Equine Pituitary Pars Intermedia Dysfunction (Cushing’s Disease)

Pituitary Pars Intermedia Dysfunction (AKA Cushing’s Disease; PPID) in horses is caused by an abnormal pituitary gland. Overgrowth of the gland results in production and release of excessive stress hormone circulating in the body.

Signs of PPID

Classic clinical signs are long shaggy hair, laminitis, chronic founder, pot-bellied appearance, excessive drinking, excessive urination and a big cresty neck. However, recent improvements in diagnostic testing have allowed us to diagnose this disease much earlier. Now we associate this disease with much more subtle clinical signs such as: Failure to completely shed out the hair coat in the spring (long hairs may linger on the neck) recurrent foot abscesses (particularly in the spring and fall), muscle loss, poor topline, and lameness due to suspensory ligament desmitis.

Diagnosis

In severely affected patients, diagnosis may be made based on clinical signs alone. In the past, blood testing for PPID was difficult to perform due to cumbersome protocols and results were often inconclusive. However, since 2015 we have been using a new test known as the TRH Response test. The protocol for this new test is easy and fast. Samples can be collected over a ten-minute period during a regular appointment and then mailed to a lab for testing. Ideally, this test should not be run in the fall from mid-September to mid-November as the shortening day length can affect hormone release and thus the result of the test. Most importantly, the TRH Response test has been crucial in allowing us to diagnosis this disease in horses as young as 10 years old! Now we can begin treatment YEARS before the patient progresses to a point of chronic founder and life threatening complications.

Treatment

At this time there is NO CURE for PPID. Fortunately, there is a very effective treatment. Prascend (pergolide) is the only FDA-approved product to treat PPID in horses. Prascend is a tablet given daily that acts on the pituitary gland to reduce the excessive hormone secretion that causes clinical signs. This medication is lifelong and will require adjustments over time. Once treatment begins, patients should be retested in 60 days to determine whether the dosage is adequate or whether an adjustment is needed. During that time, you should notice that hair length decreases and abnormal fat deposits are reduced. Once regulated, a test should be conducted once yearly or anytime that the clinical signs appear. Since this disease cannot be cured, it WILL worsen over time. However, with proper treatment and management, many horses will have an excellent quality of life and continue their normal level of use.

Management of PPID

There are several steps in dietary and daily management that are crucial in overall management of PPID.

Pasture Management

Horses with PPID are exquisitely sensitive to sugar (simple carbohydrates) and more specifically fructans. Fructans are the horse equivalent of high fructose corn syrup. Fructan content in pasture grasses varies by type of grass, length of grass, weather conditions and time of day.

Type of Grass: Cool season grasses have periods of particularly high sugar content. These include orchard grass, fescue and Kentucky bluegrass – all of which are very common in West Virginia. Sugar content in these grasses rises seasonally when we have cool nights and warm days (Think, 35-45 degree nights and 65-70 degree days of spring and fall). This is the main reason we see more episodes of laminitis during the spring and fall. In our practice, the exact timing of this critical risk period ranges from March to May and August to November, but depends on county of residence and elevation. For your own location, consider when you see frost while still having nice weather through the day.

Length of Grass: New grass has soft tender structure and more sugar compared to older, taller grass. As the grass grows it develops more lignin (fiber) which provides strength and structure. Therefore, as the grass gets taller it has proportionately less sugar in each bite (Think, tender sweet baby vegetables compared to large older vegetables that are tough and chewy). Access to pasture should be avoided in the spring when you see the young bright green grass starting to emerge. Pasture access should be restricted until the grass has reached at least 8 to 10 inches in height and the fiber content is higher.

Time of Day: Research conducted at Virginia-Maryland College of Veterinary Medicine found that fructan content in the grass changes within the same day. Fructan content is highest in the grass during the afternoon after a cool night. Based on this, we recommend avoiding grazing times in the afternoons, or turn out at night and restrict daytime grazing during the grazing season.

Fertilizer: Generally, good pasture management is great for increasing yield. Unfortunately, this is exactly what you don’t need for PPID horses. Reconsider your pasture management, you may find that you actually need to decrease treatments to reduce grazing quality.

Muzzles vs Drylot vs Timed Turnout

We encourage as much turnout as possible for mental well-being, socialization and exercise. Ultimately you will need to choose a method that works with your property and lifestyle.

Muzzles: Must be left on anytime the horse is grazing. Monitor the face for rubs and the bottom of the muzzle for being worn out and grazing hole enlargement. Muzzles often hard to keep on if there are multiple horses in the pasture as they will play and rip them off.

Drylot (or reduced pasture size): This is a more expensive but more permanent option. In some cases, just increasing the number of horses on the property to “overgraze” the pasture will be helpful. In other cases, you will need to cross fence and reduce access to a smaller area. This is convenient because it does not require a muzzle or daily maintenance but may be difficult if you have “hard keepers” and “easy keepers” in the same pasture. In our area, this seems to be the most successful long term management plan. Reducing the pasture requires an investment of fencing but requires less day to day management in the long term.

Timed Turnout: This works well in boarding stables where turnout is often limited anyway. However, it is important to note horses can eat an entire day’s worth of calories in short period of time. Therefore, if using this method, you must use a drylot or still use a muzzle to restrict intake during the turnout.

Dietary Management

Hay: Ideally, hay should be tested prior to feeding to ensure a low starch count (NSC). Hay testing can be done through Equi-Analytical. Information can be found at https://equi-analytical.com/.

However, keep in mind that hay quality may vary within the same farm and even the same field. If tested hay is not available, generally first-cutting hay will be a more appropriate choice than second-cutting hay. Just as the pasture length described above, second-cutting hay is more sugar-dense. First-cutting hay must grow longer and go to seed before it is cut, which lowers the sugar content in the stem.

Overweight Horses: Feed first-cutting hay at a rate of 2-3 % of bodyweight or 20-30 lbs per day. Use a scale to weigh the flakes of hay. Hay should be fed in a slow feeder. Slow feeders will mimic more natural feeding and help keep the horse occupied as you reduce their overall calorie intake. When introducing the slow feeder, offer the full ration as normal and then extra ration in the slow feeder. Slowly increase the portion offered in the slow feeder and decrease the portion that is free fed until eventually the entire ration is offered in the slow feeder. Gradual transition to the slow feeder will prevent stress and hunger panic from the horse as it becomes accustomed the new feeding method. There are many slow feeders available on the market and several versions that can be hand made. We recommend NibbleNets. As an alternative, you may place the hay in several piles around the lot instead of one large pile. However, this generally produces more waste than a NibbleNet or other homemade slow feeder. Caution: some horses will cause abnormal wear on their incisor teeth from chewing at nylon or metal grates on the slow feeders. This should be monitored.

