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Thread: Molly, 13 yr, shih tzu - lhasa aspo - Molly has passed

  1. #11
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    Hi Sharlene,

    Welcome to you and Molly!

    My Squirt is another one who currently has very high ALP, but her vets aren't worried about it. However, she is actively cushionoid and Molly isn't so that may be why your vet is concerned. It takes more than just the ALP elevation to indicate a real problem - that would show as elevations just about across the board via the liver enzymes. The liver is an amazing organ that can take a whole lot of punishment before it rebels. If you are really concerned about the liver function, a bile acid test may be worth discussing with your vet.

    You are wise to wait on treatment as signs are a critical part of not only diagnosing but monitoring treatment. Without strong signs, handling this disease is much more difficult and risky. So take your time - it sounds as it you have plenty of it to learn a lot before you start treatment.

    I started to tell you about Squirt's story but since you have been reading for two years I didn't want to repeat something you may well be familiar with. If you aren't and would like to hear it, I will be happy to share! In a nutshell, she was diagnosed in '08 and is doing great today at the ripe old age of 14!

    I'm glad you found us and look forward to learning more as time passes!

    Hugs,
    Leslie and the gang

    PS. On the normal ranges you added for the LDDS...(20 - 300)...is that the range for all three values - base, 4, and 8 hour?
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  2. #12
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    Hi Sharlene.

    I’ve fallen behind in reading everybody’s threads so I apologize for just now getting around to welcoming you and your precious Molly Muffin. I’d like to make some observations and maybe ask some more questions and the easiest way tie my questions to the information you’ve provided is to type my stuff in blue text within the body of your post. Please see below.

    Quote Originally Posted by molly muffin View Post
    Her ALP's have been high consistently and we try to balance that using the SO food, that encourages her to drink more water and the crystals not to form. She only had them once, that was enough.

    If Molly has cushing’s, it is highly unlikely that prescription or nonprescription food will have any effect on ALP.

    2012 June tests
    ALP 1003 (5 - 141) (this has actually decreased a bit since March)
    ALT 152 (6 - 118) (while this has gone up a bit since March)

    In subsequent posts I noted that you are very concerned about the progressive increase in ALT. 152 would be considered a mild elevation, which is the norm for a dog with cushing’s. This doesn’t mean a dog’s liver is being damaged but rather is being overworked from the effects of high cortisol. It also should not be the primary factor in determining whether a dog should start treatment.

    Cor1 - Cortisol (base) 172 (30 - 300)
    Cor 21 - Cortisol (ACTH) - 1 hour 924
    Cor 22 - Cortisol (ACTH) - 2 hour 1014

    Lab states, that in a normal animal Cortisol will increase above 250 but not above 600.
    The results are consistent with Cushings Disease; Pituitary-Dependent Hyperadrenocorticism

    This appears to be an acth stimulation test, probably using an acthar gel, with peak concentration occurings two hours after stimulation, thus the two post blood draws. Here in the states most vets prefer to use cortrosyn as the stimulating agent, with peak concentrations occurring 1 hour after stimulation, requiring only one post blood draw. Regardless of which stimulating agent is used, an acth stimulation test does not differentiate between pituitary and adrenal based disease. Could you please recheck your paperwork to make sure you aren’t missing some text.

    okay, so now that is out of the way, my vet, who has been Molly's vet since we brought her home as a rescue baby at 11 months, feels that this has been caught at the very earliest of stages. Her recommendation is to begin treatment with Vetoryl 30 mg. In fact, it is sitting here on my desk right now. It is the monster in the closet, under the bed, or in my case, in front of this computer monitor.

    So I asked her why begin treatment now,( actually she has called me once since they told me on Wednesday, to discuss and then we spoke again today, when I went to pick up copies of lab results) and she said, that although it is not clinically necessary to start right now and we can decide when we would want to start medications for the cushings, that her experience is that when treatment is not started, the risk increases greatly for dog to develop diabetes and/or pancreatitis. That she feels and she has had good results with early treatment.

