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You Can Win Back
The Vaccine Business Lameness assessment with MRI Download a client handout Fixing third tarsal bone slab fractures
Vol 6 Issue 4 2016
Table of Contents
Cover story:
can win back the 4 You vaccine business Cover photo Shutterstock/ ChiccoDodiFC
client Handout on Vaccines
Link to a client handout you can download and print for clients ...........................8 Orthopedics
Fixing third tarsal bone slab fractures...........................................................................3 MRI complements, not replaces, the clinical exam ..................................................10 Technician Update
Successful treatment of pleural pneumonia..............................14 Dentistry
Focus on chewing to find TMJ..........................................................17 News
Neonatal encephalopathy survival.............................................16 Need a lift?.............................................................................................19 Key to EEE transmission in the Southeast ..................................19 advertisers Shanks Veterinary Equipment.................................. 3 Hallmarq........................................................................ 5 PS Broker........................................................................ 6
Merck Animal Health.................................................. 7 AAEVT............................................................................13
The Modern
Equine Vet Sales: Matthew Todd • ModernEquineVet@gmail.com Editor: Marie Rosenthal • mrosenthal@percybo.com Art Director: Jennifer Barlow • jbarlow@percybo.com contributing writerS: Paul Basillo • Kathleen Ogle COPY EDITOR: Patty Wall Published by PO Box 935 • Morrisville, PA 19067 Marie Rosenthal and Jennifer Barlow, Publishers percybo media publishing
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Orthopedics
Large screw fixation for certain slab fractures does a good job of stabilizing the injury allowing some racehorses to return to work, according to a recent study. Surgeons from the Newmarket Equine Hospital in Suffolk, U.K., surgically repaired slab fractures of the third tarsal bone in 17 Thoroughbred racehorses between 2009 and 2014. They wanted to effectively compress the fracture, reduce secondary osteoarthritic changes and potentially reduce the time before return to training compared with conservative management. To plan for the procedure and to guide them intraoperatively, the researchers took several radiographic views until an image showing a single fracture line was obtained. The fracture was displaced in 12 cases. A ‘wedge-shaped’ third tarsal bone has been thought to contribute to stress fractures; however, this conformation was present in only three cases. Periarticular new bone formation, loss of trabecular pattern, loss of bone density and loss of subchondral bone plate definition at the fracture site were present in several cases. Surgical repair was performed under general anesthesia with the affected limb held in extension. The proximal and distal margins of the fracture were defined by percutaneous needle markers. The area between these markers and the long and lateral digital extensor tendons was used to access the third tarsal bone. An 18-gauge spinal needle was placed in the center of this area in line with the required trajectory of the implant screw. A vertical stab incision was made at the spinal needle. Under radiographic guidance, a glide hole was created along the spinal needle to the fracture site. A 2.5 mm thread hole was drilled before insertion of a 3.5 mm cortical screw. Fracture compression was confirmed radiographically and the skin incision closed. After surgery, the horses were confined to stall rest for one to five weeks before starting twice daily walking exercise for a minimum of four weeks, then four weeks of trotting before they re-entered race training. Eleven horses (64%) raced post operatively (of which five had raced previous to surgery), three horses remained in rehabilitation, two were in training but had not yet raced and one had retired to stud. The mean time from surgery to first race was seven months. Radiograph-
ic follow-up was performed in 15 horses. All fractures were healed at between four and six months post operatively. In cases where loss of trabecular pattern, bone density or subchondral bone plate definition had been a feature, these progressively improved with fracture healing. New bone formation progressed in five out of five cases and occurred post operatively in one case. Based on these results, the surgeons concluded that the technique was a viable way to repair these fractures and could be an alternative to conservative management. MeV
Photo courtesy of The Equine Veterinary Journal
Fixing Third Tarsal Bone Slab Fractures
Large screw fixation with a 3.5 mm cortical screw.
Lifting Large Animals Since 1957
For more information: Barker WHJ, Wright IM. Slab fractures of the third tarsal bone: Minimally invasive repair using a single 3.5 mm cortex screw placed in lag fashion in 17 Thoroughbred racehorses. Equine Vet J. 2016 March 8 [Epub ahead of print]. http://onlinelibrary.wiley.com/doi/10.1111/evj.12570/abstract
www.shanksvet.com • info@shanksvet.com ModernEquineVet.com | Issue 4/2016
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cover story
You Can Win back the
vaccine business Veterinarians should be vac-
cinating horses because it gets the veterinarian on the farm, offers an opportunity to provide other wellness services, allows the veterinarian to catch more serious conditions at an earlier point and ultimately leads to a healthier horse. Yet, that basic wellness message can be a hard sell, admitted Michael Erskine, DVM, DABVP (equine) and Matt S. Povlovich, DVM, because owners don’t want to spend the money on that service.
