Navigating the available oncology diagnostics can be challenging. Many tests are being recommended from many sources (standard diagnostic labs, mailings received at the practice, CE events). I have prepared a summary of uses and sample submission details of some potentially useful diagnostics.

PCR - Polymerase chain reactionPCR is performed using cellular DNA. DNA is a very stable product; cells can be collected and stored indefinitely in EDTA from blood, nodes, spleen, or any solid organ. PCR is used to differentiate between lymphocytes or plasma cells that are present due to inflammation or immunostimulation and those that are present due to a neoplastic condition.

• PcR sample submission> Aspirate organ of interest with 22 or 25 g needle with

syringe attached> Transfer material into purple top tube> Re-aspirate several times to create a cloudy appearance

to the EDTA in the tube> Ship to lab such as CSU immunopathology diagnostic service> Can order from biopsy sample for certain tissues and species;

example: STAT Lab submits to UC Davis for clonality.

Flow Cytometry Flow Cytometry is another test that is useful to differentiate between neoplastic and immunostimulated lymphocytes, though CSU recommends PCR instead of flow cytometry when trying to determine if a lymphocyte population is neoplastic instead of reactive. Flow cytometry provides detailed phenotype subset information (B- vs. T-cell) that can provide prognostic information for multicentric lymphoma. Flow cytometry differentiates between stem (primitive) cell and more differentiated lymphocyte population in a leukemia sample; this also provides prognostic information.

• Flow cytometry sample submission> Fresh Specimen Necessary! Whole blood; 1 ml in purple top> Nodal aspiration; several aspirates with 22 gauge needle

attached to syringe; purple top ideally with 0.1 ml of patient serum added to 0.9 ml saline in tube to attempt to maintain cell viability

> Bone marrow; ½ ml in purple top> Ship immediately, avoid delivery on weekends though CSU

will accept delivery before 10 am on Saturdays

Mast Cell Tumor Advanced DiagnosticsMast cell tumor prognosis is based on histopathology results (margins, grade, mitotic index). A more advanced mast cell tumor diagnostic panel may further improve ability to prognosticate.

• Mast cell Tumor Panel components> AgNor; the number of cells expressing AgNors to

gauge the speed of proliferation> PCNA; cell cycle phase of proliferating cells> Ki-67; percentage of cells that are proliferating> C-kit immunohistochemistry; uses staining patterns,

intra-cytoplasmic patterns more aggressive than membrane associated staining

> C-kit PCR to identify mutations; 20-30% have mutations, these tumors are more aggressive but may respond better to tyrosine kinase inhibitors such as Palladia

> Not every lab performs every one of these tests in their panel. Labs below offer a panel.

> MSU; $210, requires 10 positively-charged unstained slides from paraffin block

> CSU, UC Davis, NCSU

The STAT Lab website (www.statvetlab.com) has links to all of the diagnostic tests at the labs listed above.

If you have any questions about diagnostic choices for your oncology patients, please contact:

Dr. Brenda Phillips at (858) 875-7500

Dr. Andi Flory at (760) 466-0600

Dr. Blaise Burke at (858) 875-7500

Dr. Andy Loar at (858) 875-7550

RIchTER scALEHello Colleagues,

I hope you are all having a great summer. At VSH it has been a busy time of the year. We have just completed our third annual Symposium at the University of San Diego. There were over 400 attendees, who got to hear outstanding speakers, including the keynotes by Dr. Mike Lappin from Colorado State and Harold Davis from U.C. Davis. The workshops were also very effective, including neurological exams, cytology interpretation, and radiology interpretation. Even the vendor booths were crowded. Add to all that a spectacular setting and it made for a terrific day. Stay tuned for next year’s announcement!

Not only is the hospital noticeably busier, but STAT Veterinary Lab is also getting more accounts each month (thanks to all of you using the lab!). Whether you are using the lab or not, Dr. Andy Loar and/or one of our trained technologists are happy to come to your clinic for cytology rounds/cool cases or to work with your techs on basic hematology and/or UA’s.

