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The Laminitis Site

Articles about feet December 2019

12/21/2019

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The Horse published 2 articles about feet in December 2019:

Horse Hoof Anatomy, Part 1 - Christy West, www.thehorse.com, Dec 2019
The angle between the bottom (solar) surface of the coffin bone and the front of the bone is usually around 50 degrees, but it can be steeper (usually in a club foot) or flatter (usually in a long-toe, low-heeled foot). The coffin bone can fracture and remodel significantly in response to stress. Loss of the distal rim (toe edge) of the coffin bone can occur if there isn’t much foot or sole mass (for shock absorption and protection); this can be secondary to (caused by) poor foot growth, lack of sole thickness/protection, or club foot.

"The palmar angle, between the bottom or wings of the coffin bone and the ground, can be a significant indicator of foot health. For example, a normal palmar angle is slightly positive (heels slightly higher than the toe). But Rucker says an angle higher than 10° suggests the club foot is severe or laminitis has caused instability of the bone within the hoof (and severe laminitis can cause coffin bone breakdown starting at the rim and even significant loss of bone mass).  Conversely, a zero or negative palmar angle (heels lower than the toe) suggests that the foot has crushed heels and a compromised digital cushion." 

The collateral (or lateral) cartilages extend upward from either side of the coffin bone and help the hoof expand with weight bearing.  Ossification of the collateral cartilages can limit the hoof’s natural expansion and result in some sensitivity to touch via hoof testers.  Lameness isn't always seen, and this is most commonly seen in heavy horses working on hard ground.

The digital cushion lies below the coffin bone and above the frog and cushions the foot from ground forces. When a horse has a broken back hoof pastern angle and/or long toe/low heels and the heels are over-loaded, the digital cushion is crushed.  Stephen O'Grady says "The most common problem I see in internal hoof structures is poor heel structure and inadequate sole depth (due to digital cushion loss)”.

Between the coffin bone and the hoof wall lies the corium - soft tissue that includes blood vessels, nerves, and the laminae—interlocking leaflike structures that attach the hoof to the bone. If a disease or trauma causes swelling in the hoof, the hoof can’t expand to accommodate both the swelling and the blood flow, and swelling generally wins. Without blood flow, tissue and bone can die. Laminitis is disease of the laminae that can range from mild to severe and transient to chronic, often caused by metabolic problems like Equine Metabolic Syndrome and PPID (in both cases insulin dysregulation leads to laminitis).  The laminae can detach and the coffin bone rotate away from and sink down within the hoof capsule.

Hoof Trimming to Improve Structure and Function - notes from Robert Bowker 2019 NEAEP Symposium, Stephanie Church, www.thehorse.com, Dec 2019
Dr Robert Bowker, longtime podiatry researcher and former professor and head of the Equine Foot Laboratory at Michigan State University’s (MSU) College of Veterinary Medicine, described his perspectives and trimming approaches during a presentation at the Septenber 2019 NEAEP symposium.

The foot should be balanced approximately 50:50 toe:heel, so that if a perpendicular line is dropped from the center of rotation of the short pastern bone (P2), half the foot is in front of the line and half behind.

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Bowker seems many cases with chronic periodic lameness in both front feet, that have long toes and underrun heels.  When the toe is long, i.e. more foot is in front of the perpendicular line than behind, pressure is put on the coffin joint, eventually leading to navicular disease.  In these long-toed feet, the coffin bone changes shape and gets longer, reducing bone density, and the blood supply changes, with increased blood supply to the front of the foot, to the detriment of the back of the foot and the frog. Bowker says that feet with long toes and underrun heels are probably the most likely to develop navicular, and will suffer more if they develop laminitis. “With a long-toe, underrun heel, the tissues supporting and surrounding the coffin bone become compromised and the distal (bottom) end of the coffin bone gets less and less support and becomes thinner and thinner along the edges, especially the lateral (away from the midline) side of the foot. These changes will often result in pedal osteitis". 

​When a horse with peripheral thinning of P3 gets laminitis and rotation, the bone cannot support the weight of the horse and becomes crushed.  

