Lipomas

Lipomas are benign fatty tumors that develop in the subcutaneous tissue of cockatiels and other pet birds, representing one of the most common neoplastic conditions seen in avian veterinary practice. These soft, moveable masses consist of mature adipose cells that accumulate and form discrete lumps beneath the skin, typically developing on the chest, abdomen, and areas around the keel bone. While lipomas are non-cancerous and do not spread to other parts of the body, they can grow to substantial sizes that interfere with the bird's mobility, breathing, and overall quality of life. Cockatiels are particularly prone to developing lipomas, especially those fed high-fat, seed-based diets and those with sedentary lifestyles.

The development of lipomas in cockatiels is strongly associated with dietary and lifestyle factors, particularly chronic overconsumption of high-fat foods combined with insufficient exercise opportunities. Birds fed primarily seeds, especially sunflower seeds and other oil-rich varieties, are at significantly increased risk compared to those consuming balanced, pellet-based diets. The resulting obesity and metabolic imbalances create conditions favorable for abnormal fat cell proliferation and lipoma formation. Genetic factors also play a role, with some cockatiel bloodlines showing higher predisposition to developing these fatty tumors.

The impact of lipomas on a cockatiel's health depends largely on the size, location, and number of tumors present. Small lipomas may cause no noticeable problems and are sometimes discovered incidentally during veterinary examinations. However, larger lipomas can restrict movement, compress internal organs, interfere with breathing, and create significant discomfort for the affected bird. Lipomas located on the chest or sternum area may prevent normal perching and sleeping positions, while abdominal lipomas can compress the digestive tract or reproductive organs. Multiple lipomas developing simultaneously present additional challenges for management.

Lipomas in cockatiels are treatable through a combination of surgical intervention and long-term dietary and lifestyle management. Surgical excision is often recommended for lipomas that are causing functional impairment or discomfort, and the procedure is generally well-tolerated in otherwise healthy birds. However, surgery addresses only the existing tumors and does not prevent new lipomas from developing if underlying dietary and metabolic factors are not corrected. Comprehensive management therefore requires a holistic approach that includes dietary conversion to a low-fat formulation, increased exercise opportunities, and regular veterinary monitoring to catch new growths early when they are easier to manage.

The primary cause of lipomas in cockatiels is chronic dietary imbalance, specifically the overconsumption of fat-rich foods that leads to obesity and metabolic dysfunction. Seeds, which form the traditional dietary staple for many pet cockatiels, contain high levels of fat and insufficient amounts of essential nutrients, vitamins, and minerals. Sunflower seeds are particularly problematic, containing approximately 50% fat by weight, and many cockatiels selectively consume these preferred items while ignoring healthier food options. This dietary pattern results in excessive caloric intake, obesity, and the metabolic conditions that favor abnormal fat cell accumulation and lipoma formation.

Genetic and species-related factors significantly influence a cockatiel's susceptibility to developing lipomas. Cockatiels as a species demonstrate a particularly high incidence of these fatty tumors compared to many other psittacines, suggesting species-level genetic factors that predispose them to this condition. Within the cockatiel population, certain color mutations and bloodlines appear to have even higher lipoma rates, though comprehensive genetic studies are limited. Individual genetic variations affecting fat metabolism, hormone regulation, and cell growth control likely contribute to why some cockatiels develop multiple large lipomas while others on similar diets remain unaffected.

Environmental and husbandry factors beyond diet contribute significantly to lipoma development in cockatiels. Sedentary lifestyles with limited opportunities for exercise allow excess calories to be stored as fat rather than burned for energy. Small cages that restrict movement, lack of out-of-cage time, and absence of climbing, flying, and foraging opportunities all reduce caloric expenditure. Chronic stress from inappropriate housing, social isolation, or environmental disturbances can affect hormonal balance and metabolism. Poor husbandry practices that fail to provide varied diet options and adequate enrichment create conditions favorable for obesity and its associated complications.

Multiple risk factors increase a cockatiel's likelihood of developing lipomas over the course of its life. Age is a significant factor, with lipomas occurring most frequently in middle-aged to older cockatiels who have spent years consuming inappropriate diets. Obesity itself is a major risk factor, as excess body fat creates a reservoir for abnormal adipose tissue proliferation. Female cockatiels may face somewhat higher risk due to hormonal influences on fat metabolism associated with egg production. Birds with thyroid dysfunction or other metabolic disorders show increased lipoma incidence. Previous lipoma development strongly predicts future tumor formation if underlying causes are not addressed.

