Home Monitoring of Blood Glucose
ACVIM 2002
Claudia E. Reusch, DVM, PhD, DECVIM-CA; Gerhard Wess, DVM, Martina Casella, DVM
Zurich, Switzerland
18271044
Introduction
Management of diabetic dogs and cats relies on the owner's observation of clinical signs and on periodic evaluation by a veterinarian. The latter includes evaluation of the owner's observations, measurement of body weight and determination of concentrations of blood glucose and glycated proteins, which include serum fructosamine and glycated hemoglobin.Strongly increased concentrations of serum fructosamine or glycated hemoglobin suggest poor glycemic control and a need for insulin adjustment. However, these parameters do not identify the underlying problem.
Serial Blood Glucose Curves
Serial blood glucose curves (BGC) are necessary to assess insulin efficacy, glucose nadir, time of peak insulin effect, duration of the effect of insulin and degree of fluctuation in blood glucose concentration. BGC are also needed to recognize the Somogyi phenomenon. Until recently, BGC were only performed in a hospital. However, there are several problems associated with those BGC. It is time consuming and expensive and therefore, it is often not performed as frequently as required. For example, short-notice adjustments of the insulin dosage are necessary in diabetic patients with infections (increased dose) or at times of increased physical activity (mostly decreased dose). Close monitoring of blood glucose concentration is also indicated in diabetic patients that are diagnosed with and treated for a concomitant disease, such as hyperadrenocorticism, hypothyroidism, or acromegaly. Due to the abolition of the insulin resistance, the insulin dosage may have to be reduced drastically in order to prevent hypoglycemia. It is difficult to manage these cases without frequent blood glucose determinations. In hospitalized patients, the concentration of blood glucose can be markedly influenced by stress or refusal to eat. Cats in particular are sensitive to stress due to an unfamiliar environment or veterinary manipulation. Consequently, the BGC may show a continual increase in the blood glucose concentrations, or it may be elevated from the start. When the latter occurs, it is not possible to differentiate among stress-associated hyperglycemia, insulin under-dosage and the many causes of insulin ineffectiveness and resistance. Hospitalized diabetic dogs and cats frequently refuse to eat, which may result in a marked decrease in blood glucose concentration. It is then difficult for the veterinarian to decide whether anorexia or overdose of insulin is the cause of low glucose concentration.
Self-monitoring of blood glucose in human diabetics
In human medicine, those problems have been largely eradicated with the introduction of self-monitoring of blood glucose concentrations (SMBG). For SMBG, patients obtain a drop of capillary blood by pricking a fingertip with a lancing device. The drop is then placed on a test strip, and the glucose concentration is measured using a portable glucose meter (PGM). The introduction of SMBG is regarded as the single most important advance in the management of diabetes mellitus since the discovery of insulin. About 70% of human patients with type 1 diabetes think that SMBG is very important for the management of their disease.
Capillary Blood Sampling In Dogs And Cats
Until recently, SMBG in diabetic animals was not thought possible. However, recently a method has been developed for obtaining capillary blood from the ear and blood glucose concentration can then be determined using a PGM. This method is relatively inexpensive, fast and easy to perform and can be used by owners of diabetic dogs and cats to determine blood glucose concentrations and to generate BGCs at home.
Since its introduction we preferentially use the Microlet Vaculance® (Bayer Diagnostics) as lancing device. After lancing the skin, this device creates a negative pressure, which facilitates collection of an adequate amount of blood.
