This month's survey question

Thank you for responding to our August survey! Here are the results:

Practice Developer® Delivers!

Our respondents overwhelmingly indicated that product discounts are the strongest incentive to company loyalty. Combined with interest in access to members-only specials, this makes the Practice Developer® (PD) program a powerful tool for you to leverage when you purchase from IDEXX.

You can earn Practice Developer points on eligible purchases from IDEXX. And you can redeem those points for any product or service. Each point you earn is worth $1 toward your next purchase of in-house tests, analyzers, reference laboratory services, educational tools and much more.

And now, Practice Developer members can use their PD points to purchase NAVC registration at the lowest possible price! Call us at 1-800-248-2483 to take advantage of this special members-only offer.

We are always interested in hearing what members have to say about our Practice Developer program. If you have comments or suggestions, please call 1-800-248-2483 or visit our Practice Developer Web site.

Featured case study:
7-month-old female Lhasa Apso, Jennie
by Peter Kintzer, DVM, DACVIM, Boston Road Animal Hospital, Springfield, MA, and Fred Metzger, DVM, DABVP, owner of Metzger Animal Hospital, State College, PA

Physical examination
T = 102 P = 136 R = 34
Quiet to depressed, 5% dehydrated; C/R normal
Uncomfortable on abdominal palpation; remainder of exam unremarkable

Plan
Start IV fluids and begin diagnostic workup.
CBC, chemistry profile, urinalysis and abdominal radiographs

Erythron—Blood film evaluation revealed 1+ target cells, 2+ poikilocytosis and a moderate metarubricytosis (22 nRBCs/100 WBCs). This nucleated red blood cell response is often characterized as "inappropriate" since there is no accompanying polychromasia/reticulocytosis. Conditions that cause this response primarily include some type of bone marrow stromal damage (toxic, hypoxia, mechanical, etc.); the physical and physiologic features of the bone marrow typically restrict movement of nucleated red blood cells into circulation.

Leukon—Only a very mild eosinopenia and decreased basophil count are identified. These changes are insignificant in light of no other quantitative leukocyte abnormalities. Morphology of the leukocytes is within normal limits. Leukocyte changes remove severe inflammatory disease as might be seen with conditions such as sepsis or overwhelming inflammation, which could be one cause for the "inappropriate" metarubricytosis noted above.

Thrombon—Platelets are adequate in number and normal in morphology.

Chemistry Profile—The minimal to mild elevations in phosphorus, calcium and ALKP are likely due to bone growth in this young animal.

Urinalysis—No significant abnormalities are noted in the urinalysis.

Figure 1. click to enlarge

Diagnostic Imaging—Radiographs reveal no obvious obstructive pattern. A few small flecks/granules of radiodense material are seen in the intestinal tract.

Presumptive Diagnosis—Lead toxicity, viral gastroenteritis, gastrointestinal foreign body or dietary indiscretion.

Diagnostic Plan
Blood lead level

Blood lead level - 146 ug/dL (0 - 20 ug/dL)

Final Diagnosis
Lead toxicity

Comments
Acute heavy metal toxicity can result in bone marrow stromal damage in dogs; metarubricytosis is one of the more common hematologic abnormalities seen. Basophilic stippling is also often present along with metarubricytosis; however, this was not seen in this case. The inappropriate nucleated red cell response (nucleated red blood cells without regenerative anemia) is the key finding in this case. Nucleated red blood cells (metarubricytes) are the precursor cell to reticulocytes and they are typically restricted from migration into the peripheral blood because of both physical (small diameter pores separating hematopoietic tissue and circulating blood) and physiologic mechanisms. Low to moderate numbers of metarubricytes may be seen in marked bone marrow responses more commonly seen with severe anemia; however, when seen, they are much lower in numbers compared to the polychromatophils/reticulocytes present in circulation. The polychromatophils/reticulocytes are used to classify the anemia as regenerative or nonregenerative, not the metarubricytosis.

It is important to note that impedance-based hematology analyzers include nRBCs in the total white blood cell count, resulting in a falsely elevated total white blood cell count and possible misinterpretation. Advanced hematology analyzers using optical measurements with laser flow cytometry technology allows the differentiation between nRBCs and leukocytes. With impedance-based technology, it is even more critical for blood film evaluation to assure that nRBCs are not present; if nRBCs are present and impedance technology is used, a corrected white blood cell count must be calculated. The CBC in this case was performed with a LaserCyte® Hematology Analyzer (IDEXX Laboratories), which is a laser-based technology analyzer; no correction to the white blood cell count is required.

Clinical Outcome Chelation therapy with calcium disodium EDTA was instituted. Recovery was uneventful. Further questioning of the owners revealed they were renovating an older house and removing several layers of paint, which were found to be lead based. Owners were advised to consult their physician regarding potential lead exposure to persons in the home.

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 to get the process started.

IDEXX Learning Center

Visit the IDEXX Learning Center to see a full listing of available Webinars, seminars, teleconferences and on-line 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 event to view the details. Fill out and submit the form to register.

