Date   

Re: Wellness Ready Laminitis test kit???

Nicole Sicely
 

I wonder if the vet part is simply because they think most horse owners wont draw blood.  But if you could draw your own blood, would you need a vet?  I'd love to have my vet use this and then run the regular insulin test at the same time to see how the results compare.
--
Nicole in VT

Joined 9/22/04


Re: Cody's test results

Kirsten Rasmussen
 

Hi Sherry,

You can post the CBC results as a separate document (pdf) in your case history folder,  or you can post it as a photo (jpg) in your photo album.  Basically, that's if you want feedback from Dr Kellon, but if you are comfortable with your vet's feedback then that's fine.

You could add your BSC estimate to your Case History if you get a chance.

--
Kirsten and Shaku (IR) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
Shaku's Case History
Shaku's Photo Album


Re: Dr Kellon/Dr. Clougher - need help re significant increase in triglycerides

Cindy Giovanetti
 

moderators are doing a good job

Thanks Daisy. All the volunteers appreciate your noticing.  Nancy

I noticed too.  And I noticed Dr. K was absent.  I was concerned for her.  Love to all.

 

Cindy


--
Cindy, Oden, and Eeyore, North Texas
On ECIR protocol since 2/19
https://www.facebook.com/LifeWithOden/
History: https://ecir.groups.io/g/CaseHistory/files/Cindy%20and%20Oden
Photos:  https://ecir.groups.io/g/CaseHistory/album?id=91125


Re: Update on Vinnie- Post Hospitalization for Hypertriglyceridemia

Nancy & Vinnie & Summer
 


Stallions and IR

Bonnie
 

In the messages regarding the lovely stallion in the insulin test video, Lavinia commented:

In general, being a stallion helps prevent EMS/IR - even in high risk breeds - but that protection fades along with the testosterone, as they age.

My pony developed a large fallen crest (in his former home) at about age 3. It ended his show career. The owners sold him to me at age 8, soon after he had been gelded. Other signs of IR became apparent, then ECIR came into our lives!
Could diet have an IR-promoting effect on a stallion? Lad's first owner used Calf Manna as a feed. Also his deworming method was to dump a truckload of carrots into the pasture. "They eat till their manure turns orange," he told me, "and that clears out the worms."
--
Bonnie and Lad
North Ontario
Dec 2008
 


Re: New IR diagnosis: confirmation and calculator assumptions help needed

Kirsten Rasmussen
 
Edited

Hi Laura, great job on getting everything in order!  I did noticed in your Case History there is some confusion regarding what Magic is actually eating.  Your notes say you stopped the Nutrena pellets so could you add a line below the Nutrena with the date they were stopped?

As you know, our cutoff is NOT based on fasting, although our cutoff number is so low that is probably confusing to others.  Based on Magic's results I'd say he is an IR horse, or more correctly "he has EMS", but he is not as sensitive as some EMS horses.  Likely the timothy hay, the regular work, and his relatively young age (15) are all working towards minimizing his EMS tendencies and his bloodwork shows he is doing really well.  It tends to get worse with age so it's great that you are being proactive and noticing some subtle signs now!  You know him better than any others so don't doubt yourself.  Reducing his weight will help, too, and it's already been pointed out that he is overeating a little...

Have you tried double-netting his overnight hay?   What I like do for overnight is split the hay into 2 portions, and put half in a single net that I know my horse will empty in about 2 hours, and half in a doubled net that I know will slow him down a bit.  That allows him to fill his belly quickly with the first net, then more slowly work on the second one thru the night.  He also gets 2/3 of his hay overnight because it's a 14 hr stretch for my guy.

--
Kirsten and Shaku (IR) - 2019
Kitimat, BC, Canada
ECIR Group Moderator
 
Shaku's Case History
Shaku's Photo Album


Re: New IR diagnosis: confirmation and calculator assumptions help needed

Sherry Morse
 

Hi Laura,

You'll have a full welcome soon but a couple of things jump out at me from your Case History.  The first is your ideal weight for Magic vs. his current weight.  If you want him to lose weight you need to feed 1.5% of his current weight or 2% of his ideal weight TOTAL (hay and concentrates) per day.  For Magic those numbers would be 15.6lbs or 19lbs.  At this time he's getting more than that in hay alone.