Portable Blood Glucose Meters
Since their introduction, the quality control of PBGM has been a frequent topic of discussion in human medicine. Studies have shown that accuracy can vary greatly. Accuracy is poor for very low as well as for very high glucose concentrations. Factors with a possible effect on the results of glucose measurements include variation in hematocrit, altitude, environmental temperature and humidity, hypotension, hypoxia and triglyceride concentrations. Overall performance of these systems depends on analytical performance of the meter, quality of the test strips and proficiency of the user. Recently, error grid analysis has proved to be a convenient method to assess blood glucose results and has gained widespread acceptance. Although it does not provide any information about the analytical accuracy of an instrument, it categorizes individual measurements on the basis of potential therapeutic consequences into 5 zones (A through E). Values in zone A or B are clinically acceptable. Values in zone C , D or E are potentially dangerous and are not acceptable from a clinical point of view. All studies have shown that certain instruments are more accurate than others. Error grid analysis was used in two veterinary studies to assess glucose concentration of venous blood of dogs and cats using the following PBGM: Glucometer Elite (Bayer Diagnostics), Glucometer DEX (Bayer Diagnostics), SureStep (LifeScan Inc.), Precision QID (MediSense Inc.) and Accu-Chek Simplicity (Roche Diagnostics Inc.). With the exception of venous blood measurements in cats obtained with the Glucometer DEX, all results were in the clinically acceptable zones A and B. The Glucometers Elite (Bayer Diagnostics) and Accu-Chek Simplicity (Roche Diagnostics Inc.) were also evaluated using capillary blood from the ear of dogs and cats, again all measurements were in zones A and B. In people, most errors in SMBG are associated with blood collection or the use of the PBGM. For pet owners, home monitoring of an animal can constitute a challenge and therefore it is important to minimize any technical difficulties as much as possible. Owners should choose a portable blood glucose meter that is simple to operate. In our experience, of all meters on the market, the Glucometer Elite (Bayer Diagnostics) is the easiest to operate: it has no buttons to press, turns on automatically when the test strip is inserted and requires a very small amount of blood (2 µl), which is automatically aspirated into the reaction chamber after contacting the test strip. It is remarkably small and easy to handle with a measurement range of 20 to 600 mg/dl. The result is displayed after 30 seconds and the last 20 measurements are stored. However, as with all portable blood glucose meters, problems may occur. It is important that the test strip chamber be filled to the mark. When too small a volume of blood (< 2 µl) is used, the acoustic signal, that normally marks the end of the aspiration of blood, erroneously sounds, and measurement follows, producing an inaccurate low reading. Blood glucose concentrations that are measured by PBGM almost always vary slightly from those measured by a reference method; values obtained by the Glucometer Elite consistently underestimate true concentrations. In the dog, the mean difference between the glucose concentration of capillary blood obtained by Glucometer Elite and that of venous blood obtained by the reference method (Autoanalyzer) is -11 mg/dl in the low glycemic range (< 72 mg/dl), - 22 mg/dl in the normal range (72 - 140 mg/dl) and - 42 mg/dl in the high glycemic range (> 140 mg/dl) in dogs. In cats, the corresponding differences are - 7.2 mg/dl, - 22 mg/dl and - 16 mg/dl
Home-monitoring in diabetic dogs and cats
For approximately three years, we have been involved in home monitoring of blood glucose concentrations of diabetic dogs and cats by owners. The results have been extremely positive. The majority of owners are very interested in performing blood glucose determinations in their pets, and more than 70% have been capable and willing to do this on a long-term basis. There are a number of steps we feel that should precede the introduction of home monitoring. The first step is a definitive diagnosis of diabetes mellitus. The owner then receives detailed information on various aspects of diabetes mellitus and careful instruction on injection technique, and the concept of home monitoring is introduced for the first time. The second step consists of re-evaluation of the patient after one week. At the time of discharge, the importance of the BGC in the control of the disease is emphasized. In addition, the advantages of home monitoring are discussed and she/he is informed that this procedure can be started after the next re-evaluation. The third step follows approximately two to three weeks later. The owner is now provided the opportunity to learn the technique of home monitoring. This requires a minimum of 30 minutes and consists of repeated demonstrations of the use of the lancing device and the portable blood glucose meter. The owner then performs the technique several times using her/his pet. The owner is also taught how to calibrate the blood glucose meter, check its accuracy using the control strips and record the blood glucose values on forms prepared by us. Home monitoring is not started before the third week after a diagnosis of diabetes mellitus. This allows the owner to become familiar with the disease and to gain experience with the injection of insulin. However, introduction of home monitoring is delayed to a later date if the owner does not seem ready for it.
Frequency of blood glucose measurements by pet owners
Fasting blood glucose concentration is determined twice weekly and a BGC once monthly. The former serves to detect morning hypoglycemia, in which case the owner is instructed to call us. Since all our diabetic animals receive insulin BID the BGC is performed for 12 hours. The owner sends the results, and appropriate changes in treatment are discussed, if necessary, over the phone. Over time, the owners gain experience in the collection of blood and operation of the blood glucose meter. During the first few weeks of home-monitoring, periodic re-evaluations of the entire procedure are performed at the clinic. This includes that a veterinarian is watching the owner performing the procedure. After this the animal is hospitalized to perform a BGC. Possible technical problems can be discussed with the owner, and the owner's technique for blood collection and operation of the blood glucose meter can be assessed. After a few weeks (or months, depending on the reliability of the owner) the re-evaluation in the hospital may be reduced to consideration of clinical signs, body weight and fructosamine measurements. Because home monitoring has not been used widely in veterinary medicine, there are no studies to indicate how often re-evaluation should be performed. Currently, we feel that the owner should determine a BGC once monthly and the patient be re-assessed a minimum of twice a year by a veterinarian.
