VetInfo Digest October 2003
Monthly Note
Lameness in Dogs and Cats:
During the Growth Period
In Middle Age
In Older Pets
Update on VetInfo Services
As many of my clients fled from Hurricane Isabel, they stopped by the practice to ask for sedatives for their dogs, some for the car rides, some for the storm itself, some for motel visits and some for boarding. This was apparently a last minute thought for most of the folks who came in. If you suspect that your dog or cat will need sedatives if you must evacuate your home, even if just for vacationing, it is much better to try the sedative at home once prior to the actual event. There are several reasons for this. Individual dogs and cats react differently to sedatives. Some pets will not show much effect at all while others are nearly knocked out by similar dosages. Knowing how your pet reacts can help your vet tailor the dosage to your pet's needs. If the first sedative doesn't help at all it may be necessary to use a different medication. In some cases, it will be apparent that sedation or tranquilization is just an all around bad idea for a particular pet. It is a lot better to find this out at home rather than 500 miles from home!
Moe and I didn't leave during the hurricane. Instead we sat and watched the Chesapeake Bay rise up over its banks and surround our house. Soon we found ourselves frantically moving our storm supplies and favorite treasures upstairs, as we were pretty certain the first floor was going under water any minute. Fortunately, the tide changed and our house was mostly spared. I don't think that we'll ignore another evacuation order. We pretty much decided that proving that stupidity isn't fatal once is enough. We did not have electricity until the night of September 29th, so this month's issue of the VetInfo Digest was written on a topic that I could do mostly from memory and is a little less organized and edited than usual. Hopefully this is understandable.
Lameness in dogs and cats
Lameness is a fairly frequent complaint from pet owners in our clinic, for both dogs and cats. The causes of lameness vary by species, breed, age and working status of pets. I am not sure that our experiences with lameness match those of all vets, but it is likely that there aren't major differences.
By far the most common cause of lameness in cats in our practice is abscesses from bite wounds. Many of my clients are unaware that their cats are fighting and do not suspect an abscess when their cat is lame. An abscess should be suspected when a cat who has access to the outside, or housemates, seems depressed, won't eat and is lame, especially if there is visible swelling over the affected leg anywhere. Once in a while we even see abscesses in house cats who live alone. I don't know how that happens, but it does. In kittens it is sometimes possible to confuse bacterial infections of the joints with abscesses. Bacterial joint infections are not common in puppies or kittens but they do sometimes occur in patients who have immune system problems due to other illnesses or congenital weaknesses in the immune system.
For dogs osteoarthritis is probably the most common cause of lameness overall, but there are several other causes of lameness that occur frequently enough that arthritis has some competition. We frequently see lameness in dogs from interdigital pyoderma, cruciate ligament injuries, hip dysplasia, elbow dysplasia and even tendonitis. Sorting through the causes of lameness is sometimes a little more difficult in dogs than in cats, simply because there are more possibilities and more variables due to larger numbers of breeds and sizes.
Lameness in the Growth Period
Young dogs tend to have lameness that is related to congenital or growth problems. These include osteochrondritis dissecans, hip dysplasia, elbow dysplasia, hypertrophic osteodystrophy and growth related bone deformities causing angling of the limbs. Young cats may have short term lameness, usually with fever and lasting three or four days, associated with calicivirus infection which is common in kittens. This sometimes occurs after vaccination with calicivirus, part of the combination vaccine often referred to as RCP or FVRCP vaccine on invoices and medical records. This is usually a milder form of the lameness but may last a day or so. Due to the prevalence of bacterial infections from bite wounds in cats, it is important to consider this possibility in young kittens with swelling or lameness, especially when a single joint is affected. In kittens, an infection with l-form bacteria may not show up in any testing procedures, including cultures of the affected joint. A short term course of a tetracycline class antibiotic is reasonable in cats with abscesses or joint swelling that is non-responsive to other therapy.
