CONNECTEDYo u r L i n k to V e t e r i n a r Y S P e C i a Lt Y H o S P i ta L | o C t – D e C 2 01 3

SAN DIEGO 10435 Sorrento Valley Rd San Diego, CA 92121 | NORTH COUNTY 2055 Montiel Rd San Marcos, CA 92069 | www.vshsd.com

AlTERNATIvE ImmUNOSUppRESSIvE DRUGSIN THIS ISSUE:

iMaGinG DePartMent eXPanDS

CLiniCaL triaLS

uPCoMinG eVentS

announCeMentSDr. Sean Aiken spoke at the 19th International Veterinary Emergency and Critical Care Symposium held in San Diego September 7-11. His three lectures covered Emergency Surgery Cases from the Trenches, Approach to Penetrating Trauma, and Surgical Management of Wounds in the ER. As a member of the review board, Dr. Monica Clare was also a key participant at the conference.

Drs. Sean Aiken and Josh Jackson both lectured on a variety of surgery topics at the recent Central Veterinary Conference held in San Diego October 31-November 3.

Dr. Fred Pike led laboratories on facial reconstruction and tibial tuberosity advancement at the American College of Veterinary Surgeons (ACVS) annual meeting October 24-26 in San Antonio, Texas.

Dr. Keith Richter has finished editing the Hepatobiliary-pancreas section of the third edition of the Veterinary Clinical Advisor. This is one of the most practical and useful reference texts in the profes-sion. Look for it next year.

Congratulations to Dr. Amber Hopkins for successfully completing her exams and becoming a board-certified veterinary anesthesiologist!

We‘re LiSteninGWe are getting ready to print another complimentary batch of co-branded after-hours magnets and ER booklets for you to distribute to your clients. Simply visit the Co-branded Order Form page under the Veterinarian tab on our website and submit your request by November 11.

10435 Sorrento Valley Rd Suite 100

San Diego, CA 92121

SaVe tHe DateApril 27, 2014 – vSH 4th Annual Symposium 8:00 am - 4:30 pm at the University of San Diego Multiple Educational Tracks for Veterinarians, Technicians and Managers, plus Workshops! Registration information and more details to come.

FAll CE Dinner and lectures November 14, 2013* 6:00 - 9:00 pm Stone Brewing World Bistro & Gardens – Liberty Station

• anesthetic Considerations for High risk Patients Amber Hopkins, DVM, cVMA, DACVAA

• the Scrambled Brain: inflammatory Brain Disease Robin Levitski-Osgood, DVM, DACVIM (Neurology)

• Benefits of oral Care for Compromised Patients Brook Niemiec, DVM, DAVDC Southern California Veterinary Dental Specialties

*Note: This is the same program that was offered on Oct. 10 at the

Ponte Family Estate Winery in Temecula.

Case-based presentation of Neurological Cases Sorrento Valley Facility December 14, 2013 6:30 - 8:00 pm

FACE Foundation 2013 Golf Tournament

We are proud to support the 2013 FACE Foundation golf tournament on November 4 at the Lomas Santa Fe Country Club. This unique event welcomes well-behaved dogs and includes an evening of festivities with all proceeds benefitting FACE.

in our CoMMunitY

TAKE NOTEcURRENT cLINIcAL TRIALsInternal medicine – Effectiveness of maropitant (Cerenia) in Cats with liver DiseaseDr. Keith Richter is leading a study to determine how maropitant (Cerenia) is metabolized in cats with liver disease, and how effective it is as an antiemetic in cats with liver disease (compared with metoclopramide). We are actively recruiting cases, so if you have a cat with liver disease, please contact us. Clients receive significant financial incentives.Contact Dr. Keith Richter at (858) 875-7500

Internal medicine – Feline Hepatic lipidosis StudyWe are now enrolling cats with confirmed hepatic lipidosis (HL) with the objective of evaluating vitamin-B metabolism and lipid profiles associated with this disease process. The objective of this study is to expand our understanding of vitamin-B and lipid metabolism in cats with HL.Contact Dr. Steve Hill at (858) 875-7500

Internal medicine – Canine IBD and probiotic vSl#3We are enrolling dogs with chronic gastrointestinal signs that are suspected of having idiopathic inflammatory bowel disease (IBD). Endoscopy will be performed, and if IBD is confirmed, dogs will be randomized to receive treatment with prednisone and diet, or prednisone, diet and probiotic VSL#3. This is an 8-week study requiring two endoscopic procedures. The cost of the probiotic VSL#3 and the cost of the second endoscopy will be funded.Contact Dr. Steve Hill at (858) 875-7500

Internal medicine – Glomerular Disease StudyVSH is participating in a multi-center prospective study evaluating increased dosing of enalapril in dogs with glomerular disease. Client incentives include reduced cost of some initial testing and no cost for scheduled recheck visits and tests.Contact Dr. Julie Fischer at (760) 466-0600

Oncology – Canine Soft Tissue SarcomaTrial examining novel biologic therapy for dogs with MEASUREABLE soft tissue sarcoma.Eligibility criteria:• Generally good health• Potentially resectable, dermal or subcutaneous tumors

measuring 1-7 cm in longest dimension (please call to discuss if tumors are larger than 7 cm as exceptions may be made)

Contact Dr. Brenda Phillips at (858) 875-7500

Oncology – Canine lymphoma TrialVSH is now accepting enrollment for dogs with multicentric lymphoma in several trials. Contact Dr. Brenda Phillips at (858) 875-7500

*NEW* Quality of life for Cats with GI lymphomaThis is a trial that will lead to the design of a validated quality of life survey tool for cats with GI lymphoma. This will enable the profession to study different interventions that may impact quality of life. Clients will be required to fill out survey information to develop this tool. Clients will receive a financial incentive. If you have an UNTREATED cat with GI lymphoma (or suspect GI lymphoma), they are eligible to participate. Contact Drs. Brenda Phillips or Keith Richter at (858) 875-7500

For more details about these and other clinical trials, please visit our website at www.vshsd.com.

vSH 2013 Holiday pet Food Drive

VSH will once again hold our holiday pet food drive December 2-January 3.

