Dog Pod - Episode 10
Elderly Dogs with Vet Dr Kevin

Dog Pod - Episode 10 - Elderly Dogs with Vet Dr Kevin.jpg__PID:5371ca54-12dc-4721-a787-0261771a5a8b

Episode #10 "Elderly Dogs" and What to Look for as Dogs Age.

Listen in as we discuss:
- Signs of hearing and vision deterioration
- What it means when a dog "vocalises" its pain
- What is "Pannus"?
- The #1 breathing symptom that should red flag a VET check
- Why your dogs fur/hair has turned from white to brown?
- How to know when it's time to put your dog to sleep
- and Dr. Kevin's 5 Tenets of Quality of Life

Learn all this and more on this special episode on Elderly Breed Dogs!

Listen to episode Here

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Scott: Well, welcome back to another Dog Pod Episode, and back with me this week is our award-winning vet, Dr. Kevin Cruickshank, from Gold Coast Vet Surgery. So welcome back, Kevin.

Dr. Kevin Cruickshank: Thanks, Scott. Good to be with you.

Scott: Yes. So, this is our tenth episode. Do you believe it already? We have made it to a double-digit.

Dr. Kevin: What a milestone, fantastic.

Scott: Unbelievable. So this week, we have actually got a question from Simone that has come through on Facebook, and I thought this would be a good one to talk about today, probably flows on a little bit from some of the things we have spoken about, a little bit, but she has got a very specific example here. So I might just read this out first. So it says, "Can I suggest- so, thank you, loving your podcast and all that," which is great, thank you so much, "but can I suggest a podcast on elderly dogs, i.e., the aging process, what to expect, warning signs, and when to take to vet. Example, my fifteen-year-old Dingo has suffered from effects of gravity, breathes more heavily, glazed eyes, graying, walking more rigid, I thought would make an interesting pod". So thanks very much, Simone, for the questions, the cracking questions.

Dr. Kevin: Certainly a great topic, very, very important. And, yes, nobody knows exactly when and, I find it's a big burden on people, they worry when should they be speaking to a vet. They can't necessarily put their finger on one particular thing, and it is like so much in medicine, the earlier you pick up on things sometimes there is more that you can do about it. You might not be able to cure things, but you can keep the quality of life good as well.

Scott: Yes, absolutely. So let's go through some of the things that she talks about here and a Dingo is an unusual pet. You do not see a lot of people with Dingos.

Dr. Kevin: You do not see a lot, you do see quite a few crosses. It also depends on which part of the country you are working in, but even in suburbia here, there are sometimes people who have been working in a more rural area, and yes, they can make fantastic pets, definitely.

Scott: Yes, fantastic. So effects of gravity I guess is probably just the, I guess, the weight on their body over time. I guess that might be what Simone is referring to there, and it probably comes back to the arthritis which we spoke about in many a podcast before but it is a big one for elderly dogs and so I am not sure where to start with that, really, but I do not think it is... take it away, take it away [crosstalk].

Dr. Kevin: Yes, I would be happy to. So to go through some of the symptoms and really, often, the thing is that people say, "Oh, my dog is just getting old," and in fact, that's because there are certain things that are going wrong that we are seeing when we say they are just getting old. Getting old itself is not an illness or disease. So, just being that little bit slower to get up when they get out of their bed and warm-up fairly quickly after a few minutes. They're moving around a bit better, but they still may be cannot get up on the sofa like they used to, on your bed, can't jump into the car, just sort of every day to day things that you might notice. They do not necessarily limp on one specific leg. They don't cry and yelp. Often people say to me, "My dog is not in pain because it does not cry," but when we think about ourselves, you can be stiff and sore and you are not actually vocalizing or crying. So they are walking slowly and gingerly because they are sore, so it is a very painful condition and I think that is one of the nicest things is to keep them free of pain.

Scott: Yes, you have mentioned something to me when we are on a run, about the vocalization of dogs, when they finally do, if they are vocalizing some sort of pain whether it is a grimace-y type, groan, or--

Dr. Kevin: Whimpering, as well. They sometimes do, yes.

Scott: That is when it's actually got pretty bad, is it not?

Dr. Kevin: That is my opinion, yes. We do not-- and you could have a very painful tooth, you could have a sore leg or toe or something like that, but you can be walking along, and that person with you may not even be aware of the pain that you are in. You can hide it fairly easily and you are not-- but you might be in quite a lot of pain but you are not actually crying or yelping out or anything like that. So it is only when it is really quite advanced or it might be a sharp shooting type of pain that you or then a dog would actually cry out. So if we think about the amount of pain that we sometimes endure on a day-to-day basis, even something like a migraine or headache, how do we express that? We're not-- it is not only through crying or vocalizing, and so we have got to look for more subtle symptoms of pain, animals that would normally be coming running over to greet you, don't really. I suppose getting back to Simone's questions, some of the other things that we see as dogs get older is loss of some of their senses. So, their hearing, you might find that you can actually surprise your dog, walk up behind it without it having heard you coming or it's no longer meeting you at the door because it has not heard the car drive up, and so deafness, unfortunately, is something that we suffer with as we get older and so do dogs. The other sense is their vision, unfortunately, they can start to get-- a lot of people recognize cloudy eyes and--

Scott: Yes, and I think that might be what Simone is referring to with the glazed eyes a little bit there as well--

Dr. Kevin: The glazed eyes, indeed.

Scott: It is that white, milky, sort of look over the top--

Dr. Kevin: Yes, or sometimes it looks a bit blue-y. It is much more noticeable in dim light and especially if you have got a bright light behind you and then look in their eyes and you see this cloudy appearance. Now, it in itself does not necessarily mean that the dog is going blind. It is a process that goes under quite a few different names but something called lenticular sclerosis, or nuclear sclerosis, or very colloquially, people often say, "I think my dog has got cataracts," and we understand what people mean by that. It is actually not a true cataract, just the same as when we hit our sort of mid to late forties. Lots of us need to start getting glasses for reading and that sort of thing and that is because our lens capsule is not as flexible as it used to be so it can't get fat or thin to accommodate and focus for reading. It's the same process in the dog's eyes, the lens capsule is not as flexible anymore but, unfortunately, theirs gets discolored, ours stays clear. So it is probably very similar to getting very dirty glasses and it is a slow process and sometimes you would not notice that your glasses are actually smudged or dirty until you take them off and have a look at them. So, in the early stages, the dogs cope very well with that. Sure, if they had to read a book they probably would not be able to, but luckily for them, they don't have to. But where you might notice it is in dim light. They might just misjudge a step, trip over at something that you would have expected them to have seen.

