CONNECTED
In Our Community
Complimentary Eye Exams for Service Dogs in May
VSH Ophthalmologists Dr. Holly Hamilton and Dr. Nicole Roybal will participate in the
ACVO/Merial National Service Dog Eye Exam program that helps serve the dogs who
dedicate their lives to serving us. Please help get the word out to your appropriate clients.
They must first register online at www.ACVOeyexam.org. Appointments are filled on a firstcome, first-served basis.
10435 Sorrento Valley Rd
Suite 100
San Diego, CA 92121
FACE Foundation’s 3rd Annual Bags & Baubles Fundraiser
This year’s Bags & Baubles event is Sunday, April 28th! The silent
auction will include over 300 new and gently-loved designer handbags,
stunning jewelry, and a new men’s section with designer ties, belts, and
wallets. With raffle prizes, wine tasting, estate tours, and delicious
appetizers, this event promises a good time for all. 100% of the
proceeds will benefit family pets in need of life-saving veterinary care!
Free to attend; RSVP required. Contact: [email protected].
TAKE NOTE
cURRENT CLINICAL TRIALs
* NEW * Internal Medicine – Effectiveness of Maropitant (Cerenia)
in Cats with Liver Disease
Dr. 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, and
clients receive significant financial incentives.
Contact Dr. Keith Richter at (858) 875-7500.
* NEW * Internal Medicine – Feline Hepatic Lipidosis Study
Now 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#3
Now 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 Study
VSH 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
Y o u r L i n k t o V e t e r i n a r y S P E C IA L T Y H O S P ITA L | A P R – J UN 2 0 1 3
The Morris Animal Foundation’s Canine
Cancer Walk on February 23 was a
tremendous success! Thanks to
everyone for supporting Cancer Bites,
the VSH team. Over $60,000 was
raised, with over $20,000 just from our
team - more than 5 times the amount
raised by any other team! We were also
the recipient of several awards.
Oncology – Canine Solid Tumor and Mast Cell Tumor Trials
Trials examining novel biologic therapy for dogs with
MEASUREABLE mast cell tumors and other solid tumors,
excluding osteosarcoma.
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 (858) 875-7500
Oncology – Dogs Receiving Doxorubicin
We are investigating the benefit of Fortiflora™ nutritional
supplement in dogs receiving doxorubicin chemotherapy.
Dogs already receiving doxorubicin are eligible.
Contact: Dr. Andi Flory (760) 466-0600 or (858) 875-7500 x719
For more details about these and other clinical trials, please visit
our website at www.vshsd.com.
WE’RE LISTENING
If you don’t have time for a Lunch and Learn program, our
specialists are available for brief, 30 minutes or less presentations
for you and your staff. It could be a quick refresher on a procedure
or disease, a general question and answer session or simply an
opportunity to find out more about one of our services. It’s our
pleasure to present this to you, and we’ll even bring a snack!
Please visit www.vshsd.com/togo or contact Caren Folbre
at (858) 875-7580.
LIKE US ON FACEBOOK TO KEEP
UP WITH THE LATEST VSH NEWS
AND HAPPENINGS!
www.facebook.com/VeterinarySpecialtyHospital
Announcements
Dr. Sean Aiken spoke on mobile veterinary surgery at the recent
VSIPP meeting held in February in Coronado.
Escherichia coli and response to fluoroquinolone antimicrobials.
J Vet Intern Med. 2013 Jan-Feb;27(1):56-61. doi: 10.1111/jvim.12020.
Epub 2012 Dec 3.
Berghoff N, Parnell NK, Hill SL, Suchodolski JS, Steiner JM. Serum cobalamin and methylmalonic acid concentrations in dogs with chronic gastrointestinal disease. Am J Vet Res. 2013 Jan;74(1):84-9. doi: 10.2460/ajvr.74.1.84.
On March 15, Drs. Fred Pike and Josh Jackson participated in a
ground-breaking session that featured a live, video-link case-based
tibial plateau leveling osteotomy. The goal of the session was to
provide an overview of the TPLO technique with a primary focus on
aseptic surgical technique and surgical anatomy. Attendees at the
AAHA meeting in Phoenix obtained a brief overview of the TPLO
concept and watched a live surgery from San Diego.
Dr. Marie Chartier, third year Internal Medicine resident will be presenting
an abstract at the ACVIM 2013 Annual Forum in Seattle, Washington on
Evaluation of Canine Pancreas-specific Lipase (Spec cPL®) Concentration
and, Amylase and Lipase Activities in Peritoneal Fluid as Complementary
Diagnostic Tools for Acute Pancreatitis in Dogs.
Dr. Fred Pike and Dr. Sean Aiken presented a poster at this year’s
VOS (Veterinary Orthopedic Society) meeting in Colorado on a new
technique for the surgical management of patella alta.
Dr. Keith Richter is editing the Hepatobiliary/Pancreas section of Veterinary
Clinical Advisor (3rd Ed). His chapter on Feline Gastrointestinal Lymphoma in
Current Veterinary Therapy XV should be coming out soon.
In March, Dr. Andi Flory was invited to lecture at City University
in Hong Kong in conjunction with the Hong Kong Veterinary
Association. The topic was lymphoma therapy in dogs and cats.
Dr. Keith Richter recently spoke on behalf of the Comparative Gastroenterology Society at the most recent North American Veterinary Conference.
Dr. Brenda Phillips presented a lecture, “Veterinary Oncology
Diagnostics” at last month’s SDCVMA Sunday Specialists’ series.
Dr. Nicole Boynosky, third year dermatology resident, will be
presenting the abstract from her residency research project
entitled A Retrospective Evaluation of the Prevalence, Antimicrobial
Sensitivity, and Clinical Response of Corynebacterium spp. in Canine
Dermatitis at the North American Veterinary Dermatology Forum in
Louisville Kentucky on April 18.
Dr. Steve Hill will be speaking at the ACVIM 2013 Annual Forum
in Seattle, Washington, June 12-15 in the CGS GI tract on PLE.
Dr. Hill has also been co-author on three recent publications:
Arnell K, Hill S, Hart J, Richter K. Persistent regurgitation in four
dogs with caudal esophageal neoplasia. J Am Anim Hosp Assoc.
2013 Jan-Feb;49(1):58-63. doi: 10.5326/JAAHA-MS-5826. Epub
2012 Nov 12.
Manchester AC, Hill S, Sabatino B, Armentano R, Carroll M, Kessler
B, Miller M, Dogan B, McDonough SP, Simpson KW. Association
between granulomatous colitis in French Bulldogs and invasive
Drs. Andi Flory, Margo Karriker and Brenda Phillips, have completed a chapter on
veterinary chemotherapy safety to be published in Current Veterinary Therapy
XV. These doctors are also part of a panel that is completing a nationwide
consensus document on veterinary chemotherapy safety that will be published
and will likely be the worldwide guide for veterinary chemotherapy safety.
save the date
May 19, 2013 – VSH 3rd Annual Symposium
8:00 am - 4:30 pm at the University of San Diego
2 Vet Tracks, 1 Tech Track, 1 Mgmt Track + Workshops!
Register online now at www.vshsd.com/symposium.
