Diagnosed 6/21/19 – Hanging Tough!!! – Second Chance AIHA Dogs

Allan

Guest

Hi. My girl Zoe is a 4-year-old Great Pyrenees mix that I rescued and have had since she was 12 weeks old . She was recently diagnosed with IMHA on 6/21/19…..6 days after she’d received her 3-year rabies, bordatella, and annual booster vaccinations all at once, which my vet agreed was likely the cause of the onset of IMHA. After her condition continued to deteriorate over the next 2 days after diagnosis, we immediately took her to Blue Pearl Emergency hospital in Sandy Springs, Ga. Her PCV was around 15 when she was admitted, and they immediately began her first blood transfusion. After being there for 6 days, receiving 5 blood transfusions, an IVIG treatment, and still not seeing a positive response, we chose to bring her home on a prayer that the combination of removing her from that stressful environment, getting her back with her family, and hoping the meds she had been on would finally kick in (Prednisone, Mycophenolate, Omeprazole, and Clipodogrel) would all result in a miracle of sorts. The vet was very honest with us about the fact that she would likely not survive, even going so far as to document the possibility of us having to let her go, which we were prepared to do based on our observations of her condition and quality of life over the weekend.
Long story short, I’m beyond happy to report that as of now, our prayers were and continue to be answered. Our girl began eating again less than 24 hours after she was back home, and her PCV checks have (until recently) steadily improved. She got all the way up to 35 over the next couple of weeks, but then dropped back down to 30 and has been holding there for the past 10 days or so. I have a copy of her latest blood report, which also showed mild agglutination as well as a slight drop in her regenerative response. We have learned that dropping back a few points during this process isn’t necessarily uncommon, and to not freak out about it. Needless to say, we are hoping that the improving numbers we were seeing will have resumed on her next check.
Also, she began sneezing about 2 1/2 weeks ago, developed a very red and irritated right eye and showed an elevated WBC count. Although my vet was not able to pinpoint exactly what was wrong for obvious reasons, she was put on a course of Enrofloxacin, which she just finished today. Fyi, I initially suspected that this sneezing might be kennel cough resulting from her weakened immune system being exposed to the inside of my vet’s office during her checks, so now she stays in my truck and they go draw her blood there to eliminate that unnecessary risk of exposure. Her eye has improved and her activity level is good for the most part, all things considered. She’s eating, drinking and peeing (a lot, obviously), and pooing just fine.
Regarding the eating part, she has a history of UTIs and as such, has been on eating Royal Canin’s Urinary S/O formula. She also is on Proin for spay incontinence. Before the IMHA, my vet and I had worked together to resolve her UTI issues, and with the addition of these 2 things, was doing great.
So, I guess my questions are: 1) Does anyone have any thoughts on this slight decline and “pause” in her PCV number? 2) Are there any additional (and obviously safe) supplements or dietary changes/additions that could help as she continues this fight? She really needs to stay on the Royal Canin to prevent any precursors to another UTI from forming, so I’m not willing to take her off that. However, I’d be willing to add whatever may help as long as the Royal Canin remains the base. Oh, and she is getting 1/4 cup of cooked beef liver once daily with her evening meal.
Also, she was previously on Revolution for her flea and heartworm management, but those are obviously now not an option. I’ve explored a Seresto collar for fleas and ticks, and essential oil collars/sprays for heartworm prevention (to keep mosquitos from biting her at all). Although mostly an inside dog, she does go outside to potty and play when healthy, so I want to make sure she’s covered to that end. Any thoughts on viable options for addressing the flea, tick and heartworm issues going forward?
That pretty much covers all of the things that have resulted in the indescribable emotional rollercoaster that we, like most all of you, have endured over the past 1 1/2 months. It has been beyond difficult. We really want to get our girl through this, so any and all advice and/or suggestions would be most welcome. Thank you all in advance for anything you may be able to offer!

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Patrice

Keymaster

Alan,
My apologies for being MIA. I’ve just read through your comprehensive report. Let me address things in that order.

It is a shame that you did not have access to Dr. Dodds minimum vaccination schedule in June. I do agree that this was an overwhelming number of vaccinations. And is likely -one- of the triggers that caused this onset of IMHA. Dr. Dodds is not anti-vax and she does recommend responsible vaccinations. But she is also clear that once a dog has had their proper puppy series they have developed life long immunity to the diseases they were vaccinated against, except for the legally required rabies. From this point on you will never allow a vet to talk you into “updating or boostering those vaccines!” Print Dr. Dodds Minimal Vaccination Schedule and carry it with you when you visit any vet. Also keep copies of the past vaccines so you can prove that they have been given properly.