Scott: Okay.

Dr. Kevin: And then as it progresses, and not all of them have trouble in daylight, but as it progresses, you might find that if you are at a park they don't recognize you from thirty or forty meters away, and only when you are a bit closer they might be able to make out your outline. So, it is a subtleness and, unfortunately, we can't ask dogs to read an eye chart, but also they are not so dependent. They are not driving vehicles, or so dependent, or watching TV and needing that very acute vision. So it's-- I do not feel that they are suffering too badly if they are slowly starting to lose that, but just thinking about if you take them out for their last wee before bedtime or something, turn on an outside light for them, it will help and improve, just simple things.

Scott: So they do not slip and then hurt themselves in other ways as well too.

Dr. Kevin: Absolutely, yes.

Scott: Humans get like pterygium across the eye as well. It is like that little blob that sits on the white of their eye. Do dogs get anything like that, as well? Or is it just another--?

Dr. Kevin: Yes, dogs do get certain growths, and certain breeds can be prone to it, it is not necessarily part of the aging process, but there is a condition called pannus that breeds like a German Shepherd, unfortunately, are very prone to, and that is a brown pigment that often grows from the corner of the eye outwards. Pugs, unfortunately, also suffer with that a lot and it is sometimes associated with dry eye or sun exposure but it is an immune-mediated process and it is very treatable and manageable. You can't cure it but you can manage it, but it's not really an aging one.

Scott: Yes, okay. What about the breathing more heavily part, is this something that a lot of dogs start to suffer with where their breathing gets a lot more labored as they become into the real elderly years?

Dr. Kevin: It can be but that is certainly something that would be a signal I would say to see your vet because there can be so many different conditions. It can be simply that the lungs are not as elastic as they used to be or they starting to get a bit of calcification, but it could be because of a heart condition, even just arthritis and a lot of exercise, that will make them breathe up a lot. They could have some sort of respiratory condition. So these are obviously very different conditions, but all of them very, very serious. So if you are noticing that their respiratory rate is up, they are taking longer to recover from a walk, or they are having some coughing, definitely, that would be a signal I would strongly recommend that that sort of symptom being checked out by a vet because there's-- and then depending on what is found to be the cause, some of those are more treatable than others.

Scott: Would you see a dog, like stopping mid-walk and trying to rest more often and things like that and--

Dr. Kevin: Yes. So we would think also about heart conditions. Often, arthritis, yes, they will battle on a walk but they might cope while they have warmed up and they sort of plodding along okay. They might reach, depending on how long the walk, they might reach a point where they don't want to walk any further, but that is about it. I would be checking out their hearts as one of the first things because heart disease, and dogs do not get the same type of heart disease that humans do.

Scott: How does it differ?

Dr. Kevin: So, in humans, we have a lot of problems with our coronary arteries. So that is clogging up, unfortunately, things like smoking and fatty diets make you a higher risk factor but there is genetics as well. So you hear about people having a heart attack and that is when they get a blockage to some of the blood vessels that supply part of the heart. Dogs don't really get heart attacks. We do not have to worry about monitoring dog's cholesterol. So it's different heart disease. In dogs, it is predominantly to do with the valves in the heart, and that those valves then become a leaky valve. They get like wrinkles on the valves, and so the heart, the pump mechanism of the heart, doesn't work as efficiently as it used to.

Scott: Right.

Dr. Kevin: Then you can get a-- heart failure is not such a short-term sudden thing like a heart attack, but it is where that heart is no longer pumping efficiently and you get lots of secondary consequences from that.

Scott: Okay. What are some of the secondary stuff because there is a fascination here, obviously, with how that affects circulation around the body as well, so what is happening?

Dr. Kevin: So the most common one is that you get a back pressure in the blood vessels, and then you get fluid building up in the lungs, and then that fluid causes you to cough, and it also then, if there is fluid lining the membranes in the lungs you cannot transfer oxygen as efficiently into the body so, therefore, you cannot get oxygen to your cells and that sort of thing.

Scott: Okay. What sort of things do you start to see degrade when that starts happening?

Dr. Kevin: So coughing is the big one to look out for, and exercise intolerance, so just not being able to cope or recover from exercise as well as they used to.

Scott: Yes. What sort of advice would you give someone around exercise and walking dogs? Do you try and sort of track how many minutes? Is it starting to get shorter? Is that something that would be good to do? They used to walk for twenty minutes, now it is eighteen, now it is sixteen.

Dr. Kevin: That would be a good one to be aware of, how long they are going, how they managed to recover. If you find yourself walking in front and sort of encouraging them to come along instead of you starting to drag them on the lead, that is a clear indicator that they are not coping. If they are comfortable walking at your pace next to you or they still pulling out in front, they are probably coping quite well.

Scott: Okay. It is a pretty clear tell-tale sign. Cool, yes, I like that.

Dr. Kevin: But, I think, as dogs age, some of the other things that we are yet quite concerned about is some of the internal organs. So kidney failure or liver problems, and the symptom that we look out for there is drinking more water.

Scott: Okay.

Dr. Kevin: And as a consequence drinking more water, urinating a lot more.

Scott: All right.

Dr. Kevin: So, it is a long list. It is a sort of very typical student exam question, list us all the things that if a dog is drinking more it could be but the big ones-- so it is quite a strong indicator if you were to see that happening in your dog, it is time probably for a senior health check. So a lot of vet clinics actually do offer and when dogs are in for their annual health check and vaccination, it, we'll always check relevant to their age and go through that sort of thing, and then a lot of clinics offer actual senior consultations for that, and that normally includes a urine test and a blood profile as well because catching these sorts of things earlier, there is a lot more that can be done. So even if you had to pick between the blood test and the urine, probably the first one would be the urine test. It is much broader, but it is not as costly as blood test.

Scott: Okay.

Dr. Kevin: And you can really get some good indications because if that urine is very concentrated, well, then you probably do not have the types of problems like kidney failure and they might be drinking more because they are a bit dehydrated. Whereas if they are drinking a lot and that urine is very dilute, then that is a reason to start thinking more seriously about doing blood tests and that.

