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A York veterinary hospital has completed a 12-month transformation following a £325,000 investment.

RVN Katie Tallett (left) and practice manager Emma Darling in the reception of The Minster Veterinary Practice in Salisbury Road, York. Image © The Minster Veterinary Practice

The major revamp of The Minster Veterinary Practice’s main hospital in Salisbury Road – part of the VetPartners group – includes some of the most high-tech, state-of-the-art veterinary equipment, including a £250,000 CT scanner.

Reconstruction

The upgrade has seen a significant reconstruction of the site to create a new waiting room, extra consulting rooms, dental treatment suite with dental x-ray machine and veterinary nurse station.

Meanwhile, the separate dog and cat wards have been rebuilt with new kennels to provide additional space, and a dedicated isolation ward allows hospitalisation of infectious patients.

Other new equipment includes:

  • anaesthetic machines
  • dental equipment
  • operating tables
  • anaesthetic monitoring machines
  • endoscope equipment
  • diagnostic laboratory equipment
‘Biggest investment’

Minster Vets practice manager Emma Darling, who has overseen the work, said: “This project has been the biggest investment in the practice, and we are absolutely delighted with the results.”

As well as its main veterinary hospital in Salisbury Road, Minster Vets has five other branch surgeries across York.

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ABSTRACT

The most frequently reported broad categories of disease syndromes recorded in the 2017 National Equine Health Survey1 were skin problems (31% of all syndromes recorded); lameness, including laminitis (23%); metabolic diseases (8.1%); eye problems (7.6%); gastrointestinal diseases (7.5%); and respiratory (5.9%).

This article will address the key presenting signs associated with skin problems, lameness, gastrointestinal disease and respiratory syndromes, detailing the common differential diagnoses and a suitable first line treatment approach when dealing with each of these syndromes prior to definitive diagnosis.

Medical general practitioners now use online patient-side searches for clinical signs and treatment protocols as standard.

However, in first opinion mixed and equine practice, despite the availability of various veterinary apps, it is still essential the initial assessment highlights the key clinical signs, and the clinician is aware of the common differentials for that presenting sign and can administer appropriate first aid treatment prior to any further treatment or investigation.

Figure 1. In some skin conditions, such as this case of urticaria, a diagnosis may be made on the basis of the history and appearance of the lesions. Image: XLEquine image archive.

This initial treatment is often based on a presumptive diagnosis and the response (or lack of) will add to the evidence to assist a more definitive diagnosis.

Skin disease

Skin disease is most commonly characterised by pruritus, scaling, nodules or hair loss. The two most commonly reported skin diseases are Culicoides hypersensitivity (sweet itch) and dermatophilosis (mud fever), while other differentials that should be considered include atopy, urticaria, dermatophytosis, Chorioptes, lice (Damalinia equi) and sarcoids.

In some cases – for example, urticaria – the history, appearance and distribution of the lesions may lead to a definitive diagnosis (Figure 1) and specific treatment can be instigated immediately.

Many other cases exist where a specific diagnosis will require further diagnostic tests; early diagnostic testing is prudent to improve accuracy and prevent the cost of inappropriate non-targeted treatment.

Punch biopsies (8mm) taken from several sites for histopathology can be extremely useful to assist with the diagnosis of many skin diseases, including pastern dermatitis, urticaria, leukocytoclastic vasculitis, eosinophilic granuloma and hypersensitivity reactions.

Hair plucks and culture are the procedure of choice to identify dermatophyte, and scrapes or coat brushing can be used to identify Chorioptes. Intradermal skin testing is complex, but can provide valuable assistance in the diagnosis of hypersensitivity reactions.

Figure 2. Owners should be made aware of the potentially infectious nature of some skin diseases, for example, dermatophilosis. Image: XLEquine image archive.

The majority of skin cases may not need fist aid treatment prior to definitive diagnosis, with the exception of severe hypersensitivity and urticarial reaction, which will benefit from immediate treatment with systemic glucocorticoids to prevent severe self-excoriation. Owners should be made aware of the potentially infectious nature of some skin diseases – for example, dermatophilosis (Figure 2) and dermatophytosis – and advised of appropriate hygiene precautions.

Lameness

Lameness is a common presenting sign in the general equine population, with a high proportion suffering one or more episodes of lameness per year1,2,3.

Lameness may be acute or insidious in onset and, as such, clinical signs range from a loss of performance to recumbency or the inability to bear weight. Numerous causes of lameness exist, including foot abscess, solar bruise, laminitis, tendon and ligament injuries, fractures, sepsis of a joint or tendon sheath, cellulitis/lymphangitis, joint disease and exertional rhabdomyolysis.

A comprehensive history is essential and will often provide valuable diagnostic information. Clinical examination of the lame horse should seek to identify the degree of lameness and which limbs are affected, the strength of digital pulses in all limbs, and the presence of any heat, pain or swelling of the structures of the limb.

The severely lame horse can often present a challenge and judging if one or more limbs are affected can be difficult – particularly as prolonged gait analysis in such a case is not recommended. Observation at rest, and a preliminary examination of all limbs and digital pulses, may provide helpful information on the likely site of lameness prior to observation at walk. Gait analysis should seek to identify the upward movement of the head or sacrum during placement of the lame limb. Placement on a hard surface may be associated with a softer sound, compared to the footfall of the other three legs.

