December 17, 2018 – Dr. Kelly Diehl discusses feline hypertrophic cardiomyopathy with Dr. Elizabeth Rozanski, a veterinary researcher and clinician with the Cummings School of Veterinary Medicine at Tufts University. The ailment is the most common form of heart disease in cats, where the muscle in the heart itself thickens to the point that the heart can no longer function correctly to pump blood through the rest of the body. Ultimately, this can lead to heart failure. Dr. Rozanski details this problem and her Morris Animal Foundation-funded research, which looks at ways to train veterinarians to screen cats for the disease.
00:14 Dr. Kelly Diehl: Welcome to Fresh Scoop Episode Three, Hypertrophic Cardiomyopathy in Cats. I'm your host, Dr. Kelly Diehl, Morris Animal Foundation's Senior Director of Science and Communication. And today, we'll talk to Dr. Elizabeth Rozanski, Associate Professor in the Cummings School of Veterinary Medicine at Tufts University and a Morris Animal Foundation-funded researcher. For those of you who may be new to Fresh Scoop, this is our monthly podcast of Morris Animal Foundation, the largest non-profit foundation in the world dedicated to funding studies that find solutions to serious health threats in animals. Founded in 1948 by Dr. Mark Morris Sr., a veterinarian, we've invested more than $126 million in more than 2600 studies that have improved and protected the health of companion animals like cats, dogs, and horses, as well as wildlife.
01:15 DD: In each episode, we feature one of the researchers we fund or one of our staff members, discussing their work in advancing animal health. Whether you're a practicing veterinarian, technician or student, or just an animal-loving science geek, Fresh Scoop is the podcast for you. You can learn more about us at morrisanimalfoundation.org. Okay, on to today's show. Today, we welcome Dr. Elizabeth Rozanski, a veterinary researcher and clinician. Dr. Rozanski is, what we in the business, referred to as a "double dip." She is a diplomate of both the American College of Veterinary Internal Medicine and the American College of Veterinary Emergency and Critical Care. Dr. Rozanski has earned several grants from Morris Animal Foundation, but today we're going to focus on her most recent one which dealt with hypertrophic cardiomyopathy in cats. So, welcome, Dr. Rozanski. It's great to have you on with us. And I'm going to start with some basic questions for our audience, which is a little bit... If you could tell us, how common is heart disease in cats, to begin with?
02:27 Dr. Elizabeth Rozanski: Sure. Well, I'm delighted to be here. This has been a great opportunity to help cats and help learn more. Heart disease in cats, it's hard to actually know how common it is because a lot of cases are undiagnosed. When we look at some cats that die from heart disease, a number of cats can... Up to 20% can die from heart disease in some studies. There's some evidence that a number of cats have subclinical or undetected heart disease. I do mostly ER stuff, and so, when we see cats that come in with shortness of breath, probably half of those cats have heart failure. It's a really common disease in a lot of the surveys that are out there. It's right up there with kidney disease, heart disease and cancer as some of the big killers of our pet cats, so very common.
03:14 DD: Wow. Okay. I have another question. Can you explain to our audience, we have both veterinarians and lay folks, a little bit about, very briefly, the types of heart disease that we see in cats?
03:29 DR: Sure. We see all sorts of different heart disease in cats. The most common is a type that's called hypertrophic cardiomyopathy. It's the same thing that people can get sometimes, so there's a lot of, one, health implications of it. But basically what happens is that the muscle in the heart itself gets really thick. And when the muscle is thick, the heart can't do its job correctly, and so the heart can't relax and fill up with blood, and it can't pump blood through the rest of the body. And over time, as that happens, the left atrium, which is the holding chamber for the blood, gets stretched out, gets very full because of back pressure. And if that happens to... Gets too big, the cat can actually go into heart failure or they can develop a blood clot that goes elsewhere in their body. So, hypertrophic is probably the most common, by far, that we see.
04:18 DR: We used to see a lot of the type of heart disease called dilated cardiomyopathy, which is a disease where the heart muscle is stretched out, and it's not able to contract and pump the blood around the body very effectively. We don't see that very often in cats anymore after we've identified some nutritional needs for cats, their need for taurine, so we don't see that one very commonly, but it's certainly still out there. We see some unclassified forms of cardiomyopathy, so diseases where definitely the heart is not working correctly but doesn't fall neatly into one category or another category, so we'll typically call those an unclassified cardiomyopathy. And then we sometimes see cats being born with heart diseases, where their heart didn't form normally before they were born, and they can have a hole in their heart or an extra shunting blood vessel called ductus arteriosus. But by far, in a way, the most common is something called hypertrophic cardiomyopathy.