Concentrate Feed (grain): Avoid feeding any grain with excessive starch such as sweet feeds or corn. Feed only a ration balancer pellet. Ration balancers offer all the benefits of much needed protein and minerals without any excess sugar. Search for a product with a minimum 28% protein content. Ration balancer pellets are readily available from many brands at many feed stores. However, many brands will refer to them by different names such as “grazing pellet, hay stretcher pellet or protein supplement” which certainly makes it difficult to choose. Locally available balancer pellets include: Enrich (PurinaMills), Empower Topline Balance (Nutrena), Essential K (Tribute), and 30% Ration Balancer (Triple Crown). Note that with any of these protein supplements, you will feed much less than with a senior feed or sweet feed. Generally, these protein supplements are designed to feed at a rate of 1-2 lbs per 1,000 lbs of bodyweight.

Weight Issues

Overweight Horses: Many horses with PPID are overweight. Once the PPID is appropriately managed, patients that remain overweight should be tested for concurrent insulin resistance (IR) or insulin dysregulation (ID). IR or ID can occur as a result of PPID or as an independent problem. If insulin abnormalities are present, additional medications, such as metformin and levothyroxine, can be prescribed for continuous or seasonal therapy to help manage the patient.

Underweight/Poorly Muscled Horses: In recent years, we have grown to appreciate more and more that not all PPID horses are obese. Many PPID horses will have chronic muscle loss, failure to gain weight and weak toplines.

For weight gain, add a fat supplement to increase calorie intake. Omega-3 fatty acids are an excellent source of dietary fat for horses. In horses, flaxseed, rice bran and flaxseed oil or rice bran oil are the most commonly recommended sources. These are generally very palatable and easy to find in feed stores. Omega-3 fatty acids offer several benefits such as anti-inflammatory effects that benefit horses with arthritis, inhalant allergies and skin allergies. Note that fats may get rancid in storage, so ensure that you have a fresh source. In addition, fat is not always palatable to every horse, particularly when given in high amounts, and it may cause some loose stool. Search for a product that has a minimum 22% fat. Locally available fat supplements include: Essential Omega Blend liquid (Triple Crown), Amplify pellets (Amplify), or K Finish (Tribute). Feed as a directed on the product label. Generally, since these products are very calorie dense, you will not need to feed a very high volume.

Supplements: There are tons of supplements marketed for both PPID and IR (or ID) horses. Most of these supplements contain chromium and/or magnesium. Research has not proven any benefit from these supplements. Therefore, we do NOT recommend any particular supplements.

Farriery/Hoof Care

Horses with PPID are at great risk of developing laminitis and chronic founder. Hooves should be regularly trimmed to maintain appropriate angles and a shortened toe. Special care or special shoes may be recommended for patients with discomfort from chronic laminitis. Monitor patients closely for foot abscesses. Recurring foot abscesses are a sign of micro-episodes of laminitis. Foot abscesses, particularly recurring foot abscesses, in a horse with PPID are an indicator that the patient’s PPID is not well regulated.

Monitoring

Horses with PPID should be continually monitored for signs that they are not appropriately regulated (i.e.: recurrent foot abscesses, dental disease, laminitis, failure to shed their hair coat in the spring, abnormal sweating, etc.). Annual blood tests should be conducted during the spring.

Long-Term Management

Most horses with PPID will continue to live comfortably and have long, successful careers. Many owners comment that their horses seem to be more active, more energetic and generally “feel” better once they are regulated. This may be due to the general decrease in “stress” hormone and/or decrease in foot pain related to micro-episodes of laminitis.

Diabetes Mellitus in Dogs and Cats

What Is Diabetes?

Diabetes mellitus (DM) is an endocrine disorder that results in abnormally elevated blood sugar (glucose). Glucose is a critical energy source for the body and comes from food that is ingested. The pancreas is a small but important organ next to the digestive tract. The pancreas secretes insulin that helps cells absorb and process glucose. In patients with diabetes mellitus, there is an imbalance in the insulin and glucose where either the pancreas is unable to produce enough insulin or the cells do not respond to insulin.

What Are the Clinical Signs?

• Weight loss (especially weight loss with a great appetite)
• Excessive urination – Excess glucose in the blood is filtered into the urine by the kidneys. This results in increased urination and frequent urinary tract infections.
• Excessive drinking
• Cataracts (especially dogs)
• Weakness (especially in the hind limbs)

How Is Diabetes Mellitus Diagnosed?

Fortunately, diabetes mellitus can be diagnosed with routine bloodwork and urine samples done in our hospital. Occasionally, other tests are performed to determine whether there is other underlying disease or infection. Normal ideal blood glucose should be between 70-120 mg/dL. It is common for cats to have a blood glucose up to 250 mg/dL due to stress just from entering the hospital. Therefore, cats often need repeat bloodwork or additional tests to determine whether an elevated blood glucose is due to stress or diabetes.

How Is Diabetes Treated?

 
Hospital Treatment
Some patients are very sick when they present at our hospital and require admission for treatment of diabetic ketoacidosis. This is a life-threatening condition that occurs from chronic unregulated diabetes mellitus.

At-Home Treatment & Long-Term Care
Treatment for Diabetes is Lifelong. Some cats may experience remission and can be managed strictly with diet, eliminating the need for insulin injections. It is important to note that many of these cats may need insulin injections again at a later time.

Insulin – Most patients can be controlled with insulin injections given 1-2 times daily. This may sound intimidating, but most owners quickly become comfortable with administering the injections to their pet. We are happy to coach you through this!
• Please note that insulin must be kept refrigerated.
• There are several types of insulin available for treatment. Insulin is chosen based on effectiveness, length of action (short-acting vs long-acting), availability and cost.
• Be sure that the insulin syringe matches the insulin you are using. Most insulins used in pets are U-40. Human insulin syringes are U-100. Using a U-100 syringe with some veterinary insulins may result in an overdose!
• To administer an insulin injection: Pull the loose skin between the shoulder blades with one hand. With the other hand, insert the needle directly into the “tent” that is created by holding the skin up. Draw back on the plunger to check for blood. If you see blood, remove the needle and do not inject. If no blood is noted, depress the plunger on the syringe and complete the injection.
• It is helpful to feed a small treat at the time of the insulin injection. This serves as a reward to the pet and will help prevent resentment of the treatment.

