Online training is the way to go!

Online training is a convenient way to learn more and keep up with current trends. IDEXX offers several opportunities for training each month through the IDEXX Learning Center.

At the IDEXX Learning Center, you’ll find:

• A calendar of events, including seminars, Webinars courses and teleconferences. Many offer CE credit.
• Access to online training courses that you can take where and when it’s convenient for you.
• A training record so you can easily track your CE credits and courses.
• Certificates of completion to document your progress.

Visit the IDEXX Learning Center today and choose your next learning adventure!

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Featured case study:
15-year-old castrated male Pomeranian, Zeke
by Dennis B. DeNicola, DVM, PhD, DACVP, Chief Veterinary Educator, IDEXX Laboratories, Inc.

Physical exam
Zeke has lost a little weight according to the owners but appears to be in relatively good body condition. He is slightly lethargic. There are no abnormalities and there is no demonstrable pain on abdominal palpation. Auscultation of the thoracic cavity was unremarkable. There was a small pink mass on the medial canthus conjunctiva (later removed and determined to be a nonviral papilloma that was completely excised).

Diagnostic plan
Because of the history of chronic waxing and waning gastrointestinal signs, a broad base of diagnostics and collection of a minimum database of laboratory data are planned. The primary plan is to investigate possible problems including parasitism as well as inflammatory and neoplastic processes in the digestive tract and liver. Because of the historic chronic problem, Zeke is referred to Purdue University for a complete diagnostic workup.

Parasitology
Multiple fecal examinations, including zinc sulfate centrifugation techniques, are negative.

Diagnostic imaging
Radiography—No significant abnormalities observed.

Ultrasound—No significant abnormalities associated with the pancreas; mild chronic parenchymal disease in the kidneys.

Erythron—No significant abnormalities are observed.

Leukon—The total leukocyte count is within reference interval limits, however, there is a mild eosinophilia supporting the presence of an active inflammatory process. Systemic parasitism and hypersensitivity responses should be considered in the differential.

Thrombon—Platelets are clumped, preventing accurate enumeration, however, platelet numbers are estimated to be adequate and no significant morphologic abnormalities are observed.

Lipase—There is a significant increase in lipase. The finding of a lipase value greater than three-fold higher than the high end of the reference interval limit is strongly supportive of pancreatitis, particularly in light of a lack of any other reported cause for nonspecific increases in lipase activity (steroid therapy, decreased glomerular filtration rate, etc.). Because clinical signs are not “classic” for acute necrotizing pancreatitis and no significant ultrasonographic changes were identified with the pancreas, confirmation with a canine pancreas-specific lipase test (Spec cPL® Test) should be considered. In addition, other diagnostic procedures to investigate possible underlying primary intestinal disease would be warranted.

Calcium—The calcium is slightly decreased from the reference interval, however, there are no clinical signs attributable to hypocalcemia and the degree of decrease is minimal and considered to be of no clinical significance. Hypocalcemia is reported with cases of acute pancreatitis due to a combination of possible mechanisms, including calcium collection in necrotizing fat around the pancreas. Calcium levels should be monitored in the future and if persistent decreased calcium is observed, additional investigation, including measuring ionized calcium, should be considered.

Urinalysis—No significant abnormalities are noted.

Presumptive diagnosis
The primary differential is acute pancreatitis, however, because of clinical signs and presentation, inflammatory and noninflammatory disease within the intestinal tract should be considered also.

Diagnostic plan

1. Perform endoscopic examination and biopsy of the intestinal tract.
2. Request a Spec cPL Test at IDEXX Laboratories, Inc.
3. Request previous laboratory data for review from the primary referring veterinarian.
4. Perform serial hematology and chemistry testing to follow the progression or regression of disease.

Endoscopy
Several areas within the upper small intestines had slight mucosal hyperemia but no significant pathologic changes were observed. Multiple pinch biopsy specimens were collected from the stomach and small intestines for histologic evaluation.

Gastric mucosa – There were no significant histopathologic alterations.

Small intestinal mucosa – Mild to moderate, patchy, lymphocytic and eosinophilic enteritis of unidentified etiology was identified. A comment from the pathologist indicated that changes were too mild to identify any specific cause. Both primary inflammatory bowel disease and potential secondary enteric changes associated with conditions such as pancreatitis should be considered in the differential.

Canine pancreas-specific lipase activity
Spec cPL    355µg/L    High    (Ref Interval; < 200)

Previous laboratory data review
Since the primary veterinarian generated most laboratory data using an IDEXX VetTest® Chemistry Analyzer, which utilized the same dry-slide technology used at Purdue University, serial lipase and amylase data could be examined graphically. During at least one previous clinical episode, Zeke had similar vague clinical signs; however, a lipase value of greater than 15,000 U/L was measured and the Spec cPL measured at the same time was 686 µg/L, which is highly diagnostic for acute or active pancreatitis. In addition, there were several lipase values measured during Zeke’s apparent clinically normal periods and these values were consistently near 1,000 U/L, which could be established as the baseline value for Zeke. This information strongly supports an episode of active pancreatitis for this current clinical presentation. Changes in the intestinal tract were interpreted to be secondary changes associated with primary pancreatitis.

