This article first appeared in EQUUS magazine.
After a long, dreary winter, most horse people look forward to the coming of summer with great anticipation. Whether we are pleasure riders who live to hit the trail or serious competitors gunning for the top prize, summer is prime horse time, and we want our horses to be at their very best. Fortunately, horses generally have fewer health problems in the summer months, but this doesn’t mean we can take their health for granted. In fact, there are a number of ailments associated with the insects, heat, sun and activities of summer – some of which can be quite serious. Therefore, if you want your horse to remain hale and hearty throughout the summer season, you need to know what problems to look out for, and what you can do to prevent them.
What’s Bugging You: The serious health threats
The presence of insects is an inescapable and irritating part of life in the summer -- but insects can be more than just an irritation to your horse. Explains Bob Wright, DVM, Veterinary Scientist, Equine and Alternative Livestock, Ontario Ministry of Agriculture, Food & Rural Affairs (OMAFRA), “You’ve got to be aware of insects, especially mosquitoes, for their potential to spread serious diseases like West Nile Virus, Eastern Equine Encephalomyelitis and Western Equine Encephalomyelitis. That potential increases towards the end of summer, and into the Fall.” Because all of these diseases are potentially fatal, it is extremely important to be familiar with their clinical manifestations, as well as what measures to take to help keep your horse from contracting them.
West Nile virus (WNV) causes serious and potentially fatal neurological disease in horses. Mosquitoes bite infected birds and then spread the virus to other species. Although the number of equine cases has dropped off markedly, WNV continues to be a threat, with an equine mortality rate of about 30%. Those at greatest risk are the young, the old, and those with compromised immune systems.
Neurological symptoms such as muscle twitching, incoordination and muscle weakness are the most common clinical manifestations of WNV in horses. Additional signs may include fever, somnolence (sleepiness), inability to eat and drink, recumbency, and seizures.
If a horse survives a WNV infection, it is protected from development of clinical disease for an extended period of time. Nonetheless, prevention remains the best option. There are now several types of vaccine available, and most veterinarians recommend vaccinating all horses, especially in areas where WNV is known to be present.
Encephalomyelitis refers to a disease that causes inflammation of the brain and spinal cord, usually as a result of an infectious agent. There are two variants of equine encephalomyelitis of concern in North America: Eastern (EEE) and Western (WEE), both of which are caused by viruses transmitted mostly by mosquitoes. Either disease can be serious, but EEE has a much higher fatality rate than WEE.
Typical symptoms of Eastern Equine Encephalomyelitis include loss of appetite, fever, and change in behavior. Within 12 to 24 hours of the initial symptoms, the horse will exhibit head pressing, circling, and will often become blind. As the disease progresses, the horse may become recumbent and might suffer seizures. In the worst cases, horses die from respiratory arrest two to three days after the onset of clinical signs.
The fatality rate for horses with EEE may be as high as 90%. Horses that do survive are frequently left with permanent neurological impairment. Treatment is mainly supportive, as there are no anti-viral drugs available for EEE. Fortunately, EEE is relatively rare and is generally restricted to the eastern, southeastern and some southern states.
Western Equine Encephalomyelitis manifests quite differently. After an incubation period of one to three weeks, horses will develop a fever up to 105 degrees. In many cases, this will be the only symptom, as the horse’s natural immune response will clear the virus from the body within 48 hours after the onset of the fever. If the horse is unable to clear the virus, the situation becomes much more serious. The central nervous system is attacked, resulting in symptoms that include agitation, compulsive walking and circling,and sometimes crashing into walls. This stage is followed by extreme depression, reluctance to move, and drooping posture. The horse may also have tremors, difficulty swallowing, and an uncoordinated gait.
If the horse remains standing, it may fully recover, but horses that become recumbent have a poor prognosis. Overall, the fatality rate for WEE is close to 50%. WEE is the most common strain of equine encephalomyelitis, with outbreaks recorded in the western and mid-western states. Variants of WEE have also caused sporadic cases in the northeast and southeast. The risk of exposure and the geographic distribution of WEE and EEE vary from year-to-year depending on the distribution of mosquitoes and birds that act as reservoirs for the virus.