Go to this page: https://www.secondchanceaihadogs.com/vaccine-resources
Click on the picture of 2016 Dodds Vaccination Protocol for Dogs
It will open the website page for this protocol. Print it.

What is a titer, that Dr. Dodds recommends? Many years ago, breeders started questioning, “how do we know that all the puppies in the litter actually responded to their vaccinations and developed appropriate immunity?” Titers were developed for human health. The antibody titer is a test that detects the presence and measures the amount of antibodies within the blood. The amount and diversity of antibodies correlates to the strength of the body’s immune response. So breeders began doing titers on their puppies to make sure that the puppy series of vaccinations had indeed taken hold.

Titers are not very well known and somewhat unpopular with some of the veterinary community. It’s complicated by the fact that most don’t really understand what titers mean. The titer measures a moment in time and returns a report that at that point, but body has sufficient antibodies to protect against that disease. If a dog were to be exposed this disease that level would indicate sufficient protection against disease. What it cannot tell us is if the dog’s immune system can respond well enough to the challenge. Dogs that are not well may have an inadequate response to the immune system challenge. Thus Dr. Dodds recommends performing titers every three years. Her non profit Hemopet.org provides these titer tests via mail.

I have never had any of my dogs re-vaccinated except for the mandatory rabies vaccination and I have had the titers done by Dr. Dodds every 3 years. She assures me my dogs all have immunity.

Rabies is the vaccine that is the most dangerous of all of them. Considering the severe response Zoe has had to vaccinations it would be advisable to get an exemption written by your vet. This exemption is to provide your local licensing body so they can exempt Zoe from any rabies vaccinations. However it is not a perfect solution, Zoe would still fall under the rabies law of your state if she bit someone or was in contact with a wild animal, and those repercussions can be pretty drastic for a dog that is “unvaccinated.” So I do caution that you discuss this carefully with your vet. In any case I highly recommend Zoe never gets another vaccine again if at all possible. But it will be your responsibility to make sure she never engages with a human or wild animal so that it won’t trigger the authorities.

Zoe really had a severe reaction, HCT PCV 15% is considered severe anemia. I am not sure I agree with 5 transfusions in 6 days, mainly because transfusions are not benign treatments. Blood types in dogs are different that in humans, they have about 11 different types that complicate transfusions. Funny though, their first transfusion is always free of complications so they can accept any blood type. But from that point on, whatever type that was changes their type so each transfusion must be typed and matched for safety. So even if this process is done properly, a dog can have a transfusion reaction or difficulties with the transfusion if it is not done slowly enough. So each single incident of a transfusion is risky. I would like to know if they were using intravenous Dexamethasone instead of oral prednisone. This would be a far stronger immunosuppressive and might have slowed down the autoimmune attack on the RBC faster, thus reducing the need for so many transfusions. The fact is though, she survived all of this.

The drugs they started with are quite acceptable. The Prednisone performs a rapid and severe depression of the immune system which is really necessary in a serious situation like this.

Mycophenolate or CellCept is a different type of modulator of a single part of the immune system most responsible for the destruction of RBC. These are called T-cell lymphocytes or “killer” t-cells. They are actually a normal part of the immune system function and usually do a great job. They are made in the bone marrow and then are sent to the thymus gland where they are “instructed” what to do. Sometimes they can go rogue and start attacking “self.” This is not limited to dogs but is similar to many human autoimmune diseases. CellCept is not a veterinary drug but is used in human medicine, the same as prednisone. But many drugs are used in this manner, due to the lack of enough money and interest in doing complex trials on dogs. But plenty of vet clinics have experimented with different protocols and have found this drug to be effective, in recent years.

Omeprazole is used to treat symptoms caused by excess stomach acid. Prednisone is particularly erosive in the stomach and combined with stomach acid can lead to severe ulcers in dogs (who usually have a much lower pH acid than humans.) Do not discontinue this until you stop giving prednisone. It is best given about 30 min to 1 hour before meals. Give prednisone in the middle of the meal wrapped in some treat like a little tiny meat and bread sandwich. This will help get it past the esophagus and deliver it to the stomach where the acid pH will be reduced.