Trending of many chemistry and hematology values can prove extremely beneficial for early detection of developing disease, because most of the commonly measured parameters in the CBC and chemistry profile are relatively consistent during periods of health for an individual animal. These baseline values can be used as “reference” values for that particular animal. When significant increases or decreases are observed, even if they do not progress out of the reference interval, developing problems may be identified.

This is particularly true for a test like lipase, which has both consistency during health and a relatively wide reference interval ( 200–1800 U/L). A change from an observed healthy value of 200–400 µ/L for an individual animal to 2000–4000 U/L in the same animal with exocrine pancreatic disease represents a 10-fold increase from that animal’s baseline value. Changes of this magnitude can be highly supportive of pancreatitis even though the “abnormal” value is not at least a three-fold increase above the high end of the reference interval.

Final diagnosis
Acute/active pancreatitis

Clinical case outcome
Zeke received fluids and general supportive care over the next several days and clinical improvement was observed. A prescription Science Diet® was recommended. He was released to his owners and returned in approximately one month’s time for re-evaluation. Zeke was clinically normal at that time and his lipase and amylase values were 1,702 U/L (reference interval 104–1,753 U/L) and 541 U/L (reference interval; 378–1,033 U/L), respectively.

The recommendations contained in Diagnostic Edge educational materials are intended to provide general guidance only. As with any diagnosis or treatment, you should use clinical discretion with each patient based on a complete evaluation of the patient, including history, physical presentation and complete laboratory data. With respect to any drug therapy or monitoring program, you should refer to product inserts for a complete description of dosages, indications, interactions and cautions.

Tell us what you think of this case, or let us know if you have a case that you would like to submit. E-mail us at diagnosticedge@idexx.com with your comments.

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The Scoop on Poop

A proper fecal exam protocol is vital to the success of any internal parasite control and treatment program. The Companion Animal Parasite Council (CAPC) has established guidelines for your clinic’s fecal protocol.

A simple flotation is the most common examination procedure used in fecal exams, however, it is not as sensitive or accurate as centrifugal flotation. CAPC recommends a fecal float by centrifugation using a zinc sulfate solution (sp. gr. 1.18) or sugar solution (sp. gr. 1.25) for the greatest recovery of parasite eggs. Zinc sulfate is preferred with a suspected Giardia infection, as a sugar solution will collapse Giardia cysts.

• Mix 2 to 5 grams of feces with flotation solution and strain into a centrifuge tube using a tea strainer or cheesecloth.
• Fill the tube with flotation solution to form a slight positive meniscus and place a coverslip on top of the tube.
• Centrifuge the sample at 1,200 rpm for 5 minutes.
• Remove the tube and let it stand for 10 minutes.
• Lift the coverslip upward and place on glass microscope slide. Most parasites can be identified at 10x magnification.

When an animal presents with diarrhea and/or vomiting, immediate results and treatment are essential to the animal’s health. To diagnose or rule out giardiasis, CAPC recommends:

• Fecal flotation with centrifugation
• Direct smear
• Sensitive, specific fecal ELISA optimized for use in companion animals

SNAP® Giardia is the only commercially available ELISA test on the veterinary market.

To read more about the CAPC fecal examination guidelines, please visit www.capcvet.org.

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IDEXX Learning Center

Visit the IDEXX Learning Center to see a full listing of available Webinars, seminars, teleconferences and online training courses from IDEXX about emerging trends and best practices in veterinary diagnostics in a forum designed to involve, educate and motivate you and your staff. Click the date to view the details. Fill out and submit the form to register.

Here are some of the opportunities available this month:

• Feline Dentistry Course 1: Building Your Feline Dentistry Practice
  • Identify common and problematic oral diseases.
  • Apply consistent guidelines for evaluation.
  • Improve your patients’ overall health through feline dentistry.
    
    
• Feline Retrovirus Course 2: Testing For and Managing Retrovirus-Positive Cats
  • Learn about new research on retrovirus prevalence in cats with bite wounds from Julie Levy, DVM, PhD, DACVIM.
  • Evaluate care options with help from Susan Little, DVM, DABVP (Feline).
  • Improve compliance with tips from Lynn Buzhardt, DVM.
    
    
• VetTest Certificate course: Get 50% off! Use promo code DE2007 at checkout.
  • Increase productivity and streamline workflows.
  • Increase your knowledge of dilution preparation.
  • Get tips on sample preparation and handling.
  • Earn CE credits and much more!

Webinars Preanesthetic Evaluation: Avoid Anesthetic Nightmares Fred Metzger, DVM, DABVP Evaluate Your Blood Film in Less Than Three Minutes Dennis DeNicola, DVM, PhD, DACVP

Seminars A Practical Approach to Feline Retroviruses Erin Evans, DVM The Most Commonly Misdiagnosed Diseases in Veterinary Medicine Fred Metzger, DVM, DABVP The Practitioner's Approach to Feline Retroviruses Lynn Buzhardt, DVM

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Choosing digital radiology for your practice—involve your clients
Part Three of a Three-Part Series
by Ernest E. Ward Jr., DVM

In part one of this series, we talked about getting started. Part two discussed the various aspects we considered when deciding which digital radiography (DR) system would work best for our clinic.

