This month’s survey question

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

Healthy teeth for healthier, happier pets

As more and more veterinarians are including dentistry in their routine wellness programs, it is not surprising to find that 84% of respondents to last month’s Diagnostic Edge survey have a dental grading system in place at their practice. Largely through the educational efforts of veterinarians, pet owners have become aware that dental disease can be both serious and debilitating, greatly affecting the quality of life of their beloved pet.

Dental disease and its associated pain and discomfort is something we can all relate to. Serious dental disease and its consequences also impact on the human/animal bond. Halitosis can get in the way of an otherwise perfect friendship! Including dentistry in your wellness program is a definite practice builder.

The feline dental disease/retroviral infection connection

Although awareness of canine oral health is on the rise, feline dental disease is one of the most overlooked areas in veterinary practice. It's been reported that more than 85% of cats older than four years have periodontal pathology.¹

Additionally, a recent nationwide study conducted by IDEXX has shown a significant correlation between retroviral infection and oral disease.² Presenting cases included cats with plaque, calculus, gingivitis, periodontal disease, feline odontoclastic resorption lesions, gingivostomatitis and other oral diseases as defined by the practitioner.

The study showed that one in every seven cats screened with oral disease also had a retroviral infection. In the study, 8,982 orally diseased cats were screened for FIV and FeLV, and 1,276 tested positive for retrovirus infection—a prevalence of 14.2%.¹ This study suggests screening cats with oral disease for retroviral infection to help understand and treat the multifactoral underlying causes. Review the nationwide study.

References

1. Levy JK, Crawford PC, Brien JL. Prevalence of FIV and FeLV in the United States. Proceedings from: Seventh International Feline Retrovirus Research Symposium; September 11–15, 2004; Pisa, Italy.
2. Bellows, J, Lachtara, J. Prevalence of Retroviruses in Feline Oral Disease Cases; 2006. IDEXX Laboratories.

Check out our feline dental health course. Call us for more information at
1-800-355-2896.

Featured case study:
5-year-old spayed female mixed-breed dog, Jada
by Heather Derreberry-Salica, VT, and Ned R. Bartlett, DVM, owner, Harbor Animal Hospital, Winthrop Harbor, IL

Physical exam
Jada was lethargic, with moderately tacky, pink mucous membranes and was estimated to be approximately 10% dehydrated. There was no pain on abdominal palpation. Her temperature was 100.2°F.

Differential diagnoses
Pancreatitis, dietary indiscretion/toxin ingestion, gastrointestinal foreign body, systemic lupus erythematosus (prior history of lameness), gastrointestinal parasitism, hypoadrenocorticism (Addison’s disease) and ketoacidosis were all considered. Metabolic disease such as acute/chronic renal failure and hepatic failure were also considered. Infectious disease was also considered: Lyme, Ehrlichia, bacterial (e.g., hemorrhagic gastroenteritis) and viral.

Diagnostic plan
A complete blood count (CBC), complete chemistry profile including electrolytes and a urinalysis were performed in order to assess potential primary and secondary organ involvement. Given the degree of gastrointestinal (GI) signs, survey radiographs of the abdomen were performed.

Laboratory data

Erythron—The elevations of the red blood cell count, hematocrit (HCT) and hemoglobin (HGB) were likely due to hemoconcentration secondary to dehydration. Due to the degree of increased HCT, other influencing factors including splenic contraction are also likely even though splenic contraction typically plays only a minor role on a red blood cell mass in the dog. No red blood cell morphology abnormalities were seen upon review of the blood film.

Leukon—The leukon was characterized by a moderate monocytosis consistent with inflammation, where there is a tissue demand for macrophages. The lack of identifying a lymphopenia or eosinopenia, two of the more common leukocyte quantitative abnormalities associated with a glucocorticoid influence (“stress”) in the dog, on a patient with a clinical presentation where stress would be likely was highly suggestive of possible adrenal insufficiency (possible Addison’s disease). No leukocyte morphologic abnormalities were noted when reviewing the blood film.

Thrombon—No significant quantitative or morphologic abnormalities were noted.

Renal panel—The minimally increased BUN and phosphorus and the creatinine at the high end of the reference interval suggested slight decreased glomerular filtration. The clinical dehydration suggests that there was at least a prerenal component to this azotemia. The urine was concentrated, which also supported this interpretation. Other components of the urinalysis were within normal limits.

Hepatic panel—The total bilirubin was mildly elevated and was most likely associated with slight in vivo hemolysis since there is no support for prehepatic icterus (hemolytic disease) or cholestasis.

