Right now with the pandemic, I don’t think a day goes by when I’m not thinking about vaccines. Granted, a big part of my job is vaccinating your furry family members to help keep them healthy and maintain their legal status, but with most of us having “Moderna/Pfizer versus Johnson & Johnson” or “one- or two-shot protocols” swirling in our head, I’m hoping to review a little bit about vaccines and their importance while I take a break from working on my NCAA bracket.
What Is a Vaccine?
I’m sure this is common knowledge at this point, but as a reminder, a vaccine is a composite of either a dead or modified-live version of a virus or bacteria that you expose the body to so the immune system to be able to quickly build a response if or when exposed to the actual virus or bacteria in the future. (We will not worry about the newer mRNA vaccines, as at this time the veterinary field does not use them.) Using a sports analogy, you can think about vaccines as giving the immune system a little practice with a disease, so it will be ready for game day.
When Do You Booster Vaccines?
In order for a vaccine to work, the immune system needs enough exposure to build up long-term immunity. That means, when the body is exposed, it not only remembers the disease, but can build a defense quickly, before the disease causes significant illness. Sometimes you need more than one practice session to master that layup; it’s the same with the immune system. Some immune systems need more practice than others. This mostly pertains to puppies and kittens: their immune systems are less developed, so they require more practice than an older more “skilled” immune system.
Why Do Some Vaccines Last Longer Than Others?
It can get a little confusing to know how long each vaccine last for. Some vaccines, such as canine and feline distemper, can provide immunity for up to 3 years in most adult pets. Others (e.g., leptospirosis and feline leukemia) need boosters every year to maintain adequate immunity. This is because the immune system is better at remembering certain diseases than others. Some people will never forget how to shoot a free throw, but it will probably take a lot more practice to maintain that hook shot.
What Vaccines Should My Pet Have?
Ultimately, you should discuss this question with your vet. Recommendations will vary based on your pet’s lifestyle and geographical location. Here is what we currently recommend for the average dog and cat that live in Chicago:
Dogs: DAPP (Distemper virus, Adenovirus, Parvovirus, and Parainfluenza virus), Leptospirosis, Bordetella, and Rabies
Cats (indoor only): FVRCP (Feline Viral Rhinotracheitis, Calicivirus, and Panleukopenia) and Rabies
When they are current on these vaccines, your dogs’ and cats’ immune systems will be ready to fight and win on the big game day.
Let’s hope our Illini are ready to do the same! I-L-L
Alyssa Kritzman, DVM
What’s Your Diagnosis?
This is Chang Lu, a 10-year-old Shih Tzu. Chang Lu visited Medical District Veterinary Clinic in December with a history of straining to urinate, increased frequency of urination, and bloody urine.
During her exam she was trying to urinary every few minutes and was producing small, blood-tinged urine droplets each time. Initial diagnostics included urinalysis and X-rays. Her urine revealed significant bacteria and an overabundance of white blood cells. Below are her X-rays.
What is your diagnosis?
If you diagnosed Chang Lu with urinary tract infection and urinary bladder stones (urolithiasis), then you are correct. The large egg-shaped structures should not be there. Those are large urinary calculi (stones). Below I have notated the X-ray to point out various organs.
Urolithiasis (urinary bladder stones) are common in both dogs and cats. In people, most urinary stones originate in the kidneys, but in animals, more than 90% originate in the bladder, or lower urinary tract.
Urolithiasis (Urinary Bladder Stones)
Many factors, including genetic predisposition, can lead to bladder stones. Smaller breed dogs are at higher risk of developing urinary calculi (stones). Other predisposing factor include urinary tract infections, urine pH, urine mineral composition, and urine concentration.
When we see patients exhibiting the signs Chang Lu came in with (inappropriate urination, bloody urine, straining to urinate, increased frequency of urination), the most likely cause in dogs is a urinary tract infection and in cats is idiopathic (stress-induced) cystitis. In both species, however, it is important to rule out bladder stones, especially if urinary issues have been an ongoing problem for the pet.
To diagnose urinary bladder stones, veterinarians need to look inside the abdomen using X-rays and/or ultrasound. Seeing these stones is easier on X-rays than with ultrasound, and the number of stones can be more easily counted. Unfortunately, not all stones show up on X-rays, so ultrasound is needed to diagnose the non-radiopaque stones. Luckily, those that can’t be seen on X-ray are the much less common than those that can.