Shutterstock/135pixels
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But it’s not an impossible sell. In fact, both veterinarians started successful vaccination programs at their practices. They discussed the programs that have enabled them to win back the vaccine business at the American Association of Equine Practitioners meeting in Las Vegas. “We are the experts, right? You believe that; I believe that. The client? He doesn’t believe that we are the experts on vaccines,” admitted Dr. Povlovich, of the Tennessee Equine Hospital in Thompson Station. “The client doesn’t understand
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Standing Equine MRI
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the value,” he said. “You have to find that program that fits your practice that is going to get you on the farm; that is going to get you in front of that horse. We want that client relationship that is important for the provision of more services and better care for the horse.” Cost is the number one reason why clients administer their own vaccinations, according to Dr. Povlovich. “They don’t think we are the experts on this issue, and they want to save money,” he said. “What clients really want is value for their money, just like everyone else in this room. I want the cheapest set of tires for my truck. However, I don’t want those tires to wear out at 10,000 miles, so I am looking for value.” Convincing clients that they are getting value for the veterinarian’s time and expertise should be the start of any discussion about vaccinations, he said.
Focus on Health
That is the way, Dr. Erskine, of Damascus Equine Associates in Mt. Airy, MD, works. He has developed a program that emphasizes the efficacy of the vaccines
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and the veterinary service that is provided, instead of the cost of the vaccination. His clients are primarily sport and pleasure horses and most are actively used by the client. They travel, compete and are in boarding stables. “I classify the majority of our patients as higher risk as far as the transmission of disease,” he said. “So, when we talk about marketing the service, it is important to focus on the services we provide and not focus on the product.” He emphasizes the prevalent diseases and how his program can help keep high-risk horses healthier. “We let them [clients] know that it is a professionally designed program and managed by us. We take the entire responsibility for the program once they select to implement it over the year. The clients will choose among three different programs. And these are centered around how many visits per year they would like,” he explained. “These also afford us an opportunity for touch points with the patient and the clients, and I think that has been a critical aspect of the program,” he said. They spread the annual costs of the health program into equal payments so that owners know what to expect and it removes the emphasis on vaccine costs and places it on the horse’s health, he explained. Although they charge for their time, they do not charge a separate farm call fee. All fees for the health visit and vaccination are included in the program. Any other services that are provided are added to the appointment schedule and charged appropriately. Dr. Erskine offers three different programs centered on the number of visits, and which vaccines will be included: core, seasonal or high-risk. “I do emphasize seasonal disease. We are in the Mid-Atlantic region with a lot of seasonal diseases. I make recommendations that are incorporated into the program,” Dr. Erskine said. “But I also give the client the choice, so they can opt in or opt out of certain programs or specific vaccines that we offer.” The gold program has the veterinarian on the farm every other month; the silver is every four months and the bronze, which is tailored for low-risk horses, is twice a year. “Any client who wants to add a vaccine or service can do that at any time,” he said. These include other vaccinations, and other services, such as dentistries. They begin scheduling the visits in November for the following year and the visits are grouped by location and farm size. The health program serves as a template for the entire year's schedule, and Dr. Erskine has a pretty good idea of expected performance for the coming year.
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“In November or December, we will have a rough outline of the following year, and then when we get our clinical cases, we can place them around our health program visits. I think that this was an important part of implementation. If we relied on the client to respond to a reminder and call in when they want to schedule the spring shots, we found they would be calling in May for their spring shots. So we took over that responsibility,” Dr. Erskine explained. “We send out a letter in December, along with an AAEP calendar with a sticker of the proposed dates. They look forward to this calendar. If they don’t get the calendar, they will call. And they use this throughout the year to plan around our schedule.” The owner can reschedule any conflicting dates. All the scheduling is done using an Excel spreadsheet, and each farm has its own spreadsheet. In addition to the vaccine schedule, they schedule the Coggins test and any other services. There is also a column for notations, such as a horse that resents a twitch or a client who
is opposed to a certain vaccine. Then each can be printed out before the veterinarian heads to the farm. “We can accommodate a lot of customization with these call sheets,” he said. Of the horses that his practice cares for regularly, 69% have selected one of the programs, he said. In addition, they do provide some vaccinations for clients who continue to give other vaccines. They also give vaccines for some farms that haven’t joined the program, but still want spring and fall shots. “They are not on a program, but we will still provide them,” he said.
Promises to Keep
The program at Tennessee Equine, a large hospital with 14 veterinarians, was the result of some outside the box thinking, admitted Dr. Povlovich. They wanted to develop a program that provided clients with tangible value. They told clients that if they joined the wellness program at Tennessee Equine, which included vaccinations, they would provide colic surgeries free up to $7,500. They call it the Promise Program. At first glance, it seems like a
Remarkable Work of Vaccination and Your Horse’s Immune System By Earl Gaughan, DVM, DACVS Your horse’s immune system does extraordinary and complex work, but even this intricate defense mechanism can’t go it alone. Vaccination has proven to be an extremely effective and safe way to provide a targeted boost to the immune system to help safeguard horses against deadly infectious diseases. Unfortunately, there is an abundance of misinformation and myths circulating about vaccination. Belief that vaccination is unnecessary if the disease is rarely seen in a particular region, or farm; natural immunity is better; or concern the immune system can be overloaded by vaccination, are just a few. These untruths are often perpetuated by the Internet. A better understanding of the equine immune system, along with how vaccines enhance immune responses can be helpful in dispelling these myths and improving the overall health and welfare of our equine companions. The relationship you have with your veterinarian, who is your partner and your horse’s best line of defense against infectious disease, is a vital link to making the best health care decisions for your horse.