Osteochrondritis dissecans (OCD) occurs when cartilage in a joint is undermined and a cartilage flap forms, resulting in a painful spot in the joint. This is most common in the shoulder joint but sometimes occurs in other joints, as well. OCD lesions are either extremely uncommon or do not occur in cats. This can be a very painful condition in some dogs but seems more like chronic nagging pain in others. Pain when the affected joint is fully extended or deeply flexed often occurs with OCD. The diagnosis of OCD can usually be made by X-rays but some cases require exploratory surgery or arthroscopic examination to pinpoint the cartilage damage. This is a bigger problem in large breed dogs but does sometimes occur in smaller breeds. . It is unusual to see new OCD lesions in dogs over a year of age. OCD is usually considered to be a condition for which surgery is the best treatment, although some dogs do seem to recover pretty good use of the affected limb without surgery. A good compromise for dogs that are not in really severe pain is probably to wait three to six weeks before having surgery, just to be sure that flap doesn't break free on its own, causing the problem to resolve itself. During this time using pain relief medications is a good idea as it encourages use of the limb which may (this is debatable) enhance the chances of the cartilage flap coming loose, allowing the joint to go ahead and heal on its own. When surgery just isn't possible, for whatever reason, we have found that many dog will eventually become comfortable using the limb but that arthritis may be a long term consequence of not correcting the defect surgically.
Most pet owners are familiar with hip dysplasia but may not realize the importance of early diagnosis and management of puppies with hip dysplasia. In addition, there is good evidence that keeping puppies thin while they are growing can significantly decrease the incidence of hip dysplasia in puppies who are prone to this disease. If there is a problem with hip dysplasia in your puppy's blood line, it is particularly important to make an effort to keep the puppy thin. In this case, it is best if you can see 3 to 5 ribs easily while the puppy is growing. Hip dysplasia is a malformation of the hip joint. It leads to arthritis over time and the arthritis causes most of the clinical symptoms associated with this disease.
Early diagnosis of hip dysplasia allows for several surgical options that are not available after the growth phase is over. A relatively new procedure, juvenile pubic symphysiodesis, in which the growth plate of the pubic region of the pelvis is fused with electrosurgery looks promising for treating hip dysplasia when affected puppies can be identified by 16 weeks of age. While this is very young it is possible to diagnose hip dysplasia at this age in many puppies if it is suspected. Later in the growth phase triple pelvic osteotomy (TPO) can be helpful. This procedure involves carefully breaking the pelvis in several locations and then repositioning the hip socket. The pelvis is then stabilized in the new position. This surgery seems to work well in lessening the severity of hip dysplasia, even to the point that the dog can go into a working situation such as active field trialing.
When hip dysplasia is diagnosed after the growth phase total hip replacement is the best option, if it is financially feasible. When it is not, good pain control medications may provide sufficient relief to keep a dog comfortable for years despite the presence of arthritis as a result of hip dyplasia. In the past it was fairly common to perform a procedure referred to as femoral head ostectomy (FHO) to control chronic pain in dogs with hip dyplasia. This surgery involves removal of the ball portion of the hip which lessens long term pain, even though it does effectively destroy the joint. While there are better options for patients whose owners can afford hip replacement surgery, an FHO may provide some relief for pets when total hip replacements simply isn't an option.
There is some confusion about diagnosing hip dysplasia. The Orthopedic Foundation of America (OFA), which has been the major certifying organization for classifying hip dysplasia in the U.S. won't provide a definite certification that a dog is free from the disorder until it is two years old. They state that hip dysplasia status can change up to that age. This is true, but hip dysplasia rarely, if ever, gets better with growth -- so if a puppy can be shown to have the condition by X-rays earlier, it is better to go ahead and plan for treatment. Don't get confused at this point by the two year age limit for certification -- your puppy isn't going to get an OFA good or excellent rating if it already shows signs of the disorder when it is 4 months old. On the other hand, a puppy might have reasonably good looking hips at this age and still develop detectable hip dysplasia later. A second diagnostic procedure patented under the name "Penn-Hip" is helpful in predicting the future potential for hip dysplasia at early ages and may be used as an initial diagnostic procedure or to help confirm hip dysplasia diagnosed using standard X-rays or other means.
Hip dysplasia does occur in cats. It is unclear how common it is because cats are not affected by the malformation of the hip joint as badly as dogs are. Many cats with hip dyplasia will show no clinical signs at all. Most cats who do develop clinical signs do so late in the cat's life when arthritis formation finally becomes sufficient to cause a decrease in jumping ability or finally becomes painful enough for the cat that obvious signs of lameness occur. We have performed femoral head ostectomy surgery to relieve severe chronic pain in a few cats and this procedure works very well in cats, although the necessity for it is rare.