    Symptoms are a big components of a diagnosis and a cushing’s savvy vet would not confirm a diagnosis and launch into treatment in the absence of overt symptoms. The primary goal of treatment is not to cure the disease but rather to eliminate clinical signs. If there are no overt clinical signs, there is no need to jump into treatment. As a matter of fact, I would be hesitant to start treatment without validating the ACTH stimulation test and determining which form of the disease Molly has.

    I asked also about the Davis study suggesting a lower dose and she said that the Davis study is already out dated compared to more recent studies, from universities around the world.

    The UC Davis protocol was established as a result of their extensive experience with Trilostane. Based on the 100’s of threads here, I believe UC Davis protocol is much safer than the dosing recommended by Dechra, the manufacturer of Vetoryl. One of our administrators was actually told by an internal medicine specialist on staff with Dechra that they are verbally recommending to vets that they use the very lowest end of the range for dosing but they have not yet published a revision to packaging inserts.

    That she has had good luck with this dose for Molly's size. Starting the medicine she said would be followed up with tests at day 10 - 14 (she suggested day 12) after starting treatment and then based upon how molly is doing, either 4 weeks or sooner if she feels that it is needed.

    Proper protocol dictates that an acth stimulation test be done at 10 to 14 days and again at 30 days. I would recommend that if and when you start treatment, your vet should follow proper protocol, especially in the first 30 days of treatment.

    I find myself second guessing how well I thought molly was/is. She does lay around more, but has a great time playing when she wants to. She doesn't eat all at once every day, usually she eats maybe half or even less, and then later will finish off (around dinner time). She drinks, but not overly so and we in fact try to encourage her to drink since she had issues with the crystals forming. She does have some times when she doesn't want to jump up or she has to make a running leap for that window seat she loves. And yes, there is the pot belly. (we thought she just really loved those treats a tad bit too much and that is probably still true)

    With symptoms being limited to a pot belly, I absolutely would not start treatment until symptoms became apparent. I would, however, want an abdominal ultrasound done to make sure there is not some other problem going on. A very small number of dogs have cushing’s caused by tumors outside the pituitary and adrenal glands that secrete acth, so having a look at internal organs is a really good idea. In these cases the treatment of choice would be to remove the tumor. One of our moderators has a dog who had elevated cortisol but it was later discovered, via an abdominal ultrasound and subsequent surgery, that the cause for the elevated cortisol was a tumor on the spleen. Once removed, cortisol levels fell. Oddly enough, these dogs usually have higher levels of circulating cortisol, like Molly. With just an acth stimulation test and no symptoms, how does your vet know what she is truly dealing with?

    Quote Originally Posted by molly muffin View Post
    I actually had the same concerns and mentioned them today to the vet. She said that not all dogs display the same symptons but that she does feel that the cushings diagnosis is correct. I don't know if it is or not and that is why I haven't jumped on starting her on medicine. The liver is high, the cortisol is definitely there in the ACTH test.

    For what it’s worth, you’re conclusion is the same as mine so I’m glad you have not rushed into treatment. Based on the information you have provided thus far, your vet has determined that Molly has elevated cortisol via an acth stimulation test. Absent further testing to validate and differentiate, I personally wouldn’t assume the diagnosis is correct.
    Quote Originally Posted by molly muffin View Post
    John,

    The lab said Pituitary-Dependent Cushings, not adrenal based.

    As I mentioned previously, I have no idea how the lab can make this determination.
    And they think that the symptoms will start to show that literally it has been caught very early.

    That’s possible but I’m not sure what constitutes catching the disease early with no clinical signs of the disease.

    Kim, I'm in Canada. Not sure what the conversions would be, but have included the lab ranges as given.

