Date   

Re: Bugsy is sore :(

hdavis
 

Hi Judy,

sorry to hear about Bugsy.  I feel your pain as have been through this with my horses and such a struggle...but this group has helped me immensely and my horses are still alive because of them.

In addition, the only thing I have to add is maybe ask your vet if Boehringer is offering free testing again this year for PPID?  I did this last year with my mare Riosa and it sure helps as always nice to have some costs offset.  I think they offer the program pretty regularly but haven’t heard about it yet for 2020, but might be worth the ask?

Thinking if you and Bugsy!
--
Heather
August 5, 2017, Brandon, Manitoba, Canada

Riosa Case History
https://ecir.groups.io/g/CaseHistory/files/Heather%20and%20Riosa

 Photos

https://ecir.groups.io/g/CaseHistory/album?id=8819&p=pcreated,,,20,2,0,0  .


Storm

Case History



photos

 
 

 




Re: Thoughts on laminitis episode for Canadian mare

Lavinia Fiscaletti
 
Edited

Testing will give you a definitive diagnosis, tell you where you stand and give you a base to compare with later on. Depending on her age, which isn't in her case history, PPID may be part of the issue. If it is, then she will definitely need medication, as well as a controlled diet and good trim, to get and keep her sound.

Horses' feet are not designed to provide support totally on the walls. The walls should provide no more than 10-15% of the total weight bearing. Your farrier was correct to remove the excess wall length so the entire bottom of the foot would be engaged in supporting the horse. To get the trim fixed, she really should be on a tighter trim schedule than 6 week intervals, as the toe regrowth and heel crushing under will just continue to outpace the trim cycle.

Given the information you have already provided regarding the barn's management practices (feeding her more than you tell them and than she needs, not taking the time to get her muzzled properly, turning her out onto grass more than she should be), I'd be inclined to believe she was left out for the 6 hours rather than the amended 2-3..

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Re: ACTH results

Sherry Morse
 

Hi Kris,

Treating a horse as if he were Cushings involves putting them on medication as it's not something that can be controlled without it. You can refer to the Liphook graph here: https://liphookequinehospital.co.uk/wp-content/uploads/Seasonal-Changes-in-ACTH-Secretion2.pdf and look at week 33 for August 10th which indicates that the average horse will have an ACTH of slightly over 40. 

At this point you can choose to start him on Pergolide or wait and retest him in the early spring and see what his ACTH is at that point.  Some horses only need to be treated during the rise in the early stages of the disease and he may be one of them.




Re: Thoughts on laminitis episode for Canadian mare

Lavinia Fiscaletti
 

Hi Pat,

Agree with Sherry that she should be wearing her boots most of the time as long as she is sore - so good that is happening. Liberally dusting her soles/frogs/collateral grooves with an athlete's foot powder each time you change her boots will help keep her feet drier and help prevent any greeblies from taking hold in that dark, moist environment.

You didn't cause laminitis by taking off her shoes. Although she may have needed boots for a time to allow her feet to toughen up for being barefoot, that is a normal transition step. The trim needs to get the toes back more, RF more than the LF. The chipping along the perimeter walls is a combination of some excess wall length, toe too long horizontally and the need to have the diet provide a better balance of necessary minerals so she has all the building blocks she needs to grow strong feet. Her heels are underrun, again worse on the RF than LF. That's going to take finessing them back into place while maintaining the vertical height. There doesn't appear to be wall flaring, so that's a good thing. Her soles appear fairly flat, with little collateral groove depth near the apex of the frog. This generally points to thin soles, which would contribute to her being tender without boots.

All of the mechanical elements are quite fixable once the trim and diet are appropriate. How soon you get the diet and trim optimized will determine how long she needs to refrain from formal exercise.

--
Lavinia, George Too, Calvin (PPID) and Dinky (PPID/IR)
Nappi, George and Dante Over the Bridge
Jan 05, RI
Moderator ECIR


Re: V/M supplement/ diet help

Sherry Morse
 

Hi Kristin,

Last question first - if you're replying from the website "reply to the group" is the option you want. If you're replying from Gmail just hit "reply". 

Glad to hear he was sound with the Soft Rides.  That's a pretty good sign he needs more sole depth and possibly some trim tweaking to help get him there.

As far as the medicating - I believe that's more of an issue if you were to try to test him for IR so my suggestion for now would be to treat the PPID and modify his diet appropriately and if there is any elevation in insulin due to the PPID it will hopefully be resolved that way.

