Veterinary Care Consultants (2024)

12/05/2023

We're going to start chatting about a requested topic today- ACTH stim vs. LDDST. We'll first review quick details that I find helpful about the ACTH stim, and in a follow-up post we will discuss the LDDST!

I have included the hypothalamic-pituitary-adrenal axis as a refresher for those who haven't thought about it in a while! When we perform an ACTH stim, we are taking advantage of the pituitary's communication to the adrenals with ACTH. We are providing exogenous ACTH to stimulate maximal cortisol production from the adrenals (adrenal reserve of cortisol).

The specificity is where the ACTH stim test shines. It's about 90%. This means that you have a low chance of a false positive. You'll see why this becomes an important discussion point in the next post about the LDDST. When I'm particularly reliant upon the specificity of this test is when I have a patient with unregulated/unknown concurrent disease or one that is excessively anxious or stressed, both of which can increase the amount of cortisol produced in any patient.

The sensitivity of the ACTH stim test is different for pituitary-dependent and adrenal-dependent Cushing's cases. If you think about the pituitary-adrenal axis, the change in sensitivity makes a lot of sense. The sensitivity of this test in adrenal-dependent disease is about 60%, while for pituitary-dependent disease it's about 85%. In adrenal-dependent disease, there is an adrenal tumor independently secreting cortisol. This means that the adrenal tumor will also be less likely to respond to exogenous ACTH.

Remember, It's not about having one "go-to" test regardless of the situation. Instead, it's important to understand both tests and how they work so that you can choose the best test for an individual patient. This helps to maximize your chance of success!

Photo credits:
HPA axis: American Medical Student Research Journal 2018 Vol 5 Number 1
ACTH stim: Ettinger 8th Edition Ch 306 Hyperadrenocorticism in Dogs

25/04/2023

Check out our most recent review! 🎉

Let us know how Dr. Davis or Dr. Kraenzlin can help you!

18/01/2023

We wanted to update everyone on upcoming availability of IM consults!

Dr. Davis will be on vacation Tuesday, January 24th - Monday, January 30th. During this time, phone consults will be unavailable. You can still submit written consults as needed throughout the week, but they will not be returned until Tuesday, January 31st.

Dr. Kraenzlin will still be available for critical care consultations as usual during this time.

Please let us know if you have any questions!

13/01/2023

Today we are talking about PUPD! This is a pretty detailed topic so this discussion is going to be broken into multiple parts over the course of several posts.

I think that more thoroughly understanding the physiology behind a certain disease or clinical sign can help you better care for your patients! This is why we are going to start our conversation with organizing differentials based on why the PUPD physiologically occurs.

We think of PUPD as either primary polydipsia (polydipsia COMES FIRST and polyuria is compensatory) OR primary polyuria (polyuria COMES FIRST and polydipsia is compensatory).

The main form of primary polydipsia that we see in veterinary medicine is psychogenic/behavioral polydipsia in the dog.

The bulk of our PUPD conversation will involve the mechanisms/diseases that cause primary polyuria. These include:

- Central Diabetes Insipidus
- Nephrogenic Diabetes Insipidus, which can be either primary or acquired/secondary
- Osmotic diuresis
- Medullary washout

We will delve deeper into all of the above mechanisms in future posts! That's when we will discuss more physiology, differentials for each mechanism, and clues on your physical exam and diagnostics that can help you get to the diagnosis!

FUN fact #1: Many of the diseases on our differential list cause PUPD via the acquired/secondary nephrogenic diabetes insipidus mechanism.

FUN fact #2: Polydipsia is technically defined as consumption of >100 mL/kg/day of water. Polydipsia is suspected at 80-100 mL/kg/day of water consumption. These parameters can be helpful when you are presented with patient histories that are less straightforward. Having clients measure daily water intake over several days at home can be instrumental in helping you determine if a patient is truly PUPD.