    If the acth stimulation test is in nmol, you would convert to ug/dl by dividing the results of each draw by 27.59. Conversion of Molly’s acth stim test is

    Cor1 - Cortisol (base) 6.23
    Cor 21 - Cortisol (ACTH) - 1 hour 33.4
    Cor 22 - Cortisol (ACTH) - 2 hour 36.75
    Quote Originally Posted by molly muffin View Post
    Vet thinks Vetoryl will get the cortisol under control so that she won't end up with any major organ damage.

    Cushing’s is a very graded disease, progressing at a snail’s pace and it takes a very, very long time to do any internal organ damage. Thanks to my ignorant gp vet, my dog was overtly symptomatic for almost two years before an internal medicine specialist finally diagnosed her. If any dog with cushing’s was going to have internal organ damage from long term excess cortisol, it would have been my Lulu but she is fine. I just had a senior panel done and her kidney levels and liver enzymes are perfectly normal.

    Just to validate what I have been saying about not treating in the absence of symptoms, here are some excerpts from reference material published by renown and well published endocrine specialists as well as a much utilized veterinary text book. You should share these with your vet and ask her why she disagrees with the experts.

    Excerpt from reference paper written by Dr. Mark Peterson, entitled Cushing’s Disease in Dogs: Recommended Diagnostic Protocol and Treatment Options.

    False positive results are common in dogs suffering from non adrenal disease. Because such false-positive test results occur for all of the commonly employed screening tests (ACTH stimulation), low-dose dexamethasone suppression, urinary cortisol: creatinine ratio), the definitive diagnosis of hyperadrenocorticism should never be made purely on the basis of results of one or more of these screening tests, especially in dogs without classic signs of hyperadrenocorticism or in dogs with known non-adrenal disease. If a dog has no clinical signs of Cushing’s syndrome, we do not recommend treatment.
    Excerpt from Dr. Rhett Nichols, entitled Canine Cushing’s Syndrome: Diagnosis and Treatment (Part 1: Typical, Atypical, and Pseudo-Cushing’s Disease.

    Based on the lab tests, does the dog have Cushing’s syndrome:

    The most important criteria for making a diagnosis of Cushing’s syndrome or hyperadrenocorticism (HAC) is the patient must have signs and symptoms consistent with the disorder. The importance of signalment, history, and physical examination finding cannot be overstated.
    Excerpt from Merck Veterinary Manual:

    Diagnosis can be challenging; it should be based on clinical signs and laboratory abnormalities and confirmed via an appropriate screening test for hyperadrenocorticism. If results of screening tests are inconclusive or if laboratory abnormalities associated with hyperadrenocorticism are noted in a dog without clinical signs, the dog should be retested 3-6 mo later.
    Whew, that was a novel and I commend you if you are still with me. I've been typing this off and on since early this morning but have been interrupted a number of times. I hate it when work gets in the way. I see that others have posted since I started this epic saga so please excuse any duplication.

    Glynda

  3. #13
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    I am absolutely with you still! Thank you all so much for your very informative information and for calming my up and down panic attacks.

    Okay, to answer John, no they didn't do the LDDS after the ACTH test. That is the one with DEXA right? They did this 2 years ago in May 2010, with negative results.

    So it sounds like a high density ultrasound is the best option at the moment. It is possible that a liver supplement might help her liver values come down. I'll ask the vet about that. Also, a confirmation with a follow up Low Dose DEXA test.

    I have asked the vet about these tests since her determination that Molly had Cushings and she said that I pay her to know what tests are needed and what are not. She didn't feel a follow up is needed, that I'd be wasting money.

    Her values from this lab are in nmol/L for the ACTH test.

    Glynda I am going to type out exactly what it says within the text for results on the ACTH test. Keeping in mind that their text recommendations will be based upon the nmol/L ratios.
    (thank you for taking the time to type all that out btw! wow!)

