LBAH Informational Articles

Proventricular Dilatation Syndrome (PDS)

Proventricular Dilatation Syndrome (PDS) , also known as Macaw Wasting Disease (it was first seen in macaws), is a devastating disease of mostly young psittacines. The proventriculus is the chamber of the digestive tract just in front of the ventriculus (gizzard). When it dilates there is an inability of the stomach to digest food. It can be a problem in any psittacine, but is found most commonly in macaws and cockatoos.


A virus is the most likely cause.


Birds that have this problem are weak, have lost weight, and can have difficulty perching. Many of them will regurgitate and pass undigested seeds in their droppings.

Regurgitation of a mucous like fluid is one of the classic signs of PDS. There might be seeds adhered to the mouth and feathers around the face.


Young cockatoos and macaws that have symptoms of this disease warrant further diagnostic tests. Other diseases can mimic PDS, so it is important to follow a thorough diagnostic process. Baby birds and those with infections, cancer or toxicities can also have a dilated proventriculus. Sometimes a biopsy of the crop or proventriculus is needed to confirm the diagnosis.

X-rays are a significant aid in making this diagnosis. The chambers of the stomach will show enlargement, which can be outlined with barium. Barium allows us to see the structures of the digestive tract more clearly. It also lets us know if the digestive tract is normal by assessing how long it takes for the barium to pass through to the end.

To understand how we perform a radiographic analysis of this problem it is important to understand the radiographic anatomy of a bird:

This is a normal x-ray of a bird laying on its right side. The head is towards the left. The diagram below explains the structures.

AS- air sac

PV- proventriculus

Vent- ventriculus (gizzard)

S- spleen

H- heart

This bird has PDS. The arrows circle the hugely dilated proventriculus.

We frequently give barium to help in outlining the digestive tract and to look for causes of the dilated proventriculus other than PDS.

In this x-ray the barium filled crop is on the far left (arrow on far left), there is barium in the esophagus (arrow in middle) and the ventriculus has barium in it (arrow on far right). The dilated proventriculus, without any barium in it, can be seen just to the left of the ventriculus.


PDS carries a poor prognosis. Medication to minimize vomiting and supportive care with fluids, antibiotics, and feeding small amounts of food at each meal might be helpful temporarily.

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Lead Toxicity

Lead is a heavy metal and can easily cause a toxicity (called plumbism). Other heavy metals, notably zinc, can also cause toxicity.


Birds are sometimes drawn to shiny objects, hence they will eat metallic objects that can contain lead. Birds are natural chewers and will chew cage bars and painted walls. In older homes there are sometimes layers of paint below the surface layer that contain lead. Lead particles can build up on the ventriculus (gizzard) and become toxic if in large enough quantity.

Lead is a heavy metal that is poorly absorbed by the intestines. Unfortunately, only a small amount is needed to cause problems. It eventually gets distributed to all body tissues, with particular emphasis on the digestive system, the red blood cells, the bone marrow, the liver and the nervous system.

Sources of lead could include; old paint, old cages, solder, stained glass, curtain weights, foil, fishing weights, batteries, linoleum, plaster, and putty.


Symptoms depend on how much lead is ingested over how long a period of time. The disease is sometimes broken down into acute lead toxicity and chronic lead toxicity.

In the acute version birds might be weak, depressed, produce abnormal droppings, and vomit. Neurologic signs could include walking in circles, twitching, incoordination and even convulsions.

Here is a short video of a bird with neurologic signs that could be caused by lead toxicity

Lead Toxicity Bird

Chronically infected birds can have similar symptoms to acute toxicity. In addition, they might lose weight, be partially or fully paralyzed, and even blind.



In some lead infected birds there is a history of recent chewing of paint on the walls. In some cases the owners did not suspect any exposure to lead.

Physical Exam

The physical exam may or may not reveal significant abnormalities. It all depends on how much lead has been ingested over how long a period of time.

This bird has lead toxicity. It chewed the paint on the floor after the owner did some remodeling in an old home. He is alert and eating well but cannot walk well on his back legs.

Diagnostic Tests

A blood panel might be useful in this disease. In some birds we might see anemia or evidence of liver disease. When we suspect lead toxicity we can run a lead level on the blood.

A blood lead level gives us a more accurate indication if lead toxicity is present

This is from the bird above. His lead level is 0.5 parts per million, far above the normal range of less than 0.06

Some brids can have a zinc toxicity also.

One of the most consistent ways to diagnose lead toxicity is with an x-ray. Lead is a heavy metal and will show up vividly on a radiograph, usually in the ventriculus (gizzard).

This radiograph is also from the above bird. It has normal grit in the gizzard, but if you look closely some of the grit looks brighter than normal. The brighter objects are lead particles, not grit.


Birds that are weak, losing weight, or not eating need supportive care. This consists of fluids and supplemental feeding. We will frequently hospitalize them until they regain their strength. If they are having seizures we can put them on anticonvulsant medication.

It is important to try to remove the lead from the ventriculus. Treatment with lubricating agents or even peanut butter will help pull the lead out of the gizzard to be passed in the droppings. On rare occasions, especially if the lead particles in the ventriculus are too large to pass, we will perform surgery to remove them.

Once your bird is stable and we have attempted to remove the lead from its ventriculus we use a class of medications called chelating agents. Their job is to go into the organs, especially the bone, where the lead has accumulated and counteract its affects. It can take several courses of treatment to completely treat your bird. These medications are not without risk, so they are used intermittently to give your bird a rest period in between doses.

We will treat until the lead level in the blood test is back to normal and there is no more radiographic evidence of lead in the ventriculus.


It is the nature of birds to be chewers and put metallic objects in their mouth. Minimizing their exposure to lead containing objects is an obvious way to prevent this problem. Also, feeding them a balanced diet (not just seed) will help keep them from looking for nutrients they need and are not receiving in their diets.

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Egg Binding

Egg Binding is a problem that occurs most often in the smaller female birds. Canaries, lovebirds, cockatiels, budgies (parakeets) and finches are the commonly affected breeds. Egg binding can be a serious problem, and is considered an emergency, requiring delicate and professional care. Unfortunately, some birds can succumb in spite of this care.


Infection, trauma to the reproductive tract, inadequate nesting area, excessive egg laying, obesity, and nutritional problems are some of the factors involved with this problem. Those birds on all seed diets or those with an inadequate calcium intake are particularly prone. An egg that is too soft can also cause the problem. Some birds are just prone to the problem, and even environmental factors like hypothermia can be involved. Determining the exact cause can be difficult.


