This month's survey questions

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

More testing for seniors?

Last month’s survey indicates that a full 80% of practices who participated have senior care testing programs, but it also highlights that nearly 50% of seniors are not getting the full screening they could.

With the onset of a pet’s senior years—beginning around the age of seven—many begin to develop common “senior” diseases, such as diabetes, heart disease, endocrine diseases and cancer. Because animals with these diseases often display no symptoms in the early stages, comprehensive preventive care is essential in helping senior pets live longer, healthier lives.

During a pet's senior years, laboratory tests are often recommended every six months. For the most thorough screening, these tests should include:

• A complete chemistry profile
• A complete blood count
• A complete urinalysis
• T₄ testing

By running the IDEXX General Health Profile (GHP) or Diagnostic Health Profile (DHP) on the VetTest® Chemistry Analyzer, a CBC on the LaserCyte® Hematology Analyzer, a complete urinalysis, including urine strip testing on the IDEXX VetLab® UA™, and T₄ testing on the SNAP® Reader, you can feel confident that your senior patients are receiving the complete screening they need. And all of this can be done quickly, in-house, with the IDEXX VetLab® Suite during your patient’s visit.

The IDEXX Reference Laboratories can help with all your testing needs if you do not yet have the in-house diagnostic capabilities to do this complete senior care screening.

*For this survey, senior patients are 7 years and older.

For more information on senior care testing, the IDEXX VetLab® Suite of in-house instruments or IDEXX Reference Laboratories, please call
1-800-355-2896.

Jerky Treats causing Transient Fanconi's Syndrome

Background: The American Veterinary Medical Association recently has posted a Media Alert to their Web site warning veterinarians that multiple brands of jerky treats manufactured in China have been making dogs sick. No cats have been reported to be affected. A contaminant has yet to be identified. At this time there is no list of specific brands affected and there is no recall in effect, so these products are still being sold to consumers.

Presenting Signs and Laboratory Findings: The dogs appear to be developing an acquired Fanconi’s syndrome which appears to be transient. Small dogs with a history of ingesting jerky treats (mostly chicken jerky) are typically affected. Clinical signs include vomiting, diarrhea and lethargy. Physical examination findings have been unremarkable. In addition to mildly elevated liver enzymes, the most common clinicopathologic abnormalities include severe hypokalemia and acidosis along with glucosuria and granular casts on urinalysis. Azotemia is not a consistent finding.

Testing Recommendations: IDEXX internal medicine consultants have also noticed an increase in consultations on dogs with apparent Fanconi’s syndrome. We recommend a CBC, chemistry panel including electrolytes, urinalysis and urine culture. Blood gas analysis, if available, is ideal. Additional testing for other causes of acute proximal tubular damage including leptospirosis serology is also recommended. Renal imaging, fractional clearance studies and Fanconi screens on urine may be warranted in some cases.

IDEXX Reference Laboratory Testing Recommendations:

In-House Testing Recommendations: The IDEXX VetLab® Suite of analyzers also offers in-house diagnostic options to test your patients. The IDEXX VetTest® Chemistry Analyzer offers panels such as the General Health Profile and single slides such as BUN, creatinine and phosphorus. The IDEXX VetStat® analyzer is available for blood gas analysis and measurement of electrolytes. Electrolytes can also be measured on the IDEXX VetLyte® analyzer. The IDEXX VetLab® UA™ analyzer and IDEXX UA™ Strips are available for in-house urinalysis. Microscopic evaluation of urine sediment is also recommended.

Treatment Recommendations: Treatment should be tailored to the individual patient. During hospitalization, hypokalemia should be treated with potassium supplementation while closely monitoring electrolytes. Acidosis may require bicarbonate administration while monitoring blood gases. After discharge, or if the dog is treated as an outpatient, oral potassium supplementation may be required. Prognosis appears to be good with appropriate treatment and monitoring.

If you have any questions on diagnosis or management of these patients, please do not hesitate to call IDEXX’s internal medicine consulting service at 1-888-433-9987, option 4, option 2.