Diet – Proper diet is essential to management of diabetes. Several prescription diets are available to help reduce blood sugar. The daily ration should be split into two meals that are fed after each insulin treatment.

Cats: Purina DM, Hill’s m/d Glucosupport, Royal Canin Glycobalance, Hill’s Multi-benefit W/D

Dogs: Purina OM, Royal Canin Glycobalance, Hill’s W/D, Royal Canin Diabetic

Treats & Snacks – Diabetic patients should adhere to a strict diet. Treats are not recommended unless specifically approved by one of our veterinarians. In most cases, we recommend the following options:
• Use an approved diabetic canned food to make small meatball treats. These may be kept in the freezer and fed as needed. These also make great treats for hiding medications.
• Green beans may be fed raw or steamed to dogs. These are a great healthy snack that are well liked by most dogs. Do not feed green beans cooked or canned in bacon or pork fat.

Monitoring Response to Treatment

Clinical Signs: It is important to always monitor your pet’s clinical signs. Should you note an increase in thirst or urination, this may indicate that the diabetes is no longer regulated or has a concurrent urinary tract infection. Recurrence of clinical signs should always prompt a medical progress checkup.

Regular Checkups: Diabetic patients will require regular visits to monitor them for appropriate management. During these visits we will perform a blood glucose check and a urine check. In some cases, we may choose to perform a blood fructosamine. This test is not performed on-site and thus, results are not immediately available. Fructosamine helps determine if the blood glucose has been consistently high over the prior week.

Urine Test Strips: Urine test strips can be provided for at-home screening of glucose in the urine. These strips are only effective if the glucose is over 250 mg/dl. However, they are quick and easy to use, and thus, a great at home screening tool if you are concerned that your pet is experiencing high glucose. Pets with a positive urine test strip should be examined.

Continuous Blood Glucose Monitor: Our preference for monitoring is to install a continuous blood glucose monitor. The continuous monitor is a small painless disc that is attached to the patient and then worn at home for a period of 7-14 days. This is much more accurate than spot checks, gives us a much more accurate reading from the pet in their natural environment and regular schedule, and reduces the number of needle punctures. A scanner is used to relay the measurements to an app on a smart phone. This has revolutionized our treatment of diabetes!

Preventative Care

As diabetic, your pet’s immune system will be more stressed and thus more susceptible to infection. Thus, it is imperative that your pet receive regular physical examinations, dental care and preventative care.

Signs of Low Blood Sugar (Hypoglycemia)

It is important to become familiar with signs of hypoglycemia as this can be a serious complication that can result in death. Hypoglycemia may occur from an insulin overdose or if your pet does not eat. Signs of hypoglycemia include: lethargy, weakness, sleepiness, drunken walking, stumbling or seizure and loss of consciousness.

If you note these signs: try to get your pet to eat. If your pet will not eat or is unconscious you may give light Karo syrup, honey or even sugar water. Rub the mixture on the gums or place on the tongue. This will absorb through the mouth and does not need to be swallowed. A ¼ teaspoon or less is usually sufficient for a cat. Large dogs may require more than a tablespoon. You should note improvement within a few minutes. We recommend trying a small amount and then contacting our office for further instruction.

Difficult to Regulate Diabetics

Some patients are particularly difficult to manage. This occurs most often in dogs. Often these patients have concurrent underlying disease such as hypothyroidism or hyperadrenocorticism (Cushing’s). Therefore, if the patient is persistently difficult to regulate we may recommend further testing.

Canine Cranial Cruciate Ligament Injury

Stifle Anatomy

 
The stifle, or knee, is a fairly complicated joint. It consists of the femur above, the tibia below, the kneecap (patella) in front, and the bean-like fabella behind. Chunks of cartilage called the medial and lateral menisci fit between the femur and tibia like cushions. An assortment of ligaments holds everything together, allowing the knee to bend the way it should and keep it from bending the way it shouldn’t.
 
There are two cruciate ligaments that cross inside the knee joint: the anterior (or, more correctly in animals, cranial) cruciate and the posterior (in animals, the caudal) cruciate. They connect from one side of the femur on top to the opposite side of the tibia on the bottom, the two ligaments forming an X (hence the name cruciate) inside the knee joint. They are named for their attachment site on the tibia (the cranial cruciate attaches to the front of the tibia and the caudal cruciate attaches to the back of the tibia). This may be hard to visualize based on the description but the illustration above shows the orientation of the two crossing ligaments effectively. The anterior/cranial cruciate ligament prevents the tibia from slipping forward out from under the femur.
 

Finding the Rupture

 
The ruptured cruciate ligament is the most common knee injury of dogs; in fact, chances are that any dog with sudden rear leg lameness has a ruptured anterior cruciate ligament rather than something else. The history usually involves a rear leg suddenly so sore that the dog can hardly bear weight on it. If left alone, it will appear to improve over the course of a week or two but the knee will be notably swollen and arthritis will set in quickly. Dogs are often seen by the veterinarian in either the acute stage shortly after the injury or in the chronic stage weeks or months later.
The key to the diagnosis of the ruptured cruciate ligament is the demonstration of an abnormal knee motion called a drawer sign. It is not possible for a normal knee to show this sign.
 

The Drawer Sign

 
The drawer sign is exhibited when the tibia is able to forward from underneath the femur (similar to a drawer opening). If this action is demonstrated, the cruciate rupture is confirmed. The motion is exaggerated here for the purposes of illustration.
 
The veterinarian stabilizes the position of the femur with one hand and manipulates the tibia with the other hand. If the tibia moves forward (like a drawer being opened), the cruciate ligament is ruptured.
 

 
Another method is the tibial compression test where the veterinarian stabilizes the femur with one hand and flexes the ankle with the other hand. If the ligament is ruptured, again the tibia moves abnormally forward.
 
If the rupture occurred some time ago, there will be swelling on side of the knee joint that faces the other leg. This is called a medial buttress and is a sign that arthritis is well along.
 
