By A. Hamlar. Sterling College, Sterling Kansas.

Women with atrophic vaginitis should try to avoid substances that tend to dry the mucous membranes cheap 20 mg levitra mastercard, including antihistamines best order for levitra, alcohol purchase discount levitra line, caffeine, and diuretics. Underwear made from natural fibers, particularly cotton, is often recommended, as it allows the skin to breathe, thus decreasing the incidence of vaginal infections. Regular sexual intercourse is also beneficial, as it increases blood flow to vaginal tissues; this blood flow helps improve tone and lubrication. However, good lubrication must be maintained; there are many oil- and water-based lubricants available, such as K-Y jelly. Bladder Infections About 15% of menopausal women experience frequent bladder infections. Apparently there is a breakdown in the natural defense mechanisms that protect against bacterial growth in the urinary tract. The primary goal in the natural approach to treating bladder infections is to enhance a woman’s normal resistance to urinary tract infection. Specifically, increase the flow of urine through proper hydration, promote a pH that will inhibit the growth of microorganisms, and prevent bacteria from adhering to the endothelial cells of the bladder. See the chapter “Cystitis and Interstitial Cystitis/Painful Bladder” for further information. Cold Hands and Feet Cold hands and feet are common among women in general, not just menopausal women. In most instances, there are three major causes of cold hands and feet: hypothyroidism, low iron levels in the body, and poor circulation. It is important to rule out hypothyroidism by measuring blood levels of thyroid hormones. A complete physical exam is also required, with particular attention to any other signs of decreased blood flow. Forgetfulness and Inability to Concentrate Forgetfulness and an inability to concentrate are common symptoms of menopause. Often these symptoms are simply a result of decreased oxygen and nutrient supply to the brain, due not to menopause per se but rather to atherosclerosis (hardening of the arteries) of the blood vessels supplying oxygen and nutrition to the brain. Although it weighs only 3 pounds, the brain utilizes about 20% of the oxygen supply of the entire body. To deal with symptoms of forgetfulness and inability to concentrate, the goal is to improve the supply of blood, oxygen, and nutrients to the brain. Menopause as a Social Construct While there is undeniably a physiological process involved in menopause, menopause is much more than simply a biological event. Modern society has placed great value on the allure of youth, resulting in a deeply entrenched cultural devaluation of older people, particularly women. Advocates of a social and cultural explanation of menopause often point to this cultural devaluing of older women as the root of the negativity associated with achieving menopause. In contrast, in many cultures of the world, women look forward to menopause because it brings with it greater respect. Studies of menopausal women in many traditional cultures demonstrate that most will pass through menopause without hot flashes, vaginitis, and other symptoms common to menopausal women in developed countries. Even osteoporosis is extremely rare, despite the fact that the average woman in many traditional cultures lives longer than the average woman in the United States. Cross-cultural research clearly demonstrates that the cultural view of menopause is directly related to the symptoms of menopause. In contrast, if menopause is associated with little negativity or viewed in a positive light, symptoms are far less frequent. One of the most detailed studies of the effects of culture on menopause involved rural Mayans. None of these women experienced hot flashes or any other menopausal symptom, and not one woman showed evidence of osteoporosis, despite the fact that their hormonal patterns (levels of the various female sex hormones) were identical to those of postmenopausal women living in the United States. The researchers felt that the Mayan women’s attitude toward menopause was responsible for their symptomless passage. The Mayan women saw menopause as a positive event that would provide them acceptance as respected elders, as well as relief from childbearing. This attitude is much different from the dominant attitude toward menopause that is common in industrialized societies. If our society adopted a different cultural view of older women, it is likely that the symptoms of menopause would cease to exist. According to Wilson, without estrogen replacement therapy women were destined to become sexless “caricatures of their former selves. Before this question can be answered, the benefits and risks of estrogen replacement therapy must be considered, as well as the natural alternatives. Therapeutic Considerations As we’ve noted, the current conventional medical treatment of menopause remains