Birds that have this problem might exhibit depression, labored breathing, straining, abdominal distention, lack of droppings, whitish droppings only, fluffed appearance, and poor appetite. There might even be a broken bone due to inadequate calcium. These are also the symptoms of other avian diseases. Pressure from a stuck egg can even interfere with nerve function to the legs. Sometimes the only symptom is your bird sitting at the bottom of the cage. Unfortunately, the only symptom in some cases is a dead bird found at the bottom of the cage.

Even a bird that is eating can have serious illness



In many egg bound birds there is a history of recent egg laying. Some birds exhibit sexual behavior and even build nests. During physical examination of a bird with a distended abdomen an egg can sometimes be palpated. There are other causes besides egg binding in sick birds with distended abdomens, so it is important to follow a thorough diagnostic process.

X-rays are a significant aid in making this diagnosis, but only if a bird is strong enough. Eggs shells have a high level of calcium, so depending on how well they are developed, might show up vividly on an x-ray. Some eggs are poorly calcified and do not show up well on a radiograph.

It’s not difficult to see the egg on this bird that is laying on its back. The circular whitish material just above the egg is grit in the gizzard (ventriculus).


Egg bound birds are very ill and require emergency care. Many are hypothermic and require immediate warming. They can be toxic from the inability to eliminate waste products and dehydrated from poor appetites and weakness, so warm fluids are also administered. If the bird is in shock we will give these fluids via an intraosseus catheter. Calcium is also administered to aid in muscle contractions and hopefully expulsion of the egg on its own. Medications to stimulate the uterus to contract are also used. Whether or not they help depends on the cause of the problem.

If medical therapy does not work we attempt to help in the removal of the stuck egg. Once the bird is more stable we can sometimes gently expel the egg with liberal lubrication and digital pressure. If the egg is adhered to the uterus digital pressure might not work. Inserting a needle with a syringe attached directly into the egg allows us to collapse the egg and make expulsion easier.

This female is being examined with a lubricated speculum to determine the exact nature of her problem. We can deflate the egg by passing the needle through the speculum. The arrow points to a high intensity cool light that allows greater visualization.


There are factors involved with this problem that we have no control over. Factors we can control are good nutrition, a clean environment, spaying birds that are predisposed to egg binding or are excessive egg layers, minimizing obesity and stimulating exercise.

Careful daily observation of your pets daily habits will help you recognize the early symptoms of this disease. No matter what the problem, any time your pet bird shows any symptoms of a disease, no matter how subtle, it is considered significant and requires immediate veterinary care. This is because birds are masters at hiding illness, and we are all too often presented with sick birds in advanced stages of disease. Our ability to return these birds to normal health is diminished because proper care has not been given early on in the disease process where it is most beneficial.

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Scaley Face Mites

Birds are occasionally infected with a mite called Knemidicoptes (if you want to make an effort at pronouncing this word the K is silent). We usually encounter this problem in parakeets (Budgies) at our hospital. This parasite causes extensive crusting and hair loss, fortunately it is readily treatable.


Scaley face disease is caused by a mite called Knemidicoptes that is spread from bird to bird by contact. Some birds acquire this parasite while young and do not develop symptoms until they are young adults.


This disease is diagnosed by the character of the lesions and the fact that it has occurred in a Budgie. Microscopic examination by a skin scraping will reveal the mite.

This bird has the telltale lesions of scaley face mites. There is crusting on the neck and face, and a honeycombed appearance to the beak. This is a severe case. In addition, this bird has a growth on its beak.

Lesions also occur in other areas, most noticeably in the vent and on the feet.


Years ago the only treatment we had was an ointment that was used to treat pubic lice in people. It was messy and had to be applied daily, but it usually worked. Now we use the drug Ivermectin, given every week or two until the problem is gone, usually within 3-4 weeks.

This is the same bird as above 10 days after its first Ivermectin treatment. We removed the growth on its head a few days before this.

Here he is 2 weeks after his second treatment. He is almost completely healed and feeling a million times better. Hard to believe its the same bird.

He was brought into our clinic and dropped off as part of our wildlife program since he was a stray and was found by one of our clients. He has a great personality, and once we got him looking like this we had no problem finding him a home (with a girlfriend).

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Parrot Fever (Psittacosis)

Parrot fever has many names, including Chlamydiosis, Psittacosis and Ornithosis. It is called Psittacosis when it occurs in people and psittacine (parrot types) birds, and Ornithosis when it occurs in passerine (pigeons, doves, etc.) birds. Psittacosis is difficult to diagnose, and is a mysterious disease that does not “follow the rules” of typical avian diseases.

Important Regulations

The United States Department of Agriculture regulates the importation of domestic birds in order to protect the domestic poultry industry. These imported birds must be accompanied by a health certificate. Upon admission they are quarantined for 30 days at a special facility and tested for Newcastle disease. During the 30 days they are given food supplemented with medication that will treat Psittacosis. This medicated feed needs to be continued for at least an additional 15 days when the bird is released from quarantine.

State Health Regulations

Psittacosis is a reportable disease. When a positive diagnosis of Psittacosis is made an inspection might occur to determine the cause of the outbreak, number of birds affected, and any human exposure. Depending on the specifics of the situation a quarantine and treatment might be initiated.

Human Health Significance

Humans can get Psittacosis (Chlamydia psittaci) from birds. Cats get Chlamydia psittaci and show evidence of eye problems, but there is no evidence that cats can spread this disease to people. Other species of the Chlamydia bacteria that occur in sheep, goats, and cattle can cause disease in humans, but those diseases are not called Psittacosis.

Exposure is usually due to the inhalation of dried bird droppings that contain the organism, incubation is 6-19 days. Other potential sources of infection are from respiratory secretions and feathers. Symptoms in people range from nothing to severe disease with pneumonia. Typical symptoms include fever, chills, headache, muscle aches and cough. Inflammation of the heart, liver, and nervous system can occur, with even fatal cases reported. With proper treatment most people recover. According to the Centers for Disease Control and Prevention, between 50-100 cases of human Psittacosis are reported each year, with probably many more undiagnosed. Probably due to increased awareness and diagnostic testing, annual incidence of Psittacosis in humans is decreasing.


