Waiting on more tests to confirm cushings

[Northern85girl]

Hi All, My name is Elizabeth, and My 6 yr old (S) Female Havanese, Emma, had been in/ out of vet for months with mild stomach, skin, ear infections. I pushed for more tests....and finally brought her to a new Vet.
I suspected thyroid which came back at (L) T4 1, other results
H) Alkaline Phosphatase (ALKP):

(H) Albumin (ALB):

(H)Protein (TP):

(H) Cholesterol (CHOL):

(L) Chloride (Cl-):

(H) NRBC:

(L) PLATELET:

In three months of thyroid meds and increasing dose her levels of T4 have not changed. Time for more tests.
Friday the vet did a series of blood draws with introducing medications and testing after to confirm if it is Cushings.

Is the blood work above consistent with Cushings? I don't get the new test results for 5 days and my mind is racing.

Thank you,
Elizabeth in MN

[Squirt's Mom]

Hi Elizabeth and welcome to you and Emma! :)

There were no numbers with your test result for the ALP, etc. so if you will edit your post to include those results along with the little letters and normal ranges that would be great. The lab results will look something like -

ALP 319 ug/dl 110 - 150

It is not uncommon for our untreated cush pups to have low thyroid results but that usually levels out once the cortisol is under control but lets not get ahead of ourselves so we will wait for the test results to come in. Was this the all day test or one that took only a couple of hours that you are waiting for?

The most important thing I can tell you is Cushing's is NOT a death sentence for the majority of our babies. Most go on to live out their normal life span...and beyond because we give them such excellent attention and care. ;) So try to take a deep breath and relax a bit. Enjoy your sweet girl every chance you get. Read the threads here, check out the Helpful Resource section, and ask questions...any question you may have. We will do our best to help you understand.

You and Emma are now part of our little family here at K9C and this family sticks together thru thick and thin. You are no longer alone.

Hugs,
Leslie and the gang

[judymaggie]

Hi, Elizabeth and Emma! The symptoms you mention that were concerning to you are not typically the ones that makes one think of Cushing's. Here is a list of symptoms from Kate Connick's article about Cushing's:


The most common symptoms include:
• increased/excessive water consumption (polydipsia)
• increased/excessive urination (polyuria)
• urinary accidents in previously housetrained dogs
• increased/excessive appetite (polyphagia)
• appearance of food stealing/guarding, begging, trash dumping, etc.
• sagging, bloated, pot-bellied appearance
• weight gain or its appearance, due to fat redistribution
• loss of muscle mass, giving the appearance of weight loss
• bony, skull-like appearance of head
• exercise intolerance, lethargy, general or hind-leg weakness
• new reluctance to jump on furniture or people
• excess panting, seeking cool surfaces to rest on
• symmetrically thinning hair or baldness (alopecia) on torso
• other coat changes like dullness, dryness
• slow regrowth of hair after clipping
• thin, wrinkled, fragile, and/or darkly pigmented skin
• easily damaged/bruised skin that heals slowly
• hard, calcified lumps in the skin (calcinosis cutis)
• susceptibility to infections (especially skin and urinary)
• diabetes, pancreatitis, seizures

Very often it is the dramatic increase in thirst, urination and hunger that raise red flags. Have you seen any these with Emma?

With regard to thyroid, I am wondering if your vet has run any thyroid tests other than T4. Dr. Jean Dodds is a well-known canine thyroid expert and it might be helpful for your vet to send blood samples to her for more thorough thyroid testing. Here is a link to her website:

http://www.hemopet.org/hemolife-diagnostics/veterinary-thyroid-testing.html

[Northern85girl]

THANK YOU for education.
Her symptoms are she looks pregnant with her belly hanging, constant ear, skin, stomach infections that go away but as soon as treatment stops come back for last year. Her coat changed in texture and color, she is much lighter and her hair grows slower and is thin but no bald spots.
Her back legs are weak and she has a tough time getting up on the deck, the first jump is about 1.5 steps high. Slow moving and low energy, but LOVES her food. Super super sweet dog but could accidently take your hand off if you were trying to hand feed her. She would eat any and all put in front of her. Not food aggressive just over excited like she is starving.

I got the results from the Dexamethasone suppression test.