We welcome donations from you, your staff and clients. Feel free to bring an item if you’re coming to any of our CE programs, and please share this information widely!

For more information on Continuing Education events, please visit vshsd.com/Veterinarians or contact Ann Ong at (858) 875-7544 or ann.ong@vshsd.com.

Corticosteroids in combination with either azathioprine or cyclo-sporine are commonly used immunosuppressive medications for treatment of several different immune mediated diseases in dogs such as immune mediated hemolytic anemia (IMHA), immune mediated thrombocytopenia (ITP), immune mediated polyarthritis (IMPA), immune mediated skin diseases (IMSD) and idiopathic chronic hepatitis. These drugs, alone or in combination, may be ineffective at controlling the disorder or may cause uncontrollable or life threatening side effects such as vomiting, anorexia, diar-rhea, marked weakness and muscle wasting, pancreatitis, myelo-suppression or hepatopathy. In those circumstances there are several other medications that we use at VSH as alternatives to the more commonly used immunosuppressive treatment protocols. This article will briefly discuss those drugs.

Mycophenolate mofetil (Cellcept®) (MMF) is a drug that inhibits the enzyme that controls the rate of synthesis of guanine monophos-phate in the de novo pathway of purine synthesis. This pathway is important in the proliferation of B and T lymphocytes. Reported doses range from 10-15 mg/kg PO q8-12h. Side effects include myelosuppression (rare), immunosuppression, vomiting, diarrhea and anorexia. A recent abstract reviewed 31 dogs treated with prednisone + mycophenolate for IMHA. Twenty four of those dogs survived to discharge and 18 were alive at the study end. Five dogs developed diarrhea on the medication. The drug has also been used for other immune mediated disorders including glomerulonephritis and immune mediated dermatopathies. I have had success limiting the potential GI toxicity using a compounded liquid starting 10 mg/kg PO q12h and then slowly increasing the dose over the next few weeks up to a maximum of 15 mg/kg q12h in several cases of IMHA. In cases that develop large bowel diarrhea, metronidazole at a dose of 10-15 mg/kg PO q12h is often effective at controlling the problem. Cost for the generic form is less than that of cyclosporine.

Leflunomide (Arava®) is an immunomodulatory drug that inhibits the mitochondrial enzyme dihydroorotate dehydrogenase, an enzyme involved in de novo synthesis of the pyrimidine ribonucle-otide uridine monophosphate (rUMP). The inhibition prevents the expansion of activated lymphocytes by interfering with their cell cycle progression while non-lymphoid cells are able to make their ribonucleotides by use of salvage pyrimidine pathway, which makes them less dependent on de novo synthesis. The drug has been used in dogs with IMHA, ITP and IMPA, however there are

few case reports documenting use or efficacy. In a study using leflunomide in 14 dogs with IMPA the drug was well tolerated with 8 dogs completely responding and a partial response in 5 dogs. Adverse effects include decreased appetite, lethargy, vomiting, lymphopenia, and anemia. Reported dosage is 2-4 mg/kg PO q24h. Trough levels of the active metabolite can be obtained to guide therapy. The drug had been extremely expensive but is now available as a generic and is less expensive than cyclosporine.

Human Intravenous Immunoglobulin (hIVIG) is a purified human globulin that has been used in dogs for IMHA, ITP, Myasthenia Gravis and IMSD. Theoretical benefits include blockage of Fc recep-tors on primed macrophages, enhancement of C8 function which can stimulate more rapid clearance of antibodies, non-specific suppression of polyclonal B-cell biosynthesis, and inhibition of inflammation. Reported dosage is 0.5-1.5 g/kg IV over 6 hours as a single infusion. Side effects are uncommon, primarily being anaphylaxis to a foreign protein or volume overloading. There have several published studies on its use in IMHA showing efficacy. The largest and most recent study evaluated 28 dogs which were either initially treated with hIVIG and then started on single agent prednisone or given a placebo and started on prednisone. Twenty five of 28 dogs (89%) were discharged from the hospital. Thirteen dogs received hIVIG and 12 received placebo. Twenty four dogs (86%) were alive 14 days after enrollment (13 were given hIVIG and 11 were given placebo). The conclusion was that for initial treatment of dogs with IMHA, the addition of hIVIG to corticoste-roid treatment did not improve initial response, nor did it shorten hospitalization. A recent study found similar efficacy when used in ITP when compared to vincristine. Both groups were treated with corticosteroids. We often use this medication in resistant cases of IMHA, when there is intravascular hemolysis, or with Evan’s syndrome. In these instances, the prognosis is guarded, but we have had some successes. The drug is unfortunately very expen-sive, costing upwards of $80-100/gm.

RIchTER scALEHi Everyone,

I hope you are all having a fabulous year as we close in on the end of the last quarter. I talk to a lot of you out there and the consensus is that we are all a little busier (and some a lot busier). I think that’s a great sign for our profession.

Some exciting news for us is the arrival of our two new board-certified Radiologists, Drs. Miriam Shanaman and Jen White. They come by way of the University of Illinois and Washington State. Our imaging department is truly exceptional with their expertise, our brand new 1.5 Tesla MRI, and our soon-to-arrive new state-of-the-art ultrasound machine. As technology evolves, we are committed to go along for the ride. Read the accompanying article in this issue of Connected to find out more about the enhanced services of our imaging department.

STAT Lab has continued to grow this year. One addition is a brand new chemistry analyzer. This has unparalleled accuracy, high volume capacity, and automatic rechecks of critical values. Our techs are the best around and take such pride in their work. Give Dr. Andy Loar (Clinical Laboratory Director) a call if you are interested in trying our services, have a question, or want cytology rounds in your hospital. Also let us know if you are interested in bundling radiology and laboratory services.

