Help - there is SO MUCH information. I honestly don't know where to start. Overwhelmed is an understatement. Euthanasia has been considered if I cannot get her comfortable.
I live in Chesapeake, VA - and if you don't like the weather right now, wait a minute it will change. It is getting ready to be 27 degrees for the high - 13 degrees for the low. I'm at a loss.
What we thought initially at the beginning of November was sore feet has turned into my 11 year old Appaloosa mare (who I have had since a weanling) being in her stall since.
When foot sore - farrier put shoes on 11/13 (makes sense). My mare could hardly walk the next day.
Vet out 11/14 - she felt pounding pulses and diagnosed at laminitis. At that time she was given banamine 10ml iv - which I continued giving orally. She was currently on Thyro L - which I continued to give. Magic hoof was suggested. The magic hoof seemed to make things worse, but kept trying.
Made a plan for vet to come out and xray - which she did December 1st.
By Saturday she was no better - spoke with different vet at same clinic - started her on ACE, compounded sucralfate, banamine, and doubled Thyro L. He suggested make "clogs" out of Styrofoam board, which I did. Initially it seemed to help, but once compressed did not.

Initially banamine seemed to make a difference - but only at the 10ml dose.
Vet out - xrays, happy to share. Thin sole, slight rotation. Continued all the above, with isoxsuprine added, Chinese herb Hot Hoof II, and she was tested for IR. IT was obvious, and she was being fed as such, but just as confirmation. In addition, I purchased soft ride boots with laminitic inserts - again initially they worked.
Friday the 16th - I was googling and ran across "winter laminitis" - this seemed like the culprit. Not sure vet agreed - but I remember the weather and there were drastic drops. I started blanketing her, and wrapping her legs with polo wraps. I cut up a wool blanket to make quilts to go under the polos. Vet started her on metformin, and gabapentine (too hard to get - so was only on 2 days)  I ordered APF and LaminOX - it was delayed started last night.
My barn is not insulated - I have closed up - it is deeply bedded in pine shavings, I have added straw for additional warmth and have a heater on to take the chill out of the air.
She is on Hygain Zero -
Timothy/orchard (hardly any orchard) and on orchard grass (12 pounds a day) Both are below ESC and WSC 5%.
Not sure what else I can do for her.
How long before APF and LaminOX would show some improvement? Should I continue the banamine? ACE? Isoxsuprine?

Absolutely - ANY HELP is appreciated.
I am weary - and struggling taking care of her day and night, while working a full time job, and tending to my other two horses, and dogs.

--
Brynn Gordon - Chesapeake, VA 2022

Hi Brynn. I'm sorry you have had to find your way here. Your first post triggers our welcome letter which will give you the cornerstones of our protocol. First, there is alot of information here on the site and in the welcome letter. So, take your time reading through. 

If you can, it would be really helpful for you to put together your Case history and upload it so we can review it.  Do you happen to have her bloodwork results? Insulin? Glucose? Was she tested for PPID/Cushings? It would also be helpful to see her xrays...there are directions here  on the Wiki  how to post your xrays. It sounds like you already were feeding your horse as if she were Insulin Resistent (IR). So, that's a good thing. The cold could definitely be a factor in all of this, so keeping her warm and wrapped is not a bad thing and certainly won't hurt her as you figure all of this out.  If you could also post your hay analysis results that would also be helpful. Body shots and hoof photos would also be helpful along with the xrays...what is the doseage of the metformin? ...
Metformin information-  https://ecir.groups.io/g/main/files/4%20Insulin%20Resistance/Metformin/Metformin%2008.08.20%20FINAL.pdf 

If you get stuck on the case history, just let us know and we can assist you. 
  

Welcome to the group! 

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 etiquette, what 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 (look under the Hay Balancing file if you want professional help balancing). 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.

EXERCISE: The 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. 