The mechanism of lipoma development involves the abnormal proliferation of adipocytes, the specialized cells that store fat, within the subcutaneous tissue. In healthy birds, adipose tissue growth is tightly regulated by hormonal signals and metabolic feedback mechanisms. When these regulatory systems are disrupted by chronic overnutrition, obesity, and metabolic dysfunction, adipocytes may begin to multiply and accumulate without normal growth controls. The resulting mass of mature fat cells forms a discrete, encapsulated tumor that continues to grow as long as excess dietary fat is available. Lipomas typically have a good blood supply that supports their continued expansion, and without intervention, they may grow to impressive sizes over months to years.

Early warning signs of lipomas in cockatiels are often subtle and may go unnoticed until the tumor reaches a size that causes visible changes or functional impairment. Initial indications may include slight changes in the bird's posture or perching position as it adjusts to accommodate a developing mass. Owners who regularly handle their cockatiels may notice a small, soft lump beneath the skin during petting or grooming sessions. Some birds may show subtle reluctance to be touched in certain areas where lipomas are developing. Changes in activity level or movement patterns may occur as the bird compensates for discomfort or altered balance caused by growing tumors.

The most common and recognizable symptom of lipomas is the presence of one or more visible lumps beneath the skin. These masses typically appear on the chest, over the keel bone, on the abdomen, or under the wings. Lipomas characteristically feel soft, smooth, and somewhat moveable under the skin, though very large tumors may feel more fixed in place. The overlying skin usually appears normal unless the lipoma has grown large enough to stretch the skin tightly. Most lipomas are painless when touched, though very large masses may cause discomfort due to their weight or pressure on surrounding tissues. The tumors may appear yellowish when the skin is stretched thinly over them.

Behavioral changes associated with lipomas depend largely on the size and location of the tumors and the degree to which they interfere with normal activities. Birds with chest lipomas may have difficulty maintaining normal perching positions and may be observed sitting on the cage floor more frequently. Appetite changes can occur in either direction, with some birds eating less due to discomfort while others continue overeating, worsening their condition. Reduced activity and reluctance to fly or climb are common as the tumors make movement more difficult or uncomfortable. Some cockatiels become irritable or aggressive when the area around lipomas is touched.

Physical signs of lipomas extend beyond the visible masses themselves to include general signs of the obesity that underlies their development. Affected cockatiels typically show obvious obesity, with fat deposits visible on the chest, abdomen, and sometimes around the neck and thighs. The keel bone may be difficult to palpate due to overlying fat, or in severe cases, the bird may have a distinctly rounded, heavy body shape. Feathers may appear spread apart over lipoma sites as the tumors grow. In advanced cases, the skin over large lipomas may become thin, discolored, or develop stretch marks. Respiratory effort may be visible in birds whose lipomas compress the airways or air sacs.

Symptom progression in untreated lipomas follows a pattern of gradual growth punctuated by periods of apparent stability. Lipomas typically grow slowly over months to years, though growth rates vary considerably between individual tumors and birds. Initially small, manageable lumps can eventually reach the size of grapes, walnuts, or even larger. As tumors enlarge, they begin to cause more significant functional impairment, including difficulty moving, breathing problems, and inability to perch or groom normally. Multiple lipomas may develop simultaneously or sequentially, compounding the challenges faced by affected birds. Without intervention, severely affected cockatiels may become unable to perform normal activities.

Emergency symptoms requiring immediate avian veterinary care include sudden respiratory distress in a bird with known lipomas, as this may indicate compression of airways or air sacs by rapidly enlarging tumors. Signs of circulatory compromise such as bluish discoloration of the feet or skin warrant urgent attention. Ulceration or breakdown of skin over lipomas creates infection risk and needs prompt treatment. Any sudden change in a lipoma's appearance, including rapid growth, hardening, or attachment to underlying tissues, should be evaluated immediately to rule out malignant transformation. Birds that become unable to perch, eat, or maintain normal body temperature due to their tumors require emergency intervention.

