Date   

Re: Re-addressing fructan level #Fructans

 

In addition to Sherry's excellent and accurate response, a reminder to go full circle with "diagnosis."

First and foremost, what is the cause of the laminitis? We often forget that laminitis is a secondary outcome. Treating laminitis is like trying to get the cows back in the barn - how did they get out in the first place?

If the horse has or had documented high insulin and that is the known cause of the laminitis, the question should be, "Did the diet change result in a reduction of insulin?" If yes, then the diet is effective and the source of the current symptoms need to be investigated. Other things to consider - does the horse have unmanaged PPID? Does the horse have abscesses brewing from post-laminitic damage? Is the trim/hoof support adequate? Is there an underlying infection?

If fructan is an issue related to laminitis, then the mechanism is through endotoxemia or "sepsis-induced laminitis." In that case (which, BTW, has never been documented on pasture and certainly not hay), then there would be symptoms accompanying or preceding the laminitis, like a gut upset. 

In the experiments where researchers triggered sepsis-induced laminitis using rapid induction of inulin fructan, they needed a minimum of 5 lbs to trigger laminitis in 30% of animals and 8 lbs in 100%. That's pure fructan, delivered to the gut all at once. If this horse is eating hay (slowly) with 4.64% estimated fructan, fed at 2% bodyweight per day, that's about 1 lb of fructan, and a different form of fructan than that derived from artichokes, delivered over the course of the day. I would be more than happy - thrilled actually - if someone could explain to me how that would trigger sepsis-induced laminitis. Even the unproven theory that there is a release of fructose/glucose molecules as the fructan is being fermented and that somehow results in hyperinsulinemia is squishy in this case because even if you use NSC (WSC+starch), it's barely above 10%. So... where's the logic?

Sorry - don't mean to shoot the messenger and you were absolutely correct to ask. It's just that, after over 10 years of illogical argument with no data to support it, it gets annoying. Take this quote for example,

"Although laminitis has yet to be induced experimentally by feeding fructan-rich pasture or a fructan-rich extract, there are anecdotal reports of clinical laminitis occurring when diets are below 10% ESC+starch but high in NSC." Again... what is the cause of the laminitis? Notice that it doesn't say, "there are reports of hyperinsulinemia..." again (and again) pointing to the outcome, not the cause. The paragraph concludes with, "Until specific research data are available, horse and pony owners would be well advised to avoid feeding high-NSC pasture and hays,... to soak... to use grazing muzzles."

As a scientist and advisor to this group, I find this completely illogical. It basically says, "There is no proof, but let's put the burden on the horse owner." Not only is there no proof, there's no physiologic basis for the rationale. Fructans are pre-biotic and are likely more beneficial than not. They certainly don't have a role in glucose or insulin production unless the horse is a species unlike all other mammals. 

Argh... sorry - it's not you - it's this topic!
--

Kathleen (KFG in KCMO)

Director and Research Advisor, ECIR Group Inc.

Missouri, USA, 2005

https://scholar.google.com/citations?hl=en&user=3-I7UI0AAAAJ 

 


Re: Vitex/Chasteberry study #Vitex_CHB_Chasteberry

 

This link to the article,  Use of the Chasteberry Preparation Corticosal® for the Treatment of Pituitary Pars Intermedia Dysfunction in Horses,  works for me. 
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos


Re: New Bloodwork Results in updated Case History- Please Review

Sherry Morse
 


Hi Leigh,

Looks like you are definitely heading in the right direction so that's wonderful news.  If May is comfortable enough to get back to work you may find that brings her insulin down even more.




Re: Vitex/Chasteberry study #Vitex_CHB_Chasteberry

chemelle
 

Thank you for this!
I recently added the chasteberry (evitex) to improve shedding and I think Andy already has a very pronounced seasonal rise.
--
Chemelle
Hillsboro, OR
2019
https://ecir.groups.io/g/CaseHistory/files/Chemelle%20and%20Andy 

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


Jiji's Blood Test Results

 

