Need some help with my mare


tara sullivan
 

Hello All.  Hoping someone can review my mare's ch and give me some advice.  Divina was diagnosed in April 2015 with Cushings and what we thought was peripheral IR.  Her ACTH was not that high at 76, but she looked  like a more advanced case.  Loss of topline, very heavy coat (she shed out but still needed to be body clipped in summer), lethargic and just frail like an old horse.  Spent the summer tweaking her pergolide and testing to see where we were.  To be honest, I never addressed the lurking IR because I truly thought that once the acth was controlled the IR would go away.  She ate a balanced diet that did include pasture, .5 lb of oats, and some alfalfa (sometimes)....all no no's!  She is not laminitic....though her soles are a little thin and her coffin bones are ground parallel.  
Although her acth is responding to the pergolide....I feel like she could never shake the veil.  I have struggled to keep her eating all summer and fall since she has been on it.  Also note that this horse is compromised by Lymes disease.
Have there been horses that just don't do well on this drug??  If someone could review her history and give me some feedback I surely would grateful.


Tara and Divina
NY 2014

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/


Lavinia Fiscaletti
 

Hi Tara,

Thanks for updating Danvina's case history. Here is a clickable link to it:

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/

Agree with you that as she is a TB the IR is most likely secondary to the uncontrolled PPID, and the leptin results support that, but as long as she is IR she needs to have her diet managed accordingly. You MAY be able to ease up on the diet once the PPID is well controlled IF her IR resolves. Whether it will or not s unknown right now. The ACTH of 76pg/ml in April was about 3 times what it should have been for that time of year, so she has probably been PPID for some time - her muscle wasting, IR status, heavy coat needing shearing would all be consistent with untreated longer-term PPID. Uncontrolled PPID will also make the Lyme worse and will prevent you from making much headway in treating it as it suppresses the immune system.

It would be really helpful to see the xrays and pictures of her feet. Could you please put those into an album in the Photos section of ECHistory8? That way, we can help fine tune some of the other issues you've mentioned. The toe crack she developed is due to trim issues imbalance, not to Lyme/PPID/IR treatment. You mention long toes, which will cause cracks all by themselves.

Her ACTH appears to have responded to the pergolide but not quite to the point where it is under good control. You are looking to get those numbers down into the low to mid-twenties at all times. To do this will require a higher dose of pergolide than the current 2mg (compounded) she is on. It is not likely a veil-type response that is causing her appetite issues as she has been on the perg since May and her ACTH still hasn't been brought down into mid-normal range.

The temperature she is running (101*-102*) could be a big factor in her depressed appetite and attitude. Chronic Lyme, and the Anaplasmosis she has been currently diagnosed with, will certainly make her feel crappy. Oral antibiotics can cause manure to be loose and smell nasty and adding bute could have pushed her gastrically over the edge. Might consider adding in a quality probiotic(containing live organisms in the BILLIONS) to her daily regimen to see if that helps. Will need to administer it 2 hours AFTER each dose of her antibiotic in order for it to be effective. Generally, you do not need to mitigate a temperature that is 102* or lower, just monitor it, but need to discuss that with your vet.

Treating her for the chronic Lyme would also be something to discuss with your vet. Oral abx aren't usually enough to make headway, tho, so would consider discussing a longer term treatment plan such as a month of the IV oxy-tet, followed by another 3 months of oral doxy and/or minocycline to really try to get at it.

Good that you are syringing in her supplements, even tho it is a pain to do. Have you had her hay analyzed and mineral balanced? Whether it is first or second cut really doesn't matter as neither is inherently more or less suitable. In fact, the majority of grass hays (first and second cut) test fine for ESC+Starch.

So, to sum it up:
  1. Raise pergolide dose to get solid control of ACTH (test results in med-twenties)
  2. Design and implement a comprehensive Lyme treatment protocol
  3. Get hay analyzed and diet tightly mineral balanced to provide nutritional basis for healing and health
  4. Get and post feet pix/xrays for analysis

HTH.

Lavinia, Dante, George Too and Peanut
Jan 05, RI
EC Support Team



Eleanor Kellon, VMD
 

I just finished a long answer and had it go “poof”. Trying again.


This is a multifactorial case and pergolide probably isn't a major issue. Please discuss with your vet.