April 18, 2013 – Educational Dinner Program
6:00 pm at Mia Francesca (Del Mar)
Nutrition and Veterinary Orthopedics: Bridging the Chasm
Mauricio Dujowich, DVM, DACVS
Sponsored by Hill’s Pet Nutrition
RSVP by April 10th: [email protected]
or leave message at 1-800-255-2403 ext 6401.
Nonhealing
Corneal Ulcers
IN THIS ISSUE:
Zonisamide and Levetiracetam
for Adjunctive Seizure
Management — PART 1
Clinical Trials
Upcoming Events
SAN DIEGO 10435 Sorrento Valley Rd San Diego, CA 92121 | NORTH COUNTY 2055 Montiel Rd San Marcos, CA 92069 | www.vshsd.com
Richter scale
Greetings Colleagues,
I hope you are all having a great start to 2013. I’m starting my quarterly update with
some of our plans for “big” equipment changes. We have just completed the installation of our new MRI. This unit is a true state-of-the-art 1.5T unit, with incredible
software and image quality. It does everything but do the laminectomy for us! I
thought our former unit was pretty good, but technology has really come a long way.
This will open us up to imaging other body parts far beyond the nervous system. Put
simply, the scans are better and faster. We are also upgrading our linear accelerator
to provide stereotactic radiosurgery (STS). This is a technology that allows a much
more focused delivery of radiation so that the patient can have a full course of
treatment divided into only 1-3 fractions (compared to a conventional fractionation
schedule that could be 15-17 treatments). This will also allow us to treat more
invasive tumors (such as nasal tumors) with fewer side effects. This will be among the
most advanced radiotherapy systems in veterinary medicine. This should be much
more appealing to clients while also upgrading the care to their pets. So, those are
the exciting additions (unless you consider our new high-def colonoscope exciting!).
Our blood donor program is one of our interesting projects that is progressing nicely.
This is led by our new board-certified criticalist, Dr. Tracy Julius. The program rivals
that of any commercial or academic blood bank, and the best part is our employees’
and clients’ pets supply the blood. Another great program is our employee engagement (workplace passion). We have an incredible staff, and we have instituted several
actions to make them even more passionate about their work. Feel free to contact me
for some of our team’s ideas. Our VSH Green Team is also in high gear. For example,
we just replaced every fluorescent light with an LED light. It is amazing how much
power this saves in a 27,000 sq ft building.
I will also use this opportunity as a shameless plug for our lab (STAT Veterinary Lab).
With Dr. Andy Loar’s guidance, the lab has evolved into an elite reference laboratory.
If you could get better quality, better service, faster results, and cheaper prices, why
wouldn’t you use it? Even if you have an existing contract, maybe use us for sameday cytology results, stat samples, or whatever you want. Just give us a call!
Check out our Symposium program for Sunday May 19th. Dr. Mike Lappin is the
keynote speaker for veterinarians; Harold Davis highlights the tech program; there is a
practical management track, workshops, all at a spectacular venue! Don’t miss it!!
Well, the football season is over, so for me that means I’m back on clinics on Saturdays and Sundays. Yes, you read it correctly. I’m happy to see new referrals (including
urgent cases) or a patient needing an ultrasound or endoscopy exam on both
weekend days, so bring it on. Sadly I’ll miss the Sunday day games at Petco Park…
see the sacrifice I’m willing to make?
Enjoy the Spring everyone!
Keith Richter, DVM
Diplomate ACVIM
Nonhealing
Corneal Ulcers
Zonisamide and
Levetiracetam for
Adjunctive Seizure
Management —PART 1
by HOLLY L. HAMILTON, DVM, MS, DIPLOMATE ACVO
by Tammy Stevenson, DVM, Diplomate ACVIM (Neurology)
Introduction
Indolent corneal ulcer, refractory corneal erosion, persistent
corneal ulcer, recurrent corneal erosion syndrome, Boxer ulcer, and
spontaneous chronic corneal epithelial defect (SCCED) all describe
a type of superficial corneal ulcer that is slow to heal, does not
heal, or recurs. Expected to heal within 5-7 days, these superficial
corneal ulcers can persist for 6 months or longer. Many breeds are
subject to this condition which usually affects middle age to older
dogs (>8 years). The pathophysiology resulting in abnormal healing
is complex. The basement membrane of the corneal epithelium has
abnormal attachment to the corneal stroma or is discontinuous
commonly with loss of the normal epithelial architecture. Beneath
the ulcer is an acellular hyalinized zone in the corneal stroma that
provides an additional barrier to epithelial cells adhering to the
underlying stroma.
Clinical Findings
Clinical signs of indolent corneal ulcers are similar to other ulcers
and include: pain, lacrimation, photophobia, and blepharospasm.
The intensity of pain tends to decrease with chronicity. These
ulcers are slow healing or unresponsive to traditional therapy. The
ulcers can change shape and size which initially is often misinterpreted as healing. Indolent corneal ulcers are superficial ulcers
with no loss of corneal stroma and a characteristic nonadherent lip
of epithelium. Fluorescein stain migrates under the adjacent
corneal epithelium. Many patients have intense corneal vascularization. The hallmark of an indolent ulcer is the loose corneal
epithelium. After instillation of topical anesthesia (proparacaine)
the edges of an indolent ulcer will peel back when gently touched
with a cotton-tipped applicator, often significantly increasing the
size of the ulcer.
Treatment
Healing of indolent ulcers requires a specific method of corneal
debridement. Keratotomy is used to debride degenerate basement
membrane and expose the healthy stroma. This is achieved through
grid or multipunctate keratotomy or more recently, use of a
diamond tipped corneal burr. A cotton tip applicator provides
debridement of the epithelium but not the basement membrane and
is inadequate for debridement of an indolent ulcer. A grid keratotomy (GK) is performed with a small gauge needle creating overlapping vertical and horizontal lines. Multiple punctate keratotomy
(MPK) is a series of small anterior stromal punctures just below the
basement membrane. A rotary diamond burr provides a newer
method of corneal debridement that is safer and yields faster
healing with less scar tissue. All three procedures remove abnormal basement membrane and anterior stroma and in many cases
can be performed with just topical anesthesia. Superficial keratectomy has a high success rate for indolent corneal ulcers, but
requires general anesthesia.
Other Considerations
Case selection is essential. Corneal debridement by MPK, GK, or
corneal burr is indicated only for superficial ulcers that are not
healing due to the abnormal basement membrane. If corneal
debridement is performed in the wrong cases, severe complications
can occur ranging from slower corneal healing to corneal perforation. Tragic results could occur if these methods of keratotomy are
applied to descemetoceleles, deep corneal ulcers, infected or
melting ulcers. Cats frequently have corneal ulcers secondary to
feline herpes virus and application of MPK or GK will result in a
deeper corneal herpes infection (interstitial keratitis) and predispose to formation of corneal sequestrum.
Phenobarbital (PB) and potassium bromide (KBr) are the drugs most
veterinarians choose as the initial therapy for seizures. Phenobarbital
seems to provide the most reliable seizure control for the most
patients1 with generally few adverse effects (blood dyscrasias,
hepatotoxicity, superficial necrolytic dermatitis, dyskensis), which are
reversible if caught early. Potassium bromide is also a good anticonvulsant, although not as reliable as phenobarbital.1 Adverse effects
(pancreatitis, panniculitis, and anecdotally megaesophagus) are rare.
