The Modern
Equine Vet www.modernequinevet.com
Cribbing and colic What's next for EIPH? Closer look at chronic laminitis A good offense is the best defense
Vol 4 Issue 10 2014
Table of Contents
Cover story:
4 Cribbing and windsucking may increase risk of colic Cover photo by Bob Langrish boblangrish.com
Metabolism
Obesity growing problem in UK breeds........................................................................... 3 Respiratory
What's next for exercise-induced pulmonary hemorrhage?....................................9 technician update
Dreading going to work every day?................................................................................11 Orthopedics
Closer look at chronic laminitis.........................................................................................12 Horse of a different stripe gets a leg up.........................................................................14 Practice Management
A good offense is the best defense...........................................18 News
Reproduction in ancient equids similar to modern horse..............................................................................21 How much should this cost?........................................................21 advertisers Shanks Veterinary Equipment.............................. 3 Merck Animal Health............................................ 6
Avalon Medical..................................................... 8
The Modern
Equine Vet Sales: Robin Geller • newbucks99@yahoo.com Editor: Marie Rosenthal • mrosenthal@percybo.com Art Director: Jennifer Barlow • jbarlow@percybo.com contributing writer: Paul Basillo 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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Metabolism
Obesity growing problem in UK breeds Equine obesity is an increasing but under recognized welfare issue in the United Kingdom, according to new research from the Animal Health Trust (AHT). The researchers found that 31% of 785 horses and ponies were obese. From 2009 to 2011, the researchers followed the horses to see which factors contributed to the risk of equine obesity.
highlights the risk of obesity is greater in pleasure or non-ridden horses, which are nearly three times more likely to be obese. Competition animals will receive increased exercise at a higher intensity and be fitter than non-competition animals, further reducing the risk of obesity. “Competition horses are likely to be managed in different ways compared with non-competition or non-ridden animals, and this may also contribute to the reduced risk of obesity within this sub-population,” she said. The study was funded by World Horse Welfare. MeV
For more information: Robin CA, Ireland JL, Wylie CE, et al. Prevalence of and risk factors for equine obesity in Great Britain based on owner-reported body condition scores.
ShutterStock/omihay
Lifting Large Animals Since 1957 They identified several factors, according to the study published in the Equine Veterinary Journal. Pony breeds, particularly UK native breeds and heavier horses, such as draught and cob horses, were all significantly more likely to be obese compared with Thoroughbreds. The increased risk may be due to these native breeds having adapted to thrive in harsh environments with sparse grazing available, the researchers said. “Native breeds may be genetically better adapted to survive in harsh conditions having a so-called thrifty genotype, increasing their risk of obesity when maintained in an environment where food is of better quality and readily available,” explained Charlotte Robin, research assistant at AHT and lead author of the paper. Horses that were described by their owners as readily being able to gain weight or being “good doers” were more than three times more likely to be obese, compared with those that normally maintained weight. The research also highlighted various links to human obesity, she added. “In humans obesity is associated with poor health status and chronic health conditions, including diabetes, hypertension, respiratory disease and arthritis. Similar associations between obesity and adverse health events have been described in equines.” Similarly in humans, exercise significantly improves insulin sensitivity, and it is thought the same response is mirrored in horses. For example, the AHT’s research
www.shanksvet.com • info@shanksvet.com ModernEquineVet.com | Issue 10/2014
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cover story
Cribbing and windsucking may increase risk of colic B y
M a r i e
R o s e n t h a l ,
Between 2.1% and 10.5%
of domestic horses exhibit cribbing or windsucking behaviors, which may put some of them at increased risk of colic, according to a recent UK study. “We do not suggest that crib-biting/windsucking behavior causes colic, and the majority of horses in the present study had no prior history of colic. However, it is possible that a sub-population of horses that display crib-biting/windsucking behavior exists that may have some inherent difference in intestinal function that is associated (potentially causally with respect to colic) with both crib-biting and windsucking and colic,” the researchers wrote in BMC Veterinary Research, where the study appeared. During cribbing, a horse repeatedly seizes fixed objects with its incisors and pulls at them while grunting. The behavior and sounds made in windsucking are similar 4
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but the horse does not grab a fixed object.
Health and behavior questionnaire
Researchers from the University of Liverpool asked owners of horses that exhibit these behaviors to fill out a questionnaire about the horse’s behavior and health. They then investigated any colic that occurred within the previous 12 months and compared it with any history of colic. A total of 550 questionnaires were sent out and 370 were completed and returned. Data from 367 horses were examined. The owners reported a total of 672 episodes of colic in 130 horses; 126 cases of colic were reported in the preceding 12 months of which 69 required a veterinarian. Thirteen required surgical intervention. Several of the horses had more than one episode of colic. “The prevalence of colic within
a UK population of horses that display crib-biting/windsucking behavior appeared to be high (38 colic episodes per 100 HYAR [horse years at risk] for all colic episodes and 20 veterinary attended episodes of colic per 100 HYAR)," according to the researchers, which is more than the prevalence of colic in horses in general, which varies from 3.5-10.6 colic episodes per 100 horses per year (i.e. per 100 HYAR). In this study, horses that were frequent crib-biters or windsuck-
ers appeared to be at higher risk of colic, which may be due to altered gastrointestinal function. “The results of the present study may suggest that, if there are differences in the inherent and complex interrelationship between brain and gut function, these differences may also vary between horses that display crib-biting/behavior. This could be a plausible explanation for why horses with most marked expressions of these forms of behavior are also at significantly increased risk of
colic,” they wrote. “Horses that displayed increased frequency of crib-biting/windsucking behavior when eating forage (such as hay or haylage) were around twice as likely to have a history of colic (ever) compared to those in which behavior patterns remained unchanged,” they said. Lack of dietary forage is a factor implicated in the development of cribbing or windsucking, and providing sufficient forage together with opportunities for horses to dis-
play normal foraging behavior are recommended methods of inhibiting the behaviors.