If you haven’t already met her, I want to introduce our Practice Liaison, Margaret Trinh. She will be spending her time visiting you and acting as the conduit between your hospital and ours. We hope to better understand your hospital from top to bottom: what your business focuses on, what your team cares about, and your favorite baseball team (Go Padres!). By getting to know each other just a little better, we can improve our client and patient care and create a longer lasting relationship between our hospitals. In her past life, Margaret was a technician at VSH; she is exceptionally experienced in both the operational and managerial aspects of the hospital. Don’t forget to ask about her cupcakes!

We have had some cool procedures here at VSH. Dr. Aiken completed another success-ful limb spare procedure for osteosarcoma, using bone matrix for structural integrity. We have also completed a few more thoracoscopic lung lobectomies for primary lung tumors. It’s quite gratifying to be able to do major interventional procedures in the chest with the aid of scoping and special instrumentation technology.

As I write this, the Padres just ended their 10 game losing streak...FINALLY! Despite this momentary collapse, I remain optimistic about their chances. They are within striking range. More importantly, I am still on pace for going to 70 games this year. And that does not include the playoff and World Series!

I hope you all have a great summer!

Keith Richter, DVM

Diplomate ACVIM

AdvANcEd ONcOLOgy dIAgNOsTIcsby BRENdA PhILLIPs, dvM, dAcvIM (MEdIcAL ONcOLOgy)

It is helpful to look at seizure control in two parts: 1) Prolonging the interval between seizures or seizure clusters (I will refer to this as the maintenance phase), and 2) limiting the number of seizures in a cluster. The first is accomplished using maintenance medication that the patient takes daily. The second is accomplished by adding or increasing drugs starting after the first seizure in a patient known to have cluster seizures.

Good maintenance control is usually a seizure-free period of 2 months or more, although rarely we will consider one seizure/seizure cluster per month adequate to balance quality of life issues with adverse drug effects. Any of the maintenance medications discussed in Part I of this series can be increased or added to try to achieve this goal. Maximizing one medication before adding in another is ideal (fewer drugs, fewer adverse effects, less monitoring etc.). In hard to control patients taking multiple drugs, serum drug levels are helpful to know which medications are best to increase when necessary.

When seizures become refractory to treatment, IV or gas anesthesia to achieve a pharmacologic coma is sometimes necessary to break the seizure cycle and allow the brain to rest. Prior to getting to this point, we can attempt aggressive oral dosing in patients with a known history of hard-to-control clusters to break the seizure cycle. The patient needs to be coherent enough to swallow, otherwise, hospital-ization with IV medications will be needed.

The most common add-on medication for the treatment of cluster seizures is diazepam. Diazepam is helpful in patients whose seizures are close together (within minutes to an hour). Due to its short half-life, it may not be effective in patients whose seizures are spaced farther apart. Although rectal diazepam is the traditional method of delivery, nasal diazepam is a better alternative. Since there is no first pass effect with nasal administration, a smaller volume can be used and there is greater bioavailability than for published rectal doses.1

Since many patients’ seizures are, at least initially, spaced hours apart, increasing maintenance medications to achieve temporary high serum concentrations is an easy strategy for clients to institute at home. It is advisable to increase the medication(s) with the fastest onset of action and the shortest half-life. For our commonly used medications that would be levetiracetam > zonisamide > phenobarbital > potas-sium bromide. See Part I of this series for the pharmacokinetics of levetiracetam and zonisamide.

The following table is a general guideline for increasing medications depending on which medication a patient is taking:

Drug 1st Seizure 2nd Seizure 3rd Seizure

Levetiracetam 3x MD 2x MD 1x MD

Zonisamide 2x MD 2x MD 1x MD

Phenobarbital 2x MD 1x MD 1 x MD

KBr 160mg/kg once

MD = maintenance dose Clients should seek veterinary advice after the third seizure

In severe cluster patients, you can have clients increase two of the maintenance medications that peak a few hours apart (ie. levetirace-tam and phenobarbital). Clients should not skip the regular mainte-nance dose, unless the patient is excessively sedate or the added doses fall within 4 hours of their regular dosing interval. If so, then they should resume the next dose at the appropriate interval from the last dose given (i.e. 12 hours from the previous dose for phenobarbital and zonisamide). Once the pet has been seizure-free for 24 hours, they can adjust medications to get back on a normal schedule.

