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• Education: 4-year-old intact, female Samoyed, Nala
• Health Watch: New Pet Food Recall—Mars PetCare U.S. issues voluntary dry pet food recall
• IDEXX Innovations:
  • Get IDEXX SmartService™ Solutions, IDEXX’s highest level of customer support
  • IDEXX Practice Profile™ from Cornerstone®
  • IDEXX Real PCR™ Respiratory Disease Prevalence Program
  • Spec fPL™ Test announcement
• Training and Events:
  • Webinars, seminars and online training opportunities available this month
  • IDEXX Learning Center update
• Research Corner: Study illustrates importance of reticulocytes in differentiating anemias
• Protocol Guidance: New American College of Veterinary Radiology guidelines for digital imaging
• Practice Management: Invest in diagnostics for significant tax savings—Part 1 of a 3–part series
• Technical Tips:
  • Swab cats for IDEXX Real PCR™ Feline URD Panel
  • Rotate stock for best results and easier inventory management
• Interactive Challenge: Earn FREE continuing education credit in the United States, Australia and parts of Canada! Interpret a hepatic panel and give the most reasonable cause for the changes shown by the results.
   

Featured case study:
4-year-old, intact female Samoyed, Nala
Submitted by Jeffrey S. Milburn, DVM, Edgewood Animal Hospital, Gorham, Maine

Physical examination
Nala was bright, alert and in good body condition on presentation. There were no detectable abnormalities on the general physical examination.

Diagnostic plan
As part of the recommended annual wellness visit, a SNAP 4Dx Test, complete blood count (CBC), general chemistry profile (including electrolytes and complete urinalysis) were performed to screen for subclinical metabolic, endocrine, inflammatory and infectious disease.

Laboratory data

Erythron—Despite a normal hematocrit (HCT), there is a mild reticulocytosis present, indicating hematopoietic response to a peripheral demand for erythrocytes and increased oxygen carrying capacity. Differentials include an appropriate response to shortened erythrocyte life span (hemolytic disease); increased erythropoietin production caused by a renal tumor; and hypoxia indicative of right-to-left shunt, altitude or severe pulmonary disease. Developing polycythemia vera, a rare myelodysplastic disease, was also considered. A review of annual hematology from the previous two years revealed an HCT of 60.1% and 58.5% respectively. Unfortunately, no reticulocyte counts were performed. No significant erythrocyte morphologic abnormalities were noted on blood film review; however,
mild-to-moderate crenation was present that might have masked any underlying subtle abnormality. The crenation was likely an artifact from storage in EDTA; too small a sample volume for the amount of EDTA in the blood collection tube was noted.

Leukon—All parameters are within reference-interval limits and no morphologic abnormalities were noted on blood film review.

Thrombon—Platelet numbers are within reference-interval limits and no morphologic abnormalities were noted on blood film review.

Chemistry—The chemistry panel and electrolytes were unremarkable except for a nonspecific, minimally elevated cholesterol. Elevation of cholesterol can be associated with a nonfasted sample, diabetes mellitus, pancreatitis, hyperadrenocorticism, hypothyroidism, nephrotic syndrome and cholestatic liver disease. In this case, since the patient was fasted and because of the history of chronic mild lethargy, insidious weight gain and the finding of a mildly elevated cholesterol, hypothyroidism was considered. Review of previous annual chemistry results for the last two years revealed cholesterol and all other chemistry profile parameters to be within reference-interval limits. Interestingly, Nala had a high-normal HCT and evidence of erythropoiesis (elevated reticulocyte count). This is contrary to the mild normochromic, normocytic nonregenerative anemia that is more commonly seen in the classic hematology profile of a hypothyroid dog.

There were no detectable abnormalities on the urinalysis. The findings of trace protein and a 1+ bilirubin are considered to be a normal finding in concentrated canine urine samples.

SNAP® 4Dx® Test: Positive for Lyme disease

A Lyme Quant C6® Test was recommended since Nala had no obvious clinical signs of Lyme disease. This is recommended to establish a baseline level of C6 antibody, which can be used to evaluate response to therapy if therapy is deemed necessary.

