Chemotherapy for dogs (& cats, although I've never done a cat)
Fantastic flea products, so I don't have to send home grocery bags of spray, bombs, and treatment schedules
Humane organizations, who are so compassionate and giving of their time and energy- I am humbled to get to help these wonderful people help pets
Surgical lasers: less bleeding, less pain
Digital Xray systems -- I remember when we used to take Xrays, then go into the darkroom to dip them in developer, then hang them up to dry. It would take about 10-15 minutes per film, and if they were bad, we'd have to repeat the whole process. Now? 60 seconds per film, and digitally manipulate it if it's under- or over-exposed
Animal emergency clinics -- no more trips to the clinic at 2:00AM for me!
My hospital team -- compassionate, dedicated, talented
Wet tongues and wagging tails
Cerenia: the Parvo puppy's best friend
Convenia: no more antibiotic pills for sick cats. One shot, and we're good for two weeks!
Black & white cats -- my favorites!
Pet insurance
Care Credit
A really understanding wife and kids who were willing to share a BIG part of me these past 24 years
Happy Thanksgiving everyone!!!
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Wednesday, November 23, 2011
Friday, October 21, 2011
Dog Days
This one is going to be a simple update on the latest goings-on at Horseshoe Lake Animal Hospital. No agenda, no specific teaching points. My English professors would hate this! But it IS a blog, and not an essay, so....
We have seen several dogs with proptosed ("popped out") eyes in the past week. Gruesome. Usually this happens in flat-faced dogs with head trauma. Most of the time the eye is so badly damaged that we have to remove it. What is amazing is that these little guys seem really chipper in spite of their horrible appearance. The indomitable dog: one of the reasons I'm glad to take care of pets and not people.
We've also seen our share of cardiac problems lately. There are so many great diagnostic tests available for heart disease now, but it is still tricky to diagnose in some cases, much to my frustration. There is also an exciting new drug called Vetmedin for the treatment of canine heart failure. We've been prescribing it a lot lately!
Allergic ear, skin, and respiratory disease seems to be a year-round problem. As the seasons change, we see a new group of dogs (and cats) whose allergens rise in that particular season. The "summer allergy" pets are finally getting some relief, but it's been a rough fall for the "autumn allergy" gang.
Speaking of relief, how about those Cardinals? The bullpen finally lost a game for us last night, but otherwise the relief corps has been over-achieving. It is thrilling to live in St. Louis when the Cards are in the post-season. We are wearing Cardinals apparel every Friday to support the home team. Dr. Randla supported his hometown Phillies when we played them, but even he is on board now.
We received a surprise visit from Pastor Sig Bjorklund and members of St Lukes United Methodist Church on Wednesday. They brought in breakfast and a certificate for going "above and beyond" in our work here. It was really heartwarming to see the "heros" who work so hard here get some recognition. Some of them were brought to tears. On Thursday, I was treated to a delicious potluck lunch brought in by my staff here for Bosses Day. Yep, I'm getting fatter!
Well, that's it. A rambling recount of the latest happenings in our little world. I can't wait to see what next week will bring. Go Cardinals!
We have seen several dogs with proptosed ("popped out") eyes in the past week. Gruesome. Usually this happens in flat-faced dogs with head trauma. Most of the time the eye is so badly damaged that we have to remove it. What is amazing is that these little guys seem really chipper in spite of their horrible appearance. The indomitable dog: one of the reasons I'm glad to take care of pets and not people.
We've also seen our share of cardiac problems lately. There are so many great diagnostic tests available for heart disease now, but it is still tricky to diagnose in some cases, much to my frustration. There is also an exciting new drug called Vetmedin for the treatment of canine heart failure. We've been prescribing it a lot lately!
Allergic ear, skin, and respiratory disease seems to be a year-round problem. As the seasons change, we see a new group of dogs (and cats) whose allergens rise in that particular season. The "summer allergy" pets are finally getting some relief, but it's been a rough fall for the "autumn allergy" gang.
Speaking of relief, how about those Cardinals? The bullpen finally lost a game for us last night, but otherwise the relief corps has been over-achieving. It is thrilling to live in St. Louis when the Cards are in the post-season. We are wearing Cardinals apparel every Friday to support the home team. Dr. Randla supported his hometown Phillies when we played them, but even he is on board now.
