Current practice for the chemical immobilisation of non-domestic feline species: An online survey study.

BACKGROUND: Safe chemical immobilisation of wild felids is essential for both conservational management and clinical purposes. However, little is known about drug protocols and current practice. METHODS: This study was designed as an online survey based on a questionnaire. Descriptive/correlation statistics and analysis of proportions were used for data analysis. RESULTS: The preferred immobilisation technique was the use of darts (37% of the respondents), while the most popular drug combination was a mixture of benzodiazepines, alpha-2 adrenoreceptor agonists and dissociative anaesthetics (27%). The inclusion of ketamine in the drug mixture was associated with a quicker anaesthetic onset, as estimated by the participants (p < 0.001). Common complications were prolonged recovery (46%), bradycardia (35%), hypoventilation (32%), hypothermia (26%) and arousal (26%). Commonly encountered problems were inappropriate equipment (39%), lack of suitable drugs (27%) and inadequate knowledge of species-specific pharmacology (29%) and physiology (24%). LIMITATIONS: Incomplete adherence to the Checklist for Reporting Results of Internet E-Surveys is acknowledged. CONCLUSIONS: Drug protocols including both alpha-2 adrenoreceptor agonists and dissociative anaesthetics are preferred in wild felids, and the inclusion of ketamine may be useful to achieve a quick onset. Equipment/drug availability and species-specific knowledge are potential areas of improvement to improve wild felid anaesthesia.

Persistent socket pain in a dog after the enucleation of the eye and its clinical management.

Persistent socket pain is a condition described in humans after enucleation of the eye. This report aims at describing this condition in dogs. A 10-year-old male-neutered crossbreed was presented to the referral veterinary surgeon for enucleation of the right ocular globe. Anaesthesia and surgery were uneventful although during the postoperative period the dog was reluctant to open the mouth and to be explored by the referral veteterinary surgeon. Despite treatment with meloxicam, paracetamol and tramadol, no improvements were observed. Ten weeks after surgery, the dog was referred to the Dick White referrals for further investigations. Ophthalmic examination was normal, though palpation of the wound triggered an avoidance response. Magnetic resonance imaging showed changes compatible with orbital cellulitis. The area of interest was evaluated with the use of the mechanical Von Frey filaments. A response, characterised by sudden turning of the head and attempts to withdraw it, was evoked with filament 4.93 (8.0 g) during stimulation of the periorbital area. After induction of anaesthesia, an ultrasound-guided injection containing levobupivacaine 0.5% and methylprednisolone was performed within the retrobulbar area. Three hours after recovery from anaesthesia, no discomfort was observed during palpation of the area. Re-evaluation was performed with the Von Frey filaments; no response could be evoked during testing with all 20 filaments (from 2.36 to 6.65) applied on either side of the face. The patient was discharged with a course of gabapentin and, 3 weeks after the intervention, the dog showed no clinical signs of pain. Persistent socket pain is an unpleasant sensation at the level of the enucleated orbit, and it should be regarded as a challenging condition to diagnose and treat. The MRI findings appeared to be essential to select the most appropriate interventional treatment. The injection of local anaesthetic and steroid into the retrobulbar space was useful for both confirming the diagnosis and treating pain by reducing the peripheral signalling and decreasing the residual inflammation.

Inter-observer reliability of three feline pain scales used in clinical practice.

OBJECTIVES: The present study aimed to evaluate the inter-observer reliability of three feline pain scales commonly used in clinical practice. METHODS: Twenty cats undergoing elective neutering surgery were assessed both pre- and postoperatively by three independent assessors (a board-certified anaesthetist, a veterinary anaesthesia nurse and a final-year veterinary student) using three different pain scales: the Glasgow Feline Composite Measure Pain Scale (CMPS - Feline), the Colorado State University Feline Acute Pain Scale (CSU - FAPS) and the Feline Grimace Scale (FGS). Reliability statistics was used to evaluate the level of agreement between assessors. RESULTS: Twenty-seven groups of paired observations were evaluated, of which 16 (59%) showed fair agreement, eight (30%) showed none to slight agreement and the remaining three (11%) showed moderate agreement based on Cohen's weighted kappa statistics. Based on Cronbach's alpha statistics, 12 (44%) of the 27 groups of observations showed moderate reliability, 12 (44%) showed poor reliability and the remaining three (11%) showed good reliability. No scale was superior to the others in terms of inter-rater reliability (P = 0.179); however, the pair composed of the final-year veterinary student and anaesthesia nurse showed better agreement than the two other pairs of assessors, both of which included the board-certified anaesthetist (P = 0.015). CONCLUSIONS AND RELEVANCE: Despite the usefulness of behavioural pain scales as clinical tools, their users should bear in mind their limitations, particularly the intrinsic subjectivity and potential variability of outcome between assessors with different backgrounds and level of expertise.