To reduce the likelihood of horses contracting WNV, WEE, and EEE, the American Association of Equine Practitioners (AAEP) advises vaccination of all horses against these diseases. In addition to vaccinations, a good health program will include minimizing your horse’s exposure to mosquitoes, and mosquito control. To reduce mosquito exposure, stable horses at dusk and dawn; use fly blankets, masks, and leg wraps; turn barn lights off; use fans to move air; and use mosquito repellents. Mosquito control programs include reduction of standing water, encouraging natural predators (fish, birds, etc.), and use of chemicals for larval and adult mosquito control.
However, there are other serious diseases that may be spread not only by mosquitoes, but also by biting flies. Equine Infectious anemia (EIA), also called swamp fever due to the higher incidence in warm, wet areas, is just such a disease. Says Dr. Wright, “The EIA virus is mechanically transmitted from one horse to another by the bloodsucking horse flies, deer flies (Tabanids), stable flies (Stomoxys spp.), mosquitoes and possibly midges. For transmission of the EIA virus to occur, the horse fly (vector) must first find and begin feeding on an infected horse, be interrupted in its feeding, and then transfer the virus during a subsequent feeding on a susceptible horse. Feeding must occur within a short period of time.”
The first symptom of EIA is usually fever, which comes on 7-30 days after infection. In most cases, the initial fever goes undetected, and the disease is not recognized until it becomes chronic and the symptoms are more obvious. As Dr. Wright explains, “Chronically infected horses experience episodes of fever, weight loss, depression, progressive weakness, anemia and edema. These signs occur every two weeks in recurring cycles. Other symptoms which may occur during the course of the disease include: loss of appetite, frequent urination, diarrhea, weakness, paralysis of the hindquarters, paleness of the mucous membranes, yellowish discoloration of the conjunctiva, small pinpoint hemorrhages beneath the tongue, rapid breathing and accelerated pulse. Pregnant mares may abort.” Most frightening is that any symptomatic episode can be fatal, even if the horse has survived many of them in the past.
An unusual characteristic of the EIA virus is that it remains permanently in the body. Therefore, even though a horse may be in symptom-free remission, it is still a source of possible infection for other horses. Because of this, recommendations are that affected horses be euthanized or permanently segregated in a fly-proof building. Unfortunately, there is currently no vaccine available to prevent EIA, and no specific treatment for the disease. What we do have is the Coggins test, a blood test that detects antibodies to the EIA virus. Utilization of the Coggins test has helped reduce the incidence of EIA, and many facilities now require a negative Coggins test certificate before a horse is allowed onto the property.
Bug Off: The Uncomfortable
Many other insect-related problems are not life-threatening, but they can make life very unpleasant for your horse. Of these, one of the most common – and most uncomfortable, is insect bite hypersensitivity. Bites from summer-loving insects such as midges, mosquitoes and black flies can cause varied dermatological reactions in different horses. While one horse may not be bothered much by multiple bites of a given species, another horse may have a marked reaction to even one bite.
Reactions to insect bites range from small bumps to the severely itchy allergic condition known as recurrent seasonal pruritis (RSP) or “sweet itch”. Horses with RSP are allergic to the serum of tiny biting flies of the genus Culicoides, commonly known as midges or “no-see-ums”. In these horses, the bites cause intense itching, skin irritation, and patchy hair loss, most commonly in the mane and tail areas. The relentless itchiness can cause horses to rub their skin raw, sometimes leading to permanent skin damage or secondary infections.
General symptoms of a dermatological reaction to insect bites include:
- itching of the skin, mane or tail
- raised lumps on or under the skin
- bald patches
- raw, bleeding patches
While the relentless onslaught of Culicoides and other irritating insects may seem insurmountable, there are measures you can take to protect a horse with insect bite hypersensitivity. “Management of this problem is largely environmental,” says Brooke Johnson, DVM, of Kulshan Veterinary Hospital in Lynden, WA. “The best strategies are to avoid peak insect feeding times by stabling horses at sunrise and sunset, using screened windows on barns, fly control via repellents and minimizing standing water, fans to keep a breeze that interferes with insect flight control, and physical barriers such as fly sheets that prevent insects from contacting skin. Medications such as anti-inflammatories and antihistamines can provide additional relief.” It is also wise to avoid housing or turning out horses near manure piles, marshy areas or wooded areas, all of which are particularly attractive to insects.