We received a surprise visit from Pastor Sig Bjorklund and members of St Lukes United Methodist Church on Wednesday. They brought in breakfast and a certificate for going "above and beyond" in our work here. It was really heartwarming to see the "heros" who work so hard here get some recognition. Some of them were brought to tears. On Thursday, I was treated to a delicious potluck lunch brought in by my staff here for Bosses Day. Yep, I'm getting fatter!
Well, that's it. A rambling recount of the latest happenings in our little world. I can't wait to see what next week will bring. Go Cardinals!
Monday, October 10, 2011
Indoor Cats Need Vets Too!
A recently-published survey done by the Brakke Consulting Group has identified a disturbing trend in pet care. It seems that many cat-owners, especially those with indoor cats, do not seek routine veterinary care for their pets. The study sites a number of reasons for this behavior: people are using the internet to self-diagnose (and treat?) sick cats, cats hate going to the vet, the economy makes people less likely to spend money on vet visits, and most-disturbingly, they feel like indoor cats don't really need veterinary care.
I want to focus here on the first and last reasons given. What most people don't realize is that a sick cat will often be sick for days, to weeks, to months before the owner notices. Why? Because a sick cat often acts about the same as a not-sick cat! Cats sleep a lot, eat when they want (usually when no one is around), and seek out the privacy of the litter box to urinate and defecate. There aren’t many cat owners (including me) who will notice subtle variations in their cat’s bathroom, feeding, drinking, or other behaviors. They certainly aren’t nearly as easy to track as dogs! If your dog is urinating excessively, you’re cleaning up messes, or at the very least, having to let him out more. If my dogs don’t greet me when I get home, I know something is wrong. And so forth…
As a veterinarian, I know that my sick feline patients have usually been sick a lot longer than my sick canine patients, for the reasons stated above. I also know that I frequently diagnose asymptomatic cats with major health problems when I see them for routine check-ups. These cats are lucky to see me, because the prognosis is generally a whole lot better if I diagnose them before they are “overtly sick.” I know this also from personal experience with one of my own (http://horseshoepets.blogspot.com/2011/06/my-sick-cat.html ).
This is my blog topic today because this morning I discovered a heart murmur in a 3-year old feline patient (100% indoor cat!) who came in for her annual checkup (and vaccines). This cat has a high risk for having a serious problem, and the owner wouldn’t have known had they not come in. Now we can do something about it. Later, when I was walking in from lunch, one of our techs was caring for a 2-year old (100% indoor!)cat on oxygen and IVs who was jaundiced and bloated. The cat had not seen a vet since she was spayed as a kitten. We didn’t have a diagnosis yet, but just by looking at her, I knew the prognosis was grim. I couldn’t help but wonder if this couldn’t have been prevented by a simple annual check-up.
I want to focus here on the first and last reasons given. What most people don't realize is that a sick cat will often be sick for days, to weeks, to months before the owner notices. Why? Because a sick cat often acts about the same as a not-sick cat! Cats sleep a lot, eat when they want (usually when no one is around), and seek out the privacy of the litter box to urinate and defecate. There aren’t many cat owners (including me) who will notice subtle variations in their cat’s bathroom, feeding, drinking, or other behaviors. They certainly aren’t nearly as easy to track as dogs! If your dog is urinating excessively, you’re cleaning up messes, or at the very least, having to let him out more. If my dogs don’t greet me when I get home, I know something is wrong. And so forth…
As a veterinarian, I know that my sick feline patients have usually been sick a lot longer than my sick canine patients, for the reasons stated above. I also know that I frequently diagnose asymptomatic cats with major health problems when I see them for routine check-ups. These cats are lucky to see me, because the prognosis is generally a whole lot better if I diagnose them before they are “overtly sick.” I know this also from personal experience with one of my own (http://horseshoepets.blogspot.com/2011/06/my-sick-cat.html ).
This is my blog topic today because this morning I discovered a heart murmur in a 3-year old feline patient (100% indoor cat!) who came in for her annual checkup (and vaccines). This cat has a high risk for having a serious problem, and the owner wouldn’t have known had they not come in. Now we can do something about it. Later, when I was walking in from lunch, one of our techs was caring for a 2-year old (100% indoor!)cat on oxygen and IVs who was jaundiced and bloated. The cat had not seen a vet since she was spayed as a kitten. We didn’t have a diagnosis yet, but just by looking at her, I knew the prognosis was grim. I couldn’t help but wonder if this couldn’t have been prevented by a simple annual check-up.