Risk of burnout and depression: A survey of veterinary anaesthesia specialists in-training during COVID-19.

OBJECTIVE: To investigate risk, risk factors and effects on adherence to adequate clinical standards, of burnout and depression in veterinary anaesthesia residents. STUDY DESIGN: Closed online cross-sectional survey study. STUDY POPULATION: A sample of 89 residents registered to the European and/or the American Colleges of Veterinary An (ae)sthesia and Analgesia out of a total of 185. METHODS: A link to access an online questionnaire, which included the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), the Harvard National Depression Screening Day Scale (HANDS) and 28 questions developed to assess adherence to adequate clinical standards, was sent by email to 185 residents. The three components of the MBI-HSS namely emotional exhaustion (EE), depersonalization and reduced personal accomplishment were analysed separately. Analysis of proportions and two-step regression statistical modelling were used for data analysis, and p values < 0.05 were considered statistically significant. RESULTS: The response rate was 48%. Based on HANDS and MBI-HSS scores, 49% of the residents were at high risk of both depression and burnout. These residents expressed greater concern of delivering inadequate animal care (p < 0.001), of decreased quality of supervision during COVID-19 (p = 0.038) and of negative impact of the pandemic on their training programme (p = 0.002) than residents at low-to-moderate risk. Working in a clinical environment for ≥ 60 hours/week was a risk factor for both depression (p = 0.016) and EE (p = 0.022), while female sex was a risk factor for EE only (p = 0.018). CONCLUSIONS AND CLINICAL RELEVANCE: A large proportion of residents is at high risk of depression and burnout, a scenario likely worsened by the pandemic. The findings of this study suggest that reducing the clinical workload and increasing the level of support and supervision may help to improve residents' mental health.

Effects of low-level laser therapy on impaired mobility in dogs with naturally occurring osteoarthritis.

BACKGROUND: Osteoarthritis is common in the aging dog and is associated with chronic pain and impaired mobility. The main objective of this study was to determine whether low-level laser therapy (LLLT) would increase physical activity in dogs with osteoarthritis. METHODS: Twenty-three dogs with osteoarthritis were instrumented with an accelerometer 48 h before the first LLLT session (baseline), to record daily activity. Each dog underwent six consecutive weekly laser treatments. The scores of the Canine Brief Pain Inventory and the Liverpool Osteoarthritis in Dogs' were recorded for clinical purposes, as a tool to titrate the analgesic therapy of each individual dog, before LLLT (as baseline) and then weekly for 6 weeks. RESULTS: The number of daily activities increased during week 2 (161,674; SD, 103,666) and remained higher than baseline (93,481; SD, 107,878) until week 6 (179,309; SD, 126,044; p < 0.001). Daily step count increased from week 1 (4472; SD, 3427) compared to baseline (1109; SD, 1061) and remained higher than the baseline until the end of week 6 (8416; SD, 3166; p < 0.001). Average energy expenditure during the study period was 179 [range, 2-536] kcal/day; there were no statistically significant differences in this variable between weeks of treatment. Systemic analgesics therapy was decreased in 50% of the dogs during the study period. CONCLUSIONS: Laser therapy may advance the management of osteoarthritis by increasing the level of activity of dogs, therefore improving their quality of life.

An Observational Survey Study on the Use of Locoregional Anaesthesia in Non-Conventional Species: Current Practice and Potential Future Developments.

