What is this?

Ok, I have a few pictures to show you. I will tell you this about it. The pictures are of the skin of a 4 year old Golden Retriever. He has a brain condition which required him to be put on long term phenobarbital and prednisone. The neurologic issues resolved with medication. Approximately 6 months after the medication was started, this happened:

The lesions are hard and crusted. The hair that is attached easily pulls off. There is some itching/discomfort associated with it but overall the dog is doing well - happy, eating, etc.

This WAS biopsied and so we do have a definite diagnoses.

Any thoughts or further questions?

A Few Lessons in This One

I realize what *I* commonly see, may be "weird" or "rare" or frankly, SHOCKING, to most of you.

One of the most common things I see is dogs or cats with late stage cancer that were showing no signs until the day or two before they came into my office. Sometimes, thankfully rarely, people ignore signs like weight loss, lethargy, vomiting and inappetence and let it go for months. Though THAT does happen. It saddens me because there are times we can help those pets.  

We have to remember our pets often deal with pain and disease better than we do. It's truly part of their "predator" nature to hide illness. Or else they could become "prey."  It's truly amazing what processes animals are going through and yet they continue to eat and greet us as happily as ever.


But remember, we too can have things going on that no doctor in the world could see and often we have tests that are negative or normal while severe disease rages on inside. 

The other day an older German Shepherd came in (7 years) for being lethargic and a distended abdomen. The owner noticed this. Now, because I know what I know and do what I do, one of the top things that came to MY mind - breed, age, signs - bleeding splenic tumor. This is very common in our GS, Goldens and Rotties as they get older. I've seen dogs come in fine and they went out for  a run and collapsed because the bleed was fast. I've seen dogs I've examined and palpated come back in 3 months later with a mass that was NOT there before. 

This is how cancer works - in us and them.

So this dog needed some tests to confirm this and also to see how good of a surgical candidate we were - always possible for other diseases to be going on AT the same time. Dogs, cats and people can live just fine without a spleen.

Other questions:
1. Was there any evidence of spread (namely to the chest)?
2. How anemic was this dog (do we need a blood transfusion)?

Dogs can have benign or malignant splenic tumors. The only way to know is to remove the spleen and send tissue to the pathologist. The most common cancer is hemangiosarcoma.

The dog was moderately anemic (not in need of a transfusion) and the x-ray confirmed a bleeding mass with loss of detail on the image in the area of the spleen. An ultrasound was done to check for any spread to the liver (other types of cancer would do that - mast cell, lymphoma).   

We do these things to see what kind of surgical candidate the dog is AND to help the owner make the most educated decision possible.  This is a serious surgery and they can die from secondary cardiac arrhythmias, blood clots, etc. 

So, we take the dog to surgery and this is what we see:

What you see is a big mass on top of the spleen, a smaller one off the front edge and then hundreds of little red/brown masses all over the omentum, and I mean, ALL over. There are more than what is even in this picture. 

This was not going to be visible on any other test other than..bingo: an exploratory surgery. Sometimes the best test is using your eyeballs! 

There was evidence that some of these "little" spleens had started to grow and bleed out. There was NO way this was resectable. The owner was notified and chose to humanely let the dog go while she was sleeping. No other choice really. The kindest but hardest one. 

We thought we could fix this one. We couldn't. We didn't know until we got in there. This is what happens sometimes. 

Belated Answer

This is another picture of the same cat's feet a month or two later.  I'm not sure if you can truly appreciate how crusted and thickened the toes/feet are. This was present on all four feet. I cannot imagine this would be very comfortable for kitty. I didn't have a second picture of the face/ears but suffice it to say it was much worse and the cat was now clinically not doing well. She was losing weight and not very active. This, despite steroids.

So what is this?

Well, ONLY a biopsy of the affected tissues would tell us but the most likely two differentials, given the lack of response to typical skin medications, the severity of the disease and the progression to affect overall health are:

1. Autoimmune disease

2. Cancer (neoplasia)

We do see cancers that present ONLY as generalized skin disease. It's not as common as other types of cancers in pets. Cutaneous lymphoma is a "more common" one seen in dogs.  

Also, other types of cancer can result in skin disease from the suppression of normal immune system function.

