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LeVine DN, Goggs R, Kohn B, Mackin AJ, Kidd L, Garden OA, Brooks MB, Eldermire ERB, Abrams-Ogg A, Appleman EH, Archer TM, Bianco D, Blois SL, Brainard BM, Callan MB, Fellman CL, Haines JM, Hale AS, Huang AA, Lucy JM, O'Marra SK, Rozanski EA, Thomason JM, Walton JE, Wilson HE. ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats. J Vet Intern Med 2024. [PMID: 38779941 DOI: 10.1111/jvim.17079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 05/25/2024] Open
Abstract
Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but there are no evidence-based guidelines to assist clinicians with treatment decisions. Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include secondary immunosuppressive drugs such as azathioprine, modified cyclosporine, and mycophenolate mofetil, usually selected based on clinician preference. Vincristine, human IV immunoglobulin (hIVIg), and transfusion of platelet or red blood cell-containing products are often used in more severe cases. Splenectomy and thrombopoietin receptor agonists are usually reserved for refractory cases, but when and in which patient these modalities should be employed is under debate. To develop evidence-based guidelines for individualized treatment of ITP patients, we asked 20 Population Intervention Comparison Outcome (PICO) format questions. These were addressed by 17 evidence evaluators using a literature pool of 288 articles identified by a structured search strategy. Evidence evaluators, using panel-designed templates and data extraction tools, summarized evidence and created guideline recommendations. These were integrated by treatment domain chairs and then refined by iterative Delphi survey review to reach consensus on the final guidelines. In addition, 19 non-PICO questions covering scenarios in which evidence was lacking or of low quality were answered by expert opinion using iterative Delphi surveys with panelist integration and refinement. Commentary was solicited from multiple relevant professional organizations before finalizing the consensus. The rigorous consensus process identified few comparative treatment studies, highlighting many areas of ITP treatment requiring additional studies. This statement is a companion manuscript to the ACVIM Consensus Statement on the Diagnosis of Immune Thrombocytopenia in Dogs and Cats.
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Affiliation(s)
- Dana N LeVine
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Barbara Kohn
- Small Animal Clinic, School of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Andrew J Mackin
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA
| | - Linda Kidd
- Linda Kidd Veterinary Internal Medicine Consulting, Carlsbad, California, USA
| | - Oliver A Garden
- School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Marjory B Brooks
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Erin R B Eldermire
- Flower-Sprecher Veterinary Library, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA
| | - Anthony Abrams-Ogg
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Elizabeth H Appleman
- Department of Internal Medicine, The Animal Medical Center, New York, New York, USA
| | - Todd M Archer
- Bluff City Veterinary Specialists, Memphis, Tennessee, USA
| | - Domenico Bianco
- College of Veterinary Medicine, Western University of Health Sciences, Pomona, California, USA
| | - Shauna L Blois
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Mary Beth Callan
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Claire L Fellman
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Jillian M Haines
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Anne S Hale
- Zia Pet Hospital, Rio Rancho, New Mexico, USA
| | | | - John M Lucy
- Oradell Animal Hospital, Paramus, New Jersey, USA
| | - Shana K O'Marra
- Northwest Veterinary Critical Care Services, Vancouver, Washington, USA
| | - Elizabeth A Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - John M Thomason
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA
| | - Jenny E Walton
- Veterinary Apheresis Service UK, Washington, Tyne and Wear, United Kingdom
| | - Helen E Wilson
- Langford Vets, University of Bristol, Langford, Somerset, United Kingdom
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Burroughs DL, Lorch G, Guo Y, Hill K, Schroeder EL, Cole LK, Phelps MA. Noncompartmental pharmacokinetics of three intravenous mycophenolate mofetil concentrations in healthy Standardbred mares. Vet Dermatol 2022; 34:222-234. [PMID: 35929548 DOI: 10.1111/vde.13109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/10/2022] [Accepted: 05/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is the prodrug of mycophenolic acid (MPA) which acts as an immunosuppressive agent. During the biotransformation of MMF to MPA, additional metabolites including MPA phenol glucuronide (MPAG), MPA acyl glucuronide (AcMPAG) and MPA phenol glucoside (MPG) are formed. OBJECTIVE To define the noncompartmental pharmacokinetic (PK) parameters of three single doses of intravenous (i.v.) MMF and its downstream metabolites in healthy horses. ANIMALS Six healthy Standardbred mares. MATERIALS AND METHODS Generic MMF (Par Pharmaceuticals; Chestnut Ridge, NY, USA) was reconstituted and administered as a single i.v. bolus at 1.0 mg/kg, 5.0 mg/kg and 10.0 mg/kg with an eight day washout between treatments. Blood samples were collected immediately before MMF administration and over 24 h. A liquid chromatography-tandem mass spectrometry assay was developed following FDA guidance to determine plasma MMF, MPA, MPAG, AcMPAG and MPG concentrations. Plasma concentrations were analysed independently, followed by calculation of geometric mean and coefficient of variation. RESULTS Noncompartmental PK parameters were determined for MMF and all metabolites at all doses. MMF was rapidly converted to MPA in all horses. Each incremental dose of MMF resulted in increases in Cmax and AUCinf _obs for MPA and the three additional metabolites. Within the 10-fold dose range, the increase in Cmax and AUCinf _obs for MMF and its metabolites was nonlinear. CONCLUSIONS AND CLINICAL RELEVANCE Horses biotransform MMF into MPA, MPAG, AcMPAG and MPG via the glucuronidation and glucosidation clearance pathways. Equine reference PK profiles for MPA and the metabolites, MPAG, AcMPAG and MPG were established.