Psittacosis is caused by a bacterium called Chlamydia psittaci that is an obligate intracellular parasite. It has been isolated from many birds, especially cockatiels and parakeets. After exposure the incubation period can vary from 3 days to weeks.

Healthy birds can be carriers of Psittacosis, shedding the organism in their droppings intermittently. It is also found in respiratory discharge. Shedding is stimulated in birds by stress like overcrowding, chilling, and shipping. The shed Psittacosis bacteria can remain infectious in the environment for several months.


Birds are masters at hiding any symptoms of illness, especially in Psittacosis. An apparently healthy bird that is singing and eating in the morning can be gravely ill or be found dead by the same afternoon. It is imperative that you tune in to subtle signs of disease in your pet bird, and bring it in for an exam at the first sign of a problem. If you are unsure, it is better to be safe than sorry.

Some birds with Psittacosis do not show any symptoms and can become carriers, shedding the bacterium intermittently, especially when stressed. Others might get a chronic illness or become severely ill and die. Symptoms depend on age at infection, species, virulence of the specific strain of the bacterium, exposure amount, and stress factors.

Typical symptoms, if present, might include a fluffed appearance, poor appetite, weight loss, respiratory disease, and lime green droppings. The droppings might appear to be diarrhea, but in reality they are usually watery urates, the equivalent of bird urine. Some birds have ocular discharge, leading to the term “one eyed cold”. These symptoms occur with many other avian diseases, so it is imperative to follow proper diagnostic parameters when making this diagnosis.

This parrot has a problem as evidenced by its fluffed appearance. It is fluffed because a disease process is preventing it from keeping itself warm, so it is trapping air under its feathers in order to insulate itself. Birds that do this consistently are ill. Psittacosis can cause this, but so can many other bird diseases.



In some cases we have a high degree of suspicion because a bird has been imported into the country illegally. This means it has bypassed the USDA quarantine and treatment facility. These smuggled birds commonly come from Mexico. They can be purchased at swap meets for a low price, so you must be wary of these potential disease carriers.

Physical Exam

The physical exam may or may not reveal significant abnormalities. An exam of a bird gives us limited information compared to dogs and cats. This is because of the unique anatomy and physiology of a bird. Several examples will elucidate this point.

  • A birds body temperature can go well over 107 degrees F and still be normal
  • They do not have external lymph nodes that can be felt during an exam
  • Their heart rate can easily be up to 500 beats per minute, making it almost impossible to detect murmurs and arrythmias
  • They do not have a diaphragm, the muscle of breathing that separates the abdomen from the chest
  • They use air sacs as a major part of their respiratory physiology, as opposed to dogs and cats using only lungs.
  • Their keel bone extends far down over their abdomen, making it impossible to accurately palpate abdominal organs.

Diagnostic Tests

Since a physical exam on birds yields significantly less information compared to a dog or cat, we need to rely more on diagnostic tests.

Taking a blood sample from the small veins of a bird is a refined art. One of our nurses is taking one from the leg vein of a cockatoo.

A blood panel might be perfectly normal, or it might show significant problems. This is a blood panel from a bird positive for Psittacosis on the ELISA test. The arrows point to the significant abnormalities. The white blood cells (WBC count) are elevated, it is anemic (HCT is low), and its liver test (AST) is high. These findings give us an indication that this bird might have Psittacosis, but they can also occur with other avian diseases though.

Another diagnostic test helpful in Psittacosis is radiology because it allows us to visualize internal organs. This radiograph is also from the above bird. It has an enlarged spleen (S), the circular structure in the middle of its coelomic cavity.

If you would like to learn more about reading a bird radiograph click here.


Culture is used to detect the Chlamydia organism itself, and is one of the most accurate methods of making an accurate diagnosis. It is time consuming, requires special techniques and laboratories, and since shedding of the bacteria can be intermittent, samples need to be collected for several days. Also, it can take up to several weeks before the result is available, which defeats the purpose of the test for many ill birds. Unfortunately, the laboratories that perform this culture are not readily available to us.

Psittacosis tests

Psittacosis tests have been developed to aid us in our diagnosis. No test is perfect or applies to every situation and species. In some cases we will perform several of these tests to increase accuracy:

  • Antibody Tests- These tests check for antibodies made by the immune system when it is exposed to the Chlamydia organism. Birds that are stressed, in poor nutritional state, or have other diseases, might not produce antibodies at all. Also, it is possible for these tests to be negative early in the course of the disease when the immune system has not had enough time to produce antibodies.
    • EBA- Elementary Body Agglutination checks the antibody called IgM (immunoglobulin M), which is found early in the course of the disease. As a result, it is used as a screening tool for healthy birds or if a bird is suspected to be early in the course of the disease. A positive result does not easily differentiate a bird that actively has the disease from a bird that has been exposed in the past and is currently not ill. It only requires a small amount of blood in relation to other blood tests. IFA- Immunofluorescent Antibody checks for IgG (immunoglobulin G) that builds up in the bloodstream later in the course of the disease. It gives a better long term perspective as a result.
  • Antigen Tests- These tests check for the shedding of the Chlamydia organism in the feces. Viable Chlamydia are not needed for a positive diagnosis since they test for antigen or DNA of Chlamydia.
    • ELISA-Enzyme-Linked Immunosorbent Assay is used on ill birds. It was originally developed to detect human Chlamydia. Like the culture, samples should be taken over several days to increase the chance of finding the problem in intermittent shedders. It is an easy test to administer and can be performed as an outpatient basis with immediate results. False negatives and false positives can occur. a bird with a negative on this test still could have Psittacosis. A bird with a positive on this test might have Psittacosis.PCR- Polymerase Chain reaction is another antigen test. It has great promise and might become the test of choice in the future.

Autopsy (Necropsy)

Unfortunately, Psittacosis is sometimes accurately diagnosed only at necropsy.

This dark red organ is the enlarged spleen of a bird that died of Psittacosis.

This air sac is cloudy, an indication of an infection. Psittacosis could be a cause of this.


Birds that are suspected of having Psittacosis are immediately isolated. Protective clothing should be worn at all times when treating these suspects. Routine surgical masks might not be adequate to prevent exposure.

Birds that are weak, losing weight, or not eating need supportive care. This consists of fluids and supplemental feeding. We will frequently hospitalize them until they regain their strength. The mainstay of treatment is with the tetracyclines.

There are several different methods to get this medication into a birds system in order to achieve adequate blood levels.