Scott: Okay, interesting. Another point that Simone raised was the graying and it might not sound like a big deal and maybe it is not, I am kind of curious like when you are-- we see it in all people aging, their hair starts to turn gray. I have heard and I have seen a lot of sort of scientific papers around certain minerals and nutritional deficiencies that will lead to the greying of hair. Do you think that is fairly valid or do you think it is something that is relevant in dogs?

Dr. Kevin: I think the person who can solve the situation of graying without having to resort to dyes, they are going to get a lot of recognition and do well. So it is a fact of life and some breeds show it more than others, unfortunately. I think some even just show their age a bit more, something like a Cocker Spaniel, it is a beautiful young dog, but they start to show their age as they get a bit older. Another one that does that sometimes is Beagles, and yet some other dogs really don't show their age that much.

Scott: Is it something that happens really light in their sort of more senior years or is it something that is sort of progressively happens from midlife on or--?

Dr. Kevin: From early senior. So, in general, it is variable, on breed size. Older dogs, unfortunately, age earlier, so like Great Danes.

Scott: Sure.

Dr. Kevin: But as a generalization, we consider a dog a senior over seven and eight years of age.

Scott: Yes.Dr. Kevin: But some of them are happily living into fourteen, fifteen years of age. So that is, for those types, then that sort of midlife really, it is seven or eight. But, often, it is in certain areas like around the muzzle and the face and I do not think there is much that would stop that and it would not be-- that would not on its own be a reason to have them investigated, but what you sometimes see is, black dogs in particular, so something like a black Labrador, might lose the luster of its coat, or actually the black is starting to change to be a bit more of a brown color and that very much I think is a nutritionally based thing.

Scott: Right.

Dr. Kevin: We often find putting them onto a really good quality diet with appropriate, especially the oils, the omega-3 and omega-6 fatty acids, and good quality protein. There are also senior dog foods because we actually don't want senior dogs to have too much protein to have to digest, you want enough, you want good quality proteins so that you do not start losing muscle mass but not-- if there is too much, then, in particular, the kidneys have a harder job to process and get the waste products out of the body.

Scott: Yes, makes sense.

Dr. Kevin: So that-- and the brown also sometimes, this is a bit more applicable to cats that lick and groom themselves a lot more in certain parts on the body, but saliva in contact with fur long term has a chemical reaction and then with sunlight and causes a lot of brown coloring. You often see it on dog's paws, especially some of the white dogs, going brown-pink, reddy-brown color, and that will immediately tell me that that poor dog is very itchy that it licks a lot at its feet or wherever else it is turning brown.

Scott: It is a good sign, yes, excellent. I suppose there is the inevitable part with dogs aging, when they are getting obviously too old and one of the questions I want to ask about was, I guess the percentage of dogs, and maybe it's a hard one to answer but a percentage of dogs sort of dying naturally versus being put down at some point. It is in human beings, we let everyone go til they drop themselves naturally, but in dogs, it is more of that euthanasia.

Dr. Kevin: Yes. We are very privileged that we have got the option of euthanasia. A lot of people ask me, "How can you be a vet? How can you put dogs to sleep?" I see it as a real privilege to be part of that process and help people decide. It is a big burden. I see a lot of stress with people when they know their dogs is getting older but is it the time now, and the dogs typically play on your emotions, not intentionally, but just when you are thinking, "Yes, it must be coming," then they rally around and they are so much better and you think, "Oh, no, it's not his time yet." So, that is hard but that is a role that your vet can help you with, it is discussing when is that approaching, when is it appropriate.

Scott: Yes, because people want to feel like timing it right is the right thing to do, because they--

Dr. Kevin: Nobody wants to keep them going too longer--

Scott: No one wants to do it too early, no one wants it to go too long. It is a hard one, is it not? I have been there with you and I know you are amazing the way you sort of gently guide people through it and we have talked about off air some of the other experience you have had with people doing it nicely down near a beach or--

Dr. Kevin: Absolutely. If we can accommodate a home visit or a sentimental place, we would always try and accommodate that for people.

Scott: How do you time it though, I mean, it is hard and I have personally been through it as well, but you still, as a dog owner, you question did I do it right? Have I waited too long? There is all that sort of stuff that can play on your mind as a dog owner. Dr. Kevin: In your original question, you are saying what percentage pass naturally and those that we have to decide when we put them to sleep, difficult one, I don't really have an answer to that but we always mostly hope and wish that our pets will pass away in their sleep and we would not have to be in this position. But probably--

Scott: Do you see a lot of that though?

Dr. Kevin: Not that much, and probably more of them because we are able to, I think more we do make that decision and help guide owners as to when that is right because we can often save that loss without suffering, that their last bit of time does not have to be effectively dying of dehydration or starvation and the consequences of a lot of the end diseases.

Scott: Yes.

Dr. Kevin: So I find that a lot of people inherently, you know, you have a gut feeling, you have probably had that pet for a long time and you know when they are having more poor quality time or more bad days than good days. So that is one very simplistic way of looking at it. They are having more bad days than good. Sometimes you will just wake up and you really know something is a bit different and you will know that is the appropriate day. Suddenly, they can't do a certain thing, but what I talk to people a lot about is helping-- is looking at the five tenets of quality of life and you will see that these are a quite sort of advanced or extreme things but it helps people to realize that just because they are little bit unwell does not necessarily mean that is definitely the time.

Dr. Kevin: So I think a big overriding one is mobility because you need to have your mobility as a dog to go to the toilet, and that is actually number two, is how are they coping with toileting. Can they squat still comfortably, or do they keep falling over into their urine or their feces, or they are having a lot more accidents indoors because they can't get outside? That is not a nice quality of life for them. They know that inherently they should not be messing inside, so they feel bad when they keep on having accidents with that. With their mobility, if they want a drink of water they have got to walk there to get that. We can have all sorts of devices, mobility scooters, live-in carers, all that sort of thing, so if we are not that mobile, it does not matter, but mobility is such an important one for them.

Dr. Kevin: So, number three is how are they eating and drinking. Not eating for one day, whilst it is concerning, that would not necessarily be a reason that their quality of life is poor enough, but if we are getting to two or three days, and especially if that is while they on already some medication and they have had a diagnosis and we know why, and then they are just not responding to treatment and going for three or four days without eating, that is a poor quality of life. That dog is not well, not happy.

Scott: Yes.