We have locked in the date for next year’s Fourth Annual VSH Symposium: April 27th, 2014. It will be held again at the prestigious and beautiful University of San Diego’s Joan B. Kroc Institute for Peace & Justice. There will be multiple veterinary tracks, technician tracks, workshops, and a management track. The highlight this year will be our keynote speaker: Dr. Alexander deLahunta! Dr. D (as we Cornellians call him) has pioneered veterinary clinical neurology, neuroanatomy, and neuropathology. He is the most dynamic speaker you can imagine, and this is an opportunity you don’t want to miss and won’t forget!

We just completed Technician Appreciation Week. We have terrific techs who keep our place running. They deserve the credit for our outstanding patient care and client service. They keep us doctors on track, and we can’t live without them! To show our appreciation, our doctors did whatever our techs asked us to do this week. I got to mop the floors, fill prescriptions, and answer the phones. But the highlight of the week was when one of our techs asked me to throw a pie in Dr. Jackson’s face. I could not refuse. That shows how dedicated I am to our team!

Well, for my sports update, I’m proud to announce my new record for Padres game attendance: 66 games! That made it a successful year, capped off by the Dodger’s choke in the playoffs. And no sooner does the baseball season end, but my schedule has changed to stop working weekends to accommodate college football and the Chargers. It’s been over a decade since I’ve missed a Chargers game, and that streak has no end in sight. I’m even making plans for our playoff run in January! That’s it for now. Have a terrific end to 2013 everyone!

Keith Richter, DVM

Diplomate ACVIM

ALTERNATIvE ImmUNOsUppREssIvE DRUgsby JOhN R. hART, Dvm, DAcvIm

mRI UpGRADE

Magnetic resonance (MR) imaging offers excellent soft tissue contrast, enables imaging in any slice orientation and does not use ionizing radiation. While we have always had MR imaging capability, the technological advances in resolution, imaging quality, work flow and scan speed had outpaced our old system so we felt we needed a change. With these factors in mind we had decided to upgrade our MRI.

The project took 5 months to complete and was finished this summer. We now have a 1.5T Siemens Symphony scanner with the highest power gradients for fast and high detail images. Siemens is known as one of the highest quality medical imaging systems in the world. The software has also been upgraded with the Syngo® platform which is extremely easy to use and offers many post image processing functions. It is also the same

software used in our CT systems so our technicians are easily able to hone their skills on both scanners. This scanner allows us to obtain our images in less time and with far more detail, and we can perform more sophisticated scans such as MR angiography and diffusion imaging (ideal for stroke patients). This scanner will also allow us to image a variety of orthopedic diseases which is not practical on older systems.

ImAgINg DEpARTmENT ExpANDs sERvIcEs

We are pleased to announce the return of the VSH radiology service featuring our two board-certified radiologists, Dr. Miriam Shanaman and Dr. Jennifer White. We are excited that they have joined VSH and they bring the expertise and energy to make this service the most comprehensive radiology department in Southern California. Both Dr. Shanaman and Dr. White are committed to providing the highest quality of service and professional care for your patients, including the provision of out-patient radiology services such as ultrasound, nuclear medicine, CT, and MR imaging.

Having two radiologists means we can evaluate imaging and perform advanced procedures six days a week. This translates into less waiting time for your patients, faster results, and no

delays in starting necessary treatments. This also allows us to focus on inpatients and outpatients equally, providing them all swift and sure specialist care.

The other change to our imaging department is the develop-ment of our teleradiology service, with six days a week cover-age from Drs. White and Shanaman. They will also be accepting outpatient ultrasound examinations, six days a week, with the case sent back to you for ongoing management. If one of your patients’ needs a CT or MRI, our board-certified anesthesiolo-gist, Amber Hopkins, has defined the anesthesia protocols we use so the procedure is safe and informative. We can also arrange for radiology rounds in your hospital.

Corticosteroids in combination with either azathioprine or cyclo-sporine are commonly used immunosuppressive medications for treatment of several different immune mediated diseases in dogs such as immune mediated hemolytic anemia (IMHA), immune mediated thrombocytopenia (ITP), immune mediated polyarthritis (IMPA), immune mediated skin diseases (IMSD) and idiopathic chronic hepatitis. These drugs, alone or in combination, may be ineffective at controlling the disorder or may cause uncontrollable or life threatening side effects such as vomiting, anorexia, diar-rhea, marked weakness and muscle wasting, pancreatitis, myelo-suppression or hepatopathy. In those circumstances there are several other medications that we use at VSH as alternatives to the more commonly used immunosuppressive treatment protocols. This article will briefly discuss those drugs.

Mycophenolate mofetil (Cellcept®) (MMF) is a drug that inhibits the enzyme that controls the rate of synthesis of guanine monophos-phate in the de novo pathway of purine synthesis. This pathway is important in the proliferation of B and T lymphocytes. Reported doses range from 10-15 mg/kg PO q8-12h. Side effects include myelosuppression (rare), immunosuppression, vomiting, diarrhea and anorexia. A recent abstract reviewed 31 dogs treated with prednisone + mycophenolate for IMHA. Twenty four of those dogs survived to discharge and 18 were alive at the study end. Five dogs developed diarrhea on the medication. The drug has also been used for other immune mediated disorders including glomerulonephritis and immune mediated dermatopathies. I have had success limiting the potential GI toxicity using a compounded liquid starting 10 mg/kg PO q12h and then slowly increasing the dose over the next few weeks up to a maximum of 15 mg/kg q12h in several cases of IMHA. In cases that develop large bowel diarrhea, metronidazole at a dose of 10-15 mg/kg PO q12h is often effective at controlling the problem. Cost for the generic form is less than that of cyclosporine.