Gastroenteritis is more common but can usually be managed by
dividing the dose and giving it with food. Potassium bromide should
not be used in cats due to the risk of life threatening eosinophilic
pulmonary infiltrates causing an asthma-like condition.
There are many external causes for delayed healing of superficial
corneal ulcers including eyelid abnormalities (distichia, ectopic
cilia, entropion, eyelid mass, and foreign body), low tear production, qualitative tear film deficiencies, infection, lagophthalmos or
facial nerve paralysis. In cats feline herpes virus is the most
frequent cause of corneal ulceration. These underlying issues need
to be addressed.
Both KBr and PB have inconvenient side effects (sedation, pelvic limb
weakness, PU/PD and polyphagia), so therefore it may be desirable to
choose an alternative adjunctive therapy when a patient is failing one
of these first line therapies.
Keratotomy performed incorrectly has potential for serious
consequences. Appropriate topical analgesic and patient restraint
are essential. Corneal perforation can result from selection of a
large bore needle. Epithelial inclusion cysts can be created when
the corneal epithelium is inadvertently introduced into the deep
stromal layers producing small, white lesions in cornea that may
ulcerate and can be painful.
MPK, GK, or corneal burr debridement are beneficial and frequently necessary for healing of indolent corneal ulcers, but are not
without complications. They have a very specific and unique
indication: indolent corneal ulcers.
Zonisamide and levetiracetam are now available in generic form, and
have therefore become far less expensive. In my experience, they tend
to be less reliable when used as the sole anticonvulsant and are better
reserved for adjunctive therapy.
Zonisamide is a sulfonamide-based drug and a weak carbonic anhydrase inhibitor. It inhibits voltage gated sodium channels and T-type
calcium channels, enhances GABA release and inhibits glutamate
release.2 It is 70% bioavailable and mostly excreted in the urine. About
20% is metabolized, primarily in the liver. 3 Therefore, co-administration of phenobarbital will increase its clearance.4 The half-life is 15-20
hours in the dog (steady state will be achieved in 3-4 days) and 33
hours in the cat (steady state in 6 days). 3,5 The dose range for dogs is
3-12 mg/kg BID, and for cats 5-20 mg/kg SID-BID. We typically start
both at 8-10 mg/kg BID. It comes in 25, 50, 100 mg capsules. We rarely
appreciate significant side effects in our patients, however sedation,
ataxia, gastrointestinal upset and weight loss have been reported.6
Possible adverse reactions include those associated with other sulfa
drugs such as immune-mediated disease (KCS, polyarthritis, IMHA),
and there have been two cases of apparent hepatotoxicity 7,8 and one
case of renal tubular acidosis9 attributed to zonisamide therapy.
Levetiracetam is a pyrrolidine-based anticonvulsant whose mechanism
has not been fully elucidated. It does work at synpatic vesicle protein
2A to reduce presynaptic neurotransmiter release (regulates exocytosis)
but it may have more than one mechanism of action.10 It is 100%
bioavailable, and even though there is no apparent hepatic metabolism,
Fig. 1: Indolent corneal ulcer in a dog with
loose surrounding corneal epithelium and
corneal vascularization.
Fig. 2: Diamond corneal burr
debridement of an indolent ulcer
in a dog.
there is increased clearance when used in conjunction with phenobarbital.11 The reason for this is not understood. It is 70% eliminated in
urine, and the remainder is hydrolyzed in serum and organs other than
the liver.6 The half-life in dogs is 3-4 hours and in cats 2-4 hours.12,13
The recommended starting dose is 20mg/kg TID.12,13 It comes in 100mg/
ml oral solution, 250mg, 500mg, 750mg and 1000mg tablets and
100mg/ml IV solution. The greatest disadvantage is the necessity for TID
dosing. If the patient is 20 kg or greater extended release tablets may
be used at 20 mg/kg BID (500mg, and 750mg formulations). Of course,
these tablets should not be split. Some clients have reported seeing the
tablets undigested in feces, so they may not work well in all dogs.
Levetiracetam is very safe; even at 6x the recommended dose, the side
effects (salivation, restlessness, ataxia, vomiting) resolve within 24
hours.6 At normal doses it has no greater side effects than placebo in
dogs.14 Levetiracetam appears to have a “honeymoon effect” in many
veterinary patients. It works well initially but then tolerance develops
within several months and it becomes ineffective. The study reporting
this finding, noted tolerance in 6/9 patients by 8 months of therapy.14
Auburn University, College of Veterinary Medicine can assay serum
drug levels for both of these anticonvulsants. Peak and trough levels
are ideal with the rapidly metabolized levetiracetam. Drug levels are
expensive and usually reserved for patients that are unusually sedate
(that may be experiencing an overdose) or have poor control of
seizures despite increasing doses.
Look for Part II of this article on strategic anticonvulsant use in the
next Connected newsletter.
Please visit the Connected-Newsletter page under the Veterinarian
tab on our website for a list of references.
Richter scale
Greetings Colleagues,
I hope you are all having a great start to 2013. I’m starting my quarterly update with
some of our plans for “big” equipment changes. We have just completed the installation of our new MRI. This unit is a true state-of-the-art 1.5T unit, with incredible
software and image quality. It does everything but do the laminectomy for us! I
thought our former unit was pretty good, but technology has really come a long way.
This will open us up to imaging other body parts far beyond the nervous system. Put
simply, the scans are better and faster. We are also upgrading our linear accelerator
to provide stereotactic radiosurgery (STS). This is a technology that allows a much
more focused delivery of radiation so that the patient can have a full course of
treatment divided into only 1-3 fractions (compared to a conventional fractionation
schedule that could be 15-17 treatments). This will also allow us to treat more
invasive tumors (such as nasal tumors) with fewer side effects. This will be among the
most advanced radiotherapy systems in veterinary medicine. This should be much
more appealing to clients while also upgrading the care to their pets. So, those are
the exciting additions (unless you consider our new high-def colonoscope exciting!).
Our blood donor program is one of our interesting projects that is progressing nicely.
This is led by our new board-certified criticalist, Dr. Tracy Julius. The program rivals
that of any commercial or academic blood bank, and the best part is our employees’
and clients’ pets supply the blood. Another great program is our employee engagement (workplace passion). We have an incredible staff, and we have instituted several
actions to make them even more passionate about their work. Feel free to contact me
for some of our team’s ideas. Our VSH Green Team is also in high gear. For example,
we just replaced every fluorescent light with an LED light. It is amazing how much
power this saves in a 27,000 sq ft building.
I will also use this opportunity as a shameless plug for our lab (STAT Veterinary Lab).
With Dr. Andy Loar’s guidance, the lab has evolved into an elite reference laboratory.
If you could get better quality, better service, faster results, and cheaper prices, why
wouldn’t you use it? Even if you have an existing contract, maybe use us for sameday cytology results, stat samples, or whatever you want. Just give us a call!
Check out our Symposium program for Sunday May 19th. Dr. Mike Lappin is the
keynote speaker for veterinarians; Harold Davis highlights the tech program; there is a
practical management track, workshops, all at a spectacular venue! Don’t miss it!!