Treatment for Urinary Bladder Stones
Once stones have been diagnosed, treatment usually consists of a cystotomy (surgical removal of the stones) and treating the infection, if one is present. In some cases, prescription diets can be used to try to dissolve the stones. I personally have had great success with dissolution of stones in cats but very little to no success of dissolving stones with diet in dogs.
Chang Lu underwent a cystotomy, and two large stones were removed from her urinary bladder (see photo). At the time of surgery, we took a bacterial culture of her bladder, and the results showed that she had a resistant bacterial urinary tract infection. A resistant bacterial infection means the bacteria present in her bladder was resistant to most antibiotics, including the one she was initially prescribed. She was prescribed a new antibiotic in hopes the infection would be cleared.
How to Prevent Urinary Bladder Stones
Once stones have been diagnosed, it is very important to identify the type of stone to understand steps that can be taken to help prevent re-occurrence. After any cystotomy, the stones are sent to the University of Minnesota Urolith Laboratory, where the stones are evaluated. Knowing the mineral composition of the stone helps veterinarians determine the best way to prevent stones in the future. In many cases, pets are started on a long-term prescription diet to help alter their urine pH, encourage urine dilution, and limit the mineral components of the diet that lead to stone formation.
Chang Lu’s stones were determined to be 100% struvite stones, most likely secondary to her resistant bacterial infection. After she finished the course of new antibiotics, her urine was re-cultured, and the infection was completely cleared. Moving forward we will be screening her urine for infection every 3 to 6 months. She has also been switched to a prescription food designed to keep new stones from forming. Chang Lu is currently doing great and all her clinical signs have resolved.
– Dr. Drew Sullivan
You bring your dog to the vet every year for a physical examination and vaccinations. But do you recall why your dog is receiving her shots and how her doctor has decided which ones she needs? The following is a summary of the vaccinations we offer and the diseases they prevent.
Rabies is a virus that is contracted through the saliva (usually a bite) from an infected animal. Because rabies is always fatal and can be transmitted to humans, it is required by law that pet dogs be vaccinated. The first rabies vaccine your pet receives can be given as young as 12 weeks of age and must be re-administered one year later. Subsequent vaccines are given at either one- or three-year intervals.
DAPP, aka Distemper
This combination vaccine protects your dog from four respiratory, neurologic, and gastrointestinal viruses (distemper, adenovirus, parvovirus, and parainfluenza) that are in the environment and easy to contract through contact with an affected dog or contaminated feces. It is especially important that puppies receive this inoculation at appropriate intervals. The immune system of puppies is immature and not ready to battle these diseases. We administer this vaccine starting at 6 to 8 weeks of age, and continue every 2 to 4 weeks until your dog is at least 16 weeks of age. As your dog gets older, this vaccine will be given less frequently since his immune system is armed with antibodies to fight illness.
A bacteria found in standing water, leptospirosis is transmitted through the urine of infected rodents. A dog can contract the bacteria by drinking out of, or even walking through, a contaminated puddle. Symptoms range from mild gastrointestinal signs to liver and/or kidney failure. This potentially fatal disease is communicable to humans, so we strongly recommend all dogs receive the vaccine once a year.
There are several vaccines we give to dogs based on their lifestyles, which determines their risks.
Bordetella is the bacteria implicated in “kennel cough,” a respiratory illness that is easy to transmit through contact with an infected dog or through nasal or oral secretions. If your dog has contact with dogs you don’t know at a park or kennel, she should receive this vaccine. Puppies can get this vaccine as young as 6 weeks of age. It requires annual boosters.
The Lyme disease vaccine protects dogs against the spirochete Borrelia burgdorferi, which is transmitted by ticks. Lyme disease is characterized by arthritis, lameness, fever, and rarely, a serious kidney disease. If your dog spends any time in the woods and has exposure to ticks, this vaccine is recommended. It’s worth noting that protection against ticks is an essential part of disease prevention, since Lyme is not the only disease ticks can transmit.
Canine Influenza virus
Canine flu causes fever, cough, and fatigue and can lead to life-threatening pneumonia. It’s transmitted through oral or nasal secretions or through contact with a contaminated surface. If your dog spends time around dogs you don’t know at a park or a kennel, this vaccine is an important part of disease prevention.
