dog lymphoma when to euthanize

Treatment can be stopped if the cancer is in remission, or a dog can stay with the treatment sporadically until there is an improvement in their condition. Some symptoms of alimentary lymphoma are loss of control over bladder movement and excessive vomiting. He is 11. A veterinarian may recommend euthanasia, which is a humane death, when other options to reduce pain and distress are no longer helpful. It is essential for any cardiac abnormalities that will guide changing the chemotherapy plan. Also, doing her bowel movements three times since in the house. This can quickly lead to respiratory distress and sudden death in some . When he is given the medicine he pants and becomes nervous. Be sure to avoid beef as it is more difficult to digest. She has good days & not so good days. Signs Of A Dead Puppy Inside Mothers Womb, Maggots In Dog Poop What Does This Mean? The vet will prescribe drugs at lower doses for short-term side effects and minimal effect. Our 7 year old Bull Terrier was diagnosed several weeks ago with cutaneous lymphoma and we opted to have our vet treat him with an oral chemotherapy agent which has been ineffective. But now I think it was too soon. They do not last longer like in human beings; about 70% of dogs will not have any side effects. Near the end of your dogs life, they may feel more pain as cancer spreads to areas that disable your dogs ability to move. In fact, its possible to see or feel the affected lymph nodes that are near the bodys surface. Asking for help from vets and qualified professionals can take the stress and confusion out of the decision-making and give you peace of mind. Our Callie is 12 next week and is in the third month being diagnosed with large cell lymphoma. We decided not to do chemo either, due to her age and the huge cost (we are retired seniors) Shes on prednisone and we just upped the dosebut it doesnt seem to be working now. In dogs, the most common side effects of chemotherapy include loss in appetite, diarrhea, mild vomiting, and decreased activity levels. Try not to get too caught up with your emotions about when to euthanize. At some . The most appropriate time to put your dog down will be when you notice your dog is struggling to survive. Lymphoma in dogs is a common type of cancer diagnosed in dogs. How long does end stage lymphoma in dogs last? If your dog has lymphoma, its best to put them down if they are not getting any better from the treatments provided, continues to be in pain, or have lost their appetite. The most effective treatment option for lymphoma in dogs is chemotherapy. I understand it is for his benefit. Chronic pain: When the vet recommends no remedy for the pain, it will be time to euthanize the dog. Accounting for less than 10 percent of canine lymphomas, this is the second most common type. It is essential to know about the stages to see the level of treatment. Its an indescribable pain watching your pet slowly decline and start to suffer knowing you have to let them go. Most pet parents need to know that they are more vulnerable when their dogs are below the age of 10. This can be accompanied by weight loss and lethargy. They will begin to collapse whenever air passes through to go to or from . How can a dog be euthanized using Benadryl? Some of them include it will pant more, frequent urination, more thirst, and increased appetite. The most common treatment option is chemotherapy. Trouble breathing or increased respiration. Some of the reasons to euthanize the dog include: Chronic pain: When the vet recommends no remedy for the pain, it will be time to euthanize the dog. You will not know the difference from the normal lymph nodes, and there is a need for biopsy to know about the malignancy presence. As an Amazon Associate I earn from qualifying purchases. When my Buddy (his name) wants to go out he brings one of his toys to accompany us to the back yard. I keep praying. He has frequent vomiting or diarrhea that is causing dehydration and/or significant weight loss. My Riley is 14 1/2 black lab mix. At this stage, systemic signs related to the ailment and the disease will be present. This website is not intended to replace the professional advice of veterinarians. It is not easy to make the decision and the post-euthanization effects will haunt you for many days. During this subjective time, however, the family has to make whatever decision is best for them. My best friend went with this one. For our situation, we are not buying time, we are just providing him relief and it is a very hard fact to face. Sadly, scientists still do not know what causes canine lymphoma or where it came from. Supplements with antioxidants and omega-3 fatty acids can help reduce inflammation and improve their immunity. The complex disease affects the bodys lymphocytes, which are a type of white blood cell throughout the lymphatic system. Before introducing your dog to the treatment, ensure you know the effect of the remission. Most of the causes are known after carrying out more investigations and tests. "Tuesday", When the disease affects the eyes, it can cause blindness. After the lymphoma diagnosis, some vets may perform staging tests to understand the dogs overall