It is not unusual for animals to be tense or frightened at the vet’s office. Tense muscles can temporarily stabilize the knee, preventing demonstration of the drawer sign during examination. Often sedation is needed to get a good evaluation of the knee. This is especially true with larger dogs. Eliciting a drawer sign can be difficult if the ligament is only partially ruptured so a second opinion may be a good idea if the initial examination is inconclusive.
 
Since arthritis can set in relatively quickly after a cruciate ligament rupture, radiographs to assess arthritis are helpful. Another reason for radiographs is that occasionally when the cruciate ligament tears, a piece of bone where the ligament attaches to the tibia breaks off as well. This will require surgical repair and the surgeon will need to know about it before beginning surgery. Arthritis present prior to surgery limits the extent of the recovery after surgery though surgery is still needed to slow or even curtail further arthritis development.
 

How Rupture Happens

 
Several clinical pictures are seen with ruptured cruciate ligaments. One is a young athletic dog playing roughly who takes a bad step and injures the knee. This is usually a sudden lameness in a young large-breed dog.
 
A recent study identified the following breeds as being particularly at risk for this phenomenon: Labrador retriever, golden retriever, Rottweiler, Neapolitan mastiff, Newfoundland, Akita, St. Bernard, Chesapeake Bay retriever, and American Staffordshire terrier.
 
On the other hand, an older large dog, especially if overweight, can have weakened ligaments and slowly stretch or partially tear them. The partial rupture may be detected or the problem may not become apparent until the ligament breaks completely. In this type of patient, stepping down off the bed or a small jump can be all it takes to break the ligament. The lameness may be acute but have features of more chronic joint disease or the lameness may simply be a more gradual/chronic problem.
 
Larger, overweight dogs that rupture one cruciate ligament frequently rupture the other one within a year’s time.
 
An owner should be prepared for another surgery in this time frame.
 
The cranial cruciate rupture is not limited to large breed dogs. Small dogs can certainly rupture their ligaments as well and, while arthritis is slower to set in when the patient is not as heavy, there is an association with cruciate rupture and medial luxating patella that is very common in small breed dogs. With the patellar luxation, the kneecap flips in and out of the patellar groove. If the condition is relatively mild, it may not require surgical correction but it does stress the cranial cruciate ligament and can predispose to rupture and need to correct both conditions surgically.
 

What Happens if the Cruciate Rupture is Not Surgically Repaired?

 
Without an intact cruciate ligament, the knee is unstable. Wear between the bones and meniscal cartilage becomes abnormal and the joint begins to develop degenerative changes. Bone spurs called osteophytes develop resulting in chronic pain and loss of joint motion. This process can be arrested or slowed by surgery but cannot be reversed.
 
• Osteophytes are evident as soon as 1 to 3 weeks after the rupture in some patients. This kind of joint disease is substantially more difficult for a large breed dog to bear, though all dogs will ultimately show degenerative changes. Typically, after several weeks from the time of the acute injury, the dog may appear to get better but is not likely to become permanently normal.
• In one study, a group of dogs was studied for 6 months after cruciate rupture. At the end of 6 months, 85% of dogs less than 30 pounds of body weight had regained near normal or improved function while only 19% of dogs over 30 pounds had regained near normal function. Both groups of dogs required at least 4 months to show maximum improvement.
 

What Happens in Surgical Repair?

 
There are three different surgical repair techniques commonly used today. Every surgeon will have their own preference for which technique is best for a given patient’s situation.
 
Extracapsular Repair
This procedure represents the traditional surgical repair for the cruciate rupture. It can be performed without specialized equipment and is far less invasive than the newer procedures described below. First, the knee joint is opened and inspected. The torn or partly torn cruciate ligament is removed. Any bone spurs of significant size are bitten away with an instrument called a rongeur. If the meniscus is torn, the damaged portion is removed. A large, strong suture is passed around the fabella behind the knee and through a hole drilled in the front of the tibia. This tightens the joint to prevent the drawer motion, effectively taking over the job of the cruciate ligament.
 
• Typically, the dog may carry the leg up for a good two weeks after surgery but will increase knee use over the next 2 months eventually returning to normal.
• Typically, the dog will require 8 to 12 weeks of exercise restriction after surgery (no running, outside on a leash only including the backyard).
• The suture placed will break 2 to 12 months after surgery and the dog’s own healed tissue will hold the knee.
 
Tibial Plateau Leveling Osteotomy (TPLO)
This procedure uses a fresh approach to the biomechanics of the knee joint and was developed with larger breed dogs in mind. The idea is to change the angle at which the femur bears weight on the flat “plateau” of the tibia. The tibia is cut and rotated in such a way that the natural weight-bearing of the dog actually stabilizes the knee joint. As before the knee joint still must be opened and damaged meniscus removed. The cruciate ligament remnants may or may not be removed depending on the degree of damage.
This surgery is complex and involves special training in this specific technique. Many radiographs are necessary to calculate the angle of the osteotomy (the cut in the tibia). This procedure typically costs substantially more than the extracapsular repair as it is more invasive to the joint.
• Typically, most dogs are touching their toes to the ground by 10 days after surgery although it can take up to 3 weeks.
• As with other techniques, 8-12 weeks of exercise restriction are needed.
• Full function is generally achieved 3 to 4 months after surgery and the dog may return to normal activity.
 
Tibial Tuberosity Advancement (TTA)
The TTA similarly uses the biomechanics of the knee to create stability though this procedure changes the angle of the patellar ligament. This is done by cutting and repositioning the tibial crest where the patellar ligament attaches and implanting a titanium or steel “cage,” “fork,” and plate as well as bone grafts to stabilize the new angle. Like the TPLO, bone is cut, special equipment is needed including metal implant plates. Similar recoveries are seen relative to the TPLO.
 

Which Procedure is Better?

 
The TTA and TPLO are much more invasive, much more expensive, and require special equipment and specially trained personnel. They have greater potential for complication. Are they worth it? For dogs under 45 lbs, it is generally accepted that there is no clear advantage of the newer procedures over extra capsular repair. For larger dogs, there is great controversy. For all the theory behind TPLO and TTA, results one year post-operative seem to be the same regardless of which of the three procedures the dog had performed. There is some evidence that recovery to normal function may be faster with the newer procedures. Controversy continues and there are strong opinions favoring each of the three procedures. Discuss options with your veterinarian in order to decide.
 

