Dr. Andrea Eriksson De Rezende, veterinary cardiologist, joins Dr. Andy Roark to discuss a cardiology case. Dr. Roark has an 11yo FS chihuahua with a grade V/VI systolic heart murmur that needs a dental cleaning. The patient is reportedly starting to cough at home. Dr. Roark wonders if this patient is safe for anesthesia and what sort of diagnostic workup and treatment plan would be appropriate. Dr. Eriksson lends her expertise!
This episode is brought to you by CEVA Animal Health.
LINKS
Explore Free CE from Ceva: https://www.cevaconnect.com/ce/?utm_source=TheConeOfShame&utm_medium=podcast&utm_campaign=Susanne_cardio
Cardalis Info: https://www.cevaconnect.com/cardiology/products/
Skyline Veterinary Specialists: https://skylinevetspecialists.com/
Email: andreaeriksson@skylinevetspecialists.com
Dr. Andy Roark Exam Room Communication Tool Box Team Training Course: https://drandyroark.com/on-demand-staff-training/
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Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. Andrea Eriksson De Rezende is a native of Eugene, Oregon and completed her undergraduate studies at Willamette University in Salem, Oregon. She received her veterinary degree from Oregon State University in 2005, which was followed by a one-year rotating small animal and surgical internship at Oregon State University. She then completed a three-year residency in cardiology at North Carolina State University. Dr. Eriksson De Rezende became a Diplomate of the American College of Veterinary Internal Medicine (Cardiology) in 2009. Until mid 2011, Andrea was an assistant professor of cardiology at Virginia-Maryland Regional College of Veterinary Medicine. Andrea then moved to Brooklyn, NY to join the Veterinary Emergency and Referral group. Currently, Andrea is managing partner at Skyline Veterinary Specialists in Matthews, NC. Her research interests include management of congestive heart failure with particular interest in the renin-angiotensin-aldosterone system as well as cardiac imaging. Personal interests include cooking, travel & singing.
EPISODE TRANSCRIPT
Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I got a great one today. I am here with my friend, Dr. Andrea Eriksson. Andrea is a boarded veterinary cardiologist in Charlotte, North Carolina. Man, she’s a wealth of information. I am super happy to have her here to talk to her about a case.
I have a little bitty, itty bitty… Pepita is an 11-year-old chihuahua who’s got a grade 4 heart murmur. And, owner’s report, she’s having a bit of a cough. Well, you’re not going to believe this, this 11-year-old chihuahua has got some dental disease and is really going to need a dental prophy here.
And I’m having some concerns about putting this pet under anesthesia. I’m wondering, “How safe is this? How do I need to work this up? Is it time for some medical management for Pepita beyond what she’s been getting?” Dr. Eriksson walks me through everything. So, guys, this is a quick, action-packed, pearl-packed, little episode that, let’s be honest, you’re going to see this case and you’re going to want to know what to do.
So, anyway, we get into that. We talk about a new drug called Cardalis, which you may or may not be familiar with. But, anyway, it’s great. We’re going to learn a lot. Let’s get into it. Gang, this episode is brought to you ad-free by CEVA Animal Health.
Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Dr. Andrea Eriksson. Thanks for being here.
Dr. Andrea Eriksson:
Oh, thank you so much for having me. I’m very excited to be here.
Dr. Andy Roark:
Yeah, it’s my pleasure. For those who don’t know, you are a boarded veterinary cardiologist. You are right up the road from me. You’re in Charlotte. You and your husband own Skyline Vet Specialists, where he’s an internal medicine specialist and you are a cardiologist. And then, you guys also have an emergency practice. Is that separate or is that together?
Dr. Andrea Eriksson:
It’s together with us.
Dr. Andy Roark:
Oh, wow, okay.
Dr. Andrea Eriksson:
Yep, I know, I know.
Dr. Andy Roark:
That’s amazing. All right, wonderful. Well, I am so glad that you’re here. I have a case that I want to work up with you. Is that okay?
Dr. Andrea Eriksson:
I love it.
Dr. Andy Roark:
Good, good, good.
Dr. Andrea Eriksson:
It’s my favorite.
Dr. Andy Roark:
Okay, here we go.
Dr. Andrea Eriksson:
Yeah.