The diagnostic process for lipomas in cockatiels begins with a comprehensive initial examination by an avian veterinarian who can differentiate lipomas from other types of masses. The veterinarian will obtain a detailed history including the bird's diet, weight trends, activity level, and the timeline of mass development. Physical examination includes careful palpation of all palpable masses to assess their size, location, consistency, and mobility. The characteristic soft, moveable, subcutaneous nature of lipomas often allows tentative clinical diagnosis based on physical examination alone. The veterinarian will also assess the bird's overall body condition, noting obesity and other signs that support a diagnosis of diet-related lipomatosis.

Diagnostic testing for suspected lipomas may include various imaging and sampling techniques to confirm the diagnosis and rule out more serious conditions. Fine needle aspiration, in which a small needle is inserted into the mass to collect cells for microscopic examination, can confirm the presence of fat cells characteristic of lipomas. Radiographs may be taken to visualize the extent of lipomas and check for involvement of internal structures, though fatty masses can be difficult to distinguish from surrounding tissues on x-rays. Ultrasound examination may provide better visualization of mass boundaries and internal characteristics. Blood tests including lipid panels and thyroid function tests help identify metabolic factors contributing to lipoma development.

Differential diagnosis is important because not all lumps found on cockatiels are benign lipomas. Liposarcomas, the malignant counterpart of lipomas, must be ruled out, as they require more aggressive treatment and carry a different prognosis. Xanthomas, which are inflammatory masses containing lipid-laden macrophages, can appear similar to lipomas and often develop in similar locations. Hernias, particularly in the abdominal area, may be mistaken for soft tissue masses. Abscesses and cysts can also present as subcutaneous lumps. Feather cysts, common in certain mutations like lutino cockatiels, appear as discrete masses but have different characteristics on examination. Accurate diagnosis ensures appropriate treatment planning.

Confirmation of lipoma diagnosis may require histopathological examination of tissue samples obtained through biopsy or surgical excision. Cytological examination of fine needle aspirate samples can provide presumptive diagnosis in many cases, showing the characteristic appearance of mature adipocytes. Definitive diagnosis is achieved through histopathology of excised tissue, which confirms the benign nature of the tumor and its complete removal. In cases where surgical removal is planned, histopathology of the excised mass serves both diagnostic and therapeutic purposes. Following confirmed diagnosis, the veterinarian will discuss treatment options, prognosis, and management strategies to address both existing lipomas and the underlying metabolic conditions that caused them.

Emergency and immediate treatment for lipomas is rarely necessary unless complications have developed that threaten the bird's immediate health. Birds presenting with respiratory distress due to lipoma compression may require oxygen supplementation and supportive care while stabilization is achieved. Ulcerated or infected lipomas need wound care and antibiotic therapy to control infection before definitive treatment can be pursued. Severely debilitated birds may require fluid therapy, nutritional support, and careful warming before they are stable enough for anesthesia and surgery. In most cases, lipomas present as non-emergent conditions that allow time for thorough evaluation and treatment planning.

Medical management of lipomas focuses primarily on dietary modification and weight reduction, which can slow tumor growth and, in some cases, lead to partial regression of fatty masses. Conversion from a seed-based diet to a high-quality, low-fat pellet formulation is fundamental to management. This dietary transition must be accomplished gradually over weeks to months to ensure the bird accepts the new food and maintains adequate nutrition. Weight loss through caloric restriction and increased exercise can help reduce the size of lipomas and prevent new tumors from developing. Some veterinarians recommend specific supplements such as L-carnitine or thyroid support to enhance fat metabolism, though evidence for their efficacy in avian lipoma management is limited.

Surgical excision is the definitive treatment for lipomas that are causing functional impairment, growing rapidly, or located in areas where continued growth would create problems. Avian surgery requires specialized expertise, equipment, and careful anesthetic protocols due to the unique physiology of birds. Lipoma removal is generally straightforward when tumors are small to moderate in size and have clear margins separating them from surrounding tissues. The surgeon carefully dissects the mass from its subcutaneous attachments while preserving blood supply to overlying skin. Multiple lipomas may be removed during a single surgical session if the bird's condition permits, though very large or numerous tumors may require staged procedures.