So - is that hay weight and all the concentrates listed actual weights or just estimated? 

In addition, neither the Nutrena product nor the alfalfa pellets are suitable for a suspected IR horse, even if he's compensated IR.  The Nutrena product is double our recommended amount of fat (that's in the Diet section of your welcome letter) and well over our recommended level of sugar+starch so it's a good thing that was stopped, but the alfalfa pellets aren't a good replacement. 

If you can replace the alfalfa pellets with Triple Crown Naturals Timothy Balance cubes as a carrier that would probably help with the weight loss goal in addition to making sure he's eating no more than the 19 pounds total per day. 




On Tuesday, April 13, 2021, 7:19:55 PM EDT, Laura <laernst64@...> wrote:


Hello to all:)

I believe my horse is insulin resistant!  I ran my first metabolic panel this March, input the values into the ECIR calculator and it appears that my boy may be compensated insulin resistant!  

This is my first horse and my first time delving into such topics, so I would love to have some feedback as to wether I'm reading this correctly or not.  My Vet, barn manager, farrier and trainer all say my horse is the perfect picture of health with nothing to worry about.... just a few pounds to lose, yet he is a VERY easy keeper and I want to head off any future problems.  I took ownership In January and consulted with a nutritionist to remove junk food from his diet.  Between her advice and FEEDXL nutrition calculator, I actually found my way in February, quite by accident, to feeding him Timothy hay in a net (to slow him down - he's a vacuum cleaner) and the Amino Trace+ vitamins/minerals.  He also has some Smartpakequine joint support and a handful of alfalfa pellets as a carrier for the supplements.  Last year, Magic did not have an owner or an exercise program, so he began his return to work last fall with the trainer to the point where he is now developing muscle and conditioning.  Unfortunately, he has not lost any weight in spite of his new diet and exercise.  This is what prompted me to run a metabolic panel to see if there were any underlying conditions.  I believe we prepared for the test correctly by avoiding the breakfast feeding and allowing him access to hay for 4 hours prior to the blood draw (he does not receive any hay overnight). Nor was he turned out or exercised.  When I confronted my nutritionist with my findings, she indicated that the cutoffs for IR derived by the ECIR Group were based on complete fasting not hay fasting (I know I read on the calculator that the material is based on hay testing).  In any event, no one thinks my horse is IR!

Can someone please confirm that my observations, assumptions and calculations are correct?  I"m not happy knowing this information but find myself completely relieved to know there is a group like this with such detailed guidance and support that I can find a way to take the best care of my new equine partner!! If there are any additional diagnostics that would be helpful, please let me know.

Many thanks to all of you who do what you do - you are appreciated!!


--
Laura & Magic, NJ joined 2021

https://ecir.groups.io/g/CaseHistory/files/Laura%20&%20Magic/Magic%20Case%20History.pdf

https://ecir.groups.io/g/CaseHistory/files/Laura%20&%20Magic/Hay%20Analysis/Magic%20hay%20analysis%20jan%202021.pdf


Re: andy ideal weight?

Sherry Morse
 

Hi Chemelle,

I would rate him about a 4.5 which is good for a Haflinger.  How much does he weigh as per a weight tape or estimate?




Re: New IR diagnosis: confirmation and calculator assumptions help needed

Candice Piraino
 

Hello Laura!

Welcome to the group! 

Thank you for being so thorough and such an ambassador for Magic! He is very lucky to have you! And of course Lipizzans are very near and dear to my heart, since my heart horse Shark is a Lipizzaner gelding! I will tell you to remove that Redmond rock salt- we do not want to ever add iron to a equine's diet if we can help it. Iron is in everything and it can cause issues. To search on that topic later for a "rainy" day! Also, I would also nix the alfalfa pellets. You can read more about diet below in the provided links. I am concerned about his lack of access to hay. Over 4 hours without access to forage can lead to ulcers and of course other issues. My Lipizzan would be a raging Rogue if he were to be without hay overnight. Can you provide safe hay in slow feeding nets with 1 inch holes? That will help slow him down and make the hay last longer throughout the night. 

Others will comment, but I wanted to get your welcome letter out. Excellent job in being proactive!!!! 

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). Please explore our website where you'll find tons of great information that will help you to quickly understand the main things you need to know to start helping your horse. Also open any of the links below (in blue font) for more information/instructions that will save you time.