Dr. Andy Roark:
So, I have an 11-year-old female spayed chihuahua named Pepita. I’ve had pepita for a while. She has got a heart murmur. It’s grade 4. I can hear it on both sides of her chest. It’s pretty significant. When I hold her in my hand, I can’t tell if I’m imagining that I can feel it, or it’s really… Is that her natural tremble? Anyway, so it’s about that. It’s not a tiny little murmur. But, she’s always seemed to be spry. Let’s be honest, her feet never touch the ground. Mom doesn’t put her down.
Dr. Andrea Eriksson:
As it should be.
Dr. Andy Roark:
Exactly right, as it should be. She gets carried around. She’s coming due for a dental cleaning. We’re going to need to make that happen. And she’s 11. And mom has mentioned to me that she’s doing a bit of coughing at home. Now, I’m not hearing coughing on the exam, but mom says that she coughs at home sometimes.
And so, what I’m coming to you with is this, is first of all, she’s not being medicated right now in any significant way for her heart condition. How do I look into that? I guess that’s the question. Coming up on a dental, are you terrified of this? Are you saying, “Don’t do this dental, Andy?” Or are you saying, “Why don’t you send this to me and I’ll do this dental?” Help me start to look at her holistically of what does medical management look like? What does risk assessment look like? Is anesthesia even possible? How concerned should I be? So, let me just hand it to you like that and say, Dr. Andrea Eriksson, how do you treat that?
Dr. Andrea Eriksson:
Yeah. So, I would say the most practical approach would be is that we’ve got to, like you said, we’ve got a little chichi that is living her normal life, doing her normal things at home. Probably the owners, at this point, are unaware of the fact that there’s things that we can look for at home, that going forward we can look for, in addition to a progressive cough or a change in cough.
That being said, if Pepita’s going to be anesthetized in her relatively near future, just because that’s what needs to have happen because she’s not eating as well or she’s definitely feeling the effects of having pretty significant periodontal disease, then it’s definitely not a no-go for her to have anesthesia. It’s truly on your physical exam, too, everything that you’re going to look at anyways, is that you’re going to be looking to see does she still have a sinus arrhythmia?
Now, that being said, our chihuahuas can definitely have a heart rate of 160 beats per minute, just because they’re there in the hospital in your hands and not at home. But, one of the things that we do tend to look for is that, as a dog progresses into more significant heart disease, their heart rates tend to actually increase just because it is a natural tendency of the heart to try to compensate to increase cardiac output.
But, the things that you can do, and that would be strongly advised for this particular patient, one, first and foremost in your hospital, would be to do thoracic radiographs. And so, making sure that we’re getting a vertebral heart size that, for that particular patient, seems reasonable. So, that number generally is around 10 for a vertebral heart size. It does vary a little bit between having a barrel-chested dog versus a little skinny thin-chested dog. But, in general, somewhere around 10 is about right.
Then, if we’re seeing something, you’re getting a vertebral heart size that is basically 12 to 13, you actually, at that point, it doesn’t mean you can’t anesthetize them. It just means that patient does need to go onto cardiac medications. And so, we’re thinking, at that point, especially if we interview the owner and the owner is saying, “No, I don’t really see any exercise intolerance or restlessness at night,” if they were savvy and looked up maybe, “What I should be looking for in my pet that maybe has a heart murmur,” if they knew, then they might look up, “sleeping respiratory rate”. It might come across somewhere in their Google search. And so, if they were savvy enough to say, “Hey, no, I’ve done this and it’s consistently below 30 breaths per minute,” then you thankfully have another piece of information. But, many owners don’t know that they need to do that yet until you tell them to do that.
But, say, if that vertebral heart size is 9.7, then that murmur, due to that leaky valve, is not causing any sort of cardiac decompensation at that point. And so, those are patients where you could feel pretty certain that if you use basically your protocol that you would normally use for an 11-year-old dog… So, you’re not going to wallop them with a bunch of medications that are going to change your pressures and their heart rate rapidly.
You’re using things like your midazolam and torodent for your pre-med. And you’re using something like propofol, alfaxalone for your induction. And putting them on a relatively normal rate of isoflurane with your normal five ml per kg per hour type of fluid rate. You’re going to be good.
