The Rise Of
Elbow Dysplasia In The Mudi
Up until
last year (2020), I was under the impression that Elbow Dysplasia (ED) was not
a serious problem in the Mudi breed.
This is the problem with assumption, it often makes fools of us, and
this is certainly the case with ED. ED
was not considered a Mudi breed problem…...until it was.
Elbows are usually
checked at the same time hips are checked about 57.5% of the time. (In my
database I have 1506 hip checks and 866 elbow checks = 57.5%.) Although elbow checking is much more common
today than it was 20 years ago, it is still not widely done.
Patella
Luxation (PL) has been a known Mudi breed problem for a longer time, and in a
future article I will cover PL as well as one more orthopedic problem that is on the
rise.
In the past
months, I have learned of 2 young Mudis that have undergone bilateral elbow
surgery due to ED, before they were 2 years of age. There are 24 other Mudis
that have a score lower than the normal/0 score that elbows which are free of
any signs of dysplasia are given by the various orthopedic associations. This
adds up to a total of 26 known ED affected Mudis.
What Is
ED and How Does It Occur In A Breed
The purpose
of this article is not to discuss the diagnosis details, process or treatment of ED, you can find that information in the Reference and Source List
at the end of this article.
The grading
of elbows will be discussed in more detail later in this post, what is most important to
know at this point is that 0, 0/0, Free, Mentes (this term means `free` in Hungarian) and Normal are official scores
given to dogs with no signs of elbow dysplasia.
Any other score means the dog has some level of dysplasia in one or both
elbows.
Symptoms of
ED usually appear between 6-12 months of age but affected dogs may not be visibly
lame until they are much older (4-6 years of age). The typical signs of ED are lameness and an
abnormal gait. ED is often bilateral (affects both elbows rather than just one)
in 20- 35% of affected dogs (across all breeds), meaning it only affects one
elbow in the majority of cases. Males are more frequently affected than females
(across all breeds).
Unilateral (affects
only one side, left or right) ED, which is more common, is also inherited,
meaning that parents having only one affected elbow pass off the genes for ED
just as they do when affected with bilateral ED and their puppies can have one
or both elbows affected with ED as well.
ED can
appear in puppies born from 0/Normal parents too, however, according to
research, it is more likely to appear in puppies that have one or more affected
parents, and the more serious the ED grade of the parent is, the more likely
the puppies are to inherit ED, which shows that there is a moderately high
component of heritability to elbow dysplasia.
Elbow
dysplasia can be extremely painful for the affected dog, severely limiting
activity and quality of life for the dog and its family. The onset of symptoms
is usually early (under the age of 2 in most cases), and a significant number are
bilaterally affected (both legs). Currently there is no satisfactory medical
protocol or surgical procedure that would significantly alter the progression
or cure the disorder. This poor response to medical and surgical management
makes it increasingly important to reduce the incidence of the disease through
selective breeding. By breeding only phenotypically normal individuals (only those
with a score of 0/normal), a reduction in the incidence of ED has been shown to
occur in other breeds.
Multiple
studies support the theory that the various components of ED are inherited. Although
the heritability index and incidence does vary by the various factors studied,
it does appear that ED is inherited polygenically with development being
multifactorial, that is, both environmental factors and the additive effect of
many genes contribute to expression of ED in affected dogs.
Until a DNA
test is available for the detection of dogs genetically predisposed for ED,
genotype can only be estimated by knowledge of the evaluations of the extended
family and through elbow screening of as many dogs as possible, in particular,
those dogs involved in breeding, those dogs which show symptoms, and those dogs
which are closely related to ED affected dogs.
Breeding of
dogs with 0/1 or 1/1 elbow results should be avoided, however if done with
proper research and procedural implementation, it could be permitted with a
limited number of dogs.
Any dog with
a higher than 1 score should not be bred under any circumstances as the more
serious grades of ED (2 and 3) have a higher chance of producing affected
offspring according to research.
Evidence
Supporting Genetic Inheritance of ED In The Mudi
For ED to be considered as a genetically inheritable disease
in the Mudi breed, there must be some solid evidence.
The American College of Veterinary Ophthalmologists/Canine
Eye Registry Foundation (ACVO/CERF) criteria for defining a disease as
hereditary include:
1) There are published reports in the literature regarding a
condition in a particular breed with evidence of inheritance.