Autoimmune diseases are a group of conditions where the body attacks itself. In this case, the immune system is OVER doing it's job!  These are often treated with high (or immunosuppressive) doses of steroids. This cat didn't respond AT ALL to the steroids. However, there are cases where other, more potent medications are required. These often carry with them more serious side effects, so we would never want to just give them without a confirmed diagnosis.

The owner had declined biopsy from the beginning due to cost and so we will never know. The cat was euthanized the day I took this picture due to her poor and declining quality of life.  She was 5-6 years of age. 

Another quiz!

This 5-6 yr old spayed domestic short hair kitty presented to me as a sort of 3rd opinion a few months ago.

She had this skin condition (also on her feet) that had been going on for a little bit. The other vets had tried the usual antibiotics and a steroid injection to no avail.

She lived inside and was otherwise "healthy."

Any guesses on what this COULD be?

A Pre Holiday Warning

This time of year brings a spike in certain types of cases, many of which are preventable. One of the biggest illnesses we see is pancreatitis.

Here  is a link to a quick Q&A with a vet on this condition.

Please know that even a "little" of something can make your pet very sick, even IF they have had it in the past.

I recall an 11 yr old Golden Retriever that came in after Thanksgiving one year and had to be hospitalized for days for getting a small piece of turkey. He had some in past years. He almost didn't make it. Once the pancreas starts releasing digestive enzymes into the surrounding tissues - it's not only painful but very possibly fatal. This is no joke.

The Answer

Yes this dog had a urethra FULL of stones - from where it exits the pelvic canal to just before the "os penis" - which is, yes, a small bone IN the penis of male dogs and a great area for stones to lodge (the urethra cannot expand as it passes through this U shaped little bone.)

What was even more amazing was this dog somehow could still pee and had a small bladder. Of course he was very uncomfortable.

In cases like this we try to flush the stones back into the bladder where it's much easier to extract them. This is unlikely in a case of this severity and indeed, the surgeon had to open the urethra up to get some of them out. This is tough because it's already a small tube and can very easily stricture or get much narrower if sutured so we often leave it open to heal with a little time. They do quite well. In the meantime, the dog urinates out of the little hole there.  

This dog is doing very well post - op!

PS. For the person with the answer of a constipation issue : that never "presented" itself and was never an issue after surgery. However, your assessment on the radiograph was not wrong. 

Another Quiz

Can anyone tell me what's wrong with this dog? And what can we do to help him?

Your Cranky Old Cat

Of course it's always good to get scientific evidence but this makes sense and seems logical. All of us, no matter the species, age as do our brain cells.  


We already recognize "Cognitive Dysfunction" in dogs - aka "doggy Alzheimers." So I am not surprised we find it in our felines too.


CHECK THIS OUT

Answers

Excuse me if I"m a little tipsy..a bit sugared out from my wonderful experience as a judge in the Pocono Cupcake Wars. Oh the things one must endure. But hey, it was a dream come true.

I'll throw in a nice happy, non sick or disgusting pet photo from today!

Yesterday, Sue correctly guessed it was Feline Leukemia and FIV (or "kitty AIDS") Snap test that shows a Leukemia positive.

The top blue dot (think 12 o'clock) should always be present. It's the control dot and means the test ran correctly. There should be no other dots. One at 3 o'clock is FELV, one at 9 o'clock is FIV. And yes, you can have both.

This test takes just 10 mins and 0.1 mls (a VERY small amount) of blood to run in your veterinarian's office. It's recommended for any NEW cat - kitten or adult and for sick cats, even ones that were previously tested. 

This cat was not well and was a feral cat in for a neuter and release type situation. Shelters are already FULL to overflowing and there are few homes or places that will take in a FELV + cat. This disease is spread by casual contact between cats. There is an effective vaccine against it. However, many people have multiple cats and may not want to vaccinate their whole "herd" to take a positive cat in (unless they have cats that go out too - in which case they REALLY should be vaccinated anyhow.)  In addition, feral or unfriendly cats, are not the easiest to adopt. There are already (very sadly) a ton of sweet healthy kittens and cats that need homes.

A Quick Test

What is this? Does anyone know? And what does it tell us?

WHAT Did That Pet Eat?

Each year, a publication called Veterinary Practice News, puts out the word, looking for the most unique things radiographed inside our pets.

Even us vets find this stuff amazing and fascinating. You never know what an animal will eat (and it's not just dogs and cats - reptiles and other small pets are included too.) Often times, the owner doesn't even know!