05:14 DD: Okay. And I think some people may know this who are listening, but can you talk a little bit more, I'm going to focus on hypertrophic cardiomyopathy now, about the... Are there any breed predispositions, sex predispositions, age that this first is diagnosed?
05:35 DR: Sure. It can be any age cat, the youngest that we've seen in six months or so. The average cat is middle-aged to older though when they become... We identify the disease. Certain breeds, Maine Coon cats, are the classic example, have been very over-represented in cats with heart disease. Any big bone cat... There is one study that shows those really big-headed cats, big bone, big-headed cats have an increased growth factor, and also have a tendency toward cardiomyopathy. So, big male cats, big... Young to middle-aged male cats are also commonly affected. And other breeds, like Sphynx and Ragdoll cats, for example, have a higher rate of cardiomyopathy. Purebred cats of certain breeds, big male cats, young, middle-aged and older with kind of... Most of the cats being identified in the mid age to older. We do sometimes see cats that foreshow signs after an event, like neutering surgery or a dental procedure, and we sometimes see cats developing a disease in response to a stressor or in response sometimes to getting steroids, extra anti-inflammatory steroids for treatment of some other disease like skin conditions.
06:54 DD: Okay. So, sometimes it can be secondary. It's not just an inherited condition, it sounds like.
07:01 DR: It's not just inherited, for sure. There are certainly... I think one of the really interesting areas we all have a lot of fascination with is where do people get their cats from, so genetics in cats seems to be a lot harder for us to track down than genetics in dogs. There's a lot more purebred dogs, so we can follow them a lot more closely. And a lot of times people get a cat where does it... Comes home with them, they find it somewhere, they get it from a neighbor, they don't know that this cat's brother or sister also has heart disease. There's a couple of reports out there of families of cats where all the littermates were affected with heart disease. And my guess is that's far more common than we would recognize. We just don't always know what happens to the other cat's brothers and sisters from their littermates or for their littermates. There's certainly a big genetic component to it, but there is also, we believe, dietary influence, lifestyle influences as far as if they're very heavy cats, very big bone cats, very rapidly growing. All those different areas, we're still not 100% sure on, but... So certainly some genetics and some of other things.
08:08 DD: Okay, cool. Dr. Rozanski, can you tell us a little bit more about the most common signs that an owner would see, and also what are the most common for veterinarians, the most common physical exam findings that they might see in the clinic?
08:28 DR: Sure. For owners, one of the hard parts for heart disease is typically, when it's... Before it's showing sign. So, when it's asymptomatic but present, the cats don't have any signs at all. When they start to develop signs, the most common thing that people see is rapid breathing, and sometimes that's hard to recognize in cats. Sometimes they see hiding more, being less interactive, and then when they go find the cat sitting behind a couch or something like that, they'll find that they have increased respiratory rate and effort. Sometimes the first sign that they see from a cat is sudden onset of paralysis of the back legs, and so that's something called a saddle thrombus or arterial thromboembolism. Basically a blood clot forms in the holding chamber, in the left atrium, and it breaks off from where it's sitting in that chamber, and go shooting out through the heart, and gets lodged in the back right where the aorta, the big vessel and the carrying oxygenated blood in the body, splits to give blood to the right and left legs, it gets lodged right there and cuts off the blood flow to those back legs. And so sometimes that's the first sign that an owner would have of that. Generally, cats, until they get into heart failure, develop this thrombus or a blood clot, people don't see anything wrong with them.
09:50 DR: The other big challenge is from the veterinary standpoint, is when you look at these cats with heart disease typically on exam they may be completely normal, despite having significant heart disease. Sometimes we all hear about heart murmurs. Some cats that have heart murmurs have pretty advanced heart disease, and sometimes it's just a flow murmur, meaning the blood moves to the heart in a funny pattern, but it's not really any disease at all. Sometimes you can hear a gallop, which is an extra sound associated with how the blood is filling the heart, and that is typically a sign of heart disease. But those can be hard to hear sometimes. If the cat is asymptomatic to the owners, the veterinarian may be able to hear something on their exam, but they can't always, so sometimes the cats look normal on exam as well. So, that's one of our big challenging areas in diagnosing heart disease in cats.