Dr. Andy Roark:
All right. So, let me say this back to you. So, it’s funny. Yeah, I’m surprised, I think, at how much weight you put on the vertebral heart size. That’s a pretty significant line for you to go to, it sounds like. So, first of all, let me just say, real quick, can you give me a refresher on vertebral heart size just for people who are not familiar, who haven’t been in that position to use it before?
Dr. Andrea Eriksson:
Absolutely. So, it is basically a sum. So, on your right lateral thoracic radiograph, you’re basically going to take a… You can just use a piece of paper, too, where you’re going to take a line, and make a line, and measure this line from the carina down to the apex of the left ventricle. And then, you’re going to do a perpendicular line from the cranial edge of the cardiac silhouette to the caudal edge of the cardiac silhouette just underneath the caudal vena cava. Because you do want to be measuring the ventricles. You don’t really want to get the atria up in there.
So, you’re going to take those lines and you’re going to superimpose them over the thoracic vertebrae. And you’re going to start that line, the very beginning of that line, at the cranial edge of thoracic vertebra number four. And so, you’ll put that line. And then, the second line, which is that perpendicular line, same thing. Start at the edge and start measuring from thoracic vertebra number four, cranial edge. And you’re going to count how many vertebral bodies are in each line, basically, and you add that up. And so, that’s where you’re going to get that.
It’s one of those things that I have plenty of slides showing that. So, if anybody wants to reach out to me, I can shoot them an email super quick and easy. But, there’s plenty of resources out there, too, that show you that way of doing it, but that’s what…
And it’s one of those things that, yes, I get referred these cases all the time for me to echo. And it gives me additional information about that patient for sure. It gives me much more specific information. But, when we’re talking about you having to see 60 patients in a day, and you have 15 minutes to talk to an owner and say, “Hey, I’ve got to figure out if I can take out these teeth because they’re really bad,” that would be the thing that that family veterinarian could do within their hospital to get basically some really good information about that patient.
Dr. Andy Roark:
Yeah, that makes sense. Talk to me a little bit about what you’re looking for with a sleeping respiratory rate. So, I love the idea of getting the pet owner involved in this so they can look at it. Are you looking for trends here or are there certain… You mentioned 30 breaths per minute. Is there some sort of number that starts to give you pause? Walk me through how you use that tool.
Dr. Andrea Eriksson:
Yeah. So, I would say that getting them involved is key. Basically, I talk to my owners about having a triangle of care, which is myself, them being most important with their pet, and then with their family veterinarian. So, that way we can all have a good conversation about what’s going on with Pepita at home. And so, one of the things I’m talking to them about is, “Hey, what we have known about this over the past 10 years is that if we’re able to, whether you do it on an app, so there’s a number of apps, Cardalis has an app, but you basically can track what their sleeping respiratory rate is.” So, I talk to them about, “Hey, if you can get them while they’re completely passed out asleep, just absolutely snoring and sawing logs, then you’re going to watch a rise and fall of their chest, and that’s one breath. They should be, while they’re sleeping a good… nobody having any issues with their heart or anything, they’re going to have a sleeping respiratory rate that’s less than 30 breaths per minute.” Now some dogs, you just can’t catch them while they’re asleep. They know you’re stalking them.
Dr. Andy Roark:
Yeah. They crack one eye open. Yeah.
Dr. Andrea Eriksson:
They’re like, “What are you doing? You’re a creep.”
Dr. Andy Roark:
Yeah. Got you.
Dr. Andrea Eriksson:
So, yeah, they’re like, “You’re a creep.” And so, we allow those guys to get up to 40 breaths per minute because they’re going to change a little bit and fluctuate because they’re creeped out by you. Yeah, yeah. So, that’s what I’m looking for. Trends are amazing. So, if I have an owner that can give me at least data points of three to four per week, that’s like music to my ears. But, it is something I tell my owners that, “When I call you, I’m going to bug you, and I’m going to ask you what this number is, and it’s going to be annoying, so just if you do it will be less annoying.”
Dr. Andy Roark:
I bet they love it. I mean, I bet they love it. It’s something that they can actually-
Dr. Andrea Eriksson:
Yeah, because it’s involved.