Have you started your Case History? If you haven't done so yet, please join our case history sub-group. We appreciate you following the uploading instructions so your folder is properly set up with the documents inside. Go to this CH message with info on how to use various devices and forms. If you have any trouble, just post a message to let us know where you are stuck.

Orienting information, such as how the different ECIR sections relate to each other, message etiquettewhat goes where and many how-to pages are in the Wiki. There is also an FAQs on our website that will help answer the most common and important questions new members have. 

Below is a general summary of our DDT/E philosophy which is short for Diagnosis, Diet, Trim and Exercise.

 

DIAGNOSIS: There are two conditions dealt with here: Cushings (PPID) and Equine Metabolic Syndrome (EMS)/Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or EMS/IR, neither or both. While increasing age is the greatest risk factor for developing PPID, IR can appear at any age and may have a genetic component. Blood work is used for diagnosis as well as monitoring the level of control of each.

PPID is diagnosed using the Endogenous ACTH test, while EMS/IR is diagnosed by testing non-fasting insulin and glucose.

The fat-derived hormone leptin is also usually abnormally elevated in insulin resistance but because there are many other things which can lower or increase leptin ECIR is not recommending routine testing for this hormone. Leptin is the hormone that says "stop eating".

In Europe, adiponectin is tested instead of leptin. Adiponectin helps regulate glucose and fat burning, and maintain insulin sensitivity. Low levels are associated with EMS. It has come to be preferred over leptin because it is not influenced by things like weight or exercise, and also because it was the only factor other than insulin levels that predicted laminitis risk

*Before calling your vet to draw blood for tests, we suggest saving time and wasted money by reading these details and then sharing them with your vet so that everyone is on the same page regarding correct testing and protocols.

*Please remember to request copies of the results of all the tests done rather than just relying on verbal information. Your vet should be able to email these to you. If you have previous test results, please include those as well. All should go in your CH, but if you are having any trouble with the CH, just post in the messages for now. 

Treatment: EMS is a metabolic type - not a disease - that is managed with a low sugar+starch diet and exercise (as able). The super-efficient easy keeper type breeds such as minis, ponies, Morgans, Arabs, Rockies are some of the classic examples. PPID is a progressive disease that is treated with the medication pergolide. Some, but not all, individuals may experience a temporary loss of appetite, lethargy and/or depression when first starting the medication. To avoid this "pergolide veil" (scroll down for side effects), we recommend weaning onto the drug slowly and the use of the product APF. The best long term results are seen when the ACTH is maintained in the middle of the normal range at all times, including during the annual seasonal rise. To accomplish this, the amount of medication may need to increase over time. Neither condition is ever "cured", only properly controlled for the remainder of the equine's life. If your partner is both PPID and IR then both medication and diet management will be needed. 

DIET: Almost all commercial feeds are not suitable - no matter what it says on the bag. Please see the International Safe Feeds List for the safest suggestions.

No hay is "safe" until proven so by chemical analysis. The diet that works for IR is:

  • low carb (less than 10% sugar+starch)
  • low fat (4% or less) 
  • mineral balanced  

We use grass hay, tested to be under 10% ESC + starch, with minerals added to balance the excesses and deficiencies in the hay, plus salt, and to replace the fragile ingredients that are lost when grass is cured into hay, we add ground flax seed and Vitamin E. This diet is crucial for an EMS/IR horse, but also supports the delicate immune system of a PPID horse. 

*Until you can get your hay tested and balanced we recommend that you soak your hay and use the emergency diet (scroll down for it).  The emergency diet is not intended for long term use, but addresses some of the most common major deficiencies. Testing your hay and getting the minerals balanced to its excesses and deficiencies is the best way to feed any equine. If you absolutely cannot test your hay and balance the minerals to it, or would like to use a "stop gap" product until you get your hay balanced, here's a list of "acceptable" ration balancers

There is a lot of helpful information in the start here folder so it is important you read all the documents found there. The emergency diet involves soaking your untested hay for an hour in cold water or 30 minutes in hot water. This removes up to 30% of the sugar content, but no starch. Starch is worse than sugar since it converts 100% to glucose while sugar only converts 50%, so starch causes a bigger insulin spike. Make sure you dump the soaking water where the equine(s) can't get to it. 