10:48 DD: Okay. And I'm going to get back to... That was sort of a leading question, 'cause we're going to talk about your study and again this challenge of diagnosis, but I had a couple other questions first. Let's say a cat is diagnosed with hypertrophic cardiomyopathy, what are the most common ways that they are diagnosed right now? You have a cat with, let's say, a heart murmur, what are the next steps? Not thinking about your study, but what do most... Been the typical progression right now?
11:21 DR: Sure. As a veterinarian, if you hear a murmur in a cat, we typically recommend that the owners have an echocardiogram performed ideally by a veterinary cardiologist. Some radiologists or internist will do a nice job with them as well, so go for an ultrasound of the heart.
11:38 DD: Okay. And so we talked a little bit about arterial thromboembolism, and how is hypertrophic cardiomyopathy typically treated?
11:49 DR: It's treated through a couple of different ways. We'll typically treat it... If they're having signs of congestion, pulmonary edema, fluid in the lungs, treat it with a diuretic, typically one called furosemide, which helps pull water from the body. We also will give them a medication to slow down their heart rate a little bit, and the goal with that is if the heart rate is really fast, that doesn't permit enough time for the blood to fill the heart very effectively. It will slow down their heart rate either with a drug called a beta-blocker or a calcium channel blocker, then that lets the heart fill a little bit more effectively so that it can pump blood a little bit better. We also give them a drug called enalapril or another one of the ACE inhibitors, which helps with how their body deals with volume overload and helps with some remodeling of the heart.
12:39 DR: And then in some cases, we'll also add in a drug called pimobendan, which can help the heart pump a little bit better. In some cases, we worry about that if we make the heart pump too hard with that drug they could have some complications, so we're a little bit careful with that one, but that has been shown to be effective. Other things that we think about doing are limiting salt in their diet. We know from people and in dogs that salt will increase water retention, and that can increase the likelihood of developing fluid in the chest. And then the other thing that we add in, because we worry so much about these blood clots, is a drug typically one called clopidogrel, which is a drug that blocks some of the platelet function to try to decrease the ability of the blood to clot, to try to prevent these complications of the blood clot from developing.
13:28 DD: Okay. So, we're going to lead in a little bit now to your study. First of all, why did you decide to study this particular disease? And it can be personal and professional, what really motivated you to write the grant that we funded?
13:47 DR: Sure. I do mostly ER sorts of stuff, and so one of the big stressful things that we see is, a lot of times in emergency medicine, you see animals with a pretty straightforward problem, they cut their foot on the ice or they got into the garbage and they're vomiting. But one of the really sad ones that we see is we see these cats that come in with either difficulty breathing and having pretty bad heart failure, or they'll come in with a saddle thrombus, so some paralysis of their back legs. And when we look at that, when I go talk to those people, one of the big things that we identified was, some of the cats had... The cat's owners had been previously told that their cat had a heart murmur on their last vet exam, or at some point in their lives somebody said, "I think I might hear something." And then either their vet didn't recommend an echocardiogram or their owners weren't interested in an echocardiogram, but they didn't know that the cat had heart disease, they really had no warning signs associated with that.
14:50 DR: And some of the other cats that come in with heart disease, with signs from heart disease, they had nothing that anybody could hear, so there's no way that a vet would have been able to tell them to do anything or recommend anything because there just was no clinical signs. And so our big sad point, or a big pushing point, was, "Gosh, this would be a disease that if we knew about before they got sick, before they went into heart failure, before they developed a saddle thrombus, we'd be able to start some of those medications and tried to ward off the development of this disease, or at the very least let people know that their cat was at risk of this.
15:27 DR: In sharp contrast to dogs, dogs, especially small breed dogs, get a lot of a disease called a mitral valve disease, where their valve that's in between the left atrium and the left ventricle gets leaky. And when it does that, we hear a heart murmur, and that heart murmur work tends to get progressively louder with progressive disease, so it's pretty easy, in practice, to identify that this dog's heart disease is getting worse. Radiographically, when dogs get heart disease, their heart gets bigger and that's also easy for us to see on an X-ray.
