CONNECTED. Upcoming Events IN THIS ISSUE:

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1 CONNECTED Your Link to Veterinary SPECIALTY HOSPITAL OCT DEC 2015 Pemphigus foliaceus [ part 1] IN THIS ISSUE: Tips For Digital & Teleradiology Clinical Trials Upcoming Events SAN DIEGO Sorrento Valley Rd San Diego, CA NORTH COUNTY 2055 Montiel Rd San Marcos, CA

2 Richter scale Greetings Friends and Colleagues: I hope you are all having a busy and productive (but stress-free) year. We remain busy at VSH, and speaking to many of you, that seems to be the case all around. One of the cool things we just implemented is pet insurance as an employee benefit, whereby VSH is covering the premium costs for our team members (our plan pays for 90% of the medical bills). For VSH (and I suspect many of you), our staff members used to get a pretty nice discount, but despite that, some often wound up with large bills that they could not afford. Just as with our clients who have insurance, this totally takes money out of the equation. We are using a company called Figo, a relatively new player in the veterinary insurance field. So far we are very happy with them (and no, I am not getting anything by giving them a plug!). We did a lot of investigation into the different nuances of the various companies, and I am happy to share what we learned. From a business perspective, this already has great benefit for morale, and we expect that we will recoup most (if not all) of our premium costs by no longer having to discount fees. I ll try to remember to give you an update in a year or so to let you know how it s working (or feel free to check with me). It makes me wish pet insurance was more prevalent in our profession - so this is a plug for whatever company makes sense for you and please encourage your clients to enroll!). We are excited to announce the arrival of 4 new doctors to our staff, with 3 being familiar faces. Please read the Announcements section to find out more and how this helps increase the coverage of our surgery, radiology and especially the Emergency and Critical Care department in the North County. The exciting upcoming news at Stat Lab is the impending addition of histopathology. Dr. Loar s presence for cytology will be complemented by an anatomic pathologist(s). The equipment is in and validated and we have a scanning digital microscope that scans glass slides. This will allow us to send cases to any pathologist in the world, and we are now in the process of selecting our pathologist(s). Stay tuned! Lastly and sadly, being a Cubs fan is no longer the most pathetic thing in sports. It s now being a Padres and Chargers fan. I managed to attend 61 Padres games this year, and each one seemed to be more painful than the next. The one thing that made it pretty cool was still being able to go to a bunch of games with my dad, a long time Bronx native, and now converted former-yankee fan. As I get older I realize not to take that for granted. As for the Chargers, the only thing I can say is oy vay. Have a great finish to 2015 everybody! Keith Richter, DVM Diplomate ACVIM

3 Pemphigus foliaceus: BACKGROUND INFORMATION & DIAGNOSIS [ part 1] by Nicole A. Boynosky MS, BVMS Background and Clinical Presentation Pemphigus foliaceus (PF) is one of the most common autoimmune skin diseases in the dog and cat. There is no sex or breed predilection, however akitas and chow chows are overrepresented, as well as some other canine breeds. There is no obvious age distribution, however, it does tend to occur more commonly in middle aged to older dogs, with some cases reported in puppies. Most cases are idiopathic in nature, although given the breed predisposition in dogs, a genetic link is likely. UV light can be a trigger factor, and may also exacerbate the disease in patients already diagnosed with PF. There is also an association with drug administration which can include both systemic and topical mediations. The two biggest culprits in our experience are sulfa based antibiotics as well as cephalosporins. Although much less common, paraneoplastic PF has been reported in the literature. Many dermatologic lesions as well as the cytology from those lesions, can look very similar. Although it is not pathognomonic for PF, if the acantholytic cell is observed on cytology, it should raise suspicion. These cells result from immune mediated attack of the intercellular connections that hold the keratinocytes together in the stratum spinosum layer of the epidermis. Loss of this attachment results in rounded keratinocytes with an often centrally placed nucleus that resembles a fried egg. Acantholytic cells as well as leukocytes (mainly neutrophils and sometimes eosinophils) accumulate to form superficial pustules under or within the stratum corneum. Common lesions noted with PF are pustules, papules, coalescing crusts, erosive dermatitis, and alopecia. Paws are often involved and pads may exhibit hyperkeratosis, adherent crusts, and or fissures. Nasal