Foot lameness is common in the equine population, with foot abscess the most likely cause of sudden-onset severe lameness. So, it is imperative careful assessment of digital pulses and application of hoof testers is conducted in all lameness cases (Figure 3). Practitioners should be mindful many horses have chronic or long-standing injuries their owners are not aware of and may be unrelated to the lameness condition.

If a fracture is suspected on the basis of clinical exam and history, radiography of the affected area can assist with diagnosis, and should be carried out without delay to indicate prognosis and appropriate first aid treatment (Figures 4 and 5). If sepsis of a joint or tendon sheath is suspected, synoviocentesis under aseptic conditions is indicated to assess the white blood cell count.

In a severe hindlimb lameness with no signs of inflammation or pain in the distal limb, a rectal examination and ultrasound examination of the wing of ilium can assist with diagnosis of a pelvic fracture.

Ultrasound examination can also assist with the assessment of tendon, ligaments, joints and surrounding structures, but in the absence of concerns about sepsis, these examinations need not be conducted immediately, and are often better delayed until after the acute phase.

Where the site of lameness is not clear, further investigation normally requires referral to a clinic for further workup. Nerve blocking of severe undiagnosed lameness in the field is not advisable due to risk of exacerbating the injury due to increased weight bearing.

If the cause of the lameness is diagnosed on initial examination, appropriate treatment and management specific for that condition should be instigated. In cases where a definitive diagnosis cannot be reached, appropriate first-line treatment might include box rest – with moderate coverage of bedding over the whole floor area, and food and water raised, as well as phenylbutazone at 2.2mg/kg (half dose) and reassessment at 12 to 24 hours for further diagnostics to assist with localisation of the lameness.

Gastrointestinal disease Figure 6. Severe gastrointestinal disease frequently presents with colic signs. Image: XLEquine image archive.

Gastrointestinal disease has been more frequently diagnosed in recent years, with a notable increase in the number of horses diagnosed with gastric ulceration. This is most likely due to our increased knowledge of the prevalence of the disease4,5,6 and range of presenting signs (including weight loss, colic, appetite reduction, poor performance and behavioural changes), as well as the widespread availability of diagnostic gastroscopy.

Acute gastrointestinal disease normally presents with colic signs (Figure 6), including rolling, sweating, scraping the ground, looking round at flanks and urinating frequently. More subtle signs of gastrointestinal disease include reduced appetite, restlessness, increased time spent recumbent and change in dropping consistency or frequency.

The vast majority of causes of abdominal (colic) pain can be successfully treated medically7 – for example, spasmodic (gas) colic, pelvic flexure impaction, colitis, cyathostominosis, enteritis and some colon displacements. Other causes may require rapid surgical treatment (Figure 7) – for example, strangulating lipoma, gastroepiploic entrapment, colon torsion, intussusception and some colon displacements. Some cases represent a hopeless prognosis at first presentation – for example, rupture of an abdominal viscus, severe endotoxaemia and acute grass sickness.

The goal of the first opinion practitioner in assessing a colic case is to quickly differentiate between these three groups to arrange rapid referral of surgical cases, appropriate treatment or referral for medical cases and rapid euthanasia of the hopeless cases.

Figure 7. The majority of colic cases can be managed medically, but those requiring surgical treatment must be rapidly identified and referred. Image: XLEquine image archive.

Clinical assessments should be made on the degree of pain, mucous membrane colour, heart rate, respiratory rate, gut motility in all four quadrants and rectal temperature. Following the assessment of these parameters, the author favours the use of both hyoscine butylbromide (0.3mg/kg) and phenylbutazone (4.4mg/kg) prior to further diagnostic assessment, and the response to this initial analgesia is quantified and forms part of the diagnostic information.

Rectal examination provides valuable information, but may present a greater risk in small, young and poorly handled individuals. The use of low dose alpha-2 agonist and butorphanol will safely facilitate this in most patients; the prior use of hyoscine butylbromide also improves rectal relaxation.

The pelvic flexure, the region of the nephroplenic space, and position and distension of the abdominal viscera should all be palpated and assessed.

Passage of a nasogastric tube allows assessment of the degree, volume and nature of any gastric reflux. Increased reflux is associated with small intestinal obstruction, strangulation, enteritis or grass sickness. Abdominocentesis under aseptic conditions can assist in the identification of intestinal compromise.

Clinical findings consistent with medically manageable colic include heart rate below 60bpm, ingesta distended pelvic flexure and pain resolving following initial analgesia. In these cases, oral electrolytes may be administered by nasogastric tube, all food removed, and the patient closely monitored and re-examined if signs return or after 12 hours for further assessment if symptom-free.

Figure 8. Cases of suspected infectious respiratory disease must be immediately put in strict isolation and the temperatures of in-contacts monitored. Image: XLEquine image archive.

Clinical findings consistent with surgical colic include heart rate above 60bpm, pain not responsive to initial analgesia, gas distensions of intestinal loops, gastric reflux and peritoneal fluid turbid or stained red/brown.

In these cases, analgesia to facilitate travel should be administered and immediate referral to a surgical facility arranged. In cases where surgery is not an option or in advanced cases representing a hopeless prognosis – toxic red/brown mucous membranes, unrelenting pain that can’t be controlled and evidence of ruptured viscus – immediate euthanasia on humane grounds should be carried out.

Respiratory disease

Respiratory disease, perhaps surprisingly, only accounted for 5.9% of reported veterinary problems in the 2017 National Equine Health Survey, although it is likely it accounts for a greater proportion of the first opinion equine clinician’s workload than this figure suggests.