ED is shown to be inheritable in several dog breeds, such as
the Labrador Retriever, German Shepherd Dog, Golden Retriever, Bernese Mountain
Dog, Newfoundland and Rottweiler (see reference list below for published
reports).
2) The incidence of affected animals is greater than or equal
to 1% of the examined population with a minimum of five affected animals per
five years period.
The ED examined population is 866 Mudis, the number of
affected Mudis is 26, which means the incidence of affected dogs is 3% (which
is 2% greater than the required 1%) and there have been five or more ED affected
Mudis in the last 5 years officially graded as having 1, 2, or 3 level ED. (Later
in this article the ED affected Mudi statistics are provided.)
Direct
family relationships to ED:
-2
littermate brothers (2007) are affected with scores of: 0/1 and 1/1
-2
littermate sisters (2014) are affected with scores of: 1/1 and 3/0
-One ED
affected male with a score of (1/1) produced 3 affected puppies with 2/0, 1,
and 3/3 scores
-One female
that is either untested or has a non-publicized score, has produced 2 affected
puppies with 1 and 1 scores each and is grandmother to 2 affected puppies with
0/1 and 2/0 scores
-One ED
affected (1/1) male has produced one affected puppy 1/0
There are
many other family connections between most of the 26 affected Mudis in just the
first 2-3 generations of their pedigrees – that is, many share the same relatives
or relatives that are closely related to them.
The data
above clearly shows that ED is inheritable in the Mudi.
ED
History In The Mudi
The first ED
screening was made in Finland in 1995 with one Mudi, born in 1993. The score was 0/0 as were the scores for the
next few years.
The next ED screening
took place with four Mudis born in 1996, examined in Finland (2), Norway (1)
and Sweden (1).
Mudis have
been screened for ED since the late 1990’s in increasing numbers, in 24
countries around the world. The leaders
in ED screening are Finland (363), Hungary (128+), USA (120+) and Sweden (104).
The numbers
of ED examined Mudis worldwide for the last 6 years, by year of their birth:
2015 – 74
2016 – 64
2017 – 68
2018 – 101
2019 – 42
2020 – 8
Data Base
Rules
I categorize
the ED exam results by year of birth of the Mudi as the very first examined
Mudis did not always have the date of the exam available. But mostly, as the
age at which official scoring can take place has varied over the years and
still varies by country today, Year of Birth is the unifying factor that makes
the most sense.
While I know
of 866 Mudi ED exam results, I do not know of every result, particularly in
some countries, for example Hungary, this is why I follow the number with a +
plus sign, as there are surely more than this number of screened Mudis in that
country that I am not aware of, with both normal and below normal scores.
I do know of
99.9% of the exam results in Finland, Sweden and Norway as these countries list
all results, pass or fail, on their kennel club websites. It is my understanding that all Mudis undergoing
orthopedic exams in these 3 countries will have their x-rays submitted, as there
is no option to not send in the films. (So far I have confirmed this is true in
Norway, I wait for confirmation from Finland and Sweden that this is still the
case.) In these three countries, orthopedic screening is mandatory for litter
registration, which joints have to be checked and what score is allowed for breeding,
is possibly different in each of the 3 countries however.
Of course
there can be situations where a pre-screening has shown a less than normal
expected score, which was not sent in for official evaluation. Not sending x-ray’s is not helpful to those
wanting to avoid mating of two carrier lines to avoid producing dysplastic
pups, which the not submitted Mudi x-ray information could have provided. I
believe this is why these 3 countries (and maybe some others I am not aware of)
made submission of all x-rays mandatory with all results being made public as
well. There is great benefit for breeding plans in knowing the below normal
scores, as well as the normal scores. I truly hope more countries will provide
this level of open database program soon.
Missing
information is a much larger problem in those countries that allow the keeping
secret of less than normal results, such as happens in the USA and
Hungary. Hungary has the more serious
gap as there is not even a public list of normal, not dysplastic Mudis. This loss is further compounded by Hungary
having the largest population of Mudis, currently and historically. This is a serious fault of the MKOE (official
Hungarian orthopedic agency), the Hungarian Mudi breed clubs and the Hungarian
government which oversees the management of the 9 Hungarian breeds. The MKOE once had a public list, it
disappeared many years ago, why, I do not know.