Here are some of the opportunities available this month:

On-line Training Courses FREE! VetTest® Certificate Course: Promote best practices and utilize every new enhancement on the VetTest analyzer. FREE! Feline Course One: Building Your Feline Dentistry Practice NEW! Feline Course Two: Testing for and Managing Retrovirus-Positive Cats

Seminars Integrated Practice: Healthier Patients = Healthier Practice Dr. Dennis Cloud and Fritz Wood Management of Retrovirus-Positive Cats Susan Little, DVM, DABVP The Most Commonly Misdiagnosed Diseases in Veterinary Medicine Steve Levy, VMD The Practitioner's Approach to Feline Retroviruses Steve Levy, VMD

Webinar A Clinical Approach to Fluid Therapy Stepheen P. DiBartola, DVM, DACVIM

Feline Hemotropic Mycoplasma (FHM) Test
Take the guesswork out of diagnosing the cause of feline anemia

FHM is a common cause of severe hemolytic anemia in cats. In a recent study, 12.7% of healthy blood donor pet cats were infected with feline hemotropic mycoplasmas, and the rate was higher for outdoor cats and cats exposed to fleas.¹ Until now, diagnosing feline hemotropic mycoplasmosis (formerly hemobartonellosis or feline infectious anemia) has been a challenge.

With the new IDEXX RealPCR^™ FHM Test, you can take the guesswork out of diagnosing the cause of feline anemia. By routinely performing this test on your anemic patients, you can quickly begin treating infected cats or rule out an FHM infection.

Consider performing the IDEXX RealPCR^™ FHM Test on the following cats to get definitive answers on this potentially life-threatening infection:

Presenting Cats	FHM Test Benefits
Regenerative anemia with no obvious bleeding	Blood loss and hemolysis are the two main causes of a regenerative anemia. If there's no evidence of bleeding, hemolysis is most likely and FHM must be ruled out.
FeLV-positive with anemia	A regenerative or nonregenerative anemia can be present with a concurrent FeLV infection. Persistent infections with feline hemotropic mycoplasmas in these cats may promote myeloproliferative disorders.2
Other chronic illnesses where nonregenerative anemia is worse than expected	Typically, FHM results in a regenerative anemia. But if the cat has a concurrent illness that limits its bone marrow response to anemia (e.g., renal failure, neoplasia), the anemia may appear nonregenerative. FHM may compound or complicate the anemia present from the chronic illness.
Nonregenerative anemia where there is no apparent cause	If primary bone marrow disease is suspected, consider ruling out FHM prior to or concurrently with performing a bone marrow aspirate—in case it's the sole cause of or contributing to the anemia.
Blood donor cats	All blood donor cats should be screened for FHM to prevent infection of blood recipients.
1. Hackett TB, Jensen WA, Lehman TL, et al. Prevalence of DNA of Mycoplasma haemofelis, 'Candidatus Mycoplasma haemominutum,' Anaplasma phagocytophilum, and species of Bartonella, Neorickettsia, and Ehrlichia in cats used as blood donors in the United States. J Am Vet Med Assoc. 2006;229(5):700-705. 2. Sykes JE. Feline hemotropic mycoplasma (feline hemobartonellosis). Vet Clin Small Anim. 2003;33:773-789.

The IDEXX RealPCR FHM Test is currently only available in the United States.

The IDEXX RealPCR^™ FHM Test is also available as part of a health profile for the most complete picture of your patient's condition. Visit www.idexx.com/realpcr for more information, or call 1-888-433-9987, option 4, then option 2, to speak with internal medicine specialist for more information.

IDEXX VetLab® Suite of in-house analyzers
Offers you the value of having the results NOW for all patients.

Establishing Preanesthetic Testing Protocols in Your Practice—Part I

One good way to maintain the level of care your clients expect or move your practice forward may be to revisit and update your preanesthetic testing protocols to align with industry-defined 'best practices'.

To get you started, we've pulled the following information from key opinion leaders in a way that's easy to follow and implement. Of course, if you're excited and anxious to move ahead, you can visit us at www.idexx.com/prean for all the tools and information you need to get you on your way!

Step 1 is to 'Standardize Your Protocol.' Meet with your staff to determine what protocols work for your practice and provide the best care possible to your patients. Consider setting your protocols by age and wellness categories.

Step 2, 'Train Your Team.' You can energize your staff by providing the information they need and establishing roles and responsibilities so that everyone understands the benefits of preanesthetic testing. If expectations are clear and your staff is informed, they can confidently answer clients' questions. As part of this discussion, you'll also want to select the Client Tools you will use to simplify the workflow and support your position.

In next month's issue, we'll discuss next steps—setting prices and integrating your computer systems so that you can easily select the appropriate testing protocol and avoid lost charges.

With FREE Continuing Education Credit!*

NOW Approved in Australia and Parts of Canada! †

Have you taken advantage of every qualifying Interactive Challenge for FREE Continuing Education (CE) credits?

Every Interactive Challenge from June 2006 on has each been worth 0.5 continuing education credit in the United States—and you get the credit 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. Can you identify the structure (A) indicated in figures 1 and 2?
2. Can you identify the structure (B) indicated in figure 1?
3. Can you identify the many circular inclusions noted within many of the structures identified in figure 1?

These sediment preparations of urine from a dog are from a sample with a refractometry specific gravity of 1.029 and a 1+ protein on the dipstick test pad.

Figure 1. Urine sediment, unstained, low power field (10x objective) of view.



Figure 2. Urine sediment, unstained, high power field (40x objective) of view.

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Thanks for taking the 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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