The clinical signs of respiratory disease can include coughing, nasal discharge, dyspnoea, increased respiratory rate and depth, respiratory noise, poor performance and pyrexia. Initial clinical assessment should be made of breathing rate and pattern, heart rate, temperature and findings on chest auscultation.

Infectious respiratory disease will normally present with systemic illness and pyrexia, in addition to other respiratory signs; the common causes that should be considered are equine influenza, equine herpes virus, Streptococcus equi, Streptococcus zooepidemicus, Rhodococcus equi and Mycoplasma. Diagnosis should include nasopharyngeal swabs taken in the acute phase for virology and bacteriology, and paired serology. In cases of pneumonia, ultrasonography of the chest can assist with identification of pathology and diagnosis.

Prior to definitive diagnosis, NSAIDS should be administered, these cases put in strict isolation and the temperatures of in-contacts closely monitored (Figure 8).

Figure 9. Endoscopy, tracheal wash and bronchoalveolar lavage have a key role in the investigation of lower respiratory tract disease.

Non-infectious respiratory disease is not normally associated with pyrexia or systemic illness, and clinical signs may include a loss of performance and increased respiratory rate and effort – and, in severe cases, dyspnoea. In dyspnoeic patients, it is important to differentiate inspiratory dyspnoea, indicating upper airway obstruction, and expiratory dyspnoea, indicating lower airway obstruction.

The common differentials for upper airway obstruction include sinusitis, retropharyngeal abscess and laryngeal paralysis secondary to, for example, hepatic insufficiency, botulism or lead poisoning. Severe cases should not undergo diagnostic endoscopy due to further obstruction of a compromised airway and, in these cases, first aid treatment involves tracheotomy.

Lower airway obstruction and disease may be caused by marked equine asthma (formerly called recurrent airway obstruction)8, foreign body obstruction and mild equine asthma (inflammatory airway disease)8. Endoscopy with tracheal wash and bronchoalveolar lavage will provide diagnostic information on the likely nature of the inflammation (Figure 9).

Prior to definitive diagnosis, the acute case may be treated with dexamethasone, atropine and furosemide. The response to atropine administration can aid in the diagnosis of marked equine asthma.

Summary

As first opinion clinicians we are faced with daily diagnostic challenges. A working knowledge of the key common differentials, employing appropriate diagnostic tests at an early stage and using prudent first aid treatment will assist in the satisfaction of a definitive diagnosis and targeted treatment.

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A team of lecturers, quality assurance staff and office members from The College of Animal Welfare (CAW) have decided to run the 10K Race for Life in June.

Raising money for Cancer Research UK, training has begun in earnest as the team has been put through its paces by SVNs by the Royal Army Veterinary Corps.

‘Revenge’

Charlotte French, senior veterinary nursing lecturer at The CAW, said: “The students certainly got their revenge for all those hours spent sitting in lectures by designing a thorough workout, which culminated in the participants having to launch themselves down a zip wire.

“Needless to say, good fun was had by all – then it was back to the classroom for some more cerebral exercise.”

The team would be very grateful for any support. To donate, visit The CAW Cancer Research UK fund-raising page.

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The ultrasonographic image (Figure 1) is from an 11-year-old domestic short-haired cat with a clinical history of lethargy and anorexia. A segmental, small intestinal wall thickening with diffuse loss of layering was noted. A fine needle aspirate (FNA) was collected and submitted for analysis (Wright-Giemsa, 100×; Figure 2).

Diagnosis Figure 2. A photomicrograph of the fine needle aspirate from a small intestinal wall thickening of a cat, Wright-Giemsa, 100x.

The submitted smear has adequate cellularity and preservation. The background is clear, with frequent red blood cells, often clumped, a few bare nuclei and free magenta granules. It has a main population of large, discrete cells, likely lymphoid in origin (black arrows) – these have moderate amounts of lightly basophilic cytoplasm, with distinct borders, often containing small numbers of round magenta granules.

Nuclei are round, occasionally slightly indented and irregular, paracentrally located, with granular chromatin and small, round nucleoli occasionally seen. Occasional neutrophils (red arrow), likely blood derived, are also noted.

Interpretation

Large granular lymphocyte (LGL) lymphoma is a morphologically distinct form of high-grade lymphoma, frequently affecting the feline species and most often involving the gastrointestinal tract (in particular jejunum and ileum) and/or mesenteric lymph nodes.

Blood and/or bone marrow involvement are common findings at the time of the diagnosis. This form of lymphoma has generally been associated with negative FeLV and FIV serology.

Neoplastic cells origin from a subset of intraepithelial intestinal lymphocytes and have characteristic intracytoplasmic magenta or azurophilic granules, which may vary in numbers and sizes. LGL cells are grouped in two major lineages based on phenotype: T-cell (CD3+, CD5+, often CD8alpha-alpha+, and rarely CD4+) and less often natural Killer, the latter negative to all T-cell and B-cell markers.

In the feline species, LGL lymphoma has a particularly aggressive biological behaviour with poor prognosis and is only minimally responsive to standard lymphoma chemotherapy protocols. This differs from LGL neoplasia in humans and dogs, where a predominance of indolent forms has been described.

Overall, the identification of LGL lymphoma in cats is important clinically, as other forms of gastrointestinal lymphoma – especially small cell types – have a more protracted course.

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Encephalitozoon cuniculi is a microsporidian parasite that may infect several mammalian species, including rabbits.