c l i c k h e r e to D o w n lo a d thi s a r ti c l e f o r y o u r c l i e n t s 8
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crazy offer, but Dr. Povlovich and his colleagues played the odds. To an owner a colic surgery is an expensive proposition that could result in the horse being euthanized, but the odds that any given horse, even one that has colic, will need surgery is only about 1% of colicky horses. Therefore, the odds were in Tennessee Equine’s favor. “We’ve always believed that if we can discount it, the client believes we were overcharging in the first place, and I don’t want the clients to see me like that,” Dr. Povlovich said. “I want my clients to see value, not as someone trying to screw them.” Before they approached clients, they divided them into three categories: those who trust their veterinarians 100% and are very adherent to the veterinarian’s advice; those who listen to the veterinarian and weigh the advice to the cost; and those who will never let them vaccinate their horses. They focused their enrollment efforts on the first two groups. Owners think of it as insurance, but there are no premiums, just a promise to allow the veterinarian to give vaccinations and an initial physical examination to be enrolled into the program. Out of 2,256 horses, they enrolled 580 in the program, which was a 26% enrollment rate. “There are no exclusions or restrictions. Insurance is a risk pool. They kick out the highest risk. We won’t insure you if you’ve had colic surgery before. This doesn’t do that. There are no exclusions. This horse can be 3 months old, or 33 years old. It could have no colic surgeries or five colic surgeries,” he said. They don’t “cover” medical colics. In the first year of the program, they performed one colic surgery on one enrollee, but the initial physical examinations more
than paid for that surgery. They charge $50 for that enrollment physical examination, which they did for 580 horses, which grossed them $29,000. In addition, every wellness service increased by substantial margins: Coggins tests were up by 22%; fecal exams by 94%, resulting in $9,000 in revenue; botulism vaccinations by 262%, resulting in $33,000 in revenue; West Nile virus vaccinations by 36%, strangles vaccinations by 29%, combination vaccinations by 30%, resulting in $58,000 in revenue and paste dewormers went up by 55%, he said. In addition to the increased revenue, Dr. Pavlovich said there were other benefits for the horse, veterinarian and client. There was more face time with the client and the patient, so everyone got to know each other better. The horses are healthier because of that face time and services, and the program reestablished the veterinarian as the expert on wellness, he said. And in the end, there is a good possibility that his practice will put down fewer colic surgery candidates due to financial reasons. “It is important that we get in front of them, so my advice to you is — and we’ve always been big at this in our practice — don’t lower
the cost on anything. We try to give value, and we try to demonstrate that value to the client,” he said. Despite the hospital’s size and technological and surgical capabilities, he said, “wellness is a huge part of our practice, so it is important to us to continue to stress to the client that we are not just this big hospital, we are a wellness practice.” “The thing that Tennessee Equine Hospital is trying to get across to their clients is ‘we care for your horse and we do not want you to be put into a situation where you have to make a decision to euthanize the horse that you love based on money. We are not about money. We are about health,” he said. The program does have some requirements. They have to do a physical examination. “In small animal medicine, it is a given that if you take your dog to get a vaccine, that dog will get a physical examination. How many of us in this room charge for a physical exam when you go out to vaccinate your horses? Maybe 10% of the room. I never did, even though I did a lot of physical exams when I was there to vaccinate the horses. Free most of the time. I don’t even put it on the chart, so the client doesn’t see the value of it. Most of the time, it was just Matt out talking to the horse or
drawing their Coggins,” he said. “So the physical examination was our trigger. This is the enrollment fee. As soon as you do the physical exam and you pay me, I don’t need to do anything else on the farm. Your horse is now enrolled and if he colics tonight and needs surgery, he’s covered.” The hospital staff developed the comprehensive wellness program, which not only includes core and seasonal vaccination, but also fecal tests and other wellness components. In addition, just as Dr. Erskine allows owners to make adjustments to the program, veterinarians have some leeway to make adjustments based on the horse, its situation and owner preferences. And because the overall health of the horse has improved, the horse has a lower risk of colic. These are just two ways to handle the same idea, the veterinarians said, how to provide wellness care and vaccinations to resistant clients. They encouraged veterinarians to take a good look at their clients, their practices and develop their own programs that will help them provide the wellness services, such as vaccinations, that they know their clients need and they MeV should be doing.