16:02 DR: For cats with the hypertrophic cardiomyopathy, even routine X-rays don't always show enlargement of the heart because it's more internal enlargement, so it doesn't necessarily make the X-ray of the heart look bigger. So, we get into a situation where a physical exam really couldn't always tell us what was happening. Even routine X-rays in some practices like to take radiographs of cats as they get older. They have taken films and really nothing, they couldn't really see anything there, and it just is not visible. So, we were really keen to try to find some way to identify these cats earlier on. And partly it was because I was tired of giving people the story of when they came in, that, "Yeah, the cat had pretty bad heart disease. It's probably been there for a while, and there was just... We didn't have a current good way of knowing what was happening with the cat," so it was kind of looking to try to help more cats, and also a little bit selfishly for me to be able to give people more information earlier in the course of their cat's lifetime.
17:01 DD: Right. We'll talk a little bit about your study now. Can you just describe... Don't worry about the findings yet, but what your study was about, what you were looking for and a little bit about the method you used.
17:18 DR: Sure. What we were interested in trying to find out was what's a good way for primary care practitioners, who deal with the bulk of these kitties in the real world, what's the best way that they could use to identify heart disease that's severe enough to go see a cardiologist? And so one of the challenges we've touched on is some of these cats have a murmur and don't have heart disease, some of the cats have no murmur and have bad heart disease. So, we were trying to look specifically at two different types of testing that would be readily available to a primary care practitioner, and see if one of these was better at picking up heart disease.
17:57 DR: And so basically what those methods were was there's a blood test that's recently come out, that's commercially available through Idexx Laboratories, which is a blood test called an NTproBNP, and it's basically a biomarker, so a substance in the blood that is increased in the presence of left atrial stretch. So, when that hard starts to get bigger, it's able to... That value goes up. And so they have that test as both a test that can go to the lab as an add-on, but they also have, as a point of care, SNAP tests, similar to the feline leukemia tests that almost everybody runs in practice. The thought behind that test was if we did a blood sample on the cat and that test was elevated, would that be a good screening test? It's already been established, it's a great test for cats that are breathing hard but looking a little bit more at an early detection standpoint.
18:56 DR: And then the second area was, because the gold standard of significant heart disease is an echocardiogram, and because in the last 10 or 15 years more and more practices are getting ultrasounds into their clinic, would it be something that if we added a screening echo, not a comprehensive full echo but a two-minute echo, would the practitioners be able to adequately identify heart disease that was severe or at least moderately severe to the point that we could then pick up those cats? So, we were looking for two things that would be easy to be done and see if one of those was better or not. What we did was we reached out to a variety of practices in the New England and Philadelphia area, and journeyed to the practices and talked to them about this study. A lot of them were practices we already knew were worried about cats, saw a lot of cats, were eager to participate. And we did a training session for them specifically on a two-minute echo, trying to look at what we wanted them to look at, and specifically we were looking for evidence of a big left atrium or evidence of a sick left ventricle, which are both signs of heart disease. Could they see those?
20:15 DR: And then we are looking at the utility of the blood test. And so they had to... We had to practice a little bit first. It's something that we've identified through a variety of other studies that, for any sort of ultrasound, you need a little bit of practice. You need a lot of practice to be really good at it, but a little bit of practice to get some ideas of what was happening. And then we would go back to the practices when they said that they had enough cats they were ready, and they would have maybe somewhere between 10 and 20 cats that came for the day. And then we would be in one room, and one of our technicians and the doctor from the practice would be in the other room, and we would divide up the cats. And what we had was the clinician at that practice would listen to the cat, say, at that point, "I think the cat has heart disease, yes or no," based on listening alone. And then they would do an EKG using a little AliveCor handheld device, and say, "Now, I look at the EKG, I think this cat has heart disease, yes or no?" So, it's all cumulative. Then they would do the ultrasound, their two-minute ultrasound, and then based on that, "I think the cat has heart disease, yes or no?"
21:23 DR: And we also had a "I can't really tell" category. And then we would do the SNAP BNP test and then look... They could look at the results. And then based on that, yes or no. And then after all of those steps, they would have a conclusion for that cat, which was that cat... "I think this cat has heart disease that's moderate or severe enough to go see a cardiologist." Again, we're not looking for tiny, tiny bits of heart disease, but heart disease that could clinically impact these cats. And then we would be in the other room, and we would... Myself, I was with all the cats, and then we had several cardiologists involved, but John Rush, cardiologist here, did the bulk of the echoes for the cats in this project. And so then we would echo the cats and then we counted the cardiologist as the gold standard, which is what they're considered in the real world and they would say... He would say, "I think this cat has heart disease, yes or no."