Clipodogrel (Plavix) is a critical drug in dogs having these severe hemolytic attacks on the RBC. This releases so much debris from broken RBC into the blood stream that the body has trouble determining whether there should be blood clotting in the vessels or not. This can lead to a clotting cascade that is severe and to a condition called DIC disseminated intravascular coagulation, which is disorganized global clotting. A clinic can sometimes halt this if they have emergency protocols for it, but it is very complex. I am pleased that this was not the case for Zoe and I am positive that this was due to the clinic staff being on their toes.

Your vet was correct that this was a tricky case and that she might not make it. Considering the severity she did survive. We have seen this before here on Second Chance, dogs that had such a great will to live that they survived the very worst.

So at home, after a few weeks she rose to 30% PCV HCT and this is considered mild anemia. The low normal for dogs and humans is around 38-40% except in some sight hounds, whose range is closer to 55%.

So there was some dropping back a few points and that is normal considering the number of transfusions she had. The next thing I need to explain are the reticulocytes.

Reticulocytes are the “baby blood” cells of the bone marrow. These are the gold standard for determining whether a dog or human has regenerative anemia. This is sometimes hard to understand.

Our body is always destroying old RBC at around 120 days of life (never all of them at once) and making new baby blood cells in the bone marrow. We break and make RBC every day of our lives. We measure this process by evaluating the number of reticulocytes. These cells are larger than mature RBC because they still contain the RNA from the early stages, the RNA is seen to be “reticular” material inside the cell and when stained looks purple inside the cell. They usually take about 3-4 days to mature, drop the RNA and become RBC. The number that is an absolute number in terms of normal expectations is 60,000 absolute and about 1% of the total blood elements. That does not vary from humans or dogs. If you have this value, you are properly regenerative and this a normal level. So in most cases, when a human or dog has this value, they are considered normal, the HCT usually reflects this as being up around 45%, give or take.

So the sensor that tells the bone marrow what to do is, believe it or not, the kidneys. They monitor and receive messages from body cells telling them “we are getting enough oxygen to the body cells” or “we are not getting enough O2 to the body cells.” The kidneys will respond to a low O2 message by releasing a hormone Erythropoietin (EPO) to the bone marrow, MAKE MORE RETICULOCYTES NOW.

So if the HCT PCV drops to 15 % the message is loud and clear, make a whole lot of RBC immediately, so many in fact that the bone marrow will push the reticulocytes out early into circulation in response to the needs. This is a critical measurement in the CBC complete blood count. So to respond to the need at say 15% HCT, there might be as many as 500,000 absolute and 3-5% reticulocytes in the blood! If, however the lab only seeing about 40,000 absolute and <1%, the dog is considered non-regenerative.

In a dog like Zoe that loses so many RBC in such a short time the bone marrow is not able to keep up, every time they pump out more into circulation, they are destroyed.

Here is a simple way to understand this. Let’s say you have a glass and you fill it up with water at the tap. It fills and you set it down. Over a few days, evaporation will deplete some of the water, but the glass will remain pretty full. You top off the glass at the tap with small amounts of water. This is the body during normal days.

But lets say there is a hole in the bottom of the glass, you can keep trying to refill the glass but eventually you are unable to do so, the hole is too big. So comparing this to reticuloyctes, sometimes it is an ominous sign that there is massive reticulocytosis and the HCT PCV fails to respond.

So vice versa, if the dog’s PCV HCT begins to rise towards normal, the kidneys are responded to the cells message, “hey the RBCs with all that great hemoglobin are bringing us plenty of O2” and that slows down the reticulocyte values. Some owners get worried when they see this number drop and this is how I help them understand that this is a feedback loop and things are returning to normal.

So going forward with Zoe, you may never see her reach the average HCT PCV she may have been at before in her earlier life. But if you reach, say 36-38% and her reticulocyte values is 60,000 absolute 1%, then you KNOW that the body considers this normal. Do not fixate on the HCT or PCV after this time, monitor the reticulocytes to make sure her body is comfortable wherever she lands in terms of HCT PCV. By the way, in all our dogs on this list, we prefer you test PCV since it is a visual test and rely on that as the true value for Zoe. The HCT is from the automated laser analyzer and may not be quite as accurate.