Resting Cortisol was 11 (1-6 normal)
Post 4 Hr 1.3 Inconclusive
Post 8 Hr 1.6 Consistent with pituitary dependent hyperadrenocorticsm

Her other blood work numbers that were outside of Norma, the normal range in ( ):

(H) ALP: 357 (5-160)

(H) Albumin (ALB): 4 (2.7-3.9)

(H)Protein (TP): 7.9 (5.5-7.5)

(H) Cholesterol (CHOL): 350 (131-345)

(L) Chloride (Cl-): 105 (108-119)

(H) NRBC: 3 (0-2)

(L) PLATELET: 86 (143-448)

My vet is still looking for other opinions so no clear answers. Any thoughts?

Elizabeth and Emmy in MN

[Harley PoMMom]

Dogs with a thyroid problem do get constant ear infections. The thyroid function is usually checked along with the CBC/chemistry blood panel and is abbreviated as T4, do you see this listed?

Hugs, Lori

[molly muffin]

Emma's T4 was low at a 1 and 3 months on thyroid medication that number did not come back up.

So based on the LDDS this appears it could be cushings. Did they suggest a medication? If they suggested Vetroyl, keep in mind the starting dosage should be no more than 1mg/1lb. Starting low and slow is the key. Then you will do a follow up ACTH to check levels and how she is responding to the medication.

Did they suggest doing an ACTH before starting any meds? Some vets do, some don't. It isn't absolutely necessary but can be helpful for monitoring how mediation is working.

[Northern85girl]

Thyroid testing: No answer why meds are not impacting T4 levels... The vets are stumped. For some reason the meds are not getting into her system.......

Sept T4 test 1.0
Sept started 0.2 Thyrovet

6 Weeks Oct T4 test 1.1
Oct increase dose to .4 Thyrovet

6 Week Dec T4 test 1.1
Dec same dose kept at .4 Thyrovet

LOTS of tests... no definitive answers. Not treating for Cushings as thyroid not controlled yet.

Since Testing in Dec now Emma is having accidents in the house. I have a pad out but she only sometimes uses it and sometimes just stops where she is is and goes. Scheduled Urine analysis for tomorrow to rule out UTI. And I want to know if the protein is high as in her blood.

I'm VERY discouraged. No answers. My dog is getting worse. I've taken a lot of time off to bring her to appointments and spend a ton over the last year. Emma looks like she has a small football btwn where ribs end and hairless belly begins. She is overweight but this is pronounced in only this area and sides of her neck I can feel fat pads because her hair is thin. Odd weight distribution... I've never had an overweight dog but I can't imagine that's normal.

She doesn't seem to be in pain...but how do I know?? She just seems tired and much much older than she is. She is quite happy to be loved up and petted, and VERY happy about meals but other than that, lies on her side and doesn't move for hours at a time. It's sad.. and hard on her and VERY hard on me to watch

Are these things that weird that it's puzzled the vets consulted?

Elizabeth

[Northern85girl]

I’m feeling very defeated. Lots of tests, lots of vet visits, dog getting more ill. My hope is something rings with another person here and can give me some guidance.


HISTORY:
Over last year, otherwise healthy (SF) small breed dog, Havanese, at 5 yrs old prior healthy other than weight gain onset with no change in diet over 2 yrs and changed to regulated dietary intake by vet monitoring, no weight loss.
She started having chronic ear infections 10 in one year, skin infections, and stomach infections. All needed medication to clear but return shortly after.

Changed Vet to get another opinion. Now 6 yr old dog who had been very healthy is lethargic, over weight and generally uncomfortable with various mild reoccurring infections.

So begin the tests. NO answer why the thyroid meds are not increasing T4 levels. Vets are baffled. Dogs condition has got worse with now accidents in the house. I don’t think she is in pain, but is so lethargic hard to tell.

What do I do next? The only thing she is being treated for is thyroid. They want to get that under control before any other treatment.

Posting TESTS to perhaps get insight from someone who has been through this.