Dr. Andy Roark:
… do and feel like they’re involved. Yeah, exactly. I think a lot of times the hardest part with disease, whether it’s you or whether it’s your pet, is a feeling of powerlessness. And so, just the ability to be like, “Yep, I am taking action here,” I think that that’s such a healthy, good thing. So, I love this. I’m on board with the vertebral heart score. I’m with the resting breathing rates. So, I’ve got Pepita here, and let’s say that she’s trending a little bit high, so her vertebral heart size is a little bit greater than 10, maybe up 10, 10 and a half maybe. I’m like, “I don’t know. We’re kind of on the far side of this.” How you do you start to manage that case?
Dr. Andrea Eriksson:
I would say veto. 10 and a half might be a little… We’d be still within a normal range. But, if we bump that up a little bit, say 11.3 or something, and on addition to that you’re starting to see maybe that little hump of a left atrium that’s up next to your mainstem bronchus, and you’re like, “Yeah, that looks a little bit big.” Then, those guys, I typically will say, “Hey, we need to put your pet on Vetmedin, on [inaudible 00:13:49] going to start [inaudible 00:13:50].
Dr. Andy Roark:
Now, we’re going to lay there and make them lay down. Yeah, exactly. Put a box underneath them.
Dr. Andrea Eriksson:
We’re going to have to put you on the box. I wish it worked that way. What we do know about patients that have mitral valve regurgitation due to chronic degenerative valvular disease, and their hearts are getting big, we know that they’re going to live longer and stay within that pretty much asymptomatic period much longer if we get them started on pimobendan.
And so, those patients, I typically will start anywhere from a quarter to a 0.3 mg per kg twice a day Vetmedin dose. It’s well tolerated. There are some patients that may have some GI side effects, so I usually tell them, “Hey, if you see something like that, just try to give it with some food, even though the package insert will say, ‘Give 30 minutes before food.'” It’s like we have to make sure that the patient can tolerate it, and so a lot of them do get it with a little bit of food.
Those are ones where if I have a family vet that’s like, “Oh, Andrea, I need to do that procedure today,” then that’s fine. They can actually have a dose even 30 minutes before they have their procedure because it does work fast. We use it as an emergency drug. So, it does have an effect. If you can wait, maybe having them on it for about a week or so, so that way you actually have that additional support for that cardiac, basically what we’re looking for is increasing the efficiency and decreasing the workload on the heart. So, if we can have it on board before we do the procedure, that’s even better.
And so, some of these guys will get it and they’ll get it about a week before or longer before they go. But, then they stay on it afterwards. So, I usually make that clear. We’re not just using it for the procedure, we’re using it for a long-term. This is going to be something, unless something comes up where the animal doesn’t tolerate it, we’re going to be on this for the rest of Pepita’s life. And hopefully it’s a long life for our little Pepita.
Dr. Andy Roark:
No, I like it. So, great. So, you open up with pimobendan and get them [inaudible 00:15:59]. It’s a miracle drug, in my experience.
Dr. Andrea Eriksson:
Yeah, it is. Yeah. No, it changes things for sure.
Dr. Andy Roark:
Yeah. Well, great.
Dr. Andrea Eriksson:
Yeah.
Dr. Andy Roark:
So, talk to me a little bit about stages and degrees with this case. So, I’ve got Pepita, an 11-year-old chihuahua, I’ve probably got a long way to go. We’re going to start out with management in this regard. She mentioned she’s got a cough at home, things like that. Are you thinking about a diuretic of some sort? Are you not? Are there triggers that are going to send you into action in that regard? Help me walk in that direction, if you don’t mind.
Dr. Andrea Eriksson:
The time where we’ll definitely say, “Okay, we’re going to need to start a diuretic,” is, whether it’s somebody who feels very, very comfortable with thoracic radiographs and say, “Oh, yeah, I actually do see…” Typically, on a radiograph, what we would see is venous distension.
So, on the lateral radiograph, you have an artery, a bronchus, and a vein, and those guys you can see pretty clearly in that cranial thorax. If you do a left lateral, what’s nice is that vein will pop out a lot easier. So, if you do a right lateral… I typically do DV so I don’t have to put them on their back and then I’ll also do a left lateral. The left lateral just shows up that vasculature to that cranial thorax just a little bit better. So, you can compare that vein to that artery.