Well, the football season is over, so for me that means I’m back on clinics on Saturdays and Sundays. Yes, you read it correctly. I’m happy to see new referrals (including
urgent cases) or a patient needing an ultrasound or endoscopy exam on both
weekend days, so bring it on. Sadly I’ll miss the Sunday day games at Petco Park…
see the sacrifice I’m willing to make?
Enjoy the Spring everyone!
Keith Richter, DVM
Diplomate ACVIM
Nonhealing
Corneal Ulcers
Zonisamide and
Levetiracetam for
Adjunctive Seizure
Management —PART 1
by HOLLY L. HAMILTON, DVM, MS, DIPLOMATE ACVO
by Tammy Stevenson, DVM, Diplomate ACVIM (Neurology)
Introduction
Indolent corneal ulcer, refractory corneal erosion, persistent
corneal ulcer, recurrent corneal erosion syndrome, Boxer ulcer, and
spontaneous chronic corneal epithelial defect (SCCED) all describe
a type of superficial corneal ulcer that is slow to heal, does not
heal, or recurs. Expected to heal within 5-7 days, these superficial
corneal ulcers can persist for 6 months or longer. Many breeds are
subject to this condition which usually affects middle age to older
dogs (>8 years). The pathophysiology resulting in abnormal healing
is complex. The basement membrane of the corneal epithelium has
abnormal attachment to the corneal stroma or is discontinuous
commonly with loss of the normal epithelial architecture. Beneath
the ulcer is an acellular hyalinized zone in the corneal stroma that
provides an additional barrier to epithelial cells adhering to the
underlying stroma.
Clinical Findings
Clinical signs of indolent corneal ulcers are similar to other ulcers
and include: pain, lacrimation, photophobia, and blepharospasm.
The intensity of pain tends to decrease with chronicity. These
ulcers are slow healing or unresponsive to traditional therapy. The
ulcers can change shape and size which initially is often misinterpreted as healing. Indolent corneal ulcers are superficial ulcers
with no loss of corneal stroma and a characteristic nonadherent lip
of epithelium. Fluorescein stain migrates under the adjacent
corneal epithelium. Many patients have intense corneal vascularization. The hallmark of an indolent ulcer is the loose corneal
epithelium. After instillation of topical anesthesia (proparacaine)
the edges of an indolent ulcer will peel back when gently touched
with a cotton-tipped applicator, often significantly increasing the
size of the ulcer.
Treatment
Healing of indolent ulcers requires a specific method of corneal
debridement. Keratotomy is used to debride degenerate basement
membrane and expose the healthy stroma. This is achieved through
grid or multipunctate keratotomy or more recently, use of a
diamond tipped corneal burr. A cotton tip applicator provides
debridement of the epithelium but not the basement membrane and
is inadequate for debridement of an indolent ulcer. A grid keratotomy (GK) is performed with a small gauge needle creating overlapping vertical and horizontal lines. Multiple punctate keratotomy
(MPK) is a series of small anterior stromal punctures just below the
basement membrane. A rotary diamond burr provides a newer
method of corneal debridement that is safer and yields faster
healing with less scar tissue. All three procedures remove abnormal basement membrane and anterior stroma and in many cases
can be performed with just topical anesthesia. Superficial keratectomy has a high success rate for indolent corneal ulcers, but
requires general anesthesia.
Other Considerations
Case selection is essential. Corneal debridement by MPK, GK, or
corneal burr is indicated only for superficial ulcers that are not
healing due to the abnormal basement membrane. If corneal
debridement is performed in the wrong cases, severe complications
can occur ranging from slower corneal healing to corneal perforation. Tragic results could occur if these methods of keratotomy are
applied to descemetoceleles, deep corneal ulcers, infected or
melting ulcers. Cats frequently have corneal ulcers secondary to
feline herpes virus and application of MPK or GK will result in a
deeper corneal herpes infection (interstitial keratitis) and predispose to formation of corneal sequestrum.
Phenobarbital (PB) and potassium bromide (KBr) are the drugs most
veterinarians choose as the initial therapy for seizures. Phenobarbital
seems to provide the most reliable seizure control for the most
patients1 with generally few adverse effects (blood dyscrasias,
hepatotoxicity, superficial necrolytic dermatitis, dyskensis), which are
reversible if caught early. Potassium bromide is also a good anticonvulsant, although not as reliable as phenobarbital.1 Adverse effects
(pancreatitis, panniculitis, and anecdotally megaesophagus) are rare.
Gastroenteritis is more common but can usually be managed by
dividing the dose and giving it with food. Potassium bromide should
not be used in cats due to the risk of life threatening eosinophilic
pulmonary infiltrates causing an asthma-like condition.
There are many external causes for delayed healing of superficial
corneal ulcers including eyelid abnormalities (distichia, ectopic
cilia, entropion, eyelid mass, and foreign body), low tear production, qualitative tear film deficiencies, infection, lagophthalmos or
facial nerve paralysis. In cats feline herpes virus is the most
frequent cause of corneal ulceration. These underlying issues need
to be addressed.
Both KBr and PB have inconvenient side effects (sedation, pelvic limb
weakness, PU/PD and polyphagia), so therefore it may be desirable to
choose an alternative adjunctive therapy when a patient is failing one
of these first line therapies.
Keratotomy performed incorrectly has potential for serious
consequences. Appropriate topical analgesic and patient restraint
are essential. Corneal perforation can result from selection of a
large bore needle. Epithelial inclusion cysts can be created when
the corneal epithelium is inadvertently introduced into the deep
stromal layers producing small, white lesions in cornea that may
ulcerate and can be painful.
MPK, GK, or corneal burr debridement are beneficial and frequently necessary for healing of indolent corneal ulcers, but are not
without complications. They have a very specific and unique
indication: indolent corneal ulcers.
Zonisamide and levetiracetam are now available in generic form, and
have therefore become far less expensive. In my experience, they tend
to be less reliable when used as the sole anticonvulsant and are better
reserved for adjunctive therapy.
Zonisamide is a sulfonamide-based drug and a weak carbonic anhydrase inhibitor. It inhibits voltage gated sodium channels and T-type
calcium channels, enhances GABA release and inhibits glutamate
release.2 It is 70% bioavailable and mostly excreted in the urine. About
20% is metabolized, primarily in the liver. 3 Therefore, co-administration of phenobarbital will increase its clearance.4 The half-life is 15-20
hours in the dog (steady state will be achieved in 3-4 days) and 33
hours in the cat (steady state in 6 days). 3,5 The dose range for dogs is
3-12 mg/kg BID, and for cats 5-20 mg/kg SID-BID. We typically start
both at 8-10 mg/kg BID. It comes in 25, 50, 100 mg capsules. We rarely
appreciate significant side effects in our patients, however sedation,
ataxia, gastrointestinal upset and weight loss have been reported.6
Possible adverse reactions include those associated with other sulfa
drugs such as immune-mediated disease (KCS, polyarthritis, IMHA),
and there have been two cases of apparent hepatotoxicity 7,8 and one
case of renal tubular acidosis9 attributed to zonisamide therapy.
Levetiracetam is a pyrrolidine-based anticonvulsant whose mechanism
has not been fully elucidated. It does work at synpatic vesicle protein
2A to reduce presynaptic neurotransmiter release (regulates exocytosis)
but it may have more than one mechanism of action.10 It is 100%
bioavailable, and even though there is no apparent hepatic metabolism,
Fig. 1: Indolent corneal ulcer in a dog with
loose surrounding corneal epithelium and
corneal vascularization.