In patients who have a long seizure-free interval on phenobarbital and/or KBr, but have severe cluster seizures, consider adding leveti-racetam for treatment of the clusters only. It has a fast onset of action (45 minutes), and lasts about 6-8 hours. I will typically start at a loading dose of 60mg/kg after the first seizure, 40mg/kg after the second seizure, 20mg/kg after the third seizure, and Q 8 hr until the patient has been seizure-free for 24 hours. If the seizures are closer together than 45 minutes, then diazepam should be used. Always continue the maintenance medications with this protocol.

Patients that are having multiple seizures (>3) and are not returning to normal between seizures, that are too sedate to swallow medica-tions, or have a history of status epilepticus, should be evaluated by a veterinarian.

ZONIsAMIdE ANd LEvETIRAcETAM FOR AdjUNcTIvE sEIZURE MANAgEMENT —PART 2by TAMMy sTEvENsON, dvM, dIPLOMATE AcvIM (NEUROLOgy)

(1) Musulin SE, Mariani CL, Papich MG. Diazepam pharmacokinetics after nasal drop and atomized nasal administration in dogs. J Vet Pharmacol Ther. 2011 Feb;34(1):17-24.

Navigating the available oncology diagnostics can be challenging. Many tests are being recommended from many sources (standard diagnostic labs, mailings received at the practice, CE events). I have prepared a summary of uses and sample submission details of some potentially useful diagnostics.

PCR - Polymerase chain reactionPCR is performed using cellular DNA. DNA is a very stable product; cells can be collected and stored indefinitely in EDTA from blood, nodes, spleen, or any solid organ. PCR is used to differentiate between lymphocytes or plasma cells that are present due to inflammation or immunostimulation and those that are present due to a neoplastic condition.

• PcR sample submission> Aspirate organ of interest with 22 or 25 g needle with

syringe attached> Transfer material into purple top tube> Re-aspirate several times to create a cloudy appearance

to the EDTA in the tube> Ship to lab such as CSU immunopathology diagnostic service> Can order from biopsy sample for certain tissues and species;

example: STAT Lab submits to UC Davis for clonality.

Flow Cytometry Flow Cytometry is another test that is useful to differentiate between neoplastic and immunostimulated lymphocytes, though CSU recommends PCR instead of flow cytometry when trying to determine if a lymphocyte population is neoplastic instead of reactive. Flow cytometry provides detailed phenotype subset information (B- vs. T-cell) that can provide prognostic information for multicentric lymphoma. Flow cytometry differentiates between stem (primitive) cell and more differentiated lymphocyte population in a leukemia sample; this also provides prognostic information.

• Flow cytometry sample submission> Fresh Specimen Necessary! Whole blood; 1 ml in purple top> Nodal aspiration; several aspirates with 22 gauge needle

attached to syringe; purple top ideally with 0.1 ml of patient serum added to 0.9 ml saline in tube to attempt to maintain cell viability

> Bone marrow; ½ ml in purple top> Ship immediately, avoid delivery on weekends though CSU

will accept delivery before 10 am on Saturdays

Mast Cell Tumor Advanced DiagnosticsMast cell tumor prognosis is based on histopathology results (margins, grade, mitotic index). A more advanced mast cell tumor diagnostic panel may further improve ability to prognosticate.

• Mast cell Tumor Panel components> AgNor; the number of cells expressing AgNors to

gauge the speed of proliferation> PCNA; cell cycle phase of proliferating cells> Ki-67; percentage of cells that are proliferating> C-kit immunohistochemistry; uses staining patterns,

intra-cytoplasmic patterns more aggressive than membrane associated staining

> C-kit PCR to identify mutations; 20-30% have mutations, these tumors are more aggressive but may respond better to tyrosine kinase inhibitors such as Palladia

> Not every lab performs every one of these tests in their panel. Labs below offer a panel.