Electrolytes—The mild decreased sodium, moderately increased potassium and the low sodium:potassium ratio (19.7) were strongly supportive for Addison’s disease being that renal disease or other causes for the electrolyte changes were not evident. The chloride was mildly decreased and paralleled the changes with sodium.

Diagnostic imaging—Abdominal radiographs: within normal limits

Because of Jada’s signalment, chief complaint, physical exam findings and electrolyte abnormalities, Addison’s disease was strongly indicated and an ACTH stimulation test was performed. Samples were submitted to an IDEXX feference laboratory. The pre-ACTH and post-ACTH cortisol levels were both <0.2 µg/dL, which were consistent with hypoadrenocorticism (Addison’s disease).

Final diagnosis
Hypoadrenocorticism (Addison’s disease)

Diagnostic summary
Hyperkalemia and hyponatremia combined with a sodium:potassium ratio of <23–25, in the absence of renal failure or other causes of low sodium:potassium ratios, is strongly suspicious for, but not diagnostic of, Addison’s disease. The lack of a “stress leukogram” (lymphopenia, neutrophilia or eosinopenia) was additional support for Addison’s disease. The low basal cortisol and complete lack of an ACTH stimulation response were diagnostic for Addison’s disease. Prerenal azotemia and hemoconcentration secondary to hypovolemia are common in the Addisonian patient.

Therapeutic plan
Initial supportive care included intravenous fluid therapy with sodium chloride, carafate, famotidine and metoclopramide. Upon diagnosis, treatment of hypoadrenocorticism consisted of percortin 75 mg intramuscularly, 4 mg dexamethasone intravenously and a tapering dose of prednisone, starting at 10 mg twice daily. Serial laboratory data, particularly electrolytes, were collected during the initial treatment phase.

Clinical case outcome
Jada responded very well to treatment and her electrolytes, BUN and creatinine were all within reference interval limits within two weeks of treatment. The sodium:potassium ratio was 40.3.

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

The IDEXX Learning Center provides knowledge you can put into practice. Take part in the evolution of animal diagnostics through an ongoing educational partnership with leading veterinarians from across the globe and take advantage of a wide range of education resources, reference materials and events. Visit the IDEXX Learning Center to see a full listing of available Webinars, seminars and online training courses from IDEXX.
 

Create your own account on the IDEXX Learning Center and see how IDEXX can help you reach your educational goals!

Here are some of the opportunities available this month:

Seminars Advances in Diagnosis and Management of Canine Pancreatitis Presenters vary   Detection and Management of Common Senior Patient Diseases Dr. William (Bill) Fortney   Feline Infectious Diseases Dr. Coralee Sendgraff   The Most Commonly Misdiagnosed Diseases in Veterinary Medicine Dr. Fred Metzger   The Value of Now—How patients, clients and veterinary practices can benefit from in-house diagnostics Dr. Jim Irwin   New Concepts in the Management of Tick-Borne Diseases in Dogs Dr. Rick Alleman

Webinar New Insight into the Practical Diagnosis of Bleeding Disorders Dr. Urs Giger

Two new enhancements for the IDEXX VetLab® Station

New SNAP® test interpretive guides added

The IDEXX VetLab Station software (version 2.31) now contains several new additions to the interpretive guides available, including guides for each of the SNAP test results. The interpretive guides offer valuable background information, which can be particularly helpful as an aid in explaining diagnostic results to your clients.

Print a SNAP^® log report and eliminate the need for redundant bookkeeping

The newest version of the IDEXX VetLab Station software allows you to automatically generate a report that includes all of the SNAP test results entered into the IDEXX VetLab Station. The report can be generated for a specific time frame and neatly formats your SNAP results into a simple log sheet, eliminating the need for you to maintain a separate manual log for of all of your SNAP test results.

An integrated practice roundtable
The integrated practice offers both tangible and intangible benefits that improve medical care and increase client and staff satisfaction

In a roundtable discussion, 10 veterinarians and two practice managers discussed their experiences with integration and working in a paperless practice. While clinic sizes and other variables differed—even resistance to or acceptance of the idea—the results and benefits were the same for everyone.

See the entire roundtable discussion which includes three simple steps for going paperless.

All participants agreed that an integrated practice:

• Allows any member of the clinic to see a complete patient picture quickly and easily from any workstation
• Frees doctors' time to practice medicine and allows technicians time to perform higher level work
• Facilitates client communications and adds value, as they can easily see what it is you’re talking about through printouts and pet health “report cards”
• Builds client confidence and loyalty when they see how efficiently your practice runs
• Helps protocols stay consistent with templates and standards
• Increases revenues through consistent testing protocols, better tracking of records and results and fewer lost charges
• Increases staff satisfaction and reduces turnover for a more seasoned team and fewer costs associated with training
   

For more information on the IDEXX Integrated Practice, visit www.idexx.com/animalhealth and take the Integrated
Practice Tour.