the short-term use (one to four years) of hormone replacement therapy for menopausal symptoms. Not surprisingly, there was a parallel sharp decline in the rate of new breast cancer cases. This drop produced a reduction in the annual rate of breast cancer in the United States of 8. The decrease occurred only in women over the age of 50 and was more evident in women with cancers that were estrogen-receptor-positive. Unfortunately, they are just not aware of effective natural strategies to deal with menopausal symptoms or reduce the risk of osteoporosis. To determine your risk for osteoporosis and for more information on natural approaches, see the chapter “Osteoporosis. Premarin, for example, contains forms of estrogen isolated from the urine of pregnant mares and includes more than 200 substances mostly foreign to humans. Animal rights activists also have long claimed that the methods used in Premarin’s production cause suffering to the mares involved. The major health problem for women taking Premarin and other common forms of conjugated estrogens is that they are metabolized in the body to 17-beta-estradiol, the form of estrogen most strongly associated with cancer. Bioidentical hormones are made from either beta-sitosterol extracted from soybeans or from diosgenin extracted from wild yam (Dioscorea villosa). These compounds are then processed to create hormones that are biochemically identical to human hormones. Bioidentical hormones require a prescription and are available from regular pharmacies or from compounding pharmacies. Because bioidentical hormones are natural, they are not patentable—hence, there are no big drug companies promoting them. Without the promise of a financial windfall it is highly unlikely that the large trials necessary to conclusively show the advantages of bioidentical hormones will ever be conducted. Nonetheless, it makes more sense to use bioidentical hormones if hormonal support is required. Because we suggest prescription forms, we recommend consulting with your physician or seeking the counsel of a naturopathic physician. Continue at this half dosage for one month, then cut the dosage in half again by taking it every other day for another month before discontinuing it entirely. Of course, before changing the dosage of any drug, always first consult your doctor. A critical factor in hormone replacement—whether natural or conventional—is to not only measure hormone levels but also determine the makeup of their metabolites after detoxification.

In the long-run levitra 10mg online, the information about expres- sion patterns will need to be correlated with information about the genetic hetero- geneity of the human population purchase cheapest levitra. Elucidation of the com- position of the human genome would result in information and spin off technolo- gies that would revolutionize the study of disease discount levitra 10mg otc. A map or descriptive diagram of each human chromosome would involve dividing each chromosome into smaller fragments that can be propagated and characterized as well as ordering the frag- ments to correspond to their location on the chromosome. After mapping, the next step is to determine the nucleotide sequence of each chromosome fragment. Ninety percent of the human genome nucleotide sequencing project has been completed. Most recently, a highly public announce- ment was made that the human genome has been sequenced. The elucidation of the entire genome and public disclosure of the data would almost certainly identify most if not all of the major genes involved in common diseases. Already, as noted above, correlations between genetic mutations and disease susceptibility are being established with the hope that such information will lead to novel therapies targeted at defined patient populations. Genetic based diagnosis and treatment of disease have the potential to radically improve the practice of medicine (see Chapter 15). Human Genome Project The Human Genome Project began in the 1980 as part of a national scientific research effort supported by the Department of Energy. As mentioned previously, new techniques are constantly being developed and introduced into the research environment. A long-term objective of the Human Genome Project is to identify all coding sequences, including genes and regulatory elements in the human genome. Speed is increasing as a result of both incremental improvements in current methods and from the introduction of entirely new approaches, such as “sequencing by hybridizing” on microarrays or chips. In July, 1997, the first of such systems was launched and called GeneChip (p53) assay for research applications. This assay is capable of analyzing the full-length coding sequence of the human p53 tumor suppresser gene, frequently mutated in human cancers. In addition to sequencing by hybridization, entirely different approaches are being explored. Many additional initiatives are underway with a major break- through