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• Education: 14-year-old neutered male mixed-breed dog, Arthur
• Health Watch: Canine influenza virus strikes New Jersey—what you should know
• IDEXX Innovations: September is Senior Care Month—special pricing on senior panels
• Training and Events: See Webinars, seminars and online training opportunities available this month; sign up now for Cornerstone® Users Conference
• Practice Management: Invest in diagnostics for significant tax savings
• Technical Tip: New online tutorials for IDEXX-PACs™ 3.0 Imaging Software; new software envelopes
• Subscribers Say: What do you think? We’d like to hear your opinions.
• Interactive Challenge: Earn FREE continuing education credit in the United States, Australia and parts of Canada! Characterize morphologic findings and identify a leukocyte in a peripheral blood film from an EDTA anticoagulated blood specimen from an adult cat with diabetes.
   

Featured case study:
14-year-old neutered male mixed-breed dog, Arthur
Submitted by Brook R. Quinn, DVM, Main Street Veterinary Hospital, Flower Mound, Texas

Full History
Arthur has a several-year history of idiopathic epilepsy, but has had no recent seizures. His owners weaned him off anticonvulsive therapy several years ago and he is on no current medication other than monthly heartworm/intestinal parasite, flea and tick prophylaxis. He is current on all vaccinations required for boarding. Three weeks ago, Arthur presented for hind limb weakness, which seemed to be exacerbated by sleeping or prolonged periods of inactivity. A CBC (complete blood count), general chemistry panel, total T4 and urinalysis were performed and revealed mild to moderate renal azotemia (urine specific gravity at 1.012; creatinine at 3.4 mg/dL, reference interval of 0.4–1.8; BUN at 44 mg/dL, reference interval of 7–27). All other results were within the reference interval limits and a recent SNAP® 4Dx® Test was negative. The owner reported no polyuria or polydipsia at this time. Arthur was placed on a renal prescription diet. Repeating a CBC, chemistry panel and urinalysis in four weeks to monitor his renal function was recommended.

Physical examination
Arthur was nervous but friendly and in adequate body condition on presentation. He had lost three pounds during the last four months. He had bilateral nuclear sclerosis and moderate to severe dental tartar. He was nonweight-bearing on the left foreleg. The firm interdigital subcutaneous mass between digits three and four on the left foreleg that was present on physical exam one week ago had enlarged and was significantly more painful on palpation.

Differential diagnoses
Weight loss—Differentials included progressive chronic renal failure, other/concurrent systemic disease such as hepatic and gastrointestinal disease, diabetes mellitus and neoplasia.
Mass left front foot—Differentials included benign cyst, localized inflammation and neoplasia.

Diagnostic plan
CBC, general chemistry profile, including electrolytes and urinalysis, were planned to evaluate renal disease progression or regression and to screen for other infectious, inflammatory, metabolic and endocrine disease. Unfortunately, the patient urinated immediately prior to the office visit, so a urine specimen could not be obtained for urinalysis. A fine-needle aspirate of the foot mass with subsequent cytology was performed in-house. Radiographs, including lateral and anterior/posterior (A/P) views of the left front foot, were performed to assess for any boney involvement by the mass. Thoracic radiographs, including left lateral, right lateral and ventrodorsal (V/D) views, were obtained to rule out primary or metastatic pulmonary disease. An abdominal ultrasound was performed for renal and major organ evaluation and to screen for potential abdominal space-occupying lesions.

Laboratory data

Other than a mild thrombocytosis, which was thought to be clinically insignificant, no abnormalities were noted. Blood film review revealed no significant morphologic abnormalities.

Kidney panel—There was a mild to moderate increase in both creatinine and BUN indicating a mild to moderately decreased glomerular filtration rate, but the values were improved compared to those from two weeks previously, indicating possible response to the prescription kidney diet and/or compensation. Persistent azotemia in the face of concurrent weight loss in this case is highly supportive of chronic renal failure; however, there is no identifiable anemia to suggest that end-stage renal disease is present. A repeat creatinine and BUN with a complete urinalysis and CBC are needed for further characterization.

Cytology—Multiple clusters of large round cells, many with multiple nucleoli. Cocci too numerous to count and the occasional segmented neutrophil were also noted.

Abdominal ultrasound

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The right and left kidneys were normal in size and shape. There was a mild to moderate loss of corticomedullary definition in both the left and right kidney. No other abnormalities were noted. Findings are supportive of the clinical diagnosis of renal failure without end-stage renal disease.

Radiographs of the left foreleg

Lateral and A/P views of the left carpus, metacarpus and phalanges demonstrated no boney changes suggesting no bone involvement by the identified mass.

Thoracic radiographs

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Radiographic evaluation of the thorax included three views: left lateral, right lateral and V/D. The above right lateral view revealed a radiodense area/potential mass effect (yellow circle) that could not be identified on the left lateral or V/D views. Differentials for the mass effect include summation of normal tissue, neoplasia, focal pneumonia or granuloma.