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ModernEquineVet.com | Issue 4/2016
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orthopedics
MRI Complements,
Not Replaces, the Clinical Exam Although magnetic resonance imaging (MRI) is becoming a more common tool to diagnose lameness, the cornerstone of lameness evaluation is still the clinical exam, reminded Sarah J. Gold, DVM, of BW Furlong and Associates in Oldwick, NJ. “Advanced diagnostic imaging complements a complete thorough clinical evaluation and complete history. The MRI examination should not be used for screening purposes, the study should be ordered when lameness has been well B y
localized to a specific anatomic region,” Dr. Gold said at the 61st American Assocication of Equine Practitioners Annual Convention & Trade Show in Las Vegas. MRIs are complex images that can be difficult to interpret. “In the early years of MRI reporting, the reports would primarily list the findings. This was regarded as somewhat unsatisfactory to some of the veterinarians in charge of the patients,” she said, because “it was not always clear as to what the pri-
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Horse being imaged with standing MRI
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mary cause of lameness was.” The other issue was that the sensitivity of the machine created a laundry list of problems that could scare owners because no one really knew what to do with the information. “Therefore, we developed more comprehensive MRI reports to address referring veterinarians’ concerns and allow the information to be more readily correlated with the clinical scenario. “As the understanding of MRI findings has evolved, this report
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Images courtesy of Dr. Gold
field systems require general anesthesia, where the standing MRI, [Hallmarq], which is a low-field system, uses standing sedation. The study description provides information about the area that was scanned and a list of sequences that were taken. An MRI will use multiple planes to compile the 3-dimentional image and the report will probably include information about the planes (sagittal, transverse, frontal or dorsal). Each sequence provides different anatomical information, she said. “As you start reviewing images more often, you’ll train your eye to look at these patterns and the language will become sort of secondary,” she said. MRI findings are usually reported in paragraph or list form and this is the meat of the report. “For example, size, shape and margins of a ligament may be defined as 'abnormal' or a joint space may be described as having increased fluid content. While some reports describe the nature of the pathology in terms of the degree of injury, this section can also contain terminology characterizing the MR signal of the structure,” she said. Then there is usually a quick summary that recaps the findings. Most MRIs do not have definitive statements for lameness unless the pathology is quite severe. “In a lot of seasoned competitors, the lameness is multifactorial in origin or sometimes the history wasn’t provided, so it’s not appropriate to offer that definitive statement. In these cases of horses that are competitive athletes, they can have findings that are red herrings,” she said. “A radiology report does not necessarily include a statement indicating which pathologies listed are the most clinically relevant,” she said. That is where the veterinarian’s diagnostic acumen comes
Images courtesy of Dr. Sarah Gold
has been refined to offer more clinical information to the referring veterinarian, namely the most likely cause for lameness. With this information the veterinarian can correlate the MRI findings with the clinical history and offer a more tailored approach to treatment and management of these conditions,” Dr. Gold said. And what might even be more important, this information allows the veterinarian to better explain the issue to the client and improve compliance with his or her recommendations. An MR report from one facility will vary from that of another, she said, but they all should have patient information that helps identify it; the region of the horse that was imaged, technical information about the exam, pertinent findings and some interpretive comments. “It’s important for the veterinarian to provide to the MR interpreter who is doing the image as much information as possible as this insures that the correct regions are imaged and the clinical question is answered,” she said. This is so important because each horse—and the work it does—is different and that activity or lack of activity will affect the biomechanics of the animal. For instance, a Thoroughbred racehorse will have a different looking limb than a Quarter horse that is ridden for pleasure on the weekends. Dr. Gold suggested telling the the MR interpreter what type of image you are seeking. “We primarily use the standing (low-field) system, which has a smaller field of view than using the larger high-field systems,” she said. For instance if the veterinarian wants an image of the foot, a low-field image will provide just the foot. If that is not the area causing the problem, separate studies will need to be made of the fetlock and pastern. However, high-
into play: to take the report and apply it to the patient’s clinical history, signs, work, etc., which is why it is crucial to provide as much information as possible. “The most important part though when you get your MRI back is to answer the question: why is the horse
The standing MRI made by Hallmarq.
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Images courtesy of Hallmarq Veterinary Imaging
orthopedics
Top picture: Standing T1-weighted fetlock image. Bottom picture: Parasagittal carpus standing MRI image.