And so, having a vein that’s plumper, bigger than that artery, that concomitant artery, is an indicator that we’ve got some kind of… that heart’s having a harder time handling its preload, or basically the volume that it feels that’s coming into it. Then, you’re going to be obviously looking for any sort of pulmonary pattern that’s more of a interstitial alveolar pattern. And that pattern, typically in our dogs that have mitral valve regurgitation due to degenerative valvular disease, it usually will start in the right caudal thorax. And so, if you have that DV or VD, and you look in that right caudal thorax, that’s usually where they start to dump the fluid. And so, I typically tell my family that, “Hey, if you can get that view, it’s extremely helpful for us to be able to tell if there’s edema there or not.”
Those patients, if we do see that, and we’re worried about that, and even if they come in and maybe the owners haven’t really… They’ve maybe noticed a cough, but you listen, and you’re watching the dog breathe while you’re talking to the owners, and you’re like, “Well, he’s kind of using his belly to breathe a little bit, too, in addition to those clinical signs,” and owners say, “Oh, yeah, I have kind of noticed that. Anything, from when Pepita tries to run up the stairs, we kind of have to stop and breathe kind of heavy, and I just thought Pepita is getting older. We know that.” And it’s like, “Well, it’s not just getting older. Unfortunately, we need to start some more.”
So, that’s when I will definitely say, “Hey, we’ve got a constellation of clinical signs and radiographic features that do support a diagnosis of congestive heart failure. So, that takes you into, from stage B2, which Pepita would’ve been at before, where she just needed Vetmedin, to stage C, which is basically congestive heart failure. And it may be early stage C. We’ve got a little bit of clinical signs going on. It’s not an animal that’s rushing into the ER, but we’re starting to see those features of edema as well as clinical signs at home.”
So, those patients, we’re going to start them on furosemide typically. So, Lasix. A little chihuahua that is 4.5 kilograms, and is showing us those types of more subtle signs of edema, but we’re convinced this is edema, that little one is going to probably get somewhere around 6.25 milligrams twice a day of Lasix. You might think some, if they’re a little bit more clinical, and you’re listening and the lungs don’t look great, you may start with a little bit higher dose. You might go one full 12.5 milligram tablet twice a day for a little bit and then back down to a half a tablet.
If we’re starting that, then you do need to start something that inhibits the activation of the renin-angiotensin-aldosterone system. What we do know now from recent studies, and this came out a couple years ago, is that dogs will live longer, in addition to having the Furosemide on board and the vetmedin onboard, is also inhibiting the renin-angiotensin-aldosterone system. That’s best done with both an ACE inhibitor and also a mineralocorticoid receptor antagonist too. So, that would be your spironolactone.
So, I usually will say, “Hey, I know it’s a lot of drugs, but your dog’s going to live longer if we get them onto the a lot of drugs.” So, there’s a number of ways of doing that, whether it’s separating them all out where you have Lasix, vetmedin, spironolactone, and an ACE inhibitor. So, that can be your prils. So, whether you like enalapril or benazepril. Personally, this is just… I like Benazepril because it’s once a day. And so, you can get spironolactone and benazepril together and cardalis. And basically you’re going to dose the cardalis based upon the spironolactone dose that you want, which ends up being around two mg per kg. So, for that spironolactone dose. So, that ends up being about two mg per kg for spironolactone and then a quarter mg per kg for the benazepril in that dose.
Dr. Andy Roark:
Talk to me about cardalis. Just talk to me because there’s a lot of people that haven’t used it yet. They don’t have it on their shelf yet. Just give me a high level overview of cardalis as a medication, and when that plays in, and just the benefits that you see in it.
Dr. Andrea Eriksson:
Yeah. So, the benefits that I see is, honestly, what I tell my owners, backed by studies, which is really nice. There are times where I have to say, “There’s this drug, hopefully it helps.” But, I’m not your cardiologist that really likes to do those things. I love having data behind it. What’s nice about cardalis, is it does have that data. And so, their studies show that if you use the combo of spironolactone and benazepril together, it was better than benazepril alone.
So, a lot of family veterinarians feel like, “Oh, I know Andrea. I know we use the vetmedin. I know we use the Lasix.” And then there’ll probably be 50% of them that say, “Okay, I feel comfortable using the ACE inhibitor.” Now, I’m hoping that people will feel more comfortable with also layering in the spironolactone. What’s nice about the cardalis is it is one pill. And so, Pepita, she would probably get 20 milligram and 2.5 milligrams. So, 20 milligrams of spironolactone, 2.5 of benazepril. And I would probably start her on about half a tablet once a day. And then, they’re done with that drug drug.
