Ketones + Infection Advice?

Discussion in 'Feline Health - (Welcome & Main Forum)' started by scienceofcats, Mar 23, 2020.

  1. scienceofcats

    scienceofcats Member

    Joined:
    Feb 28, 2018
    Hey guys, I haven’t posted here in a really long time, so bear with me... my FDMB spreadsheet is very out of date, so I’ll try to describe where Lola has been. This is going to be pretty long, so thanks in advance for reading through it... I’m pretty worried because Lola has ketones in the urine, but I’ll get to that.

    Two weeks ago, Lola got her routine bloodwork, and her glucose was a little higher than usual at 13.4 mmol/L (241 mg/dL). That was at about +7 hours from her AM shot of 1.5 units ProZinc. Normal pre-shot values for her are between 10.0 and 12.0 mmol/L (180 to 215 mg/dL), and last time I did a curve on her (admittedly too long ago - about 8 months) she had a nadir of 7.7 mmol/L (140 mg/dL). I do realize human meters tend to slightly underreport blood glucose in cats, so that may account for some of the variance between my tests and the vet’s bloodwork.

    Her fructosamine was 425, which the vet said indicated fair regulation, so she advised to keep things as is. We didn’t have urinalysis to go off of at the time because the sample leaked during shipment to the lab, so I took her in to get a new sample last Friday. I just got the call from the vet about the results of that today, and she said there was some glucose in the urine, which she didn’t find overly concerning. However, she tested positive for ketones (it was 2+), so we are obviously very concerned.

    I remember reading that infections can influence ketones. She was actually at the vet on Friday mainly to deal with a skin infection she quickly developed on her chin (about 5 mm and deep) that had a bad odour and was secreting borderline-purulent fluid. It’s nearly completely cleared up now; I’ve been applying Isaderm (fusidic acid + betamethasone) twice daily and she’s got a collar to stop her from scratching it. Could this have contributed to the ketone value?

    Also, if I want to re-test her ketones, do I have to take her back to the vet for a urine test, or could I use a digital blood ketone meter? I can’t use Ketostix at home because it’s impossible to get fresh urine from Lola.

    I’m doing a blood glucose curve today, and she’s gone from AMPS = 11.4 (205) to +1 = 11.5 (205) and then +3 = 8.4 mmol/L (150 mg/dL). As a side note, I’m a little worried that my injection technique could use work and that there’s some kind of insulin absorption problem. I always use the same area (the scruff/loose skin above her right shoulder blade), although I try to vary the exact spot above that shoulder blade that I inject each time. Could there be scar tissue affecting this from repeated use of that area? Would it make sense to do another blood glucose curve tomorrow using a different site to see if it makes a difference?

    Any help/advice is appreciated - thanks in advance!
     
    Last edited: Mar 23, 2020
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  2. Deb & Wink

    Deb & Wink Well-Known Member

    Joined:
    Jan 31, 2013
    Absolutely. Blood Ketone meters are great for "shy peeing" cats or those difficult to catch in the litter box.

    Varying where you shoot is good. Think of the face of an old fashioned clock, with hands for hours and minutes. Use that clock face image to vary your shot location.
    Have you seen this?
    "Shooting
    We all have our own techniques for shooting but just a few thoughts and others may bring some of their ideas in as well.
    • Injection sites:
    You can shoot the scruff, side of chest, side of belly, side of flank....wherever your kitty is comfortable and you have the least chance of doing a fur shot.

    [​IMG]
    • Site Rotation
    It's actually a great idea to rotate sites in order to prevent development of a lipoma or scar tissue. A lipoma is just a thickened area of fatty cells right under the skin. If you shoot in the same place repeatedly and your kitty develops one, they often will go away on their own if you switch to another site. However, if you change injection sites every day (if possible), there is a much decreased chance in developing either a lipoma or scar tissue. Both of these can affect absorption negatively. If your cat prefers scruff shots only, you can shoot one side in the morning and the other side at night; you can also move the scruff site so the first day, you shoot at the inner scruff on one side, the next day, the middle scruff, and the third day, the outer part of the scruff. Or, if kitty is tolerant of any injection sites, you can shoot one side in the mornings and shoot the scruff the first day, the chest the next, the flank the third day. In the evenings, you can shoot the other side of the kitty but in the same order."