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Affiliation(s)
- Dylan L Burroughs
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Gwendolen Lorch
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Yizhen Guo
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Kasey Hill
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Eric L Schroeder
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Lynette K Cole
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Mitch A Phelps
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, OH, USA
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Glucocorticoids, Cyclosporine, Azathioprine, Chlorambucil, and Mycophenolate in Dogs and Cats. Vet Clin North Am Small Anim Pract 2022; 52:797-817. [DOI: 10.1016/j.cvsm.2022.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Lautz LS, Jeddi MZ, Girolami F, Nebbia C, Dorne JLCM. Metabolism and pharmacokinetics of pharmaceuticals in cats (Felix sylvestris catus) and implications for the risk assessment of feed additives and contaminants. Toxicol Lett 2020; 338:114-127. [PMID: 33253781 DOI: 10.1016/j.toxlet.2020.11.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 01/25/2023]
Abstract
In animal health risk assessment, hazard characterisation of feed additives has been often using the default uncertainty factor (UF) of 100 to translate a no-observed-adverse-effect level in test species (rat, mouse, dog, rabbit) to a 'safe' level of chronic exposure in farm and companion animal species. Historically, both 10-fold factors have been further divided to include chemical-specific data in both dimensions when available. For cats (Felis Sylvestris catus), an extra default UF of 5 is applied due to the species' deficiency in particularly glucuronidation and glycine conjugation. This paper aims to assess the scientific basis and validity of the UF for inter-species differences in kinetics (4.0) and the extra UF applied for cats through a comparison of kinetic parameters between rats and cats for 30 substrates of phase I and phase II metabolism. When the parent compound undergoes glucuronidation the default factor of 4.0 is exceeded, with exceptions for zidovudine and S-carprofen. Compounds that were mainly renally excreted did not exceed the 4.0-fold default. Mixed results were obtained for chemicals which are metabolised by CYP3A in rats. When chemicals were administered intravenously the 4.0-fold default was not exceeded with the exception of clomipramine, lidocaine and alfentanil. The differences seen after oral administration might be due to differences in first-pass metabolism and bioavailability. Further work is needed to further characterise phase I, phase II enzymes and transporters in cats to support the development of databases and in silico models to support hazard characterisation of chemicals particularly for feed additives.
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Affiliation(s)
- L S Lautz
- Radboud University Nijmegen, Houtlaan 4, 6525 XZ Nijmegen, the Netherlands
| | - M Z Jeddi
- European Food Safety Authority, Scientific Committee and Emerging Risks Unit, Via Carlo Magno, 1A, 43126 Parma, Italy
| | - F Girolami
- University of Torino, Department of Veterinary Sciences, Largo P. Braccini 2, 10095 Grugliasco, Italy
| | - C Nebbia
- University of Torino, Department of Veterinary Sciences, Largo P. Braccini 2, 10095 Grugliasco, Italy
| | - J L C M Dorne
- European Food Safety Authority, Scientific Committee and Emerging Risks Unit, Via Carlo Magno, 1A, 43126 Parma, Italy.