Foraging risk
In the present study, horses that were fed haylage were also twice as likely to have a history of colic compared with those that did not receive this form of forage. Provision of hay and specific types of hay have previously been identified to alter the risk of colic and increase continued on page 8
During windsucking, a horse displays the same behavior as cribbing and makes the same grunting sounds, but does not grab at a fixed object. Photo by Bob Langrish boblangrish.com
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Comparison of innate immune responses in equine respiratory epithelial cells to modified-live equine influenza vaccine and related wild-type influenza virus. HL Pecoraro, D. Koch, G Soboll Hussey, L Bentsen, GA Landolt; Proceedings ACVIM Annual Forum 2014. 2 UC Davis (Nicola Pusterla) & Merck Animal Health. Infectious Upper Respiratory Surveillance Program. Ongoing Research 2008 – present. 1
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cover story
the likelihood of specific forms of colic, such as ileal impactions and large colon volvulus. The results of the present study would suggest that the risk of colic in horses that exhibited windsucking or cribbing could potentially be reduced if fed other forms of forage. However, more study is needed they said. In addition, being stabled for long periods in the fall, although not at other times, was also a risk factor for colic. Increasing time spent stabled and reduced time spent out at pasture have been iden-
Increased likelihood of colic was associated with cribbing and windsucking. tified as factors that increase the risk of colic in previous studies. “The proportion of horses that
had a previous history of colic and the prevalence of colic in a population of horses that exhibit cribbiting/windsucking behavior appeared to be high in the present study. Increased likelihood of colic was associated with increased severity of crib-biting/windsucking behavior as assessed by the owner/ carer, increased duration of stabling in the autumn months, feeding of haylage and individuals in which eating forage was associated with increased expression of crib-biting/ windsucking behavior,” the reMeV searchers wrote.
For more information: Escalona EE, Okell CN, Archer DC. Prevalence of and risk factors for colic in horses that display crib-biting behavior. BMC Veterinary Research 2014. Available at http://www.biomedcentral.com/1746-6148/10/S1/S3
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respiratory
What’s next for
exercise-induced pulmonary hemorrhage? B y
P a u l
Cheryl Ann Quigley / Shutterstock.com
Racehorses are physiologically
exceptional, fast and beautiful as they fly around the track. Unfortunately, many performance horses have an Achilles’ heel. They can be bleeders. Approximately 90% of Thoroughbred horses racing today can be traced to two sires: Herod, a horse who reportedly “burst a vessel” during a race and who was notoriously inconsistent, and Bartlett’s Childers, who was given the ignominious, nickname “Bleeding Childers.”
B a s i l i o
“The horse’s heart is beating so hard [during a race] that the left side does not have time to fill,” explained Rick Arthur, DVM, who is the equine medical director for the California Horse Racing Board. “That causes blood to build up in the lungs. Whether the horse has a secondary venal occlusion or whatever the cause, the blood pressure in the lungs is increasing and blood vessels will start to break.” The treatment is furosemide, especially in the racing industry. However, that is changing as the
industry is demanding fewer drugs on the track. “I think the trend in all sports is toward no medications,” explained Dr. Arthur.
Endoscopy changed the game
During the days before fiberoptic endoscopes, a horse with obvious epistaxis was considered a bleeder. When one of Arthur’s colleagues obtained one of the first available fiber-optic endoscopes on the secondary market, the reality of the prevalence of exercise-induced pulmonary hemorrhage (EIPH)
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respiratory
started to become clear. “In the 1970s, people were still using rigid cystoscopes. You would have to get your face right up to the horse’s nose and you could barely look over the pharynx, if at all,” Dr. Arthur said. “[When we started using the fiber-optic endoscope], we were putting a lot of the horses on the bleeder’s list. The commission at the time told us that 10-15% of horses were being put on furosemide, but it’s known that only 2-3% of horses bleed.”