Small breed dogs are often affected by luxating patellas, or kneecaps that dislocate. We see this problem occasionally in cats, as well. Small breed dogs tend to have some bowing in their legs, which causes the kneecap to try to "cut the corner" and dislocate to inside (medial side) of the knee. This condition can be relatively minor, causing a puppy to "skip" on the rear legs, holding one off the ground for several steps and then going back to normal use without any sign of pain. It can also be quite severe, sometimes to the point that an affected puppy will not be able to comfortably bear weight on the rear legs.
Small breed puppies should be examined for patella luxation during their puppy visits. If they have moderate to severe problems associated with the dislocation of the kneecap early surgical correction can eliminate a great deal of future discomfort. If the problems associated with dislocation of the kneecap are minor, surgery may not be necessary but there may be problems with arthritis later in life. When cats have patellar luxation it is usually best to consider surgical correction. Large breed dogs sometimes have this condition but the dislocation will often be towards the outside of the knee (lateral luxation) in the bigger breeds. It is probably best to consider surgical correction of this problem in big breed dogs even when symptoms seem minor at first.
Small breed dogs also sometimes have aseptic femoral head necrosis, more commonly referred to as Legg-Perthes or Legg-Calve-Perthes disease. This is improper growth of the femoral head, or the ball portion of the hip joint resulting from interruption of the blood supply to this portion of the bone. This can cause acute or chronic lameness affecting one (usually) or both rear legs. Some puppies will successfully recover from this condition even after it can be diagnosed due to changes in the bone on X-rays but it is hard to count on this. Femoral head ostectomy surgery works very well in small breed dogs and is the surgery of choice for this condition. We are pretty sure we have seen this problem in a cat but it is a much more rare condition in cats. I am not sure if it is always necessary but our feline patient required an FHO procedure to regain comfortable use of the limb.
Elbow dysplasia is a relatively new term that is used to cover several growth defects affecting the elbow that used to be considered separate conditions. These are ununited anconeal processes, fragmented medial coronoid processes, osteochrondritis affecting the elbow and malformation of the elbow joint as it develops (incongruity). While these conditions are present at an early age, they are frequently missed or ignored as minor lameness until arthritis develops. When any of the underlying conditions leading to elbow dypslasia are recognized early there are surgical options for repair. It is unclear at this time how well these surgeries work but arthroscopic surgery to repair OCD lesions seems to be helpful. Just like hip dysplasia, weight control in growing puppies can be very important in limiting the damage later in life. Elbow dysplasia is a common cause of early onset arthritis in middle aged large breed dogs. At this age, surgery is not likely to be beneficial. The lack of good surgical options for elbow dysplasia when it surfaces in middle age is disheartening but at least the options for pain control have improved in recent years. While we are not certain that elbow dysplasia as seen in dogs is the underlying cause, we definitely see arthritis affecting the elbow joints pretty frequently in older cats and it seems logical that some form of elbow dysplasia is a contributing factor in at least some of these cats.
Hypertrophic osteodystrophy is joint swelling and pain, usually in the wrist (carpal) joints that affects growing puppies. It is probably most common in Weimaraners but can occur in other breeds. This disorder can occur in Weimaraner puppies after vaccination for canine distemper. It occurs in other fast growing breeds less commonly. The pain associated with this condition can be so severe that euthanasia seems necessary but the pain tends to wax and wane and it is usually better to treat the pain and wait for the problem to resolve. In some puppies there can be long term changes in the conformation of the leg that may require surgical correction but most puppies recover without having to have surgery.
Panosteitis is pain associated with long bone growth that occurs in large breed puppies. German shepherds are probably the breed most likely to be affected by this condition. The pain in this condition also tends to wax and wane over time. Affected puppies are usually in the later growth stages between 6 and 14 months of age. There is no specific treatment for panosteitis but pain relievers are helpful for getting through the periods in which pain is present. This condition will eventually disappear on its own, sometimes in a short period of time and sometimes after several months.
Lameness in Middle Age
In older dogs sudden onset lameness in which a rear leg is carried or used only when the dog is standing still is most commonly caused by rupture of the cranial cruciate ligament (CCL). The cruciate ligament's main job is to prevent the upper leg from sliding forward off the knee when the leg is straight. When it is damaged the leg is unstable and a condition that people sometimes refer to as "trick knee" develops, in which the leg simply can't be counted on to bear weigh properly.