Problems encountered in home-monitoring
It is important that owners have ready access to veterinary support. The majority of our clients call for advice one or more times, especially after the start of home monitoring. Some have specific questions regarding the procedure, while others want reassurance that they are performing the procedure correctly. Sometimes support via phone is not sufficient and additional explanation or demonstration of the technique must be provided. According to a recently performed study, the most frequently encountered technical problems included, inadequate formation of a blood drop due to excessive pressure of the finger behind the ear while lancing the ear, repeated depression of the plunger instead of allowing the negative pressure to slowly build up, and failure to fill the test strip to the mark. These procedural steps require explicit explanation and demonstration. Handling the PBGM usually is not a problem for owners, and most report that their pet tolerates blood collection well. Usually, owners feel that their technique improves quickly, which leads to increased confidence in the test results. On average, cats tolerate the procedure less readily than dogs. Many owners report that the cats are more tolerant of blood collection when they are placed in their favourite spot, such as a windowsill or bed. In dogs and cats, the skin puncture does not seem to be painful, and the puncture sites are barely visible, even after numerous blood collections. 90% of those pet owners performing home monitoring do not need a second person to help with the procedure.
Comparison of home and hospital blood glucose curves
We recently performed prospective studies in diabetic dogs and cats to evaluate what the differences are between BGC generated at home and those generated in the hospital. Owners were asked to determine 4 BGC spaced 3 to 4 weeks apart, and within one week a hospital BGC was performed after each home curve. Interestingly the maximum and mean glucose concentrations of hospital BGC were significantly lower than those of home BGC. Reduced food intake in the hospital appears to be the most likely explanation. We also compared the potential treatment decisions based on the BGC results of each animal. In more than 40% of cases, treatment decisions would have been different. However, only in a small percentage of cases would the treatment decisions have been reversed (increase vs. decrease of insulin dosage). The reproducibility of BGC is difficult to assess because the glucose concentration may vary from day to day. Further investigations are necessary to determine whether reproducibility of BGC performed at home is superior to those performed at home.
References
1.  American Diabetes Association. Consensus Statement: Self-Monitoring of BloodGlucose. Diabetes Care 19 (Suppl 1): S62-S66, 1996.
2.  Casella M, Reusch CE: Home monitoring of capillary blood glucose in dogs and cats: Technical aspects. 18th Ann Med Forum, Am Coll of Vet In Med, Abstr., 2000.
3.  Casella M, Wess G, Reusch CE: Measurement of capillary blood glucose concentrations by pet owners: a new tool in the management of diabetes mellitus. J Am Anim Hosp Assoc (accepted 2000).
4.  Cohn LA, McCaw DL, Tate DJ, Johnson JC: Assessment of five portable blood glucose meters, a point-of-care analyzer, and color test strips for measuring blood glucose concentration in dogs. J Amer Vet Med Assoc 216(2):198-202, 2000.
5.  Reusch CE, Wess G, Casella M: Home Monitoring of Blood Glucose Concentration in the Management of Diabetes Mellitus. Comp Cont Educ 23, 544-557, 2001.
6.  Wess G, Reusch CE: Capillary blood sampling from the ear of dogs and cats and use of portable meters to measure glucose concentration. J Small Anim Pract 43:60-66, 2000.
7.  Wess G, Reusch CE: Evaluation of five portable blood glucose meters for use in dogs. J Amer Vet Med Assoc 216(2):203-209, 2000.
8.  Wess G, Reusch CE: Laboratory Assessment of Five Portable Blood Glucose Meters for Use in Cats. Amer J Vet Res 61 (12): 1587-1592, 2000.
Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)
Claudia E. Reusch, DVM, PhD, DECVIM-CA
Clinic for SA Internal Medicine
University of Zurich
Winterthurerstr. 260
Zurich CH 8057
SWITZERLAND


Home Monitoring of Blood Glucose
ACVIM 2002
Claudia E. Reusch, DVM, PhD, DECVIM-CA; Gerhard Wess, DVM, Martina Casella, DVM
Zurich, Switzerland
18271044
Introduction
Management of diabetic dogs and cats relies on the owner's observation of clinical signs and on periodic evaluation by a veterinarian. The latter includes evaluation of the owner's observations, measurement of body weight and determination of concentrations of blood glucose and glycated proteins, which include serum fructosamine and glycated hemoglobin.Strongly increased concentrations of serum fructosamine or glycated hemoglobin suggest poor glycemic control and a need for insulin adjustment. However, these parameters do not identify the underlying problem.
Serial Blood Glucose Curves
Serial blood glucose curves (BGC) are necessary to assess insulin efficacy, glucose nadir, time of peak insulin effect, duration of the effect of insulin and degree of fluctuation in blood glucose concentration. BGC are also needed to recognize the Somogyi phenomenon. Until recently, BGC were only performed in a hospital. However, there are several problems associated with those BGC. It is time consuming and expensive and therefore, it is often not performed as frequently as required. For example, short-notice adjustments of the insulin dosage are necessary in diabetic patients with infections (increased dose) or at times of increased physical activity (mostly decreased dose). Close monitoring of blood glucose concentration is also indicated in diabetic patients that are diagnosed with and treated for a concomitant disease, such as hyperadrenocorticism, hypothyroidism, or acromegaly. Due to the abolition of the insulin resistance, the insulin dosage may have to be reduced drastically in order to prevent hypoglycemia. It is difficult to manage these cases without frequent blood glucose determinations. In hospitalized patients, the concentration of blood glucose can be markedly influenced by stress or refusal to eat. Cats in particular are sensitive to stress due to an unfamiliar environment or veterinary manipulation. Consequently, the BGC may show a continual increase in the blood glucose concentrations, or it may be elevated from the start. When the latter occurs, it is not possible to differentiate among stress-associated hyperglycemia, insulin under-dosage and the many causes of insulin ineffectiveness and resistance. Hospitalized diabetic dogs and cats frequently refuse to eat, which may result in a marked decrease in blood glucose concentration. It is then difficult for the veterinarian to decide whether anorexia or overdose of insulin is the cause of low glucose concentration.
Self-monitoring of blood glucose in human diabetics
In human medicine, those problems have been largely eradicated with the introduction of self-monitoring of blood glucose concentrations (SMBG). For SMBG, patients obtain a drop of capillary blood by pricking a fingertip with a lancing device. The drop is then placed on a test strip, and the glucose concentration is measured using a portable glucose meter (PGM). The introduction of SMBG is regarded as the single most important advance in the management of diabetes mellitus since the discovery of insulin. About 70% of human patients with type 1 diabetes think that SMBG is very important for the management of their disease.
Capillary Blood Sampling In Dogs And Cats
Until recently, SMBG in diabetic animals was not thought possible. However, recently a method has been developed for obtaining capillary blood from the ear and blood glucose concentration can then be determined using a PGM. This method is relatively inexpensive, fast and easy to perform and can be used by owners of diabetic dogs and cats to determine blood glucose concentrations and to generate BGCs at home.
Since its introduction we preferentially use the Microlet Vaculance® (Bayer Diagnostics) as lancing device. After lancing the skin, this device creates a negative pressure, which facilitates collection of an adequate amount of blood.