Friday, September 2, 2011
Arthritis in Dogs (and Veterinarians)
About ten years ago, a podiatrist prescribed Celebrex, an anti-inflammatory drug, (think ibuprofen) for plantar fascitis in my feet. I still have the condition, and since then I take the Celebrex as-needed. What I have noticed, however, is that as I get older, my joints are sore, and the Celebrex helps that a lot! So...I'm taking the drug more often, simply to be able to walk up the stairs in the morning without wincing in pain.
Experiencing the aging process (and the soreness that accompanies it) first-hand has made me more empathetic to my old arthritic patients. I haven't seen any statistics, but degenerative joint disease ("DJD", another name for arthritis) is an extremely common occurance in older dogs. DJD is especially debilitating in large-breed dogs, and is possibly the most common reason these dogs are euthanized.
There are a number of strategies we employ to treat DJD, and it is widely accepted that "multi-modal" therapy is most effective, although not every patient needs every form of treatment. Identifying at-risk dogs is very helpful in delaying symptoms and reducing the severity of DJD. At-risk dogs include those who have experienced bone or joint injuries in their youth (fractures, torn ligaments), overweight breeds prone to hip dysplasia, and dogs with conformational problems which could lead to abnormal stress on their joints. In my opinion, these dogs should be started on medical-quality glucosamine/chondroitin supplementation as early as possible.
Weight control and regular exercise are probably the two most important factors in preventing and treating DJD. As stated in a previous blog, dogs at ideal weights live about two years longer than obese dogs, primarily because of healthier joints. Regular exercise keeps the tissues which support the joints strong and helps the joints stay "lubricated." We have a physical therapy routine we prescribe for dogs with moderate to advanced arthritis, and some specialty hospitals even offer high-end PT (swimming, underwater treadmills, etc...)
As far as drug therapy is concerned, this is reserved for patients showing signs of pain. However, many owners don't recognize these signs! I get a lot of comments such as, "He's not sore, Doc. He just has a hard time getting up in the morning, like me." OK, Gomer, your dog is in pain. He does feel better as he starts to move around, but the pain is his body's way of saying, "There's something wrong here - I need help." Like me and my Celebrex, these dogs should be made comfortable to maximize their quality of life. We routinely use anti-inflammatories (like my Celebrex!), and supplement them as-needed with the pain reliever Tramadol.
There are now prescription diets for arthritic dogs. According to the veterinary orthopedists I have spoken with, the key ingredient in these diets is super-high levels of omega-3 fatty acids. These high levels of fatty acids have a significant anti-inflammatory effect on the joints. I am told that the levels are so high that it would be difficult to achieve them by giving fish oil, or some other fatty acid supplement. The problem is that these foods are quite expensive, especially for large dogs.
Veterinarians are now using stem cell therapy to treat arthritis. The stem cell cultures are grown from the patient's own surgically-acquired fat cells. When injected into an arthritic joint, the stem cells help control inflammation and pain, and possibly aid in the healing of damaged cartilage. While there are a lot of anecdotal success stories with veterinary stem cells, there is still a lack of hard evidence. Having said that, I recommend stem cell therapy for patients whose owners want to try everything possible. We do offer it at our practice. It aint cheap!
So if your dog, like me, is moving slowly and stiffly in the morning, or struggles to get up the stairs, or pays a big price for a day of fun and play, get him some help! He would do it for you if you were hurting.
Experiencing the aging process (and the soreness that accompanies it) first-hand has made me more empathetic to my old arthritic patients. I haven't seen any statistics, but degenerative joint disease ("DJD", another name for arthritis) is an extremely common occurance in older dogs. DJD is especially debilitating in large-breed dogs, and is possibly the most common reason these dogs are euthanized.
There are a number of strategies we employ to treat DJD, and it is widely accepted that "multi-modal" therapy is most effective, although not every patient needs every form of treatment. Identifying at-risk dogs is very helpful in delaying symptoms and reducing the severity of DJD. At-risk dogs include those who have experienced bone or joint injuries in their youth (fractures, torn ligaments), overweight breeds prone to hip dysplasia, and dogs with conformational problems which could lead to abnormal stress on their joints. In my opinion, these dogs should be started on medical-quality glucosamine/chondroitin supplementation as early as possible.