PPID: By symptoms, the PPID is advanced. She would benefit by having tighter control, including in terms of immune system function. Consider adding another 0.5 mg of pergolide mesylate by capsule.


IR: Numbers aren't horrible but rapid positive response to a tighter diet suggests it is still a significant factor. Both PPID and Lyme are likely contributing.


Body soreness: Would not rule out this being related to hoof pain, especially with the response to diet change. Poor correlation between radiographs and pain is possible, especially in Lyme horses.


Muscle loss: PPID is certainly a factor and needs tighter control. Vitamin E deficiency related myopathy also likely since your level is still only very low normal. This also influences immunity. Consider increasing to 10,000 IU/day and always give mixed in some added oil. Inadequate protein/amino acids is also possible, especially with the strain on the immune system. Consider giving 50 to 100 grams of whey protein concentrate and 40 grams of Spirulina for protein, support of immune reactions with simultaneous antiinflammatory action.


APF doesn't seem to be helping and may be fueling inflammatory immune reactions to dying Lyme organisms [Jarisch-Herxheimer reaction]. Jiaogulan at higher dose can be tried and is also antiinflammatory.


On the mineral end, this supplement at 1 scoop/day is less expensive and a better match for your regional hays if you don't have a hay analysis:


U-Balance Foundation


but best results will come with match to your hay analysis. For example, in addition to importance for IR, magnesium is involved in keeping pain and inflammation in check.


Eleanor in PA

www.drkellon.com

EC Co-owner

Feb 2001



-


tara sullivan
 

Dr. Kellon and Lavinia....THANK YOU SO MUCH!  The recommendations give me a sense of relief and confidence...we haven't hit the wall!  There is more I can do for her.  Lavinia, I created a folder "Divina" in the pics and posted her rads from April.  I religiously read and examine your markups and comments as the other members post...and have learned alot! and continue to do so.  And have interpreted this into the trim  for my mare and will get pics of her feet up as soon as I am able.  Have been backing her toes and building up her heels....her bars were very flared.  I think her feet are greatly improved-1 moreso than the other...toe crack still there, but just a few more tweaks and it will be corrected. 

Probiotics were started a week ago-am using Equine Generator.  Hoping to get my vet out 12/21 to do blood tests-acth, insulin, glucose.  FYI-blood is always drawn in the afternoon-usually between 2 and 4pm.  Mare is pergolide dosed in the evenings anywhere from 5 to 8pm.  So her acth result is like 20 hrs or so after last dose.

Dr. Kellon- Wouldn't you know I just received a fresh bag of AZ complete.  So, for now will order spirulina (she was on it all summer but not at that level) and up her Vit. e to 10,000.  Question:  whey protein concentrate or isolate?? I have always bought the isolate. 
And I will stop procrastinating and test my hay.  Funny thing is, I really should know better!   I cut my own hay and have a very good idea of how it tests from doing it for years-but every year IS different.  I suspect starch to be somewhat problematic in the first cutting....as this was a particularly odd harvest and cuttings were pushed off by at least 30 days.  We shall see.  Then I can tweak her vits and mins as necessary. 

I stopped the APF.

Once she stabilizes, I will re evaluate the "Lymes" situation.  My initial thought was to go right to IV...but to do that I have to ship my gelding (her son) off the farm.  The herd dynamic is such that I cannot separate them while on the property-they totally stress and cannot be consoled.  They just don't understand why they can see but cannot touch.  And he will rip that catheter right out...cuz he is a jerk!   No funds for that at the moment.  Is there a better oral than doxy??

Again, Thank you for your time. -my personal team of experts.  You guys are the BEST!
Tara and Divina
NY 2014
ECHistory8

 








tara sullivan
 

After extensive discussion...the mare will remain on the pergolide.  My Vet, will start calling her Dr. G-is quite unconvinced of all that I have been trying to achieve with Divina these past 5 months.  Dr. G is very suspicious of the rising number of cushing diagnosis, especially in younger horses.  She majored in Neurological Biology and is suspect of measuring the effect of a drug on just one parameter when it effects the entire brain. And she is very uncomfortable with my choice of using a compounded product. 
She has supported me through this because of our exceptional relationship and the practice of doing regular lab work to keep things in check. 