"The horse's heart is beating so hard [during a race] that the left side does not have time to fill." Dr. Rick Arthur
Fixing the bleeder's list
The commission assumed the doctors had ulterior motives for placing so many horses on the bleeder’s list, and they insisted that the official veterinarian look through the new fiber-optic scope and see the blood for himself. After the official veterinarian got a good look, the number of horses diagnosed with EIPH increased to about 25%, according to Dr. Arthur. Dr. Arthur is a proponent of a
Exercise-Induced Pulmonary Hemorrhage Scale Grade 0: N o blood noted in the pharynx, larynx, trachea, or mainstem bronchi. Grade 1: O ne or more flecks of blood or two or fewer short and narrow streams of blood in the trachea or mainstem bronchi. Grade 2: O ne long stream of blood or more than two short streams of blood over less than onethird of the tracheal circumference. Grade 3: M ultiple, distinct streams of blood over more than one-third of the tracheal circumference; blood pooling is present at the thoracic inlet. Grade 4: Multiple, coalescing streams of blood over more than 90% of the tracheal surface; blood pooling is present at the thoracic inlet. Source: Robinson NE, Sprayberry KA (eds). Current Therapy in Equine Medicine 2009;6. Elsevier Health Sciences. St. Louis, Mo.
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uniform and simplified scale for grading EIPH. “I had a practitioner tell me that he had a horse that was bleeding ‘5 out of 10.’ I had no idea what that meant.” He recommended the scale described in 2005 by Kenneth W. Hinchcliff, BVSc, PhD, DACVIM, a professor of veterinary science at the University of Melbourne, Australia (See EIPH Scale). “I think we should all use this definition,” Dr. Arthur said, because it is repeatable from veterinarian to veterinarian. “The reality is that all horses bleed,” Dr. Arthur explained. “Horses will not only have pulmonary hypertension when they race, but it is also seen when they gallop. Unless you treat every horse that gallops, you’re going to have a lot of horses develop venous occlusion that end up with chronic EIPH.” The drug of choice for EIPH has been furosemide. Double-blind studies have confirmed that furosemide is effective in reducing EIPH, which also translates into better performance on the track. Furosemide appears to have the most significant effect on horses with more severe EIPH. In one South African study, Dr. Arthur reported that of the horses treated with furosemide, there were none with EIPH grades higher than 2.
“Horses run faster with furosemide,” he said. “One study in horses that measured more than 22,000 starts showed that the average horse will run a race between three and five lengths faster when it is receiving furosemide.” The question is whether it is because of decreased bleeding, water loss, change in total carbon dioxide (TCO2), or some unidentified effect, according to Dr. Arthur, who noted that some practitioners forget that furosemide can have a fairly profound effect on the cardiovascular and pulmonary systems. Dr. Arthur’s group conducted a study that showed that the effects of furosemide were separate from the increase in TCO2. A different study by Hincliff found in a laboratory experiment that if the amount of weight that is lost through furosemide use is replaced on the horse, then the increases in performance are eliminated. The fundamental question about furosemide is whether it actually alters the long-term pathologic changes associated with EIPH, Dr. Arthur explained. “There is some research being conducted at this moment that may answer that question.”
Bad for racing
Dr. Arthur said that furosemide may be good for the horse, but bad for racing. “I think the international races that don’t use furosemide have horses that are every bit as healthy as ours. I believe being perceived as drug free is where the racing industry is going—not only with furosemide, but also with phenylbutazone and other nonsteroidal anti-inflammatory drugs. That is what the public is starting to demand, and I think we need to prepare for it,” he explained at the 54th Annual Meeting of the American Association of Equine Practitioners. MeV
technician update
Dreading going to work every day? By Marie Rosenthal, MS Working with horses is not only physically demanding, it also takes a toll on the psyche. Caring for sick animals and managing the emotional needs of horse owners can lead to compassion fatique and burnout. “We go into our jobs because we love animals, but then we experience the psychological toll of handling irate, emotional clients and working long hours for low pay. We care for sick animals and issues like euthanasia, not just happy foals and healthy horses,” explained Katherine Dobbs, RVT, CVPM, PHR, of interFace Veterinary HR Systems, LLC in Wisconsin, an expert in practice-management issues. Burn out and compassion fatigue are common throughout the industry, but particularly among veterinary technicians, who work long hours for salaries that do not reflect their education or experience.