The phylogenetic origin of microsporidia is a matter of debate, as they were originally thought to be basic eukaryotes. However, more in-depth analysis has suggested a relationship with atypical fungi (Didier and Weiss, 2006; Katinka et al, 2001; Bohn et al, 2011). Furthermore, microsporidial spores retain fungal elements, including fungal proteins such as tubulins, trehalose and 3-chitin.

Three E cuniculi strains have been identified (Didier et al, 2000; Kunzel and Fisher, 2018) and unclassified strains have also been reported in a wide host range of mammals, including rats, guinea pigs, hamsters, horses, cows, mink and non-human primates.

Encephalitozoonosis is primarily seen and considered a significant disease of captive rabbits, with its seroprevalence internationally recognised (Latney et al, 2014). Farm and lab rabbits have, for a long time, been target species, but according to a UK survey (Keeble and Shaw, 2006), healthy domestic rabbits also showed specific antibodies against the parasite in their blood, with a prevalence of 52%.

In an article by Kunzel and Fisher (2018), clinical signs, diagnosis and treatment of this common infection in domestic rabbits were reviewed, making the latest literature available to the reader.

The clinical signs associated with E cuniculi infection and its diagnosis were revised in part one of this article (VT48.16). This part will focus on updates regarding possible treatment options of this relatively common infection.

Treatment

The symptoms and signs ascribed to E cuniculi infection may not be associated with the presence of the organism itself, but rather the inflammatory lesions that develop when cells rupture and spores are released into surrounding tissues.

Therapy should, therefore, be aimed at reducing inflammation, blocking spore formation and proliferation, as well as managing associated clinical disease and severe neurological signs.

Drug therapy

Several clinical studies have evaluated the efficacy of various drug therapies in rabbits showing vestibular dysfunction related to encephalitozoonosis, with results giving a more favourable outcome compared to the past (Ewringmann and Gobel, 1999; Jass et al, 2008; Kunzel et al, 2008; Meyer-Breckwoldt, 1996).

In these studies, therapeutic protocols were mainly based on these fundamental principles:

  • in vitro susceptibility of microsporidial organisms to various pharmaceuticals
  • efficacy of drugs in the treatment of microsporidiosis in immunocompromised humans with AIDS
  • (granulomatous) meningoencephalitis treatment

Although these studies reported a recovery rate of more than 50% in rabbits with neurologic signs, it must be considered several different treatment protocols were used and studies were not controlled.

In fact, few controlled studies regarding the treatment of encephalitozoonosis have been performed so far in living rabbits and, in the absence of well-controlled documented scientific studies, most recommendations for the treatment of clinical encephalitozoonosis have been adopted based on anecdotal reports.

Response to therapy may vary greatly and “successful treatment” often depends on demonstrating a resolution of clinical signs at a certain point in time after medical intervention.

The fact a certain number of symptomatic rabbits may improve spontaneously without any therapy makes it more difficult to assess the most appropriate treatment protocols (Valencakova et al, 2008). To date, no uniform nor recognised treatment protocol has been established for the treatment of encephalitozoonosis in rabbits.

Benzimidazoles

Several studies have assessed the in vitro efficacy of several drugs against microsporidian organisms. Certain antimicrobial substances (for example, fumagillin, sparfloxacin and oxytetracycline) – and, in particular, the benzimidazoles (for example, albendazole, fenbendazole and oxibendazole) – have been found to be effective against E cuniculi in a variety of studies or clinical reports (Franssen et al, 1995; Shadduck, 1980; Beauvais et al, 1994).

Broad-spectrum antibiotics were recommended, when necessary, to reduce the risk of secondary infections. However, antibiotic treatment is no longer recommended in those cases when otitis media/interna has been ruled out (Kunzel and Fisher, 2018).

Oxytetracycline

Oxytetracycline has been included in many treatment protocols of rabbits with neurological signs from suspected E cuniculi infections based on a moderate effect demonstrated in one in vitro study (Waller, 1979). However, controlled in vivo studies are lacking.

Sieg et al (2012) could not evaluate whether oxytetracycline was a necessary adjunct to the therapy against E cuniculi infection, as all the rabbits included in their study were treated with it. Tetracyclines are effective against rickettsiae and Gram-negative and Gram-positive bacteria, therefore, they may be of use to prevent secondary bacterial co-infections. They may also be useful as an adjunct treatment for CNS inflammation because of their anti-inflammatory and anti-apoptotic properties, and because they act as scavengers of reactive oxygen species (Griffin et al, 2011).

As previously stated, microsporidia spores retain fungal elements – including fungal proteins, such as tubulins, trehalose and chitin – and are ancestral relatives of zygomycetes.

As chitin is a basic component of the microsporidian spore, in vitro studies have also been carried out to evaluate the susceptibility of the parasite to polyoxin D and nikkomycin, which are chitin synthetase inhibitors (Sobottka et al, 2002).

Domestic rabbits are commonly affected by Encephalitozoon cuniculi infection. Image: Vera Kuttelvaserova / Adobe Stock

In vitro studies have been carried out on the use of benzimidazole drugs in rabbits (Franssen et al, 1995). These drugs are microtubule inhibitors capable of blocking the extrusion of the polar filament, preventing cell infection.

Albendazole – initially used for treatment of opportunistic microsporidian infections in immunosuppressed humans during the early years of the AIDS pandemic – was subsequently found to be embryotoxic, teratogenic (Kotler and Orenstein, 1998), and a cause for bone marrow suppression and liver failure in rabbits (Mortiz, 2004).