As I have
done with epilepsy, I also do with orthopedic and other health issues, I keep
track of the affecteds (A) and mark their parents as carriers (C), as well as
their offspring. Grandparents are marked
as suspect carriers (SC). Incidence of ED can be seen on the 5 generation
pedigree I have for each of the more than 10,000 Mudis in my database. Only 5 generations are considered in health
risk assessment.
Comparing
Official Elbow Scoring Associations
ED scores of
0, 0/0, Free, Mentes or Normal, mean the dog is ED free.
FCI country’s
use scores of BL, 1, 2, 3, Enyhe (mild)=1, Közepes (moderate)=2, Súlyos
(serious)=3, represent the various levels of ED found in the examined elbows.
Some FCI orthopedic associations give one number score (2), and some give two
numbers (2/2). A slash / between numbers
is used to separate the left elbow score / right elbow score. A score of 3 or
3/3 is the most serious level of ED. BL is borderline which is given in a few
FCI countries for elbows that are not 0/0 free, but also not 1/1. I mark BL as
.5 in my database as BL is not an ED free score. BL does not indicate if one or
both elbows are affected. I am aware of only two countries with resident scored
Mudis that use BL for elbow scoring, Germany and Greece. Every FCI country has
its own system which tends to change from time to time, but most FCI countries use
only numbers now.
For those FCI
scoring associations that only use one number scores, the general rule is to
use the score of the more seriously affected elbow, for example in the case of
left elbow is 1 and right elbow is 2, the score will be 2.
OFA uses the
word Normal for ED free and Grade I, II, III for levels of ED.
The FCI
countries allow Mudis as young as 1 year of age to be screened for orthopedic evaluation
(hips, elbows, patellas, shoulders, spine).
Public score listing is dependent upon the Kennel Clubs in each FCI
country.
The OFA
requires Mudis to be 2 years of age for all ortho screening. You can submit x-rays younger than 2 years of
age and get a Preliminary score, but in this case the films are only graded by
one vet, not the usual team of 3 vets.
In my experience, the Prelim score is usually not the same result as the
official score, so spending money on Prelims is not recommended. OFA will list all
scores on their website if the owner of the Mudi being graded agrees. Many owners and breeders only allow public
listing of passing results.
BVA (British
Vet Association) uses the grading scheme of 0 = normal/free, and grades 1, 2, 3
for the varying stages of elbow degradation; they give the overall grade that
is the worse of the two elbows, meaning, if one elbow is 1 and the other is 0,
the grade will be 1, as they use the single number system for scoring.
BVA screening requires all dogs to be at least 12 months old
before they can be officially scored under the BVA/KC Canine health scheme.
PennHip does not do elbow screening.
Important
Note: *Hungary does
score the elbows separately on the official exam result certificate, the official
score only lists a single score such as Mentes (which = Normal/Free/0) or Enyhe
(= Mild/grade 1) etc., this means without my seeing the second paper that comes
with the official certificate that gives specific exam details, I cannot know
if the score was the same for each elbow or different, therefore it is not
possible to know on all Hungarian results if the elbows were unilateral or bilateral
affected. Free/Mentes/Normal results can
only be 0/0 ED free if both elbows are clear.
Mudi
Breed ED Statistics
I will use
the FCI scoring system for listing of scores to make the statistics easier to follow:
0/0=Normal or Free; .5/BL, 1/1, 2/2, 3/3=levels of ED.
Out of the 866
Mudis Tested since 1995, 26 have been scored with .5/BL, 1, 2, 3 grade elbows.
(840 scored 0/0)
These 26
scores equate to 3% of the 866 tested Mudis having dysplastic elbows.
The first
Mudi to have a below normal ED score was in Hungary, she was born in 1999 and
the score was 1/0. The second was also in Hungary, she was born in 2002 and the
score was 1/1. The third below
normal score was also a Hungarian tested Mudi, he was born in 2003 and his
score was 3/3.
The sex
ratio of below normal ED scores is: 14 males to 12 females, the difference is
not significant statistically. Although
the research ratio across all breeds shows a higher percentage of males having
below normal ED scores, the lack of sex ratio difference in the Mudi can be due
to the lower number of known results. Also more Mudi females than males have
been screened: 419 males / 447 females.