General Rehabilitation After Surgery

 
Rehabilitation following the extracapsular repair method can begin as soon as the pet goes home. The area can be chilled with a padded ice pack for 10 minutes a couple times daily. (Do not try to make up for a skipped treatment by icing the area longer; prolonged cold exposure can cause injury.) Passive range of motion exercise where the knee is gently flexed and extended can also help. It is important not to induce pain when moving the limb. Let the patient guide you. Avoid twisting the leg. After the stitches or staples are out (or after the skin has healed in about 10 to 14 days), water treadmill exercise can be used if a facility is available. This requires strict observation and, if possible, the patient should wear a life jacket. Rehabilitation for patients with intracapsular repair is similar but slower in progression.
 
Rehabilitation after TPLO or TTA is gentler. Icing as above and rest are the main modes of therapy. After 3 to 4 weeks, an increase in light activity can be introduced. A water treadmill is helpful. No jumping, running or stair-climbing is allowed at first. Expect the osteotomy site to require a good 6 weeks to heal.
 

What if the Rupture Isn’t Discovered for Years and Joint Disease is Already Advanced?

 
A dog with arthritis pain from an old cruciate rupture may still benefit from a TPLO surgery and possibly from the TTA. Ask your veterinarian if it may be worth having a surgery specialist take a look at the knee. Most cases must make do with medical management.
 

Meniscal Injury

 
We mentioned the menisci as part of the knee joint. The bones of all joints are capped with cartilage so as provide a slippery surface where the bones contact each other (if the bones contact each other without cartilage, they grind each other down). In addition to these cartilage caps, the stifle joint has two blocks of cartilage in between the bones. These blocks are called the menisci and serve to distribute approximately 65% of the compressive load delivered to the knee. The only other joint with a meniscus is the jaw (temporomandibular joint).
 
When the cruciate ligament ruptures, the medial (on the inner side of the knee) meniscus frequently tears and must either be removed, partly removed, or ideally repaired. This is generally done at the time of cruciate ligament surgery and we would be remiss not to mention it.
 
Pets with meniscal damage may have an audible clicking sound when they walk or when the knee is examined, but for a definitive diagnosis the menisci must actually be inspected during surgery. It is difficult to access the menisci and thus repairing a tear in the meniscus is problematic; furthermore, poor blood supply to the menisci also makes good healing less likely. For these reasons, removal of the damaged portion of the meniscus is the most common surgical choice. This leaves some meniscus behind to distribute the compression load on the knee but removes the painful, ineffective portion.
 
Areas of current research include techniques to improve blood supply to the healing meniscus so that repair can be more feasible. If meniscal damage has occurred in a cruciate rupture, arthritis is inevitable and surgery should be considered a palliative procedure.
 

Enhancing Recovery after Surgery

 
Confinement
Enhancing recovery post-operatively is largely about strict confinement early. This cannot be over-emphasized. Be prepared to crate your dog our employ a pen such as a child’s playpen depending on the dog’s size. A corral of sorts can be constructed with boxes and a baby gate. Be sure you understand the instructions with regard to gradual return to exercise over several months.
 
Adequan Injections
A series of Adequan injections can help with joint inflammation as well as lubrication. Typically injections are given twice a week for a total of eight injections.
 
Glucosamine
Oral joint supplements such as glucosamine contain cartilage building blocks to help the body repair cartilage damage. This is an excellent time to begin supplementation and there are numerous brands.
 
Weight Management
Overweight dogs have an increased risk for arthritis and for cruciate rupture. A weight management program can reduce the potential for arthritis and can reduce the risk of rupture of the opposite cruciate ligament. If your dog is overweight, ask your vet about a weight management plan that might be started during the recovery period.
 
Professional Rehab/Physical Therapy
Nothing compares to professional rehab for return to function. If you are lucky enough to have such a facility in your area, consider utilizing their services. A list of home exercises may be obtained and/or the dog can visit weekly or a few times weekly for exercise and treatment. Some facilities allow the dog to board and have daily treatment. Ask your vet about this option.

Dental Disease in Pets

Dental disease is not just about bad breath! Dental disease is painful! 80% of dogs and cats over 3 years of age have dental disease. Infections from poor dental health can cause permanent damage to the kidneys, liver and heart. Many pets will continue to eat, even while painful, and show little sign of their poor dental health. Our goal is to treat dental disease at Grade 2-3 to prevent permanent damage to the internal organs that occurs when dental disease progresses to Grade 4.
 
 

Effects on the Body

 
Normal
Healthy mouth allows pet to eat without pain.
Grade I – Gingivitis
Redness on gumline and plaque forming.
Grade 2 – Early Periodontitis
Tissue swelling and loss of tooth attachment. Gums may bleed. Mouth starts to get painful and odor is noticeable.
Grade 3 – Moderate Periodontitis
50% of the attachment of tooth is lost. Roots are exposed. Gums often bleed when probed. Bad breath is present. Pain associated with the teeth may start to change the pet’s behavior.
Grade 4 – Advanced Periodontitis
Teeth may fall out. Usually blood and pus are present. Bacteria spread through the body via the bloodstream and can damage the liver, kidneys, and heart.
 

Recommendations to Slow Periodontal Disease Progression

 
It is important to note that dental disease is progressive and will worsen over time. Prevention and maintenance are key to ensuring longevity of the teeth. We also recommend the following to help slow progression of disease. Please note that these recommendations offer no help in cases of severe disease, such as Grade 3 and Grade 4. Patients with Grade 3 & Grade 4 periodontal disease will require extractions and aggressive therapy.
 
Teeth Brushing: Brushing daily with a pet toothpaste and tooth brush or dental wipes is very beneficial in preventing tartar accumulation.

Diet: Feed a dental health diet such as Hill’s T/D or Royal Canin Dental. These diets are designed to help remove tartar from the tooth as the patient eats.

Treats: Feed dental treats such as Oravet Dental Chews. Not all treats actually benefit oral health. Use only treats approved by the Veterinary Oral Health Council.

Oral Rinse: Use an oral rinse such as Hexarinse.

Water Additives: You may add solutions such as Aquadent to the drinking water.
 

What is the Veterinary Oral Health Council?

 
The Veterinary Oral Health Council (VOHC) is made up of board-certified veterinarians with advanced certification as dentistry specialists and dental scientists. These council members are appointed by the president and Board of Directors of the American Veterinary Dental College. The council reviews submissions and recommends whether items are awarded a seal of approval from the VOHC.
 