Bowker trims to shorten the toe, trimming inside the white line if necessary, and promote caudal (toward the rear) migration of the heels to bring the central sulcus (the cleft between the heels) back to the sole of the foot so it makes light contact with the ground. He said trimming with these goals can improve the foot’s health and get the ratio to approach 40:60—allowing the back part of the foot to enlarge and return to its robust health.

To correct a long toe/underrun heels foot:
Bring the heels back to the level of (back of) the frog, and so that the frog just kisses the ground - too much pressure reduces the blood supply and causes the frog to atrophy.
The frog's central sulcus should be wide and shallow, and ideally the frog should not be trimmed, as trimming causes the frog to retract and reducees its ability to dissipate energy [however the frog may need to be trimmed if heels need to be lowered].
Bevel the toe from beneath (the sole), not the outside (dorsal hoof wall), trimming inside the white line every few days to keep the toe short.
Trim the foot initially every 3-4 days until the toes and heels are back under the horse, then the trim interval can be lengthened to up to 4 weeks (less when feet are growing quickly). 
Measure the feet every 3-4 days to monitor changes.

​Bowker has been able to improve digital cushions despite wide acceptance that digital cushion damage is permanent (it isn't) - he says "internal changes can occur if the farrier or trimmer gives the foot an opportunity.  A crushed digital cushion will repair itself with myxoid cells", and "you can always improve the trim to improve the internal structure of the tissues.  If you have a short toe, you'll have a pretty good foot".

"Here are some insights and tips Bowker shared on the normal equine foot and what goes wrong with typical husbandry practices:
1. The foot is extremely adaptable. Conformation is a point in time. This can be corrected and improved if the foot is given the opportunity.
2.  The foot adapts to the environment (trimming, shoeing, loading, ground surface, moisture, etc.), but the biggest environmental factors are the hoof care professional and the trim. “They can cause major environmental effects and greater biomechanical changes in a brief time period. These changes affect the internal tissues—they respond each time the foot is trimmed.”
3.  All feet are different, even in the same horse and in the same pair of legs.
4.  Long toes and underrun heels are ubiquitous, and much of the horse industry accepts them as normal. “I have several thousand sagittal photos of feet … (only) one of them is (balanced) 50:50 front to back,” he said.
5.  As the toe and coffin bone lengthen, Bowker says the coffin bone remodels internally as it attempts to support the longer toe; the bone becomes more porous due to more movement between the bone and hoof wall. “This increased porosity is not beneficial”.
6.  Navicular bone movement up and down, due to the changes in foot mechanics, damages the deep digital flexor tendon, as well as insertion ligaments of the distal sesamoidean impar ligament.
7.  With long-toe, underrun heels, the bottom end of the short pastern (P2) changes shape, too. It starts out symmetrical in its articulation with the coffin bone. But current standard trimming methods alter the biomechanics, as the ends of P2 become asymmetrical. “With the gradually increasing length of the coffin bone, chip fractures begin to appear on the navicular bone, and they can appear (at any age). Many associate these fractures with navicular syndrome. If you have a short toe, you don’t have that.”"
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Autumn Laminitis with Danica Pollard

10/4/2019

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​Danica Pollard from the Animal Health Trust and CARE About Laminitis talks about Laminitis in the Autumn with NKC Equestrian Training on 04 October 2019.

Notes:

Laminitis can happen at any time of year, not just in the spring.  

Ideally we want to prevent laminitis, but if it does happen we need to identify and treat laminitis as early as possible.

Signs of laminitis include:
Difficulty turning.
A short, stilted or pottery stride, being "footy", often worse on hard ground than soft.
Reluctance to walk.
Warmer than normal hoof wall or coronary band.
Digital pulse more "bounding" than normal at rest.
Shifting weight between affected feet, often called "paddling".
Rocked back stance, taking weight on heels.
Although 1 foot can be affected, laminitis is far more commonly seen in both front feet or all 4 feet.