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lame,” she said, and the second question is deciding what to do about it. “From an interpretation standpoint, one must remember that the purpose of the MRI report is to report on the findings. The people that are looking at these images do not usually have the luxury of seeing the patient, so when you’re looking at a set of images, how those findings correlate with the clinical scenario is a collaborative effort between referring veterinarian and the MR interpreter.” If the imager does not provide the information needed or the referring veterinarian is having trouble aligning the MRI results with the clinical picture, pick up the phone and talk through the find-
Issue 4/2016 | ModernEquineVet.com
ings with the imager. “Everybody who I’ve ever worked with that are reading images are very eager to have these conversations, so it’s definitely encouraged to have that conversation,” she said. She said complex lameness is not easy to tease out, which is why the horse was referred for the MRI in the first place. The more images one looks at the more comfortable with them they become, she said, adding that referring veterinarians who are not looking at MRIs regularly will have a learning curve. “MR imaging, just like radiographs or ultrasonography, is highly dependent on the understanding of anatomy, especially in more than one dimension. When I first started looking at MR imaging, I would basically sit there with the study images on screen, the report on another screen and Denoix’s book in my lap and just try to identify every structure that the radiologist referred to. That eventually helped me see the patterns in the images,” she said. (Denoix JM. The Equine Distal Limb: An Atlas of Clinical Anatomy and Comparative Imaging. London: Manson, 2000.) Once there is a level of comfort in viewing the images, the language becomes easier to understand, too. “Lesions of the deep digital flexor tendon in the foot are one of the more frequent diagnoses found on MR examination and the prognosis and treatment can vary depending on the size and degree of the lesion as well as the location,” she said. This can be reported as a mild degenerative injury, or some fraying or fibrillation at the top of the tendon. Although the MR report will report it as a “degenerative” injury, in a show horse or a horse that has a lot of miles on it, this is not usually a cause of lameness, according to Dr. Gold. “That word ‘degenerative’ can often make owners very un-
comfortable, but it’s important to know that that’s just the terminology of how this would be reported.” It just means some wear and tear on the tendon. One of the most dreaded reports are the ones that say: “no significant findings,” she said. These are frustrating for everyone, including the owner, who has spent significant money. “The first thing to do is go back and look at the clinical history, make sure that everything sort of fit with what you looked at. With the current understanding of the migration of diagnostic analgesia, it is possible that the lesion ordered for the MRI did not include potential other areas that could be affected by the blocks, so in these cases the margins of the studies need to be expanded during MR imaging,” she suggested. This is why a complete history is important, because most imagers will know to keep looking at neighboring areas if they have a better understanding of the clinical presentation. Explain the limitations of MRI to clients, she suggested. Subtle cartilage changes may be difficult to see, but still be clinically possible but sometimes a lack of a significant finding might just mean the horse needs rest and non-steroidal anti-inflammatories for a minor injury. “It’s important to manage those client expectations before the horse even gets the MRI so everybody understands the value of it despite what the report may or may not say,” she said. “Communication is important between referring veterinarian, the owner, trainer and anybody else who’s involved with the horse and that will allow you to be able to more substantially apply a clinical correlation with your patient,” she said. MeV
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Fo r m o re i n f o r m a t ion v ist w w w.a ae vt.or g
*American Association of Equine Veterinary Technicians and Assistants
technician update
The successful management of pleural pneumonia By Emily Zurkunlen
Images courtesy of Emily Zurkuhlen
A 7-year-old Thoroughbred brood mare was admitted to the hospital with her foal for oral extraction of No. 210 (M2) and trephine/flush of the left maxillary sinus. The mare had been diagnosed with a sinus infection secondary to a tooth root abscess based on dental examination and digital radiographs using an Eklin Mark III (Lateral, Oblique and DV views). The mare had a temperature of 98.6째 F with a pulse of 40 beats per minute (bpm), a respiratory rate (RR) of 12 and was weight taped at 1,100 lbs. There was a severely malodorous and purulent discharge from the left nostril. The foal was healthy and in good body condition. A 14-gauge Mila catheter was placed in the left jugular vein, and the mare was sedated for the procedure and a local block of the left maxillary palate was performed with mepivicaine. The mare was placed on a detomidine/butorphanol constant rate infusion (CRI). The infected tooth was removed using a dental punch. Trephination of the left maxillary sinus was performed and was flushed with 1 L of saline. The mare was given phenylbutazone. A culture and
High-field MRI of the mare's brain with contrast showing an enlarged pituitary gland.
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sensitivity of the nasal exudate was performed, growing Streptococcus alpha. The flush was repeated the next day, and the mare and foal were released with a favorable prognosis and instructions to monitor nasal discharge and to schedule a recheck in two weeks. The mare was readmitted several days later due to recurrent fevers and inappetance. Bloodwork taken at the farm the previous day indicated a high white blood cell (WBC) count (13,200), total protein (7.7 g/dL) and fibrinogen (500 mg/dL). On presentation, the mare was quiet with unilateral, foul smelling, leftsided nasal discharge and a temperature of 105째 F, a pulse of 64 bpm, and a RR of 12. Ultrasound of the abdomen and thorax was performed to determine if pneumonia was the cause of her pyrexia. The findings were within normal limits. Treatment included flunixin, potassium penicillin, gentamicin and antiinflammatory agents. The left maxillary sinus lavage was repeated for the next five days and she was released five days later, afebrile and eating well, though there was ptosis of the left eyelid and dilation of the pupil. The foal was placed with a nurse mare upon returning to the farm, due to decreased milk production, even with domperidone twice a day. Three days later the mare returned to the clinic with recurring fevers, aniscoria and ataxia. Her neurologic examination showed left eye ptosis still present. The right eye showed severe swelling of lids, conjunctiva