> MSU; $210, requires 10 positively-charged unstained slides from paraffin block

> CSU, UC Davis, NCSU

The STAT Lab website (www.statvetlab.com) has links to all of the diagnostic tests at the labs listed above.

If you have any questions about diagnostic choices for your oncology patients, please contact:

Dr. Brenda Phillips at (858) 875-7500

Dr. Andi Flory at (760) 466-0600

Dr. Blaise Burke at (858) 875-7500

Dr. Andy Loar at (858) 875-7550

RIchTER scALEHello Colleagues,

I hope you are all having a great summer. At VSH it has been a busy time of the year. We have just completed our third annual Symposium at the University of San Diego. There were over 400 attendees, who got to hear outstanding speakers, including the keynotes by Dr. Mike Lappin from Colorado State and Harold Davis from U.C. Davis. The workshops were also very effective, including neurological exams, cytology interpretation, and radiology interpretation. Even the vendor booths were crowded. Add to all that a spectacular setting and it made for a terrific day. Stay tuned for next year’s announcement!

Not only is the hospital noticeably busier, but STAT Veterinary Lab is also getting more accounts each month (thanks to all of you using the lab!). Whether you are using the lab or not, Dr. Andy Loar and/or one of our trained technologists are happy to come to your clinic for cytology rounds/cool cases or to work with your techs on basic hematology and/or UA’s.

If you haven’t already met her, I want to introduce our Practice Liaison, Margaret Trinh. She will be spending her time visiting you and acting as the conduit between your hospital and ours. We hope to better understand your hospital from top to bottom: what your business focuses on, what your team cares about, and your favorite baseball team (Go Padres!). By getting to know each other just a little better, we can improve our client and patient care and create a longer lasting relationship between our hospitals. In her past life, Margaret was a technician at VSH; she is exceptionally experienced in both the operational and managerial aspects of the hospital. Don’t forget to ask about her cupcakes!

We have had some cool procedures here at VSH. Dr. Aiken completed another success-ful limb spare procedure for osteosarcoma, using bone matrix for structural integrity. We have also completed a few more thoracoscopic lung lobectomies for primary lung tumors. It’s quite gratifying to be able to do major interventional procedures in the chest with the aid of scoping and special instrumentation technology.

As I write this, the Padres just ended their 10 game losing streak...FINALLY! Despite this momentary collapse, I remain optimistic about their chances. They are within striking range. More importantly, I am still on pace for going to 70 games this year. And that does not include the playoff and World Series!

I hope you all have a great summer!

Keith Richter, DVM

Diplomate ACVIM

AdvANcEd ONcOLOgy dIAgNOsTIcsby BRENdA PhILLIPs, dvM, dAcvIM (MEdIcAL ONcOLOgy)

It is helpful to look at seizure control in two parts: 1) Prolonging the interval between seizures or seizure clusters (I will refer to this as the maintenance phase), and 2) limiting the number of seizures in a cluster. The first is accomplished using maintenance medication that the patient takes daily. The second is accomplished by adding or increasing drugs starting after the first seizure in a patient known to have cluster seizures.

Good maintenance control is usually a seizure-free period of 2 months or more, although rarely we will consider one seizure/seizure cluster per month adequate to balance quality of life issues with adverse drug effects. Any of the maintenance medications discussed in Part I of this series can be increased or added to try to achieve this goal. Maximizing one medication before adding in another is ideal (fewer drugs, fewer adverse effects, less monitoring etc.). In hard to control patients taking multiple drugs, serum drug levels are helpful to know which medications are best to increase when necessary.

When seizures become refractory to treatment, IV or gas anesthesia to achieve a pharmacologic coma is sometimes necessary to break the seizure cycle and allow the brain to rest. Prior to getting to this point, we can attempt aggressive oral dosing in patients with a known history of hard-to-control clusters to break the seizure cycle. The patient needs to be coherent enough to swallow, otherwise, hospital-ization with IV medications will be needed.

