was ineffective as a laxative and softening them. 4. Mineral oil has been advocated as a cathartic in cases caused mucosal injury at the recommended dose. of intoxication. However, its use in cases of cantharadin toxicity may be contraindicated because it can Psyllium Hydrophilic Mucilloid Facts 1. Psyllium hydrophilic mucilloid is a bulk laxative used increase the absorption of cantharadin. to remove or prevent a sand impaction. 5. Careful attention must also always be paid to place2. The dose is 1 g/kg or 500 g in 6 to 8 L of water through ment of the nasogastric tube prior to delivery, as dea nasogastric tube 2 3 times daily. position of mineral oil in the lungs can cause a fatal 3. Difficult to administer because it has a tendency to gel. lipoid pneumonia. 4. When fed routinely (50-100g daily), fermentation of psyllium by intestinal bacteria produces short-chain Mineral Oil Myths fatty acids that might benefit healing of the colonic 1. Despite its routine use, there is little literature evidence mucosa in horses with right dorsal colitis. to support the use of mineral oil in horses. Mineral oil will lubricate ingesta but does not penetrate an impaction the same way that water does. This can be Psyllium Hydrophilic Mucilloid Myths There is conflicting evidence as to efficacy of psyllium on demonstrated with fecal balls immersed in water or the feed on a daily basis to prevent sand impaction or given mineral oil in fecal cups overnight. The water penby stomach tube to remove a sand impaction. Of twelve etrates the feces; oil does not. 30 The Practitioner Issue 1 • 2017

ponies with sand surgically placed in the cecum, six were treated with 1g/kg psyllium and 6 were untreated. All were euthanized 11 days later with no significant difference in the amount of sand retrieved between the treatment and control groups. Another trial evaluating psyllium (0.5 g/kg), wheat bran (1g/kg), and mineral oil (8g/kg) also failed to demonstrate increased sand evacuation relative to untreated controls. More recent work showed that horses given psyllium (0.5 kg q12h) in addition to mineral oil (2L q24h) had increased sand clearance relative to those administered mineral oil alone (51.0% vs 26.1% total sand removal) suggesting that psyllium may improve sand clearance. There is some concern that colonic flora will degrade psyllium after chronic exposure, thus decreasing any laxative properties. This has led to the common practice of only feeding psyllium for one week out of every month for sand prevention in endemic areas. Wheat Bran Myth A bran mash is an excellent laxative for horses and could prevent colic. In one study, it was concluded that the laxative qualities of wheat bran may be exaggerated, based on the finding that wet and dry bran mashes did not change water content of feces in ponies compared with other diets.

Intravenous Fluids Intravenous fluid therapy is a lifesaving treatment that replaces essential water and electrolytes in horses with diarrhea, colic, shock, hemorrhage, dehydration, “tying up,” kidney failure, and a variety of other diseases. Intravenous Fluids Fact Intravenous fluids are expensive, require an indwelling intravenous catheter, with the associated risk of thrombophlebitis, and may be impractical in many settings. Intravenous Fluids Myths 1. Horses with impactions should be treated with intravenous fluids in large volumes to drive water into the impaction and soften it. Most available evidence indicates that this is highly unlikely with the largest volumes that can be administered, even in a hospital setting. In fact, horses given three times maintenance IV fluids had increased urine production and sodium loss which could contribute to electrolyte abnormalities as well as rebound dehydration when fluids are discontinued. Horses with impactions can become dehydrated because of decreased fluid intake, fluid loss into the bowel in response to laxatives, and altered absorption of fluids by the obstructed intestine. IV fluids could be of some benefit to offset this level of dehydration and to prevent water movement out of the intestine to correct dehydration. 2. Horses with severe colic should be stabilized as much WWW.FAEP.NET |