Understand what you are feeling
Although they have similar characteristics, burn out and compassion fatigue are not the same, explained Dobbs, and they occur for different reasons. Burnout centers around the exhaustion someone might experience after dealing with numerous stresses during the job. Burnout can cause a technician to become less interested in his or her career and the job that they do, according to Dobbs. Factors contributing to burn out include: • Working for someone who is unsupportive, • Working with faulty, outdated equipment, • Working long hours, and • Working for a low salary. Salary is an issue for most veterinary technicians, according to Dobbs, because after graduation, they often make less than their peers with similar education and training. “Back when we got our first job in animal care, we were so excited to realize our dream that the low pay was not as much of an issue,” Dobbs said. However, the longer one spends on the job dealing with stress and other negative emotions, the situation changes from “salary is not an issue to you just can’t
pay me ENOUGH to do THIS job!” She said. “It becomes about the money when we no longer have the emotional satisfaction that carried our dream.” While external stressors drive burnout, relationships drive compassion fatigue, which stems from the relationships that veterinary technicians develop with the horse and its owners. “Compassion fatigue is the internal aspect of caring for and about those who are suffering some sort of trauma or difficulty,” she said. "It can be difficult to hold back our emotions and control our empathy when faced with a difficult case, such as euthanasia, so we can continue with the day,” Dobbs said. That effort leads to exhaustion from caring so much for these patients and clients. Signs of burn out and compassion fatigue include depression, anger and dreading going to work, Dobbs explained. Often people suffering from these negative emotions no longer care about doing a great job and they stop wanting to advance their careers and improve. Dread is common because the workplace has become intolerable. Sometimes, there is nothing a technician can do to change the situation, and if that happens, it might be better to find a new job. Sometimes, the staff mix is just not right, and finding a new veterinary hospital might be best for everyone. “If you change your environment, you might be able to find a job with less workplace stressors [closer to home, better hours, nicer facility]” Dobbs said. “However, if what you are feeling is compassion fatigue in animal health, you will carry compassion fatigue with you. One of the best solutions for compassion fatigue is to take better care of yourself,” she said. Eat right, get enough sleep, get some exercise and have a life outside of work. These will help you decompress from the day and relieve the stress. Research has found that a three-pronged approach works best to prevent and manage workplace stress: 1. Organizational responsibility to care for staff. 2. Peers supporting colleagues and 3. A personal responsibility to care for oneself. MeV
For more information: Katherine Dobbs has developed a 90 minute video about combatting compassion fatigue, which is available for purchase at http://www.katherinedobbs.com/90-minute-recorded-webinar. Carter SB. Overcoming Burnout: 10 Steps to Reignite Your Flame and Shine Brightly Once More Psychology Today. Accessed on Nov. 14, 2014 at http://www.psychologytoday.com/blog/high-octane-women/201104/overcoming-burnout. Figley CR, Roop RG. The Costs of Caring. In: Figley CR, Roop RG, Compassion Fatigue in the Animal-Care Community. Washington: The Humane Society of the United States, 2006; 1-6. ModernEquineVet.com | Issue 10/2014
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orthopedics
A closer look at
chronic laminitis B
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Despite the prevalence of
equine laminitis, the understanding of its affects on the equine distal phalanx (DP) are not well understood, so researchers at the University of Pennsylvania set out to identify, characterize and quantify progressive DP osteopathology associated with equine laminitis using micro–computed tomography (Micro-CT). “Laminitis is a multifactorial and very complex disease process that seems to be more than just skin deep,” said Julie B. Engiles, VMD, DACVP, an assistant pro-
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fessor of pathology at Penn’s New Bolton Center. “There is an overlap of vascular, inflammatory, metabolic and mechanical pathways that affect the lamellae and the distal phalanx.” Even the very dense solar cortex is alive, she explained. This cortex contains osteonal channels that periodically cycle through phases of remodeling. “If you were to look at the medullary spaces of the normal distal phalanx, they are pretty bland,” Dr. Engiles noted. “There is very little cellularity.” In cases of chronic laminitis,
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there is generation of markedly dysplastic lamellae and squamous metaplasia with a keratinized mass of tissue that is the lamellar wedge. “When that occurs, we can see that there’s dramatic distortion in the contour of the dorsal cortex and profound osteolysis and changes within the medullary spaces. The bone spicule is lined by numerous osteoclasts and osteoblasts. The rebuilding crew is no match for the demolition crew.”
Methodology
The study looked at 36 hooves
Photo by Bob Langrish boblangrish.com
from 15 horses (72% fore limbs and 28% hind limbs). The age range was from 1.5 to 22 years (mean age of 7.3 years and median age of 4 years). Being an athlete can affect bone microarchitecture, so horses were segregated by athletic performance. The team had a detailed history of the onset and inciting causes of laminitis and the duration and progression of the disease. Because many of the horses were presented for euthanasia, the team did not have complete sets of antemortem radiographs. “We had to consider the possibility that different risk factors can affect feet differently in the context of individual animals, and that subclinical laminitis could be present in feet that are considered normal,” Dr. Engiles said. “To that end, we created risk factors and designated whether those risk factors affect all four feet or select feet.” Obesity, equine metabolic syndrome, pituitary pars intermedia dysfunction (PPID) and visceral inflammatory disease were some of the factors designated as “all feet” risk factors, and sporting limb overload and orthopedic inflammatory disease were some of the processes designated as “select feet” factors. “The predominant risk factors that we saw in non-performance horses were PPID, obesity and equine metabolic syndrome,” Dr. Engiles said. In performance horses, they were local or systemic inflammatory disease and support limb overload. The harvest protocol involved two parasagittal slices—one thick for gross and histopathologic evaluation, and one thin for microscopy. Digital radiographs from each thin section were graded. “Most of the published grading schemes were from [weight-bearing] feet,” Dr. Engiles explained. “Since these were examined on necropsy, we were using radiographically apparent pathology as a barometer
for more severe pathology.” Due to the size constraints of micro-CT (See box), the distal phalanx was subsectioned into proximal and distal portions and scanned separately. “If you’re working with a mouse, micro-CT is no problem. If you’re trying to stuff bones from a horse into the machine, it’s a different matter altogether.” The multimodal grading schematic was chosen due to what Dr. Engiles calls the “iceberg analogy.” Often, histopathologically evident disease is not grossly apparent, and grossly apparent disease is often not radiographically apparent. “When I see radiographically evident dis-
Bone loss in the distal phalanx correlated to early and chronic stages of laminitis. ease, it is typically the tip of the iceberg,” she explained. “There is likely severe disease happening at the gross and histopathologic levels. Given our relatively small sample size, we used very conservative and rigorous statistical methods.”