planum can be affected resulting in depigmentation, loss of cobblestone texture, erosive dermatitis, and adherent crusts. We don t always observe intact papules or pustules, particularly in the cat. concurrent secondary infections are present. Mucosal and mucocutaneous lesions are less common to rare. More severely affected patients will often present with lethargy, lymphadenopathy, pyrexia, and anorexia. Diagnosis Acantholytic cells on cytology (ideally from an intact pustule), as well as absence of bacteria or infectious organisms should raise suspicion. If crusts are only present, it is beneficial to remove the overlying crust and perform a direct impression on the active area under the crust. When PF is suspected, 10x magnification should be used to scan the slide to look for abnormal cells. Once areas of concern are observed, higher magnification can be used, it is also important to use oil immersion to help identify the presence of bacteria. Confirmation with biopsy is relatively straightforward (ideally sent to a dermatopathologist). The punch should be centered over the lesion in question (i.e. pustule). There is no indication, to obtain a normal/abnormal skin sample. If intact pustules are not available, biopsy of skin with the overlying crust can be very beneficial and is oftentimes diagnostic. It is helpful to include crusts with the skin samples. Cytology should be used to help select areas. It is recommended to include as many samples as possible, usually 6 punches for most dermatopathologists. It is important NOT to surgically prep these areas as we do not want to scrub away the evidence. If there is concern of infection after the biopsy, the biopsy site can be flushed with the antiseptic of your choice. If the patient is not severely affected, and bacteria are observed, aerobic culture/susceptibility as well as clearing the infection prior to biopsy may be indicated. Stay tuned for part two; tips on differentiating PF from other disease based on lesion distribution and treatment. Onset can be rapid depending on the underlying cause, however it can also be insidious, particularly in the cat where it is not uncommon for waxing and waning of lesions. Lesions on the face, head, and ears are often quite striking. Ears (particularly concave pinna) often develop proliferative crusts, with otitis externa usually, but not always absent. Periocular lesions and lesions along the bridge of the nose are common sites for PF in dogs and cats, and can sometimes be the only areas affected. While nail beds, concave pinna, and the area surrounding the nipples are common sites in the cat. PF may be pruritic, particularly if Acantholytic cells at 10x magnification.

4 Tips For Digital & Teleradiology by Sarena Sunico, DVM, Diplomate ACVR With more and more veterinary practices transitioning to digital radiography, teleradiology consultations are on the rise. Ease of digital image transmission/submission, and quick turn-around times have greatly facilitated this trend in veterinary medicine. This transition has evolved quickly, and as with all new behaviors, it can be fraught with frustration. Below are some tricks and tips that will help you get the most out of your teleradiology interpretations with fewer calls, s, and repeat radiographs to follow up your interpretations. 1. Technique and positioning still matter. The switch to digital imaging has given us the gift of exposure latitude. This means that many images will have some ability to display the trunk and the extremities in the same image in a recognizable shade of grey. Unfortunately, this does not change the fact that curling the entire cat onto the imaging plate will NOT produce diagnostic images of the head, neck and extremities when truly aiming for the abdomen. When imaging the limbs and axial skeleton, radiologists still do rely on straight, orthogonal positioning to project anatomy in reliable ways so that abnormalities are evident. If you would like a radiologist to render an opinion on certain regions of interest, please include images centered on those regions of interest with appropriate positioning and exposure! 2. Review your studies before the patient goes home and get any needed extra images before you submit for an interpretation. This will greatly reduce the need for scheduling the patient to come back on the following day for additional radiographs after your interpretation comes back. a. If there is something that concerns you on the edge of one of the images, I will probably also be concerned and recommend more images! Consider getting orthogonal radiographs centered over an area of question before submitting for an interpretation and save the cost on the second interpretation and a follow up radiology appointment. b. While radiologists have specialized training in image interpretation, we are not magicians (but thank you for giving us so much credit!). If obliquity and exposure make a region completely uninterpretable to you, the