This month's survey questions

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

Chart #1
Chart #2

Jerky treat incidents highlight awareness of potential pet food issues and importance of urinalysis

Chart #1 indicates a heightened client awareness of the potential medical problems of feeding pets chicken jerky treats. Clients already on high alert due to the pet food recall of last spring are now closely monitoring their pets for clinical signs that might indicate a serious medical problem. Pet owners have been educated through a number of sources, such as veterinary practices, word of mouth through friends and family, the news media and the Internet as well as the pet food companies involved.

High-profile retailers such as Wal-Mart voluntarily removed all jerky treats and related products from their shelves (Wal-Mart on 07/26/07). On 09/26/07, the Food and Drug Administration issued the following warning: "The Food and Drug Administration is cautioning consumers of a potential association between development of illness in dogs and the consumption of chicken jerky products also described as chicken tenders, strips and treats." At the time of the warning, the FDA received more than 75 complaints about 95 sick dogs in which the owners felt there was a strong association with jerky treat consumption. The AVMA posted an alert on its Web site warning of a possible association between severe illness in dogs and recent consumption of jerky treats, and ACVIM posted a similar warning.

While the 12% of practices that have seen 1-5 cases of Fanconi’s may not seem like a significant number in Chart #2, it is important to note that acquired Fanconi's syndrome is not a common diagnosis in general practice. We can assume that the recent issue with jerky treats has heightened the awareness of Fanconi's as a potential problem. It will be interesting to note if more cases are seen in the coming months.

Any patient exhibiting signs of significant illness should have a complete workup, including a CBC, differential and blood smear, chemistry, electrolytes and blood gas and a full urinalysis. Urinalysis is an important test that is frequently overlooked in general practice. The recent problem with jerky treats and acquired Fanconi's syndrome emphasizes the importance of urinalysis. Glucosuria, as detected by routine urinalysis in patients with normal blood sugar, increases the suspicion of Franconi's. In order to achieve a definitive diagnosis of Fanconi's, amino aciduria must be demonstrated.

Do your protocols include urinalysis? The IDEXX VetLab UA™ Analyzer helps make urinalysis quicker and simpler, automatically reading veterinary-validated IDEXX UA™ Strip results and printing them for you. With the IDEXX VetLab® Station, urinalysis results are automatically printed with the rest of your diagnostic results on one report so results are never overlooked or lost.

For more information on IDEXX VetLab products and how to increase your
in-house diagnostic capabilities, call 1-800-355-2896.

Featured case study:
10 ½-year-old neutered male bearded collie, Duncan
by Dennis B. DeNicola, DVM, PhD, DACVP, Chief Veterinary Educator, IDEXX Laboratories

Physical examination
Duncan was depressed, weak and lethargic
Temperature = 104.4° F
Pulse = 138
Respiration = 44
Postsurgical draining tract around anus
Mucous membranes—pale and slightly icteric

Differential diagnoses
The brief differential list for the primary presenting findings are listed below; however, the major findings associated with the emergency presentation may be associated with the decreasing hematocrit associated with possible hemolytic disease.

Decreasing hematocrit and pale mucous membranes—Blood loss or hemolytic anemia; possible dilutional decreased hematocrit due to fluid therapy.

Icterus—Prehepatic (hemolytic disease), hepatic, posthepatic (obstructive) jaundice.

Weakness—Anemia as well as many other possibilities.

Fever—Inflammation (infectious or noninfectious), neoplasia, hemolysis.

Plan
To thoroughly characterize the emergency patient, a complete blood count (CBC), complete chemistry profile and urinalysis are essential for characterizing potential primary and secondary organ involvement. Since hemolytic disease is high in the working differential, a Coombs test, crossmatch and coagulation profile were included. Diagnostic imaging would be helpful in additional characterization of possible multisystem involvement.

On the results reports that follow, you’ll see that Duncan’s most recent prior results are shown along with his current results. This allowed his doctors to easily compare the two for more meaningful interpretations. See more about this column in the Technical Tip.

Sample quality: Moderate hemolysis and moderate icterus

Coombs test: Negative

Erythron—There is a moderate anemia. Mild polychromasia is present suggesting either mild or early regeneration. Mild anisocytosis and moderate poikilocytosis are present also. The poikilocytosis is characterized primarily as spherocytosis; however, many of the erythrocytes had small blunt projections from the surface of the cells suggestive of small Heinz bodies. The presence of Heinz bodies was confirmed with new methylene blue-stained specimens. Few ghost erythrocytes are present in the background. The finding of a negative Coombs test in the face of finding many spherocytes initially may seem contradictory but may be explainable upon identification of the underlying cause for the apparent hemolytic disease.