in this field likely. Genetic epidemi- ologists and statisticians will be needed to validate genetic linkages in conditions with polygenic inheritance patterns. Information needs to be gathered about the factors affecting expression of genes and gene mutations, so that predictions can be made about the outcome in particular individuals. Model Systems The mapping and sequencing of the genomes of other organisms as model systems is fundamental to the elucidation of the human genome. Model systems are also useful in the testing of new technologies to be applied to the human genome. Given the conservation of genetic information and the use of the mouse in animal models of disease, these data are anticipated to be highly informative. Discovery and clinical applications of novel genes is expected to continue at an accelerating pace. Gene manipulations to increase expression levels and to provide cellular specificity and control mechanisms will lead to added safety and efficacy. There does not appear to be many limitations to the accomplishments of molecu- lar biologists with regard to gene discovery and engineering. Methods and inven- tions to deliver these genes in vivo to specific cell types is an area needing improvement, and the variety of approaches presently being investigated bodes well for future breakthroughs. In particular, present delivery systems are often lacking in both specificity and efficiency. Large-scale man- ufacturing methods for production and purification will fall into place as the utility of gene therapies is demonstrated in many of the ongoing clinical trials. Smaller companies tend to be open to any oppor- tunity that fits their strategic intent. In contrast, most small companies or budding entrepreneurs will only have one of the two main components in hand. The size of the potential patient population and the accessibility of patients for a particular product is crucial. In addition, as with any new therapy, gene therapy approach for a disease state would need to have advantages over treatments currently in use. These modified mini-prep kits generally make use of the alkaline lysis method for cell disruption followed by a chromatographic cartridge purification. Quality control is concerned with sampling, spec- ifications, testing, and with documentation and release procedures ensuring satisfactory quality of the final product. On the one hand, these gene profiling techniques will detect gene therapy targets—genes whose products contribute to disease. On the other hand, they will identify genes whose products may be useful when delivered as replacement genes. Special feature: A survey of the recent patent literature on the delivery of genes and oligonucleotides. Characterization of individual polynu- cleotide molecules using a membrane channel. Surface dynamics in living acinar cells imaged by atomic force microscopy: Identification of plasma membrane struc- tures involved in exocytosis. Former Editor, Journal of the Association of Avian Veterinarians Lake Worth, Florida ©1994 Wingers Publishing, Inc. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permis- sion from Wingers Publishing, Inc. Formerly: Institut für Geflügelkrankheiten Hagen Avicultural Research Institute Ludwig-Maximilians-Universität München Montreal, Quebec, Canada Oberschleißheim, Germany Mycoses Defense Mechanisms of the Avian Host, Viruses, Bacteria, Chlamydia, Mycoplasma and Rickettsia, Columbiformes R. It has truly been an honor to coordinate Pepperburg, Charles Munn and Ken Fletcher; and the efforts of so many dedicated authors, and we for the radiographs, illustrations and photographs appreciate their giving of their personal time in par- from Stephen A. Elisabeth Krautwald-Junghanns, Murray Fowler, Brett Hopkins, Busch Gardens Tampa, Jane Turrell, We especially want to thank Dr. Korbel, Robert Schmidt who was extremely committed to the tedious and and Ellman International Manufacturing, Inc. In addition to the authors, the editors would like to thank Martin Orr, Robert Clipsham, Nina We are indebted to the international authors, par- Ungerechts, J. Göbel, Exotic Animal Medi- immense contribution to the book (some of these cal Products, Mark Spreyer, D. Jack, David Ley, Richard Cambre, Louis Filip- scrutinized the world’s literature and brought a fresh pich, Cheryl Greenacre, R. Montali, Michael Mur- perspective to this work); additionally, John Olsen, ray, L. West, Kenneth Latimer and Avery Bennett contributed be- Dan Wolf, Isabel Taylor, W. Bob Dahlhausen, Carol Partington, Elizabeth Wat- son, Ramiro Isaza, John Randolph, and Avian Re- Deep appreciation is extended to those whose lives search Associates for providing photographs used in and schedules were disrupted by the time commit- this book. Others who contributed to the graphic ment of the editors: the research team, staff and aspects include Lauri Maniccia, Lynda Hare and Tom students at the University of Georgia, including Elfers.