Leflunomide (Arava®) is an immunomodulatory drug that inhibits the mitochondrial enzyme dihydroorotate dehydrogenase, an enzyme involved in de novo synthesis of the pyrimidine ribonucle-otide uridine monophosphate (rUMP). The inhibition prevents the expansion of activated lymphocytes by interfering with their cell cycle progression while non-lymphoid cells are able to make their ribonucleotides by use of salvage pyrimidine pathway, which makes them less dependent on de novo synthesis. The drug has been used in dogs with IMHA, ITP and IMPA, however there are

few case reports documenting use or efficacy. In a study using leflunomide in 14 dogs with IMPA the drug was well tolerated with 8 dogs completely responding and a partial response in 5 dogs. Adverse effects include decreased appetite, lethargy, vomiting, lymphopenia, and anemia. Reported dosage is 2-4 mg/kg PO q24h. Trough levels of the active metabolite can be obtained to guide therapy. The drug had been extremely expensive but is now available as a generic and is less expensive than cyclosporine.

Human Intravenous Immunoglobulin (hIVIG) is a purified human globulin that has been used in dogs for IMHA, ITP, Myasthenia Gravis and IMSD. Theoretical benefits include blockage of Fc recep-tors on primed macrophages, enhancement of C8 function which can stimulate more rapid clearance of antibodies, non-specific suppression of polyclonal B-cell biosynthesis, and inhibition of inflammation. Reported dosage is 0.5-1.5 g/kg IV over 6 hours as a single infusion. Side effects are uncommon, primarily being anaphylaxis to a foreign protein or volume overloading. There have several published studies on its use in IMHA showing efficacy. The largest and most recent study evaluated 28 dogs which were either initially treated with hIVIG and then started on single agent prednisone or given a placebo and started on prednisone. Twenty five of 28 dogs (89%) were discharged from the hospital. Thirteen dogs received hIVIG and 12 received placebo. Twenty four dogs (86%) were alive 14 days after enrollment (13 were given hIVIG and 11 were given placebo). The conclusion was that for initial treatment of dogs with IMHA, the addition of hIVIG to corticoste-roid treatment did not improve initial response, nor did it shorten hospitalization. A recent study found similar efficacy when used in ITP when compared to vincristine. Both groups were treated with corticosteroids. We often use this medication in resistant cases of IMHA, when there is intravascular hemolysis, or with Evan’s syndrome. In these instances, the prognosis is guarded, but we have had some successes. The drug is unfortunately very expen-sive, costing upwards of $80-100/gm.

RIchTER scALEHi Everyone,

I hope you are all having a fabulous year as we close in on the end of the last quarter. I talk to a lot of you out there and the consensus is that we are all a little busier (and some a lot busier). I think that’s a great sign for our profession.

Some exciting news for us is the arrival of our two new board-certified Radiologists, Drs. Miriam Shanaman and Jen White. They come by way of the University of Illinois and Washington State. Our imaging department is truly exceptional with their expertise, our brand new 1.5 Tesla MRI, and our soon-to-arrive new state-of-the-art ultrasound machine. As technology evolves, we are committed to go along for the ride. Read the accompanying article in this issue of Connected to find out more about the enhanced services of our imaging department.

STAT Lab has continued to grow this year. One addition is a brand new chemistry analyzer. This has unparalleled accuracy, high volume capacity, and automatic rechecks of critical values. Our techs are the best around and take such pride in their work. Give Dr. Andy Loar (Clinical Laboratory Director) a call if you are interested in trying our services, have a question, or want cytology rounds in your hospital. Also let us know if you are interested in bundling radiology and laboratory services.

We have locked in the date for next year’s Fourth Annual VSH Symposium: April 27th, 2014. It will be held again at the prestigious and beautiful University of San Diego’s Joan B. Kroc Institute for Peace & Justice. There will be multiple veterinary tracks, technician tracks, workshops, and a management track. The highlight this year will be our keynote speaker: Dr. Alexander deLahunta! Dr. D (as we Cornellians call him) has pioneered veterinary clinical neurology, neuroanatomy, and neuropathology. He is the most dynamic speaker you can imagine, and this is an opportunity you don’t want to miss and won’t forget!

We just completed Technician Appreciation Week. We have terrific techs who keep our place running. They deserve the credit for our outstanding patient care and client service. They keep us doctors on track, and we can’t live without them! To show our appreciation, our doctors did whatever our techs asked us to do this week. I got to mop the floors, fill prescriptions, and answer the phones. But the highlight of the week was when one of our techs asked me to throw a pie in Dr. Jackson’s face. I could not refuse. That shows how dedicated I am to our team!

Well, for my sports update, I’m proud to announce my new record for Padres game attendance: 66 games! That made it a successful year, capped off by the Dodger’s choke in the playoffs. And no sooner does the baseball season end, but my schedule has changed to stop working weekends to accommodate college football and the Chargers. It’s been over a decade since I’ve missed a Chargers game, and that streak has no end in sight. I’m even making plans for our playoff run in January! That’s it for now. Have a terrific end to 2013 everyone!

Keith Richter, DVM

Diplomate ACVIM

ALTERNATIvE ImmUNOsUppREssIvE DRUgsby JOhN R. hART, Dvm, DAcvIm

mRI UpGRADE

Magnetic resonance (MR) imaging offers excellent soft tissue contrast, enables imaging in any slice orientation and does not use ionizing radiation. While we have always had MR imaging capability, the technological advances in resolution, imaging quality, work flow and scan speed had outpaced our old system so we felt we needed a change. With these factors in mind we had decided to upgrade our MRI.

The project took 5 months to complete and was finished this summer. We now have a 1.5T Siemens Symphony scanner with the highest power gradients for fast and high detail images. Siemens is known as one of the highest quality medical imaging systems in the world. The software has also been upgraded with the Syngo® platform which is extremely easy to use and offers many post image processing functions. It is also the same

software used in our CT systems so our technicians are easily able to hone their skills on both scanners. This scanner allows us to obtain our images in less time and with far more detail, and we can perform more sophisticated scans such as MR angiography and diffusion imaging (ideal for stroke patients). This scanner will also allow us to image a variety of orthopedic diseases which is not practical on older systems.