Vaccinations can protect your dog from contagious diseases, some of which are fatal. As your pet’s caregiver, you should understand the preventable diseases your dog is at risk for contracting. Please call our office if you have any questions about these vaccines.
Barrie Yallof, DVM
Oh, what a typical December in a year of continual peace and normalcy.
What’s your favorite holiday memory regarding socially distanced Zoom calls with family members you haven’t seen in person for years due to splintered political realities followed by a deadly pandemic all the while keeping your 6-year-old son inside and away from his friends for 9 months and simultaneously being forced to keep an external facade of sanity and light fun in your two-holiday household while your profession, which is universally adored and undervalued at the same time, is more in demand of your time than at any other period in history?
I have so many.
So we know what usually happens here on the holiday. There is a cute blog post about keeping your dogs and cats safe, titled something like “’Tis the Wheezin’: Asthma During the Holidays.” I have written some in the past (HERE), and feel free to read. It generally can be summed up by this wise adage: “Don’t let your dog and cat eat things or get burned and remember that New Year’s Eve in Chicago generally involves people who do not have children and animals lighting off fireworks late at night to make those of us who do angry.” And don’t buy puppies, kittens, or bunnies as gifts. Instead, buy books like this inspirational tale for the animal lover in your life.
But I’m going to write about an unrelated topic: domesticated cats and the outdoors. I can imagine, even before writing this, that many people have strong feelings about this topic. My intention is not to pass judgment on anyone. I want to just give you the veterinarian perspective, and possibly give you an excuse to see photos of my fat indoor cats sitting next to holiday decorations, because that is how we indoor-cat people are generally seen and heard.
Some cats go outside. Cats go outside because some people feel that they have no choice but to let the cat out. Some people feel that it is philosophically cruel to not let the cat out, and some cats get outside by accident. All are acceptable.
I will be upfront and tell you that my two cats, Crocodile the Russian Blue mutt and Penelope the one-eyed tuxedo, do not go outside. They both try at times and have both gotten out before, but they stay inside and tolerate the complete subservience of all surrounding them.
Some of the dangers facing an outdoor cat are pretty obvious, but let’s go through them (you and I, together, like old friends who aren’t being watched):
1. Fighting with Other Cats
Cat bites and scratches are bad, cause severe infections, and can be fatal. All veterinarians have seen cats brought in with bite wounds that have become severely infected and, at worst, can puncture the abdomen, chest, eyeball, or throat and need surgical fix, hospital stays, and even euthanasia. We clean it up and give antibiotics, but it’s always concerning. This also can lead to:
2. Spread of Infectious Disease
Feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV) are spread through the exchange of bodily fluids (blood, saliva, etc.). Let’s just assume that the cats outside getting into fights are mostly ones that are homeless, and that homeless cats comprise the largest population of cats carrying these viral diseases. Well, the logic chain/train follows, and you see the danger. We can vaccinate for FeLV, so if your cat does go outside, you can get this done. There is no vaccine for FIV. And no treatment for either disease.
3. Other Infectious Disease
Rabies is a classic viral hit and can be spread through other cats or wild animals (bats, skunks, foxes). Make sure your outside cat is vaccinated for rabies, not only because it is the law but also because, even though it is rare, your sweet rabid cat can kill you and your family. (Still waiting for the Hallmark Channel’s Very Special Rabies Christmas.)
Just for fun let’s add endless respiratory infections (that can pass on to the other cats in your house), feline distemper (get your cat vaccinated for that, too), and parasitic diseases such as fleas (get monthly flea protection), ticks (get monthly tick protection), ear mites, intestinal worms (have monthly dewormers given), and ringworm.
All but one of these diseases can be passed on to you, your children, your grandparents, their friends, their friends’ neighbor, your friends’ neighbors’ son’s cat, etc. You see how this works. If you have an outdoor cat, and you’re afraid to tell your veterinarian (which you shouldn’t be), you can still take all the precautions: vaccines, preventatives, etc.
4. And Even More Infectious Disease
For the lucky, cats bring home presents, such as mice, birds, rats, etc. The rodents bring diseases and other rodents. It’s endless.
5. Cats Get Hit by Cars…
… get hit by bikers, get stuck in garages, get hurt by bad people, get snagged on fences, freeze to death, etc. [Cut to unwatchable montage of more horrible things.] It happens.