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as possible at home with IV fluids before being transported to a referral hospital for possible surgery. This is a myth. Firstly it takes time to administer fluids at the farm and therefore delays arrival at the hospital for assessment and treatment. Secondly, some horses can appear to improve after fluid therapy and analgesics, which can create a false sense of recovery. This only adds to the delay. Thirdly, fluid therapy at home adds to the owner’s cost and could put the cost of surgery out of their reach. Fourthly, it often fails to improve the horse’s condition and can create problems through catheter related complications and fluid overload. I have never seen this approach provide any benefit and the delay is considerable. The same goal can be accomplished at the referral hospital in preparation for surgery, even if the horse deteriorated during transport. 3. Because of the size of the typical adult horse, IV fluid therapy is more likely to provide insufficient fluid and fail to rehydrate. Overhydration is unlikely because the kidneys can eliminate excesses and restore water and electrolyte balance to normal. For this reason, overhydration is harmless, and the only downside is the cost. When healthy geldings (500 ± kg body weight) were housed in climate-controlled stalls and denied food, water consumption immediately decreased to approximately 15% of the volume of water consumed when they were fed (5L/day not fed versus 34L/day when fed). When horses were not fed, they remained alert and interested in their surroundings, vital signs and physical examination findings were normal, and laboratory measurements of hydration and renal function remained within reference ranges for our laboratory. The extracellular space and plasma volume and osmolality were not altered by food deprivation, despite the decrease in water consumption. These findings suggest that the current approach to fluid therapy based on maintenance needs is flawed because maintenance water requirements were determined on fed horses. In the fed state, horses need to draw huge volumes of water from the extracellular space to support digestive processes, which are intense in a herbivore of this size. Most horses that require IV fluids are not fed so the findings of the above study are highly relevant to them. Failure to recognize this could lead to overhydration. The consequences of overhydration in equine practice are: 1. When replacement fluids are used for maintenance therapy at current recommendations, horses receive approximately 8 times the typical daily intake of Na+ and almost 7 times their water needs. Most of this excess causes diuresis that can waste Ca++ and K+ in the urine. The resulting hypocalcemia and negative K+ balance can impair recovery. 2. Based on data from normal adult horses, continued Na+ and fluid wasting through the urinary tract following overhydration can also cause a rebound dehydration.

FLORIDA-ASSOCIATION -OF-EQUINE-PRACTITIONERS | The Practitioner 31

3. Overhydration damages capillaries and causes fluid loss from plasma to the interstitium. 4. Not only is excessive fluid therapy wasteful in a physiological sense, but it is also very expensive. Prices for intravenous fluid bags for horses have undergone a considerable cost increase in recent months, and availability of these fluids can be tenuous. Therefore, this is a good time to look critically at how we apply fluid therapy and to seek opportunities to be conservative in fluid administration. The same principles are also relevant to horse owners who are assessing their horse’s daily needs for water, especially when a horse is denied food for any reason or is eating less than normal. Apparently, food intake triggers digestive processes that place huge demands on a horse’s water consumption, and these water needs decline when food intake is reduced. Therefore, assessment of water needs for horses should consider all the prevailing conditions, such as ambient temperature, humidity, activity level, fever, and, according to our research, food intake. Water consumption in horses is definitely not a one-size fits all situation.

Enteral Fluids Fluids by nasogastric tube are effective means of rehydrating horses with impaction, and may reflexly stimulate colonic secretion and/or motility. One to 1.5 gallons BID or TID is recommended if the horse's stomach has the capacity to hold these volumes. Fluids delivered by nasogastric tube can reach the cecum and large intestine within 1-2 hours in most normal horses. Also, intermittent bolus delivery can increase the volume delivered to the colon as it will overwhelm the small intestine’s capacity for absorption. Nasogastric administration may also stimulate the gastrocolic reflex, thus increasing motility. Enteral fluids are considerably less expensive and easier to prepare than IV fluids as they do not need to be sterile. Enteral fluid therapy is also slightly more forgiving than intravenous fluids. However, large volumes of plain water or hypotonic solutions may cause marked electrolyte abnormalities including hyponatremia, hypokalemia, and hypocalcemia., and a mild hemodilution. Most average size horses can tolerate 6-10L/h of intragastric fluids, although some show signs of discomfort when large volumes (>5L) of fluid are administered. Many horses treated with enteral fluids for an impaction will develop self-limiting diarrhea due to excretion of fluids as the impaction resolves. Cecal rupture has been reported, most likely when the cecum is impacted. A balanced electrolyte solution containing 5.27g NaCl, 0.37g KCl, and 3.78g NaHCO3 per 1 liter of water produces a solution with 135 mmol Na/L, 5 mmol K/L, 95 mmol Cl/L and 45 mmol HOC3-/L. In normal horses, a balanced electrolyte solution and sodium sulfate resulted in the best hydration of RDC contents, while sodium sulfate, magne-

