NOW OFFERING: Laparoscopic-Assisted Ovariohysterectomy (Spay) by Dr. Nadia Rifat

We’re so excited to offer a less invasive, less painful, way to spay your dog! Keep reading for more information and give us a call at 925 937 5000 to schedule an appointment with Dr. Nadia Rifat

Why does a dog need to be spayed?
Spaying a dog consists of performing an ovariohysterectomy (OHE). The reasons we spay dogs is to reduce pet overpopulation, reduce the chance of mammary cancer development (must be done at a very young age to gain this benefit), and to prevent a life threatening uterine infection (pyometra). Approximately 25% of intact female dogs by 10 years of age will develop a pyometra.

What are the surgical options for spaying my dog?
The traditional open ovariohysterectomy, or a laparoscopic-assisted ovariohysterectomy. The traditional open ovariohysterectomy has been performed for many decades, and when performed by an experienced veterinarian there are rarely any complications and the recovery is typically quick. More recently, laparoscopic-assisted ovariohysterectomy surgeries have become another surgical option for medium to large breed dogs. The difference is that the laparoscopic-assisted ovariohysterectomy incision is smaller than the open approach because visualization of the organs and surgery is performed through the laparoscope.

What is the benefit of having my dog undergo a laparoscopic-assisted ovariohysterctomy vs an open ovariohysterectomy?
Although there are few pain studies to compare laparoscopic procedures to an open traditional surgical approach, the opinion of veterinarians performing laparoscopic-assisted ovariohysterectomy procedures is that this approach is less invasive and less painful than the open approach. Dr. Chad Devitt evaluated the laparoscopic-assisted ovariohysterectomy versus an open traditional ovariohysterectomy (Duration, complications, stress, and pain of open ovariohysterectomy versus a simple method of laparoscopic-assisted ovariohysterectomy in dogs. J Am Vet Med Assoc. 2005;227:921–927). His conclusion was the laparoscopic-assisted ovariohysterectomy procedures caused less surgical pain than the traditional open ovariohysterectomy procedures and may be more appropriate for an outpatient setting.

What are the potential complications of a laparoscopic-assisted ovariohysterctomy?
Complications from laparoscopic ovariohysterectomy are rare but can include: hemorrhage, subcutaneous emphysema, iatrogenic perforation of the splenic capsule during trocar placement, inability to complete the procedure requiring conversion to laparotomy, pain, seroma formation, and rarely infection.

How do I schedule my dog for a laparoscopic-assisted ovariohysterectomy?
Make a pre-surgical appointment with Dr. Nadia Rifat, who is the surgeon that performs the laparoscopic-assisted ovariohysterectomy procedures at Encina Veterinary Hospital. She will perform an examination on your dog and talk to you about the procedure. We will schedule your dog for surgery and submit pre-anesthetic bloodwork to make sure your dog is in good health. If your dog is at risk for a GDV (see information about laparoscopic-assisted gastropexy) that surgery can be scheduled concurrently.

NOW OFFERING: Laparoscopic-Assisted Gastropexy by Dr. Nadia Rifat

Laparoscopic-assisted gastropexy

What is a GDV?
Gastric dilatation volvulus (GDV) is an acute emergency medical condition characterized by gastric distension and abnormal twisting of the stomach. This causes the stomach to become over distended. have a decreased blood flow, and eventually lead to circulatory shock and death. The lifetime risk for a large or giant breed dog developing GDV is 24% and 21% respectively and their risk of dying of GDV is 7%. Even with appropriate medical and surgical intervention, case fatality rates between 10% and 33% have been reported.

Why do dogs develop a GDV?
No single cause of GDV exists. Reported risk factors for GDV include a familial history of GDV, lean deep chested breeds, older dogs, dogs that eat quickly, dogs that eat from a raised bowl, and dogs that only eat dry food and/or a single large meal, and dogs that have a fearful temperament. Dogs that have had a splenectomy also might be at greater risk for development of a GDV.

Does my dog need a gastropexy?
There are many breeds that are at risk for developing GDV. The most at-risk breed is the Great Dane (40% will develop a GDV). Other breeds that are at risk include Irish Setters, Weimaraners, Standard Poodles, and Rottweilers. In general, this condition can occur in any deep chested large breed dog. Most surgeons agree that a prophylactic gastropexy in patients considered “at risk” for GDV (gastric dilatation and volvulus) is a worthwhile procedure.