My previous cat got stuck in someone’s garage. I could not find her and searched for hours around the neighborhood. I eventually heard a cat crying in a garage and called the police who, hours later, located the owner who wasn’t on premise, to open the door. That could have easily gone another way, and I will write that fan fiction novel later.
“Lost cat” signs litter my current neighborhood, and you know they aren’t lost with a hobo bag on a train. They are all either dead, or (at best) living their lives with someone else. Also please have your outdoor cats microchipped. It’s not painful and may save your cats’ lives. You can also buy GPS trackers for their collars. I am not promoting a specific brand, but they are available anywhere.
Cats are really good at making babies, causing the population of stray cats in the city to blow up. These cats either end up being helped by people/shelters that can barely deal with the cats they have or they are left to fend for themselves on the streets to die, starve, or spread more disease.
So first, get your outdoor cat spayed or neutered. It is absolutely the best thing for them, for their health, and to keep down the population of wild cats in need. I also do not need to explain to you how a wild tom cat will treat a sweet young lady cat taking a stroll down the promenade with her uterus and ovaries. If you want to reduce the chances that your boy cat doesn’t get into a fight, well, then neuter. There are conflicting statistics, but most sources suggest that one female cat and her mate and all the subsequent offspring amounts to 11 million cats in nine years.
Lastly, I fear that some of you feel like the most natural thing for the world is to let your cats outside and let them live the full entirety of their existence. I get this, I really do, but also understand how much destruction to the natural environment cats do. They destroy natural foliage and other wildlife despite their good intentions. There is some very good evidence that the best thing for “nature” is to keep your cats inside, and you can find many other resources on this topic.
There are cats that do better when they go outside. I’ve had clients keep their cats inside and later see them become anxious, yowl, not eat, urinate all over the house, etc. I don’t want your cats to suffer, but if you want to make that transition, there are things we can do. It may not be the case that your cat is anxious because it can’t go outside. In fact, it may be that it has always been anxious, but you never noticed until you kept it inside. Always have us examine your cat before making any judgments. Maybe your formerly outdoor cat is suffering from something else (UTI, pain, etc.).
As always, feel free to discuss with us at any time. This wasn’t meant to be a philosophical treatise on domesticated animals’ rights, though that is generally how I fantasize spending a great deal of my off time.
Try to relax during these times and make sure you don’t feed your dogs chocolate-covered antifreeze-infused garlic balls for the holidays, or give your cats kerosene holiday lamps for Hanukkah.
I will continue to lord over Secret Santas everywhere while I fulfill my long-standing December tradition of making holiday cookies I can’t eat in a house I don’t own.
Be safe, don’t travel, wear masks, and shop locally on-line. And Black Panther is a holiday movie.
— Brett Grossman, DVM
Life with an elderly pet brings a lot of uncertainty and anxiety. We all wish for our pets to be comfortable and happy and live as long as possible, but interpreting subtle signs shown by aging pets can be challenging.
I can relate on a personal level. Our 14-year-old mixed breed dog named Oskee was diagnosed with thyroid cancer a few years ago. My wife and I did not think he would still be with us today. He has done better than expected for a dog with this diagnosis.
We feel very fortunate that he is doing relatively well. Recently, however, we have been noticing changes that make us wonder if this is the beginning of the end.
Facing the Inevitable
How do you know if he is uncomfortable? Is he suffering? When the time comes, how will our children react? Will we know when it is time?
These are all questions that many clients are faced with, and now my wife and I are the ones contemplating them.
When you are faced with these or similar thoughts and questions, I recommend making a list of things your pet really enjoys. For example, Oskee enjoys going for walks, chewing bones, begging/taking food from our kids. As he has aged and his condition has declined, we have seen his enjoyment in these activities decrease.
Some days he does not seem to have the energy or strength to go on much of a walk. Occasionally his legs slip out from under him. He also spends much more time sleeping and is not waiting by the dinner table like he used to. Noticing these changes helps us determine a “good” day from a “bad” day.
Focus on Quality of Life
Fortunately, his good days still outnumber the bad. An anti-inflammatory pain medication seems to make him more comfortable, and he does pretty well. I recommend clients keep a journal of good and bad days. When the bad days start outnumbering the good days, the pet’s overall quality of life needs to be considered.