  • Medicated Feed- Medicated foods can be purchased or made up that contain 1% chlortetracycline (CTC). These need to be fed for 45 days. Acceptance is variable, so monitoring of food consumption is imperative. Calcium should not be greater than >7% in this diet because it can interfere with the tetracycline.
  • Oral Doxycycline- This is the drug of choice for oral treatment. It is also used for 45 days, and is given to birds that are cooperative.
  • Injectable Doxycycline- This drug, also know as Vibravenous, is given once every 5-7 days. Treatment is given for at least 6 weeks. Irritation can occur at the injection site, so it must be given under the direction of a veterinarian.


Do not purchase a bird that seems ill or you suspect has been brought into this country illegally. New birds should be examined, tested, and quarantined for at least 45 days. During this 45 days these new birds can be treated also.

People with compromised immune systems should not be exposed to birds that might have Psittacosis. Gloves, masks, and protective clothing should be used when cleaning cages and working around birds suspected of this disease.

Clean cages and feeding bowls frequently, and set up housing so droppings, food, and feathers do not contaminate other cages.

Chlamydia psittaci is susceptible to routine disinfectants. Common ones include Lysol, bleach, 70% isopropyl alcohol, and Roccal.

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Prolapsed Cloaca


A cloacal prolapse is a serious problem requiring immediate veterinary care. Trauma to the internal organs that are prolapsed through the opening can seriously affect the bird. It is seen in cockatoos and the smaller breed birds like budgies and cockatiels. It requires immediate replacement of the prolapsed organs.


Straining due to parasites, abdominal masses or tumors, chronic egg laying, abnormal eggs and poor nutrition are all predisposing factors. Determining the exact cause can be


Birds that have this problem might exhibit depression, straining, lack of droppings, fluffed appearance, and poor appetite. Sometimes the only symptom you notice at home is blood in the droppings. These symptoms occur in other diseases, so the diagnostic approach has to be thorough.


In many prolapsed birds there is a history of recent egg laying. During the physical exam internal organs (intestines or reproductive usually) are apparent at the cloaca. When diagnostic tests are used their main indication is to find the underlying cause to the problem in order to prevent recurrence. These tests include fecal exams for parasites, x-rays for abdominal masses pushing on the abdominal contents, and blood panels to determine general health and organ function.


Birds with prolapsed cloaca’s require emergency care. Many are hypothermic and require immediate warming. Others can be dehydrated so warm fluids are also administered. Antibiotics are usually administered to prevent infection in the affected organs.

Once a bird is stabilized the prolapse is replaced back into the abdomen. The sooner the better because internal organs that are exposed to the environment are easily traumatized and infected. Amputation could be needed on infected tissue or tissue that has inadequate blood supply.

In some cases we anesthetize the bird to allow muscle relaxation and subsequent easier replacement of the affected organs. This patient is in a special anesthetic chamber allowing us to safely administer the anesthetic.

This prolapse has been present for several hours. The coloration tells us it is healthy enough to allow replacement back into the abdomen. It will be gently cleansed and flushed with sterile saline. It is an internal organ and requires delicate handling.

The area is lubricated copiously with K-Y jelly and the prolapse is gently manipulated back into the abdomen using Q-tips. This process takes several minutes because the organ is swollen and predisposed to tearing.

After it is replaced special sutures (at the arrows) are used to prevent it from coming out again. They are put in tight enough to keep the organs inside but loose enough to allow droppings to pass. These sutures will be kept in for at least several days to allow the prolapsed tissue to heal.


There are factors involved with this problem that we have no control over. Factors we can control are good nutrition, a clean environment, spaying birds that are predisposed to egg binding or are excessive egg layers, minimizing obesity and stimulating exercise.

Careful daily observation of your pets daily habits will help you recognize the early symptoms of this disease. No matter what the problem, any time your pet bird shows any symptoms of a disease, no matter how subtle, it is considered significant and requires immediate veterinary care. This is because birds are masters at hiding illness, and we are all too often presented with sick birds in advanced stages of disease. Our ability to return these birds to normal health is diminished because proper care has not been given early on in the disease process where it is most beneficial.

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Budgie Growth Removal

This little guy had a growth near his cloaca that weighed almost as much as he did. We removed it because it was getting larger and interfering with bowel movements.

Birds this size have little blood, so bleeding control (hemostasis) is critical. We removed it using the laser, taking advantage of its tremendous bleeding control and lack of post operative inflammation and pain control.

Graphic photos on this page.


Birds tend to be more sensitive to anesthesia than most mammals, so special precautions are taken to minimize the risk. We always perform pre-anesthetic diagnostic tests prior to surgery to make sure there are no internal problems.

We use special monitoring equipment during the surgery in all our recent surgeries


Lisa is just starting the anesthetic process. This bird will also have hot water bottles keeping it warm during the surgery



The growth is large for a bird this size, and has probably been there for months. Luckily it was benign.


When our patient is draped and under the proper plan of anesthesia we start the laser surgery


Half way through and there is no bleeding at all


No suture are needed, and healing will be complete in a few days, with no pain or post operative swelling


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Macaw Cataract Surgery

With the significant help of our favorite veterinary ophthalmologist, Dr. Paul Jackson (deceased), along with our favorite human ophthalmologist, Dr Art Giebel, we removed a cataract from a Macaw.

This page has graphic surgical pictures.


Birds tend to be more sensitive to anesthesia than most mammals, so special precautions are taken to minimize the risk. We always perform pre-anesthetic diagnostic tests prior to surgery to make sure there are no internal problems.

We use special monitoring equipment during the surgery in all our recent surgeries




In addition to the substantial surgical expertise of our surgeons, this surgery is not possible without special equipment, especially a dual surgical microscope.


Our patient is anesthetized and ready for surgery


Dr. Paul and Dr. Art work together as a team during the surgery


A microscopic incision is literally made into the eye near the cornea. The cataract is emulsified just like in people. A new lens is not put in, unlike in people.


The start of the procedure



Removing the cataract




Finishing the procedure and suturing the cornea

Our surgery team, from left to right-

Art Giebel, MD

Carl Palazzolo, DVM

Paul Jackson, DVM



Our patient ready to go home


A healed eye

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Fractured Bird Leg

Due to the fact that birds have small, and sometimes hollow bones, it is not unusual for them to break them due to trauma. Falling off a perch, being injured by another animal, or even being stepped on by its owner are some of the more common causes of a fracture. Sometimes there are underlying problems causing the bones to be weak and susceptible to fracture during normal activity. The tibiotarsal (shin bone) is the one most commonly fractured.