Diagnostic summary
This patient clearly had two distinct problems: presumptive chronic renal failure was supported by the clinical finding of weight loss, azotemia with a lack of renal concentrating ability, persistent azotemia and the finding of decreased renal corticomedullary detail on abdominal ultrasound.

Cytology of the mass on the left front foot was supportive of possible epithelial cell neoplasia; however, because of the inflammatory component and presence of bacterial agents, benign epithelial cell hyperplasia would also have to be considered. The discovery of a mass effect on the right lateral view of the thorax, which was not apparent on either the left lateral or VD views, made primary or metastatic neoplastic disease a possibility. Access to digital radiography facilitated the rapid acquisition of a complete radiographic data set, involving three views of the thorax. Furthermore, the digital format and associated software allowed the clinician to magnify the area of interest and upload all the radiographic images both to Arthur’s medical records and to a board-certified radiologist for a second opinion.

Therapeutic plan
The owner elected general anesthesia and incisional biopsy of the foot mass. They declined complete mass removal at this time due to concerns regarding anesthetic risk and postoperative recovery time, which could be exacerbated by this patient’s underlying chronic renal failure. They were considering palliative amputation of the limb pending biopsy results. The owners understood the poor prognosis given the presence of the thoracic mass effect, chronic renal failure and the patient’s advanced age.

Histopathology
The biopsy revealed benign epidermal hyperplasia and chronic inflammation of unidentified origin.

Clinical case outcome
Appropriate antibiotic and anti-inflammatory therapy resulted in gradual improvement of Arthur’s lameness postoperatively. Arthur continues to have regular monitoring of his kidney parameters, but the elevation of the creatinine and BUN has increased in the face of an isosthenuric urine specific gravity indicating progression of his chronic renal failure. Recently his phosphorus and calcium (see below) have moderately increased and remained above reference interval limits, which is most likely associated with chronic renal failure. Hypercalcemia of malignancy was considered based on the presence of the thoracic mass and potential of neoplastic disease. Primary hyperparathyroidism would have to be considered also. A right lateral thoracic radiograph repeated five months after the first (see below) revealed significant enlargement of the presumptive mass.

The owners elected not to pursue further diagnostics and elected to continue palliative care as long as Arthur is enjoying a reasonably good quality of life.

Repeat clinical chemistry

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References:

1. Thrall DE. Textbook of Veterinary Diagnostic Radiology, 5th ed. Philadelphia, Pa: WB Saunders; 2007.
2. Latimer KS, Mahaffrey EA, Prasse KW. Duncan and Prasse’s Veterinary Laboratory Medicine: Clinical Pathology, 4th ed. Ames, Iowa: Iowa State University Press; 2003.
3. Stockham SL, Scott MA. Fundamentals of Veterinary Clinical Pathology. Ames, Iowa: Iowa State University Press; 2002.
4. Cowell RL, Tyler RD, Meinkoth JH, DeNicola DB. Diagnostic Cytology and Hematology of the Dog and Cat, 3rd ed. St Louis, Mo: Mosby; 2008.

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.

Canine influenza outbreak

Reports from New Jersey of a canine influenza virus (CIV) outbreak are alarming pet owners and veterinarians alike—especially since there’s no vaccine for CIV.

Hundreds of dogs infected
The initial outbreak occurred at a Burlington County boarding kennel in mid–June 2008. Since then, additional infections have been reported in Sussex and Mercer Counties. Several hundred dogs have become ill, with at least one fatality reported.

Isolate and test
Veterinarians who have any reason to suspect CIV should pay close attention to dogs presenting with the following signs:

• Acute “honking” cough and history of recent exposure to other dogs (at a dog park, kennel, dog show, hospital, etc.)
• Runny eyes and nose usually in conjunction with cough, fever or other signs of illness
• Mild to severe pulmonary disease
• Chronic cough

Veterinarians do have an effective weapon against CIV: the IDEXX RealPCR™ Canine Respiratory Disease (CRD) panel. Running the IDEXX CRD panel for dogs with presenting signs will provide rapid, sensitive and specific identification of CIV and six other infectious agents:

• Bordetella bronchiseptica
• Canine parainfluenza virus type 3
• Canine adenovirus type 2
• Canine distemper virus
• Canine respiratory coronavirus
• Canine herpesvirus-1 (CHV-1)
• Canine influenza virus

Whether they’re tested or not, place suspected CIV cases in respiratory isolation from other dogs as soon as possible. Isolated dogs should remain there until their shedding period is over; 10–14 days after onset is recommended.

To order the IDEXX Real PCR Canine Respiratory Disease Panel from IDEXX Reference Laboratories, use an IDEXX Reference Laboratories order form or call 1-888-433-9987 and request test code 2524, Canine Respiratory Panel. Visit our site for specimen requirements.

For more information on CIV, visit the American Veterinary Medical Association (AVMA) Web site. Visit IDEXX for more information on the IDEXX Real PCR Canine Respiratory Disease Panel.