The objectives of this study were to investigate the current attitudes of veterinarians towards the use of locoregional anaesthesia in non-conventional animal species and to identify areas for future useful research on this topic. A questionnaire was circulated online. A total of 417 veterinarians, including American and European specialists/specialists-in-training in both zoological medicine and anaesthesia/analgesia (ACZM/ECZM and ACVAA/ECVAA), participated in the study. Fifty-nine percent of respondents performed locoregional anaesthesia in rabbits, with intratesticular injections and local infiltration being the most commonly-reported techniques. ACZM/ECZM specialists reportedly performed dental blocks in rabbits more frequently than ACVAA/ECVAA specialists (p = 0.030). Forty percent of respondents performed locoregional anaesthesia in rodents, with intratesticular injections, topical/splash blocks and local infiltration being the most commonly reported techniques. The proportions of respondents who reportedly used locoregional anaesthesia in ferrets, birds and reptiles were 37.9%, 34.5% and 31.2%, respectively. The use of Tuohy (p < 0.001) and spinal needles (p < 0.001), as well as of ultrasonography (p = 0.009) and nerve-stimulators (p < 0.001), was more common among ACVAA/ECVAA compared to ACZM/ECZM specialists. Major topic areas for future research were identified as dental block techniques for rabbits and rodents and blocks for the wings of birds.

Use of mechanical thresholds in a model of feline clinical acute pain and their correlation with the Glasgow Feline Composite Measure Pain Scale scores.

OBJECTIVES: The aim of this study was to evaluate the use of mechanical thresholds (MT), measured with the SMALGO (Small Animal ALGOmeter), and to determine whether there was a correlation between MT and Glasgow Feline Composite Measure Pain Scale (CMPS-Feline) scores in cats undergoing ovariohysterectomy. METHODS: Client-owned cats undergoing flank ovariohysterectomy were recruited. Pain scores for the pre- and postoperative periods were obtained using the CMPS-Feline in each cat by two independent investigators (A and B). Following CMPS-Feline scoring, MT were measured with the SMALGO, in the surgical area, pre- and postoperatively, only by investigator A. Each cat served as its own control for the comparison of pre- and postoperative variables. Reliability statistics were used to assess the level of inter-observer agreement (A vs B) with respect to pre- and postoperative CMPS-Feline scores, while Spearman's correlation statistics were used to analyse the relationship between MT and CMPS-Feline scores. RESULTS: Twenty-nine cats completed the study. Preoperative MT (340 g [range 108-691]) were significantly higher than postoperatively (233 g [range 19-549]; P = 0.001). CMPS-Feline scores were not found to differ significantly between the preoperative period (2 [range 0-7] for investigator A and 3.2 ± 2.3 for investigator B) and postoperative period (2 [range 0-10] for investigator A and 3 [range 0-8] for investigator B) for either investigator. Reliability statistics revealed that the level of inter-observer agreement with respect to CMPS-Feline was fair for the preoperative assessments but poor for the postoperative evaluations. There was no correlation between MT and CMPS-Feline scores. CONCLUSIONS AND RELEVANCE: Although there was no correlation with CMPS-Feline scores performed at the same timepoint, MT increased postoperatively vs baseline. Assuming that, despite analgesia, susceptibility of the surgical area to mechanical stimulation would increase after surgery, this finding suggests that MT might be useful to assess feline surgical pain. The poor level of inter-observer agreement with respect to postoperative CMPS-Feline scores highlights the potential limitations of this scale.

Psittacine Sedation and Anesthesia.

Successful management of sedation/anesthesia of psittacine species relies on familiarity with their specific anatomy and physiology, and detailed knowledge of the recent advancements in applied pharmacology of the anesthetics and perianesthetic monitoring of cardiovascular and respiratory functions. Each sedation/anesthetic plan should be patient-specific, developed based on preexisting conditions, size, species, age, and estimated risk. Other key factors to improve safety, quality of perioperative care, and client satisfaction are anticipation of complications, extension of close monitoring to the recovery phase, multimodal analgesic approach, stress prevention/reduction, and transparent communication with the owner.

ISOFLURANE ANESTHESIA IN BUDWING PRAYING MANTISES (PARASPHENDALE AGRIONINA).