Another type of insect related problem more commonly seen in the summer is habronema infection. Habronema is a genus of nematode worm that is transported onto the horse by flies and can infect the skin, eyes, stomach, and lungs of horses. Most often, the microscopic larvae cause skin problems that show up as irritation, itching and ulceration. This condition is referred to as cutaneous habronemiasis, more commonly called “summer sores”. Though the larvae do not survive long in the skin, the sores they cause may attract more flies, perpetuating the cycle of infection.As they thrive in moist environments, they are most likely to be found near the mouth, nose, and eyes, or the sheath of geldings.
Since the Habronema larvae are too small to see with the naked eye, a skin biopsy is helpful for diagnosing cutaneous habronemiasis. The biopsy will also enable your veterinarian to distinguish between habronema infection and squamous cell carcinomas, which are often located in similar areas and may look somewhat similar. Deworming is the usual treatment for cutaneous habronemiasis, along with the use of steroid medications to reduce inflammation and irritation. Fly control measures, including fly sheets and repellants, may reduce or prevent infections.
Environmental Woes: When Bright is a Blight
Summer sunshine can create problems for horses in a number of ways. Three of these – sunburn, contact dermatitis and photosensitivy – have such similar symptoms that it can be difficult to distinguish one from another. “With all three of these conditions,” says Wright, “what you see is a sunburn type reaction, but this may or may not be sunburn. All of them show up as red skin, peeling skin or even full thickness peeling of the hide. Affected areas tend to be parts of the face or body with white hair and pink skin, and horses that have white hair and pink skin all over are particularly sensitive. Horses with no white can still suffer from these ailments, but if you see the symptoms on a dark-skinned horse or in dark-skinned areas, it is less likely to be sunburn and more likely to be something like a contact dermatitis.”
Contact dermatitis occurs when the skin comes in contact with an irritating substance, causing it to peel, blister or develop sores. Common summer plants that can produce such reactions include buttercups, St. John’s Wort, and stinging nettles. Such plants produce chemicals that damage the skin and sometimes cause great physical discomfort. Contact dermatitis can also occur in response to chemicals from non-plant sources, such as those found in fly sprays, so it is worthwhile to keep notes on any new products you use on your horse in case you notice symptoms later. Fortunately, contact dermatitis is generally not serious and will typically resolve without treatment if the horse is prevented from having further contact with the irritating substance.
More worrisome is photosensitivity, a condition in which exposure to sunlight causes the skin to become itchy, red, swollen, crusty and blistered, after which it will eventually slough off. While that sounds suspiciously like severe sunburn, there is more to it than that. Three factors are usually at play in the development of photosensitization: the presence of a photodynamic substance in the skin, a lack of skin pigment, and exposure to ultraviolet (UV) light. It can develop in completely dark-skinned horses, but is less common. It is a serious condition that can lead to secondary infections and take a long time to heal. It may also be a sign of liver impairment.
There are two common types of photosensitization:
Primary Photosensitization occurs when a horse eats something containing a photodynamic pigment (pigment activated by light), or in response to certain drugs. When the photodynamic substance travels through the bloodstream and reaches unpigmented areas of skin, it comes into contact with UV rays, triggering a reaction. Plants that cause primary photosensitization include St. John's Wort, perennial rye grass, and buckwheat, with pyrrolizidine alkaloid producing plants (e.g. fiddleneck, ragwort, hound’s tongue) being especially problematic. Drugs that cause photosensitization include sulfonamides, phenothiazine, thiazides and tetracycline.
Hepatogenous (Secondary) Photosensitization occurs when the liver is damaged and is unable to excrete phylloerythrin, a photodynamic end-product of chlorophyll metabolism normally excreted in the bile. Most often, the liver damage is caused by ingestion of one of the many hepatoxic plants that include ragwort, fiddleneck, fireweed, rape seed, comfrey and buttercup. Various members of the clover family are also known to cause photosensitization, though the mechanism by which they do so is not entirely understood. Explains Dr. Wright, “Alsike clover is well recognized for causing photosensitization as well as oral ulcers and hepatitis. It is unclear whether the photosensitization is primarily a photodynamic agent problem or a secondary phototoxic reaction due to liver damage, or whether alsike clover and its metabolites are truly the culprit. The photosensitization reaction could also be associated with mycotoxins (toxins produced by fungi) produced on the plant. A similar syndrome has also been observed with horses consuming lush white clover in the fall.”