    Lots more helpful info in the Marje and Gracie's Testing and Shooting Tips
    within Hometesting Links and Tips within
    Sticky INDEX: Health Links/FAQs
    within Health Links / FAQs about Feline Diabetes forum.
     
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  3. Deb & Wink

    Deb & Wink Well-Known Member

    Joined:
    Jan 31, 2013
    Yes it can.
    Ketones from when a cat is not eating enough, not enough insulin, and infection/inflammation (think bad teeth, UTI, etc). Ketones are formed as a toxic waste product of the cat's body catabolizing (burning off for energy) the fat and muscle tissue, to provide needed energy to the cat's body.
     
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  4. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    What country do you live in? I'm asking because IDEXX changed some of the fructosamine reference ranges for outside the USA.

    If you could please add your location to your user id profile, that would be great.
     
  5. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

    Joined:
    Feb 21, 2015
    I would definitely get a ketone meter and start testing for ketones today if you are unable to get a urine sample to test. Ketones is not a ‘wait and let’s see what happens’ issue. Ketones can go from small to large very quickly and then to DKA if not treated.
    To be able to manage them you need to be testing at least once a day if the are showing up in tests. We can help you with that but we need to know the level of ketones and getting your SS up to date with the last couple of weeks data would be very helpful.
     
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  6. scienceofcats

    scienceofcats Member

    Joined:
    Feb 28, 2018
    Okay, I got a Freestyle Precision Neo meter with β-ketone strips and did a test on Lola - she’s at 0.1 mmol/L. That’s great, right? I remember reading that anything under 0.4 is good. That said, I had to use two blood drops within 30 seconds to fill the strip - can you verify that there’s enough blood in there? The meter beeped and counted down as it’s supposed to, but I thought I’d ask anyway - photo attached at the end of this post.

    For context, this was taken at the same time as her +2 blood glucose, which was 10.6 mmol/L. Her AMPS bG was 11.8 mmol/L. I’ve increased her dose to 1.75 units - I figured 0.25 increments were safest. What do I want her nadir to be?

    PS: I’ll update her SS now with some recent data.

    [​IMG]
     
  7. Deb & Wink

    Deb & Wink Well-Known Member

    Joined:
    Jan 31, 2013
    That test strip looks like it sipped up the drop of blood nicely, all the way to the top of the strip. No giant smear of blood on the strip either, which could give you a false reading. Some people try to smear the blood on the test strip, instead of letting the test strip use it's capillary action to "sip up the blood."

    That is a trace of ketones, so you do want to keep a close eye on that, in case it gets to be more than that. Testing every day would not be too frequently.

    Make sure Lola is eating enough. Ketones form when the cat is burning up fat and muscle tissue to provide energy to their body, when they are not getting enough to eat or there is not enough insulin to help them process the food they are eating properly.

    Be right back with more answers to your questions.
     
  8. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    Yes, 0.25U increments are the recommended dose increases and dose decreases we recommend here.
    Waiting for those SS updates. Nothing after 3/13/20 - yet. Guess I was too fast looking at your SS. ;)

    See the Sticky PROZINC DOSING METHODS protocol for guidelines. Nadir depends on if you are using the SLGS (Start Low Go Slow) protocol or the MPM (Modified Prozinc Protocol) which is a more aggressive approach to dosing for Prozinc, similar to the TR (Tight Regulation) method that is used with Lantus and Levemir insulins.

    Threshold for decision making is now 8.3 mmol/L (150 mg/dL) for Prozinc. That does not mean skip the dose, it may mean stall, do not feed, test again in 20 minutes. It may mean give a reduced dose. It depends. See the protocol for more detailed info.