Always call your vet if you suspect laminitis.
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Reasons laminitis might occur in the autumn include:
Seasonal changes in hormones - horses have a seasonal rise in hormones [that increase insulin resistance, thought to help horses prepare for winter food shortages].
Autumn flush of grass as wet and warm weather encourage growth.
Owners often increase feed but may reduce exercise as days become shorter/weather less pleasant.
Rugging may reduce calories used keeping warm.
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​
​The digital pulse (of the digital artery) can be taken at the fetlock or pastern, on both the inside and outside of the leg.  You should know how to do this and what is normal for your horse.  Ask your vet to show you.  [Mark the best spot to check the pulse on your horse's leg with a marker pen, and] practise until you can confidently check the pulse.
​
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Weight gain is a risk factor for laminitis.  "We are the personal trainer and dietician for our horses".   
Monitor your horse's body condition score (BCS) by getting hands on to feel for fat deposits.  More information here: Body condition scoring.
Monitor weight - with a weighbridge, weight tape, a length of string or girth holes - if the girth isn't going as tight or weight increases on a horse in good condition, take action to get the horse to lose weight straight away.
Ask your vet, farrier, physio to help you assess your horse's body condition.
Assess how much grass or forage your horse is eating.  Dung production can help monitor intake - more dung usually means more food eaten.  Watch how much time your horse has his head down eating grass - a field may look bare, but if a horse is busy eating, he is finding grass!  Fence off a small area of field so that your horse can't graze it and watch how much grass grows - you may think your horse's field is bare until you see how much grass grows when he isn't eating it.
For weight loss, control intake by using slow feeder techniques, prolonging chewing time, and aiming to feed less calories without reducing the amount fed, and increase exercise.

Horses with PPID may be particularly at risk from autumn laminitis.
PPID (formerly called Equine Cushing's disease) is a progressive degenerative disease that becomes more common with age (one study found PPID in 21% of horses older than 15).  PPID has been diagnosed in horses younger than 15 [but the Equine Endocrine Pioneers Circle suggested in 2019 that PPID in a horse younger than 10 is "very unlikely"].  In horses with PPID, degeneration of neurons [in the hypothalamus in the brain] causes incorrect messages to be sent to the pituitary gland, resulting in increased levels of certain hormones, including ACTH, which is the hormone most commonly tested to diagnose and monitor PPID.
Clinical signs of PPID include changes to the coat and delayed shedding of the winter coat, lethargy, muscle loss along the topline, pot belly, abnormal fat deposits e.g. cresty neck and filled supraorbital hollows above the eyes, increased drinking and urination, lowered immunity so increased infections, and laminitis.  
Not all horses with PPID are at greater risk of laminitis - it is horses with PPID and insulin dysregulation that are at risk of laminitis, so insulin should be tested as well as ACTH if PPID is suspected to assess laminitis risk.
The treatment for PPID is Prascend (pergolide).

[Does treatment with pergolide stop/slow progression of PPID?  There has been suggestion that pergolide may reduce the hyperplasia and hypertrophy (increase in number of and size of cells) caused by the excess production of hormones from the pituitary gland, pergolide has been shown to have neuro-protective properties in other species, and Andy Durham from Liphook Equine Hospital has suggested that if PPID is well controlled and hyperplastic activity suppressed, the dose of pergolide may be able to be reduced – there may be one dose for getting PPID under control and then a lower maintenance dose (Source: "A discussion of Equine Cushing’s disease by Andy Durham and Victoria South November 2017).  The Laminitis Site sees many horses with PPID that are able to remain on a low dose for many years, suggesting that progression of the disease is controlled by treatment.] 