Supportive care following lipoma surgery includes pain management, infection prevention, and appropriate wound care. Post-operative analgesics help ensure the bird remains comfortable and resumes eating promptly. Antibiotics may be prescribed to prevent surgical site infection. The surgical site must be monitored for signs of dehiscence, infection, or hematoma formation. Activity restriction during the initial healing period helps protect the surgical site. Nutritional support ensures adequate protein intake for wound healing. Follow-up examinations allow the veterinarian to monitor healing and address any complications promptly.

Alternative and complementary treatments for lipomas have been explored with varying degrees of success. Lipid-lowering medications such as gemfibrozil have been used in some avian patients to reduce blood lipid levels and potentially slow lipoma growth. Herbal remedies and homeopathic treatments are sometimes recommended but lack scientific evidence for efficacy. Dietary supplements targeting fat metabolism may provide some benefit as part of a comprehensive management program. Physical therapy and exercise programs increase caloric expenditure and support weight management. However, none of these approaches provide the definitive results achieved through surgical excision combined with dietary management.

Treatment decisions for lipomas in cockatiels consider multiple factors including the size and location of tumors, the bird's age and overall health status, surgical risk, and practical considerations for the owner. Surgical treatment offers the most immediate resolution but carries anesthetic and surgical risks that must be weighed against the benefits. Conservative management through diet and exercise is less invasive but requires long-term commitment and may not adequately address large or problematic lipomas. Cost considerations include not only surgical expenses but also ongoing dietary management and monitoring. The veterinarian will help owners understand expected outcomes with each approach and develop a treatment plan that aligns with their goals and circumstances.

The recovery timeline following surgical lipoma removal in cockatiels varies based on the size and number of tumors removed, the complexity of the procedure, and the individual bird's healing capacity. Most cockatiels show significant improvement in comfort and mobility within the first few days after surgery as swelling subsides and pain medication takes effect. Surgical incisions typically heal within 7 to 14 days, during which time activity restriction and wound monitoring are essential. Complete recovery with return to full normal activity usually occurs within 2 to 4 weeks for uncomplicated surgeries. More extensive procedures involving multiple lipomas or challenging surgical sites may require longer recovery periods.

Post-treatment care requirements for cockatiels recovering from lipoma surgery focus on wound protection, pain management, and preventing complications. The surgical site must be kept clean and dry, with daily monitoring for signs of infection, bleeding, or wound breakdown. Some cockatiels may require an Elizabethan collar or similar device to prevent picking at sutures or staples. Pain medication should be administered as prescribed, with attention to the bird's comfort level and behavior. Activity restriction, including limiting flying and climbing, protects the surgical site during initial healing. Dietary transition to the new low-fat formulation should continue throughout recovery, as nutritional management is essential for preventing recurrence.

Prognosis for cockatiels with lipomas depends heavily on whether the underlying dietary and metabolic factors are successfully addressed. Surgical removal alone has high success rates for the tumors that are excised, with complete removal generally achieved for well-defined lipomas. However, without dietary modification, new lipomas frequently develop in other locations over time. Birds whose owners successfully convert them to appropriate low-fat diets and implement exercise programs have much better long-term outcomes. Age, overall health, and the extent of lipoma development at the time of initial treatment also influence prognosis. Cockatiels with multiple large lipomas or those with concurrent health conditions face more guarded prognoses.

Long-term outlook for cockatiels managed for lipomatosis requires understanding that this is fundamentally a chronic condition related to dietary and metabolic factors. Birds that achieve and maintain appropriate body weight on balanced, low-fat diets can expect good quality of life with reduced risk of new lipoma development. Regular veterinary monitoring allows early detection of any new growths while they are small and more easily managed. Some cockatiels may require periodic surgical intervention if new lipomas develop despite dietary management. Life expectancy is generally not shortened by lipomas themselves if they are appropriately managed, though the underlying obesity and metabolic dysfunction can impact overall health and longevity.

Environmental prevention of lipomas in cockatiels centers on providing housing and enrichment that encourages physical activity and prevents the sedentary lifestyle that contributes to obesity. Large cages that allow flight and substantial movement should be selected for all cockatiels. Multiple perches of varying diameters and heights encourage climbing and exercise. Daily out-of-cage time in safe spaces allows for extended flight and exploration. Foraging opportunities that require the bird to work for food increase activity levels while providing mental enrichment. Play gyms, ladders, and interactive toys encourage movement throughout the day. Creating an environment that stimulates natural behaviors helps cockatiels burn calories and maintain healthy body composition.