Blood Work, SEPT 2016
only the outside of Normal are listed below, the normal range in ( ):

(L) T4: 1 (1-4)

(H) ALP: 357 (5-160)

(H) Albumin (ALB): 4 (2.7-3.9)

(H) Protein (TP): 7.9 (5.5-7.5)

(H) Cholesterol (CHOL): 350 (131-345)

(L) Chloride (Cl-): 105 (108-119)

(H) NRBC: 3 (0-2)

(L) PLATELET: 86 (143-448)


THYROID
Sept T4 test 1.0
Sept started 0.2 Thyrovet

6 Weeks Oct T4 test 1.1
Oct increase dose to .4 Thyrovet

6 Week Dec T4 test 1.1
Dec same dose kept at .4 Thyrovet


Dexamethasone suppression test. 0.7mg/ml IV DEC 2016

Resting Cortisol was 11 (1-6 normal)
Post 4 Hr 1.3 Inconclusive
Post 8 Hr 1.6 Consistent with pituitary dependent hyperadrenocorticsm

I was able to have my dog stay in grooming room where she is groomed because it was empty and had my other dog stay with her to try to create a less stressful environment. I stayed the first few hours. For non stressful situation, short of them drawing blood at my home is about as good as it gets.

ANY insight if you've been through it is very welcome. It just seems my dog is a pin cushion for tests, lots of abnormal results but NO answers.

Elizabeth in MN

[judymaggie]

Elizabeth -- I know you are frustrated and hope to get more attention to your post. That said, I did go ahead and merge your two threads so that, anyone viewing your new post, will be able to go back and read some history.

It does not appear that your vet has run any thyroid tests other than T4. As I mentioned before, I think it would be beneficial to make contact with Dr. Dodds and have her take a look at Emma's complete thyroid picture. Here is a link to her website:

http://www.hemopet.org/hemolife-diag...d-testing.html

[lulusmom]

Hi Elizabeth and a belated welcome to you and Emma.

How much does Emma weigh? Is she getting the doses you posted once a day or twice a day? Are you making sure that her thyroid med is given on an empty stomach? Can you look at the labs and tell me if the T4 is a free T4 by equilibrium dialysis? To diagnose and treat based on a total T4 alone is questionable as it is subject to fluctuation and can be affected by certain drugs and high cortisol in dogs with cushing's. Is Emma on any other medication?

Dogs with hypothyroidism do not experience excessive drinking or peeing so if Emma has clinical PU/PD, it is either being caused by cushing's or a thyroxine overdose. Was a urinalysis done and were there any abnormalities. I would be particularly interested in the urine specific gravity (USG). I do think there are some lab abnormalities that are a lot more commonly associated with primary hypothyroidism than cushing's so that could explain why your vet decided to do a trial of thyroid supplementation before addressing possible cushing's. Most vets do this in reverse order because the vast number of cushingoid dogs have a transient decrease in T4 that usually returns to normal once a dog is stabilized on effective cushing's treatment. In other words, no thyroid supplementation is necessary. Can you please provide the reference range for the T4 value you posted? A T4 of 1 is usually low normal on the labs I've seen over the years. This would not be an uncommon result in a dog with cushing's nor would results less than 1.

I assume that your vet is a general practitioner, yes? It is not uncommon for gp vets to be stumped by complications of endocrine disorders and many do consult with internal medicine specialists when they hit a wall. If I were you, I would ask your vet if he has a trusted internal medicine specialist and whether he has presented Emma's case to this professional. If no to both questions, you may want to seriously consider asking for a referral. Emma can't go on the way she is and if your vet is at a loss, I think a specialist is the best option.

I look forward to your response.

Glynda

[labblab]

Hello from me, and I strongly agree with Glynda that if possible, I'd hope that a referral could be made to an internal medicine specialist who has greater knowledge re: endocrinological issues. Many of your girl's current symptoms are consistent with Cushing's, and I'm honestly not sure whether her T4 level is ever going to be easily normalized if Cushing's is involved and is left untreated. As Glynda says, the standard treatment approach with which we're familiar is to first treat the Cushing's and see whether the low thyroid reading normalizes, rather than vice versa. I'm really not sure what your vets think they are gaining by putting Cushing's treatment on the back burner. I know you've already gone to so much expense and worry, but at this point, I do hope that a specialized veterinarian may finally get a better handle on what may be an interconnected problem, and leaving the Cushing's untreated may be hurting rather than helping things.

Marianne

[Northern85girl]

Thank you. My friends think just let nature take it's course or put her down. I don't know where to turn because I think there has to be an answer. There is nothing so majorly wrong and values on blood tests have to mean something.

Emma is 30 pounds. Overweight. She should weigh 18, she is large for her breed.

Thyroid meds are twice a day before meals in little cheese. It has helped with infections even though levels are not improving.
T4 blood test is all it says on IDEXX report. I have had a dog with thyroid before, after one adjustment to her meds her hair grew back and she was completely normal for the rest of her life on meds going from 1 to a 3 in few months.