Cruciate ligament injury seems painful when it occurs and for a day or two afterwards but then usually becomes less painful or even non-painful within a couple of days. Many dogs with cruciate ligament injuries will allow manipulation of the knee without any visible sign of pain or discomfort. In fact, the most common history for patients in our practice is a sudden onset lameness that seemed to get a little better after a day or so but then stopped improving or seemed to get worse as time went on. Dogs with cruciate ligament injuries know their leg is unstable and wont' bear weight well. Since they have three legs that work well and can walk and run on these three legs, they often just stop using the affected leg for a while. The general recommendation for CCL injuries is surgical correction but there is little evidence that this has strong long term benefit, although there may be sufficient short term benefits to make surgery acceptable to many pet owners. Cruciate ligament injuries also occur in cats and sometimes cause similar clinical signs. Due their small size cats tend to have more subtle clinical signs, such as refusing to jump onto objects that were no problem to reach prior to the injury.
When chronic front leg lameness is present in a middle aged or older dog a common cause is bicipital tenosynovitis (tendonitis). This condition is most likely in middle aged and older dogs. It does not cause lameness when the dog is simply standing and it may improve a great deal after rest, only to return as the dog exercises. The biggest problem with bicipital tendonitis is that it is very hard to conclusively diagnose. This is not critically important when dogs respond well to treatment with rest and anti-inflammatory medications but it is frustrating when they don't, because surgery should be considered in those cases. Dye contrast X-rays of the shoulder joint are the most accurate diagnostic test for this condition, but it may be best to have a radiologist or orthopedic specialist take these X-rays since this is not a common procedure in most veterinary clinics.
Another cause of sudden onset lameness is a torn toenail. This most commonly happens to the nails of the front feet. It is more common in dogs than cats. When pets have torn toenails that remain partially attached the lameness tends to be very severe, with many pets refusing to use the foot at all. Often the pet will lick or chew on the foot with the torn nail. There may be bleeding from around the nail bed, but this is an inconsistent sign. This condition is resolved quickly be removal of the damaged nail. When the nail is very loose it is often possible to quickly remove the damaged nail without causing the patient much pain. If there is any question about how tightly attached the nail might be, it is probably better to have the remaining nail removed under anesthesia as it can be quite painful to tug on one of these nails if the removal process is unsuccessful. In most cases the nail will grow back normally. Keeping toenails clipped can help prevent this type of injury. Some dogs loose nails after a period of pain or inflammation. This is most common in rottweilers but does occur in other breeds. This type of problem can be very chronic and sometimes causes a lot of pain and other times doesn't. Check your pet's toenails when lameness seems to occur for no reason.
Interdigital pyoderma or pododermatitis is infection in the area between the toes. This can cause severe lameness that often affects more than one foot. Many of our clients have difficulty believing that these infections can produce lameness. Often we spend more time convincing the owner that we know why the pet is lame than we spend diagnosing the cause of the lameness when pododermatitis is present. Dogs with pododermatitis often have ear infections, itchiness or other skin disease at the same time. Examining the area between the foot pads is pretty easy, although they can be tender enough that dogs resent the examination. Normally the area between the toes looks like normal skin. If it is much redder than surrounding skin, moist on the surface and/or swollen then interdigital pyoderma is probably present. This is usually caused by bacterial infection but can sometimes be caused by fungal infection or demodectic mange. It can be quite difficult to manage this condition and it may take your vet several tries to find a medication or combination of medications that works well.
Food allergies are one of the causes of this condition, so if your vet suggests trying a special dietary trial to rule out food allergies please follow this advice. Blood testing for food allergies is very unreliable, so the food trial is a real necessity in order to rule out the possibility of food allergies. If any type of allergy is the underlying cause for pododermatitis the condition will require long term management. It is much better to keep on top of this condition and try to prevent its occurrence rather than to let it get bad and treat it.
Immune mediated polymyositis and polyarthritis can occur in both dogs and cats. In our practice, dogs and cats seem about equally susceptible to these conditions. In dogs we sometimes see this condition very early in life but more commonly as the growth phase comes to a close. In cats the onset of polyarthritis is more common in young adult cats, generally between one and five years of age. The "poly" in polyarthritis or polymyositis refers to more than one joint or limb being affected. In some cases this condition is mild and dogs and cats can adjust to the pain with the help of pain relief medications. In other cases it can be very painful and may not respond well to treatment. Rheumatoid arthritis fits into this category and does occur rarely in dogs. Whenever more than one limb is affected by chronic pain, this group of diseases must be considered. Evaluation of joint fluid, joint capsule or muscle biopsy, blood tests, X-rays and muscle function testing may be necessary to get an accurate diagnosis of these conditions. These conditions are frustrating to diagnose and can be frustrating to treat.
