Clinical Applications of Digital Venography

Digital venography is a form of contrast angiography that is used to define the vasculature of the digit. The technique is relatively simple and can be performed stall-side using standard radiographic equipment, so it can be used to evaluate a variety of clinical conditions of the equine foot. However, it is important to become familiar with the vascular patterns noted in the healthy foot to make full use of the technique in the diagnosis and management of the diseased foot. In short, venous compromise or occlusion results in a reduction or absence of contrast in the affected area. Causes of venous compromise include an alteration of load within the foot, (compression) space-occupying masses such as a keratoma, and thrombosis. Most often, venography is used to supplement routine radiography in evaluating the laminitic patient. Alterations in the contrast pattern are evident before radiographically discernible displacement of the distal phalanx, the extent of the vascular alteration being determined by the severity of pathology in the suspension apparatus of the distal phalanx (ie, the dermal-epidermal bond). Information gained from the venogram can greatly assist with treatment decisions, and serial venography is valuable in monitoring response to treatment and making modifications accordingly. So, although both the procedure and interpretation require skill development which is gained with experience, veterinarians are encouraged to use digital venography routinely in evaluating and managing the laminitic patient as well as in patients presenting with foot lameness of undetermined cause.     

Clinical Outcome of 14 Obese,Laminitic Horses Managed with the Same Rehabilitation Protocol

A specific method of rehabilitation was used to manage obese horses with laminitis, and clinical outcome was evaluated after 5 to 20 months. Clinical data from 14 similar laminitis cases were statistically analyzed to evaluate response to rehabilitation. Data were analyzed using repeated measures or logistic regression methodologies. Each horse presented as obese and laminitic with no history of a systemic inflammatory disease. The rehabilitation method emphasized a mineral-balanced, low nonstructural carbohydrate diet; daily exercise; hoof trimming that minimized hoof wall loading; and sole protection in the form of rubber hoof boots and/or hoof casts. Distal phalanx alignment within the hoof capsule was significantly improved, and hoof wall thickness was significantly decreased (P < .0001) following treatment. Solar depth was significantly increased (P < .0015). Reduction of palmar angle measurements was detected in acutely and chronically affected horses. This treatment effect was statistically greater for horses with chronic laminitis than for horses with acute laminitis (P interaction < .0001). Horses were 5.5 times more likely to be sound post-treatment than before treatment. Daily exercise, dietary modification, and removal of ground reaction force from the hoof wall were foci of the rehabilitation program. Hoof care and husbandry as applied to these horses may be an effective method of rehabilitation of horses from obesity-associated laminitis.     

Laminitis in Horses: Through the Lens of Systems Theory

Systems theory is a way of describing complex and dynamic relationships. We applied systems theory to the structure and function of the equine foot in an effort to better understand laminitis and, in so doing, reconcile the various theories of its etiopathogenesis and find more universally effective preventive and therapeutic strategies. The foot is described as an open system, and its inherent vulnerabilities are explored. Cascade failure is discussed as a potentially unifying theory of laminitis. The fundamental failure in laminitis is failure of the lamellar dermal−epidermal bond, but that endpoint can be reached via vascular, enzymatic, inflammatory, or mechanical mechanisms, or any combination thereof. Inflammation is discussed as a common denominator, making anti-inflammatory therapy of greater importance than just pain management. Multimodal anti-inflammatory therapy is discussed, including selective COX-2 inhibitors, heparin, nutraceuticals, and inhibitors of matrix metalloproteinases (MMPs). Multimodal analgesic therapy also is important and may include nonsteroidal anti-inflammatory drugs (NSAIDs), opiates, epidural analgesics, physical therapy, relief of weight bearing, diligent nursing care, deep digital flexor tenotomy, and case-appropriate trimming and shoeing. Preventing laminitis still comes down to risk management: knowing the risk factors applicable to an individual horse and adjusting the management accordingly. Examples include weight management and control of carbohydrate intake in overweight horses and ponies, the use of pergolide in patients with pituitary pars intermedia dysfunction (PPID), and distal limb cryotherapy in high-risk patients. It is anticipated that application of molecular biologic techniques will further advance treatment and prevention of laminitis.     

