In this issue:
- Education—Case study: 22-month-old, neutered male domestic shorthair, Simon
- Contest—Your votes are in and the grand-prize winner has been announced for the Ready, Set, Run contest
- IDEXX Innovations
- The ProCyte Dx® Hematology Analyzer and the Catalyst Dx® Chemistry Analyzer make beautiful diagnostics together
- Realize your vision of success with new features from Cornerstone® software version 8.1
- Technical Tip—diagnosing feline pancreatitis using the new SNAP® fPL™ Test
- IDEXX Learning Center—2011 Cornerstone® User Conference: Register early and save
- Client Value—There’s more value to fast, complete in-house laboratory results than you might think
- Interactive Challenge—Compare films to identify significant red blood cell morphologic abnormalities
Featured case study: 22-month old, male domestic shorthair, Simon
Patient
Simon, 22-month-old, male domestic shorthair
Presenting reason
Simon presented for acute onset of vomiting and soft stools.
History
Simon’s owner reported that he had vomited a total of six times in the 24 hours prior to presentation. He had eaten dinner the previous evening but did not eat the morning of presentation. The owner had also noted soft stools in his litter box that morning. Other than a previous history of recurrent episodes of sterile cystitis, Simon has been clinically healthy. He is current on all appropriate vaccinations and is a strictly indoor cat. He tested negative on a SNAP® Feline Triple® Test and had been empirically dewormed as a kitten. Recent fecal examinations were negative for ova and parasites.
Physical examination
Simon was nervous but lethargic and very nauseous on general physical examination. His temperature was 99.2° F; pulse: 180 bpm (likely secondary to nervousness); respiratory rate: 28 bpm; weight: 11.7 lbs; body condition score: 6 (1–9). He was found to be approximately 5% dehydrated with tacky and pink mucous membranes. Thoracic auscultation was within normal limits. On abdominal palpation, there was focal cranial abdominal pain with a possible mass.
Differential diagnoses
Given the patient’s signalment in combination with the clinical presentation of acute anorexia, vomiting and soft stool, primary gastroenteritis or gastroenteritis secondary to a gastrointestinal foreign body was considered to be the primary differential (e.g., linear or other foreign body, trichobezoar). Additionally, a broad list of differentials was also considered including pancreatitis, triaditis (inflammatory disease of liver, pancreas and intestines), FIP, liver disease (cholangiohepatitis, hepatic lipidosis, hepatitis, etc.), gastrointestinal disease (inflammatory bowel disease [IBD]. Endocrine disease (hyperthyroidism), renal disease, fungal infection and neoplasia were considered less likely, given the patient’s young age and clinical signs.
Diagnostic plan
To further investigate systemic disease (inflammatory or neoplastic), a complete minimum database including a CBC, clinical chemistry profile, urinalysis and urine culture was performed to characterize the extent of the disease and potential of specific organ involvement. As part of his minimum database, a SNAP® fPL™ Test was also performed. This was warranted because although an acute onset of vomiting is not the typical presentation for a cat with pancreatitis, cats can present acutely vomiting—especially if they have acute pancreatitis or a concurrent gastrointestinal illness that has suddenly worsened. Additionally, whole body radiographs were recommended for further investigation of abdominal pain and the possible foreign body/mass palpated.
Laboratory data
Erythron—No significant quantitative abnormalities were noted and no morphologic abnormalities were observed during blood film evaluation.
Leukon—No significant quantitative abnormalities were noted and no morphologic abnormalities were observed during blood film evaluation. The minimally increased basophil is considered an equivocal finding and must be considered insignificant without other leukocyte abnormalities.
Thrombon—Blood film review revealed clumped but adequate platelet numbers.