What Does the VOHC Seal Mean?

 
The VOHC Seal indicates that a pet dental product has met pre-set standards that prove that it slows dental plaque and dental tartar accumulation on teeth. Approval indicates that the product has undergone trials created by the VOHC. There are many products on the market that make a claim “to improve dental health”. We encourage you to find product with a VOHC Seal.

Canine Parvovirus

Canine Parvovirus Recovery and Environmental Decontamination
Allegheny Veterinary Services

 
Diet

Your pet is recovering from extensive damage to the intestinal tract. It is typical for stool to be a little loose at first or for no stool to be produced for a few days as the tract recovers. The stool should gradually firm up over the first 3 to 5 days at home.

Your pet may resume normal activity and attitude over the first week at home. If diarrhea persists, vomiting occurs, or your pet seems depressed, please contact our office at once for further instructions.

Your pet may be ravenously hungry after going so long without food. Do not allow him to gorge as this can result in further vomiting or diarrhea. Feed smaller meals separated by at least an hour or two.

• Feed the therapeutic diet we have provided for the first few days at home. Then resume the normal diet. Do not feed table scraps. Stick to the diet recommended by your veterinarian.

Exercise

Your pet should be considered contagious to other puppies for at least 6 weeks. Therefore, trips to the park, obedience school, or visiting other neighborhood areas where pets comingle, should be avoided during this time. If your pet is less than 16 weeks of age, he should not be allowed in public areas until the vaccination series is fully completed. He can be considered immune to parvovirus after recovery. However, puppy vaccinations include many other infectious diseases for which your pet needs to be vaccinated against.

Other Pets

Humans are not susceptible to canine parvovirus infection, though some strains can be contagious to cats. Adult dogs that have been vaccinated are not susceptible either. Introducing new puppies poses a problem as the parvovirus persists a long time in the environment. When in doubt, make the new puppy an older individual (16 weeks or so) who has already completed his/her vaccination series. Any obviously contaminated material should be removed (fecal- or vomit-contaminated objects that cannot be bleached, any remaining areas of feces, etc.). See section below on Decontamination of the Environment.

Bathing

Your pet may be bathed any time as long as you do not allow him to get cold or chilled after the bath. Bathing will reduce the amount of virus left on his fur and will help reduce contagion.

Resuming Vaccines

Your pet cannot be re-infected with this virus for at least 3 years and is probably protected for life after surviving infection. However, it is imperative that he still receives vaccinations as there are other viruses that he should be protected against.

Your pet should lead a normal life once the recovery period is completed (1-2 weeks). In rare cases, there may be lasting effects on the heart.

Disinfecting the Environment

Canine parvovirus is especially hardy in the environment and particularly difficult to remove. It is readily carried on shoes or clothing to new areas (which accounts for its rapid worldwide spread shortly after its original appearance). It is able to overwinter freezing temperatures in the ground outdoors, plus many household disinfectants are not capable of killing it indoors.

• Infected dogs shed virus (in their stool) in gigantic amounts during the 7 to 10 days following exposure. Because such enormous amounts of virus are shed, there is a HUGE potential for environmental contamination when an infected dog has been there.
• It is important to realize that because the canine parvovirus is so hardy in the environment, it is considered ubiquitous. This means that no environment is free from this virus unless it is regularly disinfected.
• A parvoviral infection can be picked up anywhere, although it is easier to pick up an infection in an area where an infected dog has been simply because of the larger amounts of virus in a contaminated area.
• Whether an individual dog gets infected or not depends on the number of viral particles the dog experiences, what kind of immune experience the dog has had with the virus before (vaccinated? previously infected? How much past exposure?), and how strong the individual dog is (stress factors, diet, etc.)

A typical/average infectious dose for an unvaccinated dog is 1,000 viral particles. For some dogs far less is needed. For other dogs, far more is needed. An infected dog sheds 35 million viral particles (35,000 TIMES the typical infectious dose) per OUNCE of stool.

Environmental Decontamination

Parvovirus is virtually impossible to completely remove from an environment. The goal of decontamination is to reduce the number of viral particles to an acceptable level. There are many cleaners on the market with claims to eliminate parvovirus. However, realistically it is virtually impossible to remove parvovirus from an environment.

Bleach: One of the best and most effective disinfectants against parvovirus is BLEACH. However, it important to note that bleach is inactivated in the presence of organic material such as feces, vomitus or other bodily fluids. Therefore, all surfaces and items must first be cleaned with a detergent or other household cleaner. Then, mix one part bleach with 30 parts water. This solution is then applied to bowls, floors, surfaces, toys, bedding, and anything contaminated that is colorfast or for which color changes are not important. The bleach solution must be allowed to soak on the surfaces and items for at least 10 minutes to be effective at killing the virus. Disinfection becomes problematic for non-bleachable surfaces such as carpet or lawn.

Steam Cleaning: Steam is also able to kill the virus.

Rescue® (accelerated hydrogen peroxide cleaner): This is a virucidal agent that we use in our hospital. It is safe on all surfaces and effective as a detergent and disinfectant. Gallons of this cleaner can be purchased if you prefer this over bleach.

Indoor Decontamination

Indoors, where normal room temperature is maintained, the virus loses its infectivity within one month. Therefore, it should be safe to introduce a new puppy indoors one month after the active infection has ended.

Outdoor Decontamination

Freezing does NOT kill the virus. If the outdoors is contaminated and is frozen, you must wait for it to thaw out and warm up before safely introducing a new puppy. Shaded areas should be considered contaminated for seven months. Areas with good sunlight exposure should be considered contaminated for five months.

If you have any questions about your pet’s care after discharge from the hospital, please feel free to contact our office.

Canine Lyme Disease

Lyme disease is an emerging infectious disease at Allegheny Veterinary Service and within our practice area. As a result, we are constantly updating our diagnostic and treatment protocols. We now test all canine patients during their annual wellness exam and sick patients that present with lameness and fever when no other obvious cause is found. In addition, vaccination against Lyme disease is recommended as a core vaccine for all canine patients.

What Is Lyme Disease?