Well, I got a text from the vet but not her actual results. I will post them once everything is in on this thread.
"Not all the results are back but so far everything is looking normal on Jiji. Neg for Cushings I, insulin resistance, and hypothyroidism. Selenium levels are above normal but not at a toxic level. Vitamin E is a normal level. I will send the final report when finalized but her sore feet don't seem to be caused by a metabolic disorder. We don't know what her vitamin E and selenium levels were before she started the supplement and started on grass so we can only speculate on that. Doesn't hurt to supplement with vitamin E in winter and keep her on something with biotin for her feet."
I've also sent in a UC Davis test for PSSM1, HYPP, MYHM, and MH. As I said I will report her actual test results (and whether she's negative for the QH diseases) with the normal lab values as soon as I get them. But it might be that her laminitis is mechanically-caused?
When I got Jiji in 2017, I will admit, I was unaware of what healthy hoof care looked like. She was shod and had extremely underrun heels, terrible thrush, and a very long toe. Quarter cracks, wall splitting, a crumbling white line on every foot. Then, when we decided to go barefoot the farrier simply said to let her rest in the pasture for a couple of days and she would be fine. (She wasn't.) He said that it was simple, if she could not remain sound whilst barefoot then she should have shoes. I ended up finding Pete Ramey's website and decided she should be kept barefoot. She has slowly developed a stronger foot but this was without the help of an educated trimmer, or an adequate, balanced diet. It has been 4 years and she still has underrun heels and distortion to her hooves. It wasn't until I read the nutrition article of Pete Ramey's that I realized her diet was off.
I am really surprised that she ISN'T positive for any metabolic issue. She is overweight. While she doesn't have noticeable fat pads or a cresty neck, she has the fat above her eyes and spongy fat around her tailhead and behind her shoulder. Her feet are terrible (bruised and a present digital pulse... though the vet said it wasn't a bounding pulse) and she looks stiff... Not the typical foundered stance but she camps out in the back and points her left front. I did the Karo Light glucose test and I could see changes in Jiji's comfort (physical stance and facial pain indicators) within an hour of administering the corn syrup. I swear something is wrong.
Any diagnostic suggestions, or ideas on what might be up with her? Could it have been a false negative? Questions for me, farrier, vet?
Jiji is being transitioned off grass and onto timothy hay as I write this. It's a slow process because not everything I need to do it is ordered, but she will soon be off grass completely. Tonight or tomorrow morning.
--
-Olivia
May 2021, Bemidji, Minnesota
Jiji's Case History
Photo Album


Re: Question about when to test hay

Nancy C
 

Hi Bill

FWIW we have used propionic hay preservative when the bales were coming in at >10%. They have only had to do that once or twice.  These are small(er) bales 30-50 pounds, typically.
--
Nancy C in NH
ECIR Moderator 2003
ECIR Group Inc. President/Treasurer  2020-2021
Join us at the 2021 NO Laminitis! Conference, August 13-15, ECIR Virtual Conference Room


New Bloodwork Results in updated Case History- Please Review

lfitz66
 

I just updated May's Case History with her latest bloodwork. Would love feedback. My farrier also came and made the adjustments to her glue ons as Lavinia suggested.
TY
--
Leigh and May
Michigan
Joined 2020
https://ecir.groups.io/g/CaseHistory/files/Leigh%20and%20May
https://ecir.groups.io/g/CaseHistory/album?id=260799


Re: Question about when to test hay

 

I feel better....we make 4x5 round bales and we have a meter we test several bales for moisture content in each field. We have 4 bales the moisture tested above 22 in just one spot on one side of the bale and below 17 everywhere else. We stack ours in the barn the day we bale because we usually are chasing the next rainfall. This year our first field was cut under cooler temps by day and night but it dried fine with the exception of some small fields we never usually cut. But because this is the earliest we have gotten any hay in and....the time of day I am very nervous about the sugars. I will go ahead and sample today and send it in for my peace of mind then take another sample in a month for my AG agent. We are planning on baling the next 2 fields this week but the temps are rising to what we normally have so we should have plenty of drying time and the ability to cut early in the morning. Thank you!


Sent with ProtonMail Secure Email.


--
Nancy and Akira
3/20/2018  Burkesville KY

Case History: https://ecir.groups.io/g/CaseHistory/files/Nancy%20and%20Akira


Re: Re-addressing fructan level #Fructans

Sherry Morse
 

Hi Delli,

Fructans have long been disproved to have anything to do with endocrine laminitis:


Now, having said that - as you should know there are more than just diet changes associated with endocrine laminitis.  Has this horse been tested to be IR or PPID? If yes, have there been further tests after diet changes to see if the bloods have improved?  If the horse was overweight, has it lost weight?  Have there been adjustments to the trim to address issues in the hooves?  What else is the horse eating besides hay? 