For those of you with aging pets or terminally ill pets, I recommend discussing with your veterinarian what medications or therapies may help improve your pet’s overall quality of life. Unfortunately, though, most of us will be faced with a very difficult decision: when is it time to say goodbye?
It is never an easy decision. No matter how sick or old your pet is, the decision is going to be gut-wrenching and difficult. My wife and I are not looking forward to making this decision, but I owe this to Oskee when the time comes. Oskee has been the best dog for the past 14 years, and I would never want to see him have anything but a good quality of life.
Dr. Drew Sullivan
I recently came across the most amazing carrier for producing a calm cat. It’s called the Van Ness Calm Carrier. It has a sliding drawer design that allows cats in the carrier to be very easily taken out, avoids the more forceful removal from the carrier, and allows for quicker and safer unloading. I was amazed by this simple and genius idea and surprised that this carrier wasn’t more widely used.
For many cats, the only time they leave their homes and see the carrier is when they are going to the vet. They associate the carrier and the departure with being at the vet, and they begin to feel heightened stress and anxiety even before they arrive. Once we see many of these cats, it can be very difficult to handle them, and just getting them out of the carrier can be a challenge.
As a hospital that utilizes Fear Free® practices on a daily basis, we at Medical District Veterinary Clinic do our best to lessen anxiety and stress for our patients before, during, and after their visits to the vet. While the carrier choice seems simple, this important step can make a huge difference in creating a calm cat.
Below are tips to help lessen anxiety and stress for your cats when they visit with us:
- The best carriers are hard sided carriers that can be easily taken apart. In a carrier in which the top can be easily removed, more stressful and fearful cats can even be examined while they remain in the bottom half of the carrier where they are more comfortable.
- Make the carrier comfortable and enjoyable for your cat. Ideally your cat will enter the carrier on their own, and even spend time there to rest and play. To help your cat see the carrier as a happy and positive place, fill it with treats, toys, and familiar bedding that they enjoy.
- A product called Feliway® emits a synthetic feline pheromone that helps create a calming environment and reduces stress. It comes as a plug-in diffuser, spray, and wipe. Use of these products in the carrier prior to transport can be very beneficial to limit the anticipated stress and anxiety of going to the vet. We use these products all the time and see positive changes in our patients.
- Consider asking your veterinarian for a prescription medication you could administer before your cat’s visit to the clinic to serve as a mild sedative and help reduce stress and anxiety. Common medications used include gabapentin and trazodone.
By following these guidelines, you can make the experience of going to the vet much more enjoyable for feline patients—and for owners and veterinary staff as well.
—Amber Slaughter, DVM
Throughout this time of quarantine, I have been spending more time outside, as I am sure many of you have, too. Besides the overabundance of cicadas in my neighborhood, currently there seems to be a plethora of mosquitoes looking for a blood meal. Just as we love summer in Chicago, so do mosquitoes. Summer is the time for peak transmission of heartworm disease across the U.S. Heartworm disease is considered endemic in Illinois, and according to the American Heartworm Association, clinics in the Chicago area see an average of 25+ cases per year.
As I sit outside, I think how lucky I am because mosquitoes don’t seem to like me; my wife is not so lucky. Then I wonder if my dog, Oskee, is getting bit as much as we are? And is he getting infected with heartworms?
The importance of prevention makes so much sense once you have a little knowledge about the disease process and how monthly preventive medication works. As described in this short video, the monthly preventive does NOT prevent exposure, but kills off any immature baby heartworms already present in your dog. If the preventives are not given every 30 days, the immature heartworms can mature to juvenile worms before the next dose, thus resulting in heartworm disease.
If you miss a dose or are late giving a dose, give the dose as soon as you remember. While uncommon, an infection may develop within your dog from a single missed dose. Multiple missed doses, especially during peak transmission months, puts your dog at high risk of infection.
The heartworm test performed at annual wellness visits screens for adult heartworms. It takes 6 to 7 months after infection for the heartworms to mature into the life stage detected by the heartworm test. Therefore, if you miss a dose, start up prevention as soon as possible. Then have your dog tested within the next year to be sure that infection did not occur during the unprotected period.
For less than $10/month your pet can be protected. While there is a treatment for heartworm disease, it is more expensive and more painful than monthly prevention. The average cost of treatment for a medium-sized dog is $1,500 vs. $10/month for prevention.