sium sulfate, and balanced electrolyte solution resulted in the most hydrated feces. Sodium sulfate caused hypocalcemia and hypernatremia, while plain water caused hyponatremia leaving the balanced electrolyte solution as the safest and most effective option.

Prokinetic Drugs 1. Prokinetic drugs are usually not needed nor recommended to treat impactions, and are rarely effective for motility disorders in horses. 2. Neostigmine, a cholinesterase inhibitor, stimulates progressive motility in the cecum, large colon and small colon. 3. Bethanecol has been used to stimulate motility in horses and seems to be most efficacious in promoting gastric emptying. 4. Erythromycin (0.5-1.0 mg/kg) can stimulate motility in normal equine colon but its use for impactions is unknown. 5. Lidocaine at 1.3 mg/kg followed by an infusion of 0.05 mg/kg/minute for 24 hours has been used as a prokinetic agent or to reduce intestinal inflammation. Lidocaine Facts Studies that have examined the benefits of lidocaine to promote intestinal motility after colic surgery have design flaws that render the results highly questionable. Lidocaine Myths Lidocaine is an effective prokinetic drug and antiinflammatory agent. If lidocaine were an effective prokinetic drug, it could be used to treat impaction colics in the field. Despite the original claim that lidocaine has prokinetic effects, subsequent studies have demonstrated the absence of such an effect and that lidocaine might even delay intestinal transit. Studies on equine small intestine subjected to ischemia and reperfusion demonstrated a positive response to lidocaine on smooth muscle contractility in vitro; however, this response could only be achieved with higher concentrations of lidocaine than can be safely achieved in plasma. Any assessment of lidocaine in management of postoperative ileus (POI) and in improving survival in horses after colic surgery should not ignore evidence that better results can be achieved without it. The anti inflammatory effects of lidocaine, which have been offered to explain its ability to promote motility in inflamed intestine and after colic surgery, have not been demonstrated in equine jejunum and colon after ischemia and manipulation. Based on recent studies, lidocaine appears to be an ineffective prokinetic drug and is not an effective antiinflammatory drug. If it does have a benefit, this might be through its visceral analgesic effects.

32 The Practitioner Issue 1 • 2017

Previously published in AAEP Proceedings 2011, volume 57, pages 284-289. References:

1. Banse HE, Gilliam LL, House AM, et al. Gastric and enteric phytobezoars caused by ingestion of persimmon in equids. J Am Vet Med Assoc 2011;239:1110-1116. 2. Bauck AG, Freeman DE, Morton AJ, Groshe A, Graham AS. Effects of a continuous rate infusion of lidocaine on mucosal injury and intramural inflammation after mechanical manipulation of equine jejunum. Vet Surg 2015;44:E42. 3. Cohen ND. Right dorsal colitis. Equine Vet Educ 2002;14:212219. 4. Cruz AM, Li R, Kenney DG, et al. Effects of indwelling nasogastric intubation on gastric emptying of a liquid marker in horses. Am J Vet Res 2006;67:1100-1104. 5. Dabareiner RM, White NA. Large colon impactions in horses: 147 cases (1985-1991). J Am Vet Med Assoc 1995;206:679-685. 6. Freeman DE, Ferrante PL, Palmer JE. Comparison of the effects of intragastric infusions of equal volumes of water, dioctyl sodium sulfosuccinate, and magnesium sulfate on fecal composition and output in clinically normal horses. Am J Vet Res 1992;53:1347-1353. 7. Freeman DE, Mooney A, Giguere S, Diskant P, Burrow J, Evetts C. Effect of food deprivation on daily water requirements in healthy horses. 11th International Equine Colic Research Symposium, Dublin, Ireland, 2014, p. 30. 8. Hammock PD, Freeman DE, Baker GJ. Failure of psyllium pucilloid to hasten evacuation of sand from the equine large intestine. Vet Surg 1998;27:547-554. 9. Jochle W, Moore JN, Brown J, et al. Comparison of detomidine, butorphanol, flunixin meglumine, and xylazine in clinical cases of colic. Equine Vet J supplement 1989;7:111-116. 10. Lester GD, Merritt AM, Kuck HV, et al. Systemic, renal, and colonic effects of intravenous and enteral rehydration in horses. J Vet Intern Med 2013;27:554-566. 11. Lopes MA, Moura GS, Jose FD. Treatment of large colon impaction with enteral fluid therapy. Proceedings. Am Assoc Equine Pract 1999;45:99â&#x20AC;&#x201C;102. 12. Lopes MAF, Walker BL, White NA, et al. Treatments to promote colonic hydration: enteral fluid therapy versus intravenous fluid therapy and magnesium sulphate. Equine Vet J 2002;34:505509. 13. Lopes MAF, White NA, Donaldson L, et al. Effects of enteral and intravenous fluid therapy, magnesium sulfate, and sodium sulfate on colonic contents and feces in horses. Am J Vet Res 2004;65:695-704. 14. Monreal L, Navarro M, Armengou L, et al. Enteral fluid therapy in 108 horses with large colon impactions and dorsal displacements. Vet Rec 2010;166:259-263. 15. Peek SF, Semrad SD, Perkins GA. Clostridial myonecrosis in horses (37 cases 1985-2000). Equine Vet J 2003;35:86-92. 16. Sanchez LC, Elfenbein JR, Robertson SA. Effect of acepromazine, butorphanol, or N-butylscopolammonium bromide on visceral and somatic nociception and duodenal motility in conscious horses. Am J Vet Res 2008;69:579-585. 17. Sellon DC, Roberts MC, Blikslager AT, et al. Effects of continuous rate intravenous infusion of butorphanol on physiologic and outcome variables in horses after celiotomy. J Vet Intern Med 2004;18:555-563.

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David Freeman, MVB, PhD, DACVS Dr. David Freeman graduated from the Veterinary College of Ireland, Dublin and completed an equine internship at the New Bolton Center of the University of Pennsylvania in 1975, and a residency in large animal surgery in 1977. He was awarded a PhD from the University of Pennsylvania in 1985. He was an equine surgeon at New Bolton Center from 1981 to 1994, became board certified by the American College of Veterinary Surgeons in 1989, then joined the faculty of the University of Illinois, College of Veterinary Medicine in 1994, becoming Head of Equine Medicine and Surgery in 1998. In 2004, Dr. Freeman joined the Department of Large Animal Clinical Sciences at the University of Florida, College of Veterinary Medicine (UFCVM), as Professor of Equine Surgery and Associate Chief of Staff. He is currently Chief of Large Animal Surgery at UFCVM, Martha and Arthur Appleton Endowed Professor in Equine Studies, and Director of the Island Whirl Equine Colic Research Laboratory. Dr. Freeman has developed 4 widely used surgical procedures in horses and has described improvements and modifications in many others. His main areas of clinical interest are diseases and surgery of the equine gastrointestinal and upper respiratory tracts, with special emphasis on improving survival after colic surgery.

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34 The Practitioner

Issue 1 • 2017

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