Praying mantises have gained increasing popularity as pets and may be anesthetized to allow morphological identification and clinical procedures. The aim of this study was to evaluate the effects and anesthetic-related complications of isoflurane in oxygen in 15 client-owned budwing mantises (Parasphendale agrionina) undergoing photographic identification. Each mantis was placed in a self-constructed anesthetic chamber and exposed to a mixture of approximately 5% isoflurane in oxygen until anesthetic induction was achieved. Time to anesthetic induction, time to recovery from anesthesia, and quality of anesthesia based on scoring of righting reflex, front legs withdrawal, and muscular tone, were evaluated and recorded, as well as the occurrence of undesired effects. In most mantises, immobility, loss of righting reflex, and myorelaxation were achieved within minutes after the beginning of isoflurane exposure and lasted a time sufficient to allow completion of the procedure. However, mantises aged ≥12 mo had longer time to anesthetic induction (4.3 ± 0.6 m), as well as shorter time to recovery (19.0 ± 8.0 m), than mantises aged <12 mo (0.8 ± 0.4 and 30.0 ± 15.0; P < 0.05). Complications were not observed, and all mantises were returned to their owner on the same evening.

Comparison of two protocols for insulin administration and fasting time in diabetic dogs anaesthetised for phacoemulsification: A prospective clinical trial.

BACKGROUND: There is a lack of evidence-based guidelines on perioperative insulin administration and fasting time in diabetic dogs. The aim of this study was to compare two protocols with respect to intraoperative changes in blood glucose (BG) concentrations compared to preoperative values. METHODS: Thirty-two dogs were included. Dogs of group AM (n = 15) underwent anaesthesia in the morning after 12 hours fasting and received half their usual insulin dose, while dogs of group PM (n = 17) had surgery in the afternoon after 6 hours fasting and received their usual insulin dose; BG was measured before premedication (baseline), after anaesthetic induction, every 30 minutes throughout surgery, at extubation and after anaesthetic recovery. The occurrence of intraoperative complications was recorded. RESULTS: There were no differences between groups in perioperative changes in BG over time, and in the proportion of dogs experiencing complications. Common complications were hypotension (53 per cent of dogs in either groups), hyperglycaemia (67 and 65 per cent in groups AM and PM) and hyperkalaemia (20 and 11 per cent in groups AM and PM). CONCLUSIONS: Either protocols may be used in diabetic dogs undergoing anaesthesia. The occurrence of hyperkalaemia in the study population supports routine intraoperative monitoring of blood potassium concentration.

Mandibular nerve block in juvenile Nile crocodile: a cadaveric study.

OBJECTIVE: To develop a technique for performing the mandibular nerve block in Nile crocodiles. STUDY DESIGN: Experimental cadaveric study. ANIMALS: A total of 16 juvenile Nile crocodile heads. METHODS: To study the course of the mandibular nerve, one head was dissected. Computed tomography (CT) examination was performed in two heads to identify useful landmarks. Thereafter, a hypodermic needle was inserted through the external mandibular fenestra of 17 hemimandibles (13 heads), and a mixture of methylene blue and iohexol was injected. Injection volumes were 0.5 (n = 7) and 1.0 mL (n = 10) for hemimandibles < 15 and ≥ 15 cm long, respectively. Iohexol spread and nerve staining with methylene blue were assessed with CT and anatomical dissection, respectively. Data were analysed with one-sample t test or Mann-Whitney U test. Significance was set at p < 0.05. RESULTS: Both anatomical dissection and imaging confirmed the external mandibular fenestra as a useful anatomical landmark for needle insertion. The CT images acquired after needle positioning confirmed that its tip was located on the medial bony mandibular surface formed by the fusion of the angular and coronoid bones in 100% cases. In all the hemimandibles, the rostrocaudal spread of contrast was > 23 mm. The length of the stained mandibular nerve in the temporal region and of the stained medial branch of the mandibular nerve, as well as the dorsoventral and mediolateral spread of iohexol, was greater in group 1.0 than in group 0.5 (p < 0.001). The caudal spread of iohexol was greater in group 1.0 than in group 0.5 (p = 0.01). CONCLUSIONS AND CLINICAL RELEVANCE: The technique developed in this study is feasible. Both injection volumes resulted in staining of the mandibular nerve. The spread of contrast in the anatomical region of interest may result in successful sensory block.

Acute Life-threatening Laryngeal Dysfunction in a Draft Horse Recovering from General Anesthesia: A Case Report.