    Cor1 - Cortisol (base) 172 (30 - 300)
    Cor 21 - Cortisol (ACTH) - 1 hour 924
    Cor 22 - Cortisol (ACTH) - 2 hour 1014

    TEXT: RESULT INTERPRETATIONS

    Normal animals: Cortisol will increase above 250nmol/L, but not above 600nmol/l.

    Primary Hypoadrenocorticism (Addisons disease; Adrenocortical insufficiency); Pre-ACTH concentration is below the reference value (often undetectable) or low normal. Post-ACTH concentration does not differ from the pre-ACTH concentration or changes very little.

    Secondary Hypoadrenocorticism: Pre-ACTH concentration of cortisol is below the reference value (sometimes undetectable) or low normal. Post-ACTH concentration is elevated 3 to 5 times above the Pre-ACTH concentration.

    Primary Hyperadrenocorticism (Adrencortical tumor); Pre-ACTH concentration of cortisol is usually above the reference value . However, because of the sporadic pattern of cortisol secretion, it's concentration may be within the reference value, even low. Post-ACTH concentration may be within the reference value, above the reference value, or unchanged from pre-ACTH conecntration. No change from pre-ACTH concentration is an excellent indication of a tumor. If the post-ACTH concentration is within or above the reference falue, additional testing (e.g., dexamethason suppression) is recommended.

    Secondary Hyperadrenocorticism (Cushings disease; Pitutary-Dependent Hyperadrenocorticism): Pre-ACTH concentration of cortisol is usually above the reference value. However, because of the sporadic pattern of cortisol secretion, its concentration may be within the reference value, even low. Post-ACTH concentration of cortisol usually is far above the reference value because of functional adrenocortical hyperplasia: serum cortisol will increase to >600 nmol/L. (This is the one I typed out earlier as it seems to be consistent with Molly's results)

    latrogenic Cushings Syndrome: Pre_ACTH concentration of cortisol is below the reference value (often undetectable) or low normal. After long-term treatement with corticosteroids, post-ACTH concentration does not differ from pre_ACTH concentration or changes very little.

    I've been watching Molly like a hawk the last couple days. (poor thing probably has a complex by now!) and to me, she seems a bit more lethargic than normal, but it is hot out, although not inside. She isn't panting at all (unless out in the heat, then we both pant together). She is drinking her normal amount of water, not exceslys (even with the heat) and eating the same, (when she wants but not all at once). I think she is above the same as Hannah. I know the vet goes on about the pot belly, but Molly has had that belly since she was about 5 maybe. I'm telling you she gets Good treats! So I'm not convinced about that either.

    I do adore out little molly. Before her I had a golden retreiver that I'd had since a baby. She was on prednisone from the time she was 2 for severe allergies. I am convinced that she died due to not being diagnosed with lastogenic Cushings. She had the severe hair loss, horrible skin condition, went to the bathroom in the house, drank as much as she could, weakness in her hind legs especially and yet, I never heard a word about cushings or that she could be treated for what she did have. That just makes me ticked off big time.

    Molly was the rescue baby I got a year after Tasha (my golden) when I could no longer stand the silence in the house. We lost one of our cats that had been Tashas constant companion since babyhood 3 months before we lost Tasha. The silence was unbearable. Molly was meant to be in our home and I want to shake my fist at fate and say, how dare you give Molly a disease of any kind.

    Okay I too cannot keep things short it seems. Sorry.

    No I haven't been on here for 2 years, that was one of the other newbies. I have however, been reading through everyone's threads, at least some of them, there are a lot more to still get through. I found this actually as a link under VeterinaryPartner.com as a recommended link. That link I got from a friend who is a vet in Maine.

    Hugs to everyone. Some moments I feel fine, and others I feel like crying and panicing a the mere thought of anything happening to molly.

    HUGS and Belly rubs to all those faithful companions of ours.
    Sharlene and the late great diva - Molly muffin (always missed and never forgotten)

  4. #14
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    I'm going to throw this out there because it really is upsetting me and I feel totally disloyal for these thoughts. I admit that I thought them as soon as my vet said she wanted to test for Cushings bakc in March when we got the first high ALT results.

