OK, thank you very much, Tim, thank you for that introduction. So I guess this talk is not should not be in this stream. This is the talk about when not to use clinical pathology, when to er er er er avoid because you're going to try a treatment anyway.
Before we start, I'd just like to declare a few conflicts of interest. I don't think any are particularly significant on this particular talk but they're up there for your interest, er and . Moving on then to what we're going to talk about today.
Clinical medicine is a series of options. Yes, we need to talk about what what when we talk about economic medicine, what are we talking about? What are those options?
What are the risks and benefits of cost reductions? Then we'll talk about some necessities before you start doing clinical therapeutic trial and then how we go about doing a therapeutic trial and we'll finish with a quick summary and reflection. We have to recognise that the white heat of modern technology has caused an increase in veterinary fees, which is way outstripping inflation.
The prices that we charge our owners are more than they were 20 years ago, and the textbook knowledge that is now out there is so much better that there is a proportion of animals which we are leaving behind. The textbook solution simply costs too much. But we shouldn't shirk from the fact that we can still help the owner.
And the animal and indeed ourselves by providing an economic medicine service. Whose challenge lies in both good medicine, a thorough understanding of the medicine, and good communication with the client about the shortcuts, as it were, that we are taking. What it's not is us being uncaring or dealing with uncaring owners.
If owners aren't interested, we should not feel so obliged to do it. It actually doesn't probably become quicker. In fact, actually we possibly need to spend more time explaining to the owners and possibly taking more time.
We should therefore continue to charge for our time as we always did. Economic medicine is not about better debt collection, that's practise management, and it's certainly not about doing things badly. It's about doing things as well as you can within the budget.
Let's deal with the elephant in the room, what is a specialist in internal medicine doing talking about economic medicine anyway. The reality is that in Glasgow, many of my clients are not insured, and many of them are cost limited. The threshold might be higher in referral practise, but the threshold is there.
The same process goes through wherever the threshold is. The same process happens regardless of where you work. It doesn't matter whether what your final budget is, it matters that the process is right.
So the first rule. Offer the gold standard first. You have no ethical basis for presupposing.
That an owner cannot afford. It's the only sensible starting point anyway for any discussion about what we can cut is starting from a position. So either we start from the zero position or we start from 100% and we adjust.
It is particularly important not to prejudge. Owners as they walk into the room. Little old lady walks in with a little old dog, and you have to think carefully about what your attitude to that situation is.
We have 3 little old ladies here. Can you tell how much they're worth? Yes, exactly.
That's the point. It really is important not to get into that, so we start with the gold standard and we work down. There are risks and benefits in cost reduction.
We risk our confidence. We can risk animal safety. We can risk our profit, and we can risk our time.
But there are benefits as well. We cut down on the number of procedures. We reduce our responsibility as long as we've communicated properly with the owner.
Our level of responsibility is less. Of course there's benefits on the owner's finances, and there may be some benefits on our time. There are some false economies.
Shorter limited examinations, particularly in diagnostic imaging, not doing the contralateral view, not doing the orthogonal view. Those are actually false economies. If you're going to take a radiograph, you need to do the proper examination.
Briefer notes, and that's not just clinical notes as in recording the history and the clinical exam, but also in assessing the tests and so forth, using inaccurate. In-house tests or any inaccurate test, partial but non-diagnostic procedures, so doing a pneumocystogram but failing to give the animal an enema beforehand, cheaper but ultimately ineffective drugs and lower and therefore less valued prices. These are actually I think false economies.
So let's talk a little bit about necessities. How do we decide how to treat an animal? Animals coming in with a problem.
We decide to make a diagnosis. I question what you mean by the definition of a diagnosis might want to reflect on that. What do you mean by the word diagnosis?
And from that diagnosis, we make a treatment. We use two patterns, 2 methods really in veterinary science, the problem oriented approach and a pattern recognition approach. Both approaches have their merits.