Yes, my vet has consulted with several other internal meds docs. The latest was out of Seattle. I was bringing her today for urine testing but due to snow storm going tomorrow. I want to rule out UTI and also find out how dilute it is.

The Vet wants a firm diagnosis before treating Is it Cushings? It is hypothyroid? Is it both?

Two 1/2 years ago, I had her tested and she was T4 1.2. Other vet told me it was normal. I never saw results. I had her tested because her coat color and texture changed dramatically over 6 months and energy was down. Not knowing it was low normal, I just thought is was her breed changing color at 4. I've never had a small dog before, only giant breeds.

With thousands spent and no answers of what it even is...that is what is maddening. If vets don't know.... when do I stop pushing it?I'm fighting an uphill battle. She's only 6 and acts 15. My big dog is 5.5 yrs and no signs of slowing down.... SO while not expert on little dogs.... I know my dog. She is very different and seems just in a haze.... I'm looking into this higher grade thyroid test. Not sure what that does. Low is low...isn't it?? I asked the vet about it before. They just said it is a more expensive test, but low thyroid is already confirmed...

Elizabeth

[molly muffin]

We've had dogs with low thyroid whose thyroid became normal once treatment for cushings was started. If it is cushings of course.

A question, the peeing seems to have come on since the thyroid medication was started?

It could be that it isn't her thyroid and if it is cushings, then once on meds for cushings, the thyroid wouldn't be an issue. 1.1 1.22 1.0 that still falls within the normal range for thyroid according to the range posted. 1 - 4 So she might run low and that could even be her normal.

She didn't fully suppress on the LDDS tests from looking at the results. Which is indicative of cushings.

[labblab]

T4 blood test is all it says on IDEXX report. I have had a dog with thyroid before, after one adjustment to her meds her hair grew back and she was completely normal for the rest of her life on meds going from 1 to a 3 in few months...

... I'm looking into this higher grade thyroid test. Not sure what that does. Low is low...isn't it?? I asked the vet about it before. They just said it is a more expensive test, but low thyroid is already confirmed...


Well, I am very worried about your vet's approach to thyroid treatment if he/she is telling you that the only test needed to confirm hypothyroidism in Emma is a simple T4. Especially for dogs suffering from certain other illnesses (or taking certain medications), the results of a T4 test alone are not necessarily trustworthy. Here's a quote from an informational page from the Michigan State University veterinary school's thyroid diagnostic center (MSU is nationally known for its specific interest in thyroid disorders). As you read this quote, bear in mind that Cushing's is well-known to be one of the non-thyroidal illnesses that can exert this skewed effect.


Non-thyroidal illness (sick euthyroid). It is well known that thyroid hormone concentrations can decrease as part of a metabolic response to non-thyroidal illness. This decrease occurs in part from changes in thyroid hormone production, characteristics of serum binding, and metabolism of thyroid hormones. In these circumstances, measurement of free T4 in the direct-serum analog assay (standard profile) may underestimate the true circulating concentration of free T4 and give a falsely low result. Free T4 by equilibrium dialysis gives a more accurate result and so will more correctly identify normal free T4 concentrations in sick animals, allowing for better identification of animals that are not hypothyroid. However, even free T4 by dialysis may be low in some euthyroid animals with nonthyroidal illness.


For dogs with complicated health issues, specialty centers like MSU offer much more complete thyroid analysis.


In addition to testing for serum levels of total thyroxine (TT4), total tri-iodothyronine (TT3), free thyroxine (FT4), and free tri-iodothyronine (FT3), this profile tests for T4 antibodies (T4AA), T3 antibodies (T3AA), canine thyrotropin (cTSH; thyroid stimulating hormone), and thyroglobulin antibodies (TgAA). The cTSH test provides much needed information in any attempt to diagnose hypothyroidism. Many non-thyroidal factors can cause decreases of TT4, TT3, FT4, and FT3 into the hypothyroid range in a dog with normal thyroid function making it difficult to differentiate sick-but-euthyroid animals from those with hypothyroidism. When thyroid hormone levels are low due to primary hypothyroidism, most (around 85%) animals will have abnormally high cTSH levels.