Spotlight on Heather Derreberry-Salica, VT
See this month’s case study submitted by Heather via our Suite Stories Contest!

Heather Derreberry-Salica has been with Harbor Animal Hospital for about 15 years—first, helping out in the kennel, and after college, working full-time as a technician. Harbor Animal Hospital is a
four-veterinarian practice that employs seven technicians and two receptionists. On a busy day, they see about 40 patients.

Heather says they’ve been doing more in-house blood work since they got their LaserCyte Hematology Analyzer. They used to send their CBCs out for confirmation, but now they trust the results they get in-house. This saves time and allows them to move ahead with treatment more quickly. In Heather’s words, “Now that we have the LaserCyte, we have accurate results and we do more blood work in-house, with chemistries and with the VetLyte analyzer. My dog, Jada, was diagnosed so quickly because the machine was accurate and I trusted it.”

“When pets come in with chronic kidney or liver problems, we can retest their values on-site and have results in 15 minutes. This saves owners from having to come back. We can adjust medications right then, and we can instruct owners how to adjust home treatments.”

“We’re able to see more patients and do a full workup while they’re here,” Heather adds. “It makes owners feel better when we can run blood work and have a diagnosis right then. They think, ‘These people really took care of my pet. They found out right away what was wrong.’ They feel more confident in their veterinarian and they’ll tell their friends. Word of mouth is the best way for others to find out about the care we provide, and we can see more animals that way.”

“I’m glad we have the ability to provide answers quickly, because sick animals don’t understand why they feel that way and they’re scared. Making them feel better as quickly as we can is the best part about it.”

Along with her pit bull mix, Jada, Heather and her husband have a 10-year-old domestic shorthaired tabby named Zorro.

Here is Heather’s Story from www.suitestories.com:
 

Reduce missed lesions with proper monitor calibration
Matthew Wright, DVM, MS, DACVR

The monitor you use to view digital images is an essential component of any digital radiography system, but it is one we often overlook. Your monitor must be properly calibrated to prevent you from missing lesions. An uncalibrated consumer-grade monitor may not fulfill this requirement. Unfortunately, there are no clear standards regarding displays used for medical imaging in either human or veterinary medicine, which makes deciding on a monitor difficult.

One way for you to get the most from your monitor is to set the ambient light in the room to a level that is about equal to the brightness of your monitor and to position the monitor at eye level.^1,2 Ambient light is important for digital radiography because the brightness of LCD screens is much less than a traditional light/view box.

Another option would be to calibrate your monitor using the American Association of Physicists in Medicine (AAPM) test target, which can be downloaded for free.

TG18-QC Pattern³

This target is composed of a number of gray boxes. Look at the lower left and lower right boxes; in each of these boxes, you should see the words “QUALITY CONTROL” (one with a black background, then gray, then white). If you do not see the words “QUALITY CONTROL” in both the left and right sides of the image, your monitor needs to be calibrated. In most cases, the brightness, gain and contrast settings on your monitor will need to be adjusted so that you can see the words “QUALITY CONTROL” in the boxes on the left and right.

Maintaining the correct calibration of your monitor takes only a few minutes and ensures that your monitor will be set for optimal diagnostic image viewing.

Read the full monitor selection and calibration article.

References

1. Brennan et al. Ambient Lighting: Effect of Illumination on Soft-Copy Viewing of Radiographs of the Wrist. Am. J. Roentgenol. 2007;188:W177–W180.
2. Acad Radiol. August 2005;12(8):957–64.
3. Samei E, Badano A, Chakraborty D, Compton K, Cornelius C, Corrigan K, Flynn MJ, Hemminger B, Hangiandreou N, Johnson J, Moxley M, Pavlicek W, Roehrig H, Rutz L, Shepard J, Uzenoff R, Wang J, Willis C. Assessment of Display Performance for Medical Imaging Systems, Report of the American Association of Physicists in Medicine (AAPM) Task Group 18, Medical Physics Publishing, Madison, Wi. AAPM On-Line Report No. 03, April 2005.

For more information on IDEXX Digital Radiography, visit www.idexx.com/digital.

With FREE continuing education credit!*

NOW 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. Which of the following is the correct identification of the crystals present in the center of the field of view?

1. Cystine crystals
2. Struvite crystals
3. Uric acid crystals
4. Cholesterol crystals

2. Is there any clinical significance of the finding of these crystals?

1. Yes, always
2. Yes, rarely
3. No

Figure 1.	Urine sediment from a dog, unstained, high power field (40x objective) 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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