What is a laparoscopic-assisted gastropexy?
Laparoscopic-assisted gastropexy is a minimally invasive surgery that allows the surgeon to perform the surgery through a smaller incision than the typical surgical approach used to perform a gastropexy. During the laparoscopic-assisted gastropexy, one small incision is made just behind the ribs on the right side of the abdomen. It is through this incision that the laparoscope is introduced into the abdomen and the gastropexy procedure performed. With this surgical technique, there is less pain and the recovery much quicker compared to the typical gastropexy approach with a large incision.

Can there be complications from the gastropexy?
Multiple studies about laparoscopic-assisted gastropexies showed only the following minor complications: temporary skin fold at the side of the of the gastropexy immediately after the surgery (47%), seroma formation at the site of the gastropexy (6%), and iatrogenic perforation of the splenic capsule during trocar placement (12%).

When should I schedule my dog for a laparoscopic-assisted gastropexy?
The timing of the gastropexy does not seem to be critical. The stomach can be successfully attached to the abdominal wall in puppies, without compromising gastrointestinal function, which means the gastropexy can be incorporated into the same procedure as a spay or castration, or when the abdomen is being explored or opened for another reason. Alternatively, it can be performed as an elective procedure.

How do I schedule my dog for a laparoscopic-assisted gastropexy?
Make a pre-surgical appointment with Dr. Nadia Rifat, who is the surgeon that performs the laparoscopic-assisted gastropexies at Encina Veterinary Hospital. She will perform an examination on your dog and talk to you about the procedure. We will schedule your dog for surgery and submit pre-anesthetic bloodwork to make sure your dog is in good health.

call us today at 925 937 5000 to schedule an appointment with Dr. Nadia Rifat to see if your dog is a good candidate for laparoscopic-assisted gastropexy

Riley the Dog’s Prosthetic Orthopedic Foot

Riley is a 1 year old mixed canine who was recently adopted from Guatemala! With the help of OrthoPets: Orthotics and Prosthetics for Animals, Board Certified Veterinary Surgeon Dr. Carl Koelher will be creating a prosthetic foot for Riley the dog. Here’s a few pictures of the process:

Hemangiosarcoma in Dogs

The spleen is an oblong organ – some would say it is tongue-shaped – seated just below the stomach. While one can live perfectly well without a spleen, the spleen does provide some helpful services to the body. Some of these functions include providing stored blood in times of acute hemorrhage, filters out infected cells, and breaks down old red blood cells.

Hemangiosarcomas are a type of malignant cancer most often found in the blood vessels of the spleen in dogs. It is also found in the liver and is actually the most common tumor found in the heart of dogs. These tumors also present themselves on the skin of a dog and may look like small red moles. Hemangiosarcomas also occur in cats, though very rare. This cancer is often found in German Shepherd Dogs and Golden Retrievers. This cancer is equivalent to Angiosarcomas in humans.

Symptoms of Hemangiosarcoma:
     • Usually the patient is suddenly weak.
     • The patient may be obviously cold.
     • The gums will be pale in color.
     • If the bleed stops on its own, the patient will be dramatically better
the next day or even a few hours later.

Unfortunately, this particular cancer is very aggressive. Most commonly when the hemangiosarcoma is attached to the splee, unless the spleen is surgically removed by an experienced surgeon such as Dr. Carl Koehler (ACVS) of Encina Veterinary Hospital, the pet will eventually pass away due to significant bleeding. Along with a splenectomy (removal of the spleen), chemotherapy is also typically suggested for the best possible outcome and longest life expectancy in this situation.

Jared Jaffey, DVM

Tibial Plateau Leveling Osteotomy (TPLO)

“TPLO” stands for tibial plateau leveling osteotomy – one of several techniques available for treating injury to the cranial cruciate ligament in dogs (equivalent to the “anterior cruciate ligament” of humans) which is found in the knee. This ligament is one of 2 cruciate ligaments which lie within the ‘knee’ joint (stifle), attaching the femur (thigh bone) to the tibia (calf bone) providing stabilization. The stifle is a complex joint, relying on a variety of anatomical structures in order to function normally (and pain-free).