Quarantine protocols for new cockatiels should include assessment of body condition and dietary history to identify birds at risk for lipoma development. New birds should be evaluated for obesity and started on appropriate dietary transition during the quarantine period. Veterinary examination during quarantine should include discussion of proper nutrition and weight management. Birds acquired from situations where they were fed seed-based diets should be flagged for careful long-term monitoring. Establishing good dietary habits during the quarantine and acclimation period is easier than correcting entrenched poor habits later.

Dietary prevention is the single most important factor in avoiding lipoma development in cockatiels. Converting cockatiels to high-quality, low-fat pelleted diets provides balanced nutrition without excessive fat and calories. Pellets should comprise 60 to 80 percent of the diet, with fresh vegetables making up most of the remainder. Seeds should be limited to small amounts offered as occasional treats rather than dietary staples. High-fat treats including nuts, sunflower seeds, and processed human foods should be avoided or strictly limited. Fresh water and appropriate vitamin supplementation support overall health. Establishing these dietary habits from a young age provides the best protection against obesity and lipomas.

Regular health maintenance through routine avian veterinary care enables early detection of weight gain and lipoma development. Annual or semi-annual wellness examinations should include body weight measurement and body condition scoring. Veterinarians can identify early lipoma formation when tumors are small and provide guidance on management before they become problematic. Regular weigh-ins at home between veterinary visits help owners track weight trends and catch increases early. Discussing diet and exercise with the veterinarian ensures that husbandry practices support healthy weight maintenance. Blood work including lipid panels can identify metabolic abnormalities before physical problems develop.

Early intervention when weight gain or small lipomas are detected provides the best outcomes for long-term management. Weight reduction programs should be implemented promptly when obesity is identified, before lipomas develop or while they remain small. Small lipomas may regress with aggressive dietary management, potentially avoiding the need for surgical intervention. Regular monitoring of known lipomas allows timely surgical intervention if growth accelerates. Owners should be educated about the connection between diet, obesity, and lipomas so they understand the importance of nutritional management. Working collaboratively with an avian veterinarian to address weight issues early helps cockatiels avoid the complications associated with advanced lipomatosis.

Daily management of a cockatiel with lipomas requires consistent attention to diet, exercise, and monitoring of tumor status. Dietary management involves providing appropriate low-fat foods while strictly limiting or eliminating high-fat seeds and treats. Food should be measured to prevent overconsumption, and foraging toys can extend eating time without increasing caloric intake. Daily exercise outside the cage provides essential physical activity for weight management. Monitoring the size of existing lipomas through regular visual examination and gentle palpation helps detect any changes that might indicate growth or complications. Recording observations including body weight, food consumption, and lipoma measurements provides objective data for tracking the bird's condition over time.

Home environment modifications support weight management and accommodate any physical limitations caused by lipomas. Cage setup should include appropriately sized perches that the bird can grip comfortably despite any lipoma-related changes in mobility. Lowered perches may be necessary for birds whose lipomas affect balance or climbing ability. Food and water dishes should be easily accessible without requiring excessive climbing. Padding on cage floors provides cushioning for birds that spend more time on the bottom due to mobility issues. Room temperature should be maintained within comfortable ranges, as obese birds with lipomas may have difficulty regulating body temperature.

Maintaining quality of life for cockatiels with lipomas involves adapting care routines to accommodate their condition while preserving opportunities for enjoyment and enrichment. Social interaction with owners remains important and should continue despite physical limitations. Modified play activities that don't require extensive mobility can provide mental stimulation. Favorite treats can occasionally be offered in small amounts as part of a managed diet. Comfortable resting spots where the bird can relax without pressure on lipoma sites contribute to daily comfort. Observing the bird's preferences and comfort levels helps identify adjustments that improve their quality of life.

Monitoring and ongoing care for cockatiels with lipomatosis should include regular veterinary evaluations and home observations that track disease progression. Scheduled veterinary examinations, typically every 3 to 6 months for birds with known lipomas, allow professional assessment of tumor status and overall health. Home monitoring should include weekly weigh-ins, regular measurement of lipoma dimensions, and observation for any changes in behavior or comfort. Signs that should prompt immediate veterinary consultation include rapid lipoma growth, changes in tumor consistency, skin changes over lipoma sites, or any decline in the bird's activity or appetite. Maintaining detailed records helps track trends and facilitates communication with the veterinary team.