Fig. 2: Diamond corneal burr
debridement of an indolent ulcer
in a dog.
there is increased clearance when used in conjunction with phenobarbital.11 The reason for this is not understood. It is 70% eliminated in
urine, and the remainder is hydrolyzed in serum and organs other than
the liver.6 The half-life in dogs is 3-4 hours and in cats 2-4 hours.12,13
The recommended starting dose is 20mg/kg TID.12,13 It comes in 100mg/
ml oral solution, 250mg, 500mg, 750mg and 1000mg tablets and
100mg/ml IV solution. The greatest disadvantage is the necessity for TID
dosing. If the patient is 20 kg or greater extended release tablets may
be used at 20 mg/kg BID (500mg, and 750mg formulations). Of course,
these tablets should not be split. Some clients have reported seeing the
tablets undigested in feces, so they may not work well in all dogs.
Levetiracetam is very safe; even at 6x the recommended dose, the side
effects (salivation, restlessness, ataxia, vomiting) resolve within 24
hours.6 At normal doses it has no greater side effects than placebo in
dogs.14 Levetiracetam appears to have a “honeymoon effect” in many
veterinary patients. It works well initially but then tolerance develops
within several months and it becomes ineffective. The study reporting
this finding, noted tolerance in 6/9 patients by 8 months of therapy.14
Auburn University, College of Veterinary Medicine can assay serum
drug levels for both of these anticonvulsants. Peak and trough levels
are ideal with the rapidly metabolized levetiracetam. Drug levels are
expensive and usually reserved for patients that are unusually sedate
(that may be experiencing an overdose) or have poor control of
seizures despite increasing doses.
Look for Part II of this article on strategic anticonvulsant use in the
next Connected newsletter.
Please visit the Connected-Newsletter page under the Veterinarian
tab on our website for a list of references.
Richter scale
Greetings Colleagues,
I hope you are all having a great start to 2013. I’m starting my quarterly update with
some of our plans for “big” equipment changes. We have just completed the installation of our new MRI. This unit is a true state-of-the-art 1.5T unit, with incredible
software and image quality. It does everything but do the laminectomy for us! I
thought our former unit was pretty good, but technology has really come a long way.
This will open us up to imaging other body parts far beyond the nervous system. Put
simply, the scans are better and faster. We are also upgrading our linear accelerator
to provide stereotactic radiosurgery (STS). This is a technology that allows a much
more focused delivery of radiation so that the patient can have a full course of
treatment divided into only 1-3 fractions (compared to a conventional fractionation
schedule that could be 15-17 treatments). This will also allow us to treat more
invasive tumors (such as nasal tumors) with fewer side effects. This will be among the
most advanced radiotherapy systems in veterinary medicine. This should be much
more appealing to clients while also upgrading the care to their pets. So, those are
the exciting additions (unless you consider our new high-def colonoscope exciting!).
Our blood donor program is one of our interesting projects that is progressing nicely.
This is led by our new board-certified criticalist, Dr. Tracy Julius. The program rivals
that of any commercial or academic blood bank, and the best part is our employees’
and clients’ pets supply the blood. Another great program is our employee engagement (workplace passion). We have an incredible staff, and we have instituted several
actions to make them even more passionate about their work. Feel free to contact me
for some of our team’s ideas. Our VSH Green Team is also in high gear. For example,
we just replaced every fluorescent light with an LED light. It is amazing how much
power this saves in a 27,000 sq ft building.
I will also use this opportunity as a shameless plug for our lab (STAT Veterinary Lab).
With Dr. Andy Loar’s guidance, the lab has evolved into an elite reference laboratory.
If you could get better quality, better service, faster results, and cheaper prices, why
wouldn’t you use it? Even if you have an existing contract, maybe use us for sameday cytology results, stat samples, or whatever you want. Just give us a call!
Check out our Symposium program for Sunday May 19th. Dr. Mike Lappin is the
keynote speaker for veterinarians; Harold Davis highlights the tech program; there is a
practical management track, workshops, all at a spectacular venue! Don’t miss it!!
Well, the football season is over, so for me that means I’m back on clinics on Saturdays and Sundays. Yes, you read it correctly. I’m happy to see new referrals (including
urgent cases) or a patient needing an ultrasound or endoscopy exam on both
weekend days, so bring it on. Sadly I’ll miss the Sunday day games at Petco Park…
see the sacrifice I’m willing to make?
Enjoy the Spring everyone!
Keith Richter, DVM
Diplomate ACVIM
Nonhealing
Corneal Ulcers
Zonisamide and
Levetiracetam for
Adjunctive Seizure
Management —PART 1
by HOLLY L. HAMILTON, DVM, MS, DIPLOMATE ACVO
by Tammy Stevenson, DVM, Diplomate ACVIM (Neurology)
Introduction
Indolent corneal ulcer, refractory corneal erosion, persistent
corneal ulcer, recurrent corneal erosion syndrome, Boxer ulcer, and
spontaneous chronic corneal epithelial defect (SCCED) all describe
a type of superficial corneal ulcer that is slow to heal, does not
heal, or recurs. Expected to heal within 5-7 days, these superficial
corneal ulcers can persist for 6 months or longer. Many breeds are
subject to this condition which usually affects middle age to older
dogs (>8 years). The pathophysiology resulting in abnormal healing
is complex. The basement membrane of the corneal epithelium has
abnormal attachment to the corneal stroma or is discontinuous
commonly with loss of the normal epithelial architecture. Beneath
the ulcer is an acellular hyalinized zone in the corneal stroma that
provides an additional barrier to epithelial cells adhering to the
underlying stroma.
Clinical Findings
Clinical signs of indolent corneal ulcers are similar to other ulcers
and include: pain, lacrimation, photophobia, and blepharospasm.
The intensity of pain tends to decrease with chronicity. These
ulcers are slow healing or unresponsive to traditional therapy. The
ulcers can change shape and size which initially is often misinterpreted as healing. Indolent corneal ulcers are superficial ulcers
with no loss of corneal stroma and a characteristic nonadherent lip
of epithelium. Fluorescein stain migrates under the adjacent
corneal epithelium. Many patients have intense corneal vascularization. The hallmark of an indolent ulcer is the loose corneal
epithelium. After instillation of topical anesthesia (proparacaine)
the edges of an indolent ulcer will peel back when gently touched
with a cotton-tipped applicator, often significantly increasing the
size of the ulcer.
Treatment
Healing of indolent ulcers requires a specific method of corneal
debridement. Keratotomy is used to debride degenerate basement
membrane and expose the healthy stroma. This is achieved through
grid or multipunctate keratotomy or more recently, use of a
diamond tipped corneal burr. A cotton tip applicator provides
debridement of the epithelium but not the basement membrane and
is inadequate for debridement of an indolent ulcer. A grid keratotomy (GK) is performed with a small gauge needle creating overlapping vertical and horizontal lines. Multiple punctate keratotomy
(MPK) is a series of small anterior stromal punctures just below the
basement membrane. A rotary diamond burr provides a newer
method of corneal debridement that is safer and yields faster
healing with less scar tissue. All three procedures remove abnormal basement membrane and anterior stroma and in many cases
can be performed with just topical anesthesia. Superficial keratectomy has a high success rate for indolent corneal ulcers, but
requires general anesthesia.