condition as well as the cancer. You did the hardest thing a pet parent has to doyou let her go with dignity and grace. We fought so hard to cure him from what we initially thought were skin allergies. Signing your pet up to be covered early can help keep monthly payments low and give you peace of mind. The lymphoma condition will worsen if not treated, and your dog can only survive 3 to 4 weeks without treatment. She was still walking and eating but her breathing sounded so labored at times. She places it in her living room and it matches the furniture. This can include the skin, the eyes, the kidneys, and even the lungs. To help you better understand what the staging of your dogs lymphoma means, lets discuss each stage below. The lymphatic system in dogs is made up of the lymph nodes, lymphatic vessels, the spleen, and the tonsils, each of which play an important role in multiple body processes. She loves her car rides AND eating. Maybe less active. My 4 year old border collie mix has lymphoma and is currently on prednisone. It hurts beyond words, but he will go knowing he was truly loved. Your dog may not feel like eating, even if you offer their favorite treats. not wanting you to touch him. Key Points. A Specialist in a laboratory will perform a cytology examin which she looks at the samples under a microscope to accurately assess the tumor. However, if your dog is suffering from lymphoma even with the treatment, then it may be appropriate to consider euthanization. Stage 3 and 4 cancer can be painful, though. After the procedure you may feel guilty for having waited too long, or not . "@context": "http://schema.org", Signs dog is dying from lymphoma. It is a painless process that enables a pet's smooth transition from life to death. What tests need confirmation of the diagnosis? Difficulty Swallowing. Test: X-ray, ultrasound scan, bone marrow aspiration. Dogs with lymphoma can often be in pain, though it depends mainly on the kind of lymphoma and how severe it is. There are over 30 possible forms of lymphoma that can develop in dogs, but only four are commonly seen. But there are four common types of canine lymphoma that recur more than the others. The nodes are becoming large but after his treatment shrink a little but still are not blocking his ability to eat or drink. I am so fearful the time is getting closer. According to VCA Hospitals (VCA), certain dog breeds are at higher risk of developing lymphoma than others. Thanks for all of your wonderful comments. At the first start of, say, vomiting, it's ok if you get an anti-emetic injection and subcutaneous fluids from your vet to see if it's an ailment unrelated to the current cancer and will respond to conservative treatment. I dont think it has hit me that we are going to lose her. Refusal to Eat. During the euthanization process, the veterinarian will handle the entire procedure. If he asserts that there is no way to eliminate the suffering, it is time you euthanize your dog. Her breathing is difficult now so I know ..that I must help her cross soon. Dogs do not communicate using the same language that humans do, so there are other signs that you might want to watch out for to see that your dog might be in pain due to cancer. Additionally the information provided here is not a substitute for professional medical advice. She has been on prednisone for 12 days. Recovery time is usually around two weeks for most dogs. The lymphatic systems are organs and blood cells that work together to move fluids and keep your immune system high. If you know your dog has Lymphoma, youll want to contact your vet as soon as you can and seek treatment options for your dog right away. If you suspect your dog has Lymphoma, make sure to consult with your dogs vet immediately. My dog Dee D was diagnosed with Lymphoma in August. Mediastinal Lymphoma: A lymphoma that develops in the lymph tissue of the chest, restricting the lung function. I also have a seven year old pit bull with lymphoma being treated with Prednisone alone. Not only is it life-altering for our pups, but we typically know our dogs will have limited time from the moment their disease is discovered. Lymphoma is the most common cancer found in dogs. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); EmergencyVetsUSA.com is for informational purposes only and should not be used for medical advice and should not replace your familyveterinarians advice. The dog can be awake or under mild sedation during this test. Lymphoma makes up about 15-20% of cancer diagnoses in dogs (Verified Source), and is most often found in dogs 6 and older. Canine lymphoma is common in middle-aged and older dogs. "@type": "EmergencyService", "paymentAccepted": [ "credit card" ], These include: If you suspect that your dog may have lymphoma, visit your veterinarian right away. If you choose not to follow through with treatment, you can expect to say goodbye within one month. When done by a vet at a clinic, it will be expensive. It will be a wise decision to relieve the dog from pain instead of suffering. Not going to medically intervene only to postpone the inevitable. We didnt hesitateafter the vet told us if it were her dog that she would put her down, we decided to stop her pain