Lyme disease is the most common tick-borne disease in the United States. The disease was first identified in Lyme, Connecticut, in the 1980s. Human and canine cases remained primarily concentrated in the northeastern United States for many years. From 2005 to 2015, our practice diagnosed 2-3 cases per year. More recently Lyme disease has migrated into our area of West Virginia. In our practice, we have noted a sharp increase in cases since 2015. As of 2020, it is common in our practice to diagnose one Lyme-positive case each day. Overall, 25% of the dogs tested at our practice are positive for Lyme disease.

How Do Dogs Get Lyme Disease?

Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi, and transmitted by an Ixodes tick bite after 2-3 days of tick attachment. These “deer ticks” live in outdoor greenery and feed on birds, mice, small mammals, deer, dogs, people, etc. Migrating birds bring infected ticks to new habitats. Lyme disease is not contagious between infected animals and people without a tick bite. An individual tick only feeds on one host each season. Nymphal ticks are mostly active in the spring; adult ticks are active in the fall.

How Will I Know if My Dog Has Lyme Disease?

Sometimes dogs show illness, such as eye problems or lameness, due to Lyme disease. Based on experimental studies, young puppies (6-12 weeks old) appear to be more sensitive, with a self-limiting illness consisting of 4 days of fever and decreased appetite, with limping occurring 2-5 months after the tick bite. Older puppies (13-26 weeks old) have a shorter, 2-day illness, and adult dogs show none of these clinical signs (“symptoms”) in an experimental setting.

How Do We Test for Lyme Disease?

Our hospital performs a screening test for Lyme disease (along with heartworm and other tick-borne diseases) on all dogs at the annual exam. In addition, dogs are often tested when presenting sick with fever from an unidentified source, lameness, or kidney disease. This test is a quick screening test performed with a small blood sample.

What if My Dog Is Positive on a Screening Test?

A positive result indicates that a patient has been exposed to Borrelia burgdorferi, the bacteria that causes Lyme disease. Not all animals that get exposed (test positive) will become sick. Up to 70% of positive cases may just be exposed and suffer no further problems. However, 5% of the cases that test positive can develop serious complications with potentially deadly consequences, such as “Lyme nephritis.”

What Further Tests Can Be Performed to Make Sure That My Dog Does Not Have Lyme Disease?

If your dog is positive for Lyme disease on our screening test during an annual exam: Our veterinarians will recommend checking a urine sample to determine whether there is kidney disease. In addition, our veterinarians may recommend a further blood test to estimate the level of infection.

What Is Lyme Nephritis?

“Lyme nephritis” is a rare but severe form of kidney damage that has been associated with Lyme disease in dogs. This appears more common in Labrador and golden retrievers. The earliest warning of Lyme nephritis is protein in the urine (proteinuria). ALL Lyme-positive dogs should be screened and monitored through urine samples over time for proteinuria, even if previously treated for Lyme disease, since treatment may not prevent the development of Lyme nephritis.

How Can I Prevent Lyme Disease In My Dog?

Vaccination: Due to the increasing risk and incidence of this disease in our area, we now recommend Lyme vaccination for ALL canine patients as part of the annual examination. This vaccination has very low risk and reactions are rare.

Canine Hyperadrenocorticism (Cushing’s Disease)

What Causes Cushing’s Disease?

Cushing’s disease, or hyperadrenocorticism, is caused by an excess of stress hormone (cortisol) from the adrenal glands. This excess can be caused by overproduction of cortisol by the adrenal glands, abnormal signaling from brain to the adrenal glands or long-term steroid usage (such as prednisone, prednisolone, Temaril P, or dexamethasone). This extra stress hormone can cause several symptoms, leading to trouble regulating blood sugar, immune-mediated problems, weak bones and cartilage, liver problems, and problems with metabolism of essential nutrients. Permanent damage to organs may occur if the disease is left untreated.

What Age & Breeds Are Typically Affected?

Although Cushing’s disease can occur in any breed, poodle breeds, dachshunds, terriers, German shepherds, beagles, and Labrador retrievers are most commonly affected. Dogs with Cushing’s disease are typically older than six, with an average age of 10 years old.

How Will I Know if My Dog Is Showing Signs?

Signs of Cushing’s disease can be non-specific, and are often confused with normal aging, making this disease tricky to recognize.

Common Signs:

-panting
-increased drinking
-frequent urination or accidents in the house
-“pot-bellied” or enlarged abdomen
-hair loss
-lethargy
-muscle wasting or loss of muscle tone

Other Signs:

-recurrent skin infections
-urinary tract infections
-hypertension / high blood pressure
-diabetes (especially those that are hard to regulate)
-bilateral cranial cruciate disease

How Can We Test My Dog for Cushing’s Disease?

Cushing’s disease can be very tricky to diagnose. Diagnosis starts with a thorough history of your dog’s health and general physical examination. Often, there are changes on basic bloodwork, such as elevated liver enzymes, that indicate possible Cushing’s disease. A complete urine exam may also be performed as Cushing’s disease often causes recurrent urinary tract infections. Abdominal x-rays or ultrasound may be needed to evaluate the health and structure of your dog’s liver and rule out other disease.

If results of these basic tests raise suspicion, we will recommend additional testing to specifically identify Cushing’s disease. Each test for Cushing’s disease has advantages and disadvantages.

Urine Cortisol / Creatinine Ratio: This test is convenient because you collect the pet’s urine at home and deliver it to the clinic for processing. The first morning urine should be collected each morning for three days in a row. The samples may be combined into one container and must be refrigerated until delivery to the clinic. Sample collection should be delayed at least six days after a visit to the veterinarian or groomer. Negative results from this test indicate that the Cushing’s disease is very unlikely. However, positive results must be confirmed with a specific blood test.

Low-Dose Dexamethasone Test: This test requires the patient to be fasted (held off of food) and stay at the clinic for the day. Three blood samples are drawn throughout the day over an eight-hour period. This test is the most sensitive test available to diagnose Cushing’s disease.

ACTH Stimulation Test: This test must be used when a patient has been receiving steroids for treatment of other disease. It is also used for monitoring treatment levels in pets currently receiving treatment for Cushing’s disease. This test requires the patient to remain at the clinic for a half day for two to three blood samples over several hours. Patients should be fasted for this test. When using this test for monitoring of treatment, Vetoryl® (trilostane) should be administered 4-6 hours prior to testing.

Unfortunately, there is no perfect test for Cushing’s disease and all of these diagnostic tests can have confusing results. For this reason, many testing trials may be required to reach a conclusion or confirm a diagnosis. This can be frustrating, but it is important to remain persistent and patient as we work through this diagnosis.