--
Trisha DePietro
Aug 2018
NH
Primary Responder
Dolly and Hope's Case Histories
Dolly's Photos 
Hope's Photos 
HOW TO SEARCH THE ARCHIVES: https://ecir.groups.io/g/main/wiki/1993     

Hi Brynn,
Welcome to the ECIR group.  We have had good results helping horse owners with metabolic laminitis get their horses comfortable again.  While not all laminitis is metabolic, most cases are but that comes with a diagnosis.  As you may have read in the welcome letter Trisha sent last night, we focus on DDT/E, which stands for Diagnosis, Diet (incl drugs), Trim and Exercise as appropriate.  

To aid in the diagnosis, we need to see blood test results for insulin, glucose and ACTH.  Her age may be young for PPID (Cushings) but we have seen others.  Radiographs and photos of her feet will also help with diagnosis.

In setting up a diet, we assume metabolic laminitis until proven otherwise as that’s the safest approach.  That involves putting your horse on the Emergency Diet with soaked and rinsed hay until it’s been shown by testing that soaking is unlikely beneficial.  There are a few additives such as table salt, vitamin E and ground flax which will be beneficial regardless of hay analysis.  With a proper hay analysis, you can collect advice on the addition of minerals to make the hay an even better source of nutrition.

The drugs you are giving may well be unnecessary.  NSAIDs, including Banamine do not relieve the pain of metabolic laminitis because the pain does not result from an inflammatory process.  In addition, NSAIDs for more than a brief period of time can cause all sorts of other unrelated issues so we discourage their use.  ACE is sometimes given to increase circulation but we recommend jiaogulan (or LaminOX) instead. ACE can interfere with pergolide, which Hope is not getting, but many others here are.  However, any drug (including herbals) used to stimulate circulation with increase hoof growth and this isn’t always a good thing if the hoof trimming isn’t optimal.  Devil’s Claw has also been helpful as horse can get quite sore while standing in ways to relieve their hoof pain.  Isoxsuprine has not been found to be particularly useful in horses, most likely because it is not well absorbed.  We recommend APF when transitioning a PPID horse onto pergolide.  I’ve never seen it recommended for laminitis pain but I feel certain other might have used it for that with success.  Gabapentin is given for pain but its effects are limited in horses.  Metformin, on the other hand, can be extremely useful in getting insulin down.  With decreased insulin comes a decrease in hoof pain so decreasing insulin is the goal with these horses.  However, we see horses being prescribed all sorts of metformin doses and it is important that it is high enough to be effective.  Here’s a link to a user friendly guide to metformin.  Metformin’s effects may not be long lasting so it’s one to save for high insulin.  If Hope’s insulin is already low, metformin isn’t likely to provide the relief needed although it has shown to be helpful with some neuropathic pain.  Thyro-L is for horses which a jump start to lose weight.  It does not decrease insulin.  If she’s been on it awhile and doesn’t need it, she needs to be tapered off very slowly as her body has adapted to its presence.  Banamine should also be tapered to prevent rebound pain.

With respect to the cold, winter laminitis is the topic of the day.  It should be relieved with warmth so if bundling Hope up doesn’t help, that’s not the source of her pain.  It’s a cold induced hoof pain, more likely in horses with compromised circulation resulting from some sort of insult to the hoof, whether or not you’ve been aware of it.  I live in a cold winter climate and have two IR ponies in a group of five PPID horses.  Last winter, I thought we might have had winter laminitis but, if so, it would have been the first time for these very senior ponies so I’m suspecting it was more likely feed related and I’m not overreacting to this year’s cold weather.  I’m ready to act if need be but we’ve already had temperatures in the low teens with no pain.

Many people feel as you do when coming here.  I’m not sure my added information will relieve your feeling of being overwhelmed by it but I think some organization of your thoughts might help.  Euthanasia is always an option, for whatever reason, but from our point of view it’s not the only option for Hope’s pain resolution.
--

Thank you Martha. 

--
Brynn Gordon - Chesapeake, VA 2022

--
Brynn Gordon - Chesapeake, VA 2022

Hi, Brynn.
No, the case history not in the right place. Please try this:
1. Go to the Files section of the CH subgroup, https://ecir.groups.io/g/CaseHistory/files
2. Click the blue button at the top +New/Upload. Select New Folder from the menu.
3. Name the new folder Brynn and Hope. Don't leave the menu until you click Add.
4. The folder is now in the CH subgroup. You can locate it by searching for Brynn and Hope.
5. Once you relocate the folder, upload your CH into it. 
6. Add the URL of the folder to your automatic signature so we can find it easily. Your signature is here: https://ecir.groups.io/g/main/editsub
After you paste the URL of the folder under your signature, enter a space or a return to make the link active. Don't leave the page until you scroll to the bottom and SAVE!