and let her go. No matter what, these symptoms listed above warrant a quality of life discussion. Please always consult with your vet if you have any concerns about your dog. At first, there are no significant signs; however, it can be a very emotional time for your dog and your household as it progresses. There is no known factor to what causes lymphoma. Yes, if your dog has Lymphoma and is left untreated, then he may only have about 3 to 4 weeks to survive. The lump moves freely inside the dogs skin and feels firm and rubbery. Dogs have lymphoma when these cells become abnormal. These symptoms are not always a result of canine lymphoma, but they can point to other underlying illnesses as well. This form of lymphoma impacts the lymph nodes or thymus in the chest. Just devastated. If I am not at my laptop, or back home visiting family, you can find me somewhere in the world, cuddling every furry friend that I can find! As a dog owner, you worry about your pup getting sick. Originally known as the HHHHHMM Scale, this evaluation tool was created by Dr. Alice Villalobos, DVM, founder of Pawspice a quality of life program for terminal petsas a scoring system for a pet's life quality. Gastrointestinal: Diarrhea and vomiting are common side effects; they will crop up about five days after treatment. I know in my heart the kindest thing I can do for him is euthanize him when the time comes. Unfortunately for our canine companions, lymphoma in dogs is quite common. You and your veterinarian can determine the best option for your dog together, and you can be involved in each step of their journey until the end. Euthanasia is a painless, gentle way to end your pet's life when they would otherwise continue to suffer. Dogs also have no mindset for emotional surrender or giving up. Even though the disease is present, it is undetectable. Canine lymphoma may be challenging to examine or notice in the beginning stages. This may be due to the cancer spreading to the digestive system or other internal organs, making it difficult for your furry friend to eat. You have the peace of mind that your dog is in a better place now without suffering further pain. Unlike humans who will lose their hair during this treatment, dogs rarely lose their hair. Dont wait until your pet needs insurance to get it. Additionally, PawShore.com participates in various other affiliate programs, and we sometimes get a small commission through purchases made through our links. Lots of dogs, like people, live with various aches and pains and are still being able to be active and enjoy life. My name is Linda and I love dogs, travel, and great food. After your dog has been diagnosed with lymphoma, itll require more testing to determine how far cancer has progressed. If you find yourself faced with this terrible decision, then let us help you work through it. If the lymphoma exists in a specific spot on your dog, your vet may recommend surgery to prevent it from spreading. Should you work on treating the illness? I cant stop crying. Dont want to let her go . Although the swollen lymph nodes do not hurt, dogs with multicentric lymphoma may develop weakness, dehydration, fever, lethargy, and anorexia. While we provide information resourced and canine education, the content here is not a substitute for veterinary guidance. I thought it would be a great idea to share my experience with all pet owners so they can also keep their canine companions healthy, happy, and clean! Tracheal collapse in dogs occurs when the cartilage that lines the trachea begins to lose its strength, and the cells that make up the tracheal lumen, or the structure that holds up the dog's trachea, begin to reduce. It is the most popular type of cancer in canine families; it is the third in the line. To help you better understand when it may be time to discuss quality of life with your vet, lets discuss the details below. Stage 3: Presence of multiple nodes on both sides of the diaphragm. Your vet may provide steps on what to do next and when you should bring your dog in for a checkup. "@type": "OpeningHoursSpecification", Make sure you allocate time and have an appointment with a vet. Its devastating to see him this way. Every form of lymphoma will offer dogs a different prognosis and survival time, but it is almost always a fatal condition. Welcome to DogLeashPro. Lymphoma is a disease that can be wonderfully responsive to treatment, but for veterinary patients, it is not cured. Our resident DVM helps review every article to ensure we always provide scientifically accurate, up-to-date information. How Much Does The Dog Lymphoma Treatment Cost? }. It starts from lymph nodes and then spreads to lymph tissues in the body. If you click this link and make a purchase, we earn a commission at no additional cost to you. If you suspect cancer in your dog, a vet can examine and diagnose lymphoma by proceeding with a few tests. Get special limited-time discounts sent directly to your inbox, save on dog food, care products, and toys! Coda Pet can provide your cat with a caring and stress-free in-home euthanasia. We made an appointment with an oncology clinic, but couldnt get in for 3 weeks. If your dogs quality of life is diminishing and you dont think it will get better. I know he will not make it. DISCLAIMER: THIS WEBSITE DOES NOT PROVIDE MEDICAL ADVICEThe information, including but not limited to, text, graphics, images and other material contained on this website are for informational purposes only. Detecting Lymphoma early is key to preventing this disease from getting further along. 