Fenbendazole, another benzimidazole, has been shown to both prevent and treat naturally acquired – as well as experimentally induced –E cuniculi infections in rabbits using a once daily dosage of 20mg/kg bodyweight administered orally over 28 days (Suter et al, 2001). However, despite the elimination of spores from the CNS in the study by Suter etal (2001), clinical signs are not always reversible in a certain number of rabbits with neurologic encephalitozoonosis.

An explanation might be the fact the granulomatous inflammatory tissue alterations within the brain remain, despite a successful reduction in the number of infectious spores. Furthermore, E cuniculi infections typically follow a chronic course, whereby the time from infection until clinical encephalitozoonosis becomes evident varies from months to years, and almost always occurs long after initial infection and only when a low number of organisms are present within affected tissues (Csokai et al, 2009).

Fenbendazole

In their study, Abu-Akkada and Oda (2016) showed oral administration of fenbendazole before experimental infection was effective, to some extent, in protecting rabbits against infection with E cuniculi and failed to observe significant effects on clinical signs when fenbendazole was administered as a treatment.

However, fenbendazole remains an essential part of the treatment regimen in most rabbits with neurologic disorders due to encephalitozoonosis. Adverse reactions have been reported with the use of benzimidazoles in rabbits, including crypt necrosis of the small intestine or bone marrow hypoplasia/aplasia.

Practitioners should, therefore, strictly adhere to recommended dosages and treatment intervals when using benzimidazole derivatives, and consider monitoring complete blood count during treatment (Graham et al, 2014).

It is known this inflammatory reaction induced by E cuniculi in target organs tends to be granulomatous in nature and may persist after the organism is no longer present.

As a result, the use of glucocorticoids has anecdotally been advised for the treatment of rabbits with neurologic disorders. However, Sieg et al (2012) found no significant difference in the long-term or short-term survival, or in neurologic sign reduction, in rabbits receiving the following treatment combinations – oxytetracycline with or without dexamethasone, oxytetracycline, and fenbendazole with or without dexamethasone.

Survival analysis performed for those rabbits that received fenbendazole demonstrated they were 1.6 times more likely to survive until day 10, compared with rabbits that did not receive fenbendazole in their treatment protocol.

Fenbendazole had a significant effect on long-term survival, but, after day 10, its efficacy was no longer consistent.

This investigation did not support the use of dexamethasone as an effective treatment modality for rabbits with neurologic disorders attributable to encephalitozoonosis.

Latney et al (2014) also discouraged the use of dexamethasone to treat E cuniculi-mediated inflammation and in the treatment of head trauma secondary to axial or longitudinal rolling for three major reasons.

Firstly, its use in the management of cerebral trauma is no longer recommended in humans. Secondly, dexamethasone has been shown to lower the efficacy of albendazole in reducing spore migration and host cell rupture (it may, therefore, reduce the serum concentration of fenbendazole and its efficacy, too), and to potentiate disease severity in experimental rodent models of E cuniculi infection.

It is, in fact, a concern the immunosuppression induced by dexamethasone may promote persistence and shedding of E cuniculi. Lastly, as seen, it has not been shown to have any therapeutic effect in chronically infected companion rabbits (Sieg et al, 2012).

Furthermore, rabbits are notoriously a corticosteroid-sensitive species and toxic changes have been reported in lymphoid organs, liver and adrenal glands (Borgmanns et al, 1976). Also, immunosuppressive doses of corticosteroids could affect the function of T lymphocytes and the production of T-cell derived cytokines, which is considered the main defence mechanism against E cuniculi (Kunzel and Joachim, 2010).

Because even ocular administration of dexamethasone phosphate disodium has been shown to result in systemic absorption in rabbits, extreme caution should be adopted with ocular administration of corticosteroids as well (Rosenblum et al, 1967).

NSAIDs

In case of ocular disease, a topical NSAID may be a safer choice if renal values are within normal limits (Sieg et al, 2012). Systemic NSAIDs may be used as an alternative to treat inflammation. NSAID therapy should be used cautiously in animals with concurrent renal disease because the kidney is a target organ for E cuniculi-associated inflammation.

However, no studies exist on the use of systemic NSAIDs for the treatment of encephalitozoonosis in rabbits and their usefulness has been called into question because tissue damage, which occurs during the course of encephalitozoonosis, is commonly irreversible.

The use of NSAIDs may also be questionable for reasons similar to those that contest the usefulness of corticosteroid anti-inflammatories in the treatment of encephalitozoonosis.

In fact, it has been seen severe histologic lesions of the brain and kidney attributable to E cuniculi are not necessarily associated with clinical disease, and histopathologic examination of the CNS revealed no significant differences in regard to the severity and distribution of inflammatory brain changes in rabbits with both latent and clinical E cuniculi infection (Csokai et al, 2009).

Supportive care

Many of the rabbits presented with vestibular signs associated with encephalitozoonosis continue to eat well, even if they cannot maintain an upright position.

Therefore, differently to dogs and cats, prevention of nausea secondary to vestibular disorders with the use of prokinetics, antiemetics or drugs designed to control dizziness (for example, metoclopramide, prochloroperazine and meclizine) is usuallynot recommended.