It was, as always, a very respectful and exhausting conversation/debate.  There is a part of me that is absolutely stunned-she really has no idea of who "you guys" are or what you have been doing over the last 15 years and counting!  And she is constantly going to seminars and lectures not just about laminitis but all sorts of topics.

And, believe me! I openly discuss all that I have learned here.  She is so crazy busy...It is a shame.

But something else occurred to me....How has she not bumped into your research and findings out there??  Are you being suppressed??  Is this a Republican conspiracy?? LOL! I couldn't resist a little humor. 

Anyway....We are having a consult with an Internist today.  Dr. G is moving away from I.M.H.A on her own based on the Mare's improvement.  Her SAA continues to drop but her temps continue to undulate.  And we are moving towards dealing with the anemia ie. blood transfusion and the dreaded dexamethasone. 
And that is precisely why I will not take her off the pergolide.

What are your thoughts and advice on this front, Dr. Kellon? Can I keep my girl out of trouble??

Thank you,

Tara and Divina

NY 2015

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/


Nancy C
 

Hi Tara

If you have not done so, point your vet to the 2013 NO Laminitis! proceedings, especially Dr Kellon on PPID and IR diagnosis, at IVIS, the International Veterinary Information Service.  This is where many vets go to find information.

Sign In page - International Veterinary Information Service - IVIS

 anyone can join.  It's free.  You cn also find this info on the ecirhorse.org website.  Your vet may be more imprseed by the IVIS connection.


We are working on the 2015 No Laminitis Proceedings.  You can send her to this link if you want for her to see a bit about what and who went on there.  Also tuck away this bit: that vets who attended received 13 hours of CE credit.


http://www.nolaminitis.org/index.php/program-schedule/2015-conference-schedule


The pergolide dbase shows a lot of members on successfully  compounded drug. I'm one of them on 14 mg.  Several members have stepped up to the plate to test their compound, at their expense, and found that it was viable.  That bit is anecdotal.


https://groups.yahoo.com/neo/groups/EquineCushings/search/files?query=pergolide%20database


I know you have a complicated case, Tara. Hope this helps.  Like you, I have found keeping the relationship healthy through regular contact and reasonable back up info,  fostering a partnership for the good of the horse, works wonders with the right vet.  Hope that continues.


Nancy C in NH
ECIR Moderator 2003
Learn the facts about IR, PPID, equine nutrition, exercise and the foot.
www.ECIRhorse.org
Check out the FACTS on Facebook
https://www.facebook.com/ECIRGroup
Support the ECIR Group Inc., the nonprofit arm of the ECIR Group
ECIR Group Inc.





---In EquineCushings@..., <sullivantara65@...> wrote :

After extensive discussion...the mare will remain on the pergolide.  My Vet, will start calling her Dr. G-is quite unconvinced of all that I have been trying to achieve with Divina these past 5 months.  Dr. G is very suspicious of the rising number of cushing diagnosis, especially in younger horses.  She majored in Neurological Biology and is suspect of measuring the effect of a drug on just one parameter when it effects the entire brain. And she is very uncomfortable with my choice of using a compounded product. 
She has supported me through this because of our exceptional relationship and the practice of doing regular lab work to keep things in check. 



Tara and Divina

NY 2015

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/


Eleanor Kellon, VMD
 

Why dexamethasone?

Eleanor in PA
www.drkellon.com        2 for 1
EC Co-owner
Feb 2001  



tara sullivan
 

Hi Nancy.  Thanks for the great post.  I have been noodling around on IVIS, looking up things about my mare, of course.  And found an interesting study about immunostimulants, naming levamisole as one,  and I.M.H.A.
The lastest cbc still shows autoagglutination and Dr. G and I were discussing this.  We got a little ahead of ourselves but she mentioned steroids as part of the course of treatment.  And my head was immediately filled with alarms and flashing red lights as soon as she said it-That's where the dex came in Dr. Kellon.  She feels that the cause of the fevers is the anemia, but we need to get the fever under better control-elimination is the goal!  But, she compared it to the treatment for EPM...and to paraphrase -after treating for a certain time with anti-protozoal drug the next course is a steroid even tho the horse may still test low positive.

We are not there yet.