Other Considerations
Case selection is essential. Corneal debridement by MPK, GK, or
corneal burr is indicated only for superficial ulcers that are not
healing due to the abnormal basement membrane. If corneal
debridement is performed in the wrong cases, severe complications
can occur ranging from slower corneal healing to corneal perforation. Tragic results could occur if these methods of keratotomy are
applied to descemetoceleles, deep corneal ulcers, infected or
melting ulcers. Cats frequently have corneal ulcers secondary to
feline herpes virus and application of MPK or GK will result in a
deeper corneal herpes infection (interstitial keratitis) and predispose to formation of corneal sequestrum.
Phenobarbital (PB) and potassium bromide (KBr) are the drugs most
veterinarians choose as the initial therapy for seizures. Phenobarbital
seems to provide the most reliable seizure control for the most
patients1 with generally few adverse effects (blood dyscrasias,
hepatotoxicity, superficial necrolytic dermatitis, dyskensis), which are
reversible if caught early. Potassium bromide is also a good anticonvulsant, although not as reliable as phenobarbital.1 Adverse effects
(pancreatitis, panniculitis, and anecdotally megaesophagus) are rare.
Gastroenteritis is more common but can usually be managed by
dividing the dose and giving it with food. Potassium bromide should
not be used in cats due to the risk of life threatening eosinophilic
pulmonary infiltrates causing an asthma-like condition.
There are many external causes for delayed healing of superficial
corneal ulcers including eyelid abnormalities (distichia, ectopic
cilia, entropion, eyelid mass, and foreign body), low tear production, qualitative tear film deficiencies, infection, lagophthalmos or
facial nerve paralysis. In cats feline herpes virus is the most
frequent cause of corneal ulceration. These underlying issues need
to be addressed.
Both KBr and PB have inconvenient side effects (sedation, pelvic limb
weakness, PU/PD and polyphagia), so therefore it may be desirable to
choose an alternative adjunctive therapy when a patient is failing one
of these first line therapies.
Keratotomy performed incorrectly has potential for serious
consequences. Appropriate topical analgesic and patient restraint
are essential. Corneal perforation can result from selection of a
large bore needle. Epithelial inclusion cysts can be created when
the corneal epithelium is inadvertently introduced into the deep
stromal layers producing small, white lesions in cornea that may
ulcerate and can be painful.
MPK, GK, or corneal burr debridement are beneficial and frequently necessary for healing of indolent corneal ulcers, but are not
without complications. They have a very specific and unique
indication: indolent corneal ulcers.
Zonisamide and levetiracetam are now available in generic form, and
have therefore become far less expensive. In my experience, they tend
to be less reliable when used as the sole anticonvulsant and are better
reserved for adjunctive therapy.
Zonisamide is a sulfonamide-based drug and a weak carbonic anhydrase inhibitor. It inhibits voltage gated sodium channels and T-type
calcium channels, enhances GABA release and inhibits glutamate
release.2 It is 70% bioavailable and mostly excreted in the urine. About
20% is metabolized, primarily in the liver. 3 Therefore, co-administration of phenobarbital will increase its clearance.4 The half-life is 15-20
hours in the dog (steady state will be achieved in 3-4 days) and 33
hours in the cat (steady state in 6 days). 3,5 The dose range for dogs is
3-12 mg/kg BID, and for cats 5-20 mg/kg SID-BID. We typically start
both at 8-10 mg/kg BID. It comes in 25, 50, 100 mg capsules. We rarely
appreciate significant side effects in our patients, however sedation,
ataxia, gastrointestinal upset and weight loss have been reported.6
Possible adverse reactions include those associated with other sulfa
drugs such as immune-mediated disease (KCS, polyarthritis, IMHA),
and there have been two cases of apparent hepatotoxicity 7,8 and one
case of renal tubular acidosis9 attributed to zonisamide therapy.
Levetiracetam is a pyrrolidine-based anticonvulsant whose mechanism
has not been fully elucidated. It does work at synpatic vesicle protein
2A to reduce presynaptic neurotransmiter release (regulates exocytosis)
but it may have more than one mechanism of action.10 It is 100%
bioavailable, and even though there is no apparent hepatic metabolism,
Fig. 1: Indolent corneal ulcer in a dog with
loose surrounding corneal epithelium and
corneal vascularization.
Fig. 2: Diamond corneal burr
debridement of an indolent ulcer
in a dog.
there is increased clearance when used in conjunction with phenobarbital.11 The reason for this is not understood. It is 70% eliminated in
urine, and the remainder is hydrolyzed in serum and organs other than
the liver.6 The half-life in dogs is 3-4 hours and in cats 2-4 hours.12,13
The recommended starting dose is 20mg/kg TID.12,13 It comes in 100mg/
ml oral solution, 250mg, 500mg, 750mg and 1000mg tablets and
100mg/ml IV solution. The greatest disadvantage is the necessity for TID
dosing. If the patient is 20 kg or greater extended release tablets may
be used at 20 mg/kg BID (500mg, and 750mg formulations). Of course,
these tablets should not be split. Some clients have reported seeing the
tablets undigested in feces, so they may not work well in all dogs.
Levetiracetam is very safe; even at 6x the recommended dose, the side
effects (salivation, restlessness, ataxia, vomiting) resolve within 24
hours.6 At normal doses it has no greater side effects than placebo in
dogs.14 Levetiracetam appears to have a “honeymoon effect” in many
veterinary patients. It works well initially but then tolerance develops
within several months and it becomes ineffective. The study reporting
this finding, noted tolerance in 6/9 patients by 8 months of therapy.14
Auburn University, College of Veterinary Medicine can assay serum
drug levels for both of these anticonvulsants. Peak and trough levels
are ideal with the rapidly metabolized levetiracetam. Drug levels are
expensive and usually reserved for patients that are unusually sedate
(that may be experiencing an overdose) or have poor control of
seizures despite increasing doses.
Look for Part II of this article on strategic anticonvulsant use in the
next Connected newsletter.
Please visit the Connected-Newsletter page under the Veterinarian
tab on our website for a list of references.
CONNECTED
In Our Community
Complimentary Eye Exams for Service Dogs in May
VSH Ophthalmologists Dr. Holly Hamilton and Dr. Nicole Roybal will participate in the
ACVO/Merial National Service Dog Eye Exam program that helps serve the dogs who
dedicate their lives to serving us. Please help get the word out to your appropriate clients.
They must first register online at www.ACVOeyexam.org. Appointments are filled on a firstcome, first-served basis.
10435 Sorrento Valley Rd
Suite 100
San Diego, CA 92121
FACE Foundation’s 3rd Annual Bags & Baubles Fundraiser
This year’s Bags & Baubles event is Sunday, April 28th! The silent
auction will include over 300 new and gently-loved designer handbags,
stunning jewelry, and a new men’s section with designer ties, belts, and
wallets. With raffle prizes, wine tasting, estate tours, and delicious
appetizers, this event promises a good time for all. 100% of the
proceeds will benefit family pets in need of life-saving veterinary care!
Free to attend; RSVP required. Contact: [email protected].