A 13-year-old Shire horse was anesthetized for an elective orthopedic procedure. During recovery from anesthesia, the occurrence of severe acute dyspnea required a second anesthetic to allow endoscopy-guided nasotracheal intubation. Endoscopic findings were decreased mobility and swelling of the arytenoids with narrowing of the laryngeal aditus. Owing to a dislodgement of the nasotracheal tube during recovery, a third anesthetic was carried out to perform emergency tracheostomy. Recovery from the third anesthetic was long and the horse developed a post-anesthetic myopathy. The clinical conditions improved during the following 48 hours, and an endoscopic examination performed before discharge revealed unremarkable laryngeal function. It was hypothesized that mechanical stimulation of the trachea during the phases of intubation and extubation caused traumatic laryngeal dysfunction, and that draft horses might require additional care during the perioperative period.

Use of nociceptive threshold testing in cats in experimental and clinical settings: a qualitative review.

OBJECTIVE: The objective of this study was to review the scientific articles on the use of nociceptive threshold testing (NTT) in cats and to summarize the clinical and experimental applications in this species. DATABASES USED: Pertinent literature was searched with PubMed, Scopus, Web of Science, Universitätsbibliothek Basel (swissbib Basel Bern) and Google Scholar. The search was then refined manually based first on article titles and abstracts, and subsequently on full texts. CONCLUSIONS: Of the four classical acute nociceptive models used for NTT, thermal and mechanical are most commonly used in cats. Thermal stimulation is applicable in experimental settings and has been used in pharmacodynamics studies assessing feline antinociception. Although mechanical stimulation is currently less used in cats, in the future it might play a role in the evaluation of clinical feline pain. However, the low response reliability after stimulus repetition within a narrow time interval represents a major limitation for the clinical use of mechanical thresholds in this species. Challenges remain when thermal thresholds are used to investigate analgesics that have the potential to affect skin temperature, such as opioids and α2-adrenergic agonists, and when a model of inflammatory pain is reproduced in experimental cats with the purpose of evaluating non-steroidal anti-inflammatory drugs as analgesics.

Preliminary clinical experience of low-level laser therapy for the treatment of canine osteoarthritis-associated pain: A retrospective investigation on 17 dogs.

Background: Osteoarthritis (OA) is common in dogs and causes chronic pain that affects the quality of life and may not respond to analgesics. Objective: The objective of this study was to determine whether low-level laser therapy (LLLT) would improve the quality of life and help reducing systemic analgesics, in dogs with OA. Methods: Seventeen client-owned dogs diagnosed with OA and associated pain were included. The diagnosis of OA was confirmed by orthopedic and radiographic examination. Pain was evaluated in each dog with the canine brief pain inventory (CBPI), compiled by the dog owners, as well as with a visual analog scale (VAS) and the colorado state canine chronic pain scale, used by the clinician. The LLLT was performed weekly in each study dog, for a total period of 6 weeks. The CBPI was then repeated at 2, 4, 6, and 8 weeks after the first laser session, whereas the VAS was reassessed at weeks 2 and 6. The dogs were observed for the occurrence of laser-related side effects. Results: Both CBPI and VAS were significantly reduced after the first laser session (9.2 ± 3.8 and 5.2 ± 1.1, respectively) compared to pretreatment values (11.8 ± 3.6 and 7.6 ± 0.9, respectively; and p = 0.018 and p < 0.001, respectively) and continued to decrease over time until the end of the therapy. Based on these results and improved function, as assessed by the orthopedic surgeon, the pharmacological analgesic therapy was reduced by the clinician at week 2 in 13 of 17 dogs. Laser-related side effects were not observed. Conclusion: This retrospective report provides a basis for future investigations, needed to clarify whether laser therapy may be beneficial to treat canine OA-associated pain. The preliminary findings are promising and suggest that LLLT may help reducing the analgesic administration and improving client satisfaction and the quality of life of dogs with OA.

Anesthesia and Anesthetic-Related Complications of 8 Elegant-Crested Tinamous (Eudromia elegans) Undergoing Experimental Surgery.