Clinical chemistry—the high-normal albumin value was likely secondary to dehydration. Mild dehydration was supported on the physical examination (tacky mucous membranes) and was further supported by the highly concentrated urine specific gravity (see below). With dehydration, the A/G ratio should stay within reference interval limits, since all the proteins are increased proportionately. The mildly increased A/G Ratio is most commonly associated with decreased globulins or a falsely increased albumin. Since no other significant protein changes or other significant chemistry profile changes were observed, this was considered insignificant. Re-evaluation with future chemistry profiles should be considered. The CK increase is minimal and insignificant, also.
Urinalysis and urine culture—As mentioned previously, the very concentrated urine specific gravity of 1.064 was supportive of dehydration. The pyuria and hematuria was consistent with sterile cystitis, given the negative urine culture results. The proteinuria was likely secondary to the pyuria although it was recommended that the urine be monitored for persistent proteinuria. A urine protein-to-creatinine ratio would be recommended if persistent proteinuria was documented in the absence of pyuria.
Result: Normal
The sample spot was lighter than the reference spot, indicating a normal feline pancreas-specific lipase concentration. (A normal SNAP fPL result indicates that pancreatitis is unlikely.) Although performing a Spec fPL® Test after obtaining a normal SNAP fPL result is not routinely indicated, a Spec fPL Test was also performed on Simon as part of a study. The Spec fPL concentration was 0.9 µg/L, which was in the normal range and consistent with the SNAP fPL test result, as expected.
Diagnostic imaging
Radiographs—Whole body radiographs were taken, including both lateral (figure 1) and ventrodorsal (figure 2) views.
Figure 1. On the lateral view, a soft-tissue foreign body (yellow arrow) is noted in the mid-to-caudal esophagus. | Figure 2. On the ventrodorsal view, obtained just after the lateral, the soft-tissue foreign body is again noted, now extending from the esophagus into the stomach (yellow arrow). |
Abdominal ultrasound—An abdominal ultrasound revealed a normal-appearing pancreas (figure 3). The stomach (figure 4), moderately distended with air and fluid, contained a moderate amount of echodense foreign material. No contractions were noted and wall thickness was normal. The small intestines were of normal diameter; there was slight corrugation to the duodenum; no foreign body was seen or obstruction was identified. The urinary bladder wall was thickened and there were echogenic sediment shadows, which, in view of the urinalysis and urine culture and in view of the history, were indicative of chronic sterile cystitis.
Figure 3. Longitudinal scan of the pancreas (yellow arrows). Note the normal, slender pancreatic shape and smooth regular margins. The right limb and body of the pancreas is not visualized as it was obscured by the air-distended stomach. The normal ultrasonographic appearance of the feline pancreas is isoechoic to slightly hyperechoic to the adjacent liver lobes, and nearly isoechoic to the surrounding mesenteric fat. | Figure 4. Transverse ultrasonographic image of the stomach. The stomach wall is indicated by the yellow arrows. |
Ultrasonographic diagnosis
Gastric foreign material and hypomotility. A trichobezoar, cloth foreign body or gastroesophageal intussusception were considered the most likely differentials. Cancer or fungal infection were considered unlikely.
Endoscopy
A large trichobezoar was identified (figure 5A) and removed during endoscopy (figure 5B).
Figure 5. Trichobezoar before (A) and after (B) removal.
Diagnostic summary
Differentials for acute severe vomiting in the cat are extensive, with the decision for intensive (endoscopy or surgery) versus medically directed therapy often dependent on diagnostic test results. Cats with pancreatitis often have vague clinical signs that are not specifically localized to the pancreas; therefore, testing is needed to rule the disease in or out. In Simon’s case, rapid, in-house testing including a CBC, biochemical panel, complete urinalysis and culture plus the SNAP fPL Test ruled out many medical causes of vomiting, including pancreatitis, and increased our confidence to move forward with additional diagnostics to obtain the correct diagnosis.
Case outcome
Simon did very well after endoscopic removal of the trichobezoar. The vomiting stopped immediately and he began to eat well upon recovery from anesthesia. Methods to reduce shedding and hair consumption were discussed with the owner (e.g., more frequent grooming, etc). Long-term lubricant therapy was prescribed.