Figure 1: 100x oil objective field of view of the monolayer of a blood film from a dog, Wright’s stain. Note the numerous spherocytes, the presence of small Heinz bodies (indicated by arrowheads), a well-characterized polychromatophil (center left) and a single ghost cell (see arrow).

Figure 2: 100x oil objective field of view of the monolayer of a blood film from a dog, Wright’s stain. Note the numerous spherocytes, the presence of small Heinz bodies (indicated by arrowheads) and a single eccentrocyte (see arrow).

Figure 3: 100x oil objective field of view of the monolayer of a blood film from a dog, new methylene blue stain. There are small Heinz bodies (indicated by arrowheads) and two reticulocytes (see arrows).

Leukon—The leukon is characterized by a slight neutrophilia as well as a lymphopenia and eosinopenia. Quantitative changes are supportive of a glucocorticoid influence (“stress”); however, upon examination of the leukocytes on the blood film, a mild left shift is noted; band neutrophils are approximately 1.00/µL. This finding allows the interpretation of inflammation plus a glucocorticoid influence.

Thrombon—Platelet numbers are normal.

Coagulation Profile—The increase in fibrinogen concentration is most likely associated with the identified inflammatory process (neutrophilic left shift). There is no support for an underlying secondary hemostasis abnormality.

Protein Profile—There is a mild hyperproteinemia characterized primarily as a hyperglobulinemia. Albumin is on the high end of the reference interval and these protein changes may be related to dehydration; however, with the slightly greater increase in globulins compared to albumin, they may also support systemic antigenic stimulation/inflammation.

Liver Panel—There is a significantly increased GGT, which is highly supportive of ongoing cholestasis. The increase in bilirubin is additional support for cholestasis; further bilirubin characterization demonstrated that approximately 60% of the total bilirubin was conjugated bilirubin. The bilirubinuria is also supportive of cholestasis.

Pancreas Panel—There is a significant increase in both amylase and lipase strongly supporting the presence of active pancreatitis. The increase in lipase is greater than threefold above the high end of the reference interval, which is highly supportive of pancreatitis. Although the increase in amylase is less than threefold above the high end of the reference interval, the increase in amylase as well as lipase compared to baseline values on this patient (results in parentheses), indicate there is a dramatic increase in both amylase and lipase.

Diagnostic summary
Moderate early regenerative hemolytic anemia associated with oxidant injury (Heinz bodies, eccentrocytes)
Inflammation possibly associated with hemolytic disease
Active pancreatitis
Cholestasis most likely secondary to pancreatitis

Further diagnostics
Investigation into the underlying cause for the obvious oxidant injury was warranted. In this particular case, the cause became evident when reviewing the case closely. Zinc oxide was administered topically on the postsurgical site after repairing the draining tract associated with the anal gland. An Elizabethan collar was applied to prevent the dog from interfering with wound healing but when at home, the dog would constantly be escaping from the collar and would lick the wound with zinc oxide. Zinc is known to be an excellent oxidant in dogs and would easily explain the hemolytic presentation. It should be noted that during the first 24 hours of hospitalization during this emergency presentation, the hematocrit dropped from 24% to 13% even in the face of whole blood and packed cell transfusions.

Final diagnosis
Acute zinc toxicosis associated with ingestion of zinc oxide—All of the hematologic findings have been well described with acute zinc toxicosis in dogs, including the presence of morphologic findings as described in this case as well as the negative Coombs test. In addition, zinc is known to be a cause for acute pancreatitis in dogs and other species, which explains the clinical chemistry findings with Duncan.

Therapeutic plan
Calcium EDTA was administered subcutaneous QID at a dose of 100 mg/kg.

Clinical case outcome
Duncan responded well to treatment over the next 14 days and was released to the owners.

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.

Help your clients keep the holidays happy—for their pets!

Every veterinarian knows that people’s holiday treats are not healthy for pets. Most pet owners know this too, yet every year, many normally cautious pet owners make exceptions and share their feasts with their four-legged friends.

From the IDEXX Suite Stories contest, here's one practice’s experience, and some helpful advice for you and your clients to help keep everyone healthy and happy for the holidays.