Images courtesy of Emily Zurkuhlen
and tissue surrounding the eye. Possible asymmetry of the muzzle/facial nerve paralysis with deviation to the right was present. Other cranial nerves appeared intact. No abnormal gait was noted at the walk, however, when circling, the mare took steps laterally to catch her balance upon stopping. This occurred in either direction. There was a small amount of left nasal discharge and she was passing small amounts of urine as she was taken out of the barn. A high field MRI of the brain with contrast was indicated and performed that day. The MRI was performed using a 1.5 T Siemens Symphony using a spine coil for image acquisition. The mare was placed under general anesthesia in dorsal recumbancy. Gadolinium (Multihance 20 cc IV) was used as the contrast agent. MRI findings included an enlarged pituitary gland with heterogeneous signal intensity and irregular margins. After contrast administration, ring enhancement was present in the area of abnormal signal intensity, consistent with an abscess. The mass appeared to be impinging upon the ventral brainstem and there was increased signal in the basisphenoid bone. There was a small amount of high T2 signal intensity in the frontal sinus consistent with fluid. Once the mare was in the recovery stall, an atlantooccipital (AO) spinal tap was performed and the CSF (cerebrospinal fluid) was sent for fluid analysis, cytology and culture. The results showed elevated WBC (3.0 cells/ÂľL) and micro total protein (MTP), and the culture grew S. alpha and Streptococcus bovis (group D). Preoperative blood work showed leukocytosis (15,000), lymphocytopenia (16%), and high serum amyloid A (3790 Âľg/mL). The mare was diagnosed with a pituitary abscess with mass effect on brainstem and chemosis of her right eye. She was placed on chloramphenicol suspension for 21 days, flunixin (10 mL IV BID) for seven days and then decreased to 5 mL IV BID for seven days, omeprazole (Gastrogard 500# PO SID), probiotic powder PO BID for seven days, and the right eye treated with GenTeal eye ointment. She was given a fair prognosis, with instructions to apply the eye lubricant several times per day if possible and to monitor attitude, appetite and temperature. On March 4, 2015 the mare was once again admitted to the hospital due to fevers and for evaluation of her right eye. The farm noted that her eye had become too painful to administer the lubricant and it was suspected that she would need an enucleation. The mare was sedated with detomidine and butorphanol and an ultrasound was performed using a Philips CX50 with a linear transducer and sterile ultrasound gel. Ultrasound findings showed hypopyon with the lens in place and the optic nerve WNL. The ptosis of the left eye was improving. An enucleation of the right eye
was scheduled for the following day, and the eye was sent to the diagnostic lab for histology. Postoperatively the mare remained at the hospital for 12 days while her incision was monitored, the medial canthus was opened and the orbit packed with Sorbact, and strikethrough of the bandage noted. No complications arose post op, though the mare was skittish on her right side for several days after the enucleation. Histopathology of the eye found Pseudomonas putida and Pseudoflavorifractor capillosus. The diagnosis was severe chronic active suppurative periocular myositis and cellulitis, optic neuritis and panopthalmitis with intralesional bacteria. Comments by the pathologist noted that the microscopic findings were consistent with bacterial panopthalmitis and that the lesion may have developed by extension from the tooth root abscess/sinusitis. The mare remained on chloramphenicol, omepra-
Views of the dental pathology.
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technician update
zole and probiotics and received a 3 L LRS bolus with 300 mL of DMSO SID. Three days post op, metronidazole was added to her regimen. Eight days after surgery the IV catheter was pulled, and she was switched to flunixin. She was released with a fair prognosis and was to remain on antibiotics and anti-inflammatories for three weeks, with a 10-day follow up scheduled with her attending clinician. The mare remained afebrile and bright, and the farm returned the mare to the hospital on April 14 for a follow up MRI. Preoperative bloodwork was unremarkable. The exact protocols from the initial MRI were performed, with Gadolinium (Multihance 20cc) used again as the contrast agent. Findings showed that the pituitary abscess had resolved and that the size of the gland had decreased dramatically. Compression of the brainstem was no longer present and increased signal seen in the thalamic region had resolved. There was increased signal intensity within the left rostral maxillary sinus and ventral conchal sinus surround-
ing the site of the tooth that was previously removed. The AO spinal tap was repeated in the recovery stall and the fluid analysis was WNL. No growth was seen on culture. The mare was released with a fair prognosis and instructions to continue the left sinus flush. Upon follow-up exam the theriogenologist determined that the mare was in chronic anestrus due to the previous pituitary abscess, likely due to the fact that follicle stimulating hormone production in the pituitary gland has been affected. Otherwise, both the mare and foal are doing well. MeV
About the author
Emily Zurkuhlen is the Imaging Technician at Rood and Riddle Equine hospital, where she has worked since 2007. Emily is currently working on obtaining her LVT and specializes in MRI and ultrasound, working with Dr. Katie Garrett who is the head of the Imaging department.