Stay tuned for more! If you have specific questions about PUPD that you would like me to address in these posts, please let me know!

04/01/2023

HAPPY 2023 from Veterinary Care Consultants!

We are excited to see what 2023 brings for VCC, and we hope we have the opportunity to help so many more of you and your patients!

Upcoming posts will include reviews of PUPD with Dr. Davis and xylitol toxicity with Dr. Kraenzlin! As always, please let us know if you have any specific topics you would like us to review in the future.

We hope everyone is having a great start to 2023!

21/12/2022

Happy Holidays from VCC! We hope everyone has a safe and happy holiday!

Consults will be available during our normal business hours this week and next week. Let us know how we can help you and your patients!

15/12/2022

Veterinary Care Consultants provides thorough and practical critical care and internal medicine consults to the general practitioner, ER doctor, or fellow specialist that may not have in-house access to our specialties!

If you have any questions about our consults, please do not hesitate to comment below, message us, or email us at [email protected]!

Please visit vetcareconsultants.com for more information. You can also find Veterinary Care Consultants on Instagram and LinkedIn!

We look forward to helping you and your patients in the future!

02/12/2022

Today I'd like to discuss some terminology I think is important in understanding how to approach canine chronic gastrointestinal disease cases! As a reminder, these are the patients that present with at least 3 weeks of some combination of the following clinical signs: intermittent vomiting, nausea, diarrhea, hyporexia, weight loss, etc. These patients have also had other intestinal diseases (such as parasites, obstruction, etc.) and extra-intestinal disease (hepatic, renal, etc.) ruled out.

I commonly hear people referring to these as patients with inflammatory bowel disease. Instead, I encourage everyone to think of them as patients with a chronic enteropathy. The term inflammatory bowel disease implies that inflammation of the gastrointestinal tract has been documented via biopsies and immunomodulation of some kind is required to control the disease. In contrast, chronic enteropathy is an umbrella term that encompasses multiples types of enteropathies. These include food-responsive enteropathies, antibiotic-responsive enteropathies, immunosuppressant-responsive enteropathies, and non-responsive enteropathies. (Gastrointestinal neoplasia should also be a differential depending upon breed, signalment, signs, etc.)

A full discussion of all the types is too broad a topic to discuss in one post, but here's a TIP: Over 50% of dogs with a chronic enteropathy will have the food-responsive type and their signs will resolve with a diet trial of a novel protein or hydrolyzed protein diet! As long as the dog is stable and eating, and without additional diagnostics such as a Texas A&M GI panel or abdominal ultrasound, a diet trial is always my first line treatment. Remember communication with the client is also SO important here. Clients should know that NO OTHER food type is allowed while their animal receives this diet AND that the animal can require 2 full weeks on this new diet for us to determine if the trial is a success or failure.

I hope this helps with your approach to your next chronic enteropathy case! If you have any questions or ideas for our next topic post, comment below or send us a message!

21/11/2022

Happy Thanksgiving week, everyone!

Here are some updates on availability for Dr. Kraenzlin and Dr. Davis this week:

Dr. Kraenzlin will not be available for consults on Thanksgiving Day, but is available the remainder of the week during our normal business hours.

Dr. Davis does not have any available phone consult times this week because she is visiting her family. She is still accepting written consults, however, and they will still be returned within 1-3 business days!

We hope everyone has a safe and happy holiday week!

18/11/2022

Our first requested IM topic with Dr. Davis is a general approach to hypercalcemia, specifically when the remainder of the minimum database is normal.

Once hypercalcemia is confirmed with an ionized calcium, the next step is to go back to your acronym from vet school! When a bloodwork abnormality has such a short list of potential differentials, take advantage of the memory tools we were taught in school. I still do! This will help to plan your next phase of diagnostics AND help make sure you don't miss anything. My preferred acronym is HOGS IN YARD.