Announcing the grand-prize winner of the IDEXX Ready, Set, Run! contest
Your votes have been counted—see which veterinary technician has won the $5,000 grand prize
Congratulations Adam Bonds of the Arizona Animal Wellness Center, Gilbert, Arizona! Adam’s video entry received the most votes, making him our $5,000 grand-prize winner.
Adam proves that with advanced instruments and an efficient laboratory work flow, in-house laboratory blood work can be simple and fast. With minimal hands-on time, Adam is able to run a Chem 17 CLIP with electrolytes and a CBC on the Catalyst Dx® Chemistry Analyzer and the ProCyte Dx® Hematology Analyzer and receive results in minutes. Adam’s in-house laboratory includes both Catalyst Dx and ProCyte Dx, and both instruments are linked with the clinic’s practice management software to maximize benefits for patients, clients and the practice.
Check out Adam’s winning video entry or watch the other videos here. And thanks to everyone who entered the IDEXX Ready, Set Run! contest.
These two make beautiful diagnostics together
The ProCyte Dx® Hematology Analyzer and the Catalyst Dx® Chemistry Analyzer—a true power couple
Now you can have comprehensive in-house hematology and chemistry results in minutes, all in one easy-to-read report. Together, the ProCyte Dx® Hematology Analyzer and the Catalyst Dx® Chemistry Analyzer can supercharge your work flow with:
- Innovative technology that delivers accuracy and reliability
- Unmatched flexibility, efficiency and throughput
- Easy load-and-go operation for less hands-on time
- Hematology results in 2 minutes and chemistries in 8 minutes, so you can share results during the patient visit
Fast, accurate and comprehensive diagnostic information in a single patient report—can you conceive of anything better?
See just how well you and IDEXX in-house analyzers can work together for your patients. To schedule a demonstration at your practice, call 1-800-551-0998.
New features for Cornerstone® Practice Management Software version 8.1
More ways to realize your vision of medical, professional and personal success
With innovative and efficient new features, Cornerstone® Practice Management Software version 8.1 makes it easier to capture, manage and access all medical and practice information. Whether it’s monitoring patient health trends or finding and previewing patient reports faster, Cornerstone 8.1 can help practices be more productive and provide more consistent, high-quality care.
With new features in this updated software release, you can:
- Efficiently monitor trends and identify changes in patient health with Vital Signs.
- View patient laboratory results as a PDF that easily attaches to the electronic medical record.
- Quickly preview and choose from more than 400 standard reports through Report Search.
- Review estimates on-screen with clients and electronically capture their signatures for approval.
- Simplify payment transactions with X-Charge® credit and debit card processing.
- Generate vaccine tags and rabies certificates as part of the patient visit.
- Void medical notes or correspondence documents without deleting them.
More than ever before, these new features show how Cornerstone software brings together medical and practice performance information to empower veterinarians and staff members to work smarter.
Realize Your Vision: The 2011 IDEXX Cornerstone® User Conference
Come with a goal—leave with a plan. October 1–4, The Westin Chicago North Shore, Wheeling, Illinois. Register at idexx.com/completeyourvision. Save $100 when you register before August 15, 2011.
How to use the new SNAP® fPL™ Test
(feline pancreas-specific lipase)
Feline pancreatitis can be difficult to diagnose. Here’s how you can use the SNAP fPL Test to give clients the answers they’re looking for.
The SNAP® fPL™ (feline pancreas-specific lipase) Test is the first pet-side test developed to measure feline lipase levels specific to the pancreas. Delivering accurate results in just 10 minutes, SNAP fPL can be used to help rule in or rule out pancreatitis, so you’re able to discuss next steps with a concerned pet owner during the patient visit.
Still, confidently diagnosing feline pancreatitis can be difficult, especially as most cats present with nonspecific GI signs. The following links offer brief video tutorials (“snippets”) about diagnosing feline pancreatitis, and how to run and interpret results for the SNAP fPL Test.