Keep us posted on how the diet changes go and if you have any questions about posting pictures or completing the Case History just let us know.




Re: Founder- Help!

Sherry Morse
 

Hi Christine,

You'll get a full welcome soon but suffice to say your pony is definitely IR based on his insulin bloodwork.  Having glucose run will help as well and knowing what his actual ACTH number is as we are at the peak of the fall rise right now which often results in winter laminitis.

Bute will not help a metabolic laminitis so unless you're using it for another reason he should be weaned off of it to avoid a rebound (information on that will be in your welcome letter).  We've had other horses here on Gabapentin and Tylenol, but again - they just mask symptoms, they don't solve the problem.  To stop the laminitis you need to find and remove the trigger. 

If he's sound in boots, leave him in them so he's comfortable.  We do not advocate any forced exercise until the horse is sound and comfortable without meds.  It doesn't sound like you're there quite yet.  If you could current pictures and the latest xrays to a photo folder (information in the welcome letter) it will be very helpful as we can help identify where his trim can be improved. It sounds like he has very thin soles in addition to whatever other issues may be going on with his feet right nwo.

Just so you know, we're less concerned about the NSC total than we are about the ESC+starch number of a given hay.  We also need to know weight of the hay and any concentrates being fed to determine if the amount being fed is appropriate.

Coolstance is not recommended here due to the high fat content. You can look in the archives for information on Heiro and experiences members have had with it.  We prefer using flax instead of Camelina as the Omega 3:6 ratio is better - you can read more about that here: https://ecir.groups.io/g/main/message/218579. Finally, the Himalayan salt licks are not recommended here due to impurities - particularly iron - that are found in them.





ACTH results

KrisA
 

16 year old Trakehner gelding.  Started to notice that his long guard hairs didn't shed normally this spring, and then when his summer coat came in it was somewhat longer and possibly finer than usual.  He normally has the shortest, slickest coat of all my horses, but this spring it came in different.  Checked with his breeder, and her farm manager said that his dam, who is about 20, had this same change in her coat, has been tested numerous times for Cushings. and tests negative.  She also goes out on lush pasture, unrestricted, and always has, and has never foundered.

So back to my gelding.  Blood was drawn for ACTH on August 10, 2020 and came back 50pg/ml.  Insulin was 20uIU/ml

My plan right now is to feed him as if he was Cushings and then have him retested in the spring.  Does that sound reasonable, or should he be put on a low dose of Pergolide?

Thank you, Kris
--
Kris Anderson
Williamstown, MA  2020


Re: Founder- Help!

 

Hello Christine,
I'm not sure if you joined this group when it was a yahoo group but I'm glad you decided to join us here for your pony's sake. I know you have been sent the instructions for creating a case history for your pony. All of the info  you have provided above will need to go into the case history form. I found it helped me to print out a copy of the form and used a pencil to begin filling it in, especially when gathering all the info for the health/illness section.

Besides this IO Group we have a web site at 
https://www.ecirhorse.org/
I urge you to read the all of the main menu topics, especially the DDT&E and EMS sections. Our "Wiki" (see column on the left side of this page) will help you with all the "How-To" use this group, create case history, signature, creating folders, etc. So any time you have difficulty with HOW to use this site go over to the Wiki.

Most new members begin with putting their equines on the  very basic and safe Emergency Diet. This will eliminate any dietary items that can worsen your EMS equines situation.

You will be getting further advice from our moderators and members. Please read the detailed New Member protocols below. I do suggest that you copy and paste this first message to a document to save it because you will want to refer back to it several times. If you save it to a document you won't have to go searching for it.

Welcome to the group! 

The ECIR Group provides the best, most up to date information on Cushing's (PPID) and 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 Insulin Resistance (IR). These are two separate issues that share some overlapping symptoms. An equine may be either PPID or 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 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: IR 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 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 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 IR/PPID individuals.

We do not recommend feeding alfalfa hay to IR/PPID 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. 

 

--
Bonnie Snodgrass 07-2016

ECIR Group Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album


Re: New Member - Bullitt Laminitis

Sarah Orlofske
 

Hello Sherry and others, 

I have first tried to work out the balancing on my own. I am furloughed and my husband is facing a potential layoff due to COVID-19 so we are trying to be as economical as we can. There are some real financial challenges we are dealing with right now. I have reached out to some people on the list but have not heard back yet. 