Dogs, especially larger breeds, often injure the cranial cruciate ligament (CCL) resulting in an unstable ‘knee’, resulting in pain. You may notice a slight limp which worsens with exercise, reluctance to exercise or jump, or sudden lameness following activity. Your pet may sit with the limb splayed out to the side. Injury to the cranial cruciate ligament can be a slow process, or occur suddenly; even partial tear of this ligament can cause pain and instability but a complete rupture often causes unwillingness to stand on that leg.

Will this happen to my dog? Conformation of canines and the angle of the joint puts excess strain on this ligament, often causing slow degradation over time. Some breeds are more susceptible than others. Although injury to the cranial cruciate ligament can occur in any breed, sex or age of dog, several factors such as obesity significantly increase the risk. There is no way to prevent this injury from occurring; however exercise helps to keep weight down and muscle strength up, possibly decreasing likelihood of injuries, illness and osteoarthritis.

How will my veterinarian diagnose this condition? Your veterinarian can make a presumptive diagnosis of a damaged CCL based on palpating (feeling) the knee as well as testing its stability. The tibia and femur which form the “stifle”, or knee, are normally stable, allowing flexion and extension; however when the CCL is damaged, the femur is free to move forward in relationship to the tibia, demonstrating “cranial drawer” motion, a strong indicator of a damaged CCL.

Radiographs (x-rays) are also a valuable diagnostic tool to confirm that there aren’t additional problems present causing your pet’s clinical signs. Although soft tissues such as ligaments are not visible on x-rays, other changes to the joint may be seen following injury to the stifle such as joint effusion, fracture or arthritis.

Does the surgery cure my dog of a ruptured CCL? There is no cure for injury or rupture of the CCL. The goal in treatment of TPLO surgery is stabilization of the stifle and pain control to keep your pet comfortable. There are many surgical options which attempt to stabilize this joint, including the TPLO, TTA (tibial tuberosity advancement), extracapsular and intracapsular techniques – some of which attempt to mimic the action of the no longer functioning CCL. Which technique will work best for you and your pet is determined by your veterinarian based on body weight, breed, activity, and other factors.

Medical treatment involves controlling the pain with anti-inflammatories such as non-steroidal anti-inflammatories (NSAID’s) and opioid-like medications such as tramadol.

What will happen to my dog’s condition should I decide no to surgery? Although the canine stifle is difficult to stabilize by using a cast, splint or bandage, over time the body will attempt to stabilize the injured knee by production of scar tissue in and around the joint. Arthritis will also develop over time. To delay these changes such as degenerative joint disease, the joint should be treated as soon as possible after the injury if determined to be the best course of action by you and your veterinarian.

What happens after surgery? The recovery process following the TPLO is crucial, involving 2-3 months of restricted activity. Physical therapy can be of benefit to maintain strength and expedite recovery during this time. X-rays are taken at the end of the recovery period to ensure adequate bone healing before removing those exercise restrictions. Most dogs return to the same or similar level of activity prior to the injury; however, as with any surgery, there are risks, including infection, implant rejection/failure, bone fracture, etc.

If you think your pet may have an injury or possibly a CCL injury, please give us a call as soon as possible to discuss your and your pet’s options for care at Encina Veterinary Hospital with Board Certified Veterinary Surgeon, Dr. Carl Koehler: (925) 937-5000

Cindi Hillemeyer, DVM

A Thousand Thanks from New Mexico

Back in July of 2011, we received a phone call from a gentleman named Kyle who was looking to schedule an appointment for a rhinoscopy for his pooch. Everything seemed fine until he explained to us he is currently in New Mexico and lives there as well. Kyle was doing some online research on what could have been causing his pooch, Oakum, to sneeze excessively, when he came across a previous blog entry of ours on a patient named Ice Bear who had a foxtail or two lodged in his lungs. This story prompted Kyle to give us a call and schedule an appointment with our Board Certified Veterinary Surgeon Specialist, Dr. Carl Koehler to help figure out what was going on with his beloved dog, Oakum.

Below you will find the detailed recount of events that Kyle went through as a pet owner with a pet in distress; the moment of panic, the numerous veterinarians and the lengths we as pet owners go to for our pets.