A consult with 2 internists yeilded 2 completely different recommendations.  Actually, both stressed the need to do a full body scan of the mare with the hope of identifying the cause of the infection.  Both agreed to change the anitbiotic.  One recommended Naxcel.  The other Oxytet. 

She went round and round with this.  In her field experience-She starts with Naxcel (usually for respiratory) and then moves to Baytri if the response wasn't enough.  But my mare was on oral Doxy when this infection came on. 
In the end we are going with the Oxytet....and the mare is getting scanned tomorrow, hopefully.

I got to witness a very interesting debate about the SAA-while everyone agrees it is very helpful.  One says it is a marker of inflammation not necessarily infection.  So I wondered....How would a compensated or severely IR horse with no other pathology test??  There is inflammation with this condition, right??  I know my mare is compromised right now...is this confusing the test??

Tara and Divina

NY 2015

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/



 


Nancy C
 

Hi Tara


I have to leave the bulk of your post to Dr Kellon however, unless the benefit outweighs the risk, which sometimes happens, I would stay away from steriods.

Also same for Naxcel

Equine Cushings and Insulin Resistance

  Equine Cushings and Insulin Resistance

 

Recs for safe antibiotics here generally are oxytet and penicillin.


Hopefully your scan today will enlighten on actual infection.


You are correct that inflammation is a biggie with these horses.Will be interested in Dr Kellon's response as to how  your test results might point to this.


Lastly, Lavmisole is the focus of the current issue of the The Horse's Mouth, Dr Kellon's ezine.  I believe she is still running a two-for-one sale on her ezine (with discussion group) and her courses, until 01.15.  IMO, all are worth it at three times the price.  :-)



Nancy C in NH
ECIR Moderator 2003
Learn the facts about IR, PPID, equine nutrition, exercise and the foot.
www.ECIRhorse.org
Check out the FACTS on Facebook
https://www.facebook.com/ECIRGroup
Support the ECIR Group Inc., the nonprofit arm of the ECIR Group
ECIR Group Inc.

 



---In EquineCushings@..., <sullivantara65@...> wrote :

She went round and round with this.  In her field experience-She starts with Naxcel (usually for respiratory) and then moves to Baytri if the response wasn't enough.  But my mare was on oral Doxy when this infection came on. 
In the end we are going with the Oxytet....and the mare is getting scanned tomorrow, hopefully.



 


Eleanor Kellon, VMD
 

OK.  Saline test was negative on the last CBC you posted. Although it is usually used with a steroid, could try methotrexate or azathioprine.

I agree with concentrating on infection as the likely root cause here, and starting with Oxytet. Failure of doxy does not mean Oxytet won't work. Would also check still for Strep equi M protein antibodies even if she has no history of exposure or having the disease.  She's immunocompromised which means all bets are off on "typical" presentations.  If high it's not diagnostic but drop with treatment (penicillin) would be.

True that SAA is a nonspecific marker of inflammation,not just infection. You might want to ask the opinion  of your internists on the low fibrinogen she had initially.  It should have been up along with the SAA. I'm wondering if she had some DIC going on when fibrinogen and platelets were low, legs swollen.

IR in horses is not inflammatory in the same way it is in people. Some minor changes have been noted but nothing dramatic.

Hate to even think it but malignancy cannot really be ruled out either, probably lymphosarcoma.

Please keep posting blood work as you get it.

Eleanor in PA
www.drkellon.com         2 for 1

EC Co-owner
Feb 2001


tara sullivan
 

Hi Dr. Kellon.  I just uploaded the last cbc taken on 1/4/2016...i thought that i already had done that.  Nothing really new at this point.  She received her 2nd dose of oxytet and her temp is currently 101.6 with last 2.5cc dose of banamine given at 4am.....hoping she doesn't spike thru the night.  Her HR has been 46-50 bpm for weeks now too. 

 

Tara and Divina

NY 2015

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/

 


Eleanor Kellon, VMD
 

Thanks for the update.  Looks like her red cells are at least holding their own, which is good.  Bands present again, always suggestive of active bacterial infection.  Suspicious of some degree of DIC with low fibrinogen and excessive platelet clumping. The elevated heart rate is because of the anemia.