[Does treatment with pergolide reduce laminitis risk in horses with PPID?  Pergolide reduces or controls the excess hormone production.  If a horse's insulin dysregulation (ID) is driven by the excess PPID hormones, and treatment reduces/controls these hormones, then it should follow that laminitis risk is reduced.  However, if ID is driven at least partly by EMS factors (being overweight, a diet too high in sugar/starch, insufficient exercise), then those factors must be controlled by management.]
The best time to diagnose PPID is in the autumn, during the seasonal rise, which peaks August to October (in the northern hemisphere).  Although all horses have an increase in ACTH during the seasonal rise, horses with PPID have been shown to have a greater increase, making the difference between  horses with PPID and normal horses greater during the seasonal rise.  Seasonally adjusted cut-offs are used, although there will always be a grey zone around cut#off figures [and other factors that influence ACTH e.g. stress], and clinical signs must be considered alongside blood test results.  ACTH can be tested and PPID diagnosed throughout the year.  If you are concerned your horse might have PPID, talk to your vet.
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To rug or not to rug?  Horses, particularly native types and ponies may not need to be rugged if they have free access to shelter and forage.  Keeping warm uses up calories and encourages weight loss.  Overweight ponies can even have a small clip (e.g. a bib clip) to encourage weight loss.  Seasonal weight loss is the owner's friend, and good doers should lose weight over the winter. 

Summary:
Laminitis can occur at any time of year - be vigilant all year round.
Autumn laminitis may occur due to seasonal rise hormones, increased grass growth and changes in management such as increasing feed, reducing exercise and rugging unnecessarily.  Monitor weight/body condition throughout the year and take action to prevent unwanted weight gain.
​
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Do all IR/EMS horses have laminitis?

3/17/2019

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All IR/EMS horses have laminitis - Dr Eleanor Kellon March 2019 

Dr Kellon suggests that adverse changes to the laminae may be taking place in every horse with above normal insulin concentrations, even when signs of pain are not evident.  The insulin level at which changes take place in the laminae has not yet been established, other than research by Melody de Laat which showed some laminar pathology when insulin levels were kept at around 200 uIU/ml for 48 hours in healthy Standardbreds.

Dr Kellon suggests looking out for signs such as "less spontaneous activity, reluctance to make sharp turns, preference for soft ground, muscle tension in the forearms, back and hindquarters, more rigid head carriage (high or low) and a subdued attitude", as these may be indicative of laminitis.  

​She concludes by saying that controlling simple sugars and starch and calories, and providing good levels of other nutrients can be successful in controlling insulin.  

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Clinical signs of PPID may vary with location

1/8/2019

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In a retrospective study of 274 horses, researchers in Australia found that the clinical presentation of PPID changed with latitude and climate, with anhidrosis and polyuria/polydipsia more commonly recognised at lower latitudes.

They also found that being a pony, having an adequate body condition score and being treated with pergolide were associated with survival. Laminitis was diagnosed in 89.9% of cases and insulin dysregulation was diagnosed in 76.5% of cases in which they were investigated (note that horses with chronic laminitis may have had previous but not necessarily current insulin dysregulation, so it is possible for horses with signs of laminitis to not test positive to insulin dysregulation - earlier testing before or at the time of the first laminitic changes might have identified insulin dysregulation).
Horn R, Bamford NJ, Afonso T, Sutherland M, Buckerfield J, Tan RHH, Secombe CJ, Stewart AJ, Bertin FR
Factors associated with survival, laminitis and insulin dysregulation in horses diagnosed with equine pituitary pars intermedia dysfunction
Equine Veterinary Journal published online 12 November 2018 https://doi.org/10.1111/evj.13041

See also: 
Equine Cushing's Disease: Australian and North American Differences - KER Dec 2018

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Velagliflozin - preventative treatment for endocrinopathic laminitis?

12/3/2018

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Professor Sillence and his research team from Queensland University of Technology are testing drug velagliflozin as a possible treatment for horses and ponies with equine metabolic syndrome to help prevent endocrinopathic laminitis.  Velagliflozin works by causing the kidneys to excrete more glucose in the urine to take the pressure off the pancreas and lower insulin levels.  Velagliflozin has been trialed in Australia and is now being trialed in Europe.