Where there is sudden weakness in both rear legs, or even paralysis of these limbs, without known trauma, it is important to consider the possibility of a sacrococcygeal injury, more commonly referred to as "tail jerk". When a pet's tail is held still and the pet continues to move, as sometimes happens when a tail is caught in a rocking chair or door, there may be separation of the spinal column between vertebrae in the tail or sacral region. This can lead to swelling or even tears in the spinal cord and resulting in spinal cord injury and loss of strength or function of the rear legs. Most of the time pets with this injury who come to our practice have no known history of a traumatic event. The trauma itself may have been minor but the consequences can be major.
Dogs and cats of any age can be affected by infectious tick or "vector-borne" diseases that can lead to joint pain, lymph node enlargement, fever, anemia and other signs of disease. Many pets associated with these conditions are very ill and the lameness is only one of many clinical signs. In some cases, especially when Lyme disease (borreliosis) is present, lameness may seem to be the most important clinical sign in some patients. Dogs are more likely to get Lyme disease than cats. Rocky Mountain spotted fever only occurs in dogs. Other tick borne diseases may affect both dogs and cats. The best support for diagnosis of these conditions that I have found comes from the vector-borne disease lab at North Carolina State University: http://www.cvm.ncsu.edu/docs/tickbornediseaselab.html These are the true "mystery illnesses" of veterinary medicine and have to be considered whenever a specific cause for lameness can't be found, especially when there are other clinical signs such as weight loss and anemia.
Sprains, strains, muscle tears and other traumatic injuries occur in dogs and cats. They seem to be a little less common in pets than in people. These can be extremely painful in the first few minutes after an injury and often clients believe that their pet has a broken leg. If your vet examines your pet and can not find evidence for a broken leg on physical exam it is usually reasonable to treat for a sprain or strain using rest and pain relieving medications. If the problem doesn't resolve within a few days, a recheck exam can be done to rule out more chronic causes of lameness and more extensive diagnostic testing can be done to rule out fractures and more severe trauma. If you really think that a pet is in severe enough pain that a fracture is very likely let your vet know. It is also reasonable to do more diagnostic testing, especially X-rays, just to be sure that a fracture isn't present.
Lameness in Older Pets
Really severe pain associated with a single joint, especially the elbow and knees in dogs and the knees and hips in cats can be a sign of bone cancer. The hallmark symptom of bone cancer is pain in a joint that is not responsive to pain relieving medications. Large breed dogs, especially rottweilers, appear to be more prone to bone cancer than smaller breeds. Whenever arthritis is suspected but there is a poor response to pain relief medications bone cancer should be ruled out, if possible. X-rays of the affected joint are often sufficient to make a tentative diagnosis of bone cancer and often are even sufficient evidence to make a firm diagnosis of cancer.
I would like to make a plea for considering amputation when bone cancer is located in a spot in which this is possible. I think of amputation solely as a pain relieving measure when dealing with a pet who has bone cancer. Amputation only rarely provides a cure for most types of bone cancer as it has usually spread to other areas of the body by the time it is diagnosed. Amputation does provide pain relief and this condition is often so painful that any relief is a blessing. Since bone cancer most commonly affects big breed dogs there is a tendency to think that amputation isn't a good idea. I have been guilty of this assumption in the past. It seems to make sense that losing a limb would be more difficult for a large breed dog but most dogs with bone cancer aren't using the leg, anyway. If they are able to get around on three legs when they have to carry the fourth leg, they should be able to get along even better without the leg.
Older cats sometimes suffer from hypokalemic myopathy, or muscle weakness associated with low potassium levels. This is a complicating factor in kidney disease, insulin regulation problems, hyperthyroidism and several other conditions that affect older cats. Affected cats may be weak in the rear legs only or may be so weak that they have difficulty holding their head up. Reluctance to move or stiffness while walking is sometimes an early sign of this condition. Testing potassium levels in the blood is very easy and overlooking this problem can have severe consequences, so it is reasonable to do blood work to rule out this condition whenever muscular weakness or reluctance to move around occurs in older cats.