It is quite possible she did contract “kennel cough” there are some more virulent strains going around in the dog world right now that seem to be more severe. No, the vaccine isn’t very good at protecting a sick dog and it constantly needs to be re-boostered. From now on, plan on never boarding Zoe again in her life. Try to keep her away from many other dogs who may be carrying this or a severe type of dog flu. She is still Zoe, but she needs to be more protected, as many of our dogs needed.

Chance was quite sick and he did recover but yes, he was not quite the same dog coming out of it that he was going in. He had been a therapy dog and I felt I needed to protect him so he made no more visits. He lived another good 3 years and then succumbed to an unrelated heart condition at the good age of 13 for a Giant Schnauzer.

Bingo was also a bit different after coming out of treatment. He was on some form of immune-suppressant the rest of his life because he had a relapse at one point. Do not be alarmed if you also need to do this, keep Zoe on a small dose of prednisone afterwards. Dr. Dodds agrees that these dogs sometimes need this.

I highly recommend you discontinue Proin. I have been using for my 15 year old Giant Schnauzer and while it worked, she did not respond well. She became physically weaker, very tired, fainting (syncope) occasionally and had a severe loss in appetite. Please stop using this right now. I recommend, if you must, using Incurin. This is a hormone and my old girl is doing fantastic on just half the dose. Her appetite is back to normal and she is more active and feeling much better. Older and sick dogs sometimes cannot tolerate medications the same way a younger dog can.

So I have answered your question about the pause in the PCV, if you have more questions, please ask me.

I would say that you need to be very cautious about supplements. There are many products on the market that sound wonderful but these are distributed by people who want to make money. The things that Zoe needs can be met by real food and you can control everything going into her body this way.

So you are on the right track but reconsider the Royal Canin. Let’s try to get her slowly moved over to a homemade diet. Consider the basics of what a dogs needs for proper nutrition. Quality protein, moderate fats and low or no carbohydrates. Dogs are unique in that they can convert fats and proteins into all the blood glucose they need for their body functions.

Think of a canine in the wild, they don’t browse wheat fields. They are more likely to scavenge eggs from nests, eat small prey like bunnies and carrion. In each of these food sources they get the kind of micro nutrition they need. The eggs supply an amazing protein content plus many valuable nutrients. Bunnies intestines contain predigested veggies, some grains and fruits etc plus the organ meats like the liver and heart (which provide the stored nutrients like iron, B12, folic acid, vitamin A.) Plus they provide bones that are small and easily digestible.

So to recreate that in a homemade diet is not too complex. The major difficulty is providing enough calcium to offset the phosphorous in the rest of the diet. You could start with mixing in scrambled egg into her regular food. The liver is a good idea but be cautious to follow this recommendation: 1 ounce of liver per 10 lbs if dog, per week. So my Giants, topping out around 100lbs, get about the equivalent of a little pinky of liver each day. More that than leads to diarrhea.

There are as many home made diets as there are dog owners. You can experiment with different foods, such as cottage cheese, pureed veggies, different meat sources. One super nutrient that Dr. Dodds always recommends are blueberries for dogs. So my dogs get these in their veggie, ground meat, egg mix. They are good antioxidants. My old girl like apples or applesauce. Sometimes I buy a deli chicken and give her some of that. For calcium, if you don’t want to feed a raw diet, you can crush egg shells and put that in the food, about a tsp a day. That will balance out the phosphorous in the meats, veggies and fruit.

I would be cautious with using flea and tick that are ingested. That means they circulate in the blood and you are essentially using your dog’s blood as a carrier to kill ticks and fleas. I have safely used Frontline Top Spot on all my Giants for years, including on Chance when he was sick. It is very effective.

Heartworm can be very dangerous. Dr. Dodds recommended to me Interceptor, which has a different ingredient that most of the other heartworm meds. I have used that for many years as well and I dose it at 45 days not 30. There is no wiggle room on this, be careful, but it is considered an effective window of time.

Really, for true protection, a rethink of lifestyle needs to happen. Do I really need to take my dog into an tick flea mosquito environment every day of the week for exercise? If I do go then I should make sure my dogs are carefully protected and they are toweled down before I leave and checked and bathed when I get home.

I also use permetherin impregnated clothing, dog vests and bandanas that are very effective against ticks and mosquitoes plus other biting insects. I have researched these products carefully and they have been well tested by the US military to be safe to wear. Do not attempt to spray permetherin on your own clothing, buy it impregnated.