​Meier A, Reiche D, de Laat M, Pollitt C, Walsh D, Sillence M
The sodium-glucose co-transporter 2 inhibitor velagliflozin reduces hyperinsulinemia and prevents laminitis in insulin-dysregulated ponies
PLoS ONE 13(9): e0203655 published 13 Sept 2018. https://doi.org/10.1371/journal.pone.0203655
See also: ​Drug shows promises in preventing laminitis in at-risk ponies - www.horsetalk.co.nz 24 Sept 2018
Giddy up: help for plump ponies is fast on its way - Dec 2018 Queensland University of Technology
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USEF allows pergolide to be taken by competing horses

11/27/2018

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From 01 December 2018, horses competing in the USA under USEF rules can apply for a Therapeutic Use Exemption (TUE) for pergolide after submitting proof of diagnosis.  This is a great step forward for the many horses with PPID that continue to compete.  See USEF Announces New Therapeutic Use Exemption (TUE) Status for Pergolide Administration Effective December 1, 2018.

The FEI continue to class pergolide as a prohibited substance - controlled medication. All members of the equestrian community are welcome to submit a suggested change to the Equine Prohibited Substances List - if you feel that the FEI should review their classification of pergolide/Prascend for horses diagnosed with PPID, complete and return the FEI ​Equine Prohibited Substances List submission form.

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Pergolide molasses-flavoured paste available in UK

11/23/2018

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A molasses-flavoured pergolide paste that can be given in small doses (less than 0.5 mg) has been tested and although not yet licensed may be available in the UK through a horse's vet.

David Rendle presented his research Efficacy of a novel palatable pergolide paste formulation for the treatment of PPID in ponies at the BEVA conference in September 2018.  Rendle suggested that the only form of pergolide currently licensed for horses in the UK, Prascend, is not always eaten readily and can be difficult to split and administer below half a tablet.  A molasses-flavoured pergolide paste from BOVA UK that can be given in small doses was given to 19 ponies who had not responded well to Prascend, and their clinical records reviewed.  They were considered to have PPID if their ACTH concentration was >50 pg/ml in July or >100 pg/ml from August to October.  All the ponies were examined after 1 and 6 months of treatment and doses adjusted if necessary according to season.  ACTH concentrations improved significantly and returned to normal in 74% of the ponies, clinical signs showed some improvement but some clinical signs either did not improve or became worse.  1 pony refused to eat the paste and 2 ponies went off their feed but this resolved when the dose was reduced.

The BOVA pergolide paste is currently not licensed, but may be used through the medicines cascade if Prascend (currently the only licensed form of pergolide) cannot be used (e.g. because it does not appear to be effective or causes significant side effects).  The paste is available to horses in the UK through their vet.  It may be possible to export to other countries if a vet in that country is prepared to import it (it cannot be distributed to anyone other than a vet).

Rendle DI, Frost R, Byrne A
Efficacy of a novel palatable pergolide paste formulation for the treatment of pituitary pars intermedia dysfunction (PPID) in ponies
EVJ Sept 2018 Vol 50, Issue S52 Clinical Research Abstracts of the BEVA Congress September 2018 P 12-13
https://doi.org/10.1111/evj.16_13008

Palatable pergolide paste for PPID: BEVA award for Rendle presentation on clinical research into new treatment option for "equine cushings disease" - The Hoof Blog Fran Jurga November 2018 
​
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NEHS 2018

8/31/2018

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National Equine Health Survey (NEHS) 2018

The National Equine Health Survey (NEHS) 2018 received information for over 13,000 horses, giving a snapshot of the health of UK horses for one week in May 2018.
38% of horses had one or more health problems recorded.
Of all the disease syndromes recorded, 29% were lameness including laminitis (23% in 2017), and 7.4% were metabolic diseases (8.1% in 2017).
Laminitis made up 5.4% of all individual disease syndromes recorded (6.5% in 2017), and PPID 5.3% (6.0% in 2017).  43% of laminitis cases were first episodes and 57% were repeat episodes (49% and 51% respectively in 2017). 

However, without knowing how many individual syndromes were reported, these figures are not particularly helpful.  All we know from the report is that 38% of 13,873 horses, so 5,272 horses, had 1 syndrome or more.
So a minimum of 2% of the population had laminitis when the survey ran for a week in May 2018 (calculated 38% of 13,873 horses = 5,272 x 5.4% = 285 / 13.873 = 2%).
Similarly a minimum of 2% had PPID, and 2.8% had metabolic diseases - but does metabolic disease include PPID, or does it mean EMS?  How many had EMS AND PPID, and how many had PPID without EMS?