How Is Cushing’s Disease Treated?

Medical and surgical methods are used to treat Cushing’s disease. Surgical treatment involves removal of the adrenal glands and may “cure” disease but is risky to perform. Medical treatment is usually preferred and will alleviate your pet’s symptoms. Medical treatment for Cushing’s disease is lifelong. Supportive care for liver disease is often recommended.

Vetoryl® (trilostane): Trilostane is the only FDA-approved medication for treatment of all types of Cushing’s in dogs. This medication may be given once or twice daily depending on the individual. An ACTH Stimulation test will be conducted two weeks after starting this medication or two weeks after any dose change. Side effects: weakness, collapse, lethargy, decreased appetite, diarrhea and vomiting. Should any of these side effects occur, please notify our office as soon as possible.

Lysodren® (mitotane): Mitotane may be used as an alternative treatment and should be discussed on a case-by-case basis.

Liver Supplements: Supplements such as S-Adenosyl-L-Methionine (SAMe) and adenosine may be recommended to support general liver health.

My Dog Has Been Diagnosed With Cushing’s! What Now?

Although lifespan is generally shortened by 2.5-5 years, dogs with Cushing’s disease may live for many years with appropriate treatment. Lifespan is also affected by concurrent disease, age at the time of diagnosis and treatment compliance.

ACTH Stimulation Tests: Monitoring of appropriate medication levels is important as serious side effects and even death may occur. An ACTH stimulation test should be conducted every six to twelve months. Some patients may require testing every three months to ensure appropriate control of the disease.

Blood Pressure: Blood pressure should be checked during regular examinations to detect hypertension.

Keep a Journal: Note changes in your dog’s habits, particularly urination and weight gain or loss. In addition, note any recurrence of clinical signs and the appearance of possible side effects.

Veterinary Visits: Semi-annual physical examinations are important to detect other problems such as skin infections, ear infections and urinary tract infections.

Pig Health

As the owner, it is ultimately your responsibility to provide a healthy environment so that your pig may flourish and grow. A keen understanding of good husbandry practices, basic infectious disease prevention, swine diseases and conditions specific to your pig and your farm are critical to the success of your project. This document is only meant to be a starting point for your farm health plan. You should also establish a relationship with a veterinarian to assist with a protocol specific to your farm.

FDA Restrictions

Off-Label use of antibiotics, dewormers and other treatments is strictly prohibited in food animals. These rules are set in place to protect the consumer and our food supply. Be sure to check all medication labels and comply with labeled use, dose and withdrawal times.

Parasites

Our doctors commonly diagnose sarcoptic mange, demodectic mange and intestinal parasites in pigs. We recommend treating pigs with ivermectin 1% at 1 cc per 75 lbs subcutaneously. Fecals may be examined to determine if other dewormers are needed.

Vaccinations

Vaccines are available for over 25 diseases in swine. Most swine vaccines are only available in large herd-size quantities, such as a 250-dose bottle. Ideally, pigs should be vaccinated by the breeder and prior to purchase or moving. It is critical that you discuss specific risks and needs with your veterinarian to customize a vaccination protocol for your farm.

At a minimum, all show pigs should be vaccinated for:

Erysipelothrix rhusiopathiae (Diamond Skin Disease) – A killed bacterin is recommended. Initial dose at 8 to 12 weeks of age. Booster 4 weeks after initial dose. This should be boostered 6 weeks prior to the fair.

Swine Influenza (H1N1, H1N2, H3N2) – Initial dose at 6 weeks of age. Booster 3 weeks after the initial dose. Do not vaccinate for 21 days prior to slaughter.

Benefits of Omega-3 Fatty Acids in the Equine Diet

What Are Omega-3 Fatty Acids?
Omega-3 fatty acids are compounds found in our diets that are very beneficial as natural ANTI-inflammatories. Omega-3 fatty acids have been shown to reduce inflammation and support immune function. We often recommend them as adjunct therapy for many conditions including:

  • Inhalant Allergies (Heaves, RAO, Equine Asthma);
  • Skin Allergies (Sweet Itch, Culicoides Hypersensitivity);
  • Other Skin Conditions (Dry Skin);
  • Respiratory Issues;
  • Arthritis and Joint Pain;
  • Reproductive Issues – Omega 3s improve fertility, and increase sperm concentration, motility and viability.; and
  • enriching colostrum quality and improving colostral antibody absorption in foals.

Are All Omega-3 Fatty Acids the same?
No. Of the omega-3 fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) have the most efficient biologic activity and therefore, are the most beneficial. As a result, we recommend sources that are specifically high in these types of omega-3 fatty acids.

What Are the Best Sources of DHA and EPA?
The best sources of DHA and EPA omega-3 fatty acids are fish oil, safflower and sunflower oil. This poses a challenge for horse owners because fish oil is not very palatable to our equine companions.

What Are Omega-6 Fatty Acids?
Omega-6 fatty acids are commonly found in the same sources that have omega-3 fatty acids. Omega-6 fatty acids are, however, PRO-inflammatory. Therefore, our goal is to find a source with high omega-3 fatty acids and low omega-6 fatty acids. Unfortunately, many ingredients commonly used in equine diets are low in omega-3 fatty acids and higher in omega-6 fatty acids. These include cereal grains such as oats, corn and many vegetable oils.

Where Do Flaxseed and Flaxseed Oil Fit in?
Flaxseed oil has alpha-linolenic acid in it that is converted to DHA and EPA by the body; however, it is unknown how efficiently this conversion occurs. Therefore, flaxseed and flaxseed oils are a reasonable choice, but may not be as effective as some other sources.

So, Now I Am Confused. What Do I Feed My Horse?

  • Feed your horse good quality hay and pasture. Although low in total fat content, hay and pasture have a high omega-3 to omega-6 ratio.
  • When feeding fats for weight gain, feed flaxseed oil or flaxseed. Avoid corn oil.
  • When feeding omega-3 for anti-inflammatory effects, we recommend EO-3™ from Kentucky Equine Research. However, there are several other brands on the market as well.

Are There Any Side Effects to Feeding Omega-3 Fatty Acids?
With increasing amounts of fat in the diet, some horses may develop soft stool. This is unlikely to occur when feeding fat for anti-inflammatory effects but may occur when feeding larger amounts for weight gain.