    As we all know, our lives change day-to-day, and often are not even remotely predictable. Events occur in an instant that can completely alter the course and thrust the most well meaning and responsible travelers on that familiar road into a fork, and an unmarked one at that. Life doesn’t come with an ‘‘instruction manual’’, and choices have to be made daily, hourly, minutely, and even second by second. Any one choice can be the wrong choice, and the devil of it is, you almost never find out until it’s too late to select ‘‘reverse’’.

    Living with an animal companion can be a very worthwhile and rewarding experience. Unfortunately, every reward carries it’s own distinct and definite risk. Illness is a very powerful force against those of us who have the fortune to be alive, and just because we love someone or something very much, doesn’t always protect the subject of our respect and our well-wishes. Love can help a great deal, but modern medicine is the only real foe for illness. The claws of medicine are instruments, it’s gaze is one of knowledge. The skill and strategy of medicine lies in the learned, and articulation and agility is empowered and enforced by scholars. To have all four in one place is certainly remarkable, and that is exactly what I found at Encina Veterinary Hospital. I traveled over a thousand miles to challenge my expectations, and when I arrived, I found them distinctly defined, and most certainly exceeded. Quantity is almost never an acceptable substitute for quality, whether it is in a book or a play, in a relationship, or even with veterinarians, quality pays for itself.

    My limits of attention were tested one evening, as I went into the backyard to work on one of my many projects. My dog followed me outside into the yard with which I share with a neighbor, and although I had asked her to keep the gate latched and shut, one way or the other it was left open by mistake, and my dog quickly exited to her delight, as to prowl and ponder the neighbors bushes and lawn. It couldn’t have been more then a minute from when I walked outside and from when I decided that it would be a good idea to check that the yard was secure and everything was OK before I set to continue construction on my home air purifier project. I let the dog out several times a day, and I try to always check that the yard is secure, but it is easier said then done, because the yard is long and the gate is around a blind corner. The dog has gotten out before, for this very same reason, so I was well aware of the danger of the risk of my neighbor leaving the gate unlatched. I had drawn up plans for a supplementary positive latch for the gate, but soon became conditioned after finding the gate closed several hundred times in a row.

    I found the dog right outside, about 20 feet from the gate, and I was quite relieved that I had found her quickly. As I got closer however, something was immediately apparent. My dog was sneezing quite violently, which is something I wasn’t accustomed to. My dog Oak was standing smack in the center of a Foxtail weed thicket, and as I looked closely, I could see that one of the crisp, lightly colored seeds had entered her little black nose. I told her to stop sneezing (a lot of good that did…) and attempted to prise the seed free with one of my fingernails. I have plenty of tools, and I even carry a select general few with me (knife, disposable lighter, ball point pen), but in the short seconds I had to attempt to fasten onto the seed and recover it, my attempts proved vain, and quite hampered by the fact that the animal was having a sneezing fit, and with each sneeze, the seed traveled further and further into the nose. A few sneezes later, it was too late, the seed had entirely disappeared into her nose, and I had to make a decision about what to do next. With my dog continuing to sneeze, I became on the verge of a panic. I figured that the seed could most certainly lodge in the throat of my dog and prevent breathing, (something that may have been entirely incorrect), and feeling totally helpless, I decided to seek assistance at the local emergency clinic. I called on the way to the clinic and was greeted coolly and not-quite-so cordially. Upon arrival, I found only that my helplessness was furthered, after waiting 8 hours for my dog to be sedated and examined with only the short stub of an otoscope, which I could have likely produced myself in that amount of time, and with a far lesser charge. The clinic was dirty, it smelled bad, and the nurses assistant acted like she had gotten in to the medicine cabinet and gave herself a little ‘‘treatment’’. I didn’t have a good feeling, but I couldn’t just change the plan now and give up! Not surprisingly, no seed was located or recovered, and I found myself wondering what to do with the rest of my weekend. Over the course of the weekend my dog continued to sneeze, and so I brought her to my usual general veterinary practitioner. This time, we held Oak to a metal table and again the vet used an otoscope to observe the immediate area local to the opening of the nostril. With the same result of no seed being observed, I again began to wonder about what to do next, as the vet had instructed me to ‘‘wait and see what happens’’. Several days passed, and my dog continued to sneeze and choke, and she became more and more out of character, as she layed around and seemed to be in somewhat of an agony. In my spare time, I researched foxtail seeds and the prognosis. I found that generally, acute foxtail inhalation usually was treated as an emergency, and that it wasn’t so unusual for the seed to enter one of the lungs and cause pneumonia, or pass through the lungs into a blood vessel and end up in the heart or brain and cause death that way. The seed could of course just remain local, and cause infection to the sinus cavity, or it could be expelled or swallowed.