So, it’s nice just because you just have it and you don’t have to say, “Here’s two other medications,” remembering which one is which and when. And what’s nice about it, too, is that that’s the actual drug that was studied. So, there’s a lot to be said about saying, “Okay, this is what was actually studied versus other combinations.” And so, when I talk to them about things, I’m like, “If it’s me and my pet, I want the one that was studied.” And then, they did all the safety data to show that there’s… I mean, it’s more than unlikely. It’s really not going to happen where you’re going to worry so much about them becoming hyperkalemic.
So, a lot of people think, “Oh, God, Andrea, if I use both of them together, their potassium’s going to be nine.” It’s not going to happen. And so, if you are worried because you did prelim blood work before you started it, and their potassium’s 5.2, and you’re like, “Oh, God, if I get up to six, it’s going to be terrible,” then start them at a lower dose. And then, just recheck them, because you’re going to recheck them anyway because they’re in heart failure. So, that’s what I typically will… that’s what I recommend in counsel to my owners.
And when they talk to me about the cost, it’s a real thing because it is more expensive than you go into the Publix or Harris Teeter pharmacy and picking out the two. I talk to them like, “Well, this is what was studied though.” So, if it comes down to it that the cost is a really big deal, then okay, but I’m going to tell them what I recommend.
Dr. Andy Roark:
Yeah. No, that totally makes sense.
Dr. Andrea Eriksson:
Yeah.
Dr. Andy Roark:
Talk to me about monitoring of this case. So, you said, “We’re going to recheck it, we’re going to follow up because they’re in heart failure.” What does follow up for you look like in a case like this?
Dr. Andrea Eriksson:
Yeah. So, ideally what I will do, if the patient comes to me, when I see them back, I usually see them back somewhere between seven to 10 days after we’ve started all these medications. Now, the caveat to that is a patient that I’m a little bit worried. So, instead of Pepita maybe being 11 with normal renal values, I feel comfortable going seven to 10 days, even a couple of weeks before I recheck her.
And when I’m rechecking, it’s just I’m rechecking blood work. So, in particular, I want to know what her [inaudible 00:25:56], her creatinine, and her electrolytes are doing. And I check their blood pressure. So, for me, I’m a little bit crazy about checking their blood pressure. But, I check with the Doppler just because I’m making sure that there’s no extra workload on that cardiac muscle. So, yes, I worry about them getting hypotensive. But, I really do worry about them getting hypertensive. And their hypertension is not because they’ve got heart disease, it is because they can develop, just from RAAS activation, them having… them developing hypertension.
Then, you’ve got dogs that are 13, 11 that can also have things like Cushing’s. They have other things. And so, I’m making sure that I’m doing everything I can to unload that heart as much as I can. So, those are the two things I like to get at is their blood pressure and their, whether you call it a renal panel or whatever you use at your clinic.
If I have a patient that I worry that their creatinine’s on a little high end of normal, then I will see them five to six days. I won’t go… It’ll be like I’ll cut out half that time. I need a good five days for the drugs to actually have their desired effect, but also have truly when they get good blood concentration. So, we know that about five days, especially with the ACE inhibitor, is going to be a good landmark for us to be able to say, “Now I can see truly what you’re going to be doing with the ACE inhibitor and the spironolactone at that point.”
Dr. Andy Roark:
Dr. Andrea Eriksson, you are amazing. Thank you so much for being here and helping me with this. I really appreciate it. Where can people find you online? Where can they learn more from you?
Dr. Andrea Eriksson:
Yeah. So, if you just look up Skyline Veterinary Specialists in Charlotte, North Carolina, because we’re a small clinic, you just hit the Contact Us, it basically goes to me. But, you can also andreaeriksson@skylinevetspecialists.com.
Dr. Andy Roark:
Excellent.
Dr. Andrea Eriksson:
Yeah.
Dr. Andy Roark:
Perfect. Thank you so much for being here. Guys, thanks for tuning in. And that’s it. That’s our episode, guys. I hope you enjoyed it. I hope you got something out of it. Thanks again to Dr. Andrea Eriksson for being here and lending her knowledge. Thanks to CEVA Animal Health for sponsoring this and making it possible. Gang, be well. Take it easy. To talk you soon.