Because other symptoms of liver damage are often vague and frequently go undetected, photosensitization can be the first sign that the horse’s liver is impaired. Any case of photosensitization should therefore be followed up with blood work to assess liver function. Because photosensitization is much less common in dark-skinned horses, liver damage in these animals can be more difficult to detect.
Treatment for photosensitization requires removing the horse from direct sun exposure, supportive care for lesions, and appropriate evaluation and treatment for any liver damage. Pastures should be carefully inspected for any plants known to cause primary or secondary photosensitization.
Environmental Woes: Something in the Air
The episodic respiratory illness commonly known as “heaves” or “broken wind” was until recently termed chronic obstructive pulmonary disease (COPD) in the medical literature. It has recently been renamed recurrent airway obstruction (RAO) to indicate that it is not the same condition as COPD in humans. RAO in horses takes two main forms: barn-associated heaves, and summer pasture-associated heaves. In both cases, the disease involves a number of factors including exposure to respirable dust particles (especially aeroallergens such as mold spores and pollens), ineffective lung clearance, and possibly even genetic predisposition.
Both types of RAO also share similar symptoms, which include:
· chronic coughing, especially in recurrent episodes
· production of mucous when coughing
· labored breathing and elevated respiratory rate
· increased abdominal movement during breathing
· flared nostrils while resting
· nasal discharge
· exercise intolerance
Where the two forms differ is in their trigger factors and management. Barn-associated RAO is triggered by confinement to a stable environment, inadequate stable ventilation, and organic dust particles found in hay and bedding. These horses typically do very well when turned out on pasture, and the recommendation is generally to keep them outdoors as much as possible. With summer pasture-associated RAO, however, horses are sensitive to grass pollens and mold spores found in grasses, and should therefore be kept indoors during the grass-growing season.
Because horses with summer pasture-associated RAO are likely to have ineffective lung clearance overall, it is important to ensure a low-dust environment for them indoors, as well. Hay should be thoroughly soaked (wetting is not enough) or replaced with a pelleted source of fiber, and bedding should be a low dust product such as peat moss, high-quality shavings, or shredded newspaper. The barn and individual stall should also be well-ventilated, and soiled bedding must be removed frequently to reduce the build-up of ammonia fumes, which can be irritating to horses with RAO. Other helpful measures include removing the horse when the stall is being cleaned, and storing hay in a separate building.
Additional treatment measures may include the use of corticosteroids to reduce inflammation, and bronchodilators may be given to relieve spasms in the airways. RAO is diagnosed through history (especially of recurrent coughing episodes), physical examination, and bloodwork, and may also include radiography, endoscopy, bronchoalveolar lavage (BAL), and pulmonary function testing.
Beat the Heat: Dehydration
Most horses will naturally consume more water when it is hot and they’ve been sweating, but nonetheless, dehydration can happen, and it has potentially dire consequences. Explains Dr. Johnson, “Dehydration may start out as a minor problem on its own, but soon gets serious because a magnifying effect can happen. Health problems that are normally of minor consequence will become amplified in a dehydrated animal. Without proper hydration, many of the regulatory processes of the body become impaired, and the more severe dehydration becomes, the less likely the animal will recover without veterinary assistance. In general, early intervention leads to better outcomes.” Dehydration can lead to muscle cramping, heart problems, metabolic disturbances and colic.
The most important preventative measure is making absolutely sure our horses have an adequate water supply during hot weather spells. Keep a close eye on buckets or small troughs which may have to be replenished more frequently than usual, and make sure that automatic waterers are working on a continual basis. Even streams can dry up in certain locations during hot weather, so if you are relying on a variable natural water source, it should be monitored as well. Lastly, be sure sources of water are free of offputting contaminants: a dead bird or rodent in a water tank can cause horses to refuse to drink, even if they are desperately thirsty.
Travelling to new locations with your horse, as many of us do for shows or camping in the summer, can also put your horse at risk for dehydration. Many horses will refuse to drink during trailering or at rest stops, even if they have been sweating profusely due to heat or nerves in the trailer. To deal with this issue, trick trainer Theresa Madok of Alturas, CA, suggests teaching your horse to drink on cue. “I teach all my horses to drink on cue,” says Madok, “as this can really be a life saver. I do this by taking them to water when I know they are thirsty (such as after a training session), giving them a verbal cue such as ‘drink’, allowing them to drink, then rewarding them with a treat after they’re done. You would be surprised at how quickly most horses catch on. I can then get them to take a good long drink just before they get into a trailer, and usually again at rest stops.”