Weight control and regular exercise are probably the two most important factors in preventing and treating DJD. As stated in a previous blog, dogs at ideal weights live about two years longer than obese dogs, primarily because of healthier joints. Regular exercise keeps the tissues which support the joints strong and helps the joints stay "lubricated." We have a physical therapy routine we prescribe for dogs with moderate to advanced arthritis, and some specialty hospitals even offer high-end PT (swimming, underwater treadmills, etc...)
As far as drug therapy is concerned, this is reserved for patients showing signs of pain. However, many owners don't recognize these signs! I get a lot of comments such as, "He's not sore, Doc. He just has a hard time getting up in the morning, like me." OK, Gomer, your dog is in pain. He does feel better as he starts to move around, but the pain is his body's way of saying, "There's something wrong here - I need help." Like me and my Celebrex, these dogs should be made comfortable to maximize their quality of life. We routinely use anti-inflammatories (like my Celebrex!), and supplement them as-needed with the pain reliever Tramadol.
There are now prescription diets for arthritic dogs. According to the veterinary orthopedists I have spoken with, the key ingredient in these diets is super-high levels of omega-3 fatty acids. These high levels of fatty acids have a significant anti-inflammatory effect on the joints. I am told that the levels are so high that it would be difficult to achieve them by giving fish oil, or some other fatty acid supplement. The problem is that these foods are quite expensive, especially for large dogs.
Veterinarians are now using stem cell therapy to treat arthritis. The stem cell cultures are grown from the patient's own surgically-acquired fat cells. When injected into an arthritic joint, the stem cells help control inflammation and pain, and possibly aid in the healing of damaged cartilage. While there are a lot of anecdotal success stories with veterinary stem cells, there is still a lack of hard evidence. Having said that, I recommend stem cell therapy for patients whose owners want to try everything possible. We do offer it at our practice. It aint cheap!
So if your dog, like me, is moving slowly and stiffly in the morning, or struggles to get up the stairs, or pays a big price for a day of fun and play, get him some help! He would do it for you if you were hurting.
Wednesday, August 17, 2011
Quick Thoughts On Pet Nutrition
I don't know if I have admitted it on here yet, but for a little over a year, we have been a Golden Retriever family. Our Golden (named "Baron") is really Kathy's dog, and she is his "person," but he is happy to include me in his activities when Kathy is not paying attention to him.
Anyway, as I was roughhousing with Baron this morning, I realized that he is really a very lean and muscular dog...and I am happy about that. In fact, he is pretty different from many of the large-breed dogs I see in my practice. Like people in America, our dogs are fatter than ever.
Now I know we are all tired of hearing about the health risks associated with obesity in people and in pets, so I'll keep this short and to the point. The most common reason large-breed dogs are euthanized at my practice is because of crippling arthritis, which is usually complicated (or caused) by obesity. Purina did an eye-opening study a few years ago in which two groups of Labrador Retrievers were free-fed, or fed limited quantities their entire lives. The average dog in the free-fed group lived eighteen months less than the average dog in the limited-quantity group. This means that lean Labradors live about 12% longer!
It is reasonable to extrapolate this information to all large breeds. I know that Kathy would do anything to get an extra 18 months of health for Baron. So our 80-pound dog gets 3 and 1/2 measuring cups of food per day, and a cracker-sized treat at night. The rule of thumb for feeding adult dogs is 1/2 cup of dog food per 20 pounds of dog twice a day. For puppies, it's 1/2 cup of puppy food per 10 pounds given twice a day. I have learned the hard way not to estimate the volume of food you're giving -- get an actual measuring cup to scoop the food!
A couple of quick notes on cat nutrition would be approriate here. Recently-published data shows that most cat food label directions will result in over-feeding cats. This data recommends (as do I) feeding adult cats 30% less than the label says. Additionally, we now know that there are a number of feline diseases which can be effectively treated by giving canned veterinary diets. Therefore, I recommend supplementing dry kitten or cat food with a teaspoon (or less) of canned food several times a week, just so these cats will learn to eat canned food in case it ever becomes necessary later in life.
I get asked a lot about raw-meat diets lately, and there is some debate about canned vs dry food in cats, so those will be topics of a future blog. I know, I know...my future blogs tend to be waaaay in the future. I will try to do better!