A total T4 was performed to screen for potential hypothyroidism. The T4 concentration was below the reference-interval limit, which can be the result of true hypothyroidism, the episodic secretion of thyroid hormone in the normal dog, nonthyroidal illness (euthyroid sick syndrome) or medications. Suppression of T4 concentrations by nonthyroidal illness or medications, such as corticosteroids or phenobarbital, may occur and should always be considered in light of the patient’s history and clinical signs. Furthermore, some breeds (e.g., Samoyeds and greyhounds) can have, in health, a T4 level slightly below or at the low end of the reference-interval limit compared to other dog breeds. A low or low-normal T4 level in dogs should be followed with further thyroid function testing to confirm hypothyroidism, especially when the history and clinical signs do not match the expected laboratory results. These include free T4 by equilibrium dialysis (fT4ED), thyroid stimulation hormone (TSH) levels, antithyroid antibodies and the TSH stimulation test.

Since Nala tested positive for Lyme disease on a SNAP® 4Dx® Test and a subsequent Lyme Quant C6 Test was elevated, the reported low T4 could be secondary to Lyme-related nonthyroidal illness. Since Nala was on no current medication, iatrogenic hypothyroidism was not considered. An elevated TSH level in this case (due to presumptive lack of negative pituitary feedback) was consistent with hypothyroidism as was the low fT4ED. Although fT4ED can be suppressed by current/prior drug therapy or nonthyroidal illness, this does not occur as frequently as with T4. There was insufficient sample to determine T3/T4 autoantibody levels. The presence of antithyroid antibodies would suggest the presence of lymphocytic thyroiditis, which may or may not lead to functional hypothyroidism. A TSH stimulation test was performed and since both pre-TSH and post-TSH levels were <1.0 µg/dL, this was consistent with a diagnosis of primary hypothyroidism.

Diagnostic summary
In dogs, the finding of a T4 concentration in the upper half of the reference-interval
(2–4.7 μg/dL) makes hypothyroidism very unlikely. Therefore determination of total T4 levels is very useful as the initial screening test for canine hypothyroidism. Increased canine TSH values may occur in dogs with untreated primary hypothyroidism; euthyroid sick dogs are expected to have low-normal TSH concentrations. Secondary or tertiary hypothyroidism (pituitary or hypothalamic lesions with a low TSH) is reported to occur in less than 5% of hypothyroid dogs. In Nala’s case, the history, clinical signs and finding of a low T4 combined with an elevated cholesterol warranted further investigation into the possibility of primary hypothyroidism. Subsequent thyroid function tests, including a TSH stimulation test, gave a definitive diagnosis of primary hypothyroidism.

Nala is an unusual case in that she had only subtle clinical signs of hypothyroidism, yet her laboratory diagnostics confirmed hypothyroidism. Furthermore, her CBC is contrary to that expected in hypothyroid patients. These patients typically have a mild nonregenerative anemia and Nala had a high-within-reference-interval HCT (50.4%) with a mild reticulocytosis. Remember that Nala’s CBC results before this clinical presentation revealed a mild polycythemia (HCT of 60.1% and 58.5%); Nala’s decreasing HCT is compatible with what is typically seen with hypothyroid dogs. Her current HCT, although high for typical hypothyroid dogs, is low compared to her previous results. Nala’s case emphasizes the importance of serial hematology data collection along with blood film review and an absolute reticulocyte count on every CBC run in-house or at the reference laboratory. Although undefined at this time, the possibility of decreased red blood cell life span (hemolytic disease) must still be strongly considered in Nala’s case and further investigation is warranted following stabilization of the hypothyroidism.

Therapeutic plan
Due to her Lyme-positive status, Nala was first placed on doxycycline 100 mg twice a day for four weeks. A Lyme Quant C6 Test was repeated one week after the completion of therapy and showed good response to treatment (C6 was 21 U/mL). Thyroid hormone replacement therapy with L-thyroxine at 0.4 mg twice a day was initiated. Response to thyroid supplementation was monitored with regular measurement of total T4 levels and observed resolution of clinical signs. Nala’s owner, being a devoted pet owner as well an informed and responsible breeder of champion Samoyeds, has elected to spay her after appropriate response to thyroid supplementation. At the time of ovariohysterectomy (OVH), her abdomen will be explored to rule out gross abnormalities such as a renal tumor. Nala’s owner will consider additional diagnostic options to further evaluate the inappropriate high HCT with reticulocytosis pending surgical findings. Also, since Nala had trace protein in her urine and because of her Lyme-positive status, it was recommended that her urine be regularly monitored for proteinuria. A urine protein:creatinine (UPC) ratio was recommended to monitor for Lyme–induced glomerulonephritis if there is persistent proteinuria in the face of an inactive urine sediment.