Conclusions
“We found that bone loss in the distal phalanx did correlate to early, as well as chronic stages of laminitis pathology,” Dr. Engiles reported at the 54th Annual Meeting of the American Association of Equine Practitioners. “We could see the progressive loss and thinning and porosity of the distal and solar cortices. The remodeling of the trabeculae becomes severe by the chronic stage.” In a normal horse, there is a dense outer cortex of compact
Quick look: Micro-CT Micro–computed tomography (Micro-CT) is a diagnostic imaging modality that provides quantitative, volumetric and morphometric measurements with detailed information pertaining to subtle changes in bone microarchitecture. This modality also provides relatively expedient in situ serologic information in the form of 3D image reconstructions. bone, a dense solar cortex, and a medullary cavity of trabecular bone with bland adipose tissue. In a horse with severe pathology of approximately six weeks’ duration, for example, investigators found that the dorsal cortex was “melted” and trabeculated, and the solar cortex became porous. “The changes in the medullary cavity included vascular remodeling, medullary fibrosis, edema and inflammation,” Dr. Engiles said. “This was surprising to see in the earlier phases of laminitis. In the dorsal cortex, you could see dramatic osteoclasts, osteolysis and neovascularization. Even in a horse with less than a one-week duration of disease, abundant inflammatory cells were present, and a chorus line of osteoclasts were starting to remove bone.” Dr. Engiles explained that it is important to remember that there are intricate connections between the lamellae and the distal phalanx. The inner limits of the deep lamellar dermis [corium] are related closely to the dorsal cortex of bone through the entheses. “Conversely,” she said, “the blood supply to these lamellae travels through the distal phalanx via perforating vascular channels.” Dr. Engiles noted that elucidation of these pathways could provide a more complete understanding of laminitis pathogenesis and progression of disease, and may lead to diagnostic biomarkers for prevention or early detection, or provide novel therapeutic targets. MeV ModernEquineVet.com | Issue 10/2014
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orthopedics
A horse of a
different stripe gets a leg up B
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The combination of a custom prosthetic hoof, bold surgical techniques, and seven months of round-the-clock care at New Bolton Center in Pennsylvania made it possible for a unique patient to regrow an entire hoof. An abscess in his foot made it impossible for Zippy, the zebra, to bear weight on his right hind leg. Despite medical treatment, the infection was so serious that the structure of the hoof was completely compromised, sepa14
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rating from the bone. “We knew there was a chance that, if we could just keep him comfortable and alive and thriving, he could simply regrow his hoof,” said Dean W. Richardson, DVM, Charles W. Raker professor of Equine Surgery, University of Pennsylvania School of Veterinary Medicine and chief, Large Animal Surgery, University of Pennsylvania School of Veterinary Medicine and chief of large animal at New Bolton Center. “So
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that’s what we set out to do.” The chance of success was only about 20-25%, Dr. Richardson thought at the time. “I absolutely thought he had a legitimate chance. He was small and he was tough,” Dr. Richardson said. “He had lost only one foot, which makes it a whole lot easier than if he had lost more. I wouldn’t have encouraged treatment if I didn’t think he had a chance.” Slim odds, yes, but his owner was committed to saving Zippy’s
life, if at all possible. Zippy arrived at New Bolton Center on Sept. 3, 2013, referred by New Bolton Center’s Field Service for lameness. After a series of radiographs, the abscess was drained. A poultice was applied, and Zippy was treated with several medications. Patrick Reilly, chief of farrier services at the center, made a special shoe for the affected hoof to make it more comfortable for Zippy to support weight on the
leg. When Zippy tried to stand for the first time in weeks, the severity of the problem became apparent when the entire hoof capsule came off, in one piece. “In Zippy’s case, the abscess undermined the whole foot,” said Reilly, explaining that the infection expanded between the hard hoof on the outside and the soft foot on the inside, destroying the sensitive lamina that connects them. Dr. Richardson performed several surgeries on Zippy over the next few months. First, he put a transfixation pin across the cannon bone and surrounded the pin with a cast. “What that does is allow him to bear weight on that leg without putting weight on his foot,” Dr. Richardson explained. “The pin transmits his weight. The foot was completely protected from weight-bearing forces.” Reilly fabricated a hydrophilic sock, which easily absorbs moisture, made out of urethane foam to help make the cast more comfortable. This material is not one usually used on horses; it was developed as a wrap for human burn victims. A traditional wrap has fibers that can cause infection. Keeping Zippy healthy and comfortable was critical to making it possible for the transfixation pin to stay in long enough to allow the hoof to start to grow, Dr. Richardson said. Regular cleaning and several cast changes allowed the pin to remain and function well for two full months. The hoof started to regenerate, growing down from the upper limit of the hoof capsule, known as the coronary band. “It was a matter of intermittent intensive work,” Dr. Richardson said. “We regularly had to put him under anesthesia to inspect and clean the foot, but in between, there really was not much we
could do other than feed him and monitor his comfort.” In October, an evaluation showed that the infection had severely damaged the coffin bone, requiring Dr. Richardson to remove nearly a third of that bone. By the end of November, enough hoof wall had grown to form a surface for Reilly to attach a prosthetic hoof he created just for Zippy.