We are not currently treating the hives; our vet is unavailable and we have reached out to another vet with no success yet. We added one of our smartpak supplements back for just 1 day over a week ago about the time we started making the switch with the hay because of the poop eating, but then we immediately stopped the supplements when the hives appeared. We were going to try that in very small amounts just until we got things figured out with the mineral balancing. At first we thought that the supplements were the issue, but like I said it has been more than a week back on just the emergency diet and he continues to decline both in the hives and in his laminitis symptoms. He is walking much worse than a week ago and has not been off stall rest. 

I appreciate your quick response. 
--
Sarah O. 
Rudolph, WI
2020


Re: V/M supplement/ diet help

Kristin Horton
 

Thank you, Sherry!

ACTH:  Pre 46.5 pg/ml  Post 467 pg/ml.  Yes, he was sedated.  My vet said he asked Cornell if that would change the results and they said it was ok- as this is the only way anyone is coming near him with a needle.  I will work on getting some pictures of his feet, I have not done xrays yet.  I did put the soft rides on for a trial this morning and he walked perfectly on the concrete with them. 

Good info on the Outlast.  I am only post ulcer treatment for 2 weeks and this is the 2nd treatment- so I am afraid to make too many changes at once, but it sounds like I need to do an entire diet overhaul.   I will order the Cal Trace today and buy some of the TC balance cubes- to see if this will work for his main meals (replacing TC30, Dynasport).  Once I get this part figured out, then I will wean him off of the Outlast and AlfaLox. I will also order some samples of the Stabul 1. 

Thank you for all your help.

P.S: Am I supposed to be relying to group or replying to sender? 

--
Kristin Horton

--
Kristin Horton, FL, 2020


Re: Thoughts on laminitis episode for Canadian mare

Pat
 

She has been wearing boots most of the time since I took her shoes off July 1. She was very sore after removing shoes.

Before I went on vacation, she seemed a lot better. I had the boots off for a couple of days, she was moving ok at a trot in the outdoor arena.

While I was away she was out on grass for quite a long time I believe. I was told 6 hours because someone forgot to shut the gate. Now they say something else - 2-3 hours.

But she was really sore when I got back and has been wearing boots all the time since then. I am only out 3x per week and the boots are removed then and cleaned, then put back on.
--
Pat
August 2020
Metro Vancouver BC Canada
Case: https://ecir.groups.io/g/CaseHistory/files/Pat%20and%20Willow
Photos: https://ecir.groups.io/g/CaseHistory/album?id=253325


Re: Bugsy is sore :(

Nancy C
 

Meant to add link to get Dr Kellon's 2017 conference lectures https://www.ecirhorse.org/proceedings-2017.php

Also -- totally agree with Sherry.  It's your money. I have asked many a vet to humor me when I wanted something done, and never was sorry.
--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2019-2020
Join us at the 2021 NO Laminitis! Conference, August 12-15, Harrisburg, PA


Re: V/M supplement/ diet help

Kristin Horton
 

Thank you, Martha! The chance that he may not be IR, is great! Yes, bloodwork was all completely normal. 

The scratches already seem to be drying out a bit, so I am hopeful this is from the meds beginning to work. Good tip on using them as a way to possibly know when his meds need adjusting. The supplier I am using for hay now grows it mainly in Idaho, though he also gets some from Canada periodically.  I will go ahead and find a way to test this batch, which should give me a guesstimate on the S/S at least. I got a sample bale of Tifton 85 which was tested and super low in S/S, good protein- but Mr. Picky will not eat it.  I will search the messages to see what else I can find. 

I will pick up some TC bance cubes this week.  I have another horse who chokes and can't have hay, so they won't go to waste.  

I really appreciate your response. 

--
Kristin Horton

--
Kristin Horton, FL, 2020


Re: Bugsy is sore :(

Nancy C
 

Hi Judy

First, based on those ambient temps, I'd be thinking about "Winter Laminitis"

As to Seasonal Rise, this is from Dr Kellon's NO Lamintis! Conference 2017 Lecture Acute Care for Endocrinopathic Laminitis

— Seasonal rise

Cutoff values for ACTH (Figure 1): Same group of individuals plotted by week as monthly chart shown previously.
Uncontrolled PPID or exaggerated seasonal rise can drive insulin higher. Liphook Equine Hospital in the UK tested more than 30,000 horses, both PPID and normal, to establish weekly normal cutoffs of ACTH values throughout the year. Because the above is unpublished data, age distribution is unknown. Lee, et al., 2010, also in the UK, found that older non-PPID horses may have a higher seasonal rise than young
horses. An older horse may go as high as 80 or 90 in the Fall and still not be PPID. 