Older dogs and cats can both suffer from degenerative joint disease or progressive arthritis with age. This is so common that it is easy to assume that any older dog or cat with lameness or weakness problems has arthritis. Despite this, it is important to consider the possibility that something else is causing the signs of pain or lameness. This is especially true when it seems necessary to use pain control medications on a regular basis. While it isn't especially common, we have strongly suspected osteoarthritis from "wear and tear" in an older dog and taken X-rays to be certain, only to find out that the dog has very little arthritis and no visible joint disease. Most of these cases have turned out to be things like spinal disc injuries but other diagnoses sometimes result from ruling out arthritis. Our practice's most embarrassing case was a dog we strongly suspected of having arthritis but whose X-rays really didn't justify the diagnosis. We had to anesthetize the dog in order to get the X-rays, as she was very anxious and wouldn't lay still. We allowed her owner to comfort her during the recovery stage from the anesthesia. He was petting and stroking her and suddenly asked "What's this?". He had found a burr that was partially embedded in the skin in the region of her knee. Removal of the burr corrected a lameness that has been present for several weeks! It is also important to remember that older dogs can have arthritis and some other condition causing pain or discomfort in the limbs at the same time -- finding arthritis doesn't always eliminate the need to consider other possibilities, especially when response to treatment is only partially successful.
It is also important to recognize that pets with arthritis may not show any sign of pain that are obvious, such as limping, crying out (vocalizing) or whining. There is often just visible weakness when a dog or cat tries to stand or a gradual decrease in daily activities. Pets do not have an effective way to communicate that chronic pain is present in their lives. You have to be a good observer of your pet and you have to remember that the most common cause of weakness in older dogs and cats is arthritis. If a pet's joints hurts enough to make a pet have difficulty standing up or if favorite activities like daily walks just aren't appealing to your pet anymore, treatment for pain is definitely reasonable and is probably a necessity if you want your pet to be comfortable.
There are several good pain control medications available at the current time. All of them have some risk associated with them but these risks have to be balanced against the potential for a life with much less pain in it. Many vets are reluctant to do lab work prior to placing pets on the newer non-steroidal anti-inflammatory medications because they are costly and the cost of lab work just makes that situation worse. For your pet's best protection, though, it is a good idea to have a basic blood chemistry panel and complete blood cell count checked before starting Rimadyl (tm), Deramaxx (tm), Zubrin (tm) or Metacam (tm). It is best to repeat this lab work a week or so after starting these medications and then periodically, perhaps every 3 to 6 months, while a pet must remain on the medications. In any case, stop giving these medications and call your vet as soon as possible if your dog or cat stops eating while being medicated for arthritis!
There are many causes of lameness. Thinking about the patient's age and breed can be very helpful in sorting through the possible causes. I have tried to cover some of the more common causes of lameness in this article but there are many less common causes of lameness and some common causes I probably didn't include. There are many disorders that affect single breeds or just a few individuals, such as Scottish fold osteodystophy in cats and cervical vertebral instability disorders in Dobermans and Great Danes. Knowing the disorders that occur in your pet's breed can be very helpful if lameness occurs, so try to familiarize yourself with breed problems.
Veterinarians are prone to hoping that lameness will respond to a short course of anti-inflammatory or pain relieving medications and may not pursue diagnostic testing early on. This is reasonable if the pet does respond quickly, but when it is obvious that medications are not helping or problems recur when medications are withdrawn, it is best to pursue an accurate diagnosis. Many of the lameness conditions will require long term therapy and prior to long term use of non-steroidal anti-inflammatory medications, which can cause harm and even death, it just seems best to be sure that the condition the medications are appropriate for actually exists. Sometimes this step just gets skipped because the response to the medications seems so convincing. Even when pets seem to respond very well to medication it still may be best to take the time and make the effort to get an accurate diagnosis. Many complicating conditions in lamenesses are missed simply because they are not considered and not looked for. If it is possible to control these conditions it may lessen or eliminate the need for lifelong use of medications.
Update on the current state of VetInfo
Michal has had some health problems which have made it difficult for her to answer much of the mail that comes to the vetinfo@vetinfo.com address. In addition, the recent worm attacks severely overloaded our mailboxes for several days, even though we could find no evidence that our computers were affected by the virus. Due to this, we have had to delete the mail files entirely on several occasions. If you have sent Michal a question that has gone unanswered it is possible that it was never received. If you have any questions about the web site or about your subscription it would be best to send them mervet@inna.net at the current time, the same address we use for subscriber questions.
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