The pattern recognition approach defines the problems that we've identified, recognises the pattern, and then jumps quickly to a diagnosis, maybe for a confirmatory test. We will often use this in an economic situation to cut out the diagnostic test, and if we recognise the pattern, go to a confirmatory treatment very quickly. We have to, however, recognise that in treating a dog on this basis, we should not presuppose that that is a diagnosis.
The fact that your patient gets well does not prove your diagnosis was correct, merely that your treatment did not affect the outcome or may have improved it. There are many situations where a diagnosis is not important. Other situations where it is.
As part of my day job, I do a lot of endocrinology and quite often we come across dogs which have an endocrine disease, but oftentimes this can be incidental. A dog comes in for an orthopaedic surgery. The orthopaedic surgeon looks at the dog and gets me involved, and to cut along Sroy's thought, we end up with a diagnosis of Cushing's disease.
Acute Addisonian crisis and death follow as a result of the treatment. And then the owners muttered the immortal words, but my dog was never Elmer before. Do we need to diagnose everything that we see?
And the answer of course is no. We have to be very clear to owners about whether we need to diagnose or not. Similarly, is treatment important?
The use of antibacterials for the prevention of infections, the use of antibacterials in GI diseases, proton pump inhibitors and H2 antagonists in the prevention of GI ulcers. See a lot of dogs that are being treated with steroids that are on omeprazole. Why?
Unnecessary treatment. Using omeprazole in in every other GI disease, antioxidants for liver disease, ACE inhibitors for extending life in renal disease probably doesn't work. There's a lot of question marks about overtreatment.
And I think we have to identify which treatments are important and which are not. Here's a good one for you, a little interactive question. 10 year old male neutered Labrador arrives at your clinic for a routine re-vaccination on all these medications.
Which one of these which of these followings would you actually give a repeat prescription for? So if you can press on your clickers. You can have one or several.
But which ones would you actually issue a repeat prescription for? So my answer is actually none of them need a repeat prescription. For me If the dog is exercising now, well, it does not need meloxicam.
OK, you might give it something there, if it becomes lame when it comes off the meloxicam, then you can put it back on. But arthritis is a waxing waning condition in some cases, and animals that are consistently medicated with meloxicam, will often have be at risk of, problems. Low fat diet to prevent pancreatitis in an animal that's had two bouts.
I would, I have to question that really. I think the evidence that well there's clear evidence that very high fat diets may cause pancreatitis. These very low fat diets as a prevention.
I'm not sure there's much evidence to confirm that, but this is the sort of justifiable questions we need to talk to owners about about just what they what they need in terms of chronic medication. What happens if we're faced with a case and we're not sure, do we need to diagnose, do we need to treat? How do we get that input?
Because sometimes these cost limited cases, we're we're starting to stray out beyond our comfort zone. Experienced colleagues, textbooks to help, your preferred laboratory, referral centres. Get the more heads you get around, the better the decision making.
No doctor is better than 3. If you are going to contact laboratories or referral centres or colleagues, get the results together before you pick up the phone or before you send the email. Make sure that it is a coherent whole.
Please do not send 85 pages of PDF and ask somebody to comment on them. That that is an afternoon of work for that person and they're probably not going to get paid, so summarise things. And above all else, if you can send a picture of whatever it is you're worried about, the appearance of the dog, the cytology that you've seen on the microscope, that will help the the radiograph, another good one, send those digital images and you can actually get a lot more out of those situations, those interactions.
Economic medicine is not about cutting your costs. Something for nothing devalues the something. Reducing charges on clients for clients is unfair on those who do pay and who may not have made a fuss about the price and the money.
It is fair to spread the load over time if you can do that and remember that if you're writing a prescription, those internet pharmacies will still charge a full price, and they don't reduce their prices. But I would advocate strongly that markups should not be a set percentage for all drugs. There's a whale of a difference between the markup that you put on an omeprazole tablet and the markup that you put on a a box of cyclosporin.