Two of these
26 ED affected Mudis have required bilateral elbow surgery, both were under two
years of age at the time of surgery and both were females. Year of birth is
2012 and 2020. One is in Hungary, the
other lived in South Africa at the time of surgery.
ED Score
statistics:
0/0 ED grade: 840
.5/BL ED
grade: 2 males, born
2015 and 2018; tested in Germany and Greece
1/0 or
0/1 ED grade: 9
Mudis; 4 males, 5 females; born from 1999 to 2017; testing done in Finland,
Hungary and Norway
1 ED
Grade: 2 Mudis; 1
male, 1 female; born in 2015 and 2019; tested in Sweden and USA
1/1 ED
grade: 4 Mudis; 2
males, 2 females; born from 2002 to 2014; testing done in Finland
1/1 or 1/0
ED Grade: 4 Mudi
males; born from 2007 to 2014; testing done in *Hungary, see note above
0/2 or 2/0
ED grade: 1 female
born in 2018; tested in the USA
3/0 or
0/3 ED grade: 1
female born in 2014; tested in Finland
3/3 ED
grade: 1 male, 2
females; born from 2003 to 2020; tested in Hungary and South Africa
Unilateral
grade = 11 --> 4
males; 7 females
Bilateral
grade = 7 --> 3
males; 4 females
Unknown = 8 (ED score does not indicate unilateral
or bilateral diagnosis) --> 7 males; 1 female
ED below
normal scores, by Year of Birth:
1999 – 1
2002 – 1
2003 – 1
2007 – 4
2008 – 1
2010 – 1
2011 – 1
2012 – 2
2013 – 3
2014 – 3
2015 – 2
2016 – 1
2017 – 1
2018 – 2
2019 – 1
2020 – 1
Of these 26 ED
affected Mudis, 14 have been bred further, 12 have not been bred.
These 14 ED
affected and bred Mudis, have produced 255+ puppies in 50 litters (+ = I am
missing complete litter data for one male).
These litters were produced in Finland, Hungary, USA and Greece.
The ED scores
of the 14 below normal parents which produced litters range from: .5/BL to 2/0,
with the majority having 1, 1/1, or 1/0 ED scores.
My Personal
ED Experience
The second Mudi
affected with a lower than normal grade score was born in Hungary in 2002, the
score was 1/1 and this Mudi happened to be my own Mudi, Angel (Ôzugrató Angyal). When I publicized my litter plans, I always
included all health test results for the parents, so her 1/1 ED score was not a
secret.
In the first
years of this century, ED knowledge was not widely available, but common sense
told me to breed only to 0/Normal males and that is what I tried to do, however
in those days, most Mudis were not even hip checked, and elbow checks were extremely
rare, with only 44 Mudis being ED checked in Angel’s age group (born from
1993-2002) from the entire Mudi population.
Angel had 5
litters (21 puppies total) with 5 different males, which had 0/0 elbows (2
males) or had no elbow check (3 males). I knew these males and they showed no signs of
limping, nor had I heard of any problems in their pups with other females.
In the first
decade of this century, ED was just not thought of as a health concern to Mudi
breeders or owners and 1/1 elbows was not considered to be a serious issue by
vets or breeders at that time. Angel
lived to be 14.5 years old and never showed any signs of elbow pain or abnormal
gait. Of her 21 puppies, 7 were elbow
scored and all given 0/normal. Of her
tested grandchildren, all tested normal/0. None of her pups or grandpups owners
reported an elbow problem.
Do I
consider Angel elbow dysplastic now, yes of course, her elbows were not 0/normal,
which means her relatives were also responsible for her 1/1 elbows. Over these past years of tracking ED, her
pedigree showed other relatives being connected to ED in her 3rd and
4th generations (several Mudis born in 1991).
If I consider
what I know about ED now and look at the pedigree risk today for the males
Angel was bred to, it would not have been impossible for some of the pups to
have had elbow problems.
Sires of
Angel’s 5 litters:
Bajnok is listed
as an ED Carrier in my database as he parented the first known Mudi to have a 0/1
score, she was born in 1999. He also has numerous ED-SC’s on his pedigree.
Csoki (ED
0/0) is an ED-SC in my database, which means he is the grandparent of a puppy
with a below normal grade score. He also has numerous ED-SC’s on his pedigree.
Csoki’s uncle is Bajnok.