Portable Blood Glucose Meters
Since their introduction, the quality control of PBGM has been a frequent topic of discussion in human medicine. Studies have shown that accuracy can vary greatly. Accuracy is poor for very low as well as for very high glucose concentrations. Factors with a possible effect on the results of glucose measurements include variation in hematocrit, altitude, environmental temperature and humidity, hypotension, hypoxia and triglyceride concentrations. Overall performance of these systems depends on analytical performance of the meter, quality of the test strips and proficiency of the user. Recently, error grid analysis has proved to be a convenient method to assess blood glucose results and has gained widespread acceptance. Although it does not provide any information about the analytical accuracy of an instrument, it categorizes individual measurements on the basis of potential therapeutic consequences into 5 zones (A through E). Values in zone A or B are clinically acceptable. Values in zone C , D or E are potentially dangerous and are not acceptable from a clinical point of view. All studies have shown that certain instruments are more accurate than others. Error grid analysis was used in two veterinary studies to assess glucose concentration of venous blood of dogs and cats using the following PBGM: Glucometer Elite (Bayer Diagnostics), Glucometer DEX (Bayer Diagnostics), SureStep (LifeScan Inc.), Precision QID (MediSense Inc.) and Accu-Chek Simplicity (Roche Diagnostics Inc.). With the exception of venous blood measurements in cats obtained with the Glucometer DEX, all results were in the clinically acceptable zones A and B. The Glucometers Elite (Bayer Diagnostics) and Accu-Chek Simplicity (Roche Diagnostics Inc.) were also evaluated using capillary blood from the ear of dogs and cats, again all measurements were in zones A and B. In people, most errors in SMBG are associated with blood collection or the use of the PBGM. For pet owners, home monitoring of an animal can constitute a challenge and therefore it is important to minimize any technical difficulties as much as possible. Owners should choose a portable blood glucose meter that is simple to operate. In our experience, of all meters on the market, the Glucometer Elite (Bayer Diagnostics) is the easiest to operate: it has no buttons to press, turns on automatically when the test strip is inserted and requires a very small amount of blood (2 µl), which is automatically aspirated into the reaction chamber after contacting the test strip. It is remarkably small and easy to handle with a measurement range of 20 to 600 mg/dl. The result is displayed after 30 seconds and the last 20 measurements are stored. However, as with all portable blood glucose meters, problems may occur. It is important that the test strip chamber be filled to the mark. When too small a volume of blood (< 2 µl) is used, the acoustic signal, that normally marks the end of the aspiration of blood, erroneously sounds, and measurement follows, producing an inaccurate low reading. Blood glucose concentrations that are measured by PBGM almost always vary slightly from those measured by a reference method; values obtained by the Glucometer Elite consistently underestimate true concentrations. In the dog, the mean difference between the glucose concentration of capillary blood obtained by Glucometer Elite and that of venous blood obtained by the reference method (Autoanalyzer) is -11 mg/dl in the low glycemic range (< 72 mg/dl), - 22 mg/dl in the normal range (72 - 140 mg/dl) and - 42 mg/dl in the high glycemic range (> 140 mg/dl) in dogs. In cats, the corresponding differences are - 7.2 mg/dl, - 22 mg/dl and - 16 mg/dl
Home-monitoring in diabetic dogs and cats
For approximately three years, we have been involved in home monitoring of blood glucose concentrations of diabetic dogs and cats by owners. The results have been extremely positive. The majority of owners are very interested in performing blood glucose determinations in their pets, and more than 70% have been capable and willing to do this on a long-term basis. There are a number of steps we feel that should precede the introduction of home monitoring. The first step is a definitive diagnosis of diabetes mellitus. The owner then receives detailed information on various aspects of diabetes mellitus and careful instruction on injection technique, and the concept of home monitoring is introduced for the first time. The second step consists of re-evaluation of the patient after one week. At the time of discharge, the importance of the BGC in the control of the disease is emphasized. In addition, the advantages of home monitoring are discussed and she/he is informed that this procedure can be started after the next re-evaluation. The third step follows approximately two to three weeks later. The owner is now provided the opportunity to learn the technique of home monitoring. This requires a minimum of 30 minutes and consists of repeated demonstrations of the use of the lancing device and the portable blood glucose meter. The owner then performs the technique several times using her/his pet. The owner is also taught how to calibrate the blood glucose meter, check its accuracy using the control strips and record the blood glucose values on forms prepared by us. Home monitoring is not started before the third week after a diagnosis of diabetes mellitus. This allows the owner to become familiar with the disease and to gain experience with the injection of insulin. However, introduction of home monitoring is delayed to a later date if the owner does not seem ready for it.
Frequency of blood glucose measurements by pet owners
Fasting blood glucose concentration is determined twice weekly and a BGC once monthly. The former serves to detect morning hypoglycemia, in which case the owner is instructed to call us. Since all our diabetic animals receive insulin BID the BGC is performed for 12 hours. The owner sends the results, and appropriate changes in treatment are discussed, if necessary, over the phone. Over time, the owners gain experience in the collection of blood and operation of the blood glucose meter. During the first few weeks of home-monitoring, periodic re-evaluations of the entire procedure are performed at the clinic. This includes that a veterinarian is watching the owner performing the procedure. After this the animal is hospitalized to perform a BGC. Possible technical problems can be discussed with the owner, and the owner's technique for blood collection and operation of the blood glucose meter can be assessed. After a few weeks (or months, depending on the reliability of the owner) the re-evaluation in the hospital may be reduced to consideration of clinical signs, body weight and fructosamine measurements. Because home monitoring has not been used widely in veterinary medicine, there are no studies to indicate how often re-evaluation should be performed. Currently, we feel that the owner should determine a BGC once monthly and the patient be re-assessed a minimum of twice a year by a veterinarian.