    Nadirs down in the green numbers, < 5.5 mmol/L (99 mg/dL) would be great. You don't want a nadir <2.7 mmol/L (50 mg/dL). That would mean a dose reduction is in order.

    p.s. Mid-cycle tests needed, to find that nadir with this dose you are giving. Both AM and PM cycles, or you are missing half your data.
     
  9. Deb & Wink

    Deb & Wink Well-Known Member

    Joined:
    Jan 31, 2013
    Thanks for the SS updates.
    Lola has more room to drop in her BG numbers. Out of those yellows and blues, and down into the greens.
    But first, let's give this increase to 1.75U of insulin a chance to see what it does. 6 cycles would be good.
     
  10. scienceofcats

    scienceofcats Member

    Joined:
    Feb 28, 2018
    For sure, I’ll test for the next couple of days in a row anyway. For what it’s worth, when I’ve used Ketostix to test her urine years ago (when she used to pee in my bathtub against my will... yeah, that was a thing), it always looked like trace to me. I do understand that ketones can change quickly, so I definitely want to see it stay low for a few days in a row.

    That said, those strips need a lot of blood (seems like 1 μL compared to what I know are 0.3 μL strips for the bG), and that really sucks for Lola. That’s mostly because she’s not the greatest bleeder - I’ve got to ‘milk’ it to get enough, and it looks like that stings a fair bit. More generally, I don’t want to be constantly poking her because of how much she hates it (despite being really good about it) - I don’t want to cause any more pain than I absolutely have to. That’s also why I don’t routinely do mid-cycle tests.

    She eats one of those ‘perfect portions’ packages (that come in pairs that you break in half) before each test + shot. She consistently (for two years now) eats about ½ to ¾ of one. I can’t leave the rest out for her because the other cats steal it. She also has access to the kibble all my cats eat, which is diabetic-friendly dry food (at least, as diabetic-friendly as kibble can be) - it’s prescription Purina D/M (dietetic management) dry food. Do you think that’s enough for her to be eating?

    No problem - thank you for continuing to give me good advice! :)

    My vet thought I should give it around a week, so maybe 10 cycles, and then doing a curve before increasing again. Is that too long, or okay to do a 10-cycle holding period?

    I did read in the ProZinc protocol you sent that the guidelines for dose adjustments are these:
    • If nadirs are more than 150 mg/dl (8.3 mmol/L), increase the dose by 0.25 unit
    • If nadirs are between 90 (5 mmol/L) and 149 mg/dl (8.2 mmol/L), maintain the same dose
    • If nadirs are below 90 mg/dl (5mmol/L), decrease the dose by 0.25 unit
    So if I’m understanding correctly, the goal is for the nadirs to be between 5 mmol/L and 8.2 mmol/L, i.e. very high greens to low blues. The dose increase trigger of 150 (8.3) sounds good to me. Do you think setting the dose decrease trigger to 100 mg/dL / 6.0 mmol/L (per my vet), rather than 90 / 5.0 mmol/L, would be reasonable?
     
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  11. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    Not particularly as low carb as we like to see generally, but it is what it is. Carb percentage of 11-13% is a touch high, but not too bad.

    Best way to see if that is enough food, is to weigh Lola once a week. Clinical signs and symptoms are as important as the BG (blood glucose) levels.

    If you have a human scale, hold her in your arms, note the weight, let her down, weigh yourself and subtract your weight from the first number. It's what I do for my cat. A couple of ounces either way can simply be a full or empty bladder on your cat.
    Do you ever do a double poke, two pokes right next to each other, to get a bigger blood drop to form?
    Are you warming the ear with a "rice" sock you have heated in the microwave? or a warm washcloth in a plastic bag or a pill bottle filled with very warm water? Or have you asked Lola to please take a nap in the sun or on top of the heating vent, to get the blood to flow better? It's easier when the ears are warm to get that blood drop. Summer time, love the summer time and warm kitty ears. Winter, not so much.

    Also, sometimes if a cat is a bit dehydrated, the blood does not flow as well.
    Paw pad testing is another option.

    Sure, that is fine. Working with your vet is always a good thing to do.