If you download the lecture you can view the graph (Figure 1) which shows : ACTH cutoff values for every week of the year (Durham, 2016, unpublished data) with the dashed line indicating previously used monthly cutoff values (Copas and Durham, 2012).

Please note, the Copas and Durham 2012 study (link below) concludes
Plasma ACTH can be used for the diagnosis and monitoring of PPID throughout the year with the use of appropriate reference intervals. Thesefindings demonstrate an increase in pituitary gland secretory activity during the late summer and autumn in both normal and PPID cases

Here are links
https://liphookequinehospital.co.uk/wp-content/uploads/Seasonal-Changes-in-ACTH-Secretion2.pdf
https://www.sciencedirect.com/science/article/abs/pii/S109002331000122X
https://beva.onlinelibrary.wiley.com/doi/pdf/10.1111/j.2042-3306.2011.00444

It may help to remind your vet it was a member of this group and her open-minded vet that found the effect of seasonal rise which led to these and other studies. When looking at a diagnosis, ECIR Group has always looked at the whole animal. This is why a Case History is so critical. I bet you know that.

Hope this helps.

--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2019-2020
Join us at the 2021 NO Laminitis! Conference, August 12-15, Harrisburg, PA


Re: Thoughts on laminitis episode for Canadian mare

Pat
 

No grass at all for 3 weeks, since I returned from vacation on August 28 and found her so sore.

She was trimmed on August 28.

The vet - who is known for being good with metabolic issues - did not recommend testing or x-rays.  The vet was puzzled by the trim (she saw Willow about four days after). I think my farrier is trimming her with a goal of reshaping the hoof. Next trim scheduled for Oct 8.  I will be seeing the vet before then.
--
Pat
August 2020
Metro Vancouver BC Canada
Case: https://ecir.groups.io/g/CaseHistory/files/Pat%20and%20Willow
Photos: https://ecir.groups.io/g/CaseHistory/album?id=253325


Re: Previcox, ok??

Sherry Morse
 

Hi Nina,

You can do a search in the message archive online, but yes Previcox is 'safe', just don't plan on forcing exercise while a horse is on it as it can mask pain.




Re: Bugsy is sore :(

Sherry Morse
 

Hi Judy,

Sorry Bugsy is sore.  You can send your vet this link as well as the information in the other Liphook article: https://liphookequinehospital.co.uk/wp-content/uploads/Seasonal-Changes-in-ACTH-Secretion2.pdf but there is no reason to not test now since most labs do offer a seasonally adjusted range for ACTH.  If he comes in at slightly higher than average you may want to consider using Prascend only during the rise but if he comes in at a grossly high level you have a pretty clear indication that PPID is an issue.

As always, you can fall back on the statement that it's your horse and your money and if you want him tested the vet should just test him but hopefully it won't come to that.




Re: Hay Results

Sherry Morse
 

Hi Tamara,

In a nutshell you want the ESC+starch to be under 10% when the analysis is done via wet chemistry.  If you had the Trainer 603 test done on this hay it's well under that number.  Other than that I can't help for mineral balancing but if you contact someone on the balancer list they can. 

All information on hay can be found on the ECIR website at https://www.ecirhorse.org/DDT+E-diet.php




Re: New Member - Bullitt Laminitis

Sherry Morse
 

Hi Sarah,

Are you working with one of the balancers on the list in the file or trying to sort the minerals out on your own?  Did anything else change other than the hay when he developed the hives?  Are you giving him anything for them?




Re: To Soak or Not to Soak???

Nancy C
 

Hi Philippa

I know this can be frustrating. My take is that when you are in doubt, soak. As you have heard, DM will be higher than As Fed, but I think you can still extrapolate that this hay may be too high for Abraham. Additionally it appears that Hill Labs uses NIR testing. Again, as you've heard, some members have found that NIR testing can be lower than Wet Chemistry is side-by-side testing.

The fructan number is higher than many of us see for sure.  I cannot speak to the lab report differences, except to perhaps be lab testing protocols and/or and sample differences. IF there were a problem from fructan, upon feeding you would see gut upset at a minimum.

Hoping Dr Kellon or others from NZ, may weigh in on testing and WSC. Bottom line from me is, I would be soaking this hay.

Hang in there.
--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2019-2020
Join us at the 2021 NO Laminitis! Conference, August 12-15, Harrisburg, PA

26881 - 26900 of 278190