I was always taught that if I reduced the price by 50% that I need to see 5 more cases. To make up for that. So let's talk about therapeutic trials.
For the purposes of this talk, I'm going to define this as a short period of treatment. Started without a diagnosis. Again, what do we mean by a diagnosis for the purposes of assessing for a positive response.
Not for the purposes of diagnosing. The animal responds and it gets better, that's all we're interested in. Which of the following presentations would you often in your practise try some treatment before diagnostic testing?
Assuming that you didn't find any abnormalities on clinical exam. OK, I thought I would probably kiss jaundice, almost nobody would just try some symptomatic treatment, whereas large intestinal diarrhoea and lameness, I think we're all pretty comfortable, we do this pretty regularly with fever and a cough somewhere, somewhere down there, that that that's probably what I would have expected and that's probably what we're doing. But I think we can be a bit braver, and I'll come to talk about the fever in a minute.
But certainly cough in a dog is reasonable to suppose that most kennel cough in dogs, most ordinary coughs in dogs, are likely to be of a bacterial infection border teller. It is reasonable to try treatment in those as a cost cost basis on economic medicine, to do a throat swab on a dog with a cough, to diagnose the border teller is probably a bit of an overkill. So the presentations that are likely to make good candidates for therapeutic trials tend to be clinical presentations that are acute, mild, and maybe be self resolving anyway.
Large intestinal diarrhoea, cough may get better no matter what you do. Yes? So these are, these are a list of presentations, remembering that these, these are all on the basis that there's very little find on clinical exam.
Vomiting, we can treat with antiemetics as a . Therapeutic trial, small quantities of food given, and little else. We certainly don't in a vomiting case, with acute mild vomiting need proton pump inhibitors and H2 blockers.
Diarrhoea diet patients, hematochezia, the large intestinal bleeding would be secondary to colitis, and both of those definitely not antibacterials, fever, pruritus, the list goes on and probably most of us are doing this. To a greater or lesser extent, we do not make diagnoses in these in these cases, and that is a reasonable reasonable way to go. Do we need antibiotics for this?
This is a photograph of a dog with diarrhoea. It starts here and it goes drops and drops and drops and drops like yes folks, this is the big sea of colitis. Do we need antibiotics for this?
Probably not. Do we need antibiotics for the cat that presents with cystitis? It is important therefore, to acknowledge that although trial treatment is an important thing, using antibiotics as a trial treatment is not a good idea.
We do not want to be doing this on many of these cases. Many of these cases we need to use things other than antibiotics for those trial treatments. What about the, the cat with cat flu or or the sterile surgery or the anorexic dog?
Interestingly, 25% of doctors will prescribe antibiotics when they don't know what's wrong. That's a figure that we need to be aware of. So before we start going down too much into the treatment trials, let's just put those caveats there about using antibiotics as a trial treatment.
What about acute fever? Is it possible to do this as a as a trial? Well, yes, I think you can.
You can control fever very easily using non-steroidals. So the only er the first question you need is, do we need to control the fever? Now, fever is something that has evolved over time.
Birds do it, bees do it. Almost every living animal does fever. There is no way that we will have conserved fever over 200 million years if it wasn't beneficial.
Fever is good for you. To a point So do we need to control the fever is a very important question that we need to consider fairly carefully. That if the fever is not life threatening, If the fever is not severely debilitating, then the fever is probably good.
Assuming that we've made that decision, then the first consult with an acute fever, we should try and find something to aspirate. Consistently the most successful diagnostic approach to fever in cats and dogs is to stick a needle in something. Any lump, anywhere, any mass, aspirated.
And then Monitor. In human beings, most fevers are completely self-limiting. There's good evidence that most acute fever in dogs is also self-limiting.
So on day one, our actual action is to do very little unless we can find something to to diagnose. Simply monitor. If that fever persists.
Then at that point, it is reasonable to start an antibacterial treatment, probably for one course of about 7 to 10 days. If that doesn't work, now clinical pathology kicks in. Now we start looking for the sources of disease.