Another travel-related issue is that many horses may be hesitant to drink water in a new location if it tastes or smells different from the water they normally drink. To avoid this situation, it can be helpful to get your horse used to drinking flavored water, both with and without electrolytes (see below for more on electrolytes). The familiar flavoring can then be added to a bucket of water at the new grounds to help encourage your horse to start drinking the “funny tasting water”.
As for what to do with a hot horse post exercise, it is best to ignore the old myth that a hot horse should not be allowed to drink until it has cooled down. Unless the horse has been galloping very hard or for a prolonged period of time, drinking right after exercise will not harm them. In fact, recent research has shown that withholding water after exercise may be potentially harmful because it prolongs dehydration. Horses are more likely to drink soon after exercise when their thirst drive is high, and they need that water intake to replace fluids lost to sweating. While it is still inadvisable to allow a very hot horse to drink ice cold water after extreme exertion, it is a good idea to allow the horse to drink in most typical scenarios.
Closely related to the problem of dehydration is the issue of electolyte imbalance. Electrolytes are substances that become ions in solution and are then able to conduct electricity. The balance of the electrolytes in living bodies is necessary for the normal functioning of cells and organs. Sodium, chloride and potassium are electrolytes lost when horses sweat. This depletion of electrolytes can trigger serious health issues such as colic and Exertional Rhabdomyolysis (ER), also known as “tying up” .
Most horses that have a healthy diet and free access to salt (sodium chloride) do not need additional electrolyte supplementation. However, horses involved in demanding sports like racing, endurance riding or eventing may benefit from the administration of additional electrolytes. There are a number of electrolyte products formulated especially for horses. In general, you should not give electrolytes made for cattle or other livestock, or electrolytes with a high amount of sugar to horses. Consult with your veterinarian if you think your horse may need electrolyte supplementation beyond salt.
Salt itself should be available to horses at all times, but is of critical importance in the summer, as the regular consumption of salt helps prevent dehydration in horses by triggering the thirst response. Horses lose a great deal of salt in their sweat (far more than humans do on a proportional basis), and it is believed that this may be why horses that have been sweating profusely do not always show an inclination to drink, even though they are dehydrated. When humans sweat, we lose proportionally more water than sodium, so our blood concentration of sodium increases, triggering the thirst response. Horses, however, lose so much sodium in their sweat that their blood concentration of sodium actually decreases if their salt intake is not adequate to compensate for the loss.
Fortunately, horses naturally choose to consume salt, usually in just the amount they need. While many people choose to provide their horses with salt in block form, some experts feel that loose salt is better for horses as it is easier for them to consume than blocks, which were designed with the rough, abrasive tongues of cattle in mind. Either way, an average sized horse in light to moderate work generally needs to consume 1-2 oz. of salt per day, depending on the amount they are sweating. If you do use blocks, it is a good idea to weigh a new block before you give it to the horse, then weigh it again every few days to see if it is being consumed at an adequate rate. If not, try switching to loose salt. If you have a horse that doesn’t consume enough salt or doesn’t drink enough water, adding up to 1 oz. of loose salt to a mash each day can stimulate drinking.
As for what type of salt is best – iodized (pink/red), plain (white/grey), cobalt (blue) or a mix of minerals added (often brick colored), this depends on what minerals are excessive or deficient in your horse’s diet. Your veterinarian or local agricultural cooperative can likely tell you what minerals typically need to be added in your region. Keep in mind that if you are adding any other mineral supplements, you may not want to add additional minerals in the salt. It is also best to avoid flavored or sugared salt blocks, as this can encourage excessive consumption.
Travelling Time: Risky Recreation?
We’ve seen that trailering and being in new locations can put horses at higher risk for dehydration, but there are other risks to taking our horses places that are worth noting, especially with the siren call of the show grounds that comes with the summer months. “Travel and showing bring extra challenges to keeping horses healthy,” says Johnson, “because horses have suppressed immune function secondary to the stress of traveling and being in new environments, plus they are exposed to significantly more infectious agents compared to horses that don’t travel. Contagious diseases such as respiratory infections, strangles, and shipping fever happen more commonly in comingled horses.”