The most common add-on medication for the treatment of cluster seizures is diazepam. Diazepam is helpful in patients whose seizures are close together (within minutes to an hour). Due to its short half-life, it may not be effective in patients whose seizures are spaced farther apart. Although rectal diazepam is the traditional method of delivery, nasal diazepam is a better alternative. Since there is no first pass effect with nasal administration, a smaller volume can be used and there is greater bioavailability than for published rectal doses.1

Since many patients’ seizures are, at least initially, spaced hours apart, increasing maintenance medications to achieve temporary high serum concentrations is an easy strategy for clients to institute at home. It is advisable to increase the medication(s) with the fastest onset of action and the shortest half-life. For our commonly used medications that would be levetiracetam > zonisamide > phenobarbital > potas-sium bromide. See Part I of this series for the pharmacokinetics of levetiracetam and zonisamide.

The following table is a general guideline for increasing medications depending on which medication a patient is taking:

Drug 1st Seizure 2nd Seizure 3rd Seizure

Levetiracetam 3x MD 2x MD 1x MD

Zonisamide 2x MD 2x MD 1x MD

Phenobarbital 2x MD 1x MD 1 x MD

KBr 160mg/kg once

MD = maintenance dose Clients should seek veterinary advice after the third seizure

In severe cluster patients, you can have clients increase two of the maintenance medications that peak a few hours apart (ie. levetirace-tam and phenobarbital). Clients should not skip the regular mainte-nance dose, unless the patient is excessively sedate or the added doses fall within 4 hours of their regular dosing interval. If so, then they should resume the next dose at the appropriate interval from the last dose given (i.e. 12 hours from the previous dose for phenobarbital and zonisamide). Once the pet has been seizure-free for 24 hours, they can adjust medications to get back on a normal schedule.

In patients who have a long seizure-free interval on phenobarbital and/or KBr, but have severe cluster seizures, consider adding leveti-racetam for treatment of the clusters only. It has a fast onset of action (45 minutes), and lasts about 6-8 hours. I will typically start at a loading dose of 60mg/kg after the first seizure, 40mg/kg after the second seizure, 20mg/kg after the third seizure, and Q 8 hr until the patient has been seizure-free for 24 hours. If the seizures are closer together than 45 minutes, then diazepam should be used. Always continue the maintenance medications with this protocol.

Patients that are having multiple seizures (>3) and are not returning to normal between seizures, that are too sedate to swallow medica-tions, or have a history of status epilepticus, should be evaluated by a veterinarian.

ZONIsAMIdE ANd LEvETIRAcETAM FOR AdjUNcTIvE sEIZURE MANAgEMENT —PART 2by TAMMy sTEvENsON, dvM, dIPLOMATE AcvIM (NEUROLOgy)

(1) Musulin SE, Mariani CL, Papich MG. Diazepam pharmacokinetics after nasal drop and atomized nasal administration in dogs. J Vet Pharmacol Ther. 2011 Feb;34(1):17-24.

PcR s

Flow c

c

RIchTER scALE gy)

It is helpful to look at seizure control in two parts: 1) Prolonging the interval between seizures or seizure clusters (I will refer to this as the maintenance phase), and 2) limiting the number of seizures in a cluster. The first is accomplished using maintenance medication that the patient takes daily. The second is accomplished by adding or increasing drugs starting after the first seizure in a patient known to have cluster seizures.

Good maintenance control is usually a seizure-free period of 2 months or more, although rarely we will consider one seizure/seizure cluster per month adequate to balance quality of life issues with adverse drug effects. Any of the maintenance medications discussed in Part I of this series can be increased or added to try to achieve this goal. Maximizing one medication before adding in another is ideal (fewer drugs, fewer adverse effects, less monitoring etc.). In hard to control patients taking multiple drugs, serum drug levels are helpful to know which medications are best to increase when necessary.