Dr. Kevin: And then number four is uncontrollable vomiting. That is a very unpleasant thing to have, vomiting. If you can't keep your food and water down-- by uncontrollable, meaning that they are already under the care of a vet and have been investigated as to why they are vomiting and they are on some medication. There is lots of good anti-nausea or sometimes treating the primary problem will control the vomiting. But if we just cannot manage to keep vomiting controlled, that is a quality of life issue.

Scott: Yes. Can I just distinguish something here-

Dr. Kevin: Sure.

Scott: -because there is a difference between you can't get it under control for the dog versus you as a dog owner does not want to clean up a dog vomiting for a day or two. That is not a reason to put a dog down-

Dr. Kevin: No, it is not.

Scott: -because if you can get it under control, what you're saying -

Dr. Kevin: Then you would not be having to clean up either.

Scott: That is right, yes. So I think it is just a really important one. It is all about the dogs first because you hear these stories, and not pointing fingers at anybody, but you hear these stories about some pet owners that just they do not want to have to be cleaning up after this sort of stuff and that is not a good situation.

Dr. Kevin: Admittedly, I think we see people bring their dogs and cats in a lot quicker if the problem is vomiting or diarrhea than for a lot of other conditions, and cynically, that is because it's having a direct impact on them. They are having to clean it up for them.

Scott: So your attention, does it not.

Dr. Kevin: Yes, it does.

Scott: Absolutely, yes.

Dr. Kevin: You cannot ignore it, really.

Scott: So that is the fourth one, the fourth tenet of quality of life.

Dr. Kevin: The last one is probably the most important, if they have got uncontrollable pain, if we can't keep their pain comfortable then it is fairer to let them go peacefully. The medication, the drug that we use to put a dog to sleep is an overdose of an anesthetic. So the very first thing that happens, it's all instant, straight on top of each other, a lot of people are amazed at how quickly that process of drifting off to sleep does take place, but the first thing that happens is all pain is relieved.

Scott: Yes.

Dr. Kevin: So what a wonderful thing. They just suddenly, even whatever pain they have been in, they might often be in the owner's arms and that is gone. Then they just feel light-headed and I am going to fall asleep. If anyone has had any sort of procedure where they have had a sedation or an anesthetic-

Scott: You will get an idea of what it feels like.

Dr. Kevin: -this will get you-- yes, but the anaesthetist will have you count back from ten and we do not get past eight and we can't remember anything else, and that is literally-- so it is very apt that we say we put them to sleep because that is what they experience, the sensation. A lot of people are scared about what is that going to be, do they feel a lot of pain, is it traumatic to witness, and it is not.

Scott: No, it is-- I can speak from experience, it is very calming, actually, for the dog. It is not so much for us witnessing it and sitting there knowing that you are letting him go, but the dogs themselves are in a very, very relaxed state. One that is incredibly peaceful for them.

Dr. Kevin: The scenarios where I really feel-- feels, in a way good, about what we have done is when it is a dog that is battling to breathe and they are gasping and battling that and it all just goes quiet. It sounds very sad, but you really feel that you have now relieved it from its suffering. It is like so in your face that they do not have to gasp for every breath as well.

Scott: I really love those five tenets. The quality of life is [crosstalk]--

Dr. Kevin: Maybe we should just recount on them. So, they are the dog's mobility, the ability to do their normal bodily functions, going to the toilet, their interest in food, uncontrollable vomiting, and then uncontrollable pain.

Scott: Yes, love it.

Dr. Kevin: And those five key things can just help us make it a more analytical decision rather than such an emotive decision. It has to be an emotive decision but when you are feeling all caught up in emotion, then one can just go back and look at those. Obviously, there are many I have not even mentioned. Breathing is another one, but just to put it down to the bare crux of things you can assess it against those.

Scott: Yes. I think those five tenets of quality of life are brilliant and it is probably a great way to wrap up this Dog Pod Episode Ten. Dr. Kevin Cruickshank, thank you so much for being with us again. You are a wealth of the wisdom.

Dr. Kevin: Thank you, Scott. I mean I think it is a very important one and just probably as a closing remark, when people have these sorts of concerns, don't be shy to discuss it with your vet, mention it to the person who is making the appointment because often, us vets will schedule extra time. It is not a conversation that we want to rush with people but it does not have to be as serious as this, as we started out at the beginning, senior-- and so there is a lot that can be done for seniors. We did not get to chat about dental disease as they get older. That is a big one as well. So looking at having a senior health check even once a year, or ideally, twice a year with a blood panel and a urine analysis can help keep those very difficult decisions a bit further away from people.

Scott: Yes, fantastic. Well, in true tradition of the circle of life, as well, we are picking up a new puppy next week which is really exciting.

Dr. Kevin: So exciting.

Scott: The kids are beside themselves and Mel is incredibly excited. So we are going to try and capture a little bit of video footage of that in picking up the little one. So maybe next week we will throw the pendulum the other way-

Dr. Kevin: Absolutely.

Scott: -and we will go from elderly dogs and what we can do with brand new puppies and-

Dr. Kevin: Something for people to look forward to.

Scott: -talk about all that stuff. So, yes, that is a nice way to finish off. Thanks so much. I hope everyone has a great week and like anyone else, if you have got any questions, please shoot 'em through on our Facebook. Check out Dr. Kevin Cruickshank on Instagram and Gold Coast Vets Surgery, and we look forward to seeing you on the next episode. Thanks.

Dr. Kevin: Fantastic. Thanks Simone for a great question.


Podcast Transcript

Scott: Welcome to another Dog pod. You're here with Scott Groves and Dr. Kevin Cruickshank. We welcome you back again, Dr. Kev.

Dr. Kevin: Thanks Scott. What a beautiful setting. I do not know where people listen to us, but it can't be better than where we are recording it.

Scott: It is a pretty nice part of the world and it is a gorgeous day here again, so welcome everybody. This week we are following on our little three part where we are talking about sort of small, medium, and this week we are up to large dogs. So we thought we thought we'd dive into some of the common issues, and I guess things that dog owners should know about some of the larger breeds, and how they can care for them better, and some of the things that we could talk about as we get into the large breeds. But I think as we cover large breeds, first to probably mention a few of them because we have got giant breeds. We are going to group them all together a little bit today.

Dr. Kevin: Yes, I think it makes a lot of sense to talk about large breeds and giant breeds. We kind of refer to large breed dogs as adult size over twenty-five kilograms, and probably the giant breeds over forty or certainly over fifty kilograms. So a lot of our popular family dogs fall in this these categories. So breeds like Labradors, Golden Retrievers, Rottweilers, Dobermans--they all are large breeds. When we are thinking of giant breeds, you think of the obvious ones like Great Danes, St. Bernard's--

Scott: Bernese Mountain?