22:19 DR: And then importantly, I would make an anesthetic recommendation or I would recommend that this cat receive a medication. And then we would meet back up with the vet later that afternoon, and we go through each of the cases and try to match up what their views were based on their assessment of the cat with all their information based on the... And then compare that to the gold standard results. It's a lengthy way of what we did through that project.
22:48 DD: Okay. And the bottom line was you guys were trying to figure out something that... We take our cats in once a year for their physicals, something that a practitioner could do with some accuracy, and I'm assuming these cats that you were looking at did not have overt signs of heart disease. Correct?
23:07 DR: That's correct. Yeah, that's exactly right. We're looking for a screening test that would be practical to be done in a small animal practice that would accurately identify cats that would benefit from going to see a cardiologist. Circling back a little bit, one of the challenges that we'd also seen is that sometimes, through our cardiology service, cats would be sent in for an echocardiogram because somebody heard something. And then good news is the cat doesn't really have any heart disease of significance. The bad news is that the owners then had a fairly high bill associated with that, so sometimes people would get frustrated with that as well. They're obviously happy their cat doesn't have heart disease, but now they've spent several hundred dollars to hear that, and then they're instructed to, "Oh, we should probably recheck next year." And so then, at that point, they're in a situation where they're worried that they have to keep coming back and they're not really sure what to do. So, the hope was to make sure that people who were... The cats that were being sent to a cardiologist had significant disease and the cats that didn't have significant disease did not have to make that trip at that point. But the ultimate goal would be this would be a technique that practitioners would add to their yearly physical exam or even twice yearly as the cats get older in order to catch heart disease earlier.
24:29 DD: Good. Yeah, and I think for those of us that own cats... My cat's a nightmare, taking him to the veterinary clinic. I hate to admit that, as a veterinarian, I dread taking my cat in. So, I think cutting down on veterinary visits is probably... Everybody would like that, including those of us who are on the other end, right, seeing cats that are not very happy about being at a clinic. [chuckle] Can you tell us something about what did you find, and did any of those results surprise you?
25:03 DR: I was actually really, really delighted by the results. What we found was that both the... The practitioners were actually very, very good, again, with relatively brief training at identifying cats that had heart disease. And they were particularly good at the category that we're really hoping to pick off, which are the cats with moderate to severe heart disease. We only had around 300 cats or so, and while a number of the cats had mild to moderate changes on the echocardiogram by the cardiologist, there were only a few cats that actually had really bad heart disease. And those were all detected by the practitioner when they did their echocardiogram, so when they did their two-minute check, they were like, "Oh, this is the cat I'm worried about," even if they didn't hear anything horrible with the cat. So, that was really, really good news to me. It was something that, without having to do an internal medicine residency, or cardio residency, or radiology residency, these people were pretty good. And they were really good at the cats that had the type of heart disease that we'd want to catch.
26:05 DR: We found actually one cat with patent ductus arteriosus at 10 years of age that hadn't been... They had heard a little bit of a murmur before, but the cat had always seemed fine. When they did their echo, they were like, "Oh, my goodness, there's something really wrong with this cat. I knew I should have pushed harder for them to go see a cardiologist." And they had known all along that that cat had a murmur, but they hadn't really realized how bad it was till they looked with their ultrasound. We also found that the SNAP BNP test, which is obviously even easier than learning to do an echo, also picked up all the cats that were badly affected. So, we found that both of those were pretty good tests.
26:44 DR: And we found that, in honesty, the echo was probably a little bit easier and had probably slightly better results than the BNP. But they were both really, really good, and I think both really good things for people to think about adding to their yearly exam of the cat. And again with the hope that, say, your cat goes... You take your cat in, "I'm not sure if I hear something or not," you do your point-of-care echo or you do a BNP, and they're abnormal, then you're like, "Yeah, I really think this cat needs further care," versus, "I don't need to go anywhere for another year. I can sit tight, everything seems okay." So, that's the big time bottom line of what we found and we are really excited by those results.
27:24 DD: Cool. You shared one success story, were there any others that, while you were doing this, that you picked up something early that probably will impact that cat's life?