likelihood that we will glean a diagnosis out of it is very low. 3. Consider converting all of your thoracic and at least some or your abdominal studies to three-view studies before submitting them for review. With digital radiography, image acquisition is usually much faster, technician time is reduced, and there is no film to waste. The cost difference between a three-projection study versus a two projection study is negligible. Please consider these scenarios: a. When evaluating the lung, three-view thoracic radiographs are the standard for metastasis check. b. When lung pathology is unilateral, it is always recommended to include the opposite lateral projection to better project that pathology in well-aerated, non-dependent lung. c. When radiographing an acutely vomiting animal, a left lateral projection will frequently move gas into the pyloric outflow tract and highlight the pyloric antrum and duodenum. Many pyloric foreign bodies can be diagnosed with this projection without a need for ultrasound! Consider a three-view abdomen any time you are radiographing an animal for vomiting. 4. Histories matter! History and physical exam findings help me rank the importance of radiographic findings and to help me make relevant recommendations. Please consider these scenarios: a. History provided: Lame. Whole body radiographs on a 12 year-old German Shepherd dog are provided. While finding orthopedic abnormalities on a 12 yr-old GSD is not hard, figuring out which one to work up will require your input on the findings from a thorough orthopedic/neurologic evaluation. Any more information you could provide would be helpful! Which leg? Which joint? Chronicity? Fever? Trauma history? Responds to medication? b. History provided: Vomiting. The 12 year-old cat that has been vomiting once daily and losing weight for the last 3 months is a very different scenario than the 2 year-old cat that has vomited 20 times in the last 6 hours and has a painful abdomen. For one history, a routine ultrasound exam appointment may be recommended, for the other scenario, an exploratory surgery or an emergency ultrasound exam would be better. 5. Don t your images. Take the time to find a teleradiology group that you like and get your hospital set up to submit DICOM images through a dedicated teleradiology platform. Each platform typically has staff that can help you troubleshoot the process of getting set up. This will expedite image submission and report turnaround time. It will also reduce image compression and loss of image quality. If you would like to discuss getting set up with the VSH teleradiology service, please give us a call at (858) Some of these tips may seem basic, but you would be surprised how many retake/follow-up radiographs or follow up conversations with your teleradiologist these simple tricks can help eliminate! VSH offers teleradiology services with our expanded radiology department. Please contact any of our board-certified radiologists: Drs. Miriam Shanaman, Sarena Sunico, and Jen White at (858)

5 In Our Community Please join us at the following community events: 4th Invitational Golf Tournament! Monday, Nov 2 Lomas Santa Fe Country Club Spend a day on the course with pros and pets! Tournament will be followed by cocktails, dinner, awards, and a live auction. Benefiting Canine Companions for Independence DogFest Walk n Roll Saturday, Nov 14, 8am-Noon NTC Park at Liberty Station December 1 January 2 Last year, in conjunction with the San Diego Food Bank, and with your help, we collected over 2 tons of food for dogs and cats throughout San Diego County. Please join us again as we try to reach our goal of 5,000 pounds of food to help keep families and their pets together! TAKE NOTE current CLINICAL TRIALs *NEW* Dermatology Topical Therapy for Hot Spots The Dermatology Service is recruiting patients for participation in a placebo-controlled clinical trial evaluating the efficacy of a topical steroid-free spray in the treatment of acute pyotraumatic dermatitis ( hot spots ). The lesion should receive no treatment prior to enrollment. Two visits will be required. All costs will be covered by the study. Contact the Dermatology Service at VSHSD (derm@vshsd.com) *NEW* Dermatology Blood Samples from Felines with History of Allergic Skin Disease The Dermatology Service is recruiting otherwise healthy cats with a history of any allergic skin disease for collection of a blood sample to be used in a study of feline allergy. Patients with manifestations of eosinophilic granuloma complex (indolent or rodent ulcers, eosinophilic plaques, eosinophilic granulomas) can be included. Subjects may not have received oral cyclosporine, oclacitinib, oral prednisone, or short-acting glucocorticoids for 2 weeks prior to their visit, and may not have received long-acting injectable glucocorticoids for 6 weeks prior to their visit. Contact Dr. Laura Stokking at laura.stokking@vshsd.com *NEW* Internal Medicine Feline IBD/GI Small Cell Lymphoma Study