If your dog is not currently on prevention or you need a refill, give us a call today. If you have questions about the different preventive medications on the market, please reach out as we would be happy to discuss your questions and concerns.
—Dr. Drew Sullivan
Because I am a human being living in the third-largest city in the United States, the coronavirus is on my mind. It’s scary, and we all are dealing with our newly realized pandemic anxiety in different ways. Turning to our pets for comfort is natural and nice, but with that also comes a possible increased focus on their every move and well-being.
Some of you have the luxury of being able to self-quarantine with your loved ones, and we all thank you. Some of us still need to be out in the real world saving people, and we all thank you too. This blog post, however, isn’t to inform you about anything related to COVID-19 and human health. For that you can look here. This blog is meant to address your animals’ health during this time.
I know that some of you are worried about your animals getting infected. Though we don’t know everything about this virus, veterinary experts say it is highly unlikely to infect or sicken pets.
What I want to discuss is the quality-of-life needs for your pets, particularly dogs, which depend on social interactions with other dogs and people to relieve boredom and anxiety. All the basic points are applicable to cats too, though the cats that go outside and meet people and other cats are rare.
We are all home (hopefully) now. As much as social interactions need to be at a minimum to help flatten the infectious curve, being outside is not unsafe. Walking your dog is not something you should avoid. In fact, strolling through the streets offers a great opportunity for quiet and reflection. What you need to be careful about, though, is stopping to talk to others and going to dog parks or places where humans congregate. Which in turn means that your dog’s social needs may go unmet.
So how can your dog’s and cat’s cabin fever be remedied?
- Attention. Because you are managing your two children who are home from CPS, trying to keep up on how many celebrities are positive, and Google-deep-diving whether coronavirus can be transmitted through ESP, you may not think that spending 10 minutes here and there playing tug-o-war with your dog is a priority. But don’t underestimate the stress dogs can pick up on. Even a small amount of attention can help them through this.
- Respect boundaries. Though most of your cats and dogs love having you around, it also the case that the sudden increase of bodies home at all times can be a stressor for your 18-year-old cat that is used to the quiet and freedom to sit on the couch alone during your work day and actually enjoy some alone time. I’ve heard from numerous people over recent weeks that they think that their dog and cat may not actually miss them as much as they assumed when they were at work every day. If your animals separate from your space to be alone, it may not mean something is wrong; you just may be annoying. Let them be and make sure there are places for them to retreat to without the clatter of your new bread-making hobby and experimentation with rave-reggae dominating your shared environment.
- Toys. Please don’t run to the store and get a bunch of toys right now, but make the existing toys in your house nice and clean and available. Make toys out of your old clothes or use a discarded water bottle, toilet paper rolls (especially you hoarders), etc. If you Google DIY dog toys, you’ll see a lot of ideas. But be careful you don’t use anything toxic or things that your dogs can swallow. I like this page: https://www.wisebread.com/10-diy-dog-toys-you-can-make-for-pennies
- Train/Teach your dog new tricks. Don’t give up on your sometimes jerk of a dog who stubbornly will not generally or ever listen to you. Don’t as it’s literally and figuratively never too late to try to teach your old dog new tricks. Maybe this is the time you spend teaching her to sit, shake, solve geometry puzzles, speak Turkish, etc. There are tons of trainers who are helping to do things remotely. I plan to have my dog braiding my hair by the summer.
- Go outside. Go outside. Go outside. It may seem contrary to our brains’ frenetic power to actually go in our yard (if you have one) and sit down, but leave your house, walk outside, even though you may need to cross the street to avoid people. You can check Twitter on your front steps with your dog as well as in your living room.
- Divide and comfort. Not all households with multiple animals live in harmony. We have an upstairs cat and downstairs cat. Both are annoyed at the upstairs and downstairs dog. Maybe your herd is split up in different ways. Just like playing tug-o-war with your dogs for 10 minutes could go a long way in fulfilling her needs, try to spend some alone time with each of your animals for a bit. Go upstairs and have a 10-minute pet-fest with your shy cat that hates your power hungry younger cat that generally hogs all the attention.
We all hope this passes soon, though that seems doubtful right now. Read books, play farm hustle, calm yourself, distance. Goodbye.
—Brett Grossman, DVM