TAKE NOTE
cURRENT CLINICAL TRIALs
* NEW * Internal Medicine – Effectiveness of Maropitant (Cerenia)
in Cats with Liver Disease
Dr. 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, and
clients receive significant financial incentives.
Contact Dr. Keith Richter at (858) 875-7500.
* NEW * Internal Medicine – Feline Hepatic Lipidosis Study
Now 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#3
Now 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 Study
VSH 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
Y o u r L i n k t o V e t e r i n a r y S P E C IA L T Y H O S P ITA L | A P R – J UN 2 0 1 3
The Morris Animal Foundation’s Canine
Cancer Walk on February 23 was a
tremendous success! Thanks to
everyone for supporting Cancer Bites,
the VSH team. Over $60,000 was
raised, with over $20,000 just from our
team - more than 5 times the amount
raised by any other team! We were also
the recipient of several awards.
Oncology – Canine Solid Tumor and Mast Cell Tumor Trials
Trials examining novel biologic therapy for dogs with
MEASUREABLE mast cell tumors and other solid tumors,
excluding osteosarcoma.
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 (858) 875-7500
Oncology – Dogs Receiving Doxorubicin
We are investigating the benefit of Fortiflora™ nutritional
supplement in dogs receiving doxorubicin chemotherapy.
Dogs already receiving doxorubicin are eligible.
Contact: Dr. Andi Flory (760) 466-0600 or (858) 875-7500 x719
For more details about these and other clinical trials, please visit
our website at www.vshsd.com.
WE’RE LISTENING
If you don’t have time for a Lunch and Learn program, our
specialists are available for brief, 30 minutes or less presentations
for you and your staff. It could be a quick refresher on a procedure
or disease, a general question and answer session or simply an
opportunity to find out more about one of our services. It’s our
pleasure to present this to you, and we’ll even bring a snack!
Please visit www.vshsd.com/togo or contact Caren Folbre
at (858) 875-7580.
LIKE US ON FACEBOOK TO KEEP
UP WITH THE LATEST VSH NEWS
AND HAPPENINGS!
www.facebook.com/VeterinarySpecialtyHospital
Announcements
Dr. Sean Aiken spoke on mobile veterinary surgery at the recent
VSIPP meeting held in February in Coronado.
Escherichia coli and response to fluoroquinolone antimicrobials.
J Vet Intern Med. 2013 Jan-Feb;27(1):56-61. doi: 10.1111/jvim.12020.
Epub 2012 Dec 3.
Berghoff N, Parnell NK, Hill SL, Suchodolski JS, Steiner JM. Serum cobalamin and methylmalonic acid concentrations in dogs with chronic gastrointestinal disease. Am J Vet Res. 2013 Jan;74(1):84-9. doi: 10.2460/ajvr.74.1.84.
On March 15, Drs. Fred Pike and Josh Jackson participated in a
ground-breaking session that featured a live, video-link case-based
tibial plateau leveling osteotomy. The goal of the session was to
provide an overview of the TPLO technique with a primary focus on
aseptic surgical technique and surgical anatomy. Attendees at the
AAHA meeting in Phoenix obtained a brief overview of the TPLO
concept and watched a live surgery from San Diego.
Dr. Marie Chartier, third year Internal Medicine resident will be presenting
an abstract at the ACVIM 2013 Annual Forum in Seattle, Washington on
Evaluation of Canine Pancreas-specific Lipase (Spec cPL®) Concentration
and, Amylase and Lipase Activities in Peritoneal Fluid as Complementary
Diagnostic Tools for Acute Pancreatitis in Dogs.
Dr. Fred Pike and Dr. Sean Aiken presented a poster at this year’s
VOS (Veterinary Orthopedic Society) meeting in Colorado on a new
technique for the surgical management of patella alta.
Dr. Keith Richter is editing the Hepatobiliary/Pancreas section of Veterinary
Clinical Advisor (3rd Ed). His chapter on Feline Gastrointestinal Lymphoma in
Current Veterinary Therapy XV should be coming out soon.
In March, Dr. Andi Flory was invited to lecture at City University
in Hong Kong in conjunction with the Hong Kong Veterinary
Association. The topic was lymphoma therapy in dogs and cats.
Dr. Keith Richter recently spoke on behalf of the Comparative Gastroenterology Society at the most recent North American Veterinary Conference.
Dr. Brenda Phillips presented a lecture, “Veterinary Oncology
Diagnostics” at last month’s SDCVMA Sunday Specialists’ series.
Dr. Nicole Boynosky, third year dermatology resident, will be
presenting the abstract from her residency research project
entitled A Retrospective Evaluation of the Prevalence, Antimicrobial
Sensitivity, and Clinical Response of Corynebacterium spp. in Canine
Dermatitis at the North American Veterinary Dermatology Forum in
Louisville Kentucky on April 18.
Dr. Steve Hill will be speaking at the ACVIM 2013 Annual Forum
in Seattle, Washington, June 12-15 in the CGS GI tract on PLE.
Dr. Hill has also been co-author on three recent publications:
Arnell K, Hill S, Hart J, Richter K. Persistent regurgitation in four
dogs with caudal esophageal neoplasia. J Am Anim Hosp Assoc.
2013 Jan-Feb;49(1):58-63. doi: 10.5326/JAAHA-MS-5826. Epub
2012 Nov 12.
Manchester AC, Hill S, Sabatino B, Armentano R, Carroll M, Kessler
B, Miller M, Dogan B, McDonough SP, Simpson KW. Association
between granulomatous colitis in French Bulldogs and invasive
Drs. Andi Flory, Margo Karriker and Brenda Phillips, have completed a chapter on
veterinary chemotherapy safety to be published in Current Veterinary Therapy
XV. These doctors are also part of a panel that is completing a nationwide
consensus document on veterinary chemotherapy safety that will be published
and will likely be the worldwide guide for veterinary chemotherapy safety.
save the date
May 19, 2013 – VSH 3rd Annual Symposium
8:00 am - 4:30 pm at the University of San Diego
2 Vet Tracks, 1 Tech Track, 1 Mgmt Track + Workshops!
Register online now at www.vshsd.com/symposium.
April 18, 2013 – Educational Dinner Program
6:00 pm at Mia Francesca (Del Mar)
Nutrition and Veterinary Orthopedics: Bridging the Chasm
Mauricio Dujowich, DVM, DACVS
Sponsored by Hill’s Pet Nutrition
RSVP by April 10th: [email protected]
or leave message at 1-800-255-2403 ext 6401.
Nonhealing
Corneal Ulcers
IN THIS ISSUE:
Zonisamide and Levetiracetam
for Adjunctive Seizure
Management — PART 1
Clinical Trials
Upcoming Events
SAN DIEGO 10435 Sorrento Valley Rd San Diego, CA 92121 | NORTH COUNTY 2055 Montiel Rd San Marcos, CA 92069 | www.vshsd.com
CONNECTED
In Our Community
Complimentary Eye Exams for Service Dogs in May
VSH Ophthalmologists Dr. Holly Hamilton and Dr. Nicole Roybal will participate in the
ACVO/Merial National Service Dog Eye Exam program that helps serve the dogs who
dedicate their lives to serving us. Please help get the word out to your appropriate clients.
They must first register online at www.ACVOeyexam.org. Appointments are filled on a firstcome, first-served basis.