This page shows a tape splint on a simple fracture.  This splint is light and stable, perfect for a small bird like a budgie (parakeet) or a cockatiel. At the end of this page you will see fractures that need surgery, with a link to seeing the full surgical repair of a fractured femur (thigh bone) in a rabbit at our hospital.


Most birds that have broken legs will not bear weight on the affected leg. Most fractures can be palpated by one of our doctors, although a bone can be fractured without any obvious evidence during examination. Taking a radiograph is one of the best methods to determine if a fracture is present.

Do you see the fracture in this view?

Avian- FxTibiotarsal-9

The fracture is more apparent in this side view. This emphasizes the importance of taking two views. This fracture is classified as a mid shaft transverse fracture of the tibiotarsal bone.



Most tibiotarsal bones heal well when splinted with special tape. We usually keep the splint on for one month, although this varies. On occasion we need to perform surgery for proper stabilization. This is more common when there is a fracture of the femur (thigh bone).

The first step in splinting this cockatiel fracture is to remove all the feathers over the fracture site. Plucking them allows them to grow back faster compared to cutting them. You can see the bruising that is apparent on this birds leg directly over the fracture. Birds routinely show bruising of many colors, which is sometimes misinterpreted as gangrene by inexperienced people.

Avian- FxTibiotarsal-10

The first layer of tape is applied directly to the skin. We use a type of tape that will cause minimal irritation to the sensitive skin during the healing process and when we remove it after the bone has healed.

Avian- FxTibiotarsal-11

These tape strips are molded over the leg to provide the beginning stages of stability. Several pieces are used to cover above and below the fracture

Avian- FxTibiotarsal-12

The next layer of tape is waterproof and much stronger. Several strips are used to provide the necessary stability.

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When all the layers of tape are applied a hemostat is used to gently mold all the layers tight up against the bone. Now the fracture site is stable and the bone can begin the healing process.

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One our doctor feels the bones are lined up properly and the fracture site is stable, the excess tape is trimmed.

Avian- FxTibiotarsal-15

The splint is trimmed for easier mobility. With the fracture stable this bird will feel substantially better, and start bearing weight very soon. It needs to remain quiet and not climb or play excessively during the healing process. The foot should be checked daily for swelling and the splint should be kept clean and dry (of course it is OK to sign the splint). Weekly rechecks by one of our doctors will ensure the splint is secure and the foot is not swelling.

Avian- FxTibiotarsal-17

This budgie also had a broken tibiotarsal bone that was repaired with a tape splint


He was grateful we took away his pain and started playing with us right away



For comparison purposes this is a cast put on a wiggly 6 year old boy named Mike. As you can see, one of his fans is signing the cast while he enjoys some R & R. Your bird needs the same kind of attention during its healing process. Make sure it gets plenty of rest and good nutrition, and remove perches initially so it can not climb around the cage. Putting something soft in the bottom of the cage is also needed.

Surgical Fractures

Some tibiotarsal fractures will not heal with a tape splint.

These are typical of  bird fractures that require surgery

Avian- FxTibiotarsalRad1

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This is not a bird tibiotarsal fracture. It gives you an idea of how we might use pins on a bird

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We would like to use plates on birds fractures like other animals. Bird bones are too thin, and the plate is too heavy, to use in a bird.

Avian- FxTibiotarsalRad2-6

This is a rabbit femur fracture


The appearance of the fracture after repair


Click here if you want to see the full surgical repair of this rabbit fracture

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Worms (Internal Parasites)

The study of parasites is called parasitology. It is an important discipline because internal parasites cause death and disease worth billions of dollars in animals each year. These parasites have highly evolved life cycles that make their elimination impossible. In addition, many internal parasites affect people with the potential for serious consequences.

Dogs and cats (especially puppies and kittens) are routinely infected with internal parasites, sometimes without apparent evidence of the infestation until it is too late. This means that a pet can have internal parasites even though the fecal sample is negative. It is suspected that internal parasites predispose your pet to IBD (Inflammatory Bowel Disease) later in life.

Fortunately, we have effective medications to treat most parasites. Many of the medications we use to treat internal parasites, called anthelmintics, treat more than one parasite. The advent of these broad spectrum anthelminitcs makes treatment much more effective. We recommend all dogs and cats get a treatment for internal parasites every 6 months.

This best method for treatment is to use flea products on a monthly basis that also kill internal parasites and prevent heart worms. We have several medications, some oral and some topical, to achieve this.

This section will discuss internal parasites that are commonly found in dogs and cats in our area. This includes:

  • Tapeworms
  • Roundworms
  • Hookworms
  • Whipworms
  • Coccidia
  • Giardia

These internal parasites differ from external parasites, which usually affect the skin and ears of dogs and cats. Click here to learn more about external parasites.


Symptoms manifested by pets that are infected with internal parasites can vary, and depend on a pet’s age, nutritional status, parasite load, duration of infestation, etc. One of the most common symptoms of internal parasitism is diarrhea. Other symptoms include poor appetite, lethargy, coughing, and abdominal distention. Some pets don’t show any symptoms while others can die from their infestation. Internal parasites tend to infest older and younger animals most commonly. Internal parasites can also make a pet more susceptible to other diseases. It is not uncommon for a puppy with Parvo virus to have internal parasites simultaneously.

Due to the prevalence of internal parasites in dogs and cats, their lack of symptoms in some cases, and the potential for humans to become infested also, your pets feces should be checked for internal parasites twice a year. Dogs and cats that are outside and exposed to other animals should have their feces checked more often. Routine worming should be performed on all dogs and cats every 6 months, even if the stool check for parasites is negative.


The majority of internal parasites are diagnosed by microscopic examination of the feces for eggs that are released by the adult female in your pet’s intestine. The number of eggs released in a given fecal sample can be variable, sometimes there aren’t any even though your pet has an adult female parasite in its intestines. This means that a negative fecal report does not guarantee that your pet is free from internal parasites. In many cases we need to run numerous samples to feel comfortable that your pet is free of internal parasites. In some cases our doctor’s will treat for a specific parasite, even on a negative fecal sample, when they feel there is a likelihood of infestation, because some internal parasites eggs are notoriously hard to detect.