Dr. Kevin: Bernese Mountain dogs, they are lovely dogs, really are. And a lot of our Mastiffs as well, Bull Mastiff, and then there'S Neapolitan Mastiffs is a very big dog as well.

Scott: What is the biggest you have seen? Is it typically Great Danes would get as big as any dog?

Dr. Kevin: Great Danes are quite a lean dog actually, so physically in size and how tall they are, yes probably some of the biggest, but may not be the heaviest.

Scott: Right.Dr. Kevin: I think Neapolitan Mastiffs are probably some of the heaviest and and biggest in size. They can be the size of a Great Dane and as stocky as a Rottweiler sort of thing, and we have some very large and muscular Rottweilers. It is not uncommon to see them up sixty-five, seventy kilograms. So that requires a bit of a team effort when we have them in the clinic as well, and we have hydraulic lift tables and lifts to manage those sorts of sizes of dogs as well.

Scott: This is something I was going to ask you about today because in thinking through this because I knew what was coming this week, I thought, you know, as dog start to age, and I know what you guys do, you are essentially almost training them up onto a table at a vet. But what do dog owners do when they have got a really big dog in their home, and the dog starts to struggle later in life.

Dr. Kevin: That is actually quite a practical consideration, definitely. Even just taking them out for walks and getting them into their vehicles, and that sort of thing, you can get a lot of very good either cut purpose-built available in pet stores ramps, and that sort of thing to get into the back of a vehicle. That sort of thing, or a lot of people make their own. So that is a practical consideration because you can not be lifting even a forty, fifty kilogram dog is difficult lifting into the back of an SUV or something like that. And then sometimes ramps over the steps, or stairs at home, if they are starting to battle there as well, that is a consideration. But I see photos of big dogs, German Shepherds, lying up on the bed at home and that sort of things that people that sometimes take top place. And even partners getting relegated to the spare bedroom or something like that. People adjust and accommodate. They also take up a fair bit of space just for their beds and sleeping and that sort of thing as well.

Scott: We are aware of that one. Okay. So let us talk about some of the common issues with the larger dogs. Obviously being longer limbed animals, the hip dysplasia certainly becomes a lot more common as a condition with these larger dogs. Is that a good place to start?

Dr. Kevin: Yes, I think so. I think a lot of what we might be talking about today is orthopaedic conditions. So hips are definitely one that some of them, and interestingly some of the breeds do not have as much of a problem with hips. And then their knee joints moving down the back legs, so the knees or what we refer to as the stifles, and the biggest problem there is cruciate disease--ruptured cruciate ligaments, or the equivalent in humans is an ACL. So we do see that a lot more commonly in a lot of these larger breeds of dogs. And moving to the front legs, elbow dysplasia is now becoming much more recognized than hip dysplasia has been known about for many years, but you can actually get. So when we talk about either hip or elbow dysplasia: it is not actually a disease directly itself, but it is an increased risk of getting severe arthritis in those joints. And that normally means the dysplasia really refers to the bad shape of those joints. So hip joints that aren't a perfect ball and cup shape quite often either the cup part of the joint is too shallow, or the shape of the head which is like the ball part that fits into the joint that shape is incorrect or at an abnormal angle. And so those make those joints often not as stable and that predisposes them to getting severe arthritis. Just because a dog has bad hips visibly, like on an X-ray, does not necessarily mean that they are going to suffer with symptoms of hip dysplasia. You can do other environmental things as well to help minimize that.

Scott: Ok.

Dr. Kevin: Even before we get to actually diagnosing it, trying to reduce these problems in the breeds, they have been known about for a long time. Selective breeding is a very important thing because if we can try and breed from dogs that are known to have better hips than average in the breed, then we can have far less problems, or less likelihood that the offspring are going to have bad hips as well.

Scott: Okay. And if they are above average in that, I guess assessment. They probably should not be breeding. Is that--

Dr. Kevin: Correct. That is the way the selective breeding works. So you get the parents that you are intending to breed with, they need to be an adult dog before these changes can actually be seen on x-rays. So they have x-rays in very specific positions, and then those x-rays--actually your regular vet can look at them and have an opinion as to how good or bad those hips are. But actually there is a list of certified hip scorers that these get sent off to and different countries all have their official schemes. They get sent off to a special radiologist who will then look at very fine criteria and come up with an actual score for each hip, and then it is known from all the dogs over the years that have had been hip scored--this process we refer to as scoring--and you can know the average for the breed. And so if a dog is better than average that's going to be a good one to breed from. If its scores are worse than average, then you rather do not breed from that dog because it is likely to push the shapes of the offspring into a worse position.

Dr. Kevin: The difficulty comes if you have got one really good hip and one not so good hip. And of course dogs are not only born with hip problems, so you have got to look at the rest of it. In a lot of these breeds something like labradors, they can get various genetic eye problems. So cataracts is an example. So you might have everything else in the dog is perfect--It does not carry the genes for the cataract problems, it does not have heart conditions, and one of its hips is marginally bad, and the other is very good--well, you might still choose based on the net assessment of the dog. It is still a good dog to breed. Never forgetting the temperament as well. You really want to choose when you are breeding. So it is a very complicated thing when they are breeding. But if you have got an outlier that has got a really bad, sort of double the average score, well that might knock it out. It is sort of like a veto that everything else might be perfect about the dog breed, but then should not be bred from.

Scott: How much of this comes back to the ethics of breeders?

Dr. Kevin: Very much. It is down to the integrity and the ethics of that individual breeder because there is no compulsion to actually have hip scoring. Obviously if they can provide evidence that the parents have been very healthy and good, they should be able to have a better reputation as a breeder and command a better price for their puppies. So it is in their best interest to do as much of this testing ahead of breeding. But there is no obligation. You do not even have to be a registered breeder to breed. And so that is also my advice to people looking at getting a new puppy: do your research; ask for these bits of information; have the parents been eye-tested, heart-tested and hip-scored.

Dr. Kevin: And nowadays as well as hip scoring, there is also elbow scoring. So the elbows are complicated joint. It is actually three bones coming together. So two below the elbow--the radius and the ulna, and the humerus above. So if there is a little bit of abnormality in the shape, they can very quickly get arthritis later on in those elbows as well. So in the same way the elbows can be scored as well.