"We knew that if we could just keep him comfortable and alive and thriving, he could simply regrow his hoof." Dr. Dean W. Richardson
“This was a first,” Reilly said, explaining the process. He cut a piece of hard plastic the size of Zippy’s foot. “I put it in a toaster oven during surgery to get it soft, and molded it right around Zippy’s foot,” he said. Reilly filled holes he made in the plastic with special polymers, and also glued the cuff of the plastic shoe onto the new hoof. Reilly is familiar with these polymers, since he regularly puts “glue-on” shoes, pioneered at Penn Vet, on his patients. Zippy wore the prosthetic hoof for four months, living at New Bolton Center, allowing the hoof to grow underneath. “And that just continued to ModernEquineVet.com | Issue 10/2014
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orthopedics
grow until finally his foot had become completely encased in hoof wall,” Richardson said. “It really was that simple.” Zippy grew an entirely new hoof. “It’s a perfectly normal-looking foot now,” Reilly said.
Laminitis
Progression of laminitis healing. Photos courtesy of New Bolton Center
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The diagnosis was laminitis, which is excruciatingly painful. Dr. Richardson said he has treated horses that have sloughed off part of a hoof, but he has not had a case like Zippy’s, in which the whole hoof fell off and was regrown. However, Zippy is not the first case at New Bolton involving the loss and regrowth of a hoof. Mystic Park, a famous Standardbred racehorse, came to New Bolton in the summer of 1983, suffering from Potomac Fever. Laminitis set in, and he eventually lost all four of his hooves. New Bolton Center’s unique recovery pool made it possible for this champion to survive while his hooves grew back, giving him relief for several hours a day. In addition, he received round-the-clock care, nurses literally fluffing and adjusting pillows to help alleviate the consequences of lying down for long periods. Mystic Park survived and went on to become a successful breeding stallion. The fact that Zippy lost only one hoof, and that he is small and tough, helped his prognosis, Dr. Richardson said. Zippy, about half the size of a full-sized horse, was happy to lie down for long periods and didn’t develop the sores that often occur in horses that cannot stand normally. In many laminitis cases, pain is a limiting factor in the decision to go forward with treatment. But pain was not a major issue for Zippy, Dr. Richardson said, adding that the transfixation cast was key to alleviating much of the pain as his foot grew down.
Zippy’s success, Dr. Richardson said, is further evidence that transfixation casts are a useful option, even in full-sized horses, especially combined with the much-improved slings that make it possible to keep a horse off the ground for longer periods. Transfixation casts have frequently been used at New Bolton Center for treatment of certain types of severe fractures.
"This case gives more support to the idea that total regrowth of a hoof is something that is possible if you manage the nursing challenges." Dr. Dean W. Richardson
“This case gives more support to the idea that total regrowth of a hoof is something that is possible if you can manage the nursing challenges,” Dr. Richardson said.
Nursing Challenges
An enormous nursing challenge with Zippy was that he could not be treated without going under anesthesia. New Bolton Center nurses have worked with patients like Zippy, including large animals from zoos and circuses. “The first time we anesthetized him was the easiest because he didn’t know what was coming,” said Kim Olson, DVM, staff veterinarian at New Bolton Center,
New Bolton Center's surgical team. Zippy required several surgeries to aid in his healing. Right: prosthetic hoof. Photos courtesy of New Bolton Center
specializing in anesthesia. “He struck me as incredibly smart,” Dr. Olson continued. “I think with a lot of creatures it gets easier after doing something new again and again, but with Zippy it got harder. We had to get more innovative on how to approach him.” When he saw a group of people wearing blue scrubs, he would back away. Dr. Olson said she would need extra staff each time they approached him. “He certainly was challenging,” she said, explaining that they used a “pole syringe” to inject him from afar. “We just had to persevere.” Zippy loved treats, however, and became excited when people approached his stall to toss bits of carrots or peppermints into his open mouth from afar. He seemed to recognize his favorites, like Amber Slonaker, a devoted veterinary technician, who earned his trust. Each day she scratched his ears through the stall bars. Over the weeks she slowly worked her way
into the stall, grooming tools in hand. She continued the favorite scratches, and gave him peppermints. Slonaker eventually was able to groom him, and he was not aggressive with her. “I made it a point to try and show him love and compassion during his stay, and I think he enjoyed it,” Slon-
aker said. “It was a joy to see him light up when he saw me with the brushes, knowing I made at least part of his day enjoyable. Seeing him walk out of here to go home was one happy day!” MeV
Zippy, a Zebra with Personality It may seem peculiar to like a zebra, since Zippy will bite off a finger if given the chance. In fact, he has bitten several unwary folks. Zebras are known for being aggressive, wild animals that are difficult to domesticate. But Zippy also has an outsized personality that has entertained his owner ever since she got him as a foal, only a week old, from the New Bolton Neonatal Intensive Care Unit. Zippy is well-known by the New Bolton Center community, and despite his dangerous behavior, he is also well-liked. Born a maladjusted, or “dummy” foal, he started his life in the NICU at New Bolton Center, and over the years has returned several times. During his recent months-long treatment, he became a bit of a celebrity, braying loudly and opening his mouth to have little treats tossed in by visitors. “We have a good, long-standing relationship with Zippy,” Farrier Patrick Reilly said. “I genuinely like him. He is one of my favorite patients, ever. But you don’t treat him like a horse. You have to respect that he is a wild animal.” Zippy has to be anesthetized every time the medical teams touch him, which made treating his condition a complicated challenge. “Zippy represents a very good collaboration between anesthesia, surgery and farrier,” said Reilly, an MeV integral member of Zippy’s medical team. “All were very important to his care and success.” ModernEquineVet.com | Issue 10/2014