In some parasites a diagnosis is made by observation of the mature parasite in your pet’s feces or during an autopsy in your pet’s intestines. This is especially true for Tapeworms. Tapeworm eggs are difficult to detect during microscopic fecal analysis, so observation of the actual worm is how they are routinely diagnosed.

The two primary methods of fecal analysis are direct observation and fecal flotation. In direct observation a smear is made of some fecal material on a microscope slide and the slide is analyzed by one of our nurses for parasite eggs. It is used to detect eggs that don’t show up well during the fecal flotation.

Fecal flotation is the most accurate way to detect most internal parasites. A sample of fresh feces is put into a special solution that causes any eggs that might be present to float to the top and adhere to a cover slip. The cover slip is put on a microscope slide for analysis. This concentration of eggs substantially increases the chance of finding any eggs that might be present. Some eggs, notably Tapeworm eggs, dissolve during this process and might be undetected. This is the reason you can see Tapeworms in your pets stool yet the fecal analysis came back negative.

We have sanitary containers for you to use to obtain a fecal sample from your pet. Once the sample is obtained it should be kept cool until we analyze it. Analysis should be within 12 hours to increase accuracy.

The flotation solution has been added to the fecal container and a cover slip has been placed on the top to collect any eggs that float to the surface after a 5 minute wait

The cover slip is put on a microscope slide and carefully scanned for the eggs of any parasite. High magnification is needed because the eggs are microscopic in size.


Internal parasites have very sophisticated life cycles that can make treatment difficult. Some of these life cycles involve mandatory maturation processes in other animals, including insects. Specific treatment modalities are set up to address these life cycles and will be discussed for each individual parasite in the following sections. It is important to follow these treatment regimens precisely.

Some parasites can only be controlled, not eliminated. In these cases it is important to check your pet’s feces routinely and to use medication on a long term basis.

There are new treatments for internal parasites that are very broad spectrum. They kill a wide variety of parasites, and are the medications we use as a routine wormer.

Revolution, will kill fleas, heartwormsear mites, and even internal parasites. We recommend it for cats.

Trifexis kills internal parasites, heartworms, and fleas, and is recommended for dogs.

Please ask our receptionist for brochures on these products.


By far the most common internal parasite we encounter is Tapeworms. The scientific name for the Tapeworm we encounter in our area is called Dipylidium.

Life cycle

The source of the infestation is a flea that has been swallowed by your pet or a cat that eats infected rodents. The flea gets the Tapeworm in its system by swallowing it during its larval stages, when the larvae eat the eggs that have been passed from pets that are already infested with Tapeworms.

The lifecycle of the Tapeworm is simple compared to other internal parasites


In spite of their prevalence Tapeworms are not a significant cause of disease in dogs and cats. Most pets do not have any symptoms, and if symptoms are present, are mild in nature. Some pets will itch at their anus or scoot on the ground when the worms cause irritation as they pass.


Most Tapeworms are diagnosed by visualizing the worm in your pets feces, crawling around its anus, or in its bedding. Tapeworms segments crawling on your dog’s anus might cause scooting, although full anal sacs are a much more common cause of scooting. They come in long attachments that usually break off into individual pieces when they exit from your pet. They usually look like pieces of white rice and turn yellow after they have been out of the body for a while.

This is a packet of Tapeworm eggs as viewed under a microscope. It is rare for us to see them in this packet because the fecal flotation solution causes this packet to burst.


Several medications are available that are highly effective at ridding you pet of Tapeworms. The most common treatment is an oral medication that rids your pet of all Tapeworms within 24 hours. This medication also kills rounds, hooks, and whipworms. It does nothing to prevent your pet from re-infecting itself. Proper flea control does.


Since fleas are directly responsible for this infestation their control is apparent. We recommend advantage and Program for safe, economical, convenient, and highly effective flea prevention. A new product, called Revolution, will kill fleas, heartworms, ear mites, and even internal parasites. Please ask our receptionist for a brochure.

Public Health Significance

Children can pick up Tapeworms from eating fleas, but it rarely causes any problem. Other species of Tapeworms exist that have significant potential to cause serious disease in people. Fortunately, we do not encounter them in our local area in dogs and cats.


A common parasite of dogs and cats, especially puppies and kittens, is Roundworms. The scientific name for their group is called ascarids. We routinely treat puppies and kittens for this parasite for 2 reasons. The first is their prevalence, the second is their potential to infest humans. The larval form of this parasite has the potential to cause serious disease in children. Fortunately it is a rare problem, and can be prevented by worming all puppies and kittens early in life. It is all prevented by monthly use of flea and heart worm prevention products like Trifexis for dogs and Revolution for cats, since these products also kill roundworms.

Life cycle

The life cycle of this parasite almost ensures that a puppy or a kitten will be exposed. They can get it from their mother while they are in the uterus (dogs), during nursing, and through contamination with infected feces. Larval forms of this parasite migrate through internal organs, get coughed up and swallowed, and become mature parasites in the small intestines. Intermediate hosts like rodents can become infected by eating eggs, and can then infect a dog or cat when they are eaten. Some larvae migrate to the tissues of internal organs and remain dormant until pregnancy where they become active and infect the developing puppies in the uterus.


Common symptoms are a distended abdomen and diarrhea. Some puppies and kittens will be vomiting, lethargic and not eating well, while others will not show any symptoms. On rare occasions the parasite load can be so heavy that the intestines become obstructed. Coughing, fever, nasal discharge and even pneumonia can occur in pups that have large numbers of larvae migrating through their respiratory tract.


In some cases the Roundworm will be present in your pet’s feces, vomitus or crawling around its ansu. This is not a consistent finding, and worms that might be present one day might not be there the next.

It looks like a curled up piece of spaghetti

The vast majority of Roundworm infestations are diagnosed on fecal analysis for eggs. Young puppies can be infected before the eggs of the parasite appear in the feces.

This is one type of Roundworm egg when viewed under the microscope. The thick membrane around the eggs prevent them from drying out when they are laid in the environment.


There are several effective treatments for Roundworms. We can easily treat your pet with an oral version given during a routine office visit. It has to be retreated in 2 weeks due to the migrating larvae since the medication does not kill the larvae. Some pets require several more treatments for a full cure. If you keep your pet on Trifexis or Revolution year round you are treating for this problem monthly. This is the best way to go.