ImAgINg DEpARTmENT ExpANDs sERvIcEs

We are pleased to announce the return of the VSH radiology service featuring our two board-certified radiologists, Dr. Miriam Shanaman and Dr. Jennifer White. We are excited that they have joined VSH and they bring the expertise and energy to make this service the most comprehensive radiology department in Southern California. Both Dr. Shanaman and Dr. White are committed to providing the highest quality of service and professional care for your patients, including the provision of out-patient radiology services such as ultrasound, nuclear medicine, CT, and MR imaging.

Having two radiologists means we can evaluate imaging and perform advanced procedures six days a week. This translates into less waiting time for your patients, faster results, and no

delays in starting necessary treatments. This also allows us to focus on inpatients and outpatients equally, providing them all swift and sure specialist care.

The other change to our imaging department is the develop-ment of our teleradiology service, with six days a week cover-age from Drs. White and Shanaman. They will also be accepting outpatient ultrasound examinations, six days a week, with the case sent back to you for ongoing management. If one of your patients’ needs a CT or MRI, our board-certified anesthesiolo-gist, Amber Hopkins, has defined the anesthesia protocols we use so the procedure is safe and informative. We can also arrange for radiology rounds in your hospital.

Corticosteroids in combination with either azathioprine or cyclo-sporine are commonly used immunosuppressive medications for treatment of several different immune mediated diseases in dogs such as immune mediated hemolytic anemia (IMHA), immune mediated thrombocytopenia (ITP), immune mediated polyarthritis (IMPA), immune mediated skin diseases (IMSD) and idiopathic chronic hepatitis. These drugs, alone or in combination, may be ineffective at controlling the disorder or may cause uncontrollable or life threatening side effects such as vomiting, anorexia, diar-rhea, marked weakness and muscle wasting, pancreatitis, myelo-suppression or hepatopathy. In those circumstances there are several other medications that we use at VSH as alternatives to the more commonly used immunosuppressive treatment protocols. This article will briefly discuss those drugs.

Mycophenolate mofetil (Cellcept®) (MMF) is a drug that inhibits the enzyme that controls the rate of synthesis of guanine monophos-phate in the de novo pathway of purine synthesis. This pathway is important in the proliferation of B and T lymphocytes. Reported doses range from 10-15 mg/kg PO q8-12h. Side effects include myelosuppression (rare), immunosuppression, vomiting, diarrhea and anorexia. A recent abstract reviewed 31 dogs treated with prednisone + mycophenolate for IMHA. Twenty four of those dogs survived to discharge and 18 were alive at the study end. Five dogs developed diarrhea on the medication. The drug has also been used for other immune mediated disorders including glomerulonephritis and immune mediated dermatopathies. I have had success limiting the potential GI toxicity using a compounded liquid starting 10 mg/kg PO q12h and then slowly increasing the dose over the next few weeks up to a maximum of 15 mg/kg q12h in several cases of IMHA. In cases that develop large bowel diarrhea, metronidazole at a dose of 10-15 mg/kg PO q12h is often effective at controlling the problem. Cost for the generic form is less than that of cyclosporine.

Leflunomide (Arava®) is an immunomodulatory drug that inhibits the mitochondrial enzyme dihydroorotate dehydrogenase, an enzyme involved in de novo synthesis of the pyrimidine ribonucle-otide uridine monophosphate (rUMP). The inhibition prevents the expansion of activated lymphocytes by interfering with their cell cycle progression while non-lymphoid cells are able to make their ribonucleotides by use of salvage pyrimidine pathway, which makes them less dependent on de novo synthesis. The drug has been used in dogs with IMHA, ITP and IMPA, however there are

few case reports documenting use or efficacy. In a study using leflunomide in 14 dogs with IMPA the drug was well tolerated with 8 dogs completely responding and a partial response in 5 dogs. Adverse effects include decreased appetite, lethargy, vomiting, lymphopenia, and anemia. Reported dosage is 2-4 mg/kg PO q24h. Trough levels of the active metabolite can be obtained to guide therapy. The drug had been extremely expensive but is now available as a generic and is less expensive than cyclosporine.

Human Intravenous Immunoglobulin (hIVIG) is a purified human globulin that has been used in dogs for IMHA, ITP, Myasthenia Gravis and IMSD. Theoretical benefits include blockage of Fc recep-tors on primed macrophages, enhancement of C8 function which can stimulate more rapid clearance of antibodies, non-specific suppression of polyclonal B-cell biosynthesis, and inhibition of inflammation. Reported dosage is 0.5-1.5 g/kg IV over 6 hours as a single infusion. Side effects are uncommon, primarily being anaphylaxis to a foreign protein or volume overloading. There have several published studies on its use in IMHA showing efficacy. The largest and most recent study evaluated 28 dogs which were either initially treated with hIVIG and then started on single agent prednisone or given a placebo and started on prednisone. Twenty five of 28 dogs (89%) were discharged from the hospital. Thirteen dogs received hIVIG and 12 received placebo. Twenty four dogs (86%) were alive 14 days after enrollment (13 were given hIVIG and 11 were given placebo). The conclusion was that for initial treatment of dogs with IMHA, the addition of hIVIG to corticoste-roid treatment did not improve initial response, nor did it shorten hospitalization. A recent study found similar efficacy when used in ITP when compared to vincristine. Both groups were treated with corticosteroids. We often use this medication in resistant cases of IMHA, when there is intravascular hemolysis, or with Evan’s syndrome. In these instances, the prognosis is guarded, but we have had some successes. The drug is unfortunately very expen-sive, costing upwards of $80-100/gm.