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Determinants of vancomycin clearance by con- tinuous venovenous hemofltration and continuous venovenous hemodialysis order 10mg levitra with visa. Diffusive and convective solute clearances during continuous renal replacement therapy at various dialysate and ultrafl- tration fow rates purchase 20mg levitra. The effect of adsorption order levitra american express, flter material and point of dilution on antibiotic elimination by haemofltration: an in vitro study of levofoxacin. Effect of drug concentra- tion on adsorption of levofoxacin by polyacrylonitrile haemoflters. The adsorption of van- comycin by polyacrylonitrile, polyamide, and polysulfone hemoflters. In vitro adsorption of gentamicin and netilmicin by polyacrylonitrile and polyamide hemofltration flters. Prolonging β-lactam infusion: a review of the rationale and evidence, and guidance for implementation. Clinical outcomes with extended or continu- ous versus short-term intravenous infusion of carbapenems and piperacillin/tazobactam: a sys- tematic review and meta-analysis. Antibiotic dosing in critically ill adult patients receiving continuous renal replacement therapy. A systematic review of antibi- otic dosing regimens for septic patients receiving continuous renal replacement therapy: do current studies supply suffcient data? Quality of pharmacokinetic studies in critically ill patients receiving continuous renal replacement therapy. Can population phar- macokinetic modelling guide vancomycin dosing during continuous renal replacement therapy in critically ill patients? Does Beta-lactam pharmacokinetic variability in critically ill patients justify therapeutic drug monitoring? Determinants of ceftriaxone clearance by con- tinuous venovenous hemofltration and hemodialysis. Pharmacokinetic evaluation of voriconazole treatment in critically ill patients undergoing continuous venove- nous hemofltration. Pharmacokinetics of amphotericin B lipid complex in critically ill patients on continuous veno-venous haemofltration. Pharmacokinetics of caspofungin in critically ill patients on continuous renal replacement therapy. Population pharmacokinetics of lorazepam and midazolam and their metabolites in intensive care patients on continuous venovenous hemofltration. How to optimise antimicrobial prescriptions in the Intensive Care Unit: principles of individualised dosing using pharmacoki- netics and pharmacodynamics. Some current issues in the pharmacoki- netics/pharmacodynamics of antimicrobials in intensive care. Effect of continuous arteriovenous hemodiafltration on the pharmacokinetics of fuconazole. Pharmacokinetics and the most suitable dosing regimen of fuconazole in critically ill patients receiving continuous hemodiafltration. Population pharmacoki- netics of fuconazole in critically ill patients receiving continuous venovenous hemodiafltra- tion – using Monte Carlo Simulations to predict doses for specifed pharmacodynamic targets. Population phar- macokinetics of colistin methanesulfonate and formed colistin in critically ill patients from a multicenter study provide dosing suggestions for various categories of patients. Most of these intoxications involve analgesics, sedatives and cardiovascular drugs [1 ]. Although in the past, decontamination techniques such as gastric lavage and admin- istration of activated charcoal have been advocated, their clinical benefit has not been confirmed in controlled studies and their use has substantially declined during recent years [1, 2]. Nevertheless, enhanced elimination of the toxic agent remains one of the cornerstones of the management of the intoxicated patient. In this chap- ter, we will give an overview of the indications and techniques for the elimination of toxic agents. Whether removal of toxins by means of renal replacement therapy is possible depends on characteris- tics of the toxin itself and of the elimination technique used (Table 19. However, hemodialysis is most suitable to remove water-soluble toxins with a low molecular weight (Table 19. Taken into account these restric- tions, hemodialysis is by far the most efficient technique in terms of clearance. The clearance of a substance depends on its molecular weight, the mem- brane surface area and type, as well as on blood and dialysate flow rates [6 , 7 ]. Increasing blood and dialysate flow rates can increase the concentration gradient between blood and dialysate, thus increasing the rate of diffusion and elimination. Intermittent hemodialysis typically uses a blood flow rate of 200–500 mL/min and a dialysate flow rate of 500–1,000 mL/min [7, 8]. When a high-flux, high-efficiency membrane is used, a urea clearance exceeding 200 mL/min can be reached [9 ]. The major drawback is the risk of rebound toxicity due to redistribution of the toxin after stopping the treatment. In