Roundworm eggs can remain viable for a long time in the environment. Children will get this parasite by eating dirt contaminated with the eggs, therefore cleaning up your pet’s feces immediately, and eliminating exposure to the feces of other animals when your pet goes for a walk, are important treatment modalities. Litter pans should be changed frequently and washed thoroughly and then allowed to dry in the sun. Keeping cats indoors also eliminates exposure to the feces of infected pets and the eating of infected rodents.

Public Health Significance

Children are of particular vulnerability to infestation because of their propensity to put things in their mouths and their attractions towards puppies. areas that might be contaminated with dog or cat feces should be off limits to children. This might include public areas such as parks or playgrounds. Even though these infestations in children are relatively uncommon, if they occur there can be significant damage to the internal organs like the liver, heart, brain, lungs, and eyes. This reason alone is why all puppies and kittens should be routinely treated for Roundworms, whether or not their fecal exam indicates they have parasites. also, teach your children to wash their hands frequently after handling pets, and not to put anything unnecessary in thier mouths.


Hookworms are blood sucking parasites that live in the small intestine. The scientific name for the Hookworm we encounter in our area is called Ancylostoma. They can be very pathogenic and even cause death due to anemia and low protein level.

Life cycle

Hookworms are spread by eating infected larvae that are in the environment. These infective larvae can also penetrate the skin and enter the blood stream where they mature into adult Hookworms in the small intestine. Puppies can also get infected while nursing or in the uterus prior to birth. Some Hookworm larvae migrate to muscles where they serve as a source of future infections.


Pets with Hookworms have the potential to be very ill,especially in dogs. Symptoms include lethargy, dark stools or diarrhea, weakness and vomiting. In severe cases they are anemic and debilitated, especially the older and younger pets. The larvae might even irritate the skin when they penetrate between the toes and pads.


Adult Hookworms are small so they are usually not seen passed in the feces. This diagnosis is made primarily by finding the distinctive egg in your pet’s feces. Any pet that is anemic should have its feces checked for this parasite.

These eggs are more oval than Roundworms, and the membrane is thinner


Infected pets might require hospitalization and even a blood transfusion if their symptoms are severe. There are different types of worming medications used, some require retreatment several weeks after the initial treatment because of the larvae that migrate through the body. All require checking your pet’s feces to make sure the parasite has been eliminated. Long term treatment and surveillance in the form of fecal exams are necessary. Dogs with chronic problems are put on heartworm preventive medication on a monthly basis since this medication also kills Hookworms. Any dog put on heartworm preventive medication needs to be checked for heartworm disease before we start preventive medication.

If you keep your pet on Trifexis or Revolution year round you are treating for this problem monthly. This is the best way to go.


Fecal exams should be performed frequently on pets that have a history of Hookworm infestation. Prompt removal of feces helps prevent contamination of the yard with larvae. Larvae are killed in cold climates when exposed to freezing temperatures.

Public Health Significance

Hookworm larvae can penetrate the skin of people and cause significant irritation. These larvae can migrate through the body and cause damage to internal organs. Just like in Roundworms discussed above, puppies should be routinely treated for this parasite at a young age.


Whipworms are blood sucking parasites that live in the large intestine, usually only in dogs. They are called Whipworms because they have a slender end and a thick end, hence the appearance of a whip. The scientific name for the Whipworm we encounter in our area is called Trichuris. They can be as pathogenic as Hookworms, and also cause death due to anemia and low protein level.

Life cycle

Female Whipworms lay eggs in the environment that eventually turn into larvae. Pets ingest these larvae when they ingest soil that is contaminated. These larvae take 3 months to develop into adults capable of causing disease.


Symptoms of Whipworm infestation include chronic diarrhea, anemia, and weight loss.


Like most internal parasites Whipworms are diagnosed by looking for the eggs in the feces. They are oval in shape and have a plug at each end that aids in identification. Their thick membrane gives them significant protection. The eggs are shed intermittently, so a negative fecal sample does not guarantee that your dog is free of Whipworms. Adult Whipworms can sometimes be visualized when an endoscope is passed into the rectum of a pet with chronic diarrhea.



Various oral medication are also used to treat Whipworms. Treatment is commonly repeated in 3 weeks and 3 months due to the life cycle of this parasite. If you keep your pet on Trifexis or Revolution year round you are treating for this problem monthly. This is the best way to go.


Control of reinfections is difficult because eggs that have been laid in the environment are very resistant. Feces need to be rechecked and a long term plan for surveillance and treatment needs to be initiated.

Public Health Significance

Human infections with this parasite might occur, although this controversial. Common sense dictates prompt removal of feces from your pet’s environment and washing your hands any time there is a potential exposure.


Coccidia are not technically a worm, but a protozoan parasite that infect dogs and cats primarily, but can be seen in other species.

Life cycle

Coccidia life cycles are complex and involve many stages of development. Coccidia produce cysts instead of larvae and eggs. Dogs and cats usually get the infection from ingesting the cysts in the environment or eating animals like mice that are already infected.


Symptoms usually occur in young animals and include diarrhea and abdominal pain. These young animals can become severely dehydrated and the infection can be life threatening. This is especially true in pets that are stressed or have other parasites. Many pets, especially the older ones, do not show any symptoms when infected.


Diagnosis of Coccidia infection is made by identifying the very small eggs in a fecal sample. They can be very difficult to detect due to their small nature and variable shedding by a pet. This is why our doctors will occasionally treat a pet for Coccidia even though the fecal exam is negative for this parasite.


Sulfa type medications or sulfa and antibiotic combinations are used to affect a cure. They need to be given for up to 3 weeks.  There is also a medication that requires only 3 days of treatment. Kittens that are very ill require hospitalization and intravenous fluids to help them fight off the infection.


Prompt removal of feces helps prevent continued environmental contamination.

Public Health Significance

A version of Coccidia, called Toxoplasmosis, is of particular significance to pregnant women since it can cause disease in unborn children. The most common source of infection for pregnant women is eating improperly cooked meat (especially pork, lamb, and venison), not necessarily from the feces of cats. In a cat that does have Toxoplasmosis, the eggs that are laid in the environment (litter pan) do not become infective until 24 hours have passed. If the litter pan is cleaned twice daily the eggs will not have time to become infective to pregnant women. Wear gloves when you change the litter pan. Better yet,have someone else clean the litter pan. When you garden you should also wear gloves since stray cats may use the soil as a litter pan. Keeping your cat indoors and not feeding it raw meat will prevent it from getting Toxoplasmosis and passing it on.