Check it Out!!

Cuterebra

It's that time of year when we see certain conditions in pets.

One of the big ones right now is fleas. We are seeing a lot of pets with fleas - even "indoor" kitties. There are great products out there folks. Ask your vet what they recommend. Remember, flea collars AND fleas are often found on the pet simultaneously - i.e., they are a waste of money.

But one of MY personal favorite things is Cuterebra.

From the Merck Veterinary Manual Online:

This opportunistic, parasitic infestation of dogs, cats, and ferrets is caused by the rodent or rabbit botfly, Cuterebra spp (order Diptera, family Cuterebridae). Flies are usually host- and site-specific relative to their life cycle. However, rabbit Cuterebra are less host-specific and are usually associated with dog and cat infestations. Rarely, cats and dogs may be infested with Hypoderma spp or Dermatobia hominis . Ferrets housed outside may be infested by Hypoderma or Cuterebra spp .


Now typically we see these in cats and rabbits. But the other day a an older dog came in for a lump.Of course since it was older, the most common thing would be...a lump. Whether it was of concern or not had yet to be determined. My technician told me it was on the front leg (inner side of area by carpus or wrist area). He said it was soft. So, I'm thinking its possibly a lipoma (benign fatty mass).

I get in the room and see this:

One look and I knew..it was something I love..and an easy fix for the dog. The thing in the center is the larva.  So all we had to was pull it out, intact and flush the wound. Send the dog home on antibiotics and it would be fine! No need for surgery -which is good - she was 16yrs old and a diabetic!

Where did she get this? She plays near and in a pond. There were a lot of flies in the area according to her owner. 

Don't worry. I rarely see this in dogs or even cats. If it happens, it's easily dealt with. In fact, if you don't remove it, it will fall out in a month, pupate and become a fly. A wound with a very regular circular edge would remain leaving you wondering what happened. Sometimes people assume the pet got shot. 

Unique Kitty Face

This is a neat story/picture about a cat with unique facial markings.

And I realize I've been a bit "absent" of late. Oh there's always interesting stuff going on in veterinary medicine. Trust me. If it's one thing my profession is NOT, it's boring. The variety of people and pets AND medical/surgical conditions make no two days alike. That doesn't mean we don't see things over and over - I've had too many "ear infection" days or urinary problem days. Yeah, they seem to come like that too - in groups. Weird. Cannot explain it. After 15 years, I just accept that's what happens. 

Enjoy!

http://blog.mysanantonio.com/animals/2012/08/cat-looks-like-she-has-two-faces/

Top Weirdest Cat Names

Before I post a link to a cute article, I just want to ask my readers a question - more rhetorical than anything else...

How many of you would call your veterinarian or doctor, get an appointment on the SAME day for a problem and then simply NOT show up? Not call, EVER?

Still DO NOT get this behavior. So rude. So wrong. Well, that's why I like and respect places that FIRE clients that do that. Especially the ones that aren't even clients yet. 

Remember, clients, like dogs, can be trained or they can TRAIN you.  

Ok, now on to fun: Top 10 Weirdest Cat Names

Some People Just Don't Know

Client education is STILL the number one preventative health care tool - in MY opinion.  

It can save lives - and dollars.

I think sometimes we - myself included - take for granted what pet owners know.

One example:

If you have certain breeds - like Dachsunds, Shih Tzu's, Bassets, to name a few - they are prone to intervertebral disc disease - or a disc herniation resulting in partial paresis (weakness in one leg) to complete paralysis (to the point of having no bladder function and no bowel control).

The thing with nerves is, once they "die" off you really can't get them back - ESPECIALLY the longer they are hurt. Deep pain is the last thing to "go." We test that by pinching the toes with a hemostat - very hard. When they dog doesn't exhibit any pain (withdrawal is a different reflex and can remain intact in the WORST of cases)

If you have a dog - ANY dog - that goes down, don't wait. If it's a weekend, YES, DO take it into the emergency hospital. This is a case where time does matter. A lot. It could mean the difference between having a dog that can walk to one that is paralyzed for life...one that you have to manually express his or her bladder every day. In some cases you may be put in the position of choosing euthanasia because of this.

Just be prepared that some of these dogs will absolutely need an MRI and surgery. And this will cost anywhere from $4000-6000. This is a major procedure performed by board certified veterinary surgeons. 