Scott: I have got about fifteen questions that has just come out based on what you have just said in the last five minutes. I want to backtrack a little bit a couple of things that we just sort of talked about. Hip dysplasia- I find in conversations with other dog owners, the true definition of dysplasia is quite confusing. Because I think a lot of people think of it like it in terms of displacement where something is moved. So what is the true definition? What is the best way to fully understand dysplasia? You mentioned the shape of the bones.

Dr. Kevin: Yes, so you could put really dysplasia as misshapen. It is just the wrong shape. So it is the how perfect the joint really is. And then what that leads to is, especially so a hip joint is a sort of classic joint, it is a ball in a socket. And if your socket is not really tight around the ball, and so I am using my hands and unfortunately the listeners can not see, but if I mean basically showing a very flat sort of almost an open palm versus a cupped up hand. If it is very flat then there is a lot more wiggle room for the ball part to move around. The body does not like that instability and what it tries to do to stabilize that is create new bone on the edges. That is actually what arthritis is. Arthritis is new bone being put down and it is trying to stabilize the joint, but instead it actually starts impairing the joint and causing pain. So arthritis is inflammation in any joint and very commonly new bits of bone growing around the edges of the joint.

Scott: And that agitates the ligaments?

Dr. Kevin: And it also limits the range of motion of the joints as well, so that is why they have a very stiff, awkward sort of gait. So that is a slow process. Now if you have got a badly shaping hip but you do not overuse that hip, you are probably not going to get a severe wear and tear on that joint, so to speak. And so if you don't over exercise that dog when it is very young, but you also keep up good exercise so that it does not get overweight.

Scott: Yeah. It is a big problem with big dogs.

Dr. Kevin: Absolutely, and yes they are carrying heavy weight. And that is also why that next problem that I spoke about the cruciate ligament problem--

Scott: Yeah, that is what I wanted to circle back to. Let us dive into that. Explain that. When you say cruciate sort of disease, what is actually happening? Like what are you seeing in the joint?

Dr. Kevin: So cruciate disease is just a group term for, the most common thing is the actual cruciate ligaments tears, but it does not necessarily snap instantaneously. It is a wear and tear disease. And so we don't often see it in dogs even younger than five. We have a bit of an acronym: fat five and female. Not fully understood why female dogs are a little bit more prone than males. It's like a 60/40 split, so it is not a big difference. But definitely overweight dogs, fat over five years old because it is a wear-and-tear thing. So if that ligament tears 10% you still got 90% of the ligament there. It is like a rope that is fraying. You are not necessarily going to see it. The dog might be a little bit sore for a day or two, and then walking around fine. So you didn't realize that necessary that actually a little bit of the ligament frayed and tore. And then over the years wear-and-tear it suddenly--they might just be doing one exercise, running down some stairs, jumping to catch a ball, or something, and then the last little percentage tears and suddenly they pull up lame.

Dr. Kevin: So that is also to do with, often, the shape of the knee joint itself and various quite technical angles of the bones in that joint. So dogs at stand with a very upright stance. So another large breed that we have not mentioned yet, the Boxers, they are typically a breed that stands with a very upright stance. If you look, they do not have much bend in the knee and the back leg really, they stand quite upright. And that predisposes, puts more strain on that cruciate ligament. So the job of the cruciate ligament is to stabilize the knee joint. It runs inside the joint and it stops the knee moving backwards and forwards in the joint. So when the dogs tear the cruciate ligament, initially it is sore, but it doesn't actually stay that sore longer term, but they still can not use the leg. Because every time they try and take weight, they just have a feeling of it collapsing or giving away on them. So then it is quite a technical thing about the different, but nearly always they need some form of surgery. There's very many different techniques of correcting that, but once they have had that surgery, they normally go very well. They can still unfortunately damage the meniscus in the joint which is part of like the shock absorbency. So definitely--

Scott: So like that gets worn away?

Dr. Kevin: Or tears actually because there is too much movement in the joint and then the meniscus can get a tear in it. So that is often checked during the time of surgery and addressed. If it has got a little tear then we correct that at the centre.

Scott: Yeah. Now that is a great understanding of that. With the breeding, you mentioned the averages. And now I want to circle back to one breed which is the Labradors, and we have spoken about it off podcast, but it is hard to find a good Labrador, you were saying, with good hips because they all tend to be fairly high in some--

Dr. Kevin: But because of breeding and selective breeding over the years, I think there has been a marked improvement in the last fifteen to twenty years.

Scott: That is great.

Dr. Kevin: We used to see it even worse. And that is why these schemes were put in place and through breeders doing the right thing. So yes, you got to be realistic that you can not expect hip scores of zero. But for example in the Labradors, the breed average is about 8.2. And it is a scale that goes right,--there is not necessarily a top point, but very bad hips can be twelve, fifteens sort of thing. So eight is actually in the scheme of things not that bad. And if you have got a dog who has got a four on one hip and a five on the other, that is really doing well better than average. So that is a good. But you might have a dog that has a two on one side and a ten on the other, that becomes a tricky decision and maybe the mother has fours or five so very good, and the father has two, an excellent hip on the one side and and one hip that is not so good. But as we were talking earlier, there might be lots of other considerations that you would still find that an acceptable combination of two dogs because there are so many other factors as well. And yes, you can not really expect to find in many breeds like that, a dog that has no problems with its hips at all.

Dr. Kevin: Another breed that has unfortunately quite a bit of hip dysplasia is German Shepherds. And amazingly even some of the smaller breeds--Pugs, if you look in the average...

Scott: Also Rottweilers as well...

Dr. Kevin: Unfortunately they get on quite a lot of hip dysplasia, they are very prone to cruciate problems as well.

Scott: What can a dog owner do, let's say I have a mate growing up and he always had Rottweilers. And he was always concerned about their hips, I remember even from a young age. What can a dog owner do? Is it matter of just keeping weight off, keeping good exercise, good mobility?

Dr. Kevin: Careful exercise. A tip that I would give people is avoiding, a lot of these breeds love fetching balls and that. But keeping them on the ground and not encouraging them to bounce and jump when they are excited. So throwing frisbees, and jumping up in the air, coming down and landing can be quite a jarring thing either for the knees or the hips. So also having good obedience with their dog that you might actually throw the ball, keep the dog at the side, and once the ball has stopped, let them go and fetch it. Because that sudden trying to stop and chasing a moving ball can be very jarring and damaging as well.