RIchTER scALEHi Everyone,

I hope you are all having a fabulous year as we close in on the end of the last quarter. I talk to a lot of you out there and the consensus is that we are all a little busier (and some a lot busier). I think that’s a great sign for our profession.

Some exciting news for us is the arrival of our two new board-certified Radiologists, Drs. Miriam Shanaman and Jen White. They come by way of the University of Illinois and Washington State. Our imaging department is truly exceptional with their expertise, our brand new 1.5 Tesla MRI, and our soon-to-arrive new state-of-the-art ultrasound machine. As technology evolves, we are committed to go along for the ride. Read the accompanying article in this issue of Connected to find out more about the enhanced services of our imaging department.

STAT Lab has continued to grow this year. One addition is a brand new chemistry analyzer. This has unparalleled accuracy, high volume capacity, and automatic rechecks of critical values. Our techs are the best around and take such pride in their work. Give Dr. Andy Loar (Clinical Laboratory Director) a call if you are interested in trying our services, have a question, or want cytology rounds in your hospital. Also let us know if you are interested in bundling radiology and laboratory services.

We have locked in the date for next year’s Fourth Annual VSH Symposium: April 27th, 2014. It will be held again at the prestigious and beautiful University of San Diego’s Joan B. Kroc Institute for Peace & Justice. There will be multiple veterinary tracks, technician tracks, workshops, and a management track. The highlight this year will be our keynote speaker: Dr. Alexander deLahunta! Dr. D (as we Cornellians call him) has pioneered veterinary clinical neurology, neuroanatomy, and neuropathology. He is the most dynamic speaker you can imagine, and this is an opportunity you don’t want to miss and won’t forget!

We just completed Technician Appreciation Week. We have terrific techs who keep our place running. They deserve the credit for our outstanding patient care and client service. They keep us doctors on track, and we can’t live without them! To show our appreciation, our doctors did whatever our techs asked us to do this week. I got to mop the floors, fill prescriptions, and answer the phones. But the highlight of the week was when one of our techs asked me to throw a pie in Dr. Jackson’s face. I could not refuse. That shows how dedicated I am to our team!

Well, for my sports update, I’m proud to announce my new record for Padres game attendance: 66 games! That made it a successful year, capped off by the Dodger’s choke in the playoffs. And no sooner does the baseball season end, but my schedule has changed to stop working weekends to accommodate college football and the Chargers. It’s been over a decade since I’ve missed a Chargers game, and that streak has no end in sight. I’m even making plans for our playoff run in January! That’s it for now. Have a terrific end to 2013 everyone!

Keith Richter, DVM

Diplomate ACVIM

ALTERNATIvE ImmUNOsUppREssIvE DRUgsby JOhN R. hART, Dvm, DAcvIm

mRI UpGRADE

Magnetic resonance (MR) imaging offers excellent soft tissue contrast, enables imaging in any slice orientation and does not use ionizing radiation. While we have always had MR imaging capability, the technological advances in resolution, imaging quality, work flow and scan speed had outpaced our old system so we felt we needed a change. With these factors in mind we had decided to upgrade our MRI.

The project took 5 months to complete and was finished this summer. We now have a 1.5T Siemens Symphony scanner with the highest power gradients for fast and high detail images. Siemens is known as one of the highest quality medical imaging systems in the world. The software has also been upgraded with the Syngo® platform which is extremely easy to use and offers many post image processing functions. It is also the same

software used in our CT systems so our technicians are easily able to hone their skills on both scanners. This scanner allows us to obtain our images in less time and with far more detail, and we can perform more sophisticated scans such as MR angiography and diffusion imaging (ideal for stroke patients). This scanner will also allow us to image a variety of orthopedic diseases which is not practical on older systems.

ImAgINg DEpARTmENT ExpANDs sERvIcEs

We are pleased to announce the return of the VSH radiology service featuring our two board-certified radiologists, Dr. Miriam Shanaman and Dr. Jennifer White. We are excited that they have joined VSH and they bring the expertise and energy to make this service the most comprehensive radiology department in Southern California. Both Dr. Shanaman and Dr. White are committed to providing the highest quality of service and professional care for your patients, including the provision of out-patient radiology services such as ultrasound, nuclear medicine, CT, and MR imaging.

Having two radiologists means we can evaluate imaging and perform advanced procedures six days a week. This translates into less waiting time for your patients, faster results, and no

delays in starting necessary treatments. This also allows us to focus on inpatients and outpatients equally, providing them all swift and sure specialist care.

The other change to our imaging department is the develop-ment of our teleradiology service, with six days a week cover-age from Drs. White and Shanaman. They will also be accepting outpatient ultrasound examinations, six days a week, with the case sent back to you for ongoing management. If one of your patients’ needs a CT or MRI, our board-certified anesthesiolo-gist, Amber Hopkins, has defined the anesthesia protocols we use so the procedure is safe and informative. We can also arrange for radiology rounds in your hospital.

CONNECTEDYo u r L i n k to V e t e r i n a r Y S P e C i a Lt Y H o S P i ta L | o C t – D e C 2 01 3

SAN DIEGO 10435 Sorrento Valley Rd San Diego, CA 92121 | NORTH COUNTY 2055 Montiel Rd San Marcos, CA 92069 | www.vshsd.com

AlTERNATIvE ImmUNOSUppRESSIvE DRUGSIN THIS ISSUE:

iMaGinG DePartMent eXPanDS

CLiniCaL triaLS

uPCoMinG eVentS

announCeMentSDr. Sean Aiken spoke at the 19th International Veterinary Emergency and Critical Care Symposium held in San Diego September 7-11. His three lectures covered Emergency Surgery Cases from the Trenches, Approach to Penetrating Trauma, and Surgical Management of Wounds in the ER. As a member of the review board, Dr. Monica Clare was also a key participant at the conference.

Drs. Sean Aiken and Josh Jackson both lectured on a variety of surgery topics at the recent Central Veterinary Conference held in San Diego October 31-November 3.