It Didn't Have To Be....

...but it was and it was too late. I wish I could reach EVERYONE and make them understand that. 


1. Trying to save money by NOT doing preventative care, not only generally costs you MORE money in the future but also can cost your pets years of life, of quality life and may even result in very premature death.


2. If you don't feel you can care for an animal, financially, it's ok to give that animal up. And then NOT get another one. 


3. If an animal is suffering, it's not only OK but part of your responsibility as a pet owner to let them go humanely - please.


4. The longer a problem is permitted to continue - be it behavioral or medical - the more expensive it'll be to ATTEMPT to fix and often the odds of fixing go down. In some cases, death is the result. 


There are a lot of things we cannot prevent or cure, a lot of diseases we are still learning about how to diagnose and treat but there are a good number of diseases we can either prevent or intervene early on to slow the progression of signs and improve quality of life. 


If you are a pet owner - don't miss out on these things:
-routine exams - the physical exam of your pet and history we get from you (so be honest and as accurate as possible) are the most important things
-vaccines for your pet's lifestyle - yes all those diseases we vaccinate for are still out there and yes, I personally have seen them
-prevention of external (flea/tick) and internal (heart worm, intestinal worms) parasites
-spaying and neutering - reducing cancers, infections and preventing unNEEDED pregnancies and behavior problems


The pet I refer to above will die from not uncommon secondary organ failure preventable with a vaccine and some great topical products. Yep. 


A veterinarian I respect and know said to me: "Vets don't kill pets, owners do."  In other words, we can recommend what is best for your pet based on your lifestyle, their exposure and our years of training and experience. Ultimately, though I may be upset about it and disagree with it, you are the one to pick and choose what you do for your pet, even if hurts the pet.

Lion Melanoma

So the kitten did NOT have rabies. Some of the other possible causes of her neurologic behavior could be: infection with other viral or bacterial agents, inflammation from trauma, etc and parasitic infection.  


Here's a cool story about the first known case of a cutaneous melanoma in a lion and the treatment they are pursuing. There's a great short video clip in the link too!


http://www.knoxnews.com/news/2012/jul/08/ut-uses-targeted-radiation-to-tackle-lions-tumor/

Rabies Scare and a Heartworm Reminder

The other day a good Samaritan brought a stray kitten in to the hospital. She was weak, had a few open wounds (one with maggots) and obvious intestinal roundworms. Anytime you have a stray and most especially, anytime that stray has wounds of unknown origin, you must consider the possibility that this animal could become rabid and therefore take appropriate precautions.  Only vaccinated individuals in the practice should touch this animal and even those should be gloved. Does this always happen? Of course not and for a variety of reasons.


So this kitten was admitted for treatment of her wounds, worms and some general supportive care as well as observation.   


The wounds were cleaned up, she was given a dose of Revolution and subcutaneous fluids and put on oral antibiotics. She was given food and water and nice bed to rest in.


The next morning, she was found to be profoundly neurologic in her behavior/ambulation. It would come and go.  She was also drooling.  


Since this was the case and multiple unvaccinated people had been exposed, the decision was made to euthanize her and have her brain tissue tested. This is a serious public health issue.


Today we found out she was negative, but clearly she had some serious neurologic issue and would likely have no survived anyhow. Now we know that several people do not need to get vaccinated or boostered.


Rabies is OUT there and most definitely is in Pennsylvania. Again, vaccines are not very expensive. It's the MINIMUM to get for any pet - barn cats and cats you "just feed" out back are the primary domestic sources of rabies. Get them vaccinated. You are protecting human health as well as the horses, sheep, cows, dogs, etc that live near them.


-----


Today I had a dog that was heart worm positive. He lives in the Poconos. He never travelled out of them. He was only 1 1 1/2 yrs old and was not on prevention. Heartworm is OUT there and in PA too! Keep your dogs on prevention...year round. 

The Root of the Problem

Most dogs lose their baby teeth and have all their adult teeth by the age of 6-7 months. A few may hang on for a bit but generally with normally chewing and teething, they fall out. 


In the smaller breed dogs, it is very common for them to remain and we call these retained deciduous teeth (baby teeth). These pose a problem because they line up right against their adult counterpart and create a great area for tartar, food and in some cases even hair, to accumulate. They can also prevent the adult tooth from coming in to a normal position.