I know this is a lot to absorb so please ask me any questions that I have not answered well enough.
my best, Patrice

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Patrice

Keymaster

Allan.
I’m glad this was helpful and I appreciate that you were able to read some it, I made some typing mistakes and in places it was a bit confusing.

It’s so good to hear that she is responding well to the protocol! It’s always a good sign when a dog starts acting like they feel better!

I will never forget the first day Chance felt better. It had been a very long year and it was such a wonderful Christmas present to me. You can read Chance’s story and see a picture of him with the vet when she announced he was healthy again!
https://www.secondchanceaihadogs.com/our-stories/chance

I do want to remind you, as Vally has also said, please go slowly on reduction of the prednisone. We are both experienced with this process. We know how it has not gone well for some owners (and vets) who rushed the decreases.

I have written up my guideline for prednisone reduction, based on the experiences of hundreds of owners over the years. It wasn’t gathered scientifically, but it is based on valid medical science. This is under our AIHA Terms, a glossary that we have built to help owners understand all the complicated language they are exposed to.
https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction

We are always here to help owners make educated decisions, not rely on emotion to make important choices. I have spent 11 years trying to build the site so that there is plenty of information available.

Because AIHA IMHA and bone marrow failure are such complex diseases there are many other conditions that come about because of complications or side effects from drugs. So I have information about those things as well. For instance long term high dose use of prednisone can cause something called Iatrogenic Cushing’s Disease. This means that the body is being flooded by too much cortisol, but not by a tumor but rather a drug. This will cause serious side effects and Cushing’s like symptoms are one of these. The whole body is affected by these high levels of cortisol. There are so many symptoms that almost seem worst than the disease that it is very discouraging to owners. We try to explain that this is temporary and once the prednisone is reduced they will go away, thus the word Iatrogenic. So I have a number of resources that describe the difficulties with prednisone. Find them on this page:
https://www.secondchanceaihadogs.com/dermatology-resources

Yes, I should have also mentioned what Dr. Dodds always references when talking about vaccination protocols. Every location often has their own particular group of diseases that are more prominent and local vets know about these. They are well versed in which dogs are contracting them and what is needed to stay safe in your community. Where you are, a warmer climate, you are have a much higher rate of heart worm than we do in NYS. The CAPC map shows that vividly, see below.

For instance tick diseases vary across the US and even from county to county. A not for profit organization Companion Animal Parasite Council provides an interactive map on their website that turns reported positive results from vets offices into a navigational map that is up to date. You can check your state and even drill down to your county to see how many dogs around you have contracted a particular tick disease or heart worm. For instance here is the US map for heartworm.
https://capcvet.org/maps/#2019/all/heartworm-canine/dog/united-states/
I have also set up a monthly email report for my county and several around me so I am up to date on which diseases are showing up in great numbers where I am. Remember, ticks don’t know about state and county boundarys, if the county next to you is high, it probably is also high in your country. And finally, these are only actual reported diagnosed positive cases. CAPC estimates that these numbers may be much lower than the actual number of cases. So if a county next to you shows a medium risk and yours shows no risk, you can be pretty sure it is more like a high risk in both counties.

So you asked about Leptospirosis, this is not on this map. But never-the-less it is a very serious and sometimes deadly disease which can only cared for by managing symptoms. I have studied this and the associated vaccine carefully. There are multiple strains of this and the vaccine may not necessarily cover the particular strain in your area. The vaccine does not last long and needs to be repeatedly given to be effective. Your vet is the best person to help you with this. Dr. Dodds has significant information about this vaccine and the disease as well. When you go to this page you will find many vaccine resources. She covers Leptospirosis in the Non Core Vaccines link. In this article she will explain exactly what you need to do about making this decision.

Leptospirosis is a disease commonly picked up in muddy wetlands and areas where other animals may urinate (how it is passed.) I have chosen to avoid this vaccine for my dogs but I also insist that neither of us expose dogs to this kind of environment. They aren’t allowed (to the best of our ability) to go into mucky back country wetlands and ponds. It’s not a perfect solution. However this vaccine scares me because it does have a reputation to be a problematic vaccine in terms of negative side effects. Read this information and make your own choice after talking with your vet.
https://www.secondchanceaihadogs.com/vaccine-resources