General References:

• Feldman EC, Nelson RW. Canine and Feline Endocrinology and Reproduction, 3rd ed. Philadelphia, Pa: WB Saunders; 2004.
• Latimer KS, Mahaffey EA, Prasse KW, eds. Duncan & Prasse’s Veterinary Laboratory Medicine: Clinical Pathology, 4th ed. Ames, Iowa: Iowa State University Press; 2003.
• Stockham SL, Scott MA, eds. Fundamentals of Veterinary Clinical Pathology. Ames, Iowa: Iowa State University Press; 2002.

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.

New Pet Food Recall
Mars Petcare U.S. issues voluntary recall for possible Salmonella contamination

Mars Petcare U.S. announced a voluntary recall of products manufactured at its Everson, Pennsylvania, facility. The pet food is being voluntarily recalled because of potential contamination with Salmonella serotype Schwarzengrund.

While there is no direct link between Mars Petcare products and human or pet illness, the company is taking precautionary action to protect pets and their owners with a voluntary recall of all products produced at the Everson facility beginning February 18, 2008, until July 29, 2008, when production was stopped. This voluntary recall only affects the United States.

Read more about presenting signs, diagnostic testing recommendations and treatment or visit the FDA Web site for specific products and full details of the recall.

For questions regarding this pet food recall or for assistance in choosing the appropriate diagnostic test for your patient, interpreting your culture or RealPCR™ diarrhea panel results or determining treatment, please call our Internal Medicine Consulting Team at 1-888-433-9987, option 4,
then option 2.

The recommendations contained in this alert 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.

IDEXX SmartService™ Solutions: An extra set of hands
Ready to improve work flow? To keep your instruments running smoothly, our newest service offers advanced support capabilities for IDEXX VetLab® analyzers.

This innovative new service puts the power of IDEXX customer support directly into your practice. With your permission, our customer support technicians can securely access your IDEXX VetLab® Station via the Internet to troubleshoot instrument issues. IDEXX SmartService™ solutions is the most advanced instrument support available to any veterinary practice, and it’s available to you at no cost.

IDEXX SmartService will:

• Quickly service your instruments for a more continuous work flow
• Minimize the amount of time you spend on the phone with customer support
• Improve the efficiency of your practice
• Maximize the benefits of your extended maintenance agreement

To obtain IDEXX SmartService you need an IDEXX VetLab Station (with software version 2.40 and above) with access to a high-speed Internet connection and an active extended maintenance agreement. Additional features are coming soon, including automatic software upgrades, data backups and much more.

For more information or to get your practice connected to IDEXX SmartService at no charge, call 1-800-355-2896 today!

IDEXX RealPCR™ Respiratory Disease Prevalence Program
Get help with two challenging diseases and help other veterinarians too

New data shows that feline upper respiratory disease (feline URD) and canine respiratory disease (CRD) are more prevalent than many practitioners realize.

Feline upper respiratory disease and canine respiratory disease are common yet challenging problems in veterinary medicine. Prompt identification of causative agents can make a big difference in the success of your diagnosis and treatment.

IDEXX data has shown that running the IDEXX RealPCR™ Feline URD Panel significantly enhances your capability of identifying the causative agents.

Practices ordering the Feline URD Panel received:

• Positives for one or more of the five organisms 52% of the time
• Positives for FHV-1 30% of the time

Practices ordering only the FHV-1 stand-alone test received positives for FHV-1 just 9% of the time.

Learn more about the prevalence of feline upper respiratory disease and canine respiratory disease in your practice by participating in our IDEXX RealPCR™ Respiratory Disease Prevalence Program. (50 KB)

It’s easy to enroll.

1. Use the link to the enrollment form below to enroll your practice in the study.
2. Run Feline URD and/or CRD panels on your next five patients presenting with respiratory signs.
3. Use these results to help you take the next steps for choosing appropriate treatment, quarantining animals as needed and improving patient outcome.
4. When you submit five samples by January 1, you will earn a $50 rebate in Practice Developer® points and receive a customized prevalence report of your patients’ results as well as results in your area.