This is why when a dog in getting spayed or neutered, one of the things we check for is any of these baby teeth. This is the time to remove them.  They are not always easy and the picture below explains why:

As you can see these are VERY long looking teeth but the part YOU would see is just the tip toward the top and down to where there is a fine line (seen better on the tooth to the right). The REST of that is solidly IN the gum and in it's socket. It takes a bit of work to get this out and if it breaks we often have to dig the root fragment out.  The hardest ones are the canine teeth and generally these are the most commonly retained. 


In the Yorkies, Maltese, Shih Tzu's etc it's also not uncommon to find retained incisors and molars also. These generally come out with more ease as the roots are not that deep.


The dog's do great post op - heck they do great post ovariohysterectomy - in both cases, they seem to fair better than us in these things - and it's a great preventative measure for later dental disease, which these dogs are already prone to getting.

Pixie-Bobs

Pixie-Bobs are a relatively recent breed, developed in the state of Washington and said to have in their lineage, naturally occurring Bobcat/domestic cat matings. However, DNA has shown these cats are purely domestic. 

The other "draw" to these cats is that they are said to get quite a bit larger than a DSH (domestic short hair). However, most do grow to about 11 lbs. Unlike other breeds, they continue to grow until 4 years of age. They don't have any major health problems. 

The are intelligent, playful and social and are said to be vocal with chirps and chatters versus many "meows."  

The pictures above showcase 2 kittens brought in to me recently for their first check up.  One was polydactyl (the one behind held up - you can see his cute mittens!).  

If you want one though, just be prepared as they can cost you >$1200.  

More BIG Cat Surgery

You know me: I can never get enough of these stories! It makes me long for my zoo days...


Joint Surgery for Two Houston Zoo "Kitties"

A "Small" Eye Problem

Eye problems - notably infections and trauma - are common in pets. Kittens can be plagued with chronic eye issues like herpes virus infections that cause permanent damage to the eye - ranging from mild corneal scarring to enough damage to require removal of the entire eyeball.


This procedure is called an enucleation. It's also done in large animals for similar reasons.


We don't remove the eye simply because it's non-visual. The decision to remove the eye is generally based on the comfort of the patient. A blind but bulging eye (often from uncontrolled or untreated glaucoma - increased INTRAocular pressure, a tumor behind or involving the eye, etc) that is clearly causing the animal pain must be removed. Signs can be subtle but include not eating well, lethargy to actually pawing at or rubbing the eye, further traumatizing it. We also remove eyes that aren't fully developed (a condition called agenesis of the eye) or that were previously ruptured and shrunk. These eyes tend to be chronic accumulators of debris and ocular discharge and also cause discomfort. 


The case below is from a kitten that very obviously need the eye removed. The initiating cause is unknown here as this was a stray kitten found with an already bad eye - certainly infection and trauma are the top two likely causes.

Before surgery

You can see how far out this goes - some of it is scab w/pus underneath but it created an issue when he'd turn and "bump" it

Post op :) 

Hope for a Dog With a Brain Tumor

This cool story involves my alma mater - Purdue. It also highlights how what we do in veterinary medicine could impact YOUR health one day!




Novel treatment for Canine Glioma

Pretty Pets

These are two beautiful pets I got to see this week:

This is a beautiful  1 yr old Abyssinian named Louie.

This is a husky pup named Bella. 

This is what most people think we vets do all day - pet cute puppies and kitties. Sometimes it is PART of the day!

Business Advice from A Dog

This is a great short article on how anyone starting a business can take a few tips from our canine companions!

Snow Leopard Surgery

I came across an article that my mom had sent me last year about snow leopard babies having eye surgery at the Philly Zoo.


I thought it was a neat story and wanted to share it with you and was happy to find it on line:  Snow Leopard Cubs Need Surgery for Coloboma

CPR in Pets

Evidence based guidelines released

Breast Tumors in Dogs

Mammary or breast masses in dogs are a fairly common finding in our older patients (> 7 years for most breeds). 


On average, approximately 50% are benign and 50% are malignant, meaning they have the chance to recur, spread to other glands and/or spread (metastasize) to other areas of the body. This is most often the lungs.