Problems encountered in home-monitoring
It is important that owners have ready access to veterinary support. The majority of our clients call for advice one or more times, especially after the start of home monitoring. Some have specific questions regarding the procedure, while others want reassurance that they are performing the procedure correctly. Sometimes support via phone is not sufficient and additional explanation or demonstration of the technique must be provided. According to a recently performed study, the most frequently encountered technical problems included, inadequate formation of a blood drop due to excessive pressure of the finger behind the ear while lancing the ear, repeated depression of the plunger instead of allowing the negative pressure to slowly build up, and failure to fill the test strip to the mark. These procedural steps require explicit explanation and demonstration. Handling the PBGM usually is not a problem for owners, and most report that their pet tolerates blood collection well. Usually, owners feel that their technique improves quickly, which leads to increased confidence in the test results. On average, cats tolerate the procedure less readily than dogs. Many owners report that the cats are more tolerant of blood collection when they are placed in their favourite spot, such as a windowsill or bed. In dogs and cats, the skin puncture does not seem to be painful, and the puncture sites are barely visible, even after numerous blood collections. 90% of those pet owners performing home monitoring do not need a second person to help with the procedure.
Comparison of home and hospital blood glucose curves
We recently performed prospective studies in diabetic dogs and cats to evaluate what the differences are between BGC generated at home and those generated in the hospital. Owners were asked to determine 4 BGC spaced 3 to 4 weeks apart, and within one week a hospital BGC was performed after each home curve. Interestingly the maximum and mean glucose concentrations of hospital BGC were significantly lower than those of home BGC. Reduced food intake in the hospital appears to be the most likely explanation. We also compared the potential treatment decisions based on the BGC results of each animal. In more than 40% of cases, treatment decisions would have been different. However, only in a small percentage of cases would the treatment decisions have been reversed (increase vs. decrease of insulin dosage). The reproducibility of BGC is difficult to assess because the glucose concentration may vary from day to day. Further investigations are necessary to determine whether reproducibility of BGC performed at home is superior to those performed at home.
References
1.  American Diabetes Association. Consensus Statement: Self-Monitoring of BloodGlucose. Diabetes Care 19 (Suppl 1): S62-S66, 1996.
2.  Casella M, Reusch CE: Home monitoring of capillary blood glucose in dogs and cats: Technical aspects. 18th Ann Med Forum, Am Coll of Vet In Med, Abstr., 2000.
3.  Casella M, Wess G, Reusch CE: Measurement of capillary blood glucose concentrations by pet owners: a new tool in the management of diabetes mellitus. J Am Anim Hosp Assoc (accepted 2000).
4.  Cohn LA, McCaw DL, Tate DJ, Johnson JC: Assessment of five portable blood glucose meters, a point-of-care analyzer, and color test strips for measuring blood glucose concentration in dogs. J Amer Vet Med Assoc 216(2):198-202, 2000.
5.  Reusch CE, Wess G, Casella M: Home Monitoring of Blood Glucose Concentration in the Management of Diabetes Mellitus. Comp Cont Educ 23, 544-557, 2001.
6.  Wess G, Reusch CE: Capillary blood sampling from the ear of dogs and cats and use of portable meters to measure glucose concentration. J Small Anim Pract 43:60-66, 2000.
7.  Wess G, Reusch CE: Evaluation of five portable blood glucose meters for use in dogs. J Amer Vet Med Assoc 216(2):203-209, 2000.
8.  Wess G, Reusch CE: Laboratory Assessment of Five Portable Blood Glucose Meters for Use in Cats. Amer J Vet Res 61 (12): 1587-1592, 2000.
Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)
Claudia E. Reusch, DVM, PhD, DECVIM-CA
Clinic for SA Internal Medicine
University of Zurich
Winterthurerstr. 260
Zurich CH 8057
SWITZERLAND