Caregiver support for owners managing cockatiels with lipomas addresses the challenges of long-term chronic disease management. Understanding that dietary management is a lifetime commitment helps set realistic expectations. Connecting with online communities for cockatiel owners provides opportunities to share experiences and gather practical tips. Financial planning for ongoing veterinary care and potential surgical needs reduces stress related to treatment costs. Celebrating successes in weight management and stable lipoma status provides positive reinforcement for continued efforts. Avian veterinary staff can provide encouragement and support while helping owners troubleshoot dietary challenges. Recognizing that lipomatosis is manageable with consistent care helps maintain optimism about the bird's long-term wellbeing.

Cockatiels represent one of the highest-risk species for lipoma development among commonly kept pet birds, with some studies suggesting that lipomas occur more frequently in cockatiels than in any other psittacine species. This predisposition likely reflects a combination of genetic factors affecting fat metabolism and the typical dietary management of pet cockatiels, which traditionally emphasizes seed-based diets that are inappropriate for this species' nutritional needs. The popularity of cockatiels as pets means that large numbers of birds are raised on these problematic diets, contributing to high rates of obesity and associated lipomatosis. Certain cockatiel color mutations may carry additional genetic factors that increase lipoma susceptibility.

Other psittacine species commonly affected by lipomas include budgerigars, Amazon parrots, and rose-breasted cockatoos, all of which share tendencies toward obesity when fed inappropriate diets. Larger parrots including African greys and macaws can develop lipomas, though prevalence appears lower than in cockatiels and budgerigars. Age is a consistent risk factor across species, with lipomas occurring most frequently in middle-aged to older birds who have spent years consuming high-fat diets. Female birds of several species show somewhat higher lipoma incidence, possibly related to hormonal influences on fat metabolism. Any bird fed primarily seeds and denied adequate exercise should be considered at risk.

Screening recommendations for lipomas emphasize regular veterinary examinations that include careful palpation of the entire body for subcutaneous masses. Annual wellness examinations for all cockatiels should include body condition scoring and discussion of dietary management. Birds showing weight gain or obesity should receive more frequent monitoring, as lipomas commonly develop in this population. Owners should learn to perform basic at-home assessments, including feeling for lumps during routine handling and monitoring body weight trends. Early detection of small lipomas provides more options for management and better long-term outcomes. Breeders should be aware of any familial patterns of lipoma development and consider this factor in breeding decisions.

Lipomas commonly co-occur with other conditions associated with obesity and metabolic dysfunction in cockatiels. Hepatic lipidosis, or fatty liver disease, frequently develops in the same birds that are prone to lipomas, as both conditions result from excessive dietary fat intake. Atherosclerosis, the accumulation of fatty plaques in blood vessels, may develop in chronically obese cockatiels. Xanthomas, which are inflammatory masses containing lipid-laden cells, can develop alongside lipomas and are sometimes confused with them. These concurrent conditions share common risk factors and respond to similar dietary and lifestyle interventions, making comprehensive metabolic management essential for affected birds.

Several conditions produce symptoms or physical findings similar to lipomas and must be differentiated through careful examination and diagnostic testing. Liposarcomas, the malignant form of fatty tumors, must be ruled out through histopathological examination, as they require different treatment approaches and carry more serious prognoses. Xanthomas appear as yellow-orange, firm masses that can develop in similar locations to lipomas. Hernias, particularly in the abdominal region, may present as soft masses that change size with the bird's activity or position. Feather cysts, common in some cockatiel mutations, appear as discrete lumps but contain abnormal feather material rather than fat. Accurate diagnosis ensures appropriate treatment selection.

Complications of untreated lipomas extend beyond the direct effects of the tumors themselves to include consequences of the underlying metabolic dysfunction. Very large lipomas can cause mechanical compression of internal organs, airways, and blood vessels. Ulceration of skin over large lipomas creates infection risk and may require emergency intervention. Mobility restrictions caused by lipomas can lead to muscle atrophy and further deconditioning. The obesity that underlies lipoma development independently increases risk for cardiovascular disease, reproductive disorders, and reduced lifespan. Rare malignant transformation of lipomas to liposarcomas has been reported. Comprehensive management that addresses both existing lipomas and their underlying causes provides the best protection against these complications.