Hyperparathyroidism
Osteolysis
Granulomatous disease
Spurious

Idiopathic (cats)
Neoplasia

Youth
Addison's
Renal disease
D- Hypervitaminosis D

You can then use the remainder of the bloodwork, physical exam, presenting clinical symptoms/history, and signalment to help guide you through your next steps!

When you have a hypercalcemic older dog and all other bloodwork is normal (or doesn't provide you further hints to a diagnosis), your thorough physical exam is normal, and the history doesn't give you a different explanation… the next best diagnostic step would be to submit a hypercalcemia of malignancy panel. This panel specifically provides an ionized calcium, PTH concentration, and PTHrP concentration. It's so important to evaluate the ionized calcium and PTH concentrations in relation to each other. A patient with hyperparathyroidism will have an elevated ionized calcium and a PTH concentration within or above the reference range. Remember that a PTH concentration within the reference range is still physiologically INAPPROPRIATE in the face of an elevated ionized calcium. If your hypercalcemic patient's malignancy panel does NOT match this description, it's worth reconsidering your other differentials, such as neoplasia in an older dog (with or without detection of PTHrP).

So this is a quick and character-limited discussion of hypercalcemia! If you have any questions, you want me to expand on anything mentioned above, or you have other ideas for topics you'd like to see, then let us know! If you have any hypercalcemic patients that aren't quite adding up, submit a consult and let me try to help you out! 😊

15/11/2022

Helping our colleagues is one of our passions here at Veterinary Care Consultants (VCC)! We would love to start sharing educational and informative posts on various ER, CC, or IM topics and questions that you guys have! Please leave a comment or send us a message about anything you’d like to see us post on and discuss.

12/11/2022

Now meet Chelsea Davis, the co-owner of Veterinary Care Consultants and our Internal Medicine specialist! Chelsea is originally from Georgia and graduated from UGA’s vet school in 2015. She completed a small animal rotating internship at Kansas State, an internal medicine specialty internship at Oklahoma State, and then returned to UGA for her internal medicine residency. Chelsea’s favorite part of her specialty is endocrine disease! She also has a special interest in immune mediated disease and gastrointestinal disease. Chelsea knows her specialty is not for everyone, and she is here to support you through any of your pesky internal medicine cases!

Chelsea and her husband Justin live in Oregon with their dog Maverick. In their spare time, they enjoy exploring all that the beautiful PNW has to offer. This includes hiking, eating delicious food, and wine tasting in the Willamette Valley. They also love going to various sporting events, but football season is Chelsea’s favorite!

09/11/2022

We are excited to introduce you to Mara Kraenzlin, the founder and co-owner of Veterinary Care Consultants! She is also our Emergency and Critical Care specialist. Mara is originally from New York and graduated from PennVet in 2016. She completed a small animal rotating internship at BluePearl New York and then her residency at Oradell Animal Hospital. Mara especially loves stabilizing trauma cases, but really just loves the full breadth of her specialty. Call her for any sick patients you may have – whether they are stable or not, she’s happy to support you!

Mara and her husband Colin recently welcomed their first baby boy Luca into the world! They live in Colorado and spend weekends taking him on hikes with their pooch Bodhi.

07/11/2022

We are Veterinary Care Consultants! We offer both Critical Care and Internal Medicine consults to the general practice community. We aim to bring you thorough and practical consults in hopes that we can meet the needs of you and your clients.

Over the next several days, you will meet our 2 specialists! Dr. Mara Kraenzlin is the founder and co-owner of Veterinary Care Consultants and is our board certified Emergency and Critical Care specialist. Dr. Chelsea Davis is co-owner and our boarded certified Internal Medicine specialist.

Our services are officially open on Monday, November 14th! Visit our website for more information. We look forward to chatting with you in the future!

Veterinary Care Consultants

12/05/2023

25/04/2023

18/01/2023

13/01/2023

04/01/2023

21/12/2022

15/12/2022

02/12/2022

21/11/2022

18/11/2022

15/11/2022

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