Enroll here or call 1-800-355-2896. (50 KB)

 

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:

• The Complete Urinalysis
  By Rick L. Cowell, DVM, MS, MRCVS, DACVP
• Advanced Fluid Therapy—An Interactive Case Review of Acid-Base Disorders
  By Stephen P. DiBartola, DVM, DACVIM
• Preanesthetic Evaluation—Helping to Avoid Anesthetic Nightmares
  By Fred Metzger, DVM, DABVP
• The ADR Cat—Could It Be Pancreatitis?
  By Jane Robertson, DVM, DACVIM

See a full listing of Webinar opportunities >

• Complete Urinalysis: The IDEXX Guide
• Learning More About the Catalyst Dx Chemistry Analyzer

See a full listing of online course opportunities >

• Several Local Dinner and VMA Seminars
  

See a full listing of seminar opportunities >

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

IDEXX Learning Center Update

The IDEXX Learning Center (ILC) has launched new online features that make it even easier for you to earn CE credits and stay current on the latest animal diagnostic research, protocols and procedures.

New Home Page
The next time you visit idexxlearningcenter.com, you’ll notice new icons representing all the different ways you can learn with the ILC. Each icon will link to a list of upcoming education events and opportunities in that category. These new icons will help you quickly navigate through our wide range of offerings and find exactly what you are looking for.

IDEXX Learning Center Library
The IDEXX Learning Center has also launched a new online Learning Library! Click the Learning Library icon on our home page to enter the library and browse our collection of multimedia education resources, reference materials, practice education tools, quick tips and tutorials.

 

Reticulocytes critical to determining anemia
Study shows red blood cell indices are not reliable

Anemia is a common abnormality in dogs and cats and is often life threatening. After being confirmed, an anemia should be further classified as regenerative or nonregenerative in order to aid in the diagnosis of the underlying cause and facilitate appropriate treatment. The absolute reticulocyte count is regarded as the gold standard to determine whether an anemia is regenerative or nonregenerative in dogs and cats and offers valuable diagnostic and prognostic information.

In-house impedance analyzers depend on red blood cell indices
An increased mean corpuscular volume (MCV) and a decreased mean corpuscular hemoglobin concentration (MCHC) may indicate regeneration. However, as the study by D. B. DeNicola et al clearly demonstrates, these red blood cell indices are an unreliable indicator of whether an anemia is regenerative or not.

Over 200,000 canine CBC samples analyzed
The objective of the study was to compare expected MCV and MCHC changes to an absolute reticulocyte count in a series of dogs with regenerative anemia. Data collected from more than 200,000 canine complete blood count (CBC) samples submitted to 14 reference laboratories across the country showed the following:

• Almost 19,000 of the 200,000 samples (9.3%) indicated anemia
• 6,752 (3.3%) were regenerative according to absolute reticulocyte count
• Of those patients with regenerative anemia, only 562 (8.3%) had an increased MCV and decreased MCHC
• Therefore, using red blood cell indices alone would mean you would miss 92% of the regenerative anemia cases seen in your practice

The IDEXX LaserCyte® Hematology Analyzer is the only in-house analyzer that provides an absolute reticulocyte count in dogs and cats. It also provides red blood cell indices, giving clinicians the most complete patient-side information available to diagnose, classify, characterize and treat anemias. In addition, qualitative microscopic assessment of blood films is always recommended for detecting abnormal cell morphologies, certain cell precursors and blood parasites.

For more information, call 1-800-355-2896 or visit www.idexx.com/lasercyte.

NEW Guidelines for Digital Imaging
American College of Veterinary Radiology seeks consistency in digital imaging standards

The American College of Veterinary Radiology (ACVR) has outlined new guidelines for digital imaging in an attempt to promote standardization across the veterinary profession. Taking into consideration many current standards and recommendations, the ACVR Digital Imaging Standards Committee (DISC) formulated and published guidelines for image resolution, DICOM® study definition and teleradiology. Here are the high-level takeaways:

Resolution and DICOM

• Spatial resolution in a clinical setting for primary and secondary capture (digital cameras, laser scanners, etc.) digital radiographic devices is 2.5 line pairs per millimeter (lp/mm).
• Definition of DICOM studies have been put in place for a variety of imaging modalities, such as CT, MRI, CR, etc. For example, with computed or digital radiography modalities (CR or DR, respectively), an image “study” consists of images from the same anatomical region taken at the time of examination; 3–view thoracic examination represents a DICOM study.

Teleradiology

• Teleradiology applications should both produce DICOM-compliant images and allow for their direct transfer to any remote server.
• Image autorouting between digital imaging systems and a remote server is recommended.
• DICOM compression for image transfer is suggested, which results in faster transmission speed and less storage space.

For a complete review of these guidelines, please visit the ACVR Web site at www.acvr.org/activities/guidelines.

To see how IDEXX Digital Imaging Systems apply these guidelines to
IDEXX-PACS™ Imaging Software, please visit www.idexx.com/pacs.