Rather than going off into long courses of antipyretic treatment. If of course the animal has responded to antibiotics and then when you take it off, it relapses, it is reasonable to carry on for a longer period of time. But if it has not responded to antibacterials, then I would contend that most of the remaining differential diagnoses are likely to respond to prednisolone.
There are of course a group of presentations that are unlikely to respond to symptomatic treatment and we generally think might need some diagnosing. Many of you identify jaundice as being one that you would always try to do some diagnosis on. I would agree with that, but what happens if, for example, the animal comes in and it's anaemic?
Can we, can we trial treatment on that one? Well, well, yes, you can to some extent. Cats, for example, it is reasonable to give a trial treatment to an anaemic cat of doxycycline.
It's a common cause of anaemia to to have hemobarin or mycoplasma Haemophilus, it's reasonable to try a course of doxycycline. It is reasonable to worm the animal. If you have a regenerative anaemia, and that would be on the blood smear, and you've done an insaline or glutination, then it would be reasonable just on the basis of a positive insaline or glutination and a regenerative anaemia to start him in a suppressive treatment.
Pretty cutting to the edge here, yes, you're taking a risk. I accept that you're taking a risk, but if clients can't afford the white heat of bone marrows and haematology and and all the rest, we have to start going towards the the most likely differential. And treating that and that's what this slide suggests.
In non-regenerative anemias, most likely this will be related to a dog with perhaps renal failure or something. It would be reasonable to try some anabolic steroids in those cases, and if you're trying all that, then you can try some B vitamin supplementation and irons. Those are reasonable supplements to be given if you're trying to treat something else.
With something else be aware that most of the multivitamins don't contain folate, and we know that chronic anaemia is associated with low folate, not as a cause, but as an effect of the chronic anaemia. So how do we decide if if I opened the possibility that we could do treatment trials, how do we decide if it's a good idea? Well, the first thing is to decide what are your differential diagnoses.
For this presentation. Do we have a short list If we do, then we're much safer to try a treatment trial. If you've got a big long list.
Then that's not you're likely to be problems, and I emphasise likely differentials. We can all write a list of 200 causes of anaemia, but what's the most common cause of regenerative anaemia in a young dog. Yes, so we can make sure that we limit things like that.
Are the diagnoses rapidly progressive, because if they are, that would push me towards a treatment trial because we may not have time to do too much more. Diagnoses that don't require urgent surgical intervention also make good good candidates. Is there an available symptomatic treatment option?
And of course, most importantly, has the cost implications of this, not just the cost savings, but also the potential future costs. Of going down this route being discussed with the owner is the owner properly informed? Have they given their proper consent to this?
And above all else, have we an ability to monitor the outcome of that trial. So we need to do a little checklist if we're going to do this in our minds of can we do this and make sure that we've ticked as many of these boxes as we can. If we are going to do a therapeutic trial, it's important that the therapy given is definitive.
That is to say that we're not sitting there a week later and saying, gosh, I wish I'd used a high dose, the proper dose. So make sure that we're using the correct dose for frequency and the duration. And I would suggest, for example, if you're going to do an antibiotic trial, that means 7 to 10 days.
And a bit of patience is required. We often see dogs that are presented to, to, to us at Glasgow, which have had a 3 day treatment trial of antibiotics. And that is not An adequate time to assess the response.
2nd golden rule. If the first course you give does not succeed, don't try, try, try again. This is common in Scotland because of this man, Robert the Bruce.
As you know, his motto was er er try, try, try again. He may have been a great general, but he was a bad vet. Do not try again.
If your first attempt at a treatment trial has failed, do not try again. We need to make a diagnosis at that point, I think. Of course, one of the major reasons why we do treatment trials is often we're treating whilst waiting for some results to come back.
You know, we've taken a blood sample, it's gone off to the lab, and we're waiting for a couple of days. It is reasonable to start treatment trials then. In select that, we need to think about the cascade, about if you're right, how likely it is to work, and if you're wrong, how likely it is to harm what's going on.