What you don't feed on the EMS/IR diet is every bit as, if not more important than, what you do feed! No grass. No grain. No sugary treats, including apples and carrots. No brown/red salt blocks which contain iron (and sometimes molasses) which interferes with mineral balancing, so white salt blocks only. 

No products containing molasses. No bagged feeds with a combined sugar and starch of over 10% or starch over about 4%, or fat over about 4%. Unfortunately, even bagged feeds that say they are designed for IR and/or PPID equines are usually too high in sugar, starch and/or fat. It’s really important to know the actual analysis and not be fooled by a name that says it is suitable for EMS/IR individuals.

We do not recommend feeding alfalfa hay to EMS/IR equines as it makes many of them laminitic. Although it tends to be low in sugar, many times the starch is higher and does not soak out. Additionally, protein and calcium are quite high, which can contribute to sore footedness and make mineral balancing very difficult.

TRIM: A proper trim is toes backed and heels lowered so that the hoof capsule closely hugs and supports the internal structures of the foot. Though important for all equines, it's essential for IR and/or PPID equines to have a proper trim in place since they are at increased risk for laminitis. After any potential triggers are removed from the diet, and in PPID individuals, the ACTH is under control, the realigning trim is often the missing link in getting a laminitic equine comfortable. In general, laminitic hooves require more frequent trim adjustments to maintain the proper alignment so we recommend the use of padded boots rather than fixed appliances (i.e. shoes, clogs), at least during the initial phases of treatment.

Sometimes subclinical laminitis can be misdiagnosed as arthritis, navicular, or a host of other problems as the animal attempts to compensate for sore feet. 

You are encouraged to make an album and post hoof pictures and any radiographs you might have so we can to look to see if you have an optimal trim in place. Read this section of the wiki for how to get a hoof evaluation, what photos are needed, and how to get the best hoof shots and radiographs.

EXERCISEThe best IR buster there is, but only if the equine is comfortable and non-laminitic. An individual that has had laminitis needs 6-9 months of correct realigning trims before any serious exercise can begin. Once the equine is moving around comfortably at liberty, hand walking can begin in long straight lines with no tight turns. Do not force a laminitic individual to move, or allow its other companions to do so. It will begin to move once the pain begins to subside. Resting its fragile feet is needed for healing to take place so if the animal wants to lay down, do not encourage it to get up. Place feed and water where it can be reached easily without having to move any more than necessary. Be extremely careful about movement while using NSAIDs (bute, banamine, previcox, etc.) as it masks pain and encourages more movement than these fragile feet are actually able to withstand. Additionally, NSAIDs (and icing) do not work on metabolic laminitis and long term NSAID use interferes with healing. Therefore, we recommend tapering off NSAIDs after the first week or so of use. If after a week's time your equine's comfort level has not increased, then the cause of the laminitis has not been removed and keeping up the NSAIDs isn't the answer - you need to address the underlying cause.

 

There is lots more information in our files and archived messages and also on our website. It is a lot of information, so take some time to go over it and feel free to ask any questions. If you are feeling overwhelmed, don't worry, you will catch on, and we are always here to help you! Once you have your case history uploaded, we can help you help your equine partner even better.

For members outside North America, there are country specific folders in the files and many international lists in the wiki to help you find local resources.

If you have any technical difficulties, please let us know so we can help you.

--

Candice Piraino

Primary Response Team

September 2018, Summerfield, FL

Shark's Case History

Shark's Photo Album 

PHCP Barefoot Trimmer @www.arkhavenfarm.com

 


Re: andy ideal weight?

 

Hi Chemelle,
He’s still a little furry, correct?  I would say from his ribbiness 4 to 4.5.  I’m one who thinks 4.5 is perfect and we have a Shetland I keep even thinner.
I just went to check his case history and I guess that wasn’t what you were hoping to hear.  I see he’s on invokana - have you been in touch with Dr. Kellon about him?  She seems to have prioritized those issues, which is wonderful.  When I first looked at his photo, I thought PPID.  His ACTH level looks good but you could probably try playing with his pergolide dose to see if you notice any changes in his appetite.
--
Martha in Vermont
ECIR Group Primary Response
July 2012 
 
Logo (dec. 7/20/19), Tobit(EC) and Pumpkin, Handy and Silver (EC/IR)

Martha and Logo


 
 


New IR diagnosis: confirmation and calculator assumptions help needed

 

Hello to all:)

I believe my horse is insulin resistant!  I ran my first metabolic panel this March, input the values into the ECIR calculator and it appears that my boy may be compensated insulin resistant!  