Eleanor in PA
www.drkellon.com     2 for 1
EC Co-owner
Feb 2001




tara sullivan
 

Kinda letting myself believe this is a really good morning!  Divina's temp at 6am was 100.7!  Down from 101.6 at 9pm last night ( and hovering in the mid 101's all that day-no banamine since 4am 1/6).  She is eating....even eating her supplements thanks to TC30 and TC Senior.  She is bright, tho all 4 legs filled over night.  Thinking this is a herx reaction.  So I have opened up the field and spread some hay all around hoping to get her to move around. 
Dr. G is scheduled to come and do an ultra sound of her ovaries.  Her heart rate seemed a tad better yesterday...more like 44 bpms down from an average of 48+.  Haven't taken that yet...hoping it corroborates the progression to better health.

Can I just give a quiet YIPPPEEE!

Tara and Divina

NY 2015

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/


tara sullivan
 

Hi Dr. Kellon.  I have not administered any NSAID since 4am on 1/6.  She has been on Oxytet for 4 days.  Her temp was well controlled yesterday-never above 101.6 and falling to 99.9 in the middle of the day.  Her appetite is getting stronger and I am definitely in the presence of horse that feels better.  Her legs stock up over night but drain nicely after turnout-not completely tight.  But her SAA is stagnant at 762...this actually is 140 point increase from the last one taken 1/4 when she was on Baytril.  And her temp this am 102.3.
cbc/chem is not in yet.  And her HR has dropped a little to 44-46 bpm.
So....I now have a body that is clearly feeling better and one lab that suggests otherwise?  Dr. G is not bothered by the SAA.  She has tested many horses with numbers that high who were absolutely fine....again so are we testing infection or inflammation?

Also interesting was the how the blood acted in the tube-this draw it seemed completely normal.  With the last draw we could clearly see the clumping in the tube....we were tipping it up and down and watching how little clumps remained on the side of the tube as it ran back down.

We wondered that if the horse is reacting to organism die off and is clearly dealing with inflammation (stocking up)-is that represented in the test??  Waiting for cbc/chem-so curious.

But today-I have a horse that feels better!  I no longer have to syringe her supplements...thanks to TC30 and Senior.  And she is also eating more hay.  Trying not to go overboard  with the concentrates.  2 base meals of .5lb TC30 + .5lb senior  + 1lb soaked bp + 6oz soaked flax and topped with all her "stuff" -2x/day she gets 5000 iu vit.e in 2oz CS oil, 1 Tbs salt, 1 tsp. jherb, 1tsp moveease.  1x/day-1 Tsp. glutamine, 1Tsp A-carnatine, 1Tsp. equine generator.  half ration of AZ complete.

Do you have recommendations on Divina's diet at this point?? 

Also waiting for visit from Internist.
Thanks for all of your help.

Tara and Divina

NY 2015

ECHistory8

 




-


Eleanor Kellon, VMD
 

SAA can't distinguish between infection and inflammation (or trauma, or malignancy).

http://www.cpl.med.miami.edu/acute-phase-protein/equine-serum-amyloid-a-testing

http://dx.doi.org/10.4236/ojvm.2013.31010

While there are very clear indicators of improvement here, she basically is not yet out of the woods. You should never ignore SAA. SAA above 20 (10 in some labs) always indicates a problem of some sort. When healing is complete, SAA will return to normal.

The Jarisch-Herxheimer reaction aka "Herx" is primarily limited to infections with spirocetes like Lyme or syphilis, is worse with chronic infections and has a sudden and usually dramatic onset within 1 to 2 hours of giving the antibiotics.  Otherwise, expected response to antibiotics is a clear reduction of fever and symptoms. Complete resolution of SAA may take up to 12 days with no complications.  Some authors have observed a second, short-lived peak during recovery but the overall trend should be downward.

The leg swelling could be related to the low albumin, viral vasculitis or antigen-antibody depostion vasculitis - even malignancy

Hematopoietic Neoplasias in Horses: Myeloproliferative and Lymphoproliferative Disorders

 

As for diet, you should make sure she is getting all nutrients she needs for a balanced immune response and antioxidant defenses including E, Se and other trace minerals especially zinc and copper with very tight Fe:Cu:Zn ratio.  If she is not eating enough to meet her daily protein needs (for her ideal weight, not current weight) supplement with whey protein isolate. I would increase L-glutamine to 30 g/day.