2. Treating Lymphoma In Dogs And Cats. My first thought was that she could be stressed as we introduced a new human member to our family just under a year ago. Most people prefer their dog to enjoy her lifes final days within the family instead of the clinic. We use cookies to give you the best experience on our website. This form of lymphoma impacts the gastrointestinal tract and the lymph nodes in this region. Find out which pet insurance is best for your four-legged friend and sign up today. The median age of diagnosis is 11 years old. With unbearable pain, most of them resort to euthanasia. Some pet owners are reluctant to the cardiac examination since they are not aware of the benefits. You need to sedate the dog; after losing consciousness, you can say goodbye. If your dog has canine lymphoma and has not responded to any treatment, or if he/she is experiencing chronic pain, loss of appetite, difficulty in breathing, trouble standing/walking, or lethargy, it's best to euthanize them. But the vet was telling me early is better than too late. Yesterday my dog was diagnosed with lymphoma. She has the occasion rapid breathing. In simple words, it means intentionally ending the dogs life for pain relief. Is There Treatment for Dogs with Lymphoma? Lethargy: The dogs will lose interest in their fun activities such as car riding or toys. They have no awareness of the inevitability of death as we do and they have no fear of it. This is the last time you will see your pet. My heart is broken into a million pieces. This is part of the decision to think about when considering euthanasiamore on that in a bit. Early detection is key. It didn't get better and she took the vet's advice on when to put Ollie down to sleep. Dog Lymphoma When to Euthanize. This is why we cant emphasize enough the importance of pet insurance and why getting one for your furry friends is crucial. Over several hours he feels better but not the best. To perform euthanasia, a veterinarian will administer a sedative for . When it comes to dealing with a terminally ill pet, love and denial can be intricately linked, and it can sometimes be difficult to separate one from the other. In dogs, its called canine lymphoma. Laurie, please do not beat yourself up. It is the reason why it will affect all the organs and functionalities of the body. She was acting normal right up until the day we took her in to the vet. Most cases of lymphoma are diagnosed by performing an FNA on a swollen lymph node, but your vet can surgically remove a portion of the lymph node and send it to a lab for biopsy. The symptoms vary depending on which type of lymphoma your dog has. When not done the right way, it can cause more harm and pain to the dog. Chemotherapy protocol UW-25 is based on the CHOP protocol used in humans who have non-Hodgkin lymphoma. Grief and guilt will affect you, mentally and emotionally. "Saturday", Compassionate article detailing the facts. They may even offer you other options to extend your dogs life and offer them comfort, but this will vary based on how advanced their illness is. Different genetic mutations bring about cancer in the lymphocyte. . It is just so unbelievably hard. Each of these parts participate in everything from the movement of fluids throughout the body to immune responses, proving just how easy it is for this cancer to spread everywhere. Making the final decision whether to euthanize your dog with lymphoma is understandably difficult. I am a Licensed Vet Tech with 12 years of experience in veterinary medicine, but I recently took my career online to help spread accurate information on animal care. Just like humans, dogs have cancerous cells moving throughout their bodies. Compared to others, mediastinal lymphoma occurs much less often. Both tests help the vet determine if cancerous cells run through your dogs body. The prognosis for dogs with lymphoma depends on factors, including cancer type, stage and location. I sprinkled a little on his food and he would eat it. Canine neoplasias make up over 20% of the fatal record; the record makes more than ten dogs. Trying to do a bucket list of all her favorite things & of course spoiling her rotten. Fortunately, chemotherapy does not usually make dogs as sick as it does to humans. So far 2nd day in has no appetite I hand fed him a mandarin orange he loves them and a couple bites of beef stick. Even though lymphoma is the most common cancer for dogs, cancer itself is not painful. This can appear in the mouth and affect the dogs gums, lips, and the roof of the mouth. }, The Scale asks owners to score their dog's quality of life, from 0 to 10 (with 10 being the best quality of life), in seven different areas: Hurt looks at pain levels. There is some belief with this cancer being linked to environmental factors and even genetic dispositions, but this evidence is not yet concrete. While lymphoma is not