If you run into any problems, let us know. We can help.
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

Brynn, the hoof photos are in the right place.

Add the URL of the album after your signature. Copy and paste this URL into your signature, add a space or return to make the link active/clickable, and save:
https://ecir.groups.io/g/CaseHistory/album?id=282570

--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

How about now?
--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope

Apologies - thinking I may have it now.
I tried to delete "old" case history, but it would not let me.
--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope
https://ecir.groups.io/g/CaseHistory/album?id=282570

Good work. I'll take care of the rogue CH.
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

Super, Brynn!  I think it all works now.  Great job!

I don’t see any blood testing results in her case history.  Are those still in the works?  Do you have an insulin testing result you could share here in the meantime?  It would help us to know what her insulin is and under what circumstances - air temperature, when fed relative to blood draw, where tested (at home or trailered) and where the analysis was done with what range of “normals”.

Did your trimmer look at the radiographs?  She has very little sole under the coffin bones in both fronts and hinds which could be quite painful.  Is she still shod?  It appears she has front boots on.  It would be better to address her comfort with boots and pads as shoes put a lot of stress on the hoof wall.  I see that she’s resting her right hind.  That seems a bit unusual for a horse exhibiting so much pain in her front feet.  She may need boots behind as well.  Does she have a deeply bedded stall where she can lie down?  Did she amble outside on her own or did you lead her?  Sorry for all the questions - just trying to get a feel for things.
--

I am still waiting to receive from my veterinarian.
Veterinarian said - she was 3x the normal range.
It was at my farm in the evening - it was cold.
She was fed - 1 to 2 hours before blood draw.

He has reviewed - we all agree with your thoughts. She is still shod. Not sure she could hold her foot up long enough to take them off.
She does have soft ride boots with laminitic inserts on the front. I didn't want to buy four ($$$$) if they weren't going to help.
I believe she is sore in all four. She is constantly shifting weight. The left front is the worst.
Her stall is deeply bedded with pine shavings and straw on top for warmth.
She lays down often - I have a camera and watch her throughout the day.
She came out on her own - hence no halter. She doesn't always come out, but I do give her the option. Amble - that is being kind.
I just received her results - I will upload to her case history.
I am so thankful to have someone to talk to about this before I lose my mind, ask away!
--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope
https://ecir.groups.io/g/CaseHistory/album?id=282570

I have uploaded the hay analysis in photos.
--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope
https://ecir.groups.io/g/CaseHistory/album?id=282570

Addressing only the hooves... it doesn't look like shoes are making Hope comfortable.  Shoes aren't the only way to protect the soles of a laminitic horse.  Did you cut off the frog ridges off the Softride pads? Many horses cannot tolerate steady frog pressure from pads. 

If necessary, poor Hope can be given an appropriate small dose of sedation to enable the farrier to remove the shoes. Don't combine sedation with Gabapentin. My experience was that Gabapentin did nothing to reduce pain but did cause sedation. Once Hope is barefoot, you can measure for the right sized therapeutic hoof boots and pads. Your farrier can help with this. Pads require trial and error to find the right combination. You might find the right sized boots in a local tack store or by mail order. If you have to wait for boots to arrive, you can cut pads from anti-fatigue mats from the Home Depot and tape them on with vet wrap and duct tape hoof boot. Duct tape doesn't give good traction, so duct tape boots aren't safe in wet, snowy or icy conditions.  If she has thrush, use a liberal dose of anti fungal foot powder on the hoof before applying the pads. Many Youtube videos show how to make duct tape boots. 