Update on Metabolic Diseases Associated With Laminitis in Horses and Ponies

Several recent scientific publications describe some important findings that may further improve our ability to diagnose and manage both equine Cushing's disease (ECD) and equine metabolic disease (EMD). This abstract provides a brief summary of recent findings in ECD and EMD that have immediate application for clinical practice.     

Assessment of Insulin and Glucose Dynamics by Using an Oral Sugar Test in Horses

Straightforward testing procedures are needed to facilitate the diagnosis of insulin dysregulation in horses because hyperinsulinemia and insulin resistance are associated with laminitis. Results of an oral sugar test (OST) were compared with those of the intravenous glucose tolerance test (IVGTT). We hypothesized that OST and IVGTT area under the curve values for glucose (AUCg) and insulin (AUCi) would be closely correlated, as defined by a correlation coefficient value ≥0.90. Both tests were performed in 10 horses meeting the criteria for equine metabolic syndrome (EMS) and 8 Quarter horse crossbred mares from a university teaching herd (control group). The OST was also performed in 21 Quarter horse crossbred mares from the same herd, and test repeatability was evaluated in 8 of these horses. All testing was performed under fasting conditions. Median AUCg and AUCi values were 1.3- and 9.0-fold higher, respectively, for the IVGTT and 1.3- and 6.8-fold higher, respectively, for the OST in the EMS group than those in the control group. AUCg (Spearman correlation coefficient [r_s] = 0.58; P = .012) and AUCi (r_s = 0.90; P < .001) values for the two tests were positively correlated. Mean ± SD coefficients of variation for repeated tests in 8 mares were 6.4% ± 3.1% and 45.1% ± 36.2% for AUCg and AUCi, respectively. We conclude that OST and IVGTT insulin results are closely correlated, so the OST warrants further consideration as a field test for insulin dysregulation in horses.     

Proinflammatory Cytokine and Chemokine Gene Expression Profiles in Subcutaneous and Visceral Adipose Tissue Depots of Insulin‐Resistant and Insulin‐Sensitive Light Breed Horses

Background: Insulin resistance has been associated with risk of laminitis in horses. Genes coding for proinflammatory cytokines and chemokines are expressed more in visceral adipose tissue than in subcutaneous adipose tissue of insulin‐resistant (IR) humans and rodents. Hypothesis/Objectives: To investigate adipose depot‐specific cytokine and chemokine gene expression in horses and its relationship to insulin sensitivity (SI). Animals: Eleven light breed mares. Methods: Animals were classified as IR (SI = 0.58 ± 0.31 × 10^?4 L/min/mU; n = 5) or insulin sensitive (IS; SI = 2.59 ± 1.21 × 10^?4 L/min/mU; n = 6) based on results of a frequently sampled intravenous glucose tolerance test. Omental, retroperitoneal, and mesocolonic fat was collected by ventral midline celiotomy; incisional nuchal ligament and tail head adipose tissue biopsy specimens were collected concurrently. The expression of tumor necrosis factor‐α (TNF‐α), interleukin (IL)‐1β, IL‐6, plasminogen activator inhibitor‐1 (PAI‐1), and monocyte chemoattractant protein‐1 (MCP‐1) in each depot was measured by real‐time quantitative polymerase chain reaction. Data were analyzed by 2‐way analysis of variance for repeated measures (P < .05). Results: No differences in TNF‐α, IL‐1β, IL‐6, PAI‐1, or MCP‐1 mRNA concentrations were noted between IR and IS groups for each depot. Concentrations of mRNA coding for IL‐1β (P= .0005) and IL‐6 (P= .004) were significantly higher in nuchal ligament adipose tissue than in other depots. Conclusions and Clinical Importance: These data suggest that the nuchal ligament depot has unique biological behavior in the horse and is more likely to adopt an inflammatory phenotype than other depots examined. Visceral fat may not contribute to the pathogenesis of obesity‐related disorders in the horse as in other species.     

Clinical Updates I—Laminitis

Managing laminitis entails a multifaceted approach and includes nutritional management in all cases. Using advanced imaging techniques, as part of the diagnostic workup, provides guidance in the treatment options and includes computed tomography, computer modeling, digital radiography and venography. The therapeutic procedures are trimming, shoeing, deep flexor tenotomy and hoof wall resection as possible considerations and is dependent on the clinical findings. When applicable, preventive measures such as cryotherapy and techniques to prevent support limb laminitis can be implemented.     