Scott: Yeah. That is a great tip. Excellent love that. With some of the other breeds when you start looking at probably some of the more, I guess winter Saint Bernards, some of the big Huskies, Bernese Mountain dogs--what sort of common conditions might you come across there? And then we will get to Great Danes in a minute.

Dr. Kevin: Quite a lot of them... slobber a lot! And that is the big lips that they have. Funny enough there is a type of cosmetic surgery, technically cosmetic, but it actually can be really helpful to keep that slobber more in their mouths. It is not commonly done. It is something that people know the breed does. It is not a medical problem, but unfortunately also, being considerate to the climate where you live. Like here on the beautiful Gold Coast, having a St. Bernard even a Bernese mountain dog, we have actually got quite a few Bernese Mountain dogs. They are very popular breed at the moment and they cope pretty well with the heat. But St. Bernard, they do suffer a lot and so not exercising them in the heat of the day. They can suffer from heat stroke very easily.

Scott: Would you keep them clippered more?

Dr. Kevin: You certainly can. People are more looking for the authentic breed, would rather not have them shaved. Sometimes that long hairy coat actually provides insulation from the heat just like you find woolly sheep in really hot climates in the outback, and that sort of thing. The wool insulates them from the heat as well. So the to the degree that happens, and also the dogs living in a hotter climate will not develop as thick an undercoat as if they are in a colder climate. They have grown up with it through their lives.

Scott: Yeah adapting over the years. Yeah.

Dr. Kevin: We just got a beautiful example of a German Shepherd walking past, a lovely lean one. They are actually a dog that a lot of people look at them and say they are far too skinny, but they are naturally actually a working dog, and they are very lean. They are very athletic dogs as well. But just seeing that beautiful one walking past reminded me of another condition that unfortunately they very prone to. They have got a very deep chest and breeds with deep chests. And so another one classically is the Great Dane, are prone unfortunately to gastric torsion. And it is a condition that people consider in having those breeds or who have those breeds really need to know about, because it is one of these things that can be an absolute emergency.

Scott: So what happens?

Dr. Kevin: Yeah, what happens with this is that their stomach which is actually hanging in the way that a dog is standing horizontally compared to us standing upright, their stomach is hanging from underneath the back. And for various different reasons, and they are not fully understood, that stomach can actually twist on itself. And then what happens is then the gas that is in the stomach can not get out, the fluid can not get out anywhere. It is of course extremely painful, and the the gas very quickly starts to build up and it actually pushes up against the diaphragm. They battle to breathe and they start to go into a medical type of shock, and within an hour or so, it can be fatal. It causes a lot of problems for the heart. The heart can't circulate the blood of course wind the whole intestine and the stomach is twisted, none of the blood can move through those twisted blood vessels, as well. So it is something that needs emergency treatment right away, whether it is the middle of the night, or daytime, and it very often does happen in the evening time.

Scott: Why is that?

Dr. Kevin: It is often associated with eating too close on exercise. So either eating first and then going and exercising, or even if they have come back from a big walk and then are fed very soon. Some of that is various hypotheses as to what is happening. And if they are swallowing a lot of gas when they are eating, their stomach can fill up. If it fills up with a lot of air and gas, we think it is more prone to twisting on itself. Very much so if they eat and then go and exercise, then the running around this coming back to their shape the deep-chested nature, there is a lot of space for that stomach to twist on itself. So if it is hanging and it has got all the for heavy food and it is swinging from side to side as they run, we think it just suddenly flops right over.

Scott: Pendulums right over?

Dr. Kevin: We have actually got to be also careful in the hospital. If we have got them under anaesthetic, if we are turning them over to operate on the other part of their body, or move them from one area of the hospital into the theatre or something like that, we also got to be very slow and gentle that we do not just flip them too quickly because you can flip their stomach as well.

Scott: Right. Wow so crazy.

Dr. Kevin: It sometimes starts where they don't necessarily have the full torsion where they are not twisted, and they have just got bloat. And then that is easier to address. We normally give them an aneesthetic and put a tube down their throat. Let that gas all out. And if you have caught them then before they have actually twisted, then they do not always need surgery.

Scott: What symptoms is a dog owner going to see?

Dr. Kevin: I think that is really important that we chat through this one because it can start off just looking like the dog's unsettled. It is restless, can not lie down, and you sort of say, "What is wrong? We have just gone for a walk. Why are you so restless?" And then very quickly they will often be trying to vomit, but most times nothing coming out. But just a bit of a retch and a retch, and they look quite quickly over twenty minutes or so, they just seem to get a lot worse. They are uncomfortable. They are lethargic, and then you might notice that their stomach is swelling. And it actually swells right up and it can be taunt like a drum. So you actually just tapping on the stomach, the stomach looks a bit bloated. They might look sort of pregnant, but it can be difficult to miss that. You would think it is so obvious, but a lot of that is underneath the rib cage.

Scott: And that is more stomach than chest? Is that where it is coming out?

Dr. Kevin: Correct. So just behind the chest, there is a whole abdomen area. And by the time you see that, it is definitely a run do not walk situation. Get to an emergency clinic straight away. But yes, the unproductive attempts to vomit, and sudden lethargy, and unsettled nature, those are the most common early symptoms of it.

Scott: Is this just something that can happen quite randomly across these breeds like German Shepherds? Is there no way of pre-checking it as part of a breeding process or part of identifying it--

Dr. Kevin: Different to what we were talking about with the orthopaedic problems, we can't screen for it, and it has not really got a genetic link. So much so that because it is quite a high-risk factor, we do all the work for the Gold Coast police dogs, and progressively they have put each one on a bit of leave and we have done a preventative surgery for them called a gastropexy. What we go in then is before they have ever had any symptoms of it, and we actually go and permanently stitch the stomach to the side of their abdomen, so that it can still bloat up, but that's not life threatening.They could still get a lot of gas building up, but it will not ever twist on itself because it is attached in one point. So it takes a bit of recovery and it is a moderately costly operation, but I think in any of the breeds that are prone to it--so your Great Danes, your German Shepherds, Dobermans, and deep-chested dogs--it's well worth considering. We often offer that if we desexing one of those breads, whether it is a male or a female, to do that operation at the same time. Because they are still a young dog, they are under anaesthetic anyway. Moderately costly operation. It is technically very challenging for us, but they recover so well. There is very little complications or problems and it is a lifelong prevention for them.

Scott: Yeah. That's great.