If they are isolated masses, we can do a lumpectomy and just remove THAT mass. If there are multiple masses, we may remove one or both "chains" -so all the glands on that side. This is obviously more invasive and painful. 


In addition, if your dog is not spayed at the time of this surgery, we will spay her. Mammary masses develop because of hormonal influences. This is why spaying BEFORE the first heat and even to a large degree after the first but BEFORE the second, reduces mammary mass incidence by nearly 99%!


The pictures below show the mass, which was located in the left inguinal area and involved the very last mammary gland. It was a firm but not deeply attached mass that still had a very good amount of vascular involvement (a lot of blood vessels needed to be tied off) and we place a drain post op to help with fluid and blood that often oozes post op for a few days.

The following pictures are not for the squeamish so be fore-warned:

This shows one of the cystic ovaries - both had large cysts on them!

The mass was filled with a very dark slightly thick fluid in a few "chambers"

I will post the pathology report on this mass once we get it back.

This dog was from a cruelty case and was taken in by the foster family to have a forever home. She had pneumonia and was severely underweight when she was brought to us late last year and made a full recovery. 

Let's hope she keeps going strong! 


June 23: This tumor turned out to be a malignant (bad) one: a mammary adenocarcinoma. The dog is healing well. The pathology report indicates complete excision with clear margins and no evidence of cancer cells into the surrounding vessels. However, as with any malignancy, there can be spread before we "see" it - so this dog will need periodic follow up chest X-rays and a close monitoring of her entire mammary chain.

Update on Story

I posted a story about a rescued panther kitten found roadside in Florida on May 12th.


The update is not entirely surprising. Even though I always say I don't count cats out ever...very young kittens and especially wild kittens, are a bit more fragile.  

Change of Cats

Well, I was hoping to have snow leopard baby pictures to show you but today's windy conditions prevented my expedition via Chris Airlines. Maybe next weekend? We'll see...


So instead, here's different cute kitty babies: Cheetah C-section and a lot of hard work save 2 of 4 cubs.

Kinda Looks Like a Cockapoo to Me

Granted probably an outrageously expensive one - and even the "poos" are overpriced mutts.


Sorry. They are cute. Yes. They are not a breed.


Mixing two breeds together and making up some name doesn't constitute a breed. Even if you add the word "designer."


What is a breed? It's a homogenous (same) group of animals with certain distinguishing characteristics that are genetically linked and can be reliably propagated. You take two x's and every time you get the same thing. You don't mate two Cocker Spaniels and some of the pups turn out to be Labradors! 


Yes, there is variation in a breed. Example: I say Golden Retreiver. Hopefully you can picture one. But, you may picture a fluffy pale yellow and your friend may picture a more smooth coated red dog but I am sure you have the general head, body type and sizes on target.  You don't picture a Standard Poodle do you? No, I say that, and you see a whole different set of dogs. But genetically they are distinct.


You mix them and you get an expensive mu...I mean..Goldendoodle. Where's the ketchup?


No really, they are all cute. They are. So are the thousands of shelter dogs that die every day or sit and sit and sit because someone had to breed cute sweet Fluffernutter.


Breeding is great - let's make a better, more beautiful, more SOUND (physically fit and healthy), and workable Golden. 


Ok, so what got me on this topic. This article about a new breed that some want to bring over from Europe. That's fine. 


This from the article:


...looks like any number of designer "doodle" dogs—a mix of a poodle and something else. The latter is a slam that gets Barbet owners like Doris Newkirk, a professor and retired psychologist in Greenbank, Wash., absolutely growling.




Um..well, then get into a breed that doesn't honey. Period.

River Rocks

...or bladder stones...

This morning, I took these out of this:

Notice this bladder has a red appearance and an "angrier" portion at the tip.


This was from a small dog that had 5 river rock like stones and about 15 smaller ones. The bladder wall was very thick. These factors left little room for urine, making the dog feel the urge to urinate all the time.  


We will send the stones out for a mineral analysis to determine what they are composed of and help us change the diet to hopefully (not a GUARANTEE) prevent others from forming. There are some breeds more predisposed to stones and this one is among the top: the Bichon Frise.


This sweet girl only starting showing signs of bloody urine despite the fact that it probably took many months to form these stones.  The owner feels guilty but should NOT. There is no way to "know" unless our pets let us know. Sometimes a physical exam can reveal these but not always. 


She's recovering quite well!