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Tag: Arthritis

  • Oh, CR*P! Using point-of-care C-reactive protein tests

    Oh, CR*P! Using point-of-care C-reactive protein tests

    Few companies now offer affordable point-of-care tests for canine C-reactive protein (CRP). As we did when we recently received our new box of CRP slides, you might soon be asking the question: what do we even do with this stuff?

    Here’s what we’ve learnt…

    CRP is one of the acute phase proteins produced by the liver in response to inflammation. Healthy patients have very low levels of CRP, but a systemic inflammatory condition will cause an increase in CRP within four to six hours. Conversely, increased levels will decrease rapidly on resolution of inflammation. This provides an almost real time measure of inflammation that is more responsive and reliable than the white blood cell response.

    In other words, CRP can indicate the presence of inflammation before the patient’s white blood cell count gives any clues, or before it becomes pyrexic – and, unlike the white blood cell count, stress and steroids do not affect CRP levels.

    Uses

    So, how do we use it?

    • I love it for early pickups of problems in those grey area cases: the dog seems okay on clinical examination, but something about it bothers me. A normal or mildly increased CRP test will make me sleep more easy, while a surprise high reading will prompt me to admit for full diagnostics, or at least get the patient in for a follow-up CRP the next day. Conversely, a localised problem – such as an abscess – combined with a normal CRP test might mean you can hold off on antibiotics and just recheck CRP in 24 hours.
    • It’s great for monitoring response to treatment. If my plan is working then I’d expect CRP to show a significant decrease by day two or three. If it’s not dipping by then, I need to reassess my treatment plan. Do I need to change antibiotics? Scan it again? Maybe we need to consider surgery? It can also be a good prognosticator. Research has shown failure of CRP to decrease significantly (around a 3× decrease) by around day three is generally bad news for patients with inflammatory conditions such as pancreatitis and immune-mediated haemolytic anaemia.
    • We are starting to play with it for post-surgical monitoring. Any surgery will cause inflammation with an increase in CRP levels, but in an uncomplicated postoperative period, you should expect levels to start decreasing by day three to five. A base line CRP 24 hours after surgery with a recheck on day three should pick up early signs of postoperative problems such as infection, and prompt investigation or intervention.
    • A potentially nifty use for it that we haven’t yet had the opportunity to use is in differentiating inflammatory lamenesses (arthritis, infection, injury) from a neurological causes – that is, is it arthritis or a nerve problem?

    Limitations

    • Remember, it’s very sensitive, so will increase with almost any inflammation. A mild upper respiratory infection or a bad gingivitis will likely induce some changes, so it’s important not to over-interpret (keep in mind that the magnitude of the increase in CRP does generally correspond with the severity of the inflammatory response). A pancreatitis case where the CRP fails to drop does not always mean death is looming – you may have just missed the concurrent skin disease. Always interpret CRP values in concert with your clinical examination.
    • Be aware that pregnancy and intense exercise can increase CRP values.
    • Not all serious conditions have an inflammatory component. CRP will be unchanged in most veterinary cases of heart disease; in common hormonal disease, such as adrenal disease and uncomplicated diabetes; urinary obstructions; many localised cancers; epilepsy and many others. Don’t presume that just because CRP is normal, everything is fine.
    • No similar test exists for cats.

    Sit up and say…

    My favourite way to explain how to use this test is by using its highly appropriate acronym – any unexpected increase should make you sit up and say: “Oh CR*P! What am I missing?”

  • The wrong end of the telephone

    The wrong end of the telephone

    Pepsi3
    Jordan and Pepsi in happier times.

    A couple of weeks ago, I received the phone call I’ve been dreading since moving away to university.

    My horse had had an accident in the field, hurt her leg, and the vet was on the way. That’s all the information I received until the next call, with the vet on the other end.

    “Communication within the tarsal joint… leg swinging… don’t think the long bone is actually fractured but significant damage to tendons at the back… rapid respiratory rate.”

    As soon as I knew which way the conversation was going, I barely heard the rest.

    My girl, who I’d had for 10 years. My girl, who’d been passed from pillar to post before we gave her the stable long-term home she’d never had. My girl, who had taught me to ride by being an infuriatingly awkward cow at the best of times.

    My girl, who, when in the mood, was unbeatable and with whom I achieved a national title. My girl, who was the only one I trusted not to hurt me after my four-week stint in hospital when another horse landed on me. My 21-year-old girl, who’d been steadily getting stiffer from arthritis over the last few months. My girl, who, when I last rode about a week before this incident, was 10 times better than she’d been in a long time.

    pepsi2
    “My girl, who, when in the mood, was unbeatable and with whom I achieved a national title.”

    My girl was about to be shot…

    All the vet language stopped making sense, the clinician rationale went out the window. I just needed to know one thing, vet to vet student: is this fair? Could it wait five hours for me to tear down the M6 to say a final goodbye or would even that be an unnecessary amount of suffering?

    I think I already knew the answer.

    I felt utterly helpless and beyond reason for the following days, but as the shock wore off I was able to consider things retrospectively.

    Having spoken to the family that were with her at the time, I’ve gathered a bit more information and been able to convince myself it was the right and only decision.

    pepsi1
    RIP Pepsi.

    I’ve seen many animals have to be euthanised, for varying reasons. Some cases were more upsetting than others, but, for the most part, I’ve been able to detach myself from it – always telling myself it was for the best, in the animals’ interest for welfare reasons, and that there were no alternatives.

    They say clients will only take in a small proportion of bad news. Now I know what that means. All the vet talk just went straight over my head, and the only thing I really got was that there was only one way it was going. This has outlined the importance of clear and concise communication when delivering bad news to my own clients in the future.

    In communication skills classes, we’re told to encourage owners to bring someone with them who can write down key points and ensure they understand before proceeding. Now I appreciate the value of this so much more, having been the receiver instead of the bearer of bad news.

    While the pain is still raw, I think I can take something from this to help me be more empathetic and ensure I communicate effectively in the future.

    You can steal all the ham sandwiches you want now, Pepsi.

     

    pepsi4

  • Don’t forget acupuncture as a possible therapy

    Veterinary acupunture
    Image ©iStock.com/Susan Chiang

    I have found acupuncture really helps some of my chronically painful canine patients, usually due to arthritis, but also in some cases of back pain too.

    I have to say I usually use this as an adjunctive, rather than sole therapy, but often with good effect.

    Evidence certainly exists in human medicine to suggest this helps (Witt et al, 2005). However, for some reason I have a mental blank and sometimes forget this as a possible therapy where dogs are not fully, or completely, responding to more traditional medications – and I would suggest this is well worth a go.

    We are lucky enough to have a veterinary surgeon in our area who practices acupuncture and we are very grateful for his efforts.

    References
    Witt C, Brinkhaus B, Jena S et al (2005). Acupuncture in patients with osteoarthritis of the knee: a randomised trial, Lancet 366:136–143.