27:38 DR: Let's see. We found one cat with dilated cardiomyopathy, and we talked earlier that that was a pretty uncommon disease to have. And this was a cat that had really no auscultatory abnormalities, and the vet, when she looked at the heart, was like, "Oh, my goodness, I can't really tell what's happening. I don't know what this is, but I know this is bad." And when we looked at the cat, I said, "Oh, my goodness, this cat has dilated cardiomyopathy," and we were able to get that cat started on some medications. That was probably another one that I was pretty happy with because that's a cat that would have gone untreated or unnoticed for some length of time before it got into problems.
28:16 DR: And we found two cats with third-degree AV block, so a very low heart rate for a cat in a relatively stressful situation. One of those cats also... Also detected both the AV block, she had it before she did the EKG, had thought that the cat was just a calm cat. It was a pretty calm cat, but the EKG, and then we were able to see the cat had third degree AV block, again, an abnormal heart rhythm. And on the ultrasound, we're able to identify that the cat had left atrial enlargement and hypertrophic cardiomyopathy. So, that was a cat that had a little bit of a murmur, but actually had far more significant heart disease than we would have guessed just simply by auscultation. And we also found a couple of cats nicely belonging to technicians in the practices that had pretty loud murmurs, that when the vet looked they were able to say, "I don't think there's anything really wrong with this cat." And they were all right on that front. So, they were able to set people's minds at ease as well, which is, I think, equally important to be able to say, "Hey, we don't need to worry about this right now, even though it sounds funny." We had a lot of stories like that, but probably the dilated cat and the cat with the PDA were the most interesting to me.
29:33 DD: So cool. I was going to ask you, have you been sharing these results yet? I know you made a cool little video, because I think we got that at Morris, your first video, that was a training film to teach people how to do this. Have you been able to share these results yet? I know you're just finishing up. And are people that when you went into the practice and taught people, are they still using this?
30:00 DR: Oh, yeah. They're using it like crazy. The places we went to have been... This has made a difference for our practice, because we feel more confident in the advice that we're giving to people. And again, that's a huge big time bottom line of making things better for the world. So, people are absolutely still using it. And I think one of the other sidelights is a lot of practices have ultrasound machines that they're not sure, they get them and they want to use them for all sorts of stuff, and then they get a little nervous, and then they sometimes either turn into coat racks or [30:30] machines to collect urine samples. And so they're like, "This is something we can use this for, and we're using it more and more often." We've definitely seen people continue to use that.
30:43 DR: We shared some of the results. We're actually hopefully sending in the manuscript this week to JAMA hopefully for consideration for publication. And we've shared some of the results at the IBX meeting where we did... Last year, we did... We had more preliminary results last year, but we did interpreting cat results or cat hearts in practice, and we talked to people about those results there. And so we've been trying to get the word out. I know this isn't... I ultimately think it would be a really nice thing to have a permanent online short course for people to look at doing that, just where they could refer to some training and get some advice on what to do. Anyway, I think very helpful for lots of different people.
31:32 DD: Awesome. I think we're ready to wrap up, and I really appreciate you coming on and talking about this, because I think it's one of those great projects that has a lot of practical and immediate applicability for our pet population, but really make a significant difference, I think, in cat health and hopefully becomes a routine part of your cat's yearly exam.
32:02 DR: Oh, absolutely. And again, I'm so grateful to the Morris Animal Foundation for sponsoring this. This has been a lot of fun to do, and I really think it'll make a big difference for cats.
32:09 DD: Okay. Well, thanks, Dr. Rozanski, and we appreciate you taking the time to talk with us.
32:15 DR: Oh, sure. It's great to talk to you guys as well.
32:18 DD: That does it for this episode of Fresh Scoop. Once again, thanks to Dr. Elizabeth Rozanski of Tufts University for joining us to talk about hypertrophic cardiomyopathy in cats. We'll be back with another episode next month that we hope you'll find just as informative.
32:34 DD: The science of animal health is ever changing, and veterinarians need cutting-edge research information to give their patients the best possible care. That's why we're here. You can find us on iTunes, Spotify, Google Play Music, and Stitcher. To learn more about Morris Animal Foundation's work, visit morrisanimalfoundation.org. There, you'll see how we bridge science and resources to advance the health of animals. You can also follow us on Facebook, Twitter, and Instagram. I'm Dr. Kelly Diehl, and we'll talk soon.