    A cycle is 12 hours. So 6 cycles would be 3 days. That is the minimum amount of time you would want to wait before increasing the dose. Unless your cat is a high dose cat, then it's possible to increase a tad faster, but not always advisable even then. But that high dose situation does not look like the case for Lola.

    Holding for 1 week or 14 cycles is fine. Or ten cycles, 5 days, or whatever you and your vet can agree on.
     
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  12. Marje and Gracie

    Marje and Gracie Senior Member Moderator

    Joined:
    May 30, 2010
    Here is info about when ketones show up on a blood ketone meter in cats.

    If you scroll down, there are two studies linked but the information indicates ketones start to show up in cats on a blood ketone meter at 2.4 so 0.1 is normal.
     
  13. scienceofcats

    scienceofcats Member

    Joined:
    Feb 28, 2018
    I tested her blood ketones again today, and the reading is 0.3 mmol/L. I’m concerned that they’re rising... thoughts?

    Thank you!! I just read both articles in detail and also a few threads on the forum discussing reference ranges. It sounds like the consensus (?) is that <0.6 mmol/L is considered completely normal in non-ketotic diabetic cats. However, because Lola has gone from 0.1 to 0.3 in one day, it makes sense to test it again tomorrow to make sure it doesn’t continue to rise, right?

    Also, I’m testing ketones mid-cycle around here expected nadir (~4 hours) - do you know if it matters when I test?

    That makes sense - I’ll start doing that and keep a log of her weights.

    I haven’t tried doing double pokes, but that’s an interesting idea - I’ll give it a go. I do already use a rice sock microwaved to be quite warm... she won’t bleed hardly at all otherwise. I had better luck getting enough blood today just by poking her more diagonally (i.e. more of the bevel on the lancet goes into the skin) and also holding the ketone testing strip on the drop for longer... I suspect part of the problem was partly that I pulled away too quickly yesterday, and going back for more is harder because the remaining blood is more smeared.

    Great, good to know. I may try sooner rather than later... I’m incentivized by the slightly rising ketones that make me nervous. Now the challenge is fighting the urge to try to fix it right away by increasing the dose too soon... but I will resist.
     
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  14. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    You can keep track of Lola's weight on your spreadsheet. Easy enough to do. Add it to the Remarks column, or add another column at the end of the SS to track the weight for your kitty.
    I do know that ketones in humans can be higher after fasting. For example, in the morning before someone has eaten. Don't know if Lola is free fed or is meal fed, so don't know if her ketones would be higher in the morning or other times of day or what.

    Daily testing would be a good idea, since Lola's ketone level is rising over the last 2 days.

    How is her hydration level? Do you know how to test a cat for dehydration? Tenting the skin, or gum check are the 2 most common ways to check. Ask for more details if you need them.

    Does her blood seem "thick" when you poke to get a BG or ketone test? That could be a sign of dehydration also.
    Still excessive amounts of peeing in the litter box? Do you add water to her wet food, to help with the hydration?
     
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  15. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    Did you realize that the bevel has a more pointed side, so the bevel side should be up when you poke?
    Do you use lancets that are 26-28 gauge? Or do you use lancets that are 30-31 gauge?
    The smaller number means the pin on the lancet is slightly bigger. It can make a difference if your cat is not a good bleeder, to use the 26-28 gauge lancets. Labeled "For Alternate Site Testing" on the box.

    Throwing out tons of ideas here. Brainstorming a bit.
     
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  16. Marje and Gracie

    Marje and Gracie Senior Member Moderator

    Joined:
    May 30, 2010
    Any time numbers are high (> 300), ketones are trending up, or kitty is post DKA, it’s smart to check ketones every day. You might want to test urine ketones most of the time but save the meter for when you see trace urine.

    It doesn’t matter what time of day you test.
     
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  17. scienceofcats

    scienceofcats Member

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    Feb 28, 2018
    Bad news - her ketones are up to 0.6 mmol/L. I’m very concerned and have called the vet - waiting for a callback. I’m going to post a new thread about this upward trend to get a few opinions on what I can do to deal with this.