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Winzelberg Olson S, Hohenhaus AE. Feline non-regenerative anemia: Diagnostic and treatment recommendations. J Feline Med Surg 2020; 21:615-631. [PMID: 31234748 DOI: 10.1177/1098612x19856178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PRACTICAL RELEVANCE Non-regenerative anemia, or anemia with reticulocytopenia, is a daily diagnosis in feline practice. CLINICAL CHALLENGES The disease processes underlying non-regenerative anemia are many and diverse. A major diagnostic evaluation may be required to correctly diagnose and treat the underlying cause. AUDIENCE All veterinarians caring for cats will face the diagnostic and therapeutic challenge of non-regenerative anemia. Readers will benefit from the review of diagnostic testing and therapeutic options for non-regenerative anemia. EVIDENCE BASE This review summarizes the currently available literature informing diagnostic and treatment recommendations related to non-regenerative anemia. The evidence available to support the recommendations in this review is graded as low and includes predominantly expert opinion, case reports and cases series, on which the authors' interpretation/consensus is based.
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Affiliation(s)
- Sarah Winzelberg Olson
- VMD, Diplomate ACVIM (Small Animal Internal Medicine) Pieper Memorial Veterinary Center, Middletown, CT, USA.,DVM, Diplomate ACVIM (Oncology and Small Animal Internal Medicine) Animal Medical Center, New York, NY, USA
| | - Ann E Hohenhaus
- DVM, Diplomate ACVIM (Oncology and Small Animal Internal Medicine) Animal Medical Center, New York, NY, USA
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Kopke MA, Galloway PEJ. Suspected hepatopathy and pancreatitis associated with mycophenolate mofetil use in a cat with immune-mediated haemolytic anaemia. JFMS Open Rep 2020; 6:2055116920905038. [PMID: 32095260 PMCID: PMC7013118 DOI: 10.1177/2055116920905038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Case summary A 5-year-old spayed female domestic shorthair cat was referred for severe
anaemia. Findings on initial work-up were consistent with a diagnosis of
idiopathic immune-mediated haemolytic anaemia. A combination of prednisolone
and mycophenolate mofetil (MMF) was instituted. On revisit approximately 2
months later, red blood cell parameters were normal, but the plasma was
described as icteric, prompting further investigation. Concurrent
hepatopathy and pancreatitis were diagnosed, suspected as being adverse
reactions to MMF, as has been reported with use of the drug in humans.
Resolution of serum biochemistry abnormalities took approximately 2 months,
following discontinuing MMF. At the time of writing, the cat remained
clinically well 1 year after initial presentation. Relevance and novel information With increasing use of MMF as an immunosuppressive agent in cats, clinicians
should be aware of both common and potentially rare adverse effects, such as
those described herein. In addition, suitable monitoring tools need to be in
place to facilitate early detection and appropriate management.
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Affiliation(s)
- Matthew A Kopke
- School of Veterinary Science, Massey University, Palmerston North, New Zealand
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Slovak JE, Hwang JK, Rivera SM, Villarino NF. Pharmacokinetics of mycophenolic acid and its effect on CD4 + and CD8 + T cells after oral administration of mycophenolate mofetil to healthy cats. J Vet Intern Med 2019; 33:2020-2028. [PMID: 31423655 PMCID: PMC6766527 DOI: 10.1111/jvim.15585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 07/23/2019] [Indexed: 12/01/2022] Open
Abstract
Background Mycophenolate mofetil (MMF) is an immunosuppressant used in human and veterinary medicine. Little pharmacokinetic and pharmacodynamic information on MMF is available in cats. Objective To evaluate the plasma disposition of mycophenolic acid (MPA) and assess its effect on total peripheral blood mononuclear cells and CD4+/CD8+ ratios after PO administration of MMF. Animals Healthy cats (n = 10). Methods Mycophenolate mofetil was administered at a dosage of 10 mg/kg q12h (n = 3), 15 mg/kg q12h (n = 3), and 15 mg/kg q8h (n = 4) for 7 days. Concentrations of MPA and derivatives were determined using ultra‐high‐performance liquid chromatography. Flow cytometry was used to assess CD4+/CD8+ T‐cell ratios. Results All cats biotransformed MMF into MPA. Half of the cats (5/10) had adverse effects within 1 week of MMF administration. Area under the curve limit of quantification (AUC0‐LOQh) of MPA ranged from 1.27 to 2.03 hours·μg/mL and from 1.77 to 8.54 hours·μg/mL after the first and last PO dose of 10 mg/kg. The AUC0‐loqh of MPA ranged from 2.18 to 31 hours·μg/mL after the first dose of 15 mg/kg of MMF. Before the first dose of MMF, the average total number of PBMC ranged from 1.2 to 9.3 million/mL. At the last dose of MMF, the average total number of PBMC ranged from 3 to 5 million/mL. Conclusion Mycophenolic acid was detected in all cats. The dose 10 mg/kg given q12h for 1 week was tolerated (n = 3). The efficacy of MMF as an immunosuppressant and long‐term safety in cats of this dosage regimen is unknown.