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Practice management
A good
offense defense is the best
Equine practitioners have a lot of unique issues that are not shared by small animal practitioners, explained Steven A. Sedrish, MS, DVM, DACVS, who owns Upstate Equine Medical Center in Schulerville, NY. • They practice more ambulatory medicine, which often means relying on owners and trainers for animal restraint, instead of veterinary technicians. • They have relationships with farm managers and trainers, not just owners, and each party has a different agenda. • Often horses, especially the expensive ones, have multiple owners. “Each owner has its own piece insured. So, now we could be dealing with four owners, four insurance companies, and all eight of them have their own agendas,” he said. • Many horses are valuable and that value increases the likelihood that the veterinarian will be sued at some point in his or her career, so it is vital that the equine veterinarian practice defensive medicine, Dr. Sedrish explained. B y 18
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Three important components are communicating clearly with all parties involved, maintaining clear and complete medical records and documentation and maintaining strict confidentiality. “The primary step in practicing preventative medicine is to prevent misunderstandings with owners and agents,” he said. Communication is crucial. “Be honest with the owners. Things go wrong in medicine, but just because things go wrong doesn’t make it malpractice,” he said. Owners who truly understand the risks and benefits are less likely to sue than owners who are surprised by a bad outcome. He talked about one patient who recovered from anesthesia with a little facial paralysis. They told the owner what happened and what they would do for the horse. The owner was a little nervous for a few days, he said, but the horse recovered fully. “We kept on top of it and kept talking with them,” he said. The medical record is your primary defense, so make sure actions, recommendations and conversations are documented correctly in the medical record.
M a r i e
Dr. Sedrish prefers a paper record, but the principles he mentioned would carry out to an electronic medical record. Make sure all records are neat, clear and readable. Don’t write in the margins. Don’t leave empty spaces. Don’t be vague. Every entry should have a date and time and if it is a paper record, make sure the ink is blue or black. If it is an electronic record, make sure you can’t go back and “change” anything. Vague statements, changes, spaces, writing in the margins are all actions that give the opposing attorney an opportunity to question the entire document because he or she can say, “You did it after the fact.” If something in the record does need to be updated or changed, make it an addendum with a date, time, signature and reason for the change. “If you do cross something out. Sign it, date it, and explain why you are crossing it out. You have to be able to read what you can cross out,” he said. “One mistake in that medical record could put that entire medical record in question,” he said. An area that is frequently
R o s e n t h a l ,
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Shutterstock/ val lawless
Communication, confidentiality and clear medical records best defense in court
missed is recovery. Even though veterinarians and technicians keep an eye on the animal, they don’t always note it in the chart. Make sure that notations are made during the entire recovery. “We take the medical record into recovery and we keep track of recovery,” he said. “Otherwise, the lawyers and the insurance company will say you never monitored them.” Get written informed consent whenever possible. If something changes during a surgery or in an emergency and you are acting on a verbal consent, make sure there is a witness. If the consent is given during a telephone call, put someone else on the phone to confirm the consent. Make sure that a signature is obtained every time the clinic releases a medical record. Make notes of any telephone discussions in the medical record that include the time, the date, a recap of the conversation and what was decided. Every time someone goes into the stall for any reason, it is noted in the chart, even to remove feces or groom it, because it shows to the court that animal was looked after periodically. He uses a special form for farm calls that must be signed and that will be added to the record when he gets out of the field. It details what was done and the reason for doing it. If someone is suppose to followup with the veterinarian, that instruction is put in the record. “We also have a statement at the bottom of our invoices that say the owner gave consent for what was done, it has our billing policy and our interest rate on unpaid bills, it actually says that any disputes will be handled in a specific matter,” he said. It is also important to note all ModernEquineVet.com | Issue 10/2014
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Practice management the options that were offered to the owner, so that he or she can’t come back and say that they didn’t know that another (cheaper, better, less risky) option was available but were never told. At Upstate Equine, the staff uses photographic documentation that also becomes part of the record. They take pictures of every horse that comes into the hospital and when it leaves. If the owner complains that the horse received a laceration in the hospital that it did not get, Dr. Sedrish can prove that it came in with it. He had a horse that had a corneal abscess that the owner said he received in the hospital. Dr. Sedrish was able to prove that he came in with the abscess because he had photographic documentation. They also weigh every horse when it comes in and when it leaves the clinic because owners were blaming weight loss on the hospital. “We bought a scale because we got this so often,” he said. The scale can also assure that you provide accurate dosing that is truly weight based, which again should be noted in the record. More and more medicine is being practiced through e-mail and text messages, he said, and he prints them and adds them to the paper record. They can also be