67% of horses were recorded as having a body (fat) score of 3 with 17.8% recorded as being thin (score of 2 and under) and 15.5% recorded as overweight (greater than 3). [However, previous research has suggested that owners tend to under-estimate their horses' body condition scores].

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Risk factors for EMS/Endocrinopathic Laminitis

8/22/2018

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According to this article from Kentucky Equine Staff
Can Body Shape Predict Metabolic Issues in Horses? KER August 2018
reporting on research by Fitzgerald et al. at Queensland University presented at the 2018 Australasian Equine Science Symposium:
Fitzgerald DM, Sillence MN, De Laat MA
Morphometric measurements for identifying equine metabolic syndrome.
Proc. Australasian Equine Science Symposium 2018 7:29
cresty neck score (CNS), but not body condition score (BCS), neck or girth circumference, was positively correlated to a post oral glucose test insulin result that suggested Equine Metabolic Syndrome.

However, 
Coleman MC, Belknap JK, Eades SC, Galantino-Homer HL, Hunt RJ, Geor RJ, McCue ME, McIlwraith CW, Moore RM, Peroni JF, Townsend HG, White NA, Cummings KJ, Ivanek-Miojevic R, Cohen ND
Case-control study of risk factors for pasture-and endocrinopathy-associated laminitis in North American horses
J Am Vet Med Assoc. 2018 Aug 15;253(4):470-478. doi: 10.2460/javma.253.4.470
looked at 199 horses diagnosed with endocrinopathic laminitis after grazing and found that "h
orses with an obese body condition (i.e. body condition score ≥ 7), generalized or regional adiposity (alone or in combination), preexisting endocrinopathy, or recent (within 30 days) glucocorticoid administration had increased odds of developing PEAL, compared with horses that did not have these findings."



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Seasonal rise in pituitary hormones

8/30/2017

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​We are now well into the seasonal rise (in pituitary hormones) in the northern hemisphere.
In the UK the seasonal rise is thought to start around the end of June/start of July, peak in September, with hormones returning to normal around the end of November/start of December.

Three important facts about the seasonal rise:

1. Horses with PPID may need an increase in their pergolide dose during the seasonal rise. Testing resting ACTH in August may help to identify horses that need an increased dose.

2. For horses suspected of having, but not yet diagnosed with PPID, testing resting ACTH in September may be the best time to differentiate horses with PPID from normal horses. Lab fees for ACTH testing are currently free for horses (in the UK) that haven't been diagnosed with PPID through Talk About Laminitis.

3. Horses with PPID may show increased clinical signs of PPID during the seasonal rise. Horses that have unexplained laminitis or infections, particularly from August to October, may need to have PPID eliminated as a contributing factor.

In all cases, if you are worried that your horse may have PPID or needs a change in his/her treatment, speak to your vet.

​(Graph: used with permission from Liphook Equine Hospital)
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    News

    ​What's new in research

    ​New Dengie Laminitis Brochure uses TLS photos
    WHW new laminitis leaflet​2020 Global Equine Endocrine Symposium proceedings
    ​Articles about feet December 2019​
    Autumn Laminitis with Danica Pollard
    ​
    Free ACTH Testing
    Do all IR/EMS horses have laminitis?
    ​Clinical signs of PPID may vary with location​​
    ​
    Velagliflozin - preventative treatment for endocrinopathic laminitis?
    USEF allows pergolide to be taken by competing horses
    Pergolide molasses-flavoured paste available in UK
    ​NEHS 2018
    ​Risk factors for EMS/Endocrinopathic Laminitis
    ​Seasonal rise in pituitary hormones​PPID - weekly ACTH cutoffs now being used
    ​
    Sole Support
    ​
    Do you CARE about laminitis?  
    Pituitary Pars Intermedia Dysfunction - The Arabian Magazine
    EMS & Insulin Dysregulation - The Arabian Magazine
    Laminitis and the Feet - The Arabian Magazine
    The Arabian Magazine Laminitis article
    Paddock Paradise in French
    New EEG Recommendations for the diagnosis and treatment of PPID

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