    I’m not the kind of person who just sits by idly, likes to be told what to do, or even does what other people think I should be doing! I just feel better making proactive decisions that change the course of my life the way I feel it should be going. I decided that I again would seek professional assistance to fight illness, and this time I would take the most decidedly extreme approach I could afford or even design. I find that usually if you throw everything you’ve got at a problem and give it your full attention, it has a tendency to wither and disappear, and quickly. I called Denver, Phoenix, Ft Collins, and Santa Fe. In addition, I called every clinic that anybody that had a recommendation had, and still I found that I was either treated queerly and coldly, I was never given a return call, or most importantly, the equipment to look inside of the nasal cavity was not available. I must have called over ten DVMs in all. The stand-out was Dr. Köhler at Encina. I found the clinic while researching. Not only did he actually call me back and took the time out of his busy schedule to answer every question I had (I had plenty), he recommended that I see somebody closer to New Mexico. That was the silver bullet. I knew that someone who would recommend another’s services instead of himself had indeed the character of true responsibility. I again called around Denver and was told that ‘‘no information can be given without an examination of the animal.’’ That’s a nice rule to follow, but rules aren’t always the most practical items.

    My friend helped me drive to make the appointment at 9:15 am in California. We left Albuquerque. at around 2pm and drove through the night to arrive at Encina Veterinary Hospital at 9:10 am. Driving is not the safest of tasks, and my friend and I took quite the risk doing it. If you have one problem, you will be stuck on the side of the road with a sick animal, possibly in severe desert heat. We had no major problems getting to the clinic, but that could have certainly been different. I did have mechanical trouble (wheel alignment) that prevented me from leaving San Fransisco immediately. So take this medicine with a pinched nose, and be sure to explore all the information you have before making a decision.

    Using fiber-optics, there was a determination made that irritation was most certainly present in the side of the nostril that I saw the seed enter. No seed was found however, which indicates that it had become mobile and exited the body or located itself in another part of the body. It could most definitely have been swallowed, and since the chest radiograms were clear, and Oak is no longer sneezing or showing any symptoms, I may never find the seed, and I hope I never do 🙂

A thousand thanks from New Mexico,
Kyle C.

Kyle has sent us an updated picture of Oakum and has shared with us that he has trained her to now respond to a hand-bell so she comes inside to a pleasant sound!

Pascal’s Thankful Thanksgiving

    Pascal is a very sweet Bedlington Terrier that has been a patient of mine since 2003. We diagnosed him with copper storage liver disease in 2003 and have treated him with medications and a prescription diet. Copper storage disease is when the liver begins to accumulate an abnormal amount of copper, which in the long run can cause liver cirrhosis and is actually common in Bedlington Terriers, Doberman Pinschers and Labrador Retrievers. Since his diagnosis, Pascal has done well and there has been no evidence that his copper storage liver disease has progressed.

    In late November, just before Thanksgiving, Pascal was rushed to us on an emergency. He was reported to have become acutely very sick and was vomiting, lethargic, and not wanting to eat. On physical examination, he appeared very depressed, dehydrated, had abdominal pain on palpation, and a fever. We hospitalized him and started intravenous fluids, pain medications, gastric protectants, and broad spectrum antibiotics, and of course took a blood sample to analyze to see what exactly was going on inside of Pascal.

    Once his blood work came back, it showed us an elevation of liver enzymes and an elevated white blood cell count. We then preformed an abdominal ultrasound on Pascal which showed one abnormal liver lobe and free fluid in the abdomen. A sample of fluid was taken from his abdomen and after looking at it under the microscope; we saw that it showed evidence of a bacterial infection. Based on these findings, our primary differential was a liver abscess.

    Liver abscesses are rare in dogs. Some potential causes are sepsis (bacterial infection in the blood), trauma to the liver, and diabetes mellitus. Pascal did not appear to have any of these underlying causes. It is possible that his copper storage liver disease predisposed him to a liver abscess but this has never been reported.