When seizures become refractory to treatment, IV or gas anesthesia to achieve a pharmacologic coma is sometimes necessary to break the seizure cycle and allow the brain to rest. Prior to getting to this point, we can attempt aggressive oral dosing in patients with a known history of hard-to-control clusters to break the seizure cycle. The patient needs to be coherent enough to swallow, otherwise, hospital-ization with IV medications will be needed.

The most common add-on medication for the treatment of cluster seizures is diazepam. Diazepam is helpful in patients whose seizures are close together (within minutes to an hour). Due to its short half-life, it may not be effective in patients whose seizures are spaced farther apart. Although rectal diazepam is the traditional method of delivery, nasal diazepam is a better alternative. Since there is no first pass effect with nasal administration, a smaller volume can be used and there is greater bioavailability than for published rectal doses.1

Since many patients’ seizures are, at least initially, spaced hours apart, increasing maintenance medications to achieve temporary high serum concentrations is an easy strategy for clients to institute at home. It is advisable to increase the medication(s) with the fastest onset of action and the shortest half-life. For our commonly used medications that would be levetiracetam > zonisamide > phenobarbital > potas-sium bromide. See Part I of this series for the pharmacokinetics of levetiracetam and zonisamide.

The following table is a general guideline for increasing medications depending on which medication a patient is taking:

Drug 1st Seizure 2nd Seizure 3rd Seizure

Levetiracetam 3x MD 2x MD 1x MD

Zonisamide 2x MD 2x MD 1x MD

Phenobarbital 2x MD 1x MD 1 x MD

KBr 160mg/kg once

MD = maintenance dose Clients should seek veterinary advice after the third seizure

In severe cluster patients, you can have clients increase two of the maintenance medications that peak a few hours apart (ie. levetirace-tam and phenobarbital). Clients should not skip the regular mainte-nance dose, unless the patient is excessively sedate or the added doses fall within 4 hours of their regular dosing interval. If so, then they should resume the next dose at the appropriate interval from the last dose given (i.e. 12 hours from the previous dose for phenobarbital and zonisamide). Once the pet has been seizure-free for 24 hours, they can adjust medications to get back on a normal schedule.

In patients who have a long seizure-free interval on phenobarbital and/or KBr, but have severe cluster seizures, consider adding leveti-racetam for treatment of the clusters only. It has a fast onset of action (45 minutes), and lasts about 6-8 hours. I will typically start at a loading dose of 60mg/kg after the first seizure, 40mg/kg after the second seizure, 20mg/kg after the third seizure, and Q 8 hr until the patient has been seizure-free for 24 hours. If the seizures are closer together than 45 minutes, then diazepam should be used. Always continue the maintenance medications with this protocol.

Patients that are having multiple seizures (>3) and are not returning to normal between seizures, that are too sedate to swallow medica-tions, or have a history of status epilepticus, should be evaluated by a veterinarian.

ZONIsAMIdE ANd LEvETIRAcETAM FOR AdjUNcTIvE sEIZURE MANAgEMENT —PART 2by TAMMy sTEvENsON, dvM, dIPLOMATE AcvIM (NEUROLOgy)

(1) Musulin SE, Mariani CL, Papich MG. Diazepam pharmacokinetics after nasal drop and atomized nasal administration in dogs. J Vet Pharmacol Ther. 2011 Feb;34(1):17-24.

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 | J u L – S e P t 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

ADVANCED ONCOLOGY DIAGNOSTICSIN THIS ISSUE:

ZoniSamide and LeVetiraCetam for adJunCtiVe SeiZure management — Part 2

CLiniCaL triaLS

uPComing eVentS

announCementSTwo of our doctors had key roles during the Pacific Veterinary Conference June 20-23 in Long Beach, CA. Dr. Tracy Julius led a lecture series for the disaster response track on a variety of topics including trauma, burns, and smoke inhalation. Dr. Keith Richter was head of the Internal Medicine section Program Committee.