However, the use of prochlorperazine – a phenothiazine derivative used to treat vertigo and labyrinthine disorders in humans – has been advocated in rabbits with torticollis (Varga, 2014), and anecdotally reported to be helpful in some cases.

Environmental modifications should be put in place to provide animals, affected by severe central vestibular signs, with protection.

Soft padding and non-metal cage barriers should be employed to prevent accidental ocular and/or limb trauma. A quiet, stress-free environment should be provided and affected rabbits must be able to reach their food.

Use of benzodiazepines, such as midazolam or diazepam, is commonly employed to control seizure activity and act as a mild sedative in animals with severe vestibular disease causing falling and rolling. Fluid therapy and assisted feeding should be started as required.

Physical therapy

Adequate physical therapy may also have an important impact on the improvement of clinical disease in rabbits with vestibular dysfunction, as it may appropriately challenge the nervous system deficits and strengthen the musculoskeletal system, allowing for an earlier return to more normal patient function (Harcourt-Brown, 2002).

Different training techniques may be adopted to help compensate for vestibular deficits. In many cases, it has proved to be sufficient to provide an opportunity for free run under strict supervision of a person that can provide support immediately if the rabbit rotates.

A period of immobilisation following an acute onset of vestibular dysfunction not only slows recovery, but also may actually impair the recovery of vestibular function (Thomas, 2000). Although most rabbits improve with physiotherapy in the form of gradually increased exercise, residual deficits (mostly minor head tilt) may persist in a certain number of treated animals.

  • Some drugs mentioned in this article are used under the cascade.
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The Royal College of Nursing (RCN) has launched the first protocol for animals in health care.

By following the evidence-based best practice criteria, hospitals and other health care settings will be able to ensure the safety of patients and health care staff, as well as the animals and their owners, while allowing patients to reap the benefits interactions with animals can bring, the RCN said.

‘Amazing impact’

RCN professional lead for long-term conditions and end-of-life care, Amanda Cheesley, said: “Anyone who’s worked in this area can see the amazing impact animals have on the health of adults and children alike.

“However, there are so many myths around the dangers of having animals in health care settings, most organisations are too concerned to try it out.“

Dispelling fears

Ms Cheesley added: “This protocol will help dispel these fears by supporting hospitals to include animals in the care they deliver in a safe and professional way.

“We hope it will encourage all health services to consider how animals can help their patients and help us remove the taboo from what is a really remarkable area of care.”

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ABSTRACT

Ketosis is a common metabolic condition seen in ewes in late gestation where blood glucose levels are low and ketone body levels are high. Diagnosis is usually made based on clinical signs aided by laboratory diagnostics; however, vigilance on the part of the farmer is important in identifying ewes before they are obviously ketotic.

Treatment is often unsuccessful; however, with prompt intervention the prognosis is improved. Multiple options are available, ranging from medical treatment to induction of parturition or elective caesarean, but these need to be considered on a case-by-case basis. It needs to be communicated to the farmer that ketosis in ewes can lead to other periparturient problems, namely mastitis, and prevention is much more achievable than cure.

The key to controlling and preventing ketosis is to manage and tailor ewe nutrition carefully, and to use all the services available to aid this, such as forage and ration analysis, pregnancy scanning and serological assessment pre-lambing.

Ketosis in sheep, otherwise known as pregnancy toxaemia or ”twin lamb disease”, is a metabolic disorder seen in ewes in late gestation. It is characterised by low blood glucose levels and high ketone body levels.

The high levels of ketone bodies in the blood inhibit hepatic gluconeogenesis, further reducing glucose levels in the blood and worsening the condition.

Ketosis is caused by unmet energy requirements at a time when fetal glucose demand is at its highest. The condition is often associated with insufficient energy provided in the ration, limited rumen capacity due to a uterus full of lambs, or a combination of both. It can also be seen when an acute reduction in feed intake is seen most commonly associated with stress, such as in extremes of weather or after moving location.

Treatment success is variable and highly dependent on early detection of cases. Without prompt intervention, cases can be unrewarding, with high mortality and culling rates.

Risk factors include too low or high body condition score (BCS). Thin ewes have reduced fat reserves for mobilisation, resulting in a negative energy balance, often exacerbated or caused by concurrent issues, such as high helminth burdens (especially liver fluke), lameness or poor dentition. In overweight or obese sheep, lipid mobilisation can easily overwhelm the liver’s capacity, resulting in hepatic lipidosis. Ewes carrying multiple lambs (”twin lamb”) are at higher risk due to increased fetal glucose demands paired with a fuller abdomen; however, it can occur in single lamb pregnancies – especially in thin ewes.

Some ewes, either individually or as a breed-dependent susceptibility, have a degree of insulin resistance. This ineffective use of insulin to facilitate glucose uptake in to cells and regulate blood glucose levels results in impaired glucose supply to maternal tissues, as well as increased lipolysis and ketone body formation (Duehlmeier et al, 2013). These ewes are more likely to shift from a subclinical to a clinical ketosis when feed intake is reduced suddenly.

As vets, we are not often called to examine these cases, but our advice and recommendations for treatment, control and prevention can be invaluable.

Clinical signs and diagnosis Figure 2. A Swaledale ewe with recumbency and depression. This ewe was treated for ketosis and hypocalcaemia.

Clinical cases start with anorexia, constipation and mental dullness, progressing to neurological signs and recumbency (Figures 1 and 2). Separation from the flock is an indicator before overt clinical signs; however, this is not always noticed – especially in large flocks.