    I discussed with Pascal’s owner that this is a very serious condition and without surgical removal of the abscessed portion of his liver, Pascal might die. Pascal’s owners elected to pursue surgery and we were able to isolate the section of the liver that was abscessed (the left medial liver lobe) and remove it successfully. We flushed his abdomen cavity with warm saline (salt water) to remove residual infection that had spread throughout his abdomen.

    Pascal has recovered well from surgery and it is great to see him back to his normal activities. You would never know that just a few months ago Pascal was deathly ill and had major surgery!

                                      Written by Dr. Peter Nurre, DVM, Dipl. ACVIM

Pascal’s owner Judy had some beautiful words for Dr. Nurre that we would like to share with you:

Dear Dr. Nurre,

   I sat down to write you a “thank you” note and I’m finding it very difficult to say what I feel. I don’t have the words to express how much Pascal means to me and then I realized that it’s okay because I think you know.

   Thinking and thinking and thinking – how can I possibly convey the flood of gratitude I feel for your incredibly generous offer to save Pascal’s life. You are in every way extraordinary special; both as a person and as a doctor!

   I normally don’t consider myself to be a lucky person but whenever I think about November of 2011, that’s the word that comes to me – lucky! I’m the luckiest person in the world to have miraculously had the good fortune to have Pascal in your care. This was a thanksgiving I will always remember. We will forever be thankful to you!

   I very best thing I could ever wish for you is that should you ever find yourself in the worst of situations, as I was, one that seems hopeless – the best thing that could happen to you is for there to be someone just like yourself, right there for you, like you were for us!

   The words “thank you” don’t even begin to come close to how grateful we are, but please except them and know that they mean infinitely, so much more.

               Wishing you the very best!
                      Judy and Pascal

Update on Ice Bear, One Cool Cat

Excited to be home at last!

We received an update from Ice Bear’s parents, along with some recovery pictures, enjoy:

“He is doing extremely well. Stitches out, and now he gets to go outside. He doesn’t seem to wander much yet, just content to hang close. That’s fine by us.”

Dreaming of the days when he can go back outside...

Stitches out, stockingnette off!

Lazing in the grass at last (under supervision)!

A Foxtail Tale With a Happy Ending

Ice Bear Fashionably Recovering

You may recall a blog post from last month regarding foxtails, one of summer’s most common veterinary snafus. We recently had a peculiar case in which a foxtail ended up in a very unlikely place. Dr. Nurre recounts the tale of Ice Bear’s illness and recovery (warning, some of the pictures are graphic):

“We recently had a cat, Ice Bear, referred to our hospital with a week long history of not wanting to eat , slight cough, and being very lethargic.  His signs were vague and could have been caused by many different underlying medical conditions.  The referring veterinarian had done bloodwork and taken radiographs of the Ice Bear’s entire body.  There was a subtle abnormality seen radiographically in one of the cat’s lung lobes.

After I examined Ice Bear it was apparent that he was feeling very sick.  I recommended using ultrasound to visualize Ice Bear’s internal organs.  The owner consented.  First, we ultrasounded Ice Bear’s abdomen which looked normal.  Then we ultrasounded his chest.  Ultrasound evaluation of his heart looked normal.  No leaky heart valves, contractility [the ability of the heart to contract] appeared normal, and no evidence of heart chamber enlargement.

Around the heart and lungs I could see a large amount of fluid which was very abnormal.
Using ultrasound guidance I passed a needle into his chest (careful not to hit his heart or lungs) and extracted some of this fluid.  The fluid analysis confirmed it was pus.  Then the question was what caused the pus to build up in the chest?  With ultrasound I could see in the left caudal  lung lobe an unusual structure that resembled a foxtail.

The red arrow on the ultrasound image indicates the location of the foxtails within the lung

I discussed with the owner that if this was a foxtail we would need to remove it to give Ice Bear a chance to survive.  The surgery was risky, but our board-certified surgeon, Dr. Carl Koehler, did a great job.  He successfully removed the 2 foxtails and lung lobe, because it was so diseased, and flushed the pus from the chest.  Ice bear recovered well and went home  the following day eating and acting quite normal. ”

The Foxtails Embedded in the Lung

The Troublesome Pair of Foxtails Following Removal

Congratulations to Ice Bear on a successful recovery! If you suspect that your pet has inhaled a foxtail, or if you notice swollen lumps or bumps on your pet that popped up quickly, call us 24 hours a day at (925)937-5000.