Source for CIV outbreak Veterinary Forum, August 2008, (Vol 25, No 8)

Special September pricing for seniors
Take advantage of Senior Care Month offers from IDEXX Reference Laboratories

*To receive special pricing, be sure to use the test codes shown above. Special pricing expires September 30, 2008.

Hurry! Special pricing ends September 30. Offer valid in the U.S. only.

If you have any questions regarding our senior panels, please call 1-888-433-9987.

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:

• A Clinical Approach to Fluid Therapy
  Dr. Stephen DiBartola
• Smart Practice Investments in a Tight Economy
  Gary Glassman

See a full listing of Webinar opportunities >

• Bleeding Disorders: The IDEXX Guide
• Cornerstone 7.5 Basic Foundation Training
• Complete Urinalysis: The IDEXX Guide

See a full listing of online course opportunities >

• A Clinical Approach to Fluid Therapy
  Dr. Stephen DiBartola
• Advances in the Diagnosis and Management of Canine Pancreatitis
  Various Presenters
• The Most Commonly Misdiagnosed Diseases in Veterinary Medicine
  Dr. Fred Metzger
• Coughing Cats: Asthma or Heartworm Disease?
  Dr. Susan Little
• Feline Heartworm Disease in Everyday Terms
  Dr. Lynn Buzhardt

See a full listing of seminar opportunities >

See a full listing of conferences and IDEXX-sponsored breakout sessions >

Time is running out to register for the IDEXX Cornerstone® Users Conference!

Join us October 12–15 in Oak Brook, IL, at the IDEXX Cornerstone Users Conference and help your whole practice work smarter by making Cornerstone software work harder.

• Learn the ins, outs and intelligence on the newest generation of Cornerstone.
   
• Meet your IDEXX peers from support, education and software development in hands-on labs.
   
• Exchange real-world insights, solutions and information with fellow professionals, including veterinarians and practice managers.

Don’t miss out! Register by September 15 and save $100!

Visit idexx.com/csconference for more information.

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 and treatment to its patients—which leads to more satisfied clients. Second, 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:*

• Purchases of capital equipment and software may be eligible for an immediate deduction of up to $250,000.
• You can expense the qualifying cost of the purchases this year instead of depreciating over several years.
• This incentive provides the full tax benefit in the year of purchase, even when the equipment is leased under a one-dollar buyout.

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/animalhealth or call
1-800-355-2896.

This information is for reference only and is not intended to be tax advice. Please discuss IRS Code Section 179 deduction with your accountant or tax advisor for complete details on current regulations, limitations and guidelines as they may apply to you.

Opperman M. The Art of Veterinary Practice Management. Leneva, Kans: Advanstar Veterinary Healthcare Communications; 1999.

New online tutorials for IDEXX-PACS™ 3.0 Imaging Software

These new, quick and convenient online guides will help you learn the basics of IDEXX-PACS Imaging Software.

The 5- to 10-minute tutorials walk you through the most commonly performed tasks in IDEXX-PACS: capturing, viewing and sending images, and backing up data. You’ll also see an introduction to new features and changes in IDEXX-PACS 3.0.

At the end of each tutorial, you’ll be able to practice what you’ve learned in a simulated version of the software using “Let Me Try” sections.

To access the online tutorials for IDEXX-PACS 3.0, visit www.idexxlearningcenter.com/library. For more information about IDEXX-PACS Imaging Software or these tutorials, please call IDEXX at 1-877-433-9922 or visit www.idexx.com/pacs.

Watch for new software upgrade packaging
IDEXX analyzer upgrade envelope gets a new look

Your analyzer software upgrade envelopes are the same size and look very similar to the way they always have, but with a couple of small changes:

• The new envelopes no longer have a picture of the analyzer being upgraded.
• Printing above the address label identifies the upgrade and analyzer.

These new envelopes provide us with the environmentally friendly option of using the same packaging for all your IDEXX VetLab® Suite upgrades, including the VetTest® Chemistry Analyzer, IDEXX VetLab® Station, Catalyst Dx™ Analyzer, Coag Dx™ Analyzer or any other of the IDEXX VetLab Analyzers. It also allows you to receive multiple upgrades in one mailing.

Be sure to open every upgrade envelope you receive and install the software immediately to ensure your analyzers have the most recent information and capabilities.

If you have questions, call us at 1-800-355-2896 and we’ll be happy to talk with you about this change.

Tell us what you think and enter to win free gas!

IDEXX is interested in your feedback. We want to be sure our manuals and quick reference guides are intuitive and easy to use. The more we hear directly from our users—YOU—the better our materials will be.

Decide who the most frequent user is in your practice, and have him or her take our quick online survey to let us know how we can improve our manuals and guides. We’ll enter their name in a drawing for three chances to win hundreds of dollars in free gas!

Take the survey by September 16 and enter our free gas drawing. Thanks and good luck!

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?

Each Interactive Challenge from June 2006 and on has 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!

Not a Diagnostic Edge subscriber? Subscribe now!

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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