Dr. Fred Pike led laboratories on facial reconstruction and tibial tuberosity advancement at the American College of Veterinary Surgeons (ACVS) annual meeting October 24-26 in San Antonio, Texas.

Dr. Keith Richter has finished editing the Hepatobiliary-pancreas section of the third edition of the Veterinary Clinical Advisor. This is one of the most practical and useful reference texts in the profes-sion. Look for it next year.

Congratulations to Dr. Amber Hopkins for successfully completing her exams and becoming a board-certified veterinary anesthesiologist!

We‘re LiSteninGWe are getting ready to print another complimentary batch of co-branded after-hours magnets and ER booklets for you to distribute to your clients. Simply visit the Co-branded Order Form page under the Veterinarian tab on our website and submit your request by November 11.

10435 Sorrento Valley Rd Suite 100

San Diego, CA 92121

SaVe tHe DateApril 27, 2014 – vSH 4th Annual Symposium 8:00 am - 4:30 pm at the University of San Diego Multiple Educational Tracks for Veterinarians, Technicians and Managers, plus Workshops! Registration information and more details to come.

FAll CE Dinner and lectures November 14, 2013* 6:00 - 9:00 pm Stone Brewing World Bistro & Gardens – Liberty Station

• anesthetic Considerations for High risk Patients Amber Hopkins, DVM, cVMA, DACVAA

• the Scrambled Brain: inflammatory Brain Disease Robin Levitski-Osgood, DVM, DACVIM (Neurology)

• Benefits of oral Care for Compromised Patients Brook Niemiec, DVM, DAVDC Southern California Veterinary Dental Specialties

*Note: This is the same program that was offered on Oct. 10 at the

Ponte Family Estate Winery in Temecula.

Case-based presentation of Neurological Cases Sorrento Valley Facility December 14, 2013 6:30 - 8:00 pm

FACE Foundation 2013 Golf Tournament

We are proud to support the 2013 FACE Foundation golf tournament on November 4 at the Lomas Santa Fe Country Club. This unique event welcomes well-behaved dogs and includes an evening of festivities with all proceeds benefitting FACE.

in our CoMMunitY

TAKE NOTEcURRENT cLINIcAL TRIALsInternal medicine – Effectiveness of maropitant (Cerenia) in Cats with liver DiseaseDr. Keith Richter is leading a study to determine how maropitant (Cerenia) is metabolized in cats with liver disease, and how effective it is as an antiemetic in cats with liver disease (compared with metoclopramide). We are actively recruiting cases, so if you have a cat with liver disease, please contact us. Clients receive significant financial incentives.Contact Dr. Keith Richter at (858) 875-7500

Internal medicine – Feline Hepatic lipidosis StudyWe are now enrolling cats with confirmed hepatic lipidosis (HL) with the objective of evaluating vitamin-B metabolism and lipid profiles associated with this disease process. The objective of this study is to expand our understanding of vitamin-B and lipid metabolism in cats with HL.Contact Dr. Steve Hill at (858) 875-7500

Internal medicine – Canine IBD and probiotic vSl#3We are enrolling dogs with chronic gastrointestinal signs that are suspected of having idiopathic inflammatory bowel disease (IBD). Endoscopy will be performed, and if IBD is confirmed, dogs will be randomized to receive treatment with prednisone and diet, or prednisone, diet and probiotic VSL#3. This is an 8-week study requiring two endoscopic procedures. The cost of the probiotic VSL#3 and the cost of the second endoscopy will be funded.Contact Dr. Steve Hill at (858) 875-7500

Internal medicine – Glomerular Disease StudyVSH is participating in a multi-center prospective study evaluating increased dosing of enalapril in dogs with glomerular disease. Client incentives include reduced cost of some initial testing and no cost for scheduled recheck visits and tests.Contact Dr. Julie Fischer at (760) 466-0600

Oncology – Canine Soft Tissue SarcomaTrial examining novel biologic therapy for dogs with MEASUREABLE soft tissue sarcoma.Eligibility criteria:• Generally good health• Potentially resectable, dermal or subcutaneous tumors

measuring 1-7 cm in longest dimension (please call to discuss if tumors are larger than 7 cm as exceptions may be made)

Contact Dr. Brenda Phillips at (858) 875-7500

Oncology – Canine lymphoma TrialVSH is now accepting enrollment for dogs with multicentric lymphoma in several trials. Contact Dr. Brenda Phillips at (858) 875-7500

*NEW* Quality of life for Cats with GI lymphomaThis is a trial that will lead to the design of a validated quality of life survey tool for cats with GI lymphoma. This will enable the profession to study different interventions that may impact quality of life. Clients will be required to fill out survey information to develop this tool. Clients will receive a financial incentive. If you have an UNTREATED cat with GI lymphoma (or suspect GI lymphoma), they are eligible to participate. Contact Drs. Brenda Phillips or Keith Richter at (858) 875-7500

For more details about these and other clinical trials, please visit our website at www.vshsd.com.

vSH 2013 Holiday pet Food Drive

VSH will once again hold our holiday pet food drive December 2-January 3.

We welcome donations from you, your staff and clients. Feel free to bring an item if you’re coming to any of our CE programs, and please share this information widely!

For more information on Continuing Education events, please visit vshsd.com/Veterinarians or contact Ann Ong at (858) 875-7544 or ann.ong@vshsd.com.

CONNECTEDYo u r L i n k to V e t e r i n a r Y S P e C i a Lt Y H o S P i ta L | o C t – D e C 2 01 3

SAN DIEGO 10435 Sorrento Valley Rd San Diego, CA 92121 | NORTH COUNTY 2055 Montiel Rd San Marcos, CA 92069 | www.vshsd.com

AlTERNATIvE ImmUNOSUppRESSIvE DRUGSIN THIS ISSUE:

iMaGinG DePartMent eXPanDS

CLiniCaL triaLS

uPCoMinG eVentS

announCeMentSDr. Sean Aiken spoke at the 19th International Veterinary Emergency and Critical Care Symposium held in San Diego September 7-11. His three lectures covered Emergency Surgery Cases from the Trenches, Approach to Penetrating Trauma, and Surgical Management of Wounds in the ER. As a member of the review board, Dr. Monica Clare was also a key participant at the conference.