This is my first horse and my first time delving into such topics, so I would love to have some feedback as to wether I'm reading this correctly or not.  My Vet, barn manager, farrier and trainer all say my horse is the perfect picture of health with nothing to worry about.... just a few pounds to lose, yet he is a VERY easy keeper and I want to head off any future problems.  I took ownership In January and consulted with a nutritionist to remove junk food from his diet.  Between her advice and FEEDXL nutrition calculator, I actually found my way in February, quite by accident, to feeding him Timothy hay in a net (to slow him down - he's a vacuum cleaner) and the Amino Trace+ vitamins/minerals.  He also has some Smartpakequine joint support and a handful of alfalfa pellets as a carrier for the supplements.  Last year, Magic did not have an owner or an exercise program, so he began his return to work last fall with the trainer to the point where he is now developing muscle and conditioning.  Unfortunately, he has not lost any weight in spite of his new diet and exercise.  This is what prompted me to run a metabolic panel to see if there were any underlying conditions.  I believe we prepared for the test correctly by avoiding the breakfast feeding and allowing him access to hay for 4 hours prior to the blood draw (he does not receive any hay overnight). Nor was he turned out or exercised.  When I confronted my nutritionist with my findings, she indicated that the cutoffs for IR derived by the ECIR Group were based on complete fasting not hay fasting (I know I read on the calculator that the material is based on hay testing).  In any event, no one thinks my horse is IR!

Can someone please confirm that my observations, assumptions and calculations are correct?  I"m not happy knowing this information but find myself completely relieved to know there is a group like this with such detailed guidance and support that I can find a way to take the best care of my new equine partner!! If there are any additional diagnostics that would be helpful, please let me know.

Many thanks to all of you who do what you do - you are appreciated!!


--
Laura & Magic, NJ joined 2021

https://ecir.groups.io/g/CaseHistory/files/Laura%20&%20Magic/Magic%20Case%20History.pdf

https://ecir.groups.io/g/CaseHistory/files/Laura%20&%20Magic/Hay%20Analysis/Magic%20hay%20analysis%20jan%202021.pdf


Re: Requesting Hoof Markups for Shiraz

Nancy K.
 

Okay. I got hind feet for both of my girls and standing leg shots.

I joked about the wind. It was not funny and Jalila does not have a cooperation hat (red-headed Arab). I’m afraid the angles on her hind leg standing shots are not what you want.  I’ve taught Jalila to come to me when I squat down and she loves the camera because I film a lot of our positive reinforcement training. I even tried sneaking up and shooting from underneath Shiraz’s belly but I couldn’t get the right angle. I will try tomorrow. It is supposed to blow again and maybe snow, but my husband can help me.

Thank you again.
Nancy Camp
Whole Horse Training
Carey, Idaho 83320



--

-Nancy K. with Jalila & Shiraz

March 2021, Blaine county Idaho

Case Histories: https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Jalila

Jalila’s Photos: https://ecir.groups.io/g/CaseHistory/album?id=262313
Shiraz's Photos: 
https://ecir.groups.io/g/CaseHistory/album?id=262467 

 


Dr. Kellon - next steps for Sunny

Patti SoCal 2020
 

Hi Dr. Kellon,

I hope you are recovering and able to rest.

I received the results of Sunny's latest CBC/chem and have uploaded them into his CH.  His triglycerides went down from 1096 (Apr 7) to 486 (Apr 13).  His AST (SGOT) and GGT remain high. He also is still anemic.  I should be receiving insulin results from Cornell in a few days.  Sunny was becoming very footsore last night so I gave him 150 mgs of Invokana, which I repeated today.

I am hoping for some input for a protocol going forward.  We (my vet and I) are thinking of the following:

Give Sunny 150 mgs/day until his footsoreness resolves, then either a) decrease the daily dose to maintain his feet and hopefully blood levels, OR b) remain at the same dose and give intermittently depending on the length of effects.  I am also planning to rerun CBC/chem/insulin in 1 or 2 weeks.  I am also going to start him on beet pulp.

I would be appreciative of your thoughts and guidance.  Also, I want to make sure I'm not missing anything.  As always, thank you for your time and help!