Featured case study:
7-year-old domestic short-hair cat, Jazz
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 = 103.5 P = 200 bpm R = 60 rpm
Mucous membrane color was pale and the CRT was 1.5 seconds. Jazz was quiet, alert, responsive and hydrated. Cardiac auscultation revealed a 1/6 left-sided systolic murmur. She was obese.

Plan
CBC, chemistry profile, urinalysis, FeLV/FIV SNAP® Combo Test and survey radiographs. An intravenous catheter was placed and fluid therapy was started.

FeLV/FIV SNAP® Combo
Negative/Negative

Erythron—There is a severe macrocytic anemia; a reticulocyte count of less than 50-60 K/µL indicates that it is a nonregenerative anemia. Typically, macrocytosis is seen with regenerative anemia since the immature erythrocytes are larger than mature erythrocytes. Morphologic evaluation of erythrocytes on the peripheral blood film shows the presence of anisocytosis without significant polychromasia and the presence of large erythrocytes in circulation as well as large atypical metarubricytes. This morphologic finding is often associated with megaloblastosis and dysplastic erythrocyte production. This is most commonly seen with FeLV infection.

Leukon—The primary leukocyte abnormality is the presence of a mild lymphocytosis. Lymphocytosis in cats is most commonly associated with physiologic lymphocytosis/leukocytosis seen with excitement. Reactive lymphocytosis associated with systemic antigenic stimulation and atypical lymphocytosis associated with lymphoproliferative disease are possible also. Lymphocytes noted in this case are morphologically normal and physiologic lymphocytosis was most likely.

Thrombon—A significant thrombocytopenia is noted and enlarged as well as atypical platelets are noted in circulation during evaluation of the blood film.

Figure 1: Peripheral blood film from a cat, monolayer, 100x oil objective field of view, Wright’s stain. Note the severe decreased erythrocyte density supporting the anemia, the lack of any significant polychromasia even thought there is significant anisocytosis, the large megaloblastic metarubricyte in the lower center field of view and the large atypical platelet in the center right field of view. All these findings are supportive of the final diagnosis of a myeloproliferative disease.

Hematology Profile Summary—Nonregenerative severe anemia associated with megaloblastosis is highly suggestive of underlying FeLV-associated myeloproliferative disease. The thrombocytopenia is likely associated with inadequate production of bone marrow. In most animals, the finding of large platelet forms supports increased rate of production at the bone marrow level; however, this is commonly not the interpretation for the cat. The atypical forms of platelets seen in circulation in this case are commonly associated with FeLV infection; however, this is not an absolute diagnostic finding. Bone marrow evaluation is highly recommended as a next tier of diagnostic testing.

Chemistry Profile—Unremarkable

Urinalysis—Unremarkable

Diagnostic Imaging—Chest radiographs were unremarkable. Abdominal radiographs showed splenomegaly. An echocardiogram revealed mild left atrial enlargement and mild mitral regurgitation. An abdominal ultrasound revealed an enlarged hypoechoic spleen.

Presumptive Diagnosis—Anemia, thrombocytopenia (R/O immune-mediated, R/O bone marrow disease)

Diagnostic Plan
Jazz was blood-typed and a blood transfusion given. A bone marrow aspirate was collected and sent to the reference laboratory for cytological analysis and an FeLV IFA test.

Bone Marrow Analysis—Cellularity was adequate with moderate blood contamination. Megakaryocytes were only rarely seen. Only few myeloid precursors were observed and the Myeloid:Erythroid ratio was 0:1. The distribution of nucleated cells consisted approximately of 10% neutrophil forms, 56% erythroid precursors including metarubricytes and rubricytes, and 34% erythroblasts. Changes are compatible with erythroleukemia (AML-M6Er designation).

FeLV Antigen IFA on bone marrow slide: Positive

Final Diagnosis
Erythroleukemia (AML-M6Er designation); FeLV infection

Clinical Outcome
Due to the poor prognosis, the client elected euthanasia.