According to the Centers for Disease Control and Prevention more than 60 million people in the United States are infected with the Toxoplasmosis parasite. Few have symptoms because a healthy immune systems keeps it in check. You may feel like you have the “flu,” swollen lymph glands, or muscle aches and pains that last for a few days to several weeks. However, most people who become infected with toxoplasmosis don’t know it. On the other hand, people with immune system problems, such as those with HIV/AIDS, those taking certain types of chemotherapy, or persons who have recently received an organ transplant, and infants, may develop severe toxoplasmosis, which results in damage to the eye or the brain. Infants who became infected before birth can be born retarded or with several other serious mental or physical problems.


Giardia are also protozoal parasites that live in the small intestines. Giarida are found every where in the world, Infection rates are variable, with younger animals having a higher rate of infection. There are various strains that differ in their potential to cause disease. The strain called Giarda lamblis (also called intestinalis or duodenalis) is the primary strain of people, companion animals. and livestock.

This parasite can be found on fecal exams of healthy pets that don’t have any symptoms. It is probably under diagnosed due to the chronic nature of the problem it presents and the difficulty of coming up with a positive diagnosis.

Giardia exists in 2 forms; trophozoites and cysts. The active and motile form, called trophozoites, are the stage which lives in the intestines of an affected mammal. These trophozoites produce non-motile cysts which are shed into the environment. The cysts remain viable in the environment for months, especially in cool and moist areas. They thrive in clear and cool water, a good reason not to drink running water in the outdoors, no matter how pristine it looks. The cysts are killed by freezing, boiling, and extended contact with disinfectants.

It is theorized that giardia make pets prone to food allergies. By interfering with the intestinal lining they let in proteins that stimulate the immune system to cause an allergic reaction.

Life cycle

The cysts in a contaminated environment are transmitted to mammals or birds upon ingestion. Gastric acid and pancreatic enzymes work on these cysts in the stomach and intestines, causing them to release 2 trophozoites. These motile trophozoites attach to the lining of the small intestine where they interfere with digestion. Within 2 weeks they encyst and are passed in the feces to contaminate the environment and await another host.


In many pets there aren’t any symptoms, while in others that do show symptoms, the problem might resolve by itself. The most susceptible pets are puppies and kittens, pets with other internal parasites, and debilitated pets. Diarrhea that occurs can be severe and can be accompanied by poor appetite and dehydration. Vomiting, weight loss and blood in the stool are occasional symptoms.


Giardia can be hard to diagnose because the parasite cysts become shriveled in the routine fecal solution that is used to bring eggs to the surface and adhere to the cover slip. Special fecal flotation solutions (zinc sulfate) are a more accurate manner to make the diagnosis. Cysts can be shed intermittently, so several samples are sometimes needed to make this diagnosis.

Fresh fecal samples that are not put in the fecal solution can sometimes show the parasite. We sometimes send fecal solutions to our outside lab for special tests when we suspect the problem yet we don’t find the parasite. Just like Coccidia, our doctors might treat for this disease even on negative fecal samples.


Flagyl is the drug routinely used to treat Giardia, although it does not cure all Giardia infections. The usual course of therapy is for 5 days, although our doctors will vary this dose depending on specific circumstances. Other medications are sometimes used if the Flagyl is not effective. There is no drug that is 100% effective against Giardia.

We recommend treating pets that are positive for Giardia even if they don’t have any symptoms. This helps eliminate environmental contamination, and helps minimize spread to people. If one pet in a household has Giardia we recommend treating all pets.


Giardia cysts in a kennel are relatively easy to destroy with routine disinfectants, and are susceptible to drying and heat. Once an environment like a lawn is contaminated though, it can be almost impossible to eliminate this parasite.

  1. Treat all in contact animals in the household.
  2. Recommend to bathe all pets every 7-14 days with mild hypoallergenic  shampoo like Hilyte or and oatmeal shampoo.  If unable to bathe then to wipe down with separate clean damp cloths/towels once a day or once every other day especially around the anal area (please save this area for last).
  3. Wipe feet and anal area  of affected pet at least once a day especially after going outside with a clean damp cloth/towel.  OK to use baby wipes around anal area.
  4. Prevent licking on surfaces outside, prevent from eating grass, and prevent from drinking water from communal water dishes at dog parks or from ponds or ditches as much as possible.
  5. Give bottle water or filtered water or water that has been boiled.  This filters should filter out up to Giardia and Cryptococcus organisms from tap water.  Boiling the water  will kill any organisms present in the tap water.
  6. Thoroughly clean food and water dishes daily with soap and hot water and sterilize the food and water dishes weekly.
  7. Pick up feces immediately or as soon as possible.  Recommend to thoroughly clean out litter boxes daily and to disinfect and sterilize the boxes at least once a week.
  8. Once done with medications bathe all pets or at least bathe both dogs and wipe down all feline pets in the house with separate clean damp cloths/towels. Also clean and vacuum entire house and clean all bedding.
  9. Once done with course of medications please bring a fecal sample the same day or the next day that the medications are finished.  If the fecal results are negative then do another fecal analysis in 30 days post-treatment.  If the fecal results are still  positive for Giardia then will recommend to proceed with other possible causes of this persistently high infestation with Giardia i.e. immune system problems that are preventing her from getting rid of this protozoal parasite.

Good nutrition, avoiding overcrowding, general parasite control, and proper sanitation procedures are all critical in prevention. Cleaning up feces on a daily basis goes a long way to preventing contamination.

A vaccine available for dogs is very helpful in persistent infections

Public Health Significance

According to the Centers for Disease Control and Prevention, Giardia is one of the most common causes of waterborne diseases in humans in the United States. Many people get Giardia from other people and and contaminated water. Symptoms in people include diarrhea, abdominal cramps and nausea. They appear within 2 weeks of exposure to the parasite.

Exposure comes from many sources. They include swallowing water from swimming pools, lakes, rivers or streams that have been contaminated with animal or human feces. Fruits and vegetables that have not been washed (with Giardia free water!), along with accidental ingestion from hands contaminated by using toys, bathrooms, changing tables, etc., are also sources of infection. This emphasizes the importance of routine washing of hands. Boiling drinking water for one minute will kill this parasite.

We routinely treat pets with Giardia in their feces, even if they are not showing any symptoms, because of the potential for people to pick up this disease. Washing your hands frequently after touching your pet and bathing your pet frequently will help minimize exposure. We have a vaccine for dogs that do not respond to routine treatment. This will help prevent human exposure.

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