The risk to the horses that travel then becomes an issue of biosecurity to the whole barn when that horse comes home. States Dr. Wright, “In the summer, everybody is moving horses in and out of the barn, so the worst case scenario is going to a show and bringing back something like strangles or herpes, especially neurological herpes. There are a number of diseases that are transmitted via aerosol, so they can spread by nose-to-nose contact, air ventilation within a barn, and fomites (hands, pails, brushes or anything that is transfered between animals).” Therefore, how you deal with horses coming and going on a property is very important, especially if you have pregnant broodmares. “Broodmares should be isolated completely away from the horses that are transient (coming and going),” says Wright. “There should be a two, preferrably three week isolation period for horses that come onto a property, and they should definitely not go right back into the barn where the broodmares are”.
Yet another health issue that crops up more frequently when horses are travelling and showing is equine gastric ulcer syndrome (EGUS). EGUS can be caused by a number of different factors alone or in combination, but anything that prevents a horse from eating for more than 6-8 hours at a time – including trailering and stress – may lead to ulcers. As for whether the stress brought on by trailering and showing is itself a cause of ulcers, no one really knows for sure. Explains Michael J. Murray, DVM, MS, Dipl. ACVIM, one of the world’s leading authorities on the formation and treatment of equine ulcers, “We really can’t say in many cases what the precise mechanism is that is causing the ulcers. We just know that in conditions which we can imagine are stressful, such as trailering and showing, we see ulcers occur frequently. The question is, what is the link between what may be stressful and the development of an ulcer? In many cases, I suspect that it involves interruption of feeding behaviors, as we know that the horse’s stomach becomes highly acidic within minutes of ceasing eating.”
To prevent a horse from developing ulcers during the travel season (or to treat a horse that has EGUS), most veterinarians recommend the use of omeprazole (Gastrogard). It has been shown to be the most effective treatment by far, with the main drawback being the price. There are also a number of herbal or naturopathic products promoted for the treatment and prevention of ulcers, but there is currently no clinical evidence to support their claims. One trial showed a very modest reduction in the severity of ulcers with the use of an herbal product, but the reduction was not enough to be considered a successful treatment. Lastly, when circumstances are such that your horse will be subjected to stress, try to minimize the stress by maintaining your feeding schedule and even bringing along a horse buddy to a show if possible.
There are a variety of treatments available to help alleviate symptoms and heal ulcers in horses. The Government of Ontario website (http://www.omafra.gov.on.ca/english/livestock/horses/facts/info_gastric.htm) lists the following:
- Antacids (aluminum and magnesium hydroxide) will reduce the acidity of the stomach for a short period but must be given every two hours to be effective.
- Histamine-receptor antagonists. Cimetidine (Tagamet) and ranitidine (Xantac) are commonly used in the horse and are considered very effective in the prevention and treatment of ulcers. They reduce both basal gastric acid production and induced acid production (e.g., from food) by competitively inhibiting histamine at the H2 receptors of the parietal cells (4).
- Omeprazole (Gastrogard, Pepsid) is the most potent anti-ulcer medication currently available. As a proton pump inhibitor, it inhibits gastric acid secretion by interfering with hydrogen ions in the final stage of acid secretion. This medication is given by mouth once daily and, therefore, owner compliance is improved. The raw chemical of omeprazole is available from compounding pharmacies. This type of product is less expensive than the commercial preparations. However, studies have shown that generic, compounded medications may be less effective. There is no quality control for compounded products. Therefore, the amount of active ingredient available in the compounded product may be very variable.
- Sucralfate (Carafate) is another type of medication that is useful in treating stomach ulcers, especially in foals. After ingestion, sucralfate reacts with hydrochloric acid in the stomach to form a paste-like complex that will bind to the proteinaceous exudates that are generally found at ulcer sites. This insoluble complex forms a barrier at the site and prevents the ulcer from further damage caused by pepsin, acid and bile (4). Sucralfate will remain adherent to the ulcer crater for more than six hours (1). Because it requires an acidic environment to be effective, sucralfate should be administered at least ½ hour prior to cimetidine or antacids.
Be aware of the often subtle symptoms of EGUS, and talk to your veterinarian about medical strategies if you’re doing all you can but still have concerns.