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Affiliation(s)
- Jennifer E Slovak
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Julianne K Hwang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Sol M Rivera
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
| | - Nicolas F Villarino
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington
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Slovak JE, Rivera-Velez SM, Hwang JK, Villarino NF. Pharmacokinetics and pharmacodynamics of mycophenolic acid in healthy cats after twice-daily intravenous infusion of mycophenolate mofetil for three days. Am J Vet Res 2019; 79:1093-1099. [PMID: 30256137 DOI: 10.2460/ajvr.79.10.1093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the plasma disposition of mycophenolic acid (MPA) and its derivatives MPA glucuronide and MPA glucoside after twice-daily infusions of mycophenolate mofetil (MMF) in healthy cats for 3 days and to assess the effect of MMF administration on peripheral blood mononuclear cell (PBMC) counts and CD4+-to-CD8+ ratios. ANIMALS 5 healthy adult cats. PROCEDURES MMF was administered to each cat (10 mg/kg, IV, q 12 h for 3 days). Each dose of MMF was diluted with 5% dextrose in water and then administered over a 2-hour period with a syringe pump. Blood samples were collected for analysis. A chromatographic method was used to quantitate concentrations of MPA and its metabolites. Effects of MMF on PBMC counts and CD4+-to-CD8+ ratios were assessed by use of flow cytometry. RESULTS All cats biotransformed MMF into MPA. The MPA area under the plasma concentration-time curve from 0 to 14 hours ranged from 14.6 to 37.6 mg·h/L and from 14.4 to 22.3 mg·h/L after the first and last infusion, respectively. Total number of PBMCs was reduced in 4 of 5 cats (mean ± SD reduction, 25.9 ± 15.8% and 26.7 ± 19.3%) at 24 and 48 hours after the end of the first infusion of MMF, respectively. CONCLUSIONS AND CLINICAL RELEVANCE Plasma disposition of MPA after twice-daily IV infusions for 3 days was variable in all cats. There were no remarkable changes in PBMC counts and CD4+-to-CD8+ ratios.
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Morassi A, Rivera-Vélez SM, Slovak JE, Court MH, Villarino NF. Ex vivo binding of the immunosuppressant mycophenolic acid to dog and cat plasma proteins and the effect of co-incubated dexamethasone and prednisolone. J Vet Pharmacol Ther 2018; 41:513-521. [PMID: 29687456 DOI: 10.1111/jvp.12507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/26/2018] [Indexed: 11/30/2022]
Abstract
Mycophenolic acid (MPA) has been shown to be promising for the treatment of autoimmune diseases in dogs and cats. In humans, MPA is highly bound to plasma proteins (~97%). It has been recommended to monitor free drug plasma concentrations because the free MPA correlates with its immunosuppressive effect. However, it is unknown if MPA is highly bound to plasma proteins in dogs and cats. The objectives of this study were to determine the extent of plasma protein binding of MPA and evaluate the effect of prednisolone and dexamethasone on the extent of protein binding of MPA in dogs and cats. The extent of plasma protein binding of MPA was determined in plasma collected from clinically healthy adult cats (n = 13) and dogs (n = 14) by combining high-throughput dialysis and ultra-high-liquid chromatography. This study reveals that MPA is highly bound to plasma proteins (>90%) in dogs and cats, mean extent of binding of MPA at 15 μg/ml to plasma proteins being 96% (range, 95%-97%) and 92% (range, 90%-93%) for dogs and cats, respectively. In dog plasma, MPA is primarily bound to albumin. In vitro, prednisolone increased the unbound MPA in dogs (p < .01) but not in cats (p = .07) while dexamethasone had no effect on MPA plasma binding in either species (p > .05). Results of this study provide valuable information for designing future pharmacokinetic and pharmacodynamic studies and also therapeutic monitoring programs for dogs and cats.
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Affiliation(s)
- A Morassi
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - S M Rivera-Vélez
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - J E Slovak
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - M H Court
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
| | - N F Villarino
- Department of Veterinary Clinical Sciences, Program in Individualized Medicine, Washington State University, Pullman, Washington
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