Anyway, as I was roughhousing with Baron this morning, I realized that he is really a very lean and muscular dog...and I am happy about that. In fact, he is pretty different from many of the large-breed dogs I see in my practice. Like people in America, our dogs are fatter than ever.
Now I know we are all tired of hearing about the health risks associated with obesity in people and in pets, so I'll keep this short and to the point. The most common reason large-breed dogs are euthanized at my practice is because of crippling arthritis, which is usually complicated (or caused) by obesity. Purina did an eye-opening study a few years ago in which two groups of Labrador Retrievers were free-fed, or fed limited quantities their entire lives. The average dog in the free-fed group lived eighteen months less than the average dog in the limited-quantity group. This means that lean Labradors live about 12% longer!
It is reasonable to extrapolate this information to all large breeds. I know that Kathy would do anything to get an extra 18 months of health for Baron. So our 80-pound dog gets 3 and 1/2 measuring cups of food per day, and a cracker-sized treat at night. The rule of thumb for feeding adult dogs is 1/2 cup of dog food per 20 pounds of dog twice a day. For puppies, it's 1/2 cup of puppy food per 10 pounds given twice a day. I have learned the hard way not to estimate the volume of food you're giving -- get an actual measuring cup to scoop the food!
A couple of quick notes on cat nutrition would be approriate here. Recently-published data shows that most cat food label directions will result in over-feeding cats. This data recommends (as do I) feeding adult cats 30% less than the label says. Additionally, we now know that there are a number of feline diseases which can be effectively treated by giving canned veterinary diets. Therefore, I recommend supplementing dry kitten or cat food with a teaspoon (or less) of canned food several times a week, just so these cats will learn to eat canned food in case it ever becomes necessary later in life.
I get asked a lot about raw-meat diets lately, and there is some debate about canned vs dry food in cats, so those will be topics of a future blog. I know, I know...my future blogs tend to be waaaay in the future. I will try to do better!
Friday, July 22, 2011
Gotta Love Pet Insurance
I have a friend who LOVES Shar Peis. She has five of the wrinkley little creatures. Now, owning a Shar Pei (by the way, "Shar Pei" is a breed of dog that is covered with wrinkles) is not for the faint of heart. These dogs have enough medical problems to keep a small veterinary practice in business all by themselves.
Anyway, my friend was telling me about her experience with her pet insurance provider, Trupanion. One of her recently-acquired pups had developed horrible ear canal disease; so much so that both ear canals had almost completely grown shut with swollen tissue. Medical therapy wasn't helping much, and the ears were miserable.
The only recourse to alleviate the suffering was to remove the ear canals altogether. The surgery is called a "total ear ablation" and required the expertise of a board-certified veterinary surgeon. As you can imagine, it wasn't cheap. I think the total cost was in the $1500 range. Right. Ouch. But the cool thing is that she had purchased a pet health insurance policy from Trupanion just after a free trial membership. She paid the bill for the surgery, then submitted the claim. Within two days she got an email telling her the claim was being processed. Within a week, she had been reimbursed for about 90% of the bill! So before the sutures were even out, the surgery was paid for, and her pup was feeling great.
This is is very typical of the feedback I get from clients who purchase pet health insurance. The premiums are reasonable, and most companies pay quickly and generously. We all know that veterinary medicine is capable of some pretty miraculous things in this new century. We also know that these miracles are only available to those with the means to pay for them. Pet insurance is a reasonable way to make the miraculous stuff available.
A few tips: 1.Buy insurance while your pet is young. Premiums will be cheaper, and there will be less chance of your pet having a pre-existing condition which won't be covered. 2.Buy a "Major-Medical" type policy that does NOT cover routine care such as shots and dental cleanings. You can plan and save for routine care, and the premiums will be much lower. 3.Some pet insurance companies will not cover certain conditions in breeds that are pre-disposed to those conditions. Check in to this before purchasing a policy.
In this age of veterinary miracles, pet insurance is your way to make sure our miracles are available to you.
Anyway, my friend was telling me about her experience with her pet insurance provider, Trupanion. One of her recently-acquired pups had developed horrible ear canal disease; so much so that both ear canals had almost completely grown shut with swollen tissue. Medical therapy wasn't helping much, and the ears were miserable.