    Her hydration seems good - her scruff skin snaps back immediately from being lifted, her gums are wet, and her blood looks normal (not thick). I don’t know how much she pees because I have 3 cats that share 3 litter boxes, so it’s impossible to know which is hers. I don’t add water to her wet food, but I do give cold fresh water daily into two fountains and a bowl. I read somewhere that adding ice can help (I guess they like it cold?), so I may try that for one of them. But all in all, I don’t see any signs of dehydration, and the vet didn’t think there was any when she was in for her chin lesion (which is healing up nicely).

    I tried the double poke method, by the way - thank you! It works great, did the ketone strip and glucose no problem on one drop.

    Thanks to both of you for your continued help!
     
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  18. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    Subq fluids. Get your cat some subq fluids to help flush those ketones out of her body.
    Food. make sure she is eating plenty of food.
    Water. make sure she is drinking plenty of water.
    Insulin. She may need more insulin.

    p.s. yeah for double pokes working to get a bigger blood drop!
     
  19. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    Did you test the urine to see if any are showing there?
     
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  20. Deb & Wink

    Deb & Wink Well-Known Member

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    Ketones show up in the blood before they show up in the urine.
    She is using a ketone blood meter now.
    What would be the benefit for also testing the urine for ketones? @Bron and Sheba (GA)
     
  21. scienceofcats

    scienceofcats Member

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    @Bron and Sheba (GA) I don’t use strips for Lola because she won’t pee when I’m around, and if I’m not around, I can’t tell which pee in the litter is hers and which belongs to my other cats. I could do it in theory if I let her into my bathroom (she has a weird obsession with peeing in my bathtub and watching it go down the drain), and then tested her urine that collected in the tub, but my thinking is with @Deb & Wink on this - ketones show up in blood before urine anyway.

    Also, urine tests react with acetoacetate (a ketone), whereas blood tests react with β-hydroxybutyrate (another ketone). β-HB is the most important ketone in humans and tends to increase much faster in ketosis compared to acetoacetate (ratio can go up to 10:1 vs 1:1 in basal conditions), so blood β-HB tests can pick up ketosis even when it might be missed due to smaller increases in acetoacetate.
     
    Last edited: Mar 27, 2020
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  22. scienceofcats

    scienceofcats Member

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    Her test result this morning at +2 is 0.3 mmol/L ketones (β-HB), so I’m very glad to see it’s going down again. I’ve increased her insulin to 2.0 units ProZinc (it’s been 6 cycles since I increased it to 1.75 from the original 1.5). Her AMPS bG = 12.1 (218) and she’s down at +2 to bG = 10.4 (187) - I’ll test again at +4. Also, a side note - I’m now alternating between injecting into the scruff above the left shoulder blade and the right shoulder blade (I used to just always use the right). Left is a little more awkward, but I’m pretty good at it now!

    Still waiting for a callback from the vet. Considering the number went down again, do you still think subcutaneous fluids are a good idea, @Deb & Wink?

    PS: I didn’t make a new thread after all because it seems a little less urgent now, but I’m still on top of it.
     
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  23. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    At least to have them on hand. Just in case. It can be tough getting into the vet right now, and getting any sort of supplies. Get them if you can would be my suggestion.

    Science background creeping in there, with your being able to talk about the blood ketones vs urine ketones. I do like the fact the blood tests for ketones shows an issue before the urine testing does. If the ketones show up in the urine, that is hours later from when they happened in the blood.

    SS for AMPS 3/27/20 still says 1.75U. Is that correct? Yes, I really do look at spreadsheets and notice discrepancies like that. Can't see the forest for the trees, too detailed some times.:rolleyes:
     
  24. scienceofcats

    scienceofcats Member

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    Feb 28, 2018
    My vet apparently isn’t in today, so I’ll have to get her on Monday, and I’ll talk to her about fluids then too. Lola isn’t showing any signs of dehydration, so I’m not super concerned - I’m thinking waiting until Monday is okay, and if anything suddenly changes, I can always take a trip to the emergency vet (who’s really good and pretty cheap - been there before). :)

    Oops, yes! Lol, you’re right, it should say 2.0 units - I’ve corrected it.
     