Interactions with other drugs and of course interactions with future tests. So here's a question for you. In a 3 year old standard poodle presents to you bright.
But it's got a low sodium, a high potassium, it's azotemic, you've done an ACTH stem, but it's Friday and the results won't be back till Monday. What would you give over the weekend? OK.
So a large number of you went for 0.9% saline, which is reasonable and fair, and then a group gave prednisolone as well, which is also fair, I would agree. But nobody gave fludrocortisone.
Oh, very few. I would argue that fludrocortisone is a, this is a good use of fludrocortisone over the weekend. It is a short acting drug, you can stop flutocortisone tomorrow.
I definitely would not be injecting Zycortal, for example, but it is reasonable to use the fact that fludrocortisone is short acting over this weekend, which may decrease your dependence on the 0.9% saline for this animal, and plus you start stabilising the dog's electrolyte balance. So that's an example of how you can use a short acting treatment.
And that is on the cascade because Frederick Cortiz is a short acting, whereas DOCP is long acting. It's nevertheless the fact when you look through clinical histories, the most common trial treatment is undoubtedly antibiotics, and clearly they are safe compared to trial treatments with non-steroidals and steroids, probably, but they breed the potential for resistant infections, so we should be using first line antibiotics and definitely avoiding using things like fluoroquinolones as a trial treatment, but I think I guess that's fairly obvious. However, when you look at antibiotic usage in current clinical practise in the UK we have a problem with cephervein.
Cephervecin is used as a trial treatment, and yet, It is a 3rd generation cephalosporin. I have to say I do question whether that is a suitable thing to use as a trial treatment, but it is quite commonly used. How long do we keep them on these trial treatments, and that's where the point about home monitoring becomes really important and monitoring the trial treatment generally.
We need to be sure. That when we start a trial treatment, we have set some objective parameters that we're going to use to justify carryingtinuing with the treatment or stopping the treatment. And that's clear and it's written down in our notes so that our colleagues, when they see the animal, perhaps a week later, now it's better, do we know how long we carry on.
So for example, if you're giving antibiotics to an animal with a fever, how long do you keep on going with those antibiotics? Clearly you can use thermometers and get the owners taking temperatures and so forth, use clinical signs, use white blood cell counts. Acute phase proteins.
None of these depend on a diagnosis. And we've treated, I've treated a number of dogs with fever over the years without ever understanding why they had their fever. I just know they got better.
But we use these things and particularly acute phase proteins are useful monitoring tools for treatment trials because they are non-specific. That's precisely the nonspecific nature of them, which is their strength. For those who you are to acute phase proteins are a group of proteins that are released from the liver under the action of various cytokines, often stimulated by inflammation or infection.
And in the dog, haptoglobin and CRP and in the cat AGP are useful acute phase proteins. These can be classified as major and minor depending on the rapidity of the response and the duration of that response. They can also be negative acute phase proteins, and many of you will already.
Using a negative acute phase protein though you may not realise it, and that's albumin. Albumin is a negative acute phase protein. If you want to monitor something cheaply in a fever or something like that, one can monitor the albumin and we'll see a response to that as you get a clinical response.
So in in a bit of summer in reflection. When owners ask us to cut costs, it's important that we have a discussion with the owner about all the options, the costs and the benefits of cost reduction, the potential for laying problems in the future, but also about the benefits. The diagnosis and the definition of diagnosis needs to be revisited in the veterinary profession.
We need to look at the reliance on clinical signs more and clinical pathology rather less in that process, but also give up trying to prove. I hear a lot of phones. I take a lot of phone calls for advice, and I hear I'm trying to prove that this dog has.
And it brings me out in a cold sweat, to be quite honest. Proof of a diagnosis is not we don't prove things. This is not law.
We can't prove things. It's not even science. Diagnosis is just a guess made at a time at a place by a particular person, and it can be really often it can be incorrect.