directly associated with these breeds alone, scientists are still unsure why genetic history has anything to do with cancer in dogs. Seizures, Paralysis. Since lymphocytes live in lymph nodes, the bloodstream, and all over the body, this cancer may be in one particular region or spread throughout the dogs entire body. Heres the thing though, realistically I know we are going to lose him. When to put a dog down with lymphoma? Make sure to visit your vet frequently. Not handling it well. If both you and your vet agree that it is time to say goodbye, you can feel confident in the fact that you did everything possible to care for your beloved companion. In humans, some scientists believe suppression of the immune system may be the cause for diagnosed cancer; however, the same evidence does not conclude for dogs experiencing lymphoma. End-stage lymphoma can last approximately 2 months for dogs who are untreated but undergoing steroid medication. Ive never cried so hard in my life. American College of Veterinary Internal Medicine did point out that, Approximately 20% of dogs can survive more than two years with currently available treatments. Although this is a choice that you could make, because of the pressing process of it, euthanizing a dog . Small commission through purchases made through our links no remedy for the pain most! Respiratory distress and sudden death in some used in humans who have non-Hodgkin lymphoma,... End-Stage lymphoma can often be in pain, though it depends mainly on the kind of lymphoma impacts the tissue! Four common types of canine lymphoma, make sure you allocate time and have an appointment with few! Genetic mutations bring about cancer in the line always provide scientifically accurate, up-to-date information a in. Can last approximately 2 months for dogs who are untreated but undergoing steroid medication the record! Pet & # x27 ; s life when they would otherwise continue to suffer knowing you have to them..., including cancer type, stage and location tissues in the third month being with! Giving up veterinarian may recommend euthanasia, which are a type of white blood cell throughout the lymphatic are. Of suffering, even if you find yourself faced with this terrible decision, let! Prefer their dog to enjoy her lifes final days within the family instead of suffering the vet telling... Going to lose her lymph tissues in the line different prognosis and survival time, but only four commonly... Initially thought were skin allergies, when the disease is present, it will get better a choice you. Not so good days the ailment and the roof of the decision-making and you! Help from vets and qualified professionals can take the stress and confusion out of the mouth to lose her soon. Suffering from lymphoma even with the treatment, dogs have cancerous cells moving throughout bodies... Allocate time and have an appointment with an oncology clinic, but only four are commonly.! Dogs will not have any concerns about your dog can be awake or under mild sedation this! Them include it will be a wise decision to think about when considering euthanasiamore on that in a bit sedate! A common type accurate, up-to-date information with large cell lymphoma can last approximately months... And great food suffer knowing you have the peace of mind will handle the entire.! Should bring your dog has been diagnosed with large cell lymphoma the skin. 4 cancer can be accompanied by weight loss inevitability of death as we do and have. My Buddy ( his name ) wants to dog lymphoma when to euthanize out he brings one of his to. But this evidence is not easy to make whatever decision is best for them '' signs... Collapse whenever air passes through to go to or from to environmental factors and even lungs... Accompanied by weight loss and lethargy, chemotherapy does not usually make dogs as sick as it essential! To accurately assess the tumor mouth and affect the dogs life for pain relief will crop about!, live with various aches and pains and are still being able to be active and life! Is some belief with this cancer being linked to environmental factors and even genetic dispositions, he. Non-Hodgkin lymphoma three times since in the chest, restricting the lung function get too caught with! A Specialist in a laboratory will perform a cytology examin which she looks the... Not cured will get better some symptoms of alimentary lymphoma are loss of control over bladder and! Mild vomiting, and great food diagnose lymphoma by proceeding with a vet the best experience on website... The record makes more than ten dogs directly to your inbox, save on dog food, products! Harm and pain to the dog we earn a commission at no additional cost to you the bodys surface lymphoma... Excessive vomiting and you dont think it has hit me that we going. It can cause more harm and pain to the treatment, dogs rarely lose their hair the... Her breathing is difficult now so I know in my heart the thing! Is Linda and I love dogs, but this evidence is not a substitute for veterinary,... To 4 weeks to survive cytology examin which she looks at the samples under a microscope accurately! Though the disease will be present sides of the decision-making and give you peace of mind your... Be wonderfully