Remember that the vaccines she was given were not the one and only specific trigger for the IMHA, there are probably several others that contributed. Avoiding vaccines is a good thing to plan on but from now on you should be very alert for changes in her behavior. Relapses do happen but usually owners are paying more attention and catch it fast.
So avoid boarding kennels, exposing to a lot of different dogs (no dog parks), walking in places where a lot of dogs visit, keeping your backyard immaculate, visiting the vet at least once every two months. Monitor gums frequently. Evaluate body tone once a week. On this page is an article Dr. Dodds wrote The Canine Immune System and Disease Resistance. It is really the best I have ever read explaining how the immune system works and what are the multiple triggers that set off a dog’s immune system.
https://www.secondchanceaihadogs.com/canine-disease-resources

Keep posting progress reports. We get very nervous when we suddenly stop hearing from an owner!
My best, Patrice

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Allan Brown

Guest

Hi Patrice,

Apologies in advance for the delayed reply. Just doesn’t seem to be enough hours in a day lately!

Zoe’s PCV this past Friday 8/9 was at 30. Not the slight rise we were hoping for and thinking we would see, but instead a couple of tics back down from the previous week. As important as the numbers are with this condition, we have to remind ourselves that they aren’t everything, and don’t always tell the whole story. As my vet says, “treat the patient, not the numbers,” so we shall continue to do that. While Zoe looks good when she’s up and about, she does lie around a lot otherwise. Since her number is hanging in there, I think this could be due to: 1) the increasingly prevalent and negative effects of continuing to have to stay on steroids/immunosuppressants, 2) decreased activity levels (which may be resulting in a touch of depression), and 3) the oppressive heat we’ve been dealing with here in the southeastern U.S. (She still has a pretty long Pyrenees-type coat, and although we do keep our house quite cool, she still MUCH prefers the cold, which like myself, results in a noticeable improvement in her behavior). It’s really frustrating not knowing *exactly* why she’s not more active around the clock at 30%, but as I said, she’s good when she’s up. Still checking all the boxes and then some at times…..eating, drinking, peeing, pooing, and even barking to let us know when we deviate from our well-set routine/schedule. :-) Within the past week or so, we’ve started taking her on walks around the block about an hour before sundown. Obviously not too long due to her condition as well as the heat, but enough to keep her moving given how weak she’s become and how much muscle mass she’s lost while on all these meds. Her declining physical condition continues to be a difficult thing to witness, and we are more than ready to begin tapering down the prednisone once the numbers show stability and indicate it’s okay to do that. Anyway, she seems to be at her brightest and most alert after that walk up until bedtime, so that tells us that they are doing her some good.

Since our last posts, I’ve spoken to my vet and we’ve arrived at a couple of critical decisions moving forward. First, we’ve opted to go with Heartgard for her heartworm prevention, and will be giving it every 6 weeks (42 days). For fleas and ticks, we’ll be using a Seresto collar. We’d previously used Revolution for all of these (minus the ticks, although the Revolution seemed to take care of those as well), so we’re certainly more comfortable not using a topical solution going forward. Lastly, we’ve decided to stick with the Proin for her incontinence for now. It completely solved that problem for her shortly after beginning it. She’s always tolerated it quite well, so we think it’s better to leave her on what we know works for now rather than introducing something new to her body that can take some dialing in. Plus, given the effects of the prednisone she’s currently on, it really wouldn’t be a fair gauge of the effects of the medicine anyway at this point.

All of this being said, we are most certainly aware that there are still risks associated with our choices. However, we’ve consulted extensively with our veterinary team, which not only consists of 2 very experienced veterinarians at Zoe’s home clinic, but also several highly experienced veterinarians at the emergency clinic (Blue Pearl, arguably the best in the state) that saved her life when this all began. All of the doctors involved at both clinics consult regularly about Zoe’s condition and progress, and make decisions regarding her care and path forward accordingly. We remain highly confident in her team, and are very satisfied with her treatment and the level of her care she’s received and continues to receive thus far.

Sooooo, I guess the gist of this update is that her PCV remains stable (although we’d love to see an uptick on her next check), and we’ve implemented some vital yet somewhat nerve-wracking measures in order to prevent the possibility of her acquiring additional serious life-threatening conditions in the future. In the near term, we remain overall encouraged by what we’re seeing, and pray that our decisions prove to be the correct ones.

As always, additional thoughts are welcome. And of course, thank you!!! More updates to come as things progress and develop here. :-)

Take care and talk soon,
Allan and Zoe

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