Drs. Sean Aiken and Josh Jackson both lectured on a variety of surgery topics at the recent Central Veterinary Conference held in San Diego October 31-November 3.

Dr. Fred Pike led laboratories on facial reconstruction and tibial tuberosity advancement at the American College of Veterinary Surgeons (ACVS) annual meeting October 24-26 in San Antonio, Texas.

Dr. Keith Richter has finished editing the Hepatobiliary-pancreas section of the third edition of the Veterinary Clinical Advisor. This is one of the most practical and useful reference texts in the profes-sion. Look for it next year.

Congratulations to Dr. Amber Hopkins for successfully completing her exams and becoming a board-certified veterinary anesthesiologist!

We‘re LiSteninGWe are getting ready to print another complimentary batch of co-branded after-hours magnets and ER booklets for you to distribute to your clients. Simply visit the Co-branded Order Form page under the Veterinarian tab on our website and submit your request by November 11.

10435 Sorrento Valley Rd Suite 100

San Diego, CA 92121

SaVe tHe DateApril 27, 2014 – vSH 4th Annual Symposium 8:00 am - 4:30 pm at the University of San Diego Multiple Educational Tracks for Veterinarians, Technicians and Managers, plus Workshops! Registration information and more details to come.

FAll CE Dinner and lectures November 14, 2013* 6:00 - 9:00 pm Stone Brewing World Bistro & Gardens – Liberty Station

• anesthetic Considerations for High risk Patients Amber Hopkins, DVM, cVMA, DACVAA

• the Scrambled Brain: inflammatory Brain Disease Robin Levitski-Osgood, DVM, DACVIM (Neurology)

• Benefits of oral Care for Compromised Patients Brook Niemiec, DVM, DAVDC Southern California Veterinary Dental Specialties

*Note: This is the same program that was offered on Oct. 10 at the

Ponte Family Estate Winery in Temecula.

Case-based presentation of Neurological Cases Sorrento Valley Facility December 14, 2013 6:30 - 8:00 pm

FACE Foundation 2013 Golf Tournament

We are proud to support the 2013 FACE Foundation golf tournament on November 4 at the Lomas Santa Fe Country Club. This unique event welcomes well-behaved dogs and includes an evening of festivities with all proceeds benefitting FACE.

in our CoMMunitY

TAKE NOTEcURRENT cLINIcAL TRIALsInternal medicine – Effectiveness of maropitant (Cerenia) in Cats with liver DiseaseDr. Keith Richter is leading a study to determine how maropitant (Cerenia) is metabolized in cats with liver disease, and how effective it is as an antiemetic in cats with liver disease (compared with metoclopramide). We are actively recruiting cases, so if you have a cat with liver disease, please contact us. Clients receive significant financial incentives.Contact Dr. Keith Richter at (858) 875-7500

Internal medicine – Feline Hepatic lipidosis StudyWe are now enrolling cats with confirmed hepatic lipidosis (HL) with the objective of evaluating vitamin-B metabolism and lipid profiles associated with this disease process. The objective of this study is to expand our understanding of vitamin-B and lipid metabolism in cats with HL.Contact Dr. Steve Hill at (858) 875-7500

Internal medicine – Canine IBD and probiotic vSl#3We are enrolling dogs with chronic gastrointestinal signs that are suspected of having idiopathic inflammatory bowel disease (IBD). Endoscopy will be performed, and if IBD is confirmed, dogs will be randomized to receive treatment with prednisone and diet, or prednisone, diet and probiotic VSL#3. This is an 8-week study requiring two endoscopic procedures. The cost of the probiotic VSL#3 and the cost of the second endoscopy will be funded.Contact Dr. Steve Hill at (858) 875-7500

Internal medicine – Glomerular Disease StudyVSH is participating in a multi-center prospective study evaluating increased dosing of enalapril in dogs with glomerular disease. Client incentives include reduced cost of some initial testing and no cost for scheduled recheck visits and tests.Contact Dr. Julie Fischer at (760) 466-0600

Oncology – Canine Soft Tissue SarcomaTrial examining novel biologic therapy for dogs with MEASUREABLE soft tissue sarcoma.Eligibility criteria:• Generally good health• Potentially resectable, dermal or subcutaneous tumors

measuring 1-7 cm in longest dimension (please call to discuss if tumors are larger than 7 cm as exceptions may be made)

Contact Dr. Brenda Phillips at (858) 875-7500

Oncology – Canine lymphoma TrialVSH is now accepting enrollment for dogs with multicentric lymphoma in several trials. Contact Dr. Brenda Phillips at (858) 875-7500

*NEW* Quality of life for Cats with GI lymphomaThis is a trial that will lead to the design of a validated quality of life survey tool for cats with GI lymphoma. This will enable the profession to study different interventions that may impact quality of life. Clients will be required to fill out survey information to develop this tool. Clients will receive a financial incentive. If you have an UNTREATED cat with GI lymphoma (or suspect GI lymphoma), they are eligible to participate. Contact Drs. Brenda Phillips or Keith Richter at (858) 875-7500

For more details about these and other clinical trials, please visit our website at www.vshsd.com.

vSH 2013 Holiday pet Food Drive

VSH will once again hold our holiday pet food drive December 2-January 3.

We welcome donations from you, your staff and clients. Feel free to bring an item if you’re coming to any of our CE programs, and please share this information widely!

For more information on Continuing Education events, please visit vshsd.com/Veterinarians or contact Ann Ong at (858) 875-7544 or ann.ong@vshsd.com.