The antibodies (T3AA, T4AA, and TgAA) are markers for lymphocytic inflammation within the thyroid gland. T3AA and T4AA are subsets of TgAA which are present in only a proportion of TgAA positive animals. The T3AA andT4AA (THAA) cross-react with T3 or T4 in immunoassays and cause false results in some thyroid hormone assays. It is, therefore, crucial to know whether they are present before interpreting thyroid hormone results.

Even IDEXX themselves offer a more complete thyroid profile than simply the T4 that is contained on their standard basic chemistry panels. So even if you don't want to pursue testing as complete as a center like MSU, your vet could easily run a more thorough analysis through IDEXX alone, and my recollection is that it is not a particularly expensive add-on (I've had it done on all my dogs).

https://animalhealth.msu.edu/sections/endocrinology/Thyroid_Canine.php

The bottom line is that for otherwise healthy dogs, it is true that treating hypothyroidism can be a very simple and inexpensive process, with great results. However, when certain other health issues are involved, more involved testing is really necessary prior to pursuing thyroid treatment. And if your vet is telling you that nothing more is needed than a simple T4 test in a dog with possible Cushing's (in conjunction with deferring treatment for Cushing's at all), that leaves me feeling quite concerned about the vet's experience with both disorders.

Marianne

[BrittanyandJJ]

Hi Elizabeth!
I completely understand your defeated feeling. I spent over a year testing and retesting JJs blood, thyroid, bladder, liver enzymes, etc...including ultrasounds, X-rays, etc... with no answers just useless meds. JJ had all the Cushings symptoms: bald belly after ultrasound where hair was not growing back, voracious appetite where JJ may take off a finger from "starvation," pot bellied look, thirst, constant urinary infections to the point of bloody urine, balding, thin skin... the list goes on. It wasn't until the Calcinosis Cutis took over his little body that an ACTH test was recommended to test for Cushings. He had already had a Dexamethsone test (which looks like you had done from your first post) and it came back NEG for Cushings! Upon receiving results from the ACTH Stimulation test though it was CLEARLY Cushings. JJ started on Trilostaine and has been on it for a bit over a month. He is doing much better. No more bladder infections,pot belly, over thirst/ hunger... etc. I think you should request an ACTH Stimulation test and see if that yields any answers. The test is expensive and if you get a Cushings diagnosis- the test needs to be repeated periodically. I have been so relieved despite the money spent to finally have an answer that yields treatment routes for my little guy. Totally worth the money which it seems you are spending anyway to get NO answers. So frustrating, I know. If you have the test run, please keep us posted. Best of luck to you!

[BrittanyandJJ]

Also, it is worth the time an research to find someone with experience with Cushings as well as educating yourself so that you know if the vet is doing things right. I have found myself educating my local vets on Cushings and ACTH test protocols. I am working with a specialist in Seattle who works in internal medicine at a special clinic a few hours from where I live. I asked him many questions before entrusting him with JJs care which through my own experience I have found is necessary or you will just get sent in circles by people who are not willing to find out what they need to in order to accurately treat this condition.

[Northern85girl]

Driving in the snow to bring Emma in today. I am praying there is something in urine sample that shows mild infection. She is peeing in the house daily now and while I do work at home many days, I'm in my office for hours and at time and the urine is damaging the wood floors. I have large pee pads out and she just doesn't always make it to it. She just started here n there having accidents in Dec but in just a month it is very frequent. UGH

If there is no infection and no answers. We are talking about putting her down once my daughter in college can come home and say her good byes. I can't believe how fast this is going down hill with no real answers.

Elizabeth

[DoxieMama]

Hi Elizabeth,

I am so sorry to read about Emma's troubles, and especially how difficult it has been for you to determine precisely what is wrong. I do .not have any answers for you either, but am standing beside you with prayers that you can figure it out soon.

Please let us know what you find out today.

Shana

[Northern85girl]

Well I come home with more questions again than answers.....

Did a sterile urine collection and waited there for the results.

Emma is a sm breed dog who is now 30 lbs should be 18.

I take that back, today she weighed 33.6 and weighed 30.2 on DEC 30, 2016 visit. (how does a dog gain 3.5 lbs in 2 weeks with no diet change??)

RESULTS: Unexplained weight gain and not normal tests but not alarming.

Some protein it showed high on dip stick 30+ but she said that shows higher than it should many times on that test??