Opisthotonus, blindness, severe ataxia and tremors can be seen, with teeth grinding a common feature of the condition. Abdominal splaying can be observed in many ewes when abdominal muscle tone is lost.

Diagnosis is made based on clinical signs and can be aided by a handheld ketone meter (normal is less than 0.8mmol/L, subclinical ketosis is greater than or equal to 0.8mmol/L, and clinical disease is greater than 3mmol/L; Olfati et al, 2013). Ketone levels can also be measured in the urine using a dip stick, although obtaining a sample can be difficult. Serum biochemistry will often show signs of dehydration, along with evidence of renal or hepatic damage, as well as increased beta-hydroxybutyrate (β-HB) levels.

Postmortem findings are not pathognomonic, but will often present with evidence of hepatic lipidosis, dead fetuses in varying states of decomposition, and poor or excessive fat stores. In some cases, the adrenal glands are enlarged with haemorrhagic cortices. Diagnosis can be aided by sampling the aqueous humour or CSF, which can be analysed for β-HB levels. Fetal brain can be submitted for histopathology to demonstrate hypoglycaemic encephalopathy.

Treatment

In first opinion practice, treatment is usually with oral propylene glycol twice daily or another oral solution with readily available energy. Dose rates vary by practitioner, but care should be taken to be conservative due to the diarrhoea associated with overdose.

Oral fluid and electrolytes should be given to correct any dehydration and the ewe penned individually and encouraged to eat palatable food. IV glucose can be useful, but may not be possible if the farmer does not want repeat visits from the vet. Some practitioners use an IV fluid and dextrose combination with varying results. Injectable calcium borogluconate is commonly given to treat concurrent hypocalcaemia, which is present in around 20% of ketotic cases (Andrews, 1997).

Anti-inflammatory drugs are recommended – especially in cases where the ewe is recumbent or has sustained any traumatic injury. However, these are likely to be off licence and, as such, appropriate dosage and withdrawal should be used. The rest of the group should be assessed for subclinical ketosis.

In severe cases, a transient improvement may be seen, but these cases tend to deteriorate and eventually die due to the degree of hepatic or renal damage. In this situation, a judgement call needs to be made as to whether pursuing treatment is appropriate.

In cases of treatment failure, either euthanasia or induction could be offered on a case-by-case basis. The farmer must be made aware death can still occur in the ewe after it has given birth due to renal and hepatic damage, as well as the likelihood of peri-parturient problems, such as retained fetal membranes, poor milk production and increased risk of mastitis (Barbagianni et al, 2015).

Ingoldby and Jackson (2001) evaluated methods of induction and concluded corticosteroids were the least costly and most commonly used drug, with birth occurring around 48 hours after administration. Corticosteroid administration may be ineffective due to high circulating cortisol levels in the ewes, resulting in failure of induction. Elective caesarean may be attempted; however, this would be dictated by closeness to due date and whether the ewe would be considered a suitable surgical candidate. Animal welfare must be evaluated at all times and, if the ewe is unlikely to survive the birth and recovery, euthanasia is the best option.

Prevention and control

In farms where a problem has been identified, a plan must be formulated to avoid the same occurring the following year.

Close attention must be paid to the nutritional and energy requirements of ewes throughout pregnancy. This can be aided by pregnancy scanning so ewes can be separated into groups by lamb numbers to facilitate a more tailored diet. Separate groups can also be made using BCS.

A nutritional investigation is always useful – especially when accompanied by forage analysis to ascertain energy levels within feed. This is particularly helpful for homegrown forages where many farmers guess at the nutritional quality or based on the previous year’s analysis.

Meeting nutritional requirements around mating and early pregnancy is essential to optimise cyclicity, ovulation and implantation. A pre-mating increase in energy-dense feed can be given to ewes (flushing), which should be carried on into the first four to six weeks of mating/pregnancy. This is also beneficial for thin ewes to increase BCS and improve cycling and lambing rate (Fthenakis et al, 2012).

During the first 100 days of pregnancy, feeding needs to be maintained so ewes do not put down excessive fat deposits or lose too much weight. Adequate nutrition needs to be provided for growth of the placenta and mammary glands. Correct management of this time period will drastically reduce the risk of ketosis in later gestation.

Fetal growth is rapid in the last month of pregnancy, with 75% to 80% of its birth weight being acquired. This results in a huge increase in energy and protein demand on the ewe, which, when coupled with reduced rumen capacity and feed intake, can result in ketosis. Using a feed that is energy dense and of suitable quality is essential.

Maintaining ewes at optimal BCS throughout pregnancy is advised and scoring should be done at regular intervals, starting at pre-mating. Feed should never be withheld, but can be adjusted gradually to requirement. Rapid weight loss or weight gain needs to be avoided to prevent ewes falling to negative energy balance. Identifying thin ewes may be of benefit in separating out for extra feeding, while fat ewes can be encouraged to exercise by walking between fields to get feed. Adequate trough space must be provided to ensure all ewes have access to sufficient feed. Phillips et al (2014) have provided a thorough overview of feeding the ewe in later gestation.

Blood sampling of late gestation ewes may be helpful to look at nutritional status by evaluating β-HB and protein levels. This can aid in identifying groups at risk of negative energy balance and ketosis, as well as assessing whether the ration supplied is providing adequate energy and whether feeding needs to be adjusted. This may also encourage the farmer to be more vigilant when looking for ewes showing early signs of ketosis.