Thanksgiving Disease

"When I was practicing in Harrisonburg, Virginia, my boss, Dr. Jeff Nester, and I shared emergency calls with the other four clinics in the area. This was great, because you were off for four weekends out of five, but on the fifth weekend, you paid the price. We worked in the Shenandoah Valley, with the Blue Ridge Mountains on the horizon, and miles and miles of farmland stretching from Washington, D.C., to North Carolina.

One of my weekends happened to fall on Thanksgiving. This was great because it meant that I would be off for Christmas, but I didn’t realize how busy I would be..."

 

Too much holiday food can cause serious problems for pets. A sick dog workup including a comprehensive pet-side chemistry and CBC profile provides you with the information that you need to help take next steps. For dogs presenting with GI symptoms, including vomiting, anorexia or abdominal pain, the culprit could be pancreatitis. In these cases, a diagnosis to support moving ahead with treatment or to rule out pancreatitis so that you can focus on finding the cause can make all of the difference in the patient's outcome.

IDEXX can be your partner to help manage these sick patients. For in-house solutions, IDEXX offers the most complete sick dog pet-side chemistry profile available, the DHP (Diagnostic Health Profile). The DHP is the only pet-side chemistry profile that includes amylase, lipase and GGT standard for every patient.

New for practices, IDEXX has the SNAP® cPL™ (canine pancreas-specific lipase) Test, now available to accurately diagnose or rule out pancreatitis within minutes. Together these two tools provide you with the most diagnostic information available pet-side to help you manage dogs with GI symptoms.

For more information about pancreatitis or IDEXX products and services, visit Products and Services Guide or call 1-800-355-2896.

From the Fluid Therapy Webinar

Over 800 practices logged on to Dr. DiBartola’s online live presentation A Clinical Approach to Fluid Therapy on September 18 and 20. Watch the Webinar archive.

Here are two of the frequently asked questions from the Webinar, with Dr. DiBartola’s responses.

Q: When can subcutaneous fluids be substituted for intravenous fluids, and which fluids are useful for administration by the subcutaneous route?

A: The subcutaneous route can be used for maintenance needs in small dogs and cats, but it should not be used for patients with acute, severe fluid losses (i.e., patients with evidence of circulating volume compromise). Likewise, this route is not recommended for extremely dehydrated or hypothermic animals that may have considerable peripheral vasoconstriction, which potentially could interfere with absorption of the fluid. Only isotonic crystalloid fluids containing lactate as a base precursor (e.g., lactated Ringer’s solution) are recommended for subcutaneous administration. The low pH and high acetate content of some Plasmalyte products and Normosol R may contribute to pain on subcutaneous injection. Five percent dextrose in water typically is not recommended for subcutaneous use because temporary electrolyte imbalance potentially may occur as extracellular fluid equilibrates with the administered electrolyte-free fluid. Lastly, there is some concern that use of dextrose-containing crystalloids subcutaneously could predispose the animal to cellulitis if bacteria are introduced on injection.

Q: When does one use 5% dextrose?

A: Five percent dextrose typically is used to replace a water deficit and not to provide calories. Except in very small animals, administration of 5% dextrose (200 kcal/L) cannot be relied upon to maintain daily caloric needs. In cases in which sepsis is a concern or if hypoglycemia from another cause is present, you can add 100 mL of 50% dextrose (i.e., 50 g) to 1 liter of lactated Ringer’s solution to create a solution that has 5% dextrose in it. In this situation, you are using the dextrose to combat suspected or documented hypoglycemia.

Click here to see all of the FAQs

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:

Get started! Introducing the Tick-borne Diseases 101 Course Tick-borne Diseases 101 Course is a free online course. Veterinarians, technicians and staff will gain useful knowledge about common tick-borne diseases they may encounter in their practices. The course will: Improve your knowledge about Lyme disease, anaplasmosis, Rocky Mountain spotted fever and ehrlichiosis Identify clinical signs of tick-borne diseases Learn about the prevalence of these diseases—and how it is changing Take the course!