    Why the heck does she keep pushing cushings disease, when all molly had was a pot belly 2 years ago, she pushed this and the results were negative. This time it was because of the liver and I feel like, gee she finally got the results she's been looking for. It kind of pissed me off at the time. Now I feel the same about pushing meds that I don't want to have her on yet if not needed.

    It makes me wonder how many dogs she has put on these meds and do they really need them, what are their life expectancies with the meds. Would I be in fact hurting molly to put her on them now or would I be hurting her more if I don't put her on them and the vet is right and she wouldn't develop diabetes or some other disease.

    The vet even told me I shouldn't be reading so much stuff on the internet, it would just confuse me. (again, way to piss me off)

    I do try to remember that she is the only vet that has ever treated molly in her life and that I know she loves her too. (molly boards with the vet and often hangs out in the vets office with her instead of in the "cage" area) So I don't doubt that she cares for her, but it still is bothering me. I just want to scream sometimes in frustration.

    Okay so got that out of my system. Thanks for letting me rant. I guess I'm like the angry mom whose kid had been diagnosed with some horrible, non-curable disease and want to blame someone for it.
    Sharlene and the late great diva - Molly muffin (always missed and never forgotten)

  5. #15
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    Hi there,

    I would be upset if that was the response I got from my vet as well. I understand that they are the experts, yes, but they don't know everything and they certainly aren't experts in everything. My vet thought it was good that I was reading about Cushing's and also felt good about me wanting to take her to an IM specialist; he gave me a recommendation for who to see.

    Also, reading and researching is what a GOOD owner WOULD and SHOULD do, so that would tick me off too! You should be sure you know what you are dealing with before you give your dog any medication, and many, many, many vets would recommend against treating when you aren't seeing symptoms. How does she expect you to know how Molly is doing if the main thing you are supposed to watch for is a decrease in drinking and ravenous eating?! That is the main reason I will not treat Hannah yet. It would be too hard to watch for.

    I am glad you are not giving meds yet. If I were you, I would push for the LDDS test and the ultrasound, if you can afford it. I would also see if there is an internal medicine specialist vet you could see in your area for a second opinion. I think your vet needs to understand that you are a concerned and proactive pet owner, who loves her pet deeply. She should not be making you feel this way.

    Keep us updated on what you decide!

    Julie & Hannah

  6. #16
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    Hi Sharlene,

    My HUGE mistake....

    I'm glad you are considering an ultrasound, tho. I am also very glad that you are not letting your vet push anything on you or Molly until you are ready. That pressure can make us feel like CRAP! I know....I refused to be pushed and was told point blank I was killing my dog because I didn't start treatment immediately (not here, on another cushing's forum)...and that was the mildest thing they said.

    When Squirt was first diagnosed, we had a great vet who took a very conservative and thorough approach to testing. Squirt had the LDDS, HDDS, ACTH, UTK panel and two ultrasounds - all positive for PDH. After the second U/S, they told me about a tumor on her spleen. In Sept of '08 that tumor and half her spleen were removed. Her cortisol returned to normal as a result. That tumor was causing her internal stress and her body responded just as it was supposed to - by releasing excess hormones including cortisol which caused all those test to be positive when they really weren't. They were all false-positive because of that tumor.

    This sort of experience like Squirt had is only one of the reasons Cushing's is so very hard to diagnose. Cortisol is one of the bodies natural responses to stress of any kind - internal or external. So just because one or even two of the cush test come back positive, that does not mean you have a confirmed diagnosis in every case - like Squirt's. FIVE tests said she had PDH in 2008 - all five were wrong. In addition, the cush signs are shared with many other conditions like liver or kidney diseases, hypothyroidism, diabetes to name a few. Diagnosing Cushing's is as much a process of ruling out all other possibilities as it is getting positives on the testing.