Summary

While ketosis in ewes does not generally carry a good prognosis, early detection is paramount to successful treatment and a full recovery. This condition is more easily prevented than cured, and nutritional management before and during pregnancy is paramount to reducing the risk and incidence.

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French bulldogs – predicted to become the most popular puppy born in the UK in 2018 – may not be the cute, cuddly, happy and non-aggressive pets they are portrayed as, according to a major survey.

Researchers analysed the clinical records of 2,228 French bulldogs, as part of the RVC-based VetCompass project, and discovered an explosion in UK breed numbers has indicated issues with both current health problems and a “huge” welfare crisis looming as today’s youthful cohort ages.

The work, “Demography and disorders of the French bulldog population under primary veterinary care in the UK in 2013” has been published in Canine Genetics and Epidemiology.

Lead author Dan O’Neill said: “French bulldogs are often bought on a whim, driven by celebrity ownership or regular misuse of the breed in the media.

Demand

“Everyone has seen these distinctive little dogs used in advertisements and they are portrayed as the most passive, stoical, perfect pets. But that isn’t as true as it may seem on the surface.

“In the study, aggression was noted in 2.3% of dogs, so these dogs are certainly not immune from aggression. But when we compare males and females, the males were much more likely to have aggression than the females. Aggression occurred in 0.8% of females and 3.7% of males, so more than four times the probability.”

Dr O’Neill added: “This is an assumption, but it may well be the current French bulldogs are a very different group to those that existed in the UK even 10 years or more ago. Back then, these were a minor breed, with small numbers bred mostly by responsible, registered breeders who vetted potential owners to ensure high welfare standards before and after sale. Those breeders have been swamped by demand.

“To supply the market, we now have huge numbers of imported dogs from eastern Europe and [the Republic of] Ireland – according to Dogs Trust, which has done a lot of very good work on this subject.

“This may mean the socialisation of these imported puppies is much poorer.

“These dogs are also being sold – often online – into homes and environments that aren’t ideal. In many cases, it may be an environmental interaction that makes the dog aggressive.

Puppy population

Dr O’Neill said the French bulldog was “unique” in terms of its population explosion in the UK. He said in most other VetCompass dog breed studies, the median age of animals lies between 4 and 6 years; however, the median age of the French bulldogs was 1.3 years.

He said: “The French bulldog in the UK is, in essence, still a puppy population. The reason for that is there were so few of these dogs around five or more years ago. This means our study looked at a very young population – and the biggest risk factor for most diseases, bar none, is ageing.

“In three, four, five, six or seven years’ time, this group of dogs will have, in all likelihood, much more severe health problems. Bad as it is now, we haven’t hit the peak.

“Our demography work warns the biggest welfare crisis for the French bulldog is yet to come – and it’s likely to be huge.”

  • Read the full story in the 21 May issue of Veterinary Times.
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Dogs and staff gathered just a stone’s throw away from Windsor Castle at Battersea Dogs and Cats Home Old Windsor centre to celebrate before Prince Harry and Meghan Markle tie the knot.

One of the VIPs was Tyson, a 10-year-old Staffordshire bull terrier that has been at the centre for more than 80 days and is looking for a home to call his own.

He wore his best Union Jack bow tie for the occasion, and even had some party tricks for the other guests, including paw, sit, stay and roll over.

Other party goers included Loki, a two-year-old lurcher; Bertie, a three-year-old greyhound; and Hope, an eight-year-old mongrel – all of which are also looking for new homes.

Waiting game

Battersea Old Windsor centre manager Kaye Mughal said: “We’re so close to the action here at Battersea Old Windsor, and all very excited.

“Kensington Palace has been encouraging people to celebrate the wedding with street parties, and we didn’t want our dogs to miss out, so we decided to hold one for them while they wait to find their new family.

“We have so many dogs here looking for homes, and they’re hoping Harry and Meghan’s luck will rub off on them and help them find their soulmates.”

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The not-for-profit event is being organised by Vetsnet and VetLed.

The very first WellVet Weekend will take place at Girton College in Cambridge from 24 to 26 August.

A sport and well-being event, the WellVet Weekend has been designed to provide vets and VNs with an opportunity to recharge, refresh and re-energise.

Sports and talks

The weekend, dubbed the Association of Vet Students sports weekend for adults, will include a variety of sporting activities, yoga classes, well-being workshops and social times, all finished off with a gala dinner on Saturday evening.

This will feature a speech by Rob Pope, also known as the ”real-life Forrest Gump” – an emergency vet by night and a marathon runner by day. Dr Pope is the first person to run across the US five times in a year and is also the Guinness World Record holder for the fastest male marathon runner in a film character costume after completing this year’s London Marathon in a time of 2:36:28.

Not-for-profit

WellVet Weekend is a not-for-profit event and being organised by Vetsnet and VetLed.

Liz Barton, founder of Vetsnet said: ”I love sport and I love this profession, so it’s fantastic to be able to organise a weekend dedicated to the physical and mental well-being of vets and vet nurses. It promises to be a brilliant weekend, and I’m excited to have Rob Pope join us to share his stories from the road.”

Special concept

Ru Clements, founding partner of VetLed, added: “We’re excited to create a community which supports veterinary professionals to thrive.

”The WellVet Weekend is a very special concept with a core mission that we wholeheartedly believe in. We hope we can make a long-lasting positive difference to those who attend the first WellVet Weekend.”

For more information and to purchase a ticket, visit the WellVet website.

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