Dr. Kevin: That is a very good thing to get done early.

Scott: It is a very good thing to be aware of, is it not?

Dr. Kevin: Absolutely. So it is called, just for people listening, gastric torsion or it also goes under the acronym of a GDV-gastric dilatation volvulus is a bit just remember GDV.

Scott: Internationally does it have any other names?

Dr. Kevin: Also referred to just as bloat.

Scott: Okay.

Dr. Kevin: So gastric torsion, bloat, GDV, they are the most common names for it. And so the other tips for people preventing it is not feeding your dog and then exercising. And I am not just talking about going for a walk, even just bouncing a ball, throwing, playing around in the backyard or in the kitchen or whatever soon after eating. Also not waiting quite a long period once it has gone for a walk, recovering from that so that it is not--

Scott: How long are we talking about?

Dr. Kevin: I would wait up to an hour before feeding, and that is thought to be because they are still breathing up quite heavily, and they are probably sucking in a lot more air when they eating their food. They are enthusiastic to eat their food and suck up air.

Scott: Some big dogs eat at a million miles an hour too--

Dr. Kevin: Absolutely. Some people are very critical of feeding dry foods then to these breeds because the dry food itself can swell up and bloat. I don't think there is a direct big problem, that has been looked at and researched a lot. But sometimes adding some water to that food can be a helpful thing. Feeding twice a day instead of once a day so that they are getting a bit of a smaller meal each time.

Scott: Right. So it's not a big large meal? Yeah, right.

Dr. Kevin: Yeah. So those are things sometimes it is thought also feeding a bit from a height, so putting the food bowl up on a little bit of a platform, on a step, then they not bending down as much. The thought is maybe they are not going to suck in as much air. That's not such a big issue there.

Scott: Yeah, great. Have we missed anything with the larger dogs?

Dr. Kevin: Quite a few of them unfortunately are prone to ear infections. Again, sometimes to do with their behaviours. So dogs that love swimming are going to get more ear infections--so your Labradors, Golden Retrievers, unfortunately. The dogs with either floppy ears coming down or big ears that are like big funnels and let everything go in, like a German Shepherd, unfortunately can be quite prone to ear infections. And skin infections, some of them, unfortunately I keep seeming to be picking today on German Shepherds, but some of them--

Scott: They are really popular, aren't they? I mean they are used as police dogs almost all over the world. They are beautiful dogs. Very intelligent.

Dr. Kevin: But unfortunately they do just seem to be quite prone to certain skin allergies, very sensitive skins as well. Seem to get yeast infections quite easily. So ear infections, my tip there is pick up on it early because they can become chronic recurring problems. Head-shaking is one of the first signs just seeing a dirty waxy area at the outside.

Scott: Okay, and in terms of prevention and maintenance, same with the sort of stuff we spoke about with some of the medium dogs or the fairy dogs, keeping clippered.

Dr. Kevin: Yes. Sometimes a routine cleaning with an ear cleaning liquid. Certainly after swimming it is a very good idea. Once a week or once a fortnight just doing an air cleaner is good.

Scott: In the medium dogs and in multiple other episodes, we have talked a fair bit about teeth and dental hygiene. Big dogs naturally have pretty strong bites and I imagine they are, I don't imagine I know, they are biting into all sorts of different things, particularly through either boredom and other stuff as well. Bones as we spoke about in the last episode with medium dogs, and the danger of bones. Talk us through teeth and dental with large dogs. What do we need to be aware of?

Dr. Kevin: Fortunately, I think it is one of the things that they seem to suffer a lot less with. We do not see as rapid a build up of calculus and tartar on them, with one exception being Greyhounds. Unfortunately, they, for whatever reason their local immunity in their mouth, they suffer from a lot of very bad dental disease. Greyhounds do, almost irrespective of diet, and that sort of thing. So Greyhounds having them have a scale and polish early to try and look after those teeth. Keep them healthy is a very good thing.

Scott: Is it the same for Whippets or some of those long snitch breed?

Dr. Kevin: No, no, sure because those long-snouted dogs definitely. Whippets, Italian Greyhounds also seemed to have, and again a smaller breed but a Dachshund, those long snout seem to just also get dental disease a lot worse. But for the rest of them, the large breeds have far slower buildup of tartar. Some of that is diet-related and chewing on things, but I think it is just more a lucky thing that theirs are not as bad.

Scott: Is it because they got bigger mouths?

Dr. Kevin: I think so. The teeth are not as crowded in, definitely. And and also the type of diet, and how much they spoilt, and soft foods, and that sort of thing. But some big breeds, like Rottweilers, tend to get a lot of chipped and actually broken teeth because they have got such a strong jaw and they might be chewing on something that they should not be. So we do see them having quite a few broken teeth sometimes. But teeth problems not too bad. And as a general rule, skin problems not too bad other than like I am saying some of the German Shepherds can be prone to skin allergies.

Scott: Is the skin allergies noticed in the same areas as we spoke about in the last episode with Bulldogs? Is it a lot of groin?

Dr. Kevin: Yes. Lower ventral abdomen and in their groin area. Their paws, quite a few of them get a lot of skin infections in between the toes and their paws. And then some are more breed-specific, Boxers are quite prone to some hormonal skin problems, having an under active thyroid gland sometimes as well. So that is something they suffer with a bit.

Scott: Interesting. Well as always you are a wealth of knowledge, Dr. Kevin. Thank you for being with us. I do not think there is anything else before--

Dr. Kevin: I think they are a lovely group of dogs, that are working dogs. They can be family dogs. Wonderful, you know that you can get out and do a lot being--

Scott: Just because they're big, I think some people fear them, don't they? And like Great Danes are some of the biggest sooks on earth.

Dr. Kevin: But it is also very important to do good obedience work in the early stages so that you have got control of a big dog, because some of them can be very aggressive. And we have not had really much time to talk about behavioural issues, but you can have behavioural problems with some of them, and you want to have good control. So good socialization when they are young and dog training would be my closing remarks.

Scott: Might make a good topic for our next next podcast.

Dr. Kevin: Indeed.

Scott: Thanks so much for joining us. And as always if anyone has got any questions, just follow us on all the socials and feel free to fire through questions and ask Dr. Kevin, and we will do our best to answer them on the next one. But thank you for joining us.

Dr. Kevin: It would be a pleasure to shoutout and answer anyone's questions indeed.

Scott: See you next time. Thank you.

Dr. Kevin: All the best.


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