That's just the tip of the iceberg on questions but if the horse is IR or PPID you can help the owner by directing hm/her to this list so we can help the horse directly by having answers to all those questions.



Vitex/Chasteberry study #Vitex_CHB_Chasteberry

Eleanor Kellon, VMD
 

This is a study from 2013 now available in full on the internet file:///C:/Users/drkel/AppData/Local/Temp/Use_of_the_chasteberry_preparation_CorticosalR_for-1.pdf . They looked at horses and ponies on Vitex only, Vitex + pergolide and pergolide only. I haven't read it in depth yet but one thing they found, as we have, is that  Vitex added to pergolide improves the coat. However,  horses on Vitex alone or Vitex + pergolide had much higher ACTH heading into seasonal rise than horses on pergolide only. Take home message is use Vitex with caution in combination with pergolide. It may block the effects on ACTH.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Re: Cushings Diagnosis

Sherry Morse
 

Hi Lynn,

You're in the right place and I have some questions for you.

1 - you have Teddy's ideal weight listed as 1250lbs but you have him listed as currently being a 6 (which is fat, not normal - normal is 4.5 - 5) and 1250lbs.  That means his ideal weight is either less than that amount or his current weight is about 100 - 150lbs more than he should be (that's a guess, we could tell more with actual pictures). 

Based on a weight of 1250lbs. he should be eating no more than 25lbs a day total and as a PPID horse he should not be eating the Blue Seal product as it's extremely high in ESC+starch (19.9% as per Blue Seal: https://ecir.groups.io/g/main/files/9c%20Analyses%20of%20Various%20Feeds/Blue%20Seal%20Products/BlueSealFeeds.5-18-2018.pdf)

I would recommend replacing that with R/S/R beet pulp if he needs a carrier for his supplements. There's more on that in the emergency diet information you'll receive. I'd also replace the iodized salt block with loose salt added to his feed so you know he's actually eating it and start him on Vitamin E again.

As far as supplements, why is he on Red Cell? If that's not current can you please make a note of that.  Please be aware that the only lab in the US that can test actual ferritin levels in horses is at KSU. 

2 - What changes were you expecting to see from starting him on Prascend? If he's been on it since the end of March you can retest now (you only need to do the basal ACTH, not the TRH test as there's no adjusted scale for post-TRH results for horses on medication) to see if it's brought his ACTH level down or he needs a larger dose of medication.

3 - Based on your note your last insulin/glucose test was done fasting.  Please read about how this can effect results on the ECIR website: https://www.ecirhorse.org/FastingInsulin-LabRefRanges.php.  Is the 212 for glucose the actual number on his paperwork or is that a typo?  If that's not a typo he's diabetic which is a whole other management issue. 





Re: Hydroxizine?

liisaacson
 

Thanks all. I’ll add spirulina & chrondroitin. Are there recommendations on dosage and supplier?

thanks again,
lisa
--
Lisa and Haven
Independence, MN
2015

Haven's case history: https://ecir.groups.io/g/CaseHistory/files/Lisa%20and%20Haven 

Haven's photos: https://ecir.groups.io/g/CaseHistory/album?id=261155 


Re-addressing fructan level #Fructans

freddelskutar@...
 

Hello ECIR.
  I am posting this topic because there is a nearby horse that has laminitic symptoms even after months of diet change. This horse is on the same low sugar hay as mine. It was mentioned that the hay could till be a trigger as it's fructan level is greater than 2. In this case the WSC is 10.08, ESC is 5.44, Fructan of 4.64, Starch 0.41 (DM). The horse breed is a Morgan, in case you were wondering. 
  I was wondering if there was any new research on acceptable dietary levels for IR/EMS horses?  And on fructan levels? I realize this may be re-opening a subject that has been discussed many times before but I felt I needed to ask. 
  Thank you.
--
DS and Julie
BC, Canada
3/2018

Case History: https://ecir.groups.io/g/CaseHistory/files/Delli%20and%20Julie

Photos: https://ecir.groups.io/g/CaseHistory/album?id=88389

 


Re: Cushings Diagnosis

 

Hi Lynn,

You can test Teddy again any time 3 weeks after starting pergolide or changing the dose.  You only need an endogenous test going forward.  You can see from you most recent TRH stim test that the pre stim value is elevated.  That value is what you need to monitor - no reason to stimulate.