There's a nice study looking at the diagnosis, the rate of successful diagnosis in clinical practise compared to postmortem findings. Do you know how often you're right? I'll tell you, about 70% of your diagnoses are correct.
At postmortem, 30% are incorrect. Which is a big failure rate. I think we have to accept that our diagnosis is rarely as specific as we think.
We need to talk about the selection of medication with the owner and monitoring the clinical signs and using home records to back this up, to keep those costs down. Thank you for listening. I'll be happy to take any questions.
Thank you, Ian. So if anyone does have any questions, if they wouldn't mind going to one of the microphones to ask it. Yeah.
A little bit of a comment perhaps rather than a question. I think slightly at one angle to what you've been saying a bit of a comment rather than a question perhaps la to what you've been saying. Because of the effect of negative and positive predictive value of tests, another restraint on running for gold standard investigation, particularly in In first opinion perhaps when when something enters your door for the first time, conditions have to kind of earn their spurs a little bit before you go too far.
What I see quite often is people who've run through every test have come up with a whole load of questionably significant results, and then the thing spirals out of control, and if you've not seeded the population they're investigating with a high enough index of suspicion. Then you then you can run yourself into trouble, so it isn't merely laziness that one doesn't do the gold standard of those presentations. There's another good reason for filtering and I never suggested that it was like and the other thing I would very strongly is that most tests that the clinical validation has gone on in a referral practise.
Those negative and positive predictive values have you know they're completely different when you go to primary care practise, so I think it's very important that when we look at these populations and all these validation processes, they all start with these animals have been properly examined, they've been looked at carefully. They've had routine haematology, biochemistry maybe before they do the specific test. Which makes the test look better than it is if you've just applied that test to the population.
Part of my residency, I started to look at T4 and TSH and rather than do it on all the dogs that I thought had hypothyroidism, I was doing it on every dog that I could get a sample from that walked into Cambridge vet school. The number of dogs with sick ewe thyroidism was huge. It took me less than 6 months to get my population requirement of sick e thyroid dogs.
It took me 3 years to get the hypothyroid population. You know, and that's what happens if you start doing T4 and TSH on every dog that walks in through the door, you're going to end up with a whole load of mess. In the USA, it is common practise to include T4 in routine routine profiles, leading to a whole load of people who think they've got hypothyroidism.
Yeah, I think, I think it's a, it's, it's an important point. Thank you for that question. We do have some questions on the text.
OK, and please do continue to send them in. The first one is I commonly have clients that bring in lethargic patients that don't want to do any investigations but just want medications to go home. What you lethargic that bring in lethargic pets that don't want any investigations but just want medication.
OK, so acute. Lethargy, what would be the symptomatic treatment for that? I actually think, think no medication, but actually monitoring and expressing concern and trying to establish the parameters for how we're going to progress this and I know it's a bit of a catch up, but you can say, how do you feel when you've got the flu?
Lethargic, yes, so let's just. See how it goes and set monitoring parameters. So it's good for example to get owners to learn how to take temperatures, but for those of you who don't know the in cats and thin dogs, you can do an axillary temperature.
You don't need to, it doesn't need to be rectal, axillary temperatures are strongly correlated with rectal temperatures, so get the owners monitoring the temperature of the animal. It gives them something to do without giving them medication. OK.
Next one, what would be your recommendation for a trial treatment antibiotic for owners that can't medicate their dogs with an oral antibiotic course of 7 to 10 days? For dogs that can't be medicated orally at home, yeah, I would be, well, I'm presuming you mean not orally medicated with a tablet. So we would go for a liquid antibiotic, ampicillin, for example, is available as a paediatric suspension, which you can mix in with a pate.
And that's a perfectly reasonable way of delivering antibiotics to both cats and dogs. Most animals will take really nice food with a bit of antibiotic mixed into it, so that's where I would go around it. I guess the hint of that question is what are we supposed to do other than give convenia?