Eleanor in PA
www.drkellon.com    2 for 1

EC Co-owner
Feb 2001


 




-


tara sullivan
 

Hi Dr. Kellon.  I didn't mean to suggest that Dr. G disregarded the SAA result.  I was totally disheartened and just want everything to corroborate a progression to health.  She felt that it is an indication that we are keeping a lid on the infection-afterall, we started with 2200+.  I think she was trying to keep my spirits up.

I posted Divina's latest cbc and chemistry.  She is holding her own.  Rbcs rising but so is GGT.  Glad to see glucose not over the top.  Temp still undulating.  It rose to 102.6 last night and same this morning.  Legs a little filled.  Eating and drinking ok.  Mare just seemed to have a headache?  No headpressing against the stall....just on me for a good while.  So I gave her 3cc banamine.  Temp started to drop in 10 minutes and her whole countenance perked up.

Finally got some feedback from the internist.  Spleen is normal but small intestine is distended.  Recommends a rectal/ultrasound.  That might happen today.

Tara and Divina

NY 2015

ECHistory8


Eleanor Kellon, VMD
 

Thanks, Tara, for keeping us updated with everything else you have on her plate. You and your team are doing a fabulous job of supporting her. What kind of testing identified a possible small intestinal issue?

Eleanor in PA
www.drkellon.com   2 for 1

EC Co-owner
Feb 2001


tara sullivan
 

Thank you so much for the encouraging words...it helps!  The recommendation was from the ultra sound done on 12/24. 
The timing of this whole episode with the holidays, lab closures, my family obligations, Dr. G's family obligations....the internists...blahblahblah  It just really contorted the whole process.
And I have totally hogged this forum-my apologies to all because this whole list is for people and their horses in crisis. 
So please accept my heartfelt Thanks to all of you who endured.  But....we aren't at the end of the story, yet!

Maybe it is time to move this to another forum-Let me know if I should.

Tara and Divina


Eleanor Kellon, VMD
 


tara sullivan
 

Hi Dr. Kellon.  Had another very interesting day with Dr. G.  She performed a rectal ultra sound and while most everything felt and looked "normal"....she was quite surprised to actually feel the spleen.  She was telling me as she was reaching in there....the right ovary...good.  Backed up a little and went left...left ovary..good. What? There is that spleen again!  She said she has never felt the spleen rectally in any other horse...it should be too far away??  It looks normal on the ultra sound just as it did back on 12/24....but she also commented then that the spleen seemed to be everywhere....it was back by her flank (where she expected, but she was surprised to see it further to the front (ventral?) 
So we started discussing displacement...Her heart rate could suggest a mild chronic colic situation, but for all this time??...the fevers are weird in the fact 2.5cc of banamine drop it like a rock.  But where does the infection come in?? necrosis??

And...here is at least one kernel of relief...we did an SAA...it dropped to 371!  And I would say that her perfusion looks better.  I wish that HR would come down now, too.

The internist will definitely be here this week. 

Earlier in our discussions on this board...this was your comment from 1st blood work.

 "On the chemistry screen, the low albumin is probably a response to the high globulin. Even with reduced albumin production the total protein is still on the high side.  The high potassium is likely coming from muscle and causing the slight reduction in sodium.  The high CK either indicates muscle is a site of inflammation (e.g. Strep myositis) or could be a red herring from a recent hard bump/fall or kick, even prolonged lying down."

I am wondering if this is consistent with the suggestion of DIC??  And also am also wondering if her situation is aggravated by an inappropriate herd mate.  I have 3 horses and it is very difficult to single one out or pair 2 off-you know what I mean.  But, I think my young gelding is now somewhat of a stress to her....he is too playful.  I need to develop this more (makes a pretty good argument to get another horse...Oh Dear Husband!)...but in the mean time I am making an effort to keep them separated and happy.

Also would like to know more about some members experience with a loopiness, trans like, sleepy kinda, behavior in their horses after giving pergolide??
This has been happening also.

Sorry for the quick random update...

Tara and Divina

NY 2015

https://groups.yahoo.com/neo/groups/echistory8/files/Divina/