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  25. Bron and Sheba (GA)

    Bron and Sheba (GA) Well-Known Member

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    Feb 21, 2015
    It would be interesting to see when the ketones appeared in the urine when she is testing the blood...purely interest on my part.
     
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  26. Deb & Wink

    Deb & Wink Well-Known Member

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    That could be interesting. If she has a cat that is cooperative with the urine testing.

    What do you think Lola's mom?
     
  27. scienceofcats

    scienceofcats Member

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    Feb 28, 2018
    True! I’m actually going to be taking Lola to the vet in a week or so to get her urine rechecked - the vet wants to double check this too and we figure it’s more accurate to use fresh urine from cystocentesis. It’s still the same nitroprusside acetoacetate dipstick reaction, just with fresh urine - I’ll do a ketone blood check the same day for comparison :)

    Also, heads up... I’m a guy lol

    PS: Blood glucose curve today with 2.0 units looked very nice :)

    Graph in mg/mL and hours. Insulin at 0 and 12 hours exactly. Red lines are reference ranges, green lines are ‘ideal’ ranges.

    [​IMG]
     
    Last edited: Mar 28, 2020 at 12:34 AM
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  28. Deb & Wink

    Deb & Wink Well-Known Member

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    Sorry, about the "gender reassignment" scienceofcats. If you could add your first name to your signature, we might not make that mistake again.

    You are the second person in the last couple of weeks where I've made that mistake. Sorry, blushing and red faced again.:oops:

    Looks ok. Still some room for improvement. We consider BG's lower than your graph "ideal ranges" show, to be achievable and desirable. Especially if you are considering remission, aka diet controlled status for you diabetic cat Lola.

    BG's down in the green ranges on the SS are what we consider the healing ranges. Giving the pancreas a break. Might not be possible to get diet controlled status for Lola, with the prednisolone and all.

    But in a few more cycles, you might consider bumping up the dose another 0.25U notch. Not yet. Give the 2U dose a bit to see what it does.
     
  29. scienceofcats

    scienceofcats Member

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    Feb 28, 2018
    No harm done, don’t worry about it! Do you know if there’s a way to change my username/display name? I can’t add it to my signature... too many characters.

    That’s good to know - okay, well I want to give her at least several days before I think about another bump up. I’m planning on doing another curve near the end of the week after she’s adjusted to 2.0 units, that way I’ve got a good reference point.
     
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  30. Deb & Wink

    Deb & Wink Well-Known Member

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    Jan 31, 2013
    Some suggestions to shorten the signature. Limit of 250 characters. Take out the spaces and only have the | to separate the info. Limit of 2 lines, so just keep typing and let the words wrap down to the next line.
    Put some of the other medications Lola receives in your User Profile, under Personal Details, About You: section.
    Take them out of the signature.
    Remove the spayed, take out the number of units of insulin and the BID, we can look at the SS to see that dosage info. Take out the word glucometer.

    Try this:

    Yourfirstname & Lola|6, female|Dx: 23/02/2018 |ProZinc|Freestyle InsuLinx|Freestyle Precision Neo β-Ketone Meter|Lola's SS|Fed wet food|Asthma|3.75 mg prednisolone|250 mcg fluticasone INH bid|1 mL/50 mg ursodiol

    What I did above, is 211 characters with spaces included. Used Word to get a character count.

    Yes, you can change your user name. Profile, personal details, advanced options, change username. Save the change. But I like your name, scienceofcats. Try what I did for your signature instead. You may simply be able to copy it. Not sure if the SS link will copy correctly, but you can link it again.

    I did this for someone else this year, shortened the signature, really did not know computers at all. She had to redo the "add SS to Signature" part again. Walked her through how to do that over the phone.

    If you do need to relink the SS for Lola, instructions are here, about half way down in the document.
    FDMB Spreadsheet Instructions
     

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