DICOM is the registered trademark of the National Electrical Manufacturers Association for its standards publications relating to digital communications of medical information.

Investing in Diagnostics and Software as a Tax Strategy: Part 1
The advantages add up to more than just significant tax savings.
by Gary I. Glassman, CPA, Burzenski & Company, P.C.

Is your practice considering an investment in new diagnostic instruments, practice management software or digital imaging equipment? 2008 presents unique opportunities because of limited-time tax incentives that can help you score high returns on your investment. And beyond big tax savings, the financial, medical and efficiency benefits of new equipment and software can help you grow your practice, even in a tight economy.

Boost Your Bottom Line with Temporary Tax Incentives
The Economic Stimulus Act of 2008 includes special tax incentives, not available in 2009, that can maximize your return on investment (ROI) on new equipment and software. Normally, investments like these are depreciated over many years. This means a portion of the cost is deducted from your taxable income each year the item is used within your practice. However, this scenario changes when the government steps in and implements tax incentives to stimulate economic growth, as they have done once again this year. Whether you invest in a single laboratory analyzer, several instruments, integrated practice management software or an advanced digital imaging system, you may be able to write off the entire cost of these purchases in 2008.

What is unique about this year’s tax incentives?

• This year, IRS tax code Section 179 allows you to immediately deduct a much larger portion of the cost than in 2007, up to $250,000 for 2008 calendar-year taxpayers, as long as total purchases are below $800,000. This means your 2008 tax bill can be significantly smaller and that money can be sitting in your bank account collecting interest rather than in Uncle Sam’s.
• Another temporary tax incentive allows you to immediately deduct 50% of the cost. So even if you cannot or choose not to use Section 179, there is still a way to cut your 2008 tax bill.

Build New Revenue Streams in a Stormy Economy
Spending hospital funds on new equipment or software is certainly a decision that should be weighed carefully. And in today’s economy, that investment may seem especially scary. However, new equipment can actually help your practice thrive in lean times. Even though the financial news seems to paint a picture of doom and gloom, in reality most clients are still willing to spend money to care for pets they see as an integral part of the family.

What’s more, most veterinary clients expect a high level of service. When clients walk in your front door, they expect an immediate diagnosis of their pet’s condition and the best, fastest medical care possible. Building advanced equipment and software into your practice is the best way to meet that demand. Plus, in addition to keeping clients happy, in-house diagnostic equipment that allows you to charge for in-house testing provides a steady stream of revenue that can help grow your practice, even in a tough economy. The additional money can also help you adapt to unexpected market dynamics such as revenue lost to online pharmacies.

See Part Two and Part Three of this series for more information.

Gary Glassman, CPA, discusses how investing in the right equipment while leveraging new tax benefits equals better business for you and better medicine for your patients. Plus, find out how best to finance these purchases and leverage all available deductions to receive the best return on investment. In addition, Gary will discuss how an integrated system is vital in capturing all of your potential revenue.

Time: This is an archived Webinar that you can access whenever it's convenient for you.

Location: www.idexx.com/invest6

Gary I. Glassman, CPA, has spoken at many national and regional veterinary conferences on topics including “Tax Tips for the Practice Owner” and “Financial Reporting to Improve Practice Results.”

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

Feline Upper Respiratory Disease (Feline URD)
How to quickly and easily identify the causative organisms

Cats presenting with signs of feline URD (sneezing, oculonasal discharge, conjunctivitis with or without coral ulceration) are probably common in your practice. The new IDEXX RealPCR™ Feline URD Panel is a quick and easy way to accurately identify the causative organisms of feline URD.

Submitting samples for the Feline URD Panel is easy. To optimize the diagnostic sensitivity of this panel, please submit samples from both sources listed below together.

Collection materials

1. Two cotton swabs; for example, two Q-tips® cotton swabs or similar swabs from a new package can be used. You can also use sterile cotton culturette swabs.
2. A sterile, plain red-top tube.

Sample sources

1. Deep pharyngeal swab
   • Rub firmly to ensure there is visible organic material on the swab
2. Conjunctival swab
   • Wipe the eye clean and swab the inside of the eyelid with a dry cotton swab or swab premoistened with a small amount of sterile saline containing no preservatives.

Submitting samples

1. The swabs should be then placed together in the same sterile, plain red-top tube. Do not add any additional saline or fluid to the tube and do not put swabs into transport media.
2. Keep the tube with the swabs refrigerated until sending to the reference laboratory.

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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