VSH doctors were also represented at this year’s ACVIM Forum June 12-15 in Seattle, WA. Dr. Steve Hill lectured on the Diagnosis and Management of Protein-Losing Enteropathy. Drs. Andi Flory and Brenda Phillips presented the American College of Veterinary Internal Medicine consensus statement about chemotherapy safety.

Dr. Nicole Boynosky was published in the June issue of Veterinary Dermatology entitled A Retrospective Evaluation of Prevalence, Antimicrobial Susceptibility, and Clinical Response of Corynebacte-rium spp. in Canine Dermatitis.

Dr. Mauricio Dujowich lectured to the Western University School of Optometry at their annual faculty retreat about internet-based learning. Dr. Dujowich is the co-founder of Vet Prep (which prepares senior veterinary students for the National Board examination).

We‘re LiSteningWe want to keep you informed in as many ways as possible. We are increasing our social media outreach (besides Facebook and our website blog). We are now posting the latest in medical findings, pet food recalls and VSH news on our Twitter account. Please be sure to follow us @VSHSanDiego.

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 StudyNow enrolling cats with confirmed hepatic lipidosis (HL) with the objective of evaluating vitamin-B metabolism and lipid profiles associated with this disease process. This is a 4-week prospective study which requires whole blood and urine collected at the time of diagnosis and at 2 and 4 week rechecks. The objective of this study is to expand our understanding of vitamin-B and lipid metabolism in cats with HL. Patients that have received cobalamin or folic acid supplementation within 8 weeks prior to diagnosis of HL may not be included in this study (supplementation is permitted following receipt of the first samples at the time of diagnosis).Contact Drs. Alexandra Hamilton or 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 x702

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 – Dogs Receiving DoxorubicinWe are investigating the benefit of Fortiflora™ nutritional supplement in dogs receiving doxorubicin chemotherapy. Dogs already receiving doxorubicin are eligible.Contact Dr. Andi Flory at (760) 466-0600 or (858) 875-7500 x719

*NEW* Oncology – Canine Lymphoma TrialThis trial will be initiated in July 2013. Please check our website for up-to-date information. Contact Dr. Brenda Phillips at (858) 875-7500

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

10435 Sorrento Valley Rd Suite 100

San Diego, CA 92121

SaVe tHe dateNorth County CE Dinner and Lecture July 30, 2013 6:30 - 9:00 pm Vintana Wine and Dine

• Current recommendations for treatment of autoimmune diseases Kevin Mallery, DVM, DACVIM

• Cytology of Selected immune-mediated disorders Andrew Loar, DVM, DACVIM (Internal Medicine and Oncology) Clinical Laboratory Director and Cytologist, STAT Veterinary Lab

A Special Program for Front Office Staff and Those Who Work with the Public San Diego and North County Facilities + Webinar August 22, 2013 6:15 - 8:00 pm

• What’s the Secret to Happy Clients and Pets? Kimberly Pope-Robinson, DVM Regional Strategic Veterinarian, Veterinary Strategic Services Zoetis

Summer CE Dinner and Lecture San Diego and North County Facilities + Webinar August 29, 2013 6:00 - 9:00 pm

• diagnosis and management of dogs and Cats with Chronic diarrhea Special guest lecturer, Jörg Steiner, med.vet., Dr.med.vet., PhD, DACVIM, DECVIM-CA, AGAF

Neurology Roundtable Discussion & Dinner North County Facility September 19, 2013 6:30 - 8:00 pm

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.

Please stop by and visit us at the following events:

Pride Festival 2013 Saturday, July 13, 12 pm to 10 pm Sunday, July 14, 11 am to 8 pm Marston Point, Balboa Park (6th Avenue & Laurel Street)

This cultural festival includes multiple stages of entertainment, more than 80 musicians, bands, comedy and dance performers, 300 participating vendor booths, an Art exhibit, cultural presentations, and great food!

in our CommunitYCardiff Dog Days of Summer 2013 Cardiff’s 8th Annual Canine Festival & Contest Saturday, August 10 10 am to 4 pm Jam-packed day of fun & festivities, all doggie-centric!