The only recourse to alleviate the suffering was to remove the ear canals altogether. The surgery is called a "total ear ablation" and required the expertise of a board-certified veterinary surgeon. As you can imagine, it wasn't cheap. I think the total cost was in the $1500 range. Right. Ouch. But the cool thing is that she had purchased a pet health insurance policy from Trupanion just after a free trial membership. She paid the bill for the surgery, then submitted the claim. Within two days she got an email telling her the claim was being processed. Within a week, she had been reimbursed for about 90% of the bill! So before the sutures were even out, the surgery was paid for, and her pup was feeling great.
This is is very typical of the feedback I get from clients who purchase pet health insurance. The premiums are reasonable, and most companies pay quickly and generously. We all know that veterinary medicine is capable of some pretty miraculous things in this new century. We also know that these miracles are only available to those with the means to pay for them. Pet insurance is a reasonable way to make the miraculous stuff available.
A few tips: 1.Buy insurance while your pet is young. Premiums will be cheaper, and there will be less chance of your pet having a pre-existing condition which won't be covered. 2.Buy a "Major-Medical" type policy that does NOT cover routine care such as shots and dental cleanings. You can plan and save for routine care, and the premiums will be much lower. 3.Some pet insurance companies will not cover certain conditions in breeds that are pre-disposed to those conditions. Check in to this before purchasing a policy.
In this age of veterinary miracles, pet insurance is your way to make sure our miracles are available to you.
Monday, June 27, 2011
My "Sick" Cat
My name is David Hall, and I'm an inconsistent blogger. It's been two months since my last blog. Hi David.
All I can say is it's been a busy summer! I'm here now, and I wanted to share a personal story about one of our family cats named "Mae". Mae is about ten years old and has lived with us almost her entire life. She started off as my oldest son Tristan's cat, then adopted my youngest son, Dylan, when Tristan moved out.
Mae is a very mellow "live and let live" kind of cat. She tolerates anything and is most happy sitting on the pillow next to Dylan as he sleeps. We had noticed that Mae seemed to be losing a little weight, but we weren't too worried about it since Mae has always struggled to maintain her ideal weight. OK, she's fat.
Anyway, when we brought Mae in for her annual check-up, labwork, and vaccines, we got an unpleasant surprise: Mae has diabetes.
The good news for Mae (and us) is that diabetes in cats can often be "cured." With a specific type of insulin (Lantis), a special diet (M/D by Hills), and monitoring and adjusting at home, any diabetic cat, if diagnosed early, has a reasonable chance of going into remission, and resuming a normal life without further insulin injections.
We have started Mae's insulin, and Dylan regularly gives her her special food. I will be teaching my wife how to get a drop of blood from Mae's toe to test her sugar levels (this has to be done four hours after the insulin when I'm typically at work). We are hopeful that we can cure her, and thankful that we did the "routine" labwork at her check-up. If Mae's diabetes had gone on undetected, we would have had a much sadder prognosis.
All I can say is it's been a busy summer! I'm here now, and I wanted to share a personal story about one of our family cats named "Mae". Mae is about ten years old and has lived with us almost her entire life. She started off as my oldest son Tristan's cat, then adopted my youngest son, Dylan, when Tristan moved out.
Mae is a very mellow "live and let live" kind of cat. She tolerates anything and is most happy sitting on the pillow next to Dylan as he sleeps. We had noticed that Mae seemed to be losing a little weight, but we weren't too worried about it since Mae has always struggled to maintain her ideal weight. OK, she's fat.
Anyway, when we brought Mae in for her annual check-up, labwork, and vaccines, we got an unpleasant surprise: Mae has diabetes.
The good news for Mae (and us) is that diabetes in cats can often be "cured." With a specific type of insulin (Lantis), a special diet (M/D by Hills), and monitoring and adjusting at home, any diabetic cat, if diagnosed early, has a reasonable chance of going into remission, and resuming a normal life without further insulin injections.
We have started Mae's insulin, and Dylan regularly gives her her special food. I will be teaching my wife how to get a drop of blood from Mae's toe to test her sugar levels (this has to be done four hours after the insulin when I'm typically at work). We are hopeful that we can cure her, and thankful that we did the "routine" labwork at her check-up. If Mae's diabetes had gone on undetected, we would have had a much sadder prognosis.
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