addition, hemodynamically unstable patients generally do not tolerate the high blood flows used in intermittent hemodialysis. However, since flow rates are lower and treatment duration is longer, it is better tolerated by hemodynamically unstable patients and the risk of rebound toxicity is diminished. Current international guidelines recommend delivering an effluent volume of 20–25 mL/ kg/h ( www. Therefore, urea clearance is low (20–30 mL/min), which makes the technique unsuitable for the treatment of intoxications. The plasma ultrafiltrate is replaced by a buff- ered replacement fluid, infused either before (predilution) or after the filter (postdi- lution). In postdilutional hemofiltration, clearance equals the ultrafiltration rate, typically ranging from 10 to 30 mL/min, with 20–25 mL/kg/h being the current recommendation for renal replacement therapy. However, for small water-soluble molecules, extracorporeal removal by hemodialysis is much more efficient. However, the efficiency of this technique is insufficient for the treat- ment of intoxications. In order to be able to be removed by hemoperfusion, the toxic substance must have binding affinity to the sorbent in the cartridge and a low volume of distribution (Table 19. Despite their efficacy, the use of hemoperfusion cartridges has declined over the last 20 years due to limitations of their indications and shelf life [7, 12, 13]. When an intoxication with one of these agents is suspected, consulta- tion of a nephrologist and pharmacologist is warranted [7, 14 ]. Their protein binding ranges from 5 % for barbital to 70 % for secobarbital, and their endogenous clearance ranges from 3 mL/min for barbital to 53 mL/min for secobarbital. Although for all barbiturates extracorporeal clearance is higher than endogenous clearance, barbital, phenobarbital, and secobarbital are most suitable for this technique because of their low endogenous clearance [15]. The choice for extracorporeal treatment in case of barbiturate overdose depends on the severity of the toxicity rather than on the serum level and should be considered in cases of severe hypotension, respiratory depres- sion, or deep and prolonged coma. However, with the use of high-flux, high-efficiency membranes, similar or even better elimination can be obtained with hemodialysis [16, 17]. Substance Preferred method Barbiturates Hemoperfusion/hemodialysis Lithium Hemodialysis Metformin Hemodialysis Salicylates Hemodialysis Theophylline Hemoperfusion/hemodialysis Table 19.

Inflation of the pouch can be prevented by wrapping the lower neck with a self- adhesive bandage cheap levitra generic, taking care not to place excessive pressure on the major vessels of the neck buy levitra with a visa. Proventriculus (p) buy levitra master card, ventriculus (v), duodenum (d), jejunum (j), ileum (i), ceca (c), rectum (r) and niche of these large grazing ungulates. Ratites have cloaca (cl) (courtesy of Murray Fowler, reprinted with permission19). The opening from the ventriculus to the duodenum is on the right side in all ratites. The small intestine is most important in the emu, in which it occupies most of the abdomen caudal to the ventricu- lus. In the ostrich and rhea, the elongated, well developed ceca, vis- ible immediately after entering the midline abdominal wall, course di- agonally from right to left in a caudal direction. The lumen of the ceca ap- pears sacculated as a result of spiral folds that increase the surface area in the organ and facilitate the fer- mentive digestion of fiber (Color 48. The large intestine of the ostrich is voluminous and occupies the caudal right abdomen (Figure 48. The long, large intestine is considered necessary to digest high-fiber food items. The gastroin- testinal transit time is slow in ostrich and rheas (36 hours) and much faster in emus (5 to 6 hours). Interestingly, emus produce a large portion of their energy through fermentation even though they have poorly developed ceca, a short colon and a rapid gastro- intestinal transit time. In the ostrich, the urodeum and co- prodeum are separated by a muscu- lar sphincter, making the ostrich the only bird that can urinate inde- pendent of defecation. The coprodeum is a large sac that may be covered by a dark tough membrane similar to koilin. There is no gallbladder in the ostrich, but this organ is present in the emu and rhea. As a hen reaches sexual maturity, the follicles begin to develop, so the ovary has many visible follicles of different sizes at any one time (see Color 29). Cranial division of the left kidney (k), left testicle (t) and left adrenal gland (a) (courtesy of Murray Fowler, reprinted with near the kidney. Male ratites have a phallus that serves to transport semen from the ejaculatory Ratites of both genders possess a genital prominence ducts in the cloaca of the male to the cloaca of the that extends from the ventral