Factors Associated With Neonatal Encephalopathy Survival
Photo courtesy of The Equine Veterinary Journal
The prognosis for foals with neonatal encephalopathy may be better than one would think, according to a recent study. Researchers did a retrospective cross-sectional study to determine the factors involved in outcome of 94 young foals hospitalized for neonatal encephalopathy (neonatal maladjustment syndrome and dummy foals). They reviewed clinical information, such as signalment, vital signs at admission, clinical signs throughout hospitalization, including signs of neurological dysfunction, laboratory variables and the duration of clinical events. The diagnosis of neonatal encephalopathy was made clinically. Of the 94 foals, 75 (79.8%) survived to discharge. The most common clinical signs were abnormal udder seeking and suckling, inability to stand, abnormal gastrointestinal motility, abnormal consciousness and
seizures. In 14 foals, neonatal encephalopathy was the sole diagnosis. In the others, concurrent conditions were sepsis, pneumonia, prematurity/dysmaturity, patent urachus, limb deformity, colic and uroperitoneum. Of the 19 non-survivors, four died and 15 were euthanized. Post-mortem reports were available for 17 of which 11 had severe pneumonia, disseminated sepsis or sepsis-related complications. Microscopic examinations of brain sections in 10 cases showed neuronal necrosis or degeneration consistent with ischemia. Factors which were significantly associated with non-survival in the multivariable logistic regression model were high total calcium concentration, low alkaline phosphatase activity, an increased number of comorbidities, recumbency and the requirement for vasopressor therapy. Non-survivors were more likely to have received treatment with vasopressors, or received mechanical ventilation or respiratory stimulants than survivors. No single therapy was shown to improve survival. Recumbency, multiple co-morbidities and use of vasopressors to treat hypotension were significantly associated with mortality. MeV
For more information: Lyle-Dugas J, Giguere S, Mallicote MF, et al. Factors associated with outcome in 94 hospitalized foals diagnosed with neonatal encephalopathy. Equine Vet J. March 16 [Epub ahead of print]. http://onlinelibrary.wiley.com/doi/10.1111/evj.12553/abstract 16
Issue 4/2016 | ModernEquineVet.com
dentistry
Focus on
Temporomandibular joint (TMJ)
chewing to findTMJ
The horses were outfitted with a system of LED lights similar to the 3-D motion tracking systems used in movies to map facial movements to follow mastication.
P a u l
B a s i l i o
Images courtesy of Dr. Travis Smith
B y
disease can often be found toward the bottom of the differential list, but pain from the disease can cause noticeable masticatory derangements and compensation. If left undiagnosed, it may even lead to quidding and anorexia. The pain associated with TMJ disease is also suspected to cause behavioral idiosyncrasies, such as head shaking, shyness, or fighting at the bit, which can make riding difficult or impossible, according to Travis T. Smyth, DVM, BSc, surgical resident at the Western College of Veterinary Medicine in Saskatchewan, Canada. “The issue with TMJ disease in horses is that we don’t really know if the disease exists, or more specifically, how often it exists,” Dr. Smyth said at the 61st Annual Convention of the AAEP in Las Vegas. “The shortage of reported literature artificially suggests that the disease is restricted to a small number of overt or endstage cases, but some research suggests that the inflammation process and degenerative joint disease in the TMJ is similar to other joints.” The researchers wanted to know whether TMJ disease was degenerative, and if so, why it was so rare. They also wanted to know whether some horses suffered less severe disease and therefore, were less painful. The TMJ is referred to as the single most active joint in the horse, so common sense would indicate that the disease would occur with more frequency, he said. “If we’re not seeing it, then either the disease isn’t painful, or we’re not using methods that are sensitive enough to pick it up,” Dr. Smyth explained. To test whether changes in the masticatory cycle could indicate the presence of underlying TMJ disease, Dr. Smyth and his colleagues examined the kinematics of the joint and characterized the movements of the ModernEquineVet.com | Issue 4/2016
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dentistry
jaw during acute, unilateral inflammation of the TMJ in response to an inflammatory agent. Dr. Smyth and his colleagues enrolled six horses without dental abnormalities or conformational disease in the study. Each horse was outfitted with a system of LED lights that are similar to the 3-D
motion tracking systems used in movies to map facial movements. The masticatory cycle can be divided into three phases: opening, closing and power (grinding) and was followed using the LED. To produce an inflammatory response, each horse was given lipopolysaccharide in the dorsal
The Inner Workings
Images courtesy of Dr. Travis Smyth
Externally, the landmarks of the TMJ can be visualized by tracing a line from the lateral canthus of the eye to the tragus of the ipsilateral ear. Bisection of this line will lead directly over the TMJ. Beneath the skin, the TMJ is bordered dorsally by the zygomatic process of the temporal bone, and ventrally by the vertical ramus of the mandibular condyle. From above, the mandibular condyle is not only convex in appearance, but rather oblong or ovoid. It is approximately three times longer in the lateral medial axis than in the rostrocaudal axis. The soft tissue structures in this joint are related to a fibrocartilaginous disk, which appears rather unique. It is thin in the center and thick around the periphery. It creates a biconcave shape that continues on to create a synovial membrane, allowing the formation of both dorsal and ventral synovial pouches. “When moving in unison with both TMJs, this allows for the complex movements in 3-dimensional space, such as the masticatory cycle,” Dr. Smyth explained. “If you are looking at the horse from directly above and slightly forward, the masticatory process can be broken into three phases: the opening phase, the closing phase, and the grinding or power phase.” A quick resetting cycle then occurs in which the mandible comes to rest and the mouth is closed in a neutral position. During the opening phase, the mandible not only extends vertically but laterally as well. The movement also occurs in the 3rd dimension, which is rostrocaudally. “This is important, because the mandible will continue in the opening phase asphase as it reaches the vertical extension,” Dr. Smyth said. “It will travel laterally, denoting the start of the closing phase. As the occlusal surfaces come together and the mandible reaches the maxilla, this defines the start of the power phase in which the feed is ground in preparation for swallowing.”