The aim of this study was to describe the anesthetic effects of an injectable anesthetic protocol, based on ketamine, midazolam, and medetomidine, followed by inhalational sevoflurane, in 8 elegant-crested tinamous (Eudromia elegans) undergoing experimental surgery. Initial doses for both injectable agents were tested in 1 bird and then refined with an algorithm based on the effects observed in the pilot procedure. Heart and respiratory rates, as well as nociceptive reflexes, were evaluated before anesthesia (baseline) and intraoperatively, at 10 minute intervals. The time from injection to anesthetic induction and surgical anesthesia, as well as the time from atipamezole injection to recovery, was recorded for each bird. The median doses of medetomidine and ketamine were 0.075 mg/kg and 33 mg/kg, respectively. Anesthetic induction was achieved within 10 (range, 4-45) minutes from intramuscular injection, whereas time to surgical anesthesia was 22 ±16 minutes. The baseline heart rate values were significantly higher than those measured intraoperatively at any time point (P = .001). Intraoperatively, 5 of 8 tinamous (63%) developed cardiac arrhythmias. Other encountered complications were regurgitation in 2 birds (25%), cardiac arrest in 1 bird (13%) soon after injection of the anesthetic agents, and prolonged recovery in another bird (13%), which was euthanized. Necropsy of the 2 fatal outcomes (25%) showed evidence of hepatic lipidosis in both (100%) and intramyocardial fat accumulation in 1 bird (50%). This report highlights the challenges of tinamou anesthesia. Cardiac complications are common in this species, and close monitoring of intraoperative cardiovascular variables is recommended for prompt recognition and treatment.

Inter- and intra-observer reliability of quantitative sensory testing performed with the SMall animal ALGOmeter (SMALGO) to evaluate pain associated with feline gingivostomatitis.

OBJECTIVES: The aim of this study was to evaluate the inter- and intra-observer reliability of quantitative sensory testing performed with the SMall animal ALGOmeter (SMALGO) in healthy cats and in cats with chronic gingivostomatitis (CGS), and to evaluate the SMALGO as a tool to detect and quantify pain in cats with CGS. METHODS: Thirty cats from a private shelter were included and assigned to one of two groups: group C (healthy cats; n = 15) or group CGS (cats with CGS; n = 15). In all cats the mechanical thresholds were measured with the SMALGO, with the sensor tip applied to the superior lip above the canine root, by two independent investigators (A, experienced; B, unexperienced), on two different occasions (day 1 and day 2) with a 24 h interval. A CGS scale was used in the diseased cats to assess the severity of the condition. For the reliability analysis, intra-class correlation coefficients (ICCs) were calculated. Other statistical tests used were Pearson correlation coefficient and a paired t-test. RESULTS: The inter- and intra-observer levels of agreement were fair (ICC = 0.50) and good, respectively (ICC = 0.73 for investigator A; ICC = 0.60 for investigator B). However, the thresholds measured in healthy cats (169 ± 59 g) did not differ from those obtained from diseased cats (156 ± 82 g; P = 0.35). There was no correlation between the scores of the CGS scale and the thresholds measured in diseased cats (Pearson correlation coefficient = 0.047; P = 0.87). CONCLUSIONS AND RELEVANCE: Quantitative sensory testing performed with the SMALGO in cats is repeatable and reliable, regardless of the expertise of the investigator. However, the findings of this study suggest that the mechanical thresholds measured with the SMALGO may not be a valuable indicator of pain in cats with CGS.

Prevalence of Electrolyte Disturbances and Perianesthetic Death Risk Factors in 120 Horses Undergoing Colic Surgery.

The objective of this study was to determine the prevalence of intraoperative electrolyte disturbances and risk factors associated with perianesthetic death in horses undergoing colic surgery. The files of 120 horses meeting the inclusion criteria were reviewed. Data retrieved from the medical records, including demographic data and the occurrence of electrolyte disturbances and other intraoperative complications, were analyzed with a two step-approach by univariate and multivariate logistic regression models. Hypocalcemia was the most represented electrolyte disturbance (52.5%), followed by hypokalemia (30.0%) that was associated with intraoperative administration of salbutamol (P = .045). Perianesthetic death occurred in 46 horses, accounting for an overall mortality rate of 38.3%. Risk factors associated with death were anesthetic duration (P = .001), body weight (P = .020), presence of gastric reflux before anesthesia (P = .021), and intraoperative tachycardia (P = .043) and acidosis (P = .025). The mortality in the study population was comparable to previously reported findings. Based on the study findings, it is advisable to optimize hemodynamics prior to anesthesia, in order to prevent intraoperative tachycardia that is associated with increased risk of death. Heavier horses and those with gastric reflux may have a higher risk of fatalities, and intraoperative salbutamol administration may contribute to hypokalemia.