Therapeutic hoof boots are expensive, but at least SoftRide is not the only manufacturer! I use EasyBoot Clouds and pads that I buy on Amazon (when the right size is available). I need two sizes because the hinds are smaller. You won't be able to measure accurately until the shoes are off, but you might be able to estimate with the shoes still on if her feet are clearly within one size range. Review the guides and videos on the Easycare website. The one thing that will make your mare even more footsore is the wrong sized boot that rubs her heel bulbs, so measure very carefully. https://www.easycareinc.com/our_boots/Easyboot-Cloud.asp  Boots need to be checked and reset daily, hooves checked, cleaned and anti fungal powder applied.

Any time your farrier visits, remember: Absolutely nothing should be removed from Hope's soles or frogs, front and back, because they are already too thin. Laminitic soles often look lumpy and uneven. That's okay. If it doesn't brush off with a stiff brush, leave it.

Is thrush is still a problem?
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

Hi, Brynn.
I looked at the three analyses. I would not feed the Orchard hay because it has excessively high protein for a grass hay at 14.4% at an excessively high moisture level.

The timothy orchard alfalfa mix is a problem because ECIR advises again feeding alfalfa mix hays -- alfalfa causes hoof tenderness in some horses.

That leaves the orchard/timothy mix. The problem with this (and the two other analyses) is that the analysis wasn't done using the wet chemistry method. That means you can't be sure it's safe to feed this hay without soaking.  Remember: WSC is not the measure of safety for a horse with EMS like Hope. ECIR advises checking ESC + starch. The total must be less than 10% and the starch should be as low as possible but never higher than 4%. This hay is likely to be safe for Hope without soaking, but the only way to know for sure is to get a good sample and have the hay sent to Equi-Analytical for a 603 Trainer analysis. https://equi-analytical.com/feed-and-forage-analysis/analytical-service-packages/  While you wait for that analysis, the safest plan is to continue to soak Hope's hay.
--
Cass, Sonoma Co., CA 2012
ECIR Group Moderator
Cayuse and Diamond Case History Folder                
Cayuse Photos                Diamond Photos

Okay, so the first order of business is to get the shoes off.
The soft ride boots came with inserts, and I purchased the laminitic pad separately. As stated - when we first put them on her, she was weight bearing and seemed comfortable. that did not last.
I do take off her boots each day - empty out shavings - and treat frogs. She has sulcus thrush in the hind feet, front feet it's under control.

Funny you should say that the soles look lumpy and uneven - they were before he trimmed and shod her. :(  

--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope
https://ecir.groups.io/g/CaseHistory/album?id=282570

Eeesh - that's unfortunate.
Honestly, you I don't even see any alfalfa in that the timothy mix - if it is, it's minimal. 
I will soak the hay, but I have terrible arthritis in my thumbs and it's painful to handle.
What about feeding her Triple Crown Safe Starch hay forage in a bag or any other options?

--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope
https://ecir.groups.io/g/CaseHistory/album?id=282570

You are already in good hands and getting spot-on advice. I wanted to add that given the thickness of the distance between her hoof wall and coffin bones in the front feet (the hoof lamellar zone), the changes to her feet have been going on a long time so you need to continue to address both the insulin and the cold.
--
Eleanor in PA

www.drkellon.com  BOGO 2 for 1 Course Sale Through End of January
EC Owner 2001
The first step to wisdom is "I don't know."

Well noted - 
The keeping her warm - hasn't made any positive changes.
She was up more today than she has been - I'll be home shortly to see first hand.
Also noteable - she did not react to hoof testers, is that normal?
Do I keep giving her the LaminOX and APF?
Thinking I made need a new farrier - 
This site is amazing - and if awards were given out for such - a GOLD MEDAL for sure.

--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope
https://ecir.groups.io/g/CaseHistory/album?id=282570

In addition - the timothy orchard is a round bale - chances of getting another are slim to none.
Sadly, I cannot afford to repeatedly test hay - so if it's not something I can readily get, I'd rather not test.
The feed store where purchased is really the only one that offers testing. All hay is from out west.  
--
Brynn Gordon - Chesapeake, VA 2022
https://ecir.groups.io/g/CaseHistory/files/Brynn%20and%20Hope
https://ecir.groups.io/g/CaseHistory/album?id=282570