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| SNAP fPL Test: Could it be feline pancreatitis? | How to Run the SNAP fPL Test | How to Interpret the SNAP fPL Test |
Take the Pancreatitis Challenge—Learn more about the health of your feline and canine patients and earn $1 for every result you submit. Call your authorized IDEXX distributor or 1-800-248-2483, or go to idexx.com/pancreatitischallenge.
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 idexxlearningcenter.com to see our full listing of available Webinars, seminars and online training courses.
Realize Your Vision
October 1–4, 2011 • The Westin Chicago North Shore • Wheeling, Illinois
Whatever your practice goals, the Cornerstone® Practice Management System can help you achieve them.At the 2011 conference, you’ll:
- Learn how to use specific features in Cornerstone to reach your goals.
- Leave with an action plan for implementing these features in your practice.
Register before August 15 and save $100 per person
We sold out last year, so don’t wait.
Call 1-888-211-0758 today or register here.
Fast and complete in-house testing delivers greater results beyond improved patient health
Reviewing blood work with clients during the patient visit can help improve understanding of your practice’s unique value and increase compliance with your recommendations.
The ability to provide diagnostic results during appointments is an efficiency that helps staff make better use of their time, as well as the client’s time. This creates more time to focus on delivering continuity of care to patients, improving client understanding and compliance, and it means that you and your staff can head home on time at the end of each day.
Make sure your state-of-the-art diagnostic capabilities and ability to run blood work during the patient visit deliver more than just patient results. The following easy-to-implement suggestions can help ensure that you get a greater return from your in-house laboratory.
Here’s how:
- Provide clients with the patient report before they leave your practice, so they have a better understanding of the services they receive from you. This also gives them a reference to share with family members and for emergency visit situations.
- Post your standard-of-care protocols at eye level in exam rooms so clients become familiar with them. The less time you spend gaining compliance with routine procedures, the more time you have to discuss dentals, weight management and other recommendations.
- Create consistent protocols and messaging for all staff by agreeing on which tests you’ll run for routine visits and run these tests in-house to provide insights and recommendations during the patient visit.
- Empower your technicians to request, draw and start diagnostic tests within the first few minutes of a sick or wellness appointment.
- Leverage your technicians’ talents and expertise to perform all nonveterinarian-specific responsibilities. This will allow veterinarians to spend 10–15 minutes of quality time with each client and patient during their visit and the rest of their time seeing other patients, following up on cases, etc.
- Stagger sick and wellness appointment schedules to allow veterinarians to see multiple patients at the same time. Schedule some appointments on the hour and half hour and other appointments at quarter to or quarter past the hour.
Learn more time and effort-saving tips with our Real-Time Care™ archived Webinar series at idexx.com/rtc. You can also start improving client understanding and compliance today by downloading free client education materials at idexx.com/petowner.
How is your practice work flow? Call 1-207-556-8045 to set up an interview and see if you are ready for a practice consultation.
Interactive Challenge #63 Hematology (RACE 106-7989)
Earn 0.5 hour of continuing education (CE) credit for this challenge when you submit your answer by 12/01/2012.† After that date, you can still take the challenge to test your skills, but continuing education credit will not be available.
Have you taken advantage of every qualifying Interactive Challenge for 0.5 hour continuing education (CE) credit? Check out the Diagnostic Edge archive and take any qualifying challenges you may have missed. The expiration date will tell you if the challenge still qualifies for credit.
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Figure 1: Peripheral blood film from an EDTA anticoagulated blood specimen from a 3-year-old, neutered male Airedale terrier dog presented to an emergency clinic. Wright’s stain, 50x objective field of view. |
Figure 2: Peripheral blood film from an EDTA anticoagulated blood specimen from a 3-year-old, neutered male Airedale terrier presented to an emergency clinic. Wright’s stain, 100x objective field of view. |
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†Course meets the requirements for 0.5 hour of continuing education in jurisdictions which 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.
These activities qualify for 0.5 AVA Vet Ed points each.
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