Seminars Making Real-Time PCR an Everyday Diagnostic Option Christian Leutenegger, DrVetMed, PhD, FVH The Most Commonly Misdiagnosed Diseases in Veterinary Medicine Fred Metzger, DVM, DACVP

Webinar New Insight into the Practical Diagnosis of Bleeding Disorders Dr. Urs Giger, Dipl. ACVIM, ECVIM and ECVCP Canine Pancreatitis: Changing our Ideas of Diagnosis and Treatment David Twedt, DVM, DACVIM

 Announcing the IDEXX Avian Health Profile—  Diagnose a broad spectrum of avian species

Ensure that the most appropriate tests are run on your avian patients for general health checkups or wellness screenings. The new Avian Health Profile is a powerful diagnostic tool offering these benefits for use on the VetTest® Chemistry Analyzer:

The Avian Health Profile includes: ALB (Albumin), AST (Aspartate aminotransferase), Ca (Calcium), GLU (Glucose), TP (Total Protein), URIC (Uric Acid) and calculated GLOB (Globulin).

For more information on the new Avian Health Profile, call 1-800-355-2896.

IDEXX VetLab® Results Reporting Improved
New and better organized information for easy comparisons

We have reorganized the IDEXX VetLab® Station report to help you make comparisons and easily identify trends and abnormalities.

Establishing Preanesthetic Testing Protocols in Your Practice—
Part 3

In our October issue we presented you with information from top experts in the preanesthetic field to get you well on your way to updating and implementing your new preanesthetic testing protocols: Step 1: 'Standardize Your Protocols' by age and wellness categories; Step 2: 'Train Your Team' so they understand the expectations and can confidently answer clients' questions; Step 3: 'Determine Your Pricing' at a level you feel covers the value of the workup, yet won't compromise patient care due to pricing constraints; and Step 4: 'Integrate Your Systems' to include your new testing protocols and pricing structure. Now we'll move on to the final steps.

Step 5: At this point, you'll want to 'Implement Your Protocol.' Set a date for launch, set expectations with your staff and then make it happen! You'll be surprised how comfortable and relaxed everyone feels knowing they've reduced the risks and provided the best possible care to your patients. Best of all, the change will be seamless to your clients, who want only the best care for their pets.

Step 6: The last step is to 'Track Your Compliance.' This is where you can measure your team's success and look for opportunities you may have missed in providing the level of care you want your patients and clients to receive. It's also a way to identify and track lost charges and make adjustments to your workflow and processes for the future. For example, you might review the number of patients you see in a given month for anesthetic events and compare it to the number of preanesthetic panels you run.

You can visit us at www.idexx.com/prean to review all the steps in more detail and for all the tools and information you need to get you on your way to establishing preanesthetic testing protocols in your practice!

Increase patient care: Increase revenue
Investing in diagnostics can result in significant tax savings.

Practice owners who invest in new in-house laboratory equipment are investing in their patients' health and making a commitment to more streamlined practice management. What may be less obvious is the many other ways these investments can really pay off.

First, in-house testing and imaging allows a practice to offer better, more immediate care to its patients—which leads to more satisfied clients. Secondly, new instruments offer integration capabilities that can improve productivity and information management—a benefit that also positively and directly affects patients and clients. Third, in-house diagnostics, paired with practice management software, can help reduce lost revenue through more complete and accurate billing.

In recent years, new tax elections have added another incentive for investing in in-house diagnostics. You may be able to take advantage of the Internal Revenue Service Code Section 179 deduction:*

One more note: If you have considered integrating your in-house equipment and software diagnostics, not only might you receive an immediate tax benefit as described above, but when your practice management system is coupled with your in-house laboratory, digital radiography and reference laboratory services, fewer testing charges are overlooked. Did you know that practitioners fail to bill clients an average of $40,000 per year for services rendered?^† Subsequently, an average three-doctor hospital could realize an additional $120,000 from missed charges. Now that’s a real benefit for your bottom line.

Talk to your accountant to learn more about possible tax savings for your practice. For more information about the integrated practice and in-house diagnostics, visit us at www.idexx.com/vetlab or call 1-800-355-2896.

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. Identify the leukocyte indicated with the arrow.
    
2. Which of the following is the best interpretation for the mild anemia evident based on the mild decrease in red blood cell density (HCT = 25%)?
   1. Regenerative anemia associated with blood loss
   2. Regenerative anemia associated with hemolytic disease
   3. Nonregenerative anemia associated with underlying renal disease
   4. Nonregenerative anemia associated with inflammation
   5. Nonregenerative anemia associated with bone marrow failure

Figure 1. Peripheral blood film from a dog with a total leukocyte count of 52,000/microliter, monolayer region of blood film, Wright’s stain, 100x objective field of view.

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All fields are required for continuing education credit records.

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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