The symptoms of PPID can be highly variable.  Why did you decide to test?  If you don’t see any improvement, it could be that you will need to increase the pergolide dose or that the symptoms are not related to PPID.  If the issue is shedding, that is not always modified by pergolide.  From your tests, Teddy is definitely PPID and needs pergolide so test again to see what his ACTH level is now.

Your insulin test preparation is not what we recommend so I would suggest also testing insulin and glucose again when you test the ACTH.  We like to test when the horse is in a normal environment.  He should have his hay 4 hours before the test and left to keep munching on it.  Also, when testing ACTH, I would do that first thing.  Any excitement, agitation or even exercise could result in an elevated value.  We advise against trucking the horse to the vet for testing for the same reason.  Teddy is on the young side to have PPID but my horse tested positive at that age and I’m quite sure he would have tested positive even a few years younger.  
--
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


 
 


Re: New member- advice for endurance competition

Eleanor Kellon, VMD
 

You won't know for sure until you retest, but his insulin probably isn't an issue on that schedule, although the rest periods could be a problem.

I would suggest you start feeding 2 lbs each, by dry weight, of beet pulp and oats plus 1 oz of salt as a soaked mash within the first hour after rides at home and during and after your 50s. Work up to the full amount. By feeding it at home his gut will be accustomed to it. Do not feed this at any other time.

There is a 2 phase boost with this combination. The oats provide energy in the form of glucose for work or storage as glycogen while the beet pulp is fermented to acetate, also immediately available for energy and spares glucose for glycogen synthesis.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001


Re: NEW CASE HISTORY ASSIST

Sherry Morse
 
Edited

Hi Sue,
 
Would you be able to post pictures of Shifty?  I notice in your Case History you have him listed as fat at 1250 but you put him as a 5 on the condition chart which is right about where we want a horse to be.  So having a better picture of if he needs to lose weight or not will help us figure out if you need to make adjustments in his diet. Going by the information you have provided he needs to be eating a total of 22lbs a day (that includes hay as well as anything else he's  consuming). It looks like you're ok on that point and his bloodwork for insulin looks ok but was that a fasting test?
 
Why is he on Previcox?
 

 

 


Re: Cushings Diagnosis

 

Hello Lynn,

Welcome to the group and thank you for getting a case history created for Teddy! I have attached our new member information document below. Embedded through out the document are clickable links (blue) to more information. A good place to begin reading is our website as you will get a good overview and explanation of terms and symptoms. The following document will give you more information.

We suggest that you get familiar with the structure of our MAIN group and how to search  thru the files and messages. Searching can be done from every page using the "SEARCH BUTTON BOX
" that you will find at the top corner. Look at the column on the left side and you will see "FILES" and "WIKI". Explore using them. The Wiki is our "HOW TO DO" tool.

You will be getting responses to your questions from our moderators and members.


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. 

 

--
Bonnie Snodgrass 07-2016

ECIR Group Primary Response 

White Cloud, Michigan, USA

Mouse Case History, Photo Album Deceased


Re: Thyroid meds and timing

Sandy
 

Thank you Dr. Kellon - I appreciate your help in the dosing.
--
Sandy Kemp
Northeast Pennsylvania
Crystal Blue PPID/IR
Tiffany PPID
2021
https://ecir.groups.io/g/CaseHistory/files/Sandy%20and%20Tiffany 
https://ecir.groups.io/g/CaseHistory/files/Sandy%20and%20Crystal%20Blue


Cushings Diagnosis

Lynnie187@...
 

This is my first post for Teddy, who was recently diagnosed with Cushings Disease and was started on 1 mg Prascend on 3/31/21.    He had the ACTH test in Sept 2020 and the TRH response test in March 2021.  When should he be retested and what type of test should be used?  There has been no change in him since starting the Prascend.  When should I expect to see a result from the medication?  I am also concerned about IR. I used the EMS calculator but don't understand the results.  Thank you for your help.
--
https://ecir.groups.io/g/CaseHistory/files/Lynn%20and%20Teddy
Lynn K
Upstate N.Y.
2021


Re: Thyroid meds and timing

Eleanor Kellon, VMD
 

Sandy,

Once a day is OK.
--
Eleanor in PA

www.drkellon.com 
EC Owner 2001

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