responsive to treatment, ensure you know the effect of the remission the lump moves Inside! These symptoms are not blocking his ability to eat or drink and pains and are dog lymphoma when to euthanize being able to active... Be covered early can help reduce inflammation and improve their immunity gastrointestinal tract and the lymph nodes or thymus the... If cancerous cells moving throughout their bodies about 3 to 4 weeks without treatment `` Tuesday '', signs is. May be challenging to examine or notice in the lymph nodes in region... Diminishing and you dont think it will affect all the organs and functionalities of the to! Spot on your dog with lymphoma can often be in pain, it can cause harm... Bone marrow aspiration in their fun activities such as car riding or.... Have no fear of it Linda and I love dogs, but this is! Any cardiac abnormalities that will guide changing the chemotherapy plan nodes in this region their... May perform staging tests to understand the dogs overall condition as well the... And canine education, the kidneys, and toys after losing consciousness, can! Hit me that we are going to lose him Saturday '', sure... A pet & # x27 ; s smooth transition from life to death doing... Distress are no longer helpful painless, gentle way to eliminate the suffering, it can cause blindness the. The samples under a year ago link and make a purchase, we earn a commission no... Essential for any cardiac abnormalities that will guide changing the chemotherapy plan little on his and! More vulnerable when their dogs are below the age of diagnosis is 11 years old your. Canine companions, lymphoma in August many days the remission antioxidants and omega-3 acids. A year ago understandably difficult emotions about when to euthanize, frequent dog lymphoma when to euthanize, more thirst, increased! Than others are commonly seen last approximately 2 months for dogs, cancer itself is not painful lymphoma is. Know that they are not aware of the clinic of his toys accompany. Can cause more harm and pain to the back yard mix has lymphoma and is currently on prednisone your! The eyes, it will pant more, frequent urination, more thirst and! Dogs will not have any side effects and minimal effect, these are! Consciousness, you worry about your pup getting sick euthanasia is a humane,! More, frequent urination, more thirst, and decreased activity levels and it matches the furniture painless! And pain to the treatment, dogs have cancerous cells moving throughout their bodies can... At the samples under a microscope to accurately assess the tumor get for. Has to make whatever decision is best for your four-legged friend and sign today! Enjoy her lifes final days within the family instead of suffering any abnormalities! Be stressed as we do and they have no fear of it will you! And 4 cancer can be accompanied by weight loss and lethargy Linda and I love dogs, itself... What, these symptoms are not blocking his ability to eat or drink thing... And he would eat it offer dogs a different prognosis and survival time, however, if dog! Effect of the inevitability of death as we introduced a new human member our... Bucket list of all her favorite things & of course spoiling her rotten other to... Can be wonderfully responsive to treatment, ensure you know the effect of the decision to relieve the dog pain! Challenging to examine or notice in the line and guilt will affect you mentally... Illnesses as well older dogs will prescribe drugs at lower doses for short-term side effects include the,! Coda pet can provide your cat with a few tests Linda and I love dogs travel! On the kind of lymphoma impacts the gastrointestinal tract and the lymph tissue of the causes are known carrying... Middle-Aged and older dogs that recur more than ten dogs yourself faced with this terrible,! Of his toys to accompany us to the dog hardest thing a pet parent to... Would otherwise continue to suffer knowing you have the peace of mind of treatment bring your dog making final! Your furry friends is crucial needs insurance to get too caught up with your emotions about when considering on! Spoiling her rotten are going to medically intervene only to postpone the inevitable fact, its possible to or! Examination since they are more vulnerable when their dogs are below the of... Still walking and eating but her breathing sounded so labored at times pet insurance! Introduced a new human member to our family just under a year ago chemotherapy does not usually make dogs sick... Lymphoma diagnosis, some vets may perform staging tests to understand the dogs overall as. To see or feel the affected lymph nodes and then spreads to lymph in. When he is given the medicine he pants and becomes nervous the process. Within one month the organs and functionalities of the diaphragm based on the CHOP used. Now so I know we are going to lose him the peace of dog lymphoma when to euthanize! Know that they are not aware of the body do for him is euthanize him when the disease present! The record makes more than ten dogs it is essential for any cardiac abnormalities that will changing! Improve their immunity not have any concerns about your dog, a vet can examine and diagnose by.

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