    So if your vet isn't willing to listen to you, to work with you as a team, then it may be worth looking into a different vet to handle the Cushing's - an IMS is a good idea. For one thing, they have more education and experience in things like Cushing's and for another, you vet might not feel as slighted if you see someone who specializes VS another GP vet. They may even be willing to work with an IMS.

    Hugs,
    Leslie and the gang
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  7. #17
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    Just a quick note. I emailed using the "contact us" Dechra site, to try to get something in writing about going with a lower dose in dogs vs the higher one in their insert and got the response that they cannot give advice to pet owners, but if you send them your vets info, they will contact That vet.

    Well, I already gave my Vet a speech about drug representatives vs other clinical studies, so I know she is in contact with the drug rep already. She told me she was. Anyway, this is just to let you know, emailing them using the form doesn't appear to do any good.

    grrrrrrr
    Sharlene and the late great diva - Molly muffin (always missed and never forgotten)

  8. #18
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    Just like in human medicine, a doctor should NEVER bully a client. You have a right and responsibility to be an informed client. I am currently in the process of trying to get my fur baby into a specialist at Cornell for a second opinion because I think my vet is rushing into Cushings and ignoring the fact that the testing is negative and he is asymptomatic.

    You should not feel bad for questioning your doctor's opinion. You are protecting your loved one and seeking the best possible treatment. I say a good doctor empowers you to have confidence in a diagnosis by supporting thier hypothesis with clinical symptoms and solid conclusive diagnostic testing. Good for you for loving Molly so much and wanting the best for her! Are there other vets near you that you could take her to for a second opinion?

  9. #19
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    what are some good omega 3 supplements or treats/food to give molly? I read that omega 3 is good for helping to naturally lower cortisol levels? Not sure if that is true or what, but figured this is the group to ask.

    I think my next course of action will be getting the ultrasound done. After that, we'll see, but I'm think about the 1st part of August to ask for an LDDS test too.

    Thoughts? I did have a couple things I thought of over the last couple days. On the morning of her test I actually gave her the revolution skin treatment. I didn't get the phone message that she should be fasting either, so she did have breakfast that morning. She does exhibit stress when going anywhere, but especially vet. She was being boarded and I asked them to do the test that day and they said they did.
    I don't know if any of this would actually affect the ACTH test or not of course. Probably and most likely, not, but still...
    So for the moment, my thought is what about the supplement idea. I spoke with a friend who is involved in pet rescue, and she suggested 2 other vets in the area, if I want a second opinion. My main thing right now, is that I want any other possibilities ruled out. It may turn out that my vet is correct and she does have Cushings, but I want to eliminate liver disease, thyroid, etc. Diabetes has already been ruled out. Anything else that would cause her cortisols to rise, other than cushings?

    Thanks Sharlene and Molly
    Sharlene and the late great diva - Molly muffin (always missed and never forgotten)

  10. #20
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    Default Re: Molly, 9 yr, shih tzu - lhasa aspo, cushing diagnosis

    Hi Sharlene,

    Yes, stress will affect the cush tests. Cortisol will naturally rise in the body, human and canine, when it is under any sort of stress, whether that stress comes from the outside - as a vet visit or change in their environment, or from the inside - as in as illness. So there are literally millions of things that can cause the cortisol to rise that have absolutely nothing to do with Cushing's. Elevated cortisol in an of itself is not a problem nor considered an illness/disease/condition. It is when the body is not able to stop releasing the cortisol even when there are no stressors in play that Cushing's becomes a possiblity.

    Hope this helps you understand a bit better. We have members who will take their babies in for the testing but not leave them between blood draws. They will take them home if they live close enough, out to a park, or just sit in the car with them to try to lower the natural stress of being at the vets. Not all pups have a problem going to the vet and do just fine being left for the duration of the test. We each have to decide what is best for our baby and what will provide the most accurate results on the tests.

    Hugs,
    Leslie and the gang
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

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