C i a Lt Y H o S P i ta L | J u L – S e P t 2 01 3

ADVANCED ONCOLOGY DIAGNOSTICSIN THIS ISSUE:

ZoniSamide and LeVetiraCetam for adJunCtiVe SeiZure management — Part 2

CLiniCaL triaLS

uPComing eVentS

announCementSTwo of our doctors had key roles during the Pacific Veterinary Conference June 20-23 in Long Beach, CA. Dr. Tracy Julius led a lecture series for the disaster response track on a variety of topics including trauma, burns, and smoke inhalation. Dr. Keith Richter was head of the Internal Medicine section Program Committee.

VSH doctors were also represented at this year’s ACVIM Forum June 12-15 in Seattle, WA. Dr. Steve Hill lectured on the Diagnosis and Management of Protein-Losing Enteropathy. Drs. Andi Flory and Brenda Phillips presented the American College of Veterinary Internal Medicine consensus statement about chemotherapy safety.

Dr. Nicole Boynosky was published in the June issue of Veterinary Dermatology entitled A Retrospective Evaluation of Prevalence, Antimicrobial Susceptibility, and Clinical Response of Corynebacte-rium spp. in Canine Dermatitis.

Dr. Mauricio Dujowich lectured to the Western University School of Optometry at their annual faculty retreat about internet-based learning. Dr. Dujowich is the co-founder of Vet Prep (which prepares senior veterinary students for the National Board examination).

We‘re LiSteningWe want to keep you informed in as many ways as possible. We are increasing our social media outreach (besides Facebook and our website blog). We are now posting the latest in medical findings, pet food recalls and VSH news on our Twitter account. Please be sure to follow us @VSHSanDiego.

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 StudyNow enrolling cats with confirmed hepatic lipidosis (HL) with the objective of evaluating vitamin-B metabolism and lipid profiles associated with this disease process. This is a 4-week prospective study which requires whole blood and urine collected at the time of diagnosis and at 2 and 4 week rechecks. The objective of this study is to expand our understanding of vitamin-B and lipid metabolism in cats with HL. Patients that have received cobalamin or folic acid supplementation within 8 weeks prior to diagnosis of HL may not be included in this study (supplementation is permitted following receipt of the first samples at the time of diagnosis).Contact Drs. Alexandra Hamilton or 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 x702

Suite 100

San Diego, CA 92121

SaVe tHe dateNorth County CE Dinner and Lecture July 30, 2013 6:30 - 9:00 pm Vintana Wine and Dine

• Current recommendations for treatment of autoimmune diseases Kevin Mallery, DVM, DACVIM

• Cytology of Selected immune-mediated disorders Andrew Loar, DVM, DACVIM (Internal Medicine and Oncology) Clinical Laboratory Director and Cytologist, STAT Veterinary Lab

A Special Program for Front Office Staff and Those Who Work with the Public San Diego and North County Facilities + Webinar August 22, 2013 6:15 - 8:00 pm

• What’s the Secret to Happy Clients and Pets? Kimberly Pope-Robinson, DVM Regional Strategic Veterinarian, Veterinary Strategic Services Zoetis

Summer CE Dinner and Lecture San Diego and North County Facilities + Webinar August 29, 2013 6:00 - 9:00 pm

• diagnosis and management of dogs and Cats with Chronic diarrhea Special guest lecturer, Jörg Steiner, med.vet., Dr.med.vet., PhD, DACVIM, DECVIM-CA, AGAF

Neurology Roundtable Discussion & Dinner North County Facility September 19, 2013 6:30 - 8:00 pm

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.

Please stop by and visit us at the following events:

Pride Festival 2013 Saturday, July 13, 12 pm to 10 pm Sunday, July 14, 11 am to 8 pm Marston Point, Balboa Park (6th Avenue & Laurel Street)

This cultural festival includes multiple stages of entertainment, more than 80 musicians, bands, comedy and dance performers, 300 participating vendor booths, an Art exhibit, cultural presentations, and great food!

in our CommunitY