aspect of the cloaca. The phallus is shaped differently in ostrich, This prominence may be visualized or palpated to emu and rhea; however, the function is the same, and 25 determine the gender of any aged individual. Venipuncture can be performed using the jugular, brachial and medial metatarsal veins. The right jugular vein is larger than the left as in other avian species and is a convenient site for venipuncture or placement of intravenous catheters (Figure 48. The brachial vein is inaccessible in the reduced wings of the cassowary and emu, but is well developed in the large wings of the ostrich and can be easily accessed. The medial metatarsal vein is readily ac- cessible in sedated or immobilized adult ratites and in unsedated chicks. The medial metatarsal vein generally is not used in standing adults due to the potential for being kicked. The medial metatar- sal vein is a common preference for intravenous catheterization of chicks (Figure 48. Catheters should be secured in place using tissue adhesive followed by a light bandage. The can be collected from the oviduct of adult hens (see cross sectional view of the reproductive organ is also provided. Abdominocentesis can be performed on proctodeum 2) phallus 3) clitoris and 4) genital eminence (modified birds with clinical signs suggestive of intestinal tor- with permission from Murray Fowler19). A lubricated gloved finger is device for use for abdominocentesis in ratites (see used to expose the cranio-ventral aspect of the cloaca. The male ostrich chick has a phallus that is conical Oral medications are relatively simple to administer in cross section, contains a palpable core of fibroelas- by orogastric tube to chicks or tractable adults. Occa- tic tissue and is characterized by the presence of a sional feedings can be provided by placing an equine seminal groove. By comparison, the clitoris in the stomach tube directly into the proventriculus; how- hen is laterally compressed, soft and lacks the semi- ever, to perform gastric lavage or supply sustained nal groove. The clitoris of the adult female remains enteral nutrition, an equine stomach tube is passed approximately one to two centimeters in length (Fig- through an esophagostomy incision and is sutured ure 48. The tube is most easily placed by introduc- male is approximately three to five centimeters in ing it orally into the esophagus, making an incision length and is readily detected on the ventral wall of over the cranial end of the tube and retracting it back the cloaca by palpation. These birds (blebs) and contamination of the shell with are best managed by surgically removing sand and debris. The chick on the left is se- The skin has been removed from the abdo- verely edematous, which in other avian men of a three-day-old emu chick to better species can be caused by excessive humid- visualize the infected yolk sac. Volvulus of the The chick on the left has a distended abdo- small intestines was caused by rotation of men caused by the retention of an infected the yolk sac. The bird on the right has a small, sac and distal portion of the small intes- tucked abdomen secondary to starvation. Aortic rupture of unknown etiology in a six-month-old female ostrich that died Color 48. The site where the aneurysm Uric acid deposits in the eyelid of a rhea formed between the intima and media of that died from renal failure. A of uric acid were also noted on the tongue, copper deficiency has been discussed as a thoracic and cervical vertebrae, heart, ven- possible cause of this lesion. The phallus is firm, conical in shape, curves to the left and has a prominent seminal groove. It has been suggested that this site may be inappropriate for the administration of nephrotoxic or renally ex- creted drugs because of the renal portal system. However, in one study involving the clearance of aminoglycoside, there was no difference in plasma levels when the drug was given in the posterior or anterior portions of the body. Adult Bird Management insurance company requirements for identification and provide unmistakable identification for record keeping purposes. Identification Nutrition It is suggested that all ratites be permanently iden- Numerous pelleted rations are commercially avail- tified. Most of these are locally produced dramatically illustrated by a case in which an ostrich and are highly variable in content and quality. Infor- was identified on a health certificate as an “African mation on the specific nutritional requirements of black” and was insured for twenty thousand dollars. In South Africa, range-raised os- The bird died, and at necropsy the veterinarian iden- triches are fed on alfalfa pastures supplemented with tified the bird as a “blue-necked” ostrich, and the maize. The insurance company de- of health and reproduction when fed a diet that con- clared that the dead bird was not insured.