downloaded into the electronic record and should be. Often owners will file a lawsuit just because they don’t want to pay the bill, so a complete and accurate record that includes every conversation will help protect you and assure the court that the owner was provided all the necessary information about the case, knew and understood the risks and agreed to pay for the treatment. “We have no tolerance for that. We will fight that tooth and nail,” he said. In veterinary medicine, as with life, remember that social media is a public forum. Don’t put anything on social media that you wouldn’t want a lawyer to hear. It can come back to haunt you, he warned. He was on a list serv that discussed the wearing of sterile gloves during castration. Some people use them; some people use regular latex gloves. Someone posted that he did not wear sterile gloves because they cost an extra dollar. If that was you, and you did a castration that became infected, as they sometimes do, would you want to go to court and defend that statement? He asked. “The first thing the lawyer will do is check social media,” he said. As soon as you have a suspicion that you might be sued, make sure you inform your malpractice car-
rier. To wait could void your coverage. In addition, the carrier might have suggestions about how to proceed and what paperwork you should gather for your case. “Confidentiality is important. And that means more than just shredding documents,” Dr. Sedrish said. “The medical information of the horse is confidential and we need to keep it confidential.” Remember that the people who work for the clinic are horse people, too, he advised, so make sure they do not discuss horses and owners at shows and events. In addition, when owners walk through the barn, take steps to protect the identity of other patients. He showed a racehorse that was in for surgery and his name was on the halter. They taped over the name to protect his identity. “We don’t want other owners to know that horse is in there for surgery. That can affect that horse’s value significantly, especially with race horses,” he explained. Practicing defensive medicine means being able to explain yourself in court and having the documentation to defend yourself. “Remember, every time you write in a medical record that medical record could end up in court. It could affect your career and it can end your career, so be careful,” Dr. Sedrish said. MeV
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news notes
Reproduction in early equids similar to modern horses A specimen of the ancient horse Eurohippus messelensis has been discovered in Germany that preserves a fetus, as well as parts of the uterus and associated tissues. It demonstrates that reproduction in early horses was similar to that of modern horses, despite great differences in size and structure. Eurohippus messelensis had four toes on each forefoot and three toes on each hind foot, and it was about the size of a modern fox terrier. The new finding was unveiled at the 2014 Annual Meeting of the Society of Verte-
Ancient horse fossil preserves uterus with unborn foal.
preserve the remains of mammals, birds and other animals that were living near what is now Darmstadt, Germany, about 47 million years ago (the Eocene epoch). No oxygen was present at the bottom of the lake when the dead animals sank down and finally became embedded in the muddy sediments. There, anaerobic bacteria immediately began to decompose skin, muscles, and other soft tissues. As a result, the bacteria produced carbon dioxide, which in turn precipitated iron ions present in the lakewater. In this way, the bacteria petrified themselves, developing only a very thin bacterial lawn depicting the soft tissue as black shadow. Consequently, Messel fossils preserve these remains not directly, but as images. The size of the fetus and the presence of fully developed milk teeth indicate that it was close to term when it and its mother died. Nevertheless, its position in the uterus indicates that the two did not die during the birthing process. The fetus was upside down rather than right side up, and its front legs were not yet extended as they should be just before birth MeV
Courtesy of Senckenberg Forschungsinstitut Frankfurt
brate Paleontology in Berlin. “Almost all of the bones of the fetus are still articulated in their original position. Only the skull is crushed,” said Dr. Jens Lorenz Franzen of the Senckenberg Research Institute, lead author of the study. The specimen was discovered by a team from the Senckenberg Research Institute nearly 15 years ago, but its extent was not fully appreciated until it was studied using micro radiograph. The micro radiograph analysis revealed a structure known as the broad ligament that connects the uterus to the backbone and helps support the developing foal. Remnants of the wrinkled outer uterine wall became visible after the specimen was prepared, a feature shared between Eurohippus and modern horses. The placenta in this specimen is only the second one that has been described for a fossil placental mammal. The oil shales at Grube Messel have long been known for their marvelous fossils. These oil shales formed at the bottom of ancient Lake Messel and
How much should this cost? Many veterinarians have identified pricing of services as one of their biggest obstacles. How much should each service be priced? Which services are delivering profit and which are not? These are just a few of the unanswered questions we’ve heard from customers. Zoetis is helping veterinarians address these challenges with a new service called Profit Solver. The company has developed a video featuring a mixedanimal practice located in Quitman, Texas, talking about the veterinarian’s experience with pricing and service. http://youtu.be/8QEfzj7TElE Zoetis is also offering webinars for veterinarians about pricing. Find the dates and register at MeV https://attendee.gotowebinar.com/rt/3197313102097728002 ModernEquineVet.com | Issue 10/2014
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