As I concluded last month, our team was ready to move ahead. But that’s still a big check to write and as the practice owner, I had to make sure it was in our financial best interest, in addition to improving the quality of care.

I knew we’d have to increase our cost of radiographs, but how much? More importantly, would our clients be willing to foot the bill for this advanced technology? Would they even care?

I set out to answer the questions the only way I know how—I asked. Our team created a simple questionnaire to present to some of our top clients to record their opinions. We decided that unless we met with significant objection, we would move forward with the purchase of a DR system. The real question was how much would our clients be willing to pay for it?

We asked 50 of what our staff considered “caring and interested” clients over a period of one month. If staff members felt comfortable talking about the DR issue with the client, they did. This wasn’t rocket science—it was real life.

The typical procedure went as follows: After completion of the examination and review of the exam report, the exam room technician, time permitting, would ask if the client was interested in hearing about an exciting technology that we were considering purchasing. The staff member would then briefly detail DR with the client, focusing on the benefits to the patient, client and environment. After giving a three- to five-minute explanation, we asked four simple questions:

1. Had you heard of DR before this conversation? If yes, where did you hear about it?
2. Do you think DR is more valuable than traditional X-rays? Yes or No
3. Based on our conversation, do you think this is something we should offer at Seaside Animal Care? Yes or No
4. How much more would you be willing to pay for DR?
   1. An additional $10-20 per X-ray
   2. An additional $30-40 per X-ray
   3. An additional $50-60 per X-ray

While certainly not scientific, we felt that these questions would help us in our decision-making and pricing strategy. Prior to completion of the study, I had begun evaluating the cost and return-on-investment (ROI) for our practice. I had calculated our ROI based on increasing our cost per radiograph by $20. Our team felt that $20 was a reasonable increase and a good starting point. Were we ever wrong.

As the questionnaires were completed, we started to see some interesting results. The trend was that we should incorporate this valuable and largely unknown service into our hospital. We expected that. What we didn’t expect was that clients were willing to spend $30-40 more per view. This made our decision much easier and my economic anxiety much less!

By asking our clients their opinion of DR and including them in the price determination, we not only gathered invaluable information but also fostered additional trust and loyalty with some of our top clients. Almost all of them expressed their appreciation of being included in the discussion and were pleasantly surprised that we thought about asking them!

If I had limited my decision-making to my own opinion, I would have missed out on the opportunity to make the investment more attractive. Additionally, we were able to hone our message and learned what our clients were most excited about. Surprisingly, the reduced chemical and film wastes and environment-friendly aspect of DR was cited by our clients as an important element. The ability to obtain a cost-effective and timely board-certified radiologist’s second-opinion was also viewed as a vast improvement over traditional radiography.

The take-home message is simple: Involve those who will be impacted by your decisions in the decision-making process. Whether it’s asking your associate doctors, management team, staff or even clients—do it. Too often we assume we know what the others will say or do and we’re off the mark. Approach big decisions methodically and engage as many people as you can enlist. Your practice and patients will benefit in ways you can’t imagine.

• View part one of this series in which Dr. Ward discusses getting started.
• View part two of this series in which Dr. Ward highlights key points to consider when choosing a digital radiography system.

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He swallowed WHAT?

Pets chew on—and swallow—the strangest things. What’s the most unusual item your practice has found in one of your patients? Share it with your colleagues in a future issue of the Diagnostic Edge!

Email a copy* of your X-ray or a scanned photograph of the item or the pet to:

Diagnostic Edge
c/o Erica Archer
IDEXX Laboratories
One IDEXX Drive
Westbrook, ME 04092

Please include your practice name, address, telephone number and a contact name in case we need to get in touch with you.

* Please send JPEG files between 30-100KB.

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With FREE Continuing Education Credit!*
Now Approved in Australia and Canada

Have you taken advantage of every qualifying Interactive Challenge for FREE continuing education credits?

Every Interactive Challenge offered since June 2006 has been worth 0.5 continuing education credit—that's five credits so far—and you get the credits just for participating! Check out the Diagnostic Edge archive and take any qualifying challenges you may have missed. Don't let these fun credits slip away!

Questions:

1. Which of the following is the BEST interpretation for the cytologic specimen from a lymph node?

1. Normal
2. Benign lymphoid reactive hyperplasia
3. Marked neutrophilic lymphadenitis
4. Malignant lymphoma

2. Which of the following is the accurate identification of the structures indicated by arrows in the two images provided?

1. Platelets
2. Tissue debris
3. Fungal forms (yeasts)
4. Lymphoglandular bodies

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Thanks for taking the April 2007 Diagnostic Edge Interactive Challenge!

*Each interactive challenge meets the requirements for 0.5 hour of continuing education credit in jurisdictions that recognize AAVSB’s RACE approval, however, participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education.

AAVSB Provider Number 106

Interactive Challenges are also approved in Australia for 0.5 AVA Vet Ed Point and from the following Canadian Veterinary Medical Associations: Alberta, Saskatchewan, New Brunswick and Prince Edward Island.

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