--
Patti
SoCal 2020                                                 
https://ecir.groups.io/g/CaseHistory/files/Patti%20and%20Sunny 
https://ecir.groups.io/g/album?id=262934  


Re: Wellness Ready Laminitis test kit???

Bobbie Day
 

Got this as well, I agree Lavinia beautiful horse !
I bet it’s probably not doable (cost wise) for most. It would be wonderful though to be able to test yourself. I am interested in what you find out too.


--
Bobbie and Desi
NRC Plus March 2020
Utah, Nov 2018

https://ecir.groups.io/g/CaseHistory/files/Bobbie%20and%20Desi

https://ecir.groups.io/g/CaseHistory/album?id=78821


Re: Important - Attention those using Invokana or other drugs in this class

Eleanor Kellon, VMD
 

Sherry,

Last insulin was 58 and she's sound. I don't know yet how this will turn out!
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Vitamin E - Potency

chemelle
 

I've been cutting the capsules open as Andy no longer eats soaked meals and they do not dissolve. Once they are opened, how long does the Vit E maintain its potency?
--
Chemelle
Hillsboro, OR
2019
https://ecir.groups.io/g/CaseHistory/files/Chemelle%20and%20Andy 

https://ecir.groups.io/g/CaseHistory/album?id=94380


andy ideal weight?

chemelle
 

Just wondering if it was possible to get some input on Andy's BCS?
Photos from 4/12/21 uploaded to photo folder.
--
Chemelle
Hillsboro, OR
2019
https://ecir.groups.io/g/CaseHistory/files/Chemelle%20and%20Andy 

https://ecir.groups.io/g/CaseHistory/album?id=94380


Re: Cody's test results

Sherry with Dusty, Blue and Cody
 

Hi Kirsten,

Yes, he is still on 2mg Prascend.  How would I post the CBC results?  My vet said everything looked good (she was originally checking for levels having to do with his liver as she said she has seen some horses on Prascend have liver issues) considering his age and PPID plus he has heaves during the seasonal rise.   

Balancing to hay is not feasible for us due to storage capability and differing suppliers in our area.  After I read your message, I had Copper and Zinc (from Uckele) left from before so I started him back on them at the dose recommended on the bag.  I forgot to add to his CH that he is also on Al-Car, Remission, (I stopped his Mag-Ox), j-herb, and 1000iu vitamin C a day.  (I'll update his CH asap) I have a very tight budget and with Remission, Tri Amino, Copper and Zinc, salt, vitamin E, I hope I am getting what he needs. His hay is soaked.  

I re-read the article on FFW that you linked.  I did try the psyllium with no luck.  As you say, it could be the grass coming in that is helping but at this point I'm just grateful it is improving.  I did order the Absorb-All (it is one of the few things I haven't tried) and will give it a go as there is some improvement but still more to go before his stools are normal.  

I would say 3.5 - 4.  His back/topline came out of winter not great, to say the least.  
--
Sherry, Feb 2018, Gates, NC
https://ecir.groups.io/g/CaseHistory/files/Sherry%20and%20Cody  

https://ecir.groups.io/g/DustyHoof/album?id=38179 

https://ecir.groups.io/g/BlueHoof/album?id=38486

https://ecir.groups.io/g/CaseHistory/album?id=38227
 


Re: Lavinia - request for mark ups

Sherry Morse
 

Hi Toni,

https://ecir.groups.io/g/main/message/217233 and https://ecir.groups.io/g/main/message/217002. Short version - as per Purina it's 15% sugar and starch which is over our recommended limit.  It also has an alfalfa base which can be an issue with some IR and PPID horses and includes molasses and wheat middlings which are on the no list for IR horses. 

https://ecir.groups.io/g/main/message/261645 - for what Outlast does vs. another option.




Re: Lavinia - request for mark ups

riggatoni@...
 

Hi Sherry,
I’ve been trying to find why outlast gastric support supplement isn’t recommended and haven’t had any luck, could you point me in the right direction.

Thanks,
Toni
--
Toni and Ella 
Pacific Northwest 2021

Case History: https://ecir.groups.io/g/CaseHistory/files/Toni%20and%20Ella/
Ella's Photos: https://ecir.groups.io/g/CaseHistory/album?id=262373

 

 

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