The landmarks of TMJ can be visualized by tracing a line from the lateral canthus of the eye to the tragus of the ipsilateral ear.
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pouch of the synovial joint. Peak inflammation was shown in the cytokine profile approximately six hours post injection; this led to a transient response that was all but gone by 12-24 hours. Prior to injection, four of six horses chewed in a counter-clockwise fashion (left-sided chewers). Following the injection, all of the horses became right-sided chewers. Results showed that acute inflammation of the TMJ led to an alteration of the chewing kinetics in the vertical and lateral directions and a decrease in chewing efficiency. “The vertical and lateral extensions of the masticatory cycle were reduced and were closer to the neutral position,” Dr. Smyth reported. “The opening phase continued in a fairly similar manner, but the closing and power phases (phases creating peak pressure in the joint) were greatly different following the injection.” Although there was still rostrocaudal movement during the closing phase, it was markedly reduced. There was also a large amount of rostrocaudal movement in the power phase, during inflammation, which indicates that the occlusal surfaces have interdigitation that can lead to a loss of eating efficiency. “Four of the six horses also had a large amount of joint effusion and hot, painful TMJs six hours after the injection,” he said. “This could predispose the horses to impaction colic or choke.” Dr. Smyth suggested that every affected horse may not show overt signs of TMJ disease, but that does not mean that disease is as rare as it appears. “The horses that showed overt signs were obviously painful, but we may be missing some of the less overt signs in the horses that come into the clinic. We may be missing some horses that still have a painful component to their disease,” he said. MeV
news
Researchers and engineers in Saskatchewan hope a robotic lift system will help to improve the odds for horses recovering from limb fractures and other traumatic injuries. "I think it will give a lot of horses a chance that before, didn't have a chance," said team leader Julia Montgomery, a large animal internal medicine specialist at the Western College of Veterinary Medicine (WCVM) at the University of Saskatchewan (U of S). The researchers teamed up with Saskatoon's RMD Engineering to design and build the lift. It is designed to help rehabilitate horses suffering from injuries and other musculoskeletal problems by providing mobility, weight distribution and support. Research team members include engineering experts, an equine biomechanics specialist and a veterinary radiologist. Hundreds of horses are fatally injured and euthanized every year in North America due to racetrack injuries, most of which are fractures, but as every veterinarian knows, even pleasure horses can suffer fractures and other orthopedic injuries. Due to a horse's heavy weight and its strong flight response, recovery from surgery is fraught with complications and secondary issues such as supporting-limb laminitis, as was the case with Barbaro. The Kentucky Derby winner shattered his right hind fetlock while racing in the Preakness Stakes in 2006. Surgeons successfully repaired his leg, but eight months later, Barbaro was euthanized after developing laminitis in his other feet. The current designs of existing slings significantly limit the animals' normal activity and support all of their weight on the thorax and abdomen, which can
lead to lung compression and pressure ulcers. Dr. Montgomery said the new lift system allows clinicians to dynamically reduce and redistribute the weight the horse is carrying. This allows the animal to be mobile with its weight partially or fully supported. Leg fractures are one of the most common injuries that will benefit from this new technology, but the lift can also be used with equine patients suffering from other musculoskeletal and neurological problems. Dr. Montgomery and her team have been conducting initial trials with the lift on three healthy horses to see how they tolerate hanging out for extended periods of time in the sling and prototype system. Next, they will use it with horses with limb fractures that would otherwise be euthanized. These trials will help them find out how the lift affects horse behavior and physiological parameters, such as muscle enzymes and blood flow. If all goes as planned, the team hopes the robotic lift system will decrease pain for equine patients, shorten recovery time and reduce complications. This will in turn help lower treatment costs and reduce emotional distress for both horse and owner. MeV
Image courtesy of Christina Weese
Need a Lift?
The equine lift in use. This lift holds the potential to help horses recover more easily from injuries.
Key in EEE Transmission in Southeast A mosquito species that's very abundant in the Southeast may play a more significant role in transmitting Eastern equine encephalitis (EEE) than originally thought. A recent study by University of Florida researchers shows that study Culex erraticus is more abundant than Culiseta melanura, so it may be more important than scientists originally thought in transmitting EEE virus, at least in the Southeast. The researchers combined data from field and laboratory studies in Florida with that collected earlier at Tuskegee National Forest in Alabama, where C. erraticus is common and C. melanura relatively rare. Their laboratory studies showed C. erraticus was about half as effective as C. melanura in transmitting the virus in the laboratory. Even though it's not as efficient in transmitting EEE virus, there are more C. erraticus mosquitoes in the Southeast than C. melanura. C. erraticus also feeds on a wider variety of animals than C. melanura, which feeds almost exclusively on birds for its blood meals. MeV With a 70% to 90% fatality rate, EEE virus poses a great threat to horses, with Florida reporting 136 cases in 2014, the most of any state.
For more information: Bingham AM, Burkett-Cadena ND, Hassan HK, Unnasch TR. Vector competence and capacity of Culex erraticus (Diptera: Culicidae) for eastern equine encephalitis virus in the Southeastern United States. J Med Entomol. 2016; 53(2): 473 DOI: 10.1093/jme/tjv195
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