Glucose - Normal
Dilute but not terrible 1.02, she said normal is 1.3
Some Red Blood Cells (puzzled)
Some Cox Bacteria (puzzled sterile sample)
Some White Blood Cells but not really high

Soooooo, I am going to try the antibiotics and see if that helps. She said the Cushings treatment on an ill dog that doesn't indeed have could kill her. I just replied, whatever she has is killing her slowly and she now hates going in the car because it never means going to the lake anymore, it means a sharp poke at the vet.

She said we can try another dexamethosone test and another more intense thyroid test after antibiotics complete.

I was hoping for a clear UTI was the issue OR totally normal and no answer why, she's just sick. But I got "hmmm that's really weird that it shows bacteria in her bladder or any red blood cells"

Tomorrow I hope she feels better.
Elizabeth

[Squirt's Mom]

If this were my baby, I would be taking her to an IMS for their input asap. Consulting is one thing, hands on and actually examining the patient is an altogether different thing...and your baby needs that chance. ;) Don't give up just yet.

Hugs,
Leslie and the gang

[labblab]

She said we can try another dexamethosone test and another more intense thyroid test after antibiotics complete.
I am so sorry that Emma is doing so poorly. I can only imagine how hard this is for her and also for you as her caretaker. However, if Emma is degenerating to the point that you are considering euthanasia, I do agree with Leslie and encourage you to ask that Emma be seen directly by a specialist ASAP. It does not seem as though your regular vet knows where to turn at this point, and with every day that's lost, Emma declines even more.

Since Emma already tested positive for Cushing's on the first LDDS test, what is the value in repeating the same test again if your vet distrusts the result? It seems as though that money could be better spent elsewhere, perhaps on an ACTH which is an alternative Cushing's diagnostic blood test that may corroborate the LDDS result. Yes, it's true that we never want to falsely treat a dog who doesn't have Cushing's. But if Emma doesn't have Cushing's and low thyroid is her primary problem, why hasn't the thyroid supplementation helped? It just seems to me that something other than hypothyroidism has to be at play here, and forgive me, but whether or not it's Cushing's your vet seems to be dilly-dallying as to what to do next -- to the point where Emma is rapidly losing all quality of life in addition to her health.

Before you give up, I hope Emma can be personally seen, at least once, by a vet with more specialized experience in these types of disorders that affect the endocrine system. In the long run, being seen by a specialist who knows which tests will be most useful may actually save you time and money, but most importantly, Emma's life.

Marianne

[molly muffin]

I am not impressed with this vet. Just my personal opinion.

My thought, go to an IMS, get an ACTH test and if it is high, start her on a vetroyl, 1mg/1lb.

If you are already thinking of saying goodbye to her, then trying treatment wouldn't hurt. You actually don't have to do the ACTH because the LDDS supports treatment, but at this point. It might be worth it. You could get your little girl back.

[Northern85girl]

accidents on the floor have been reduced by antibiotics. No further testing is planned until my next commission check comes. With holidays and several thousand already invested at vet, it is not in the financial cards to continue the guessing game at $200/$300 a visit.

Elizabeth MN

[Northern85girl]

I have a large deal that is closing on Thursday. Once it is confirmed I know I will have a commission check that can pay for specialist. My daughter is pre med at U and her good friend is going for Vet medicine. I printed off records for her friend to show professor. 4th year vet students can use as case study to recommend next steps is something I can try for free consulting.
My dog with SLO was so emotional and $10K+ of specialist and medication I had to get from human pharmacy and she died in less than a year. I made a promise to my husband I wouldn't get so "nuts" about a pet again.... 7 years later. I'm back in this situation.

I've had a dog with Addisons, SLO(lupus), and now this. DIFFERENT breeds. (Std Poodle, Giant Schnauzer, Havanese) I think it's weird that I have had issues with all of them and I feed very good food, don't over vaccinate, and pamper my pets. WHY ME?

Rant over...
Elizabeth in MN

[Joan2517]

Maybe because you take such good care of them, and that's the mom they need, someone who will love them, do what they can for them, and make them comfortable through all their illnesses.

That's how I try to look at it. It's heartbreaking, but they need all the love and care you give them...and I'm sure they know it.

[molly muffin]

That is a good idea printing everything off and using it for a case study!

It's the heart that seems to rule in the end. Logically we can say, nope not doing this again, never never and yet, the heart says..just one more thing to check and off we go. :)

I think most on here are the same way. :)