Discussion
Erythroleukemia is a rare form of leukemia in cats that carries a poor prognosis. The FeLV antigen IFA on a bone marrow slide was positive although the FeLV SNAP test on peripheral blood was negative. Although this is not a common finding, it is reported. Both tests are attempting to detect the same p27b core antigen; however, they are evaluating the presence of this antigen in different forms. The FeLV ELISA test in the FeLV SNAP® is detecting soluble antigen and the IFA on the bone marrow is testing for antigen within leukocytes.

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 online training courses from IDEXX. Topics cover 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:

NEW Online Training Courses Announcing the Fecal Analysis Workshop IDEXX Fecal Analysis Workshop is a free online course. Fecal exams are routine procedures in most practices, but are they always performed properly? In this course, a leading parasitologist will guide you through the best practice methods of fecal analysis. Train where and when it's convenient and earn 2 continuing education credits while you learn: Proper fecal sample collection and preparation How to identify common parasites Proper centrifugation techniques Why Giardia is one of the most overdiagnosed, underdiagnosed and misdiagnosed intestinal parasites

Seminars Integrated Practice: Healthier Patients = Healthier Practice Dr. Dennis Cloud and Fritz Wood The Most Commonly Misdiagnosed Diseases in Veterinary Medicine Fred Metzger, DVM, DABVP The Practitioner's Approach to Feline Retroviruses Lynn Buzhardt, DVM

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

When diagnosing anemias, it is helpful to take an ordered approach.

For example, anemias are classified as regenerative or nonregenerative based on the presence or absence of reticulocytosis. Once the reticulocyte count is determined, the cause of the anemia should be investigated.

Our algorithm to the right can be used to help organize the next steps. Click the image to enlarge.

Please note that while this diagnostic algorithm addresses the more common causes of feline anemia, it is not a comprehensive list of all causes of anemia in cats. Clinical discretion should be used with each patient based upon a complete evaluation, including history, physical examination and laboratory data.

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, option 2, to speak with internal medicine specialist for more information.

Establishing Preanesthetic Testing Protocols in Your Practice—Part 2

In Part 1 of our Preanesthetic Testing series, we offered you tips and techniques from some of the top practitioners in the field to get you started on updating and implementing your new preanesthetic testing protocols. We suggested you should consider Step 1 ‘Standardizing Your Protocols’ by age and wellness categories. Step 2 is to ‘Train Your Team’ so they understand the expectations and can confidently answer clients’ questions.

Next, you’ll want to move to Step 3: ‘Determine your Pricing’. Determine the cost you are comfortable passing on to your clients. This will be a price that you feel covers the value of the workup, yet won’t compromise patient care due to pricing constraints. Remember, a well-patient preanesthetic workup can be priced lower, for example, than a senior pet or perhaps an unwell-patient workup.

The next critical step, and the one most often neglected, is Step 4: ‘Integrate Your Computer System’ to include your new testing protocols and pricing structure. To do this, you’ll want to create or update templates and use reason codes that facilitate utilization and are harmonized with agreed-upon protocols. For example, you’ll want to make sure all surgical procedures include preanesthetic testing.

In next month’s issue, we’ll finish up our three-part series with ‘Implementing Your Protocol’ and ‘Tracking Compliance’ so you can measure success, identify missed opportunities and avoid lost charges.

As always, if you’re excited and anxious to move ahead, visit us at www.idexx.com/prean for all the tools and information you need to be on your way!

With FREE Continuing Education Credit!*

Approved in the United States, 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. To which tissue type do the nucleated cells belong?
   1. Epithelial
   2. Mesenchymal
   3. Neuroendocrine
   4. Discrete round cell
2. Which of the following is the best interpretation for these mononuclear cells?
   1. Normal
   2. Benign hyperplasia
   3. Benign neoplasia
   4. Malignant neoplasia

Figure 1. Aspirate of a thickened region of urinary bladder wall from a cat, Wright’s stain, 50x objective field of view. Note the moderate numbers of erythrocytes mixed with a single population of mononuclear cells.

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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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