and Proteomics Study We are enrolling cats with chronic gastrointestinal disease that are suspected of having either inflammatory bowel disease (IBD) or gastrointestinal small cell lymphoma (GI SC LSA). Endoscopy will be performed and GI biopsies will be obtained for histopathology, immunohistochemistry (IHC) and PCR for antigen receptor rearrangements (PARR). A 3 week follow-up will be required. Blood, urine, and fecal samples will be collected for proteomic analysis at the time of endoscopy and follow-up visit. The cost of the histopathology, IHC and PARR is funded. GI panel is also funded by the proteomic study. Contact Drs. Betty Chow, Steve Hill or Keith Richter at (858) Internal Medicine Glucocorticoids and spec cpl study Patients who will be started on glucocorticoids (minimum dose of 0.5mg/kg/day) and will need to be on them for at least 3 weeks. Patients will receive a spec cpl prior to administration of any glucocorticoids and at least 3 weeks after starting glucocorticoid therapy at no charge. Contact Drs. Sarah Cocker or Keith Richter at (858) *NEW* Oncology New Canine Lymphoma Trial Please call if you have diagnosed, but not treated a dog with multicentric lymphoma and your client might be interested in a trial option. This study is partially funded. Enrollment is limited, so please let us know if you have a patient that might qualify. We are also still enrolling dogs previously treated with ONE Adriamycin-containing chemotherapy protocol who have relapsed but not been re-treated. Contact Dr. Brenda Phillips at or Dr. Andi Flory at Oncology Funded Trial for Dogs with Cancer Clients enrolling and completing a study evaluating the use of a probiotic along with chemotherapy will receive funding toward doxorubicin chemotherapy. Some breed or patient exclusions may apply. Contact Dr. Andi Flory at (760) or (858) Oncology Quality of Life for Cats with GI Lymphoma This is a trial that will lead to the design of a validated quality of life survey tool for cats with GI lymphoma. This will enable the profession to study different interventions that may impact quality of life. Clients will be required to fill out survey information to develop this tool. If you have an UNTREATED cat with GI lymphoma (or suspect GI lymphoma), they are eligible to participate. Contact Drs. Brenda Phillips or Keith Richter at (858) For more details about these and other clinical trials, please visit our website at

6 10435 Sorrento Valley Rd Suite 100 San Diego, CA San Diego: San Marcos: Announcements We are happy to announce the arrival of Dr. Matt Cleveland to our surgery department. Matt was a former VSH specialty intern, and then just completed his residency training at Angell Animal Medical Center in Boston, one of the top training programs in the country. Matt really enjoys orthopedic surgery, but also has a special interest in minimally invasive procedures including laparoscopy, thoracoscopy, and arthroscopy. Matt will be splitting his time at both the Sorrento Valley and North County locations so we now have a surgeon seeing appointments at North County and Sorrento Valley 6 days a week (and both locations have surgeons available 24/7). Dr. Jennifer Willey, DACVECC will be joining the emergency/ critical care department in mid-october. Jennifer completed her residency here at VSH, so we know she is superbly trained! We are also very excited that Dr. Meghan Collins just joined the emergency department at our North County location, so along with Dr. Willey there will be an experienced daytime emergency doctor 7 days a week. Lastly, we welcome back Dr. Sarena Sunico full-time to our radiology team! She was greatly missed and contributes to this issue of Connected with Tips for Digital & Teleradiology. WE RE LIStening save the date Fall CE Dinner & Program Treatment of Seizures: Rehashing and Hashish A practical guide to management of epileptic patients. Joy Delamaide Gasper, DVM, DACVIM (Neurology) Surgery: Fact or Fiction! This exciting lecture will focus on some of the most common questions we hear in daily practice. We hope to dispel some of the myths and shed light on some of the newest surgical techniques available. Each attendee will take home pearls that can immediately be used in general practice. Joshua Jackson, DVM, DACVS Fred Pike, DVM, DACVS Sean Aiken, MS, DVM, DACVS Katy Fryer, DVM, DACVS November 12, :00 pm to 9:00 pm Sorrento Valley Facility: Live Program and Dinner San Marcos Facility: Video Conferencing and Dinner Webinar also available April 17, 2016 VSH 6th Annual Symposium 8:00 am - 4:30 pm at the University of San Diego Multiple Educational Tracks for Veterinarians, Technicians, Managers and Front Office Staff! North County expands Emergency and Surgery services, and our specialists are on-call for emergent cases 24/7. Below is the NC Specialists Weekly Schedule. For more information on Continuing Education events, please visit vshsd.com/veterinarians or contact Ann Ong at (858) or ann.ong@vshsd.com.