Betyár’s
(ED-0/0) parents are carriers as he has a close relative that has a serious ED
score. Although Betyár himself is not
listed as a Carrier or Suspect Carrier, his parents and grandparents are, but
they are the only ones on his pedigree.
Cimbora has one parent that is a Suspect Carrier and one grandparent
is a Carrier. There are a few ED-SC’s in
the later gens of his pedigree. This was probably the least risky male of the
5.
Lantos is an
ED-Suspect Carrier as he is connected to a below normal ED score grandpuppy. He
has one other ED-SC on his pedigree.
Knowing the ED
history of these males, it is doubtful I would have chosen any of them to breed
to Angel today and looking through the males born in the last decade, while not
impossible, it would be a challenge to find a suitable mate without close
connections to ED for her.
ED In The
Mudi Gene Pool
How can the
genes for ED be so widespread in the Mudi gene pool so quickly since ED is only
now coming to the forefront of Mudi breed health problems?
First: the
earliest occurrence of a below normal ED score was from a Mudi born in 1999,
that’s more than 20 years ago. Since
that time, below normal scores were occurring and more than half of these below
normal ED Mudis were being bred to make 50 litters which produced 255+ puppies
in several countries of the world. The
pups from these litters were also bred and some were exported to other
countries to become breeding stock. Many were not elbow tested.
Second: not
enough Mudis are being screened for ED. And
some that are examined and have below normal scores are not being revealed
publicly. This has gone on since ED screening began. This does not help breeders to avoid putting
two carrier lines together.
Third:
breeding quick and for quantity (lots of puppies to sell), size (medium class
agility sized Mudis), sports performance (aiming for behavior and temperament traits
assumed to secure high level competition success), and other single goals, does
not allow room for consideration of health issues as much as would be required
for maintenance of health in a breed.
Fourth: many
breeders think you can only get a good sport or show dog by breeding a good
sport or show dog to another good sport or show dog, thus severely limiting the
available mates they can choose from.
By following
these styles of breeding today, and not recognizing the presence of ED years
ago, the Mudi gene pool was able to become infected with carriers over the last
20+ years.
Connecting
The Dots Of the Affected Mudis
Important
note: If an ED
affected Mudi came from two parents from the same kennel, but was born under
another kennel name, I considered the kennel of the parents to be the reference
kennel. In mixed kennel parentage, the
name of the kennel which produced the litter was used.
Seven Mudi
kennels produced 16 (of the 26) below 0/normal ED grade pups, this means that 7
kennels are responsible for 61.5% of the affected pups.
Ten Mudi
kennels produced only 1 ED affected puppy (of the 26) which is = to 38.5% of
the affected pups.
Two Mudi
kennels had littermates with below normal grade ED scores, one set was brothers
and the other set were sisters. Both litters had a very low COI (Coefficient of
Inbreeding).
With further
regard to COI, the range of the 26 ED affected Mudis is: 0.00% to 18.31%.
Six below
normal ED grade Mudis had what is considered to be a high COI (above 12.5%).
One kennel produced 3 of these high COI puppies, including the one with the
highest COI.
A COI of
6.25% or lower is considered optimal for a breed, 8 lower than normal ED grade
Mudis were 6.25% or lower.
A COI
between 6.50-10% is still within preferable limits, 11 lower than normal ED
grade Mudis were in this category.
A COI
between 10.25-12-50% is still within acceptable limits, there was 1 below
normal ED grade Mudi in this category.
It is very
complicated to correlate COI to a health issue directly, ED is not an
exception. If I were to do a simple
percentage rate calculation, 6 high COI Mudis = 23.1% of the 26 affected
Mudis. While this is not insignificant,
it does not give any clear association between ED and high COI.
However, if
you look at the 6 high COI affected Mudis, 50% are coming from just one kennel which
is a cause for some concern, as the other 3 high COI ED affecteds come from 3 different
kennels. This indicates inbreeding
within the same lines can cause more ED affected individuals to occur which is one
of the well known side effects of high inbreeding levels. Therefore inbreeding on higher risk ED lines
is definitely something to be avoided.
Another
important note: Not all COI’s are created
equally. I have seen many COI’s being
given for Mudis or Mudi litters that are not correct. I saw the mistakes in this COI
providers database several years ago. As
this provider is also a breeder and tends to do line breeding, the errors are
compounding behind the mistaken parents they have entered. In most cases the
COI they provide is noticeably lower than the one I provide, and in a very few
cases the COI they give is higher.