A Fresh Look at the Process of Arriving at a Clinical Prognosis Part 1: Laminitis

Laminitis is a disease that represents a loss of the normal homeostatic mechanisms that control the day-to-day function of the distal phalanx. The degree or severity to which homeostasis is affected is directly related to the severity and the final outcome for the equine patient. A systematic approach including the physical examination, digital radiography, venography, and newer techniques such as computer tomography and magnetic resonance imaging can assist the clinician in developing a prognosis for the acute and chronic laminitis case. How quickly we are able to return the foot back to a normal state of homeostasis or the response to treatment is important as a predictive value for outcome.     

Investigation of Single and Paired Measurements of Adrenocorticotropic Hormone for the Diagnosis of Pituitary Pars Intermedia Dysfunction in Horses

Background

Paired measurement of ACTH concentration may be more reliable than a single measurement.

Hypothesis/Objectives

To determine whether the mean of 2 measurements of ACTH concentration is more reliable in assessing pituitary pars intermedia dysfunction (PPID) than a single measurement.

Animals

Paired ACTH measurements were performed on (1) 148 occasions from 124 horses being investigated for PPID, (2) 90 occasions from 76 horses with PPID that were receiving treatment with pergolide, and (3) 63 occasions from 50 horses in which there was no clinical suspicion of PPID. Histologic examination of the pars intermedia was performed in 67 of the untreated horses.

Methods

Outcome of testing using single and the mean of paired samples was compared directly and both methods were compared against histology, which was considered the gold standard.

Results

Paired ACTH measurement altered binary classification as healthy or diseased in 6 of 211 cases, all off which had equivocal initial ACTH concentrations between 20 and 39 pg/mL. Using histology as the gold standard, optimal sensitivity and specificity for diagnosing PPID were 69.4 and 80.9%, respectively, for a single measurement and 72.2 and 76.2%, respectively, for paired measurements. The area under the receiver operating characteristic curve was 0.72 and 0.73 for single and paired measurements compared with histopathologic diagnosis, respectively.

Conclusions and Clinical Importance

Paired measurement of ACTH concentration offers no advantage over a single measurement.     

Some Thoughts on Deep Digital Flexor Tenotomy

Deep digital flexor tenotomy is becoming increasingly popular as part of the treatment regimen for laminitis. The rationale for performing a tenotomy is based on the severity of the rotation of the third phalanx (coffin bone) in chronic laminitis cases with the goal of realigning the coffin bone relative to the ground. The procedure is safely performed in the mid-cannon bone and pastern regions. The farrier is an integral member of the treatment team in providing mechanical support to the foot after the surgical procedure.     

Comparison of Insulin-Induced Digital Vessel Ring Responses of Laminitic and Clinically Healthy Horses

Hyperinsulinemia leads to insulin resistance of blood vessels and interferes with circulation of laminae of the equine foot. The objective of the study was to compare the digital vessel responses of clinically healthy and laminitic horses with and without experimental induction of insulin resistance. Vessel segments (artery and vein) collected after euthanasia were cut into 3-mm wide rings and were prepared in tissue baths containing Tyrode solution for response studies. Two rings of each vessel type from each horse were used as nonresistant, and two were made insulin resistant. Insulin resistance was induced by incubating the rings with 10-μM bath concentration of insulin. Then, all rings were contracted with phenylephrine (5 μM). When the contraction reached a plateau, insulin (10 μM) was added, and the response monitored for 30 minutes. The response to insulin was calculated as a percentage of the phenylephrine response. The results showed that the responses of the nonresistant rings differed significantly between the groups. However, when all rings were made insulin resistant, the significance between the groups disappeared. In the laminitic group, responses of resistant and nonresistant rings did not differ, whereas in the healthy group, the vessel responses differed significantly. In all experiments, arterial and venous rings followed the same pattern, but the magnitudes were greater in arterial rings. The findings suggest that the vessel responses to insulin are altered in laminitis which could be due to insulin resistance.