10435 Sorrento Valley Rd
Suite 100
San Diego, CA 92121
FACE Foundation’s 3rd Annual Bags & Baubles Fundraiser
This year’s Bags & Baubles event is Sunday, April 28th! The silent
auction will include over 300 new and gently-loved designer handbags,
stunning jewelry, and a new men’s section with designer ties, belts, and
wallets. With raffle prizes, wine tasting, estate tours, and delicious
appetizers, this event promises a good time for all. 100% of the
proceeds will benefit family pets in need of life-saving veterinary care!
Free to attend; RSVP required. Contact: [email protected].
TAKE NOTE
cURRENT CLINICAL TRIALs
* NEW * Internal Medicine – Effectiveness of Maropitant (Cerenia)
in Cats with Liver Disease
Dr. 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, and
clients receive significant financial incentives.
Contact Dr. Keith Richter at (858) 875-7500.
* NEW * Internal Medicine – Feline Hepatic Lipidosis Study
Now 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#3
Now 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 Study
VSH 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
Y o u r L i n k t o V e t e r i n a r y S P E C IA L T Y H O S P ITA L | A P R – J UN 2 0 1 3
The Morris Animal Foundation’s Canine
Cancer Walk on February 23 was a
tremendous success! Thanks to
everyone for supporting Cancer Bites,
the VSH team. Over $60,000 was
raised, with over $20,000 just from our
team - more than 5 times the amount
raised by any other team! We were also
the recipient of several awards.
Oncology – Canine Solid Tumor and Mast Cell Tumor Trials
Trials examining novel biologic therapy for dogs with
MEASUREABLE mast cell tumors and other solid tumors,
excluding osteosarcoma.
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 (858) 875-7500
Oncology – Dogs Receiving Doxorubicin
We are investigating the benefit of Fortiflora™ nutritional
supplement in dogs receiving doxorubicin chemotherapy.
Dogs already receiving doxorubicin are eligible.
Contact: Dr. Andi Flory (760) 466-0600 or (858) 875-7500 x719
For more details about these and other clinical trials, please visit
our website at www.vshsd.com.
WE’RE LISTENING
If you don’t have time for a Lunch and Learn program, our
specialists are available for brief, 30 minutes or less presentations
for you and your staff. It could be a quick refresher on a procedure
or disease, a general question and answer session or simply an
opportunity to find out more about one of our services. It’s our
pleasure to present this to you, and we’ll even bring a snack!
Please visit www.vshsd.com/togo or contact Caren Folbre
at (858) 875-7580.
LIKE US ON FACEBOOK TO KEEP
UP WITH THE LATEST VSH NEWS
AND HAPPENINGS!
www.facebook.com/VeterinarySpecialtyHospital
Announcements
Dr. Sean Aiken spoke on mobile veterinary surgery at the recent
VSIPP meeting held in February in Coronado.
Escherichia coli and response to fluoroquinolone antimicrobials.
J Vet Intern Med. 2013 Jan-Feb;27(1):56-61. doi: 10.1111/jvim.12020.
Epub 2012 Dec 3.
Berghoff N, Parnell NK, Hill SL, Suchodolski JS, Steiner JM. Serum cobalamin and methylmalonic acid concentrations in dogs with chronic gastrointestinal disease. Am J Vet Res. 2013 Jan;74(1):84-9. doi: 10.2460/ajvr.74.1.84.
On March 15, Drs. Fred Pike and Josh Jackson participated in a
ground-breaking session that featured a live, video-link case-based
tibial plateau leveling osteotomy. The goal of the session was to
provide an overview of the TPLO technique with a primary focus on
aseptic surgical technique and surgical anatomy. Attendees at the
AAHA meeting in Phoenix obtained a brief overview of the TPLO
concept and watched a live surgery from San Diego.
Dr. Marie Chartier, third year Internal Medicine resident will be presenting
an abstract at the ACVIM 2013 Annual Forum in Seattle, Washington on
Evaluation of Canine Pancreas-specific Lipase (Spec cPL®) Concentration
and, Amylase and Lipase Activities in Peritoneal Fluid as Complementary
Diagnostic Tools for Acute Pancreatitis in Dogs.
Dr. Fred Pike and Dr. Sean Aiken presented a poster at this year’s
VOS (Veterinary Orthopedic Society) meeting in Colorado on a new
technique for the surgical management of patella alta.
Dr. Keith Richter is editing the Hepatobiliary/Pancreas section of Veterinary
Clinical Advisor (3rd Ed). His chapter on Feline Gastrointestinal Lymphoma in
Current Veterinary Therapy XV should be coming out soon.
In March, Dr. Andi Flory was invited to lecture at City University
in Hong Kong in conjunction with the Hong Kong Veterinary
Association. The topic was lymphoma therapy in dogs and cats.
Dr. Keith Richter recently spoke on behalf of the Comparative Gastroenterology Society at the most recent North American Veterinary Conference.
Dr. Brenda Phillips presented a lecture, “Veterinary Oncology
Diagnostics” at last month’s SDCVMA Sunday Specialists’ series.
Dr. Nicole Boynosky, third year dermatology resident, will be
presenting the abstract from her residency research project
entitled A Retrospective Evaluation of the Prevalence, Antimicrobial
Sensitivity, and Clinical Response of Corynebacterium spp. in Canine
Dermatitis at the North American Veterinary Dermatology Forum in
Louisville Kentucky on April 18.
Dr. Steve Hill will be speaking at the ACVIM 2013 Annual Forum
in Seattle, Washington, June 12-15 in the CGS GI tract on PLE.
Dr. Hill has also been co-author on three recent publications:
Arnell K, Hill S, Hart J, Richter K. Persistent regurgitation in four
dogs with caudal esophageal neoplasia. J Am Anim Hosp Assoc.
2013 Jan-Feb;49(1):58-63. doi: 10.5326/JAAHA-MS-5826. Epub
2012 Nov 12.
Manchester AC, Hill S, Sabatino B, Armentano R, Carroll M, Kessler
B, Miller M, Dogan B, McDonough SP, Simpson KW. Association
between granulomatous colitis in French Bulldogs and invasive
Drs. Andi Flory, Margo Karriker and Brenda Phillips, have completed a chapter on
veterinary chemotherapy safety to be published in Current Veterinary Therapy
XV. These doctors are also part of a panel that is completing a nationwide
consensus document on veterinary chemotherapy safety that will be published
and will likely be the worldwide guide for veterinary chemotherapy safety.
save the date
May 19, 2013 – VSH 3rd Annual Symposium
8:00 am - 4:30 pm at the University of San Diego
2 Vet Tracks, 1 Tech Track, 1 Mgmt Track + Workshops!
Register online now at www.vshsd.com/symposium.
April 18, 2013 – Educational Dinner Program
6:00 pm at Mia Francesca (Del Mar)
Nutrition and Veterinary Orthopedics: Bridging the Chasm
Mauricio Dujowich, DVM, DACVS
Sponsored by Hill’s Pet Nutrition
RSVP by April 10th: [email protected]
or leave message at 1-800-255-2403 ext 6401.
Nonhealing
Corneal Ulcers
IN THIS ISSUE:
Zonisamide and Levetiracetam
for Adjunctive Seizure
Management — PART 1
Clinical Trials
Upcoming Events
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