Having a precise database, means everything when it comes to COI
accuracy. While getting a COI that is
approximately 2-3% lower than it really is, may not seem to be that much of a
difference to some people, it is of critical importance to those that want a
low COI Mudi. If you want to cross check
any COI with me, you are very welcome to do so, it only takes a minute or two
in most cases and I don’t ask questions about why you are asking. If there is a difference, I can often explain
why. Also, I always compare my pedigree
based COI to the Embark GCOI (Genetic COI) and my COI in the vast majority of
cases thus far, is very close to Embarks.
If you would like to share your Embark GCOI with me, I welcome the
opportunity to compare!
Reducing
Occurrence of ED In The Mudi Breed
To stop the continuing
occurrence of Elbow Dysplasia in the Mudi breed, there are several things which
must happen, and it has been proven that taking steps through testing and
breeding guidelines can reduce the occurrence of ED in a breed. What are these
steps?
1) ED
screening must be done on as many Mudis as possible; it is best if done around
2 years of age.
2) ED
screening is mandatory on all breeding Mudis.
3) ED
screening results must be made public, regardless of score; there are places to
do this if your country does not have an open access database, such as the FB
group Mudi Health, which has more than 1,000 members from around the world
(link below).
4) Breeding
of only 0/normal, ED scored Mudis should occur.
5) Use lines
that are low ED risk when breeding with higher ED risk lines, and only breed puppies
from litters that have all 0/normal ED scores for every puppy. (I give free ED risk
scores for any planned or existing Mudi litter, or any individual Mudi, to
anyone.)
6) As there
seems to be a possible connection between high levels of inbreeding within the
same related lines, linebreeding with COI levels above 10% should be strictly avoided.
(I give free Mudi breed COI’s to anyone.)
7) Support
breeders and owners that make ED exam results public.
8) Do not
buy a Mudi puppy from parents that do not have a public ED test result of 0/normal
or will show you the exam certificates when asked (it’s better if they have
them available without asking on their social media platform or another publicly
accessible website) – only support those breeders with your patronage that are trying
to reduce the incidence of ED in the Mudi breed.
9) In very
rare cases, the use of an ED 1/1 or 0/1 score Mudi in breeding can be done, but
only with extreme caution, research and planning. The mate must have a 0/normal
ED score and come from very low risk lines.
All of the puppies in the resulting litter must be ED tested at 2 years
of age (not younger) and the results must be published, and no breeding of
these pups must take place without the entire litter having a 0/normal score.
Further breeding of the ED 1/1 or 0/1 parent would need to follow the same
litter planning, however no more than 2 litters should be bred.
10) Mudis with elbow grades of 2 or 3 have a significant
chance of ED being passed on to the offspring and should not be used in
breeding under any circumstances.
Elbow evaluation
should be one of many mandatory aspects of a comprehensive Mudi breeding
program.
Mudi puppy
buyers have an obligation to their new canine family member and the Mudi breed, to source their Mudi
puppy only from a responsible breeder.
Score
Charts
FCI
Reference
and Source List:
file:///C:/Users/user/Downloads/elbowarticle.pdf
https://dogwellnet.com/content/health-and-breeding/screening-tests/non-dna/elbows/elbow-dysplasia-r213/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883289/
http://www.vet-iewg.org/wp-content/uploads/2017/02/proceedingsiewg2012.pdf
https://cgejournal.biomedcentral.com/articles/10.1186/s40575-015-0021-x
https://www.acvs.org/small-animal/canine-elbow-dysplasia
https://vetspecialists.co.uk/fact-sheets-post/elbow-dysplasia-fact-sheet/
https://pubmed.ncbi.nlm.nih.gov/9760396/
https://pubmed.ncbi.nlm.nih.gov/18547017/
https://physio-vet.co.uk/blog/is-elbow-dysplasia-in-dogs-genetic/
https://www.ofa.org/diseases/elbow-dysplasia
http://www.fci.be/en/Hip-and-Elbow-Dysplasia-162.html
https://www.vin.com/apputil/content/defaultadv1.aspx?id=3859093&pid=11223&print=1
https://www.hamptonvetcentre.co.uk/practice/bva-scoring/
https://www.facebook.com/groups/295882233792474