Yes, it's kind of written on the thing of conveniia convenience, and so forth. What do you do? I think you have to try and use something else.
I, I get the sense that sometimes we don't even try, we haven't even dispensed ampicillin suspension or amoxicillin suspension or er . The azithromycin suspension, for example, you can get hold of, you know, 3rd generation cephalosporin with a 2 week holding time, that is a. Really got a question whether we should be using that.
OK, thanks. Next question, with fever, when do you think it goes from a fever to a life threatening fever? OK, so there's not a temperature.
OK, let's be clear about that. Fever, when it becomes dangerous, is not a there's not a 100 and, well, I'm gonna use Fahrenheit, 104, 106, or if you like, 39, 40, 42. Does anyone know how high the temperature of a Labrador goes when it's exercised?
I'll tell you, if you look it up, it goes to 44. There are labras out there, you exercise them hard, their rectal temperatures can rise to 44. There is no such thing as a temperature which is dangerous.
What's dangerous is when that fever starts to to cause very significant clinical signs, and that can be at a low level because fever is where the difference between the hypothalamic set point and the actual temperature. Is significantly different. If the hypothalamic set point and the rectal temperature and the body temperature are the same, the animal shows very little clinical signs, even if the temperature is 41 degrees.
What causes the animal problems is when the hypothalamic set point switches. And that then causes maximal clinical signs, so that the whole thing's fluctuating constantly changing, and that's where you start to get the clinical signs. And it's those that disparity that causes the clinical signs, not the absolute temperature.
So it's very much a clinical judgement based on such things as the length of anorexia. The lethargy of the animal, the heart rate, evidence of DIC, sepsis, anything like that, obviously we will want to intervene. And that is what determines it, not a temperature.
We know that animals which have fever. Are more prone to heat stress. So a bulldog that has a fever on a hot day in July is at risk of developing heat stress far more than the Pomeranian developing a fever in the middle of winter.
So that is another factor as well. What's their ability to cool themselves down, and that will be an important factor in deciding whether to treat a fever or not. OK, we've got another question, but do keep them coming in because we do have a few minutes left at the end of this lecture.
So the next question is, are globulins also a useful way to monitor progress as well as albumin? And how do you expect albumin to change with progress? So albumin in an acute phase response, albumin goes down and then rises, so as you as you treat it effectively, the albumin rises.
Globulin will go up, but it's nowhere near as sensitive as something like the C reactive protein. So to get inflammation sufficient to raise the globulins, you're talking about things like leishmania and lichia and things like that, which is absolutely massive inflammation. If you look at a cat with a cat bite abscess, its AGP will be high, but its globulin may not have shifted, and that's why we should be looking at these more sensitive markers nowadays rather than relying on white blood cells or globulins which are relatively insensitive markers and indeed.
OK. And the, oh no, got one more. So for a suspected Addison, Addisonian crisis at the weekend, could you use dexamethasone if it's the only injectable steroid you had and would this affect ACTH results the day after?
Yes, yes. Easy, do not inject dexamethasone into a suspected Addisonian patient until you've done an ACTH stimulation test. Or if you don't have ACTH, then take a serum sample, take an EDTA sample.
Take the EDT, spin it down straight away, and freeze the supernatant. That way you've preserved your ability to make the diagnosis, now you can do what you like, because what you're going to do in that situation is to measure endogenous ACTH and cortisol. But make sure that you've got those samples done before you inject that dexamethasone.
Next question, is CRP of no value in cats? Kim, I can answer that. We've looked at this as far as I'm aware, the answer is no, but we looked at, it's not very sensitive.
So yeah, you're better off using SAA and yes and AP as well. Yeah, or AGP yeah. OK, I think we've come to the end of the questions.
So if I could just remind you all to hand in your voting pads on the way out. There's also drinks in the arena from 4:30 later on, but hopefully you